Dental Care Services

Transcription

1 SECTION 12

2 Dental Care Services Introduction Denta Quest is delegated for the benefit administration of dental services for The Health Plan AHCCCS Plans (UFC and MHP), Maricopa Care Advantage (MCA) and University Care Advantage (UCA). The Health Plan Special Needs Plans (MCA or UCA) will cover oral exams, cleanings, fluoride treatment, and dental x-rays; benefit limitations.* Denta Quest is responsible for contracting with all dental providers, including clinics, and providing necessary authorizations and utilization management. Additionally, Denta Quest will process all dental claims, conduct some oversight of quality of care and provide all dental network communications and provider education. Denta Quest Claims Address: Denta Quest of AZ-Claims North Corporate Pkwy Mequon, WI To submit claims electronically via eclaims the Payor ID: CX014 Dedicated telephone line: Denta Quest Contact: or Please note: Outpatient and Anesthetic medical prior-authorizations related to dental care will continue to be managed by the Health Plans. Appointment Availability Standards Dental appointments must be available within the standards mandated by AHCCCS, Medicare and community standard. The dental provider is responsible for making office appointments available based on the dental needs of the member. Appointment standards also include inoffice waiting time parameters (45 minutes). The Health Plan monitors compliance with these standards as follows: DENTAL CARE SERVICES 12.0

3 Adult and Children Emergency dental appointments within 24 hours of referral Adult and Children Urgent dental appointments within three (3) days of referral Children under 21 Years of Age Routine dental appointments within forty-five (45) days of referral Members who request routine dental services are to be scheduled within 45 days of the request. *Benefit amounts are subject to change. Please contact the plan for current benefit coverage. Children s Dental Services AHCCCS members through the age of 20 years receive comprehensive health care including medical, dental and vision services through a Federally mandated program called EPSDT (Early Periodic Screening Diagnosis and Treatment). The goal of the EPSDT program is to encourage primary prevention, early intervention, diagnosis and medically necessary treatment of physical or intellectual disability. EPSDT dictates the frequency, or periodicity, of the required screening. Dental screening is to be scheduled at least once in a 12-month period (see Periodicity Schedule at end of chapter). All AHCCCS members through the age of 20 tears will be assigned to a Primary Dental Provider for their dental care. A Primary Dental Provider is also known as a Dental Home. Coordination with Children s Rehabilitative Services The Children s Rehabilitative Services (CRS) Program is administered by the Arizona Department of Health Services. CRS provides rehabilitative medical care to enrolled individuals with handicapping or potentially handicapping conditions that have the potential for functional improvement. All AHCCCS Plans are required by State statute to refer members who meet CRS eligibility criteria to CRS for care. Dental Services at CRS are limited to individuals enrolled in CRS for the following conditions: Cleft lip/cleft palate Significant functional malocclusion VP shunt Cardiac conditions, which place the individual at risk for septic bacterial endocarditis. Treatment related problems for seizure disorders such as dilantin hyperplasia DENTAL CARE SERVICES 12.1

4 Orthodontic services at CRS are limited to individuals enrolled in CRS for the following conditions: Significant Functional Malocclusion If a Health Plan AHCCCS member presents in a dental office with the above conditions, they may be CRS eligible. To verify CRS eligibility, dental providers should contact the Customer Care Center at (800) If a member is CRS enrolled or CRS eligible, the Health Plan will refer the member to a CRS dental provider. Summary of Covered and Excluded Dental Services As an AHCCCS contracted health plan, covered services are mandated by Federal and State law for AHCCCS members. Depending upon the member s plan, all therapeutic dental services will be covered when they are considered medically necessary and cost effective but may be subject to prior authorization by UFC or MHP, or AHCCCS Division of Fee-for-Service Management for FFS members. Covered Services for Children Although the AHCCCS Dental Periodicity Schedule identifies when routine referrals begin, the PCP may refer EPSDT members for a dental assessment at an earlier age if oral health screening reveals potential carious lesions or other conditions requiring assessment and/or treatment by a dental professional. In addition to PCP referrals, EPSDT members are allowed self-referral to a dentist who is included in the Health Plan provider network. AHCCCS members 0 through 20 years of age (UFC or MHP) Non-Covered Services for Children 1. Services determined to be experimental or provided for the purpose of research 2. Services or items furnished solely for cosmetic purposes 3. Any new service or procedure started before the member ceased to be enrolled with a AHCCCS plan (MHP or UFC). Adult Dental Services for AHCCCS Members Dental coverage for AHCCCS members 21 years and older is limited to the following: Emergency dental services DENTAL CARE SERVICES 12.2

5 Pre-transplant dental services Emergency Dental Services AHCCCS will cover emergency dental services for infection in mouth, or pain in tooth, or jaw for members 21 years and older. The service must be related to a treatment of a medical condition. Pre-Transplant Dental Services Dental diagnosis and elimination of oral infection prior to transplantation of organs or tissue is a covered service only after the member has been established as an appropriate candidate for transplantation. Non-Covered Services for Adults 1. All services not directly related to acute emergency or pre-transplant 2. Medically necessary dentures are no longer a covered benefit for adults 3. Any new service or procedure started before the member became ineligible with an AHCCCS plan. (Procedures involving those teeth upon which treatment has been started but not yet completed at the time eligibility is lost, must be completed by the Subcontractor). DENTAL CARE SERVICES 12.3