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Dental Details A Z Indian Health Provider Training 2012 Agenda - - PowerPoint PPT Presentation
Dental Details A Z Indian Health Provider Training 2012 Agenda - - PowerPoint PPT Presentation
Dental Details A Z Indian Health Provider Training 2012 Agenda Meet the Dental Prior Authorization Team Dental Statistics Policy Orthodontic Referrals Dental Prior Authorization Team Dr. Leon Bragg Chief Dental
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Dental Prior Authorization Team
Dr. Leon Bragg – Chief Dental Officer Dr. Richard Gilman – Orthodontic Consultant Tracy Matthews – Dental Programs Coordinator Dana Shepard – Dental Analyst II, Orthodontics Sara Gillum – Dental Analyst II, General Dental Wendy Payne – Dental Analyst II, General Dental Linda Taylor – Administrative Assistant II,
Orthodontics
Lisa Jack– Administrative Assistant I, General Dental
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Did You Know?
Approximately how many members does
SoonerCare serve?
– 266,363 Adults – 498,352 Children
How many participating dental providers in
SoonerCare?
– 1,015
How many Prior Authorizations were processed for
2011?
– 43,417
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Dental Policy WWW.OKHCA.ORG Chapter 30, Subchapter 5, Part 79
Dental Specific Encounters Policy WWW.OKHCA.ORG
Chapter 30, Subchapter 5, Part 110
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Dental Coverage for Adults
Emergency Extractions
– Legislative intent allows for removal of teeth for
relief of pain and infection.
Smoking & Tobacco Use Cessation
Counseling
Medical Surgical Services may be allowable
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Dental Coverage for Special Adult Populations
Adults residing in Intermediate Care Facilities
for the Mentally Retarded (ICF/MR); receive services similar to children
DDSD Waiver Services; all must be prior
authorized through DDSD; requires a special contract
Pregnant women may have additional limited
services; must be enrolled in Perinatal Dental Access Program (PDEN)
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PDEN Covered Codes
In addition to dental services covered for adults, other services available include:
D0120, D0150
D0220, D0230
D0272, D0274
D1110, D1204,
D2140, D2150, D2160, D2161
D2330, D2331, D2332, D2335
D2391
D4341, D4342
D9230
**Prior authorization is NOT required for this program**
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Policy Basics
Comprehensive Oral Evaluation Periodic Oral Evaluation Emergency/Limited Oral Evaluation X-Rays Dental Sealants Stainless Steel Crowns Pulpotomy or Pulpectomy Anterior Root Canals Interim Partial Dentures
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Policy Basics
The need for prior authorization is rare for
your facilities, however……..
All reimbursable dental services provided
during an encounter must follow the guidelines of OHCA policy.
Dental records are subject to post payment
review to determine alignment with OHCA policy.
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Dental Specific Encounters Policy
317:30-5-1098(B) “OHCA will cover one
dental encounter per member per day regardless of how many procedures are done or how many providers are seen UNLESS……
…..if due to an emergency, the same
member returns on the same day for a second visit and has a different diagnosis. Then, a second encounter is allowed.”
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Dental Encounter Claims
Dental encounter claims are to be filed on
the UB04 claim form
Revenue code 512
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Prior Authorization
Send all Prior Authorization requests directly
to the Dental Unit; electronic submissions are not available at this time
– OHCA – Dental Unit
2401 NW 23rd St., Suite 1-A Oklahoma City, OK 73107
All prior authorization requests are filed on
the currently approved ADA form
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Orthodontic Services
Eligibility for SoonerCare Orthodontic Services
Member must have a referral from a primary
care Dentist (Form DEN-2)
Score a minimum of 30 on the HLD Be under the age of 18 See policy for further restrictions
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Secure Site
How to obtain Dental History
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The Dental Inquiry can be found here or under the Claims link at the top.
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Enter the Member ID Enter Procedure Code if checking for Specific Code
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