Dental Dispatch. Dental Provider Resources Available on our Website

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1 Dental Dispatch FALL 2014 I Vol.3 Dental Provider Resources Available on our Website Empire has important information available online that assists our providers in obtaining information regarding contract updates, Health Care Reform, claims filing and more! Fee Adjustment Notifications Annual CDT Updates Healthcare Reform Updates Where can you find this information? Please visit our dental provider resources page at

2 Health Care Reform Dental 2015 Pediatric Dental Essential Health Benefits What are Pediatric Dental Essential Health Benefits? Starting January 1, 2014, all non-grandfathered, individual and small group health benefit plans must, by law, cover 10 Essential Health Benefits (EHBs) to be considered a Qualified Health Plan (QHP) under the Affordable Care Act (ACA). EHBs are included in all of Empire s new individual and small group health benefit plans. The Pediatric Dental EHB provides important dental coverage for children to keep their teeth and gums healthy. The Plan will be compliant with all age and eligibility requirements as determined by law in the state where the dental product is offered. Pediatric Dental EHBs for children cover diagnostic and preventive, basic and major services, periodontal and oral surgery, and other services like medically necessary orthodontia. Pediatric Dental EHBs for children have no annual maximum when children are seen by in-network dentists. There will be a member out-of-pocket maximum when members see in-network dentists. This change is required as part of the Affordable Care Act. Member out-of-pocket maximums Effective January 1, 2015, stand-alone dental plans covering the pediatric dental EHB will have a lowered out of pocket maximum. For one child, the out of pocket maximum will be $350 and for two or more children $700. What does this mean? This means once your pediatric patient has reached their out-of-pocket maximum, the Pediatric Dental Essential Health plan will cover 100% of allowed amount for Pediatric Dental EHB services. Is everyone required to have Pediatric Dental Essential Health Benefits - and pay for them? Yes, it s the law for all non-grandfathered, individual and small group health plans to have all 10 Essential Health Benefits. Pediatric dental is one of those Essential Health Benefits. Has the process or contact information changed for getting benefit, eligibility and claim information regarding the Pediatric Dental EHB? No, you will still want to refer to the member s ID card(s) for the most accurate contact and claims information. Please keep the Dental Provider Quick Guide that is included with this communication to assist in directing you to the appropriate customer service, grievance and appeals, web information available. For questions on limitations and exclusions for a member who is covered on the Pediatric Dental EHBs, please contact customer service or refer to the member s Summary of Benefits and Coverage if the member has it available with them. Do all medical and dental embedded products have in and out of network benefits? No, our embedded dental products will match the in and out of network benefit structure of medical. If the medical product which the member has allows in-network benefits only, then dental will also have in-network dental benefits only. If the medical product has in and out of network benefits, the embedded dental will also have in and out of network benefits. How do I find out if my dental office will be accepting these members who have the Pediatric Dental EHB as in-network? Our goal in this process was to try to simplify the complexities of the new environment with the Exchange/Marketplace. We decided to modify and use our commercial dental program line and existing network(s) structure to administer these benefits. The following states will be selling the Pediatric Dental EHB as either Dental Prime or Dental Complete. For your dental office to see these members as in-network you will need to be participating with 100 and/or 200 and/or 300 networks depending on the state. California, Colorado, Connecticut, Georgia, Indiana, Kentucky, Missouri, Nevada, New York, Ohio, Virginia, and Wisconsin Pediatric Dental EHB product will be offered as Dental Prime Maine and New Hampshire Pediatric Dental EHB product will be offered as Dental Complete For those of you who are already participating with Dental Prime and Dental Complete, these new products will use the same reimbursement schedules you have today with our existing commercial business. If you have any questions or are interested in contracting and participating with the exchange dental products, feel free to contact the Professional Dental Network Services Department at FALL 2014 Page 2

3 How to Complete a W9 Form A Tax Identification Number (TIN) is registered with the Internal Revenue Service (IRS) under the name of the person or the corporation of the dental practice. This name can be known as: The business entity Legal name IRS name Misrouted PHI Providers and Facilities are required to review all member information received from Empire to ensure no misrouted PHI (Protected Health Information) is included. Misrouted PHI includes information about members that a Provider or Facility is not currently treating. PHI can be misrouted to Providers and Facilities by mail, fax, , or electronic remittance. Providers and Facilities are required to immediately destroy any misrouted PHI or safeguard the PHI for as long as it is retained. In no event are Providers or Facilities permitted to misuse or re-disclose misrouted PHI. If Providers or Facilities cannot destroy or safeguard misrouted PHI, Providers and Facilities must contact Customer Service or call the number listed on the documentation received to report receipt of misrouted PHI. There can be only one IRS name per TIN, even if multiple dentists are working under the same TIN. All information listed on the W-9 form must match what has been filed with the IRS. Information listed on claims must match what is listed on the W-9 form. If the W-9 form does not match what was filed with the IRS, there may be issues with your 1099 at the end of the year. If the information submitted on claims does not match the W-9 form, there may be claim issues. (e.g. claims may process as non-participating and the payments may go to the member rather than the dental office.) * Be sure the form is signed and dated. The date on the form should be within the last 12 months. FALL 2014 Page 3

4 Credentialing Update Empire has a formalized credentialing/recredentialing process through which we objectively evaluate dentists against established standards. Credentialing/recredentialing will take place every three years. Some helpful tips to ensure a smooth credentialing process: 1.Complete all required sections on the application and ensure all information appears exactly as it does on other documents that may be cross referenced (e.g., full name, exact graduation date, etc.) 4.Use the enclosed postage paid envelopes to send the application and supporting documents. 5. Write legibly. If you have questions regarding a request received for additional credentialing/recredentialing information, please contact us at Include current copies of supporting documents, such as professional liability insurance declaration page, license, Federal Drug Enforcement Agency (DEA) Registration, etc. 3.Review disclosure questions carefully and provide any additional explanation as appropriate. How to Prevent HIPAA Privacy Incidents by Accurately Submitting Claims Did you know that an error in claims submission can easily lead to a HIPAA privacy incident? Submitting claims accurately protects your patient s information and ensures timely payment. We recommend following the guidelines listed below. Review the patient s ID card during every visit so that claims are submitted to the active carrier with correct subscriber ID. Even if a patient reports no change in coverage, important information on the ID card may have changed. Fill out all fields on the claim form, and check against the following list for completion and accuracy: State-Issued treating dentist dental license number (in the same format shown on your license) and billing tax payer identification number (billing TIN) Patient's date of birth Patient's relationship to member Member's date of birth Member s identification number, exactly as shown on the ID Card Member s or patient's authorization signature Fee for treatment with valid CDT code Treatment date(s) Tooth number, surface and quadrant, if applicable Treating dentist's signature Treating Dentist's Individual Type 1 National Provider Identifier (NPI) Number (required) Type 2 National Provider Identifier (NPI) Number (if applicable) FALL 2014 Page 4

5 Submitting Paper Claims To ensure timely claims payment, you may use the following checklist as a tool for submitting paper claims. Please check the information you are providing for completeness and accuracy. State-issued Dentist License Number as provided on your paper copy provided by the State Dental Board Tax Identification Number (TIN) Providers Individual Type 1 National Provider Identifier (NPI) Number Patient s birth date Patient s relationship to the member Member s birth date Member s/patient s signature Current ADA procedure code(s) Fee for treatment Treatment date(s) Tooth number, surface, and quadrant if applicable Dentist s signature Other Coverage (Yes or No)? If Yes, include additional information regarding other carrier Information regarding whether this is an initial placement of prosthesis. If No, then date of prior placement Member s social security number (SSN) or identification number Submitting Electronic Claims It is important to submit complete and accurate provider information to ensure claim messages and payments are directed to the correct provider. Send the Servicing/Treating Provider s Type 1 National Provider Identifier (NPI). The clinic or corporate NPI may be included, but the treating provider s NPI is needed Claims submitted without a valid NPI may be rejected Send the Servicing/Treating provider s full license number as it is shown on their paper copy state-issued dental license Include Servicing/Treating Provider TIN Servicing/Treating Provider Name Billing Address - where the payment should be mailed FALL 2014 Page 5

6 Meet Your Dental Professional Services Team items related to network participation, contract terms and reimbursement questions. Our goal is to assist you with any questions you may have regarding network participation, adding or changing a location and adding a dentist to your practice. If you have additional questions, you may contact us at (866) Experience and skills that make up our nationwide Dental Professional Services Team: The management team (shown above) leads our Professional Services associates who serve our dental offices around the country. Ken Kramer, Jenny McMorrow, Neil Goldberg and Jacquie Baker have an average of 18 years of dental/health care experience. Our Dental Professional Services Team is dedicated to providing the highest level of service to our nationwide community of dentists. The staff is available to assist with We have 38 associates dedicated to servicing our dental community nationwide. Our associates are dedicated to your region and are available to answer your questions. Our team has an average of 15 years of experience in the dental/health care industry (claims, networks, recruiting, customer service, dental office experience, etc). Dentist Update Corner Check here for state specific information, updates & notifications CDT 2015 code changes This serves as notification by Empire that CDT 15 updates are posted on our website. To view the CDT 15 updates and continued annual updates, please visit us at If you do not have access to the Internet, have questions, or would like to request a full listing of the claims processing guidelines, please call Network Professional Services at Be sure to reference frequently for other upcoming changes. FALL 2014 Page 6

7 Please detach and use for office reference Dental Provider Quick Guide If you re trying to obtain information about For Prime and Complete All Other Dental Products Paper Claims Address Electronic Claims Web Claims Submission/Status Web Eligibility Lookup Empire Blue Cross Attn: Dental Claims P.O. Box 810 Minneapolis, MN Follow current process or contact your clearinghouse Please review the back of the member's ID card to determine the appropriate dental claims mailing address. (Address varies by group.) In the absence of an address, call the number on back of the ID card for instructions on where to submit the claim. If the above does not apply, the default address is: P.O. Box 791 Minneapolis, MN Follow current process or contact your clearinghouse Customer Service #s See back of patient s ID card (800) Grievance/Appeals Dental Claims Appeals & Grievances P.O. Box 551 Minneapolis, MN Appeals - First Level Appeal Review P.O. Box 551 Minneapolis, MN Professional Services (866) (866) Credentialing (866) , ext (866) , ext Where to Send Paper Claims Please review the back of the member s ID card to determine the appropriate dental claims mailing address. (The address varies by group.) In the absence of an address, please call the number on the back of the ID card for instructions on where to submit the claim. If the above does not apply, the default address is: For Prime and Complete For all other dental products Empire Blue P.O. Box Attn: Dental Claims San Antonio, TX P.O. Box Minneapolis, MN Please note: The Oxnard, CA mailing address is no longer available. All mail sent to this address will be returned. FALL 2014 Page 7

8 Dental Dispatch FALL 2014 I Vol.3 Dr. K s Corner Dr. George Koumaras, National Dental Director, has a wealth of clinical and insurance expertise, including network development, contracting and provider relations, clinical policy development and fraud and abuse. Dr. K s Corner will be a recurring section in our newsletter in which clinical information will be placed that is relevant to dentists and office staff. Hints for submitting fixed prosthetic claims Submitting the appropriate documentation for fixed prosthetics claims can speed up the turn-around time of claims processing. The documentation should address whether the planned fixed bridge is the initial placement or a replacement of an existing prosthetic. Stating the bridge is the initial placement indicates the abutments and pontic(s) will be the first prosthetic used to replace the missing teeth in that area. On the other hand, if the bridge is not the initial placement, include the prior placement date of the existing appliance. The claim form has a specific section to document this information. Benefits for fixed bridges cannot be determined in isolation but involve an evaluation of the entire dental arch. Ideally, submit full arch X-rays and periodontal pocket probings to allow evaluation the other sextants or quadrants. If the office routinely exposes posterior bitewings and periapical X-rays of anterior teeth, make sure to include periapical X-rays of the proposed bridge abutments. In situations where you know one or more of the units of the bridge will be excluded based on prior placement date limitations and exclusions, include a narrative justifying the need for crowns/abutments on other abutments or pontics. HLD forms To qualify for medically necessary orthodontic treatment, a validated, recognized index criteria will be used to determine dental/medical necessity. Medically necessary orthodontic procedures are a benefit only when the diagnostic casts verify a minimum score of 26 points on the Handicapping Labio-Lingual Deviation (HLD) Index, or is one of the five automatic qualifying conditions. You can find a copy of the HLD form on our website at under the Forms section. Services provided by Empire HealthChoice Assurance, Inc., a licensee of the Blue Cross and Blue Shield Association, an association of independent Blue Cross and Blue Shield plans. EMPIREBCBS.13.14NY