Massachusetts League of Community Health Centers Meeting

AGENDA  MassHealth Team Introduction  MassHealth Updates 

Third Party Liability Claims

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Electronic Initiatives

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Dentures

 MassHealth Claim Denials 

Top Five Reasons / How to Avoid Denials

 Health Safety Net Denials (HSN)  Ordering and Referring  Outreach 

Age One

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Fluoride in a Medical Setting

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Sealant Program

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Introducing the MassHealth Team DentaQuest

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DentaQuest Provider Relations Marianne Leahy – Vice President, Network Management Phone: 617-886-1206 E-mail: [email protected]

Keishia Lopez – Provider Relations Rep. (Boston and Southern MA) Phone: 617-886-1727 E-mail: [email protected]

Daniel Archambault – Provider Relations Rep. (Northern MA) Phone: E-mail:

617-886-1736 [email protected]

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DentaQuest Boston MassHealth Contacts Tracy Chase – Contract Director Phone: E-mail:

617-886-1310 [email protected]

Arielis De LaRosa – Member Intervention Specialist Phone: E-mail:

617-886-1726 [email protected]

Felicia Moses – Intervention Specialist Phone: E-mail:

617-886-1725 [email protected]

Megan Mackin – Statewide Outreach Coordinator Phone: E-mail:

617-886-1728 [email protected]

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Third Party Liability Claims  As of May 1st 2015 all TPL claims must be submitted electronically  MassHealth is ALWAYS the payor of the last resort (Except HSN)  All TPL claims MUST have a primary EOB attached or a termination letter to prevent a claim DENIAL  All dates of service and procedure codes from the primary EOB MUST MATCH the claim being submitted to MassHealth

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MassHealth Electronic Initiatives 

MassHealth Requires • All Providers to be enrolled in Direct Deposit • To submit claims electronically

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Eligibility Tools Available: • 24 Hour Provider Web Portal (www.masshealth-dental.net) • 24 Hour IVR Phone System (800-207-5019)

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Denture Coverage Restoration- Adults 

Effective: May 15, 2015

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Codes Covered:  D5110-D5731  Dentures, Partials & All Associated Codes

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Benefit Change Notification

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Top Five CHC Claim Denials Service is not covered Check Office Reference Manual for Covered Service Subscriber is not eligible for services under this plan Check Member Eligibility on date of service This procedure has been submitted after the timely filing limit MassHealth allows 90 days from date of service to submit claims The patient was covered on the date(s) of service by another company which is the carrier Submit MassHealth Claim with Primary Insurance EOB Encounter rates are payable only when submitted with the encounter code with corresponding fee and at least one valid dental procedure D9450 must be submitted with a payable MassHealth Code

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Health Safety Net (HSN)Denials 

Do NOT mark “YES” for other insurance when submitting a claim to MassHealth or the claim will deny systematically looking for the Primary EOB

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HSN is always secondary

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Ordering, Referring & Prescribing Provider Requirements

Ordering and Referring Requirements 

Background:

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ACA Section 6401(b) States must require: • All ordering or referring physicians and other professionals be enrolled under the State [Medicaid] Plan….as a participating provider; and • The NPI of any ordering or referring physician or other professional…be specified on any claim for payment that is based on an order or referrals of the physician or other professional. These requirements were effective March 25, 2011. Final Rule (42 CFR 455.410(b) and 42 CFR 455.440) was published in the Federal Register on Feb. 2, 2011. Subregulatory guidance was given to states on December 23, 2011. MassHealth is currently on track to partially implement by September 1, 2015.

Ordering and Referring Requirements 

Providers that may order, refer or prescribe services for MassHealth members will need to enroll with MassHealth at least as Ordering, Referring, Prescribing (O/R/P) non-billing providers • Physicians * (including interns and residents +) • Dentists * • Podiatrist * • Optometrist * • Nurse Practitioner * • Certified Nurse Midwife * • Clinical Psychologist +

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State law (Chapter 118 of the Acts of 2012) will require that these provider types must apply to enroll with MassHealth for at least the purposes of O/R/P in order to obtain and maintain state licensure. This law will go into effect upon promulgation of MassHealth enrollment regulations, scheduled for [spring]/summer/fall of 2015. + The Supplemental Budget filed on February 27, 2015 adds the same requirement for these provider types

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Ordering and Referring Requirements •

O/R/P providers will not be required to provide services to MassHealth members

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MassHealth is finalizing a “streamlined” enrollment process for “O/R/P non-billing only” providers

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MassHealth is crafting an outreach strategy to providers currently not participating in MassHealth to inform them of this requirement

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We are on track to begin O/R/P enrollment in within the next few months and are coordinating with the boards of registration on the licensure requirements

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The state law also requires that providers must apply to enroll with MassHealth for at least the purposes of O/R/P to be included in private insurance provider networks so we will also be coordinating with the Division of Insurance on enforcement of that requirement

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Ordering and Referring Requirements List of services that must be ordered, referred or prescribed: •

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Any service that requires a PCC referral Medications Psychological Testing Therapy (PT, OT, ST) DME and Oxygen/Respiratory Equipment Prosthetics and Orthotics

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Labs and Diagnostic Tests Eyeglasses Hearing Aids Personal Care Home Health Independent Nurse Adult Foster Care Adult Day Health

Ordering and Referring Requirements •

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Claims from these provider types for the services listed slide 5 will be subject to the O&R requirements starting with dates of service on or after 9/1/15: Psychologist (05) Therapist (07) Volume Purchaser (31) Pharmacy (40) DME (41) Oxygen and Respiratory (42) Prosthetic (43) Hearing Instrument Dispenser (44), hearing aid claims only Diagnostic Testing Facility (45) Certified Independent Lab (46) Orthotic (47)

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Audiologist (50), hearing aid claims only Personal Care Attendant (58) PCA Agency (59) Home Health (60) Independent Nurse (61) Adult Foster Care and Group Adult Foster Care (62) Adult Day Health (63), except for transportation claims Group Practices (97), for Psychological testing and Therapy services only

Ordering and Referring Requirements •

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MassHealth is on track to start denying claims that don’t meet the Ordering and Referring requirements for dates of service on or after September 1, 2015. • The O/R/P provider’s NPI must be included on the claim • The O/R/P provider must be one of the provider types identified • The O/R/P provider must be enrolled with MassHealth, at least as a non-billing O/R/P provider MassHealth is preparing guidance for billing providers, that includes information about ordering and referring providers as well as other non-billing providers whose NPI may be included on MassHealth claims (e.g., to comply with HIPAA Version 5010).

MassHealth Outreach

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Age One Dental Visits 

The American Dental Association used to recommend that dentists start seeing children beginning at age 3. Those guidelines, however, have changed. The American Academy of Pediatric Dentistry (AAPD), the ADA, and the American Academy of Pediatrics all now recommend a dental visit for children by age one or the eruption of their 1st tooth.

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To access MassHealth coverage information, please refer to the MassHealth Office Reference Manual located on the MassHealth web portal at www.masshealth-dental.net. A list of covered dental codes and service limitations for members under 21 is available in Exhibit A.

1. American Academy of Pediatric Dentistry, Get It Done in Year One, http://www.aapd.org/assets/2/7/GetItDoneInYearOne.pdf, July 2010.

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Office Reference Manual : Exhibit A : March 25, 2015 Procedure Code

Description of Services

D0145

Oral Evaluation Under 3 Years of Age

D1120

D1206

D1208

Prophylaxis- Child

Topical Fluoride Varnish

Topical application of fluoride-Under 21

Age Limits

0-3

0-13

0-20

0-20

Teeth

N/A

N/A

N/A

N/A

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Prior Authorization Required

Benefit Limitation

No

Two of (D0120, D0145) per 1 Calendar year(s) Per Provider or Location.

No

Two of (D1110, D1120) per 1 Calendar year(s) Per patient. Includes minor scaling procedures.

No

One of (D1206, D1208) per 90 Day(s) Per Provider OR Location. Cannot be billed with D1208 on same date of service by the same provider or location.

No

One of (D1206, D1208) per 90 Day(s) Per Provider OR Location. Cannot be billed with D1206 on same date of service by the same provider or location.

Fluoride Varnish in a Medical Setting   

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Children up to age 3 usually see a primary care provider more than eleven times for well-child care before their first visit to a dentist. Yet early intervention is so important to the prevention of dental disease. Primary care providers are in a unique position to identify existing problems, assess the risk of future problems, and provide guidance to parents. Our goal is to increase the number of medical practices providing fluoride varnish services and promoting oral health when treating MassHealth Under 21 members.

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New Medical Providers and CHC’s

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A Sealant Program™ for Dentists-MassHealth Network

Claims Analysis  DentaQuest will analyze claims data for a specific time period to determine the number of members with sealant who visited that dentist Measurements  We will measure the percentage of these members who received sealants on their first molars (ages 6 - 9) and second molars (ages 10 14) Provider education & training  Participating dentists will be provided program information, resource toolkit, patient report and set thresholds

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Prevention Focus Program

POSTER

BROCHURE

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The Numbers Are In!  Sealant Program First Results - September 2014-February 2014  Members who were included on the list to providers: 76,724  Members who received a sealant after the mailing: 10,087 or 13%

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Some Helpful Hints & Resources

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Helpful Internet Links and Resources 

Provider Web Portal – Check eligibility, submit authorizations & claims https://masshealth-dental.net

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Vendor Web – Use this to check on payment status https://massfinance.state.ma.us/VendorWeb/vendor.asp

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NPPES – Use to obtain, verify, and update NPI information https://nppes.cms.hhs.gov/NPPES/Welcome.do

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Regulations Updates – Sign up to get notified of any changes in the regulations mailto:[email protected]

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IVR/Call Center - (800)-207-5019 available 24 hours a day

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Questions & Answers

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