GATEWAY Health Plan Dental Reference Guide. Medical Assistance Program

Transcription

1 GATEWAY Health Plan Dental Reference Guide Medical Assistance Program Administered by United Concordia December 2009

2 GATEWAY HEALTH PLAN DENTAL REFERENCE GUIDE TABLE OF CONTENTS INTRODUCTION SECTION 1 SUPPORT SERVICES Communication Sources Dental Professional Relations Representatives Dental Customer Service Representatives Interactive Voice Response (IVR) System My Patients Benefits Dental Reference Guide Dentist Newsletter Special Mailings Internet Mailing Addresses for Claim and Prior Authorization Submissions Mailing Addresses for Inquiries Telephone Numbers Helpful Websites SECTION 2 AUTOMATED SERVICES My Patients Benefits Interactive Voice Response (IVR) System Provider Check Information Identification Cards Confirm Eligibility DPW Eligibility Verification Member Benefit Packages Program Exception SECTION 3 PARTICIPATING WITH SMILENET Advantages of Participation How to Become a Participating Dentist Confidentiality Credentialing Internal Peer Review How Individual Provider ID Numbers Are Established Group Practice How to Form a Group Practice

3 Changes in Group Practice Membership / New Associates Maintaining Dentist Data Where to Send Notification of Change(s) How to Resign from Participation Gateway Member s Rights and Responsibilities Self-Referral EPSDT Dental Referral Dental Referral Specialty Care Providers Example: Credentialing Application Example: Participating Dentist Agreement with SmileNet Example: Request for Dental Group Account (Addendum C) Example: Request for Addition and/or Deletion of a Participating Provider(s) Identification Number to an Existing Group Account (form 5704) SECTION 4 POLICIES, LIMITATIONS AND EXCLUSIONS Benefits and Exclusions - General Policies Documentation Required For Specific Services Prior Authorizations Requesting a Prior Authorization Full Benefit Coverage - Covered Services Full Benefit Coverage Benefits and Limitations Limited Benefit Coverage - Covered Services Limited Benefit Coverage Benefits and Limitations Procedure Code Reporting Chart Diagnostic Material Requirements Chart SECTION 5 ORTHODONTICS Orthodontic Prior Authorizations Orthodontic Treatment Plans Orthodontic Services Full Benefit Coverage Covered Services Benefits and Limitations for Orthodontic Services Payment for Orthodontic Services Transferring Orthodontists Orthodontic Treatment In Progress New Enrollee Transferring from Another Dentist Billing Orthodontic Services Billing for New Orthodontic Patients How to Complete a Dental Claim Form for New Orthodontic Patients Billing for New Patients In Progress Orthodontic Inquiries Example: Salzmann Index Report

4 Salzmann Index Instructions SECTION 6 CLAIM SUBMISSION GUIDELINES Completing the Claim Form Claim Filing Deadline Gateway Health Plan ID Number Signature Requirements Treatment Plan /Release of Information Dentist s Signature Supporting Documentation Other Supporting Documentation Prior Authorizations Requesting a Prior Authorization Prior Authorizations and Coordination of Benefits Timeframes and Written Notification Treatment without Prior Authorization Hospitalization / Short Procedure Unit (SPU) Procedure Claim Review Process Initial Review Professional Review by Dental Advisors Example: Gateway Health Plan Claim Form Example: Dental Authorization Form for Medical Facility/Inpatient Services SECTION 7 ELECTRONIC CLAIM SUBMISSION Speed eclaim SM Electronic Data Interchange (EDI) Benefits of Submitting Claims Electronically How to Become Eligible to Submit Electronic Claims Submitting Claims Requiring Attachments Reports Functional Acknowledgement Report Claims Acknowledgement Report Healthcare Claim Payment/Advice Report National Provider Identifier (NPI) Example: NPI Questions and Answers Guide SECTION 8 COORDINATION OF BENEFITS Coordination of Medical Assistance (Medicaid) Benefits SECTION 9 PAYMENTS AND REQUESTS FOR INFORMATION Dental Explanation of Benefits (DEOB) How to Read the DEOB

5 Requests for Additional Information Post Service Claims Changing or Combining Reported Procedure Codes Example: Summary Payment Voucher Dental Explanation of Benefits (DEOB) SECTION 10 APPEALS Provider Appeal First Level Provider Appeal Second Level Provider Appeal What May Not be Appealed How to Request a Provider Appeal Member Complaint Process External Complaint Review Expedited Complaint Provider Initiated Member Grievances Provider Responsibilities When Initiating Member Appeals Member Grievances: The First Level Member Grievances: The Second Level Expedited Grievances (Internal) Expedited Grievances (External) External Grievances (Standard) DPW Fair Hearing Example: Gateway Health Plan Consent Form SECTION 11 BENEFIT SAFEGUARDS Health Insurance Portability and Accountability Act (HIPAA) Title VI of the Civil Rights Act of Important Rules and Regulations of the Standards for Electronic Transactions HIPAA Privacy HIPAA Security Utilization Review (UR) Data Collection and Statistical Analysis The Utilization Review Process Professional Consultant Reviews Follow-up Actions Utilization Letters Fraud and Abuse Department of Public Welfare Special Investigations Unit (SIU) Regulatory Compliance Coding and Billing Documentation and Record Keeping

6 Office Standards of Care Recall System Accessibility Continuity and Coordination of Care Members with Primary Care Needs Americans with Disabilities Act Effective Communication Special Needs / Care Management General Information Office Environment Sterilization and Asepsis Control PA Code, Chapter 1101 General Provisions Advanced Directives Recipient Restriction Program SECTION 12 GLOSSARY OF TERMS

7 GATEWAY HEALTH PLAN Welcome to Gateway Health Plan Gateway Health Plan (Gateway) was established in 1992 to provide a managed care option to Medical Assistance recipients in Pennsylvania. United Concordia is pleased that we are able to offer Medical Assistance recipients, who choose Gateway, quality dental care through the support of the SmileNet dental network, starting November The dental benefit package offered through United Concordia includes all Medical Assistance benefits for Gateway members. For members age 21 and over, Gateway offers either a Full or Limited Benefit package, depending upon the member s Medical Assistance benefit category. When providing care for members, please check eligibility prior to each appointment as benefit coverage may change from one package to the other or terminate altogether. Eligibility may be confirmed through My Patients Benefits, our Interactive Voice Response (IVR) System, or by contacting our Dental Customer Service department at Information on eligibility confirmation may be found in Support Services, Section 1. Should Gateway members have questions regarding their general benefits, benefit package, or policies and procedures on grievances, complaints, or Department of Public (DPW) Fair Hearings, please refer the member to the Gateway Member Services Department at Members may also use this number to request a copy of the Gateway Member Handbook. This number is designated for member use only. Information on grievances, complaints and DPW Fair Hearings is also available in Appeals, Section 10. We value your participation in the SmileNet Network. Our experienced staff works hard to make your interactions with us as simple and seamless as possible. And, we continually seek new and innovative offerings to better serve you. We look forward to providing quality service and support to you and your office.

8 About the Dental Reference Guide United Concordia and Gateway realize that the success of our partnership is dependent upon communication and educational processes. The Gateway Dental Reference Guide is designed to provide you and your office staff with information about United Concordia s policies and procedures used to administer dental benefits for Gateway Health Plan members. This document is intended to provide a general guideline for your office, as well as your source for eligibility, coverage, policies, procedures, procedure codes, claims and payments. Familiarity with the concepts, procedures and policies in this manual will ensure proper and efficient administration. If you find anything in this manual which you feel is unclear, please contact your Professional Relations Network Representative at Please retain all updates with your manual.

9 Section 1 SUPPORT SERVICES Communication Sources United Concordia is committed to providing accurate and timely information about the Gateway policies and procedures, to participating dentists. To do this, we use a number of communication channels: Dental Customer Service Representatives Interactive Voice Response (IVR) System My Patients Benefits Dental Reference Guide Dental Advisors Dentist Newsletter Connection Special Mailings Internet web site: Dental Professional Relations Representatives United Concordia maintains a field staff of Dental Professional Relations Representatives who are dedicated exclusively to assist dentists and their staff in understanding the dental programs and products offered by United Concordia. Dental Professional Relations Representatives are available to answer policy questions, provide professional support and furnish information regarding the dental programs, including Gateway. Although these representatives can usually resolve a question or concern by telephone, they also visit dental offices to provide in-person support

10 Dental Customer Service Representatives United Concordia s Dental Customer Service Department consists of approximately 160 Customer Service personnel trained to assist in responding to inquiries about our dental programs and products. To contact Customer Service by , complete the form accessible by clicking on Contact Us at the bottom of the Dentist page of our website, Or you may write to the Dental Customer Service Department at: United Concordia Companies, Inc. Dental Customer Service PO Box Harrisburg, PA When contacting United Concordia, whether by , telephone or letter, the following information is needed: Member s Name Gateway Member s Identification Number Member s Date of Birth Claim or Inquiry Number, if applicable Dentist s Identification Number (United Concordia Provider Number and/or National Practitioner Identifier (NPI)) or MPI- Master Provider Identifier Interactive Voice Response (IVR) System United Concordia s Dental Customer Service IVR System offers dentists and most subscribers access to information stored in United Concordia s records via the telephone and the capability of finalizing prior authorizations for payment. You can choose to listen to the information or in most instances, request the information by fax or mail. The IVR System connects you directly to our databases and gives you access to: Patient eligibility and benefits Claim / prior authorization status information Orthodontic information Procedure History The IVR System is accessible through United Concordia s toll-free Customer Service number at The IVR System is available 24 hours a day, 7 days a week, except when our databases are undergoing scheduled maintenance. Please refer to Automated Services, Section 2 for additional information

11 My Patients Benefits United Concordia provides direct, up-to-the-minute access to member information on our website. With My Patients Benefits, you have on-line access to the following information: Eligibility: Provides membership information including effective dates, types of plans and cancellation dates. Benefits: Gives detailed information on a patient s benefits and limitations. Claim Status: Determines if a claim is still in process or has finalized. If the claim has finalized, the check number, amount, date and payee will be displayed. If a claim is rejected, a rejection description is provided. Procedure History: Allows you to determine specific services that are on record at United Concordia for a particular patient and the dates they were last provided. Procedure Code Information: Gives instant access to procedure code descriptions, valid place of service, tooth related information, radiograph requirements and appropriate benefit categories for coverage. Access our website to register for My Patients Benefits. On-line access to My Patients Benefits using your computer is available 24 hours a day, 7 days a week. Dental Reference Guide The Dental Reference Guide is developed by United Concordia to provide SmileNet Network dental offices with important information concerning Gateway. This guide reviews the relevant policies; provides information concerning participation with United Concordia and establishes the procedures to follow when submitting Prior Authorizations and claims. Dentist Newsletter One of the most important ways we communicate with dentists and their office staff is through our newsletter, the Connection. This newsletter is designed to: Advise dental offices of new dental policies and procedures or changes to existing policies Present guidelines for accurate and timely claims submission Inform dentists and their staff of new benefits and guidelines, and Provide corporate updates The Connection is distributed to all participating dentists through the mail and is also published on our website at

12 Special Mailings In addition to the Connection, United Concordia uses special mailings to inform dental offices of significant changes in coverage, claim payment policies or procedures. Special mailings are used when we want to send information quickly or when the information is too complicated or lengthy to include in the Connection. Internet United Concordia s Internet Website provides detailed information on our customers, Electronic Options, Corporate Information, Automated Services, Press Releases and much more. Mailing Addresses for Claim and Prior Authorization Submissions Gateway Dental Claims...United Concordia Companies, Inc. Claims Processing PO Box Harrisburg, PA Gateway Dental Prior Authorizations...United Concordia Companies, Inc. Prior Authorization PO Box Harrisburg, PA Gateway Orthodontic Prior Authorizations...United Concordia Companies, Inc. Prior Authorization PO Box Harrisburg, PA Gateway Orthodontic Study Models...United Concordia Companies, Inc Deer Path Road Attention: Gateway Claims Harrisburg, PA

13 Mailing Addresses for Inquiries Routine Inquiries and Advisor Review Inquiries...United Concordia Companies, Inc. Dental Customer Service PO Box Harrisburg, PA Dental Electronic Services...United Concordia Companies, Inc. Dental Electronic Services PO Box Harrisburg, PA Dental Advisor Review...United Concordia Companies, Inc. Dental Advisor Review PO Box Harrisburg, PA Change in Provider Information...United Concordia Companies, Inc. Provider Data Management PO Box Harrisburg, PA Refunds...United Concordia Companies, Inc. Cashier PO Box Harrisburg, PA Special Investigations Unit...United Concordia Companies, Inc. Special Investigations Unit 4401 Deer Path Road, DP4F Harrisburg, PA

14 Telephone Numbers Name Telephone Number Hours of Operation United Concordia Dental Customer Service United Concordia Dental Customer Service Fax United Concordia Dental Customer Service (TDD) Dental Advisor Unit Monday Friday 8:00 AM to 8:00 PM, EST Monday Friday 8:00 AM to 8:00 PM, EST Monday Friday 8:00 AM to 4:25 PM, EST Monday Friday 8:00 AM to 4:15 PM, EST Gateway Service Unit Fax hours a day / 7 days a week Changing Provider Information Fax United Concordia Special Investigations Unit Fraud Hotline United Concordia Dental Electronic Services hours a day / 7 days a week hours a day / 7 days a week Gateway Fraud and Abuse Gateway (Member use only) Gateway (Member use only) - TTY Department of Public Welfare Provider Compliance Hotline Monday Friday 8:00 AM to 5:00 PM, EST Monday Friday 8:30 AM to 4:30 PM, EST hours a day / 7 days a week hours a day / 7 days a week DPW-TIPS Monday Friday 8:30 AM to 3:30 PM Helpful Websites United Concordia Companies, Inc.... Gateway... PA Department of Public Welfare... PA Department of Health... Health Resources and Services Admin... Centers for Medicare and Medicaid Services... or

15 Section 2 AUTOMATED SERVICES My Patients Benefits United Concordia provides direct, up-to-the-minute access to member information on our website. My Patients Benefits, a secure and HIPAA compliant feature, offers you online access to the following information: Eligibility: Provides membership information including effective dates, types of plans and cancellation dates. Benefits: Gives detailed information on a patient's benefits and limitations. Claim Status: Determines if a claim is still in process or has finalized. If the claim has finalized, the check number, amount, date, and payee will be displayed. If a claim is rejected, a rejection description is provided. Procedure History: Lets you determine specific services that are on record at United Concordia for a particular patient and the dates they were last provided. Procedure Code Information: Gives instant access to procedure code descriptions, valid place of service, tooth related information, radiograph requirements and appropriate benefit categories for coverage. Access our website to register for My Patients Benefits. On-line access to My Patients Benefits using your computer is available 24 hours a day, 7 days a week. Interactive Voice Response (IVR) System United Concordia's Dental Customer Service IVR System offers dentists and most subscribers access to information stored in United Concordia's records via the telephone and the capability of finalizing prior authorizations for payment. You can choose to listen to the information or in most instances, request the information by fax or mail

16 The IVR System connects you directly to our databases and gives you access to: Patient eligibility and benefits Claim/Prior Authorization status information Orthodontic information Procedure history Procedure allowances The IVR System is accessible through United Concordia s toll-free Customer Service number at The IVR system is available 24 hours a day, 7 days a week, except when our databases are undergoing scheduled maintenance. Provider Check Information Secure access to Provider Check Information is United Concordia s newest online feature. Dentists are able to view check summary, check detail and check related claims for a selected date range online. Registered users of My Patients Benefits or Speed eclaim SM will already have access to this new feature. Identification Cards The Department of Public Welfare (DPW) issues a Pennsylvania ACCESS card to all eligible Medical Assistance recipients, including those recipients that choose to join Gateway. Gateway members will have both a DPW Access card and a Gateway Identification Card. The Gateway member card contains the name, ID number and other enrollee information. You may verify eligibility using information from either of these cards. Because of frequent changes in a member s eligibility, each participating dentist is responsible to verify a member s eligibility through United Concordia using the 8 digit number from the Gateway identification card, as this will inform you of benefit package information. Verifying a member s eligibility will ensure proper reimbursement for services. Members should show their Gateway Identification card at each appointment. For your convenience, following is a copy of the Gateway member Identification card. Front: 2.2

17 Back: Confirm Eligibility Because of frequent changes in a member s eligibility, each participating provider is responsible for verifying a Gateway member s eligibility prior to providing services. You will also want to confirm whether the member has a Full or Limited benefit package. Eligibility should be verified when scheduling an appointment, and again at time of service. Written authorization for specific procedures is not a guarantee of payment, so this step is particularly important. Verifying a member s eligibility will ensure proper reimbursement for services. Eligibility may be confirmed by using My Patients Benefits, our Interactive Voice Response (IVR) System or by calling our Customer Service department at Please refer to Support Services, Section 1 of this manual for important telephone numbers, addresses and hours of operation intended for provider use. DPW Eligibility Verification The Pennsylvania Department of Public Welfare determines member eligibility for dental benefits. If a member presents a Pennsylvania ACCESS card, eligibility may be verified using the Department of Public Welfare Eligibility Verification System (EVS). Practitioners can determine if a member is eligible for services through Gateway. Please have your thirteen-digit Master Provider Index (MPI) Number and the member s recipient number from the member s ACCESS card available. If the recipient is covered by a managed care plan, such as Gateway, their eligibility with the plan is indicated immediately following the member s demographic information (name, date of birth, etc.). Providers must participate with the Medical Assistance Program in order to use the EVS. Member Benefit Packages Changes made in the Pennsylvania Medicaid Assistance program through the Governor s 2005/2006 budget permitted Medicaid Managed Care Plans to implement service limits in effect in the Medicaid FFS program. Gateway Health Plan has implemented service limits for those members with limited benefits

18 Program Exception Members and dentists may request a program exception for services above the limits by submitting a prior authorization request with clinical records to: United Concordia Companies, Inc. Prior Authorization PO Box Harrisburg, PA All program exception requests are reviewed for medical necessity. Any program exception received prior to the service being rendered will receive a response within 48 hours of receipt. Program exception requests received after the service has been rendered will be processed as a Provider Appeal and responded to within 30 days of receipt

19 Section 3 PARTICIPATING WITH SMILENET The SmileNet dental network consists of dentists contracted with United Concordia specifically for the Medical Assistance, Medicare Advantage or other Government Programs. Enrollees may receive dental care from any participating SmileNet dentist of their choice. A licensed dentist, who is not currently excluded, sanctioned or suspended by your licensing authority, is eligible to become a SmileNet participating dentist. Participating dentists agree to accept SmileNet s allowance as payment in full for covered services and submit claims to United Concordia on behalf of Gateway members. Gateway members cannot be balanced billed for any services. Please refer to the SmileNet Participating Dentist Agreement at the end of this section for a complete list of participating dentist obligations. Advantages of Participation Participating dentists are an important part of the SmileNet network. United Concordia is dedicated to fostering a mutually beneficial relationship with participating dentists by offering the following business incentives: 1. All payments for services are mailed directly to participating dentists. 2. Names, addresses, and phone numbers of participating dentists are regularly made available to Gateway members by contacting our Customer Service Department at Participating dentists servicing Gateway members receive United Concordia's quarterly newsletter. 4. Participating dentists servicing Gateway members will receive the Reference Guide and any subsequent updates. 5. Participating dentists benefit from simplified administrative procedures and dedicated provider service

20 6. Participating dentists may be nominated by United Concordia to participate in HONORS (X-Ray Exempt Program). This program recognizes participating dentists who consistently provide cost-effective care to our customers by relaxing the requirement for radiograph submissions and other clinical documentation. 7. Participating dentists benefit from our business relationship with Steri Check Systems to offer sterilization monitoring (spore testing) at a discount rate. This program can be used to monitor steam, chemical vapor, dryheat and ethylene oxide gas sterilizers, includes laboratory culturing service and free shipping and provides a certificate of compliance, sterilizer monitoring log and full documentation. 8. Participating dentists also benefit from our exclusive partnership with SmileCreations Dental Laboratories to offer quality crown and bridge services at specially reduced prices. This program offers special value pricing for quality dental restorations, guaranteed case turnaround in 10 working days, quality workmanship and free case planning, case design and technical support. How to Become a Participating Dentist To be eligible to participate in United Concordia s SmileNet network a dentist must: 1. Be enrolled in Medical Assistance and have an active Master Provider Index ( MPI ) number. 2. Complete a Credentialing Application; (Any negative report on the attestation will be investigated.) (Refer to a sample application at the end of this section) 3. Complete and sign a SmileNet Participating Dentist Agreement with United Concordia; (Refer to a sample agreement at the end of this section) 4. Hold an active, valid license to practice dentistry in the state(s) in which he/she practices; 5. Hold current professional liability insurance; 6. Have no current sanction, termination or other peer review action by a professional review body; state dental board or Health and Human Services (HHS); 7. Hold an active unrestricted federal Drug Enforcement Agency (DEA) certificate, if applicable; 8. Demonstrate a practice pattern within statistically based utilization standards and guidelines. 9. Complete a site assessment evaluation with a United Concordia Professional Relations representative

21 All paperwork and supporting documentation should be forwarded to: United Concordia Companies, Inc. Provider Data Management P.O. Box Harrisburg, PA Fax (717) You will be notified in writing of your assigned provider number and effective date of participation. Confidentiality Through contractual agreements, all providers participating with SmileNet agree to abide by all policies and procedures regarding member confidentiality. Providers must protect and keep confidential members medical and personal information used for any purposes in accordance with the following Laws: - The Mental Health Procedures Act, 50 P.S The Patient Bill of Rights, 28 Pa. Code and 71 P.S Pennsylvania Drug and Alcohol and Abuse Act of 1972, 71 P.S and 42 CFR, Part 2. Pennsylvania Confidentiality of HIV- Related Information Act 35 P.S et. seq. - Health Insurance Portability and Accountability Act of 1996, 45 CFR, Parts 160 and 164. Providers must assure that a member s individually identifiable health information as defined under 45 CFR , also known as Protected Health Information ( PHI ), necessary for treatment, payment or health care operations ( TPO ) is released to United Concordia, including information used for claims payment, continuity and coordination of care, accreditation surveys, medical record audits, treatment, quality assessment and measurement, quality of care issues and disease management. Further, providers will assure that PHI will be made available to the Department of Public Welfare, Department of Health, Department of Insurance, Gateway or Business Associates of Gateway for use without member consent. All other requests for release of or access to PHI will be handled in accordance with Federal and State regulations. Credentialing All dentists, either employed, or in some other manner associated with your office, who treat eligible Gateway members are required to comply with United Concordia s credentialing and recredentialing policies. These policies require that your office undergo a site survey, provide United Concordia with current copies of each participating dentist s dental license, DEA certificate, proof of malpractice insurance, and state controlled substance registration (CDS) certificate (if applicable); and that each dentist complete a brief Recredentialing Application every two years. You must forward all requested documents to United Concordia, within ten (10) business days of the initial request

22 All participating dentists must notify United Concordia immediately of any changes in the status of licensure, DEA or CDS certificates, or malpractice coverage, or if they become involved in a malpractice claim (including cases settled, denied, or sent for peer review). All dentists must be enrolled as a Medical Assistance Provider in Pennsylvania with a current PROMISe Master Provider Index (MPI) Number. All participating dentists and anesthesiologists providing anesthesia services must have appropriate certification and malpractice coverage. You have the right to appeal any decision regarding your participation made by United Concordia based on information received during the credentialing process. To initiate an appeal of a credentialing decision, please send a written request within thirty (30) days of your receipt of the determination to: United Concordia Companies, Inc. Attention: Provider Data Management Manager 4401 Deer Path Road Harrisburg, PA Providers have the right to review information submitted in support of their credentialing application and when appropriate erroneous information may be corrected. Providers also have the right to be informed of the status of their application. Internal Peer Review Your office is required to cooperate with United Concordia s internal peer review, utilization control, and/or external audit systems. You may be asked to participate as a member of United Concordia s Internal Peer Review Committee in order to render peer review determinations. United Concordia agrees to reasonable monetary compensation for your participation. How Individual Provider Identification Numbers Are Established No payment can be made to you for eligible services until you have secured an individual provider identification number. All dentists are assigned an individual provider identification number with United Concordia when the requirements for participation are satisfied, including submission of the SmileNet Credentialing Application and Agreement, a satisfactory site assessment evaluation and your dental license has been validated using the state dental license authority

23 Group Practice The purpose of establishing a group practice is to permit two or more dentists to submit claims and receive payment using one provider number. All payments will then be payable to the group practice and under the group practice tax identification number. The application for both the individual dentist and group account should be submitted concurrently. How to Form a Group Practice To form a group practice, these conditions must be met: 1. The billing entity must be arranged in the following manner: Group Practice - Two or more dentists practicing as a group may establish a group practice to have the group recognized as a single entity for purposes of billing and payment. Examples of typical group practice arrangements are: A. Two or more dentists practicing as a partnership. B. A group of dentists forms a professional corporation and the corporation becomes the employer of the dentists. C. A dentist employs one or more other dentists as associates in his or her practice. 2. All members of a group practice must be participating, enrolled with Medical Assistance, and have an active Master Provider Index ( MPI ) number. 3. To form a participating group, all required paperwork must be completed and submitted for each individual member concurrent with forming the group practice. To establish a group practice, please complete the form Addendum C of the SmileNet Agreement. Refer to a sample of Addendum C at the end of this section. Completed forms should be returned to: United Concordia Companies, Inc. Provider Data Management PO Box Harrisburg, PA Or fax to (717)

24 Changes in Group Practice Membership / New Associates You must notify United Concordia in writing within 30 days of any changes in the group s personnel by completing the Group Account Change Form (5704H). Refer to a sample of Form 5704H at the end of this section. When a new provider joins a participating group practice, the provider should complete an application and agreement, as well as Form 5704H. This notification should occur prior to any treatment being rendered to a Gateway member. When a provider leaves the group, please notify United Concordia of the dentist s new address and current tax identification number (either an Employer Identification Number or Social Security Number, as appropriate) if known. Notifying United Concordia of a member no longer associated with the group will minimize inappropriate claims payment under the group s Tax Identification Number. Maintaining Dentist Data United Concordia maintains a Provider Database, which contains pertinent information on all individual dentists and group accounts who have submitted claims to United Concordia. Your record remains active on the provider database as long as you submit claims to United Concordia or until we receive notification of retirement, death, license suspension/revocation or HHS debarment. It is important that our provider database contains accurate information regarding your practice and group practice. United Concordia urges you to keep your provider information current by reporting any changes in writing. For security reasons, we strongly recommend these changes be verified by the dentist's signature appearing on the letter. Please report changes to any of the items listed below: Dentist Name Practice Name Address (physical location) of Practice Mailing Address (if different from above) Specialty Tax Identification Number Telephone Number Change in Group Practice Open/Closed Office Status Office Hours Handicap Accessibility National Practitioner Identifier (NPI) Master Provider Index (MPI) and Service Location Codes Languages Spoken Keeping United Concordia informed of these changes will ensure timely delivery of checks and mailings

25 Where to Send Notification of Change(s) Send written notification of any changes in your group practice or individual provider information to: United Concordia Companies, Inc. Provider Data Management P.O. Box Harrisburg, PA Fax to (717) How to Resign from Participation To resign from participation with SmileNet, you must send a signed, written statement to the Provider Data Management Department at the previously specified address. You may submit a resignation at any time. Resignations are effective 60 days following the date United Concordia receives your letter. A confirmation letter indicating the effective date of your resignation will be sent to you. When resigning an entire group, please include a resignation letter or signed document with each group member s signature. Gateway Members Rights and Responsibilities Member Rights Gateway Members have the right to: 1. Get information about Gateway, the services Gateway provides, doctors and other health care providers giving you care, and your rights and responsibilities as a Gateway member. 2. Be treated with respect and recognition of dignity and right for privacy when receiving health care. 3. Work with your doctor or other health care providers in making decisions about your health care and to express preferences about future treatment decisions. 4. Openly discuss without any limitations by Gateway appropriate or medically necessary treatment choice for your condition with a doctor or other health care provider, including treatment options, risks of treatment, alternative therapies, and consultations or tests that may be self administered, regardless of the cost or if it is a benefit. 5. Receive your medical and nursing care without regard to marital status, race, color, religion, sex, sexual preference, handicap, age, national origin, whether you have an advance directive or any other basis prohibited by law. 6. Remain free from seclusion used as a means of coercion, discipline, convenience or retaliation. 7. Pick your own doctor from Gateway s network of doctors. 8. Refuse care from certain doctors. 9. File a complaint or grievance about Gateway or the care it provides. 10. Make recommendations regarding Gateway s members rights and responsibilities policies

26 11. Request a fair hearing from the Department of Public Welfare. 12. Prepare a Living Will and/or Advance Directive. 13. See, or have your medical record copied, within Federal and State laws, and to request that your medical record be changed or corrected within Federal laws. 14. Have your medical records kept private and confidential. Your choice to exercise these rights will not adversely affect the way Gateway, its providers or any State agency will treat you. Member Responsibilities Gateway Members have a responsibility to: 1. Give information to your doctor, other health care provider, or Gateway so they can provide care to you. 2. Follow the instructions and treatment plans that you agreed on with your doctor or other health care provider. 3. Provide consent to health care providers and Gateway to help them manage your care, to improve your health or for research. 4. Understand your health problems. As much as you can, take part in making a plan for treatment goals with your doctor or other health care providers. 5. See the doctor you picked on a regular basis. 6. Treat the people giving you medical care with the same respect and kindness you expect for yourself. Self-Referral Gateway members obtain most of their health care services either directly from or upon referral by their Primary Care Physician (PCP), except for services available on a selfreferral basis. Dental services are included as a self-referral service. Therefore, a referral from a Gateway member s PCP is not necessary for the member to seek care from a participating dental provider. Certain oral surgery procedures, such as removal of partial or total bony impacted wisdom teeth or procedures which involve cutting of the jaw are cover by Gateway. Members requiring these services must be referred by their primary care dentist to a participating oral surgeon. The primary care dentist may need to provide x-rays or other information to facilitate the referral. EPSDT Dental Referral DPW requires Primary Care Physicians (PCP) to refer children for a dental risk assessment based on intervals recommended by the American Academy of Pediatrics (AAP), American Dental Association (ADA), and the American Academy of Pediatric Dentistry (AAPD). The PCP will advise the parent or guardian during the EPSDT screening that a dental referral is required and will notify Gateway Health Plan that the child is due for a dental risk assessment. For more information regarding EPSDT dental referrals please contact our Dental Customer Service Department at or access the Medical Assistance Bulletin at the following website

27 ulletinid=4391. Dental Referral Any dentist, participating in the Gateway / SmileNet network, may refer a member to another participating dentist for specialty care services that are covered by Gateway using the following guidelines: The participating dental provider may refer a member to a participating specialist without a written referral. Please provide the member with written or verbal dental care recommendations. If a specialist is not available in a member s area, please contact the United Concordia Dental Customer Service department at Specialty Care Providers It is recommended that a general dentist evaluate a member before scheduling an appointment with a specialty dental care provider. However, if time does not permit a general dental evaluation, such as in the case of an emergency, the member may seek and receive treatment by a dentist specialist. Dental specialty care providers may treat a member without a referral from a general dentist in the case of an emergency. Please contact our Customer Service Department at for a listing of participating specialty dental care providers

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51 Section 4 POLICIES, LIMITATIONS AND EXCLUSIONS Gateway offers its members full or limited dental benefits based upon the member s Medical Assistance eligibility. As in most dental programs, limitations and exclusions are placed on member benefits. The following section will identify the limitations and exclusions for your patients who receive benefits through the Pennsylvania Medical Assistance program, or you may use My Patients Benefits to obtain information specific to Gateway. The policies and limitations listed within this section will be used by United Concordia in administering dental benefits for Gateway. They reflect current and acceptable practices within the dental community while ensuring that cost-effective measures are applied according to the dental contract. Procedures should be reported using the American Dental Association s current dental terminology procedure codes. If a procedure code is not available to report a specific service, a complete description of the procedure provided, including applicable tooth numbers should be reported. Procedures that are an inherent part of another procedure are considered to be integral and not eligible for separate payment. Integral procedures are not billable to the member by a SmileNet dentist or any other dentist who participates in the Pennsylvania Medical Assistance Program. To verify if a procedure is covered under a specific contract, please refer to My Patients Benefits, our Interactive Voice Response (IVR) system or contact Dental Customer Service at Benefits and Exclusions General Policies All covered services are subject to the following general policies: All dental procedures are considered to be outpatient procedures. These procedures are not compensable on an inpatient basis unless there is medical justification which is documented in the patient s medical record. Dentist and Physician are the only provider types eligible to receive payment for dental services

52 Dentist who is a board certified or board eligible orthodontist is the only provider type eligible for payment of orthodontic service. Physician is the only provider type eligible for the anesthesia allowance when provided in a hospital short procedure unit, ambulatory surgical center, emergency room or inpatient hospital. Documentation Required For Specific Services Some covered procedures require the submission of diagnostic materials, such as periodontal charting, radiographs, and/or a brief narrative report of the specific service(s) performed and any factors that may have affected the care provided. Where applicable, these requirements are indicated on the list of covered procedures. If radiographs are required, dentists are requested to submit all radiographs used for diagnosis and treatment planning. It is United Concordia s intent to request only those radiographs that are generally taken as part of diagnosis and treatment planning. If, for some reason, radiographs were not taken or are not available, a brief explanation should be included with the claim. If submitting claims electronically, please provide a brief explanation in the remarks field. Report required means that these services will be paid only in unusual circumstances and documentation of the circumstances must be submitted with the claim. Periodontal charting required means that complete periodontal charting must be submitted for review. Prior Authorization required means that an approved Prior Authorization must be obtained from United Concordia. Radiograph required means that a radiograph must be submitted for review. X = Radiograph Required P = Prior Authorization Required C = Charting Required R = Report Required A = A Pre-treatment periapical radiograph, along with radiographs documenting the presence of an opposing tooth is required. * = Only covered if performed in an in-patient setting or ASC / SPU setting. Prior Authorizations A prior authorization is required for those services for which the Pennsylvania Department of Public Welfare recommends prior authorization, requires prior authorizations and has granted approval to United Concordia to require prior authorization. Prior authorization is required for orthodontics, complete and partial dentures, crowns, surgical extraction(s) or impacted tooth/teeth, and periodontal services (except full mouth debridement which requires post operative review). All dental procedures are considered to be outpatient procedures. These procedures are not compensable on 4.2

53 an inpatient basis unless there is medical justification, which is documented, in the patient s medical record. Prior Authorization required means the practitioner must submit those procedures for approval with clinical documentation supporting necessity before performing those procedures. Please refer to the Policies, Limitations and Exclusions section for prior authorization requirements. For additional information on Prior Authorizations, please see Section 6, Claim Submission Guidelines. If a member is referred to a non-participating provider, it will be the responsibility of the non participating provider to request a prior authorization via the United Concordia Specialized Service Unit before the non participating dentist may render any services. Requesting a Prior Authorization Complete a Gateway or standard ADA claim form and check the box marked Pre- Treatment Estimate. Mail the form to the address below along with any required supplemental information. Your office will receive a Prior Authorization Notification detailing the approved services and the plan payment amounts. Address to mail the prior authorization: United Concordia Companies, Inc. Claims Processing P.O. Box Harrisburg, PA Prior authorizations are subject to the following conditions: 1. Allowances may be reduced by entitlement to other insurance benefits. 2. Total benefit maximums may not be exceeded. Actual dates of service may alter benefits payable. 3. Allowances may vary if plan benefits change prior to treatment. 4. The patient must be eligible for benefits when the services are deemed incurred. An expense is incurred when a service is performed. 5. Allowances may vary based on results of post-treatment clinical review. Once the prior authorization is finalized, United Concordia will notify both the dentist and member within two (2) business days. A prior authorization is not a guarantee of payment but indicates how much would be payable given the information available to United Concordia at the time the determination is processed. When the predetermined services have been provided, use one of the following methods to request payment. Electronic Claims Simply include the claim number printed on the Prior Authorization Notification and Request for Payment Form in the remarks field of your electronic claim request for payment. Telephone Access via the Interactive Voice Response (IVR) System - Begin by calling the toll-free IVR system at The automated system will ask for the date of service (MM/DD/CCYY), along with the following information, which 4.3