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Medicaid Electronic Health Records Incentive Program: PHCP: Anthony R. Pennacchio, B.S.D.H., MBA, Program Manager, Bureau of Dental Health (518) 474-1961, Fax (518) 474-8985 email. MetroPlusHealth members can access the Member Portal, find doctors, specialists, and pharmacies, and view member benefits. When reviewing requests for services the following general guidelines are used: Treatment will often not be approved when functional replacement with less costly restorative materials, including prosthetic replacement, is possible. Provide the highest level of healthcare in New York and save up to 20% with our narrow network. This means that every time you visit this website you will need to enable or disable cookies again. The Dental Fee Schedule became effective on 3/1/2009. Whether you have a medical appointment near your home or across town, MetroPlusHealthwants to ensure you get the care you need when you need it without the stress of getting there. View up-to-date payment information. Dr. Deborah Simmers is a graduate of the East Carolina University (ECU) School of Dental Medicine and is a member of the American Dental Association, North Carolina Dental Society, and Old North State Dental Society. Here are some good practices to follow to ensure proper oral hygiene: Child Health Plus cover routine, preventive and emergency dental services through DentaQuest. For Medicaid recipients who meet certain income, resource, age, or disability requirements. To choose a Primary Care Dentist (PCD) or if you need help finding a dentist in your area, call DentaQuest at 844-284-8819. All bills submitted using CDT code D9999 should be accompanied by a report providing the reasons why such procedures are necessary. 122 Fulton St, 2nd Floor, New York, NY 10038 4.71 65 verified reviews At Nassau Street Dental, our practice strives to achieve excellence in all aspects of dentistry especially cosmetic and our goal is to perfect your smile. Your participation in both networks may prove beneficial to your practice. Medicare members can call us 24/7 at1.866.986.0356(TTY: 711). Claims must be submitted when the product or service is completed and delivered to the recipient with the appropriate procedure code using the date that the service was actually completed and delivered as the date of service. The dental provider must have a valid NYS dental license. Requests will be reviewed for necessity based upon the presence/absence of eight points of natural or prosthetic occlusal contact in the mouth (bicuspid/molar contact). Prior approval requests for implants must have supporting documentation from the patients physician and dentist. All bills submitted using CDT code D9999 should be accompanied by a report providing the reasons why such procedures are necessary. Consequently, she could only use the left side of her mouth to eat. Where the insurer has failed to pay a claim or make reasonable request for additional information within fortyfive calendar days, the insurer is deemed to have waived any objection to liability for the claim and shall pay the claim. Our four dental networks consist of over 8,000 dentists and dental specialists practicing in New York and New Jersey. Dental services for the state's poor moved into managed care on July 1. Theyalso want to speak with Medicaid-eligible individuals who require any other dental treatments that are not covered by Medicaid including root canals, immediate dentures, osseous surgery. As a condition for payment, it may be necessary to submit, upon request, radiographic images and other information to support the appropriateness and necessity of these restorations. *1 J "6DTpDQ2(C"QDqpIdy~kg} LX Xg` l pBF|l *? Y"1 P\8=W%O4M0J"Y2Vs,[|e92se'9`2&ctI@o|N6 (.sSdl-c(2-y H_/XZ.$&\SM07#1Yr fYym";8980m-m(]v^DW~ emi ]P`/ u}q|^R,g+\Kk)/C_|Rax8t1C^7nfzDpu$/EDL L[B@X! If you are turning 65 within the next 3 months or you are 65 years of age or older, you may be entitled to additional medical benefits through the Medicare program. See Dental Policy and Procedure Code Manual, page 24. MetroPlus Health Plan Learn how to use this new tool (and more) by attending one of our scheduled WebEx trainings. How will I be reimbursed for procedures included under CPT but not CDT codes? Any dental billing forms with the appropriate code and fee as found in this dental fee schedule can be used. Low-cost plans for daycare workers in New York City. The rules and limitations for different dental services are included in the policy manual. A letter from the patients physician must explain how implants will alleviate the patients medical condition. Under this program, children can receive periodic oral evaluations and preventive, restorative, and emergency dental care. One of our representatives will reach out to you ASAP to review your plan options. How would I charge for procedures not listed on the dental fee schedule? Effective January 1, 2019, new mental health and substance use services are available with NYS Childrens Medicaid. Copies of bills and treatment plans should also be: Mailed to: NYS Workers' Compensation Board, PO Box 5205 Binghamton, NY 13902-5205, OR Email: wcbclaimsfiling@wcb.ny.gov, OR Web Upload Dental implants and related services (BUT THIS WILL CHANGE NOV. 12, 2018 to the following policy: VIII. You can also contact ushere. Log into your account, view patient information, and more. Dr. Deborah Simmers, DMD. Brush twice a day with fluoride toothpaste. If you have Medicaid, you MUST apply for Medicare as a condition of continuing eligibility. Members who need dental care should be directed to our Find a Doctor directory. The insurer did not respond to within the established time limits, OR, did not pay my dental bill in full. If you are turning 65 within the next 3 months or you are 65 years of age or older, you may be entitled to additional medical benefits through the Medicare program. Thus, if this is met, services may not be considered essential. children and youth placed in foster care in New York City, and, children and youth placed in foster care and a 29-I VFCA Health Facility, Medicaid Managed Care(including Partnership in Care and HARP Plans), Message your primary care providers office, Request refills of your prescription drugs. The appellant did not dispute that she had the 8 points of contact. Note: The HP-1.0 form is submitted through OnBoard but the rest of the process remains the same. Her testimony alone was insufficient; objective medical documentation is required. School Based Health Center dental services will continue to be carved out of Managed Care and will remain billable Fee-for- Service. Rookie FA signings by team. If there are no similar listed dental codes, CDT code 09999 "Unlisted Adjunctive Procedure By Report" could be utilized, where the provider should establish a fee consistent relative to the other fees listed in the dental fee schedule. Check member eligibility status. << Paper checks and rosters are being phased out and EFT will become mandatory Paper Submission, Prior Approval Request Form eMedNY361401 and Claim Form A are obtained through CSC at: (800) 343-9000. When an individual changes insurers (either fee-for-service to Medicaid managed care (MMC) or changes plans) in the midst of a course of treatment, the insurer at the time of the decisive appointment is responsible for the payment for the entire treatment. Available in the next 3 days . If you have any concerns about your health, please contact your health care provider's office. Study Resources. endstream endobj 119 0 obj <. Check out our blog post! Mental Health and Substance Use Services for Children. The record did not show where the teeth in need of treatment were and did not show which, if any, other teeth provided biting contact. When contacted by phone at the hearing, the Agency was not available, having provided a contact phone number that was only a recording. Just quality health care. MetroPlusHealth has offered low-cost, quality health care for New Yorkers for more than 35 years. Other supporting documentation for the request may be submitted including x-rays. See, e.g., FH #6254420Y. endobj New York State is making this change in the initial assessment process to make it easier to get the services you need. Groups range in size from as few as five employees to thousands of covered patients. Prior authorization is required for Non-MTG treatments over $1,000 and optional for Non-MTG treatment costing less than or equal to $1,000. In addition to the treatment due to the patient's accident at work, the patient also needs full mouth periodontal treatment and additional root canal and restorative treatment. FH# 6655671H(available here), Denture Replacement - REVISIONS EFFECTIVE NOV. 12, 2018. However, the Appellant asserted that she is in extreme pain, and is unable to chew her food on the right side of her mouth (the side where tooth number 18 is located). Where possible, the provider should use similar listed codes found on the Dental Fee Schedule and bill accordingly. SeeDental Policy and Procedure Code Manual,page 24. Navigators and Certified Application Counselors, NY State of Health, The Official Health Plan Marketplace, online at. There are no relevant workers compensation forms for billing purposes. FH# 7360626Q(available here), Example: Fidelis (by DentaQuest) determined to deny the Appellant's dentist's prior approval request for a root canal on teeth numbers 2 and 18 on the ground that the service is not covered for members age 21 or older and that the service could be covered if pulling the tooth cannot be done because of a medical illness or if the tooth is needed for a bridge or a partial denture the Appellant already has. Dental providers may use OnBoard to submit prior authorization requests for treatment. In the event that the recipient has a record of not successfully wearing prosthetic replacements in the past, or has gone an extended period of time (three years or longer) without wearing a prosthetic replacement, the prognosis is poor. General information about NYRx, the Medicaid Pharmacy Program can be found here along with information for Members and Providers. Legal Aid Society asks you to let themknow if you are working with Medicaid-eligible individuals who require dental implants or replacement dentures, including those whose care may not be covered based on the revised policy. No copays. They also want to speak with Medicaid-eligible individuals who require any other dental treatments that are not covered by Medicaid including root canals, immediate dentures, osseous surgery. Diagnosis & Treatment for Gum Disease and Tooth Decay , Children's Dental Health Timeline Guidance, from Newborn to Gradeschooler, FIDELIS and FIDELIS CARE are trademarks of Centene Corporation, The Centers for Disease Control Oral Health Page, Transparency in Coverage Machine Readable Files. During the 1st month no new participants joined, but 10 people under 65 in group A and 5 people over 65 in . Orthodontic exam and evaluation and treatment will be billed using the dental fee schedule. Dental services at these clinics may be accessed without prior approval and without regard to network participation. When Medicaid eligibility is lost after active orthodontic treatment has been initiated, the FFS or MMC patient may choose to continue treatment as private pay or through commercial insurance, or access Medicaid FFS for. MetroPlusHeath is proud to offer benefits and services that help you live a healthy life. FH# 6478476L (available here), Example: Appellant was approved for placement of an upper denture but was denied for a lower partial denture. All Rights Reserved. Check benefits. Visit . The agencys denial was affirmed because although the appellants testimony indicated that she might have qualified for the partial lower denture, the appellant failed to present any medical documentation that proved her medical condition. Around the NFL Staff. You may be able to continue receiving meals as long as you are eligible for this program. New York, NY 10004 Note to Out-of-Network Providers: This schedule displays reimbursements for commonly utilized services on an out-of-network basis only. Even though appellant could not eat the food she required for her diabetes, appellant presented no objective medical evidence to support her contention that her lack of the lower denture will cause her health to be compromised. Contact: Legal Aid Society Health Hotline (212) 577-3575or email . @Rt CXCP%CBH@Rf[(t CQhz#0 Zl`O828.p|OX For more information about what services are included, see the state regulation. MetroPlusHealth members can access the Member Portal, find doctors, specialists, and pharmacies, and view member benefits. These meals are tailored for your specific health needs and can help you gain access to healthy, nutritious foods. Early treatment prevents them from getting worse. Any service billed under these rate codes is carved out of Managed Care. Contains dental best-practices, parenting tips, and preventative guidance sourced from accredited institutions on each of the following topics: Dental Preventative Care Dental Care Tips for Moms Diagnosis & Treatment for Gum Disease and Tooth Decay Children's Dental Health Timeline Guidance, from Newborn to Gradeschooler. Trainings last updated: October 2022. Interrupted Treatment Policy. 0 Revised policy effective November 12, 2018 - click on these links: VI. I had to pay for some of the dental expenses outofpocket. Contact the patient or patients legal representative for this information. Managed care plans, providers, and ALJs rely on the manual in determinations about dental coverage. We use cookies to make your experience better. It is not medical advice and should not be substituted for regular consultation with your health care provider. L. 111-148).. Direct entry on the web - www.dentaquest.com Or, Via Clearinghouse - Payer ID CX014 Include address on electronic claims - DentalQuest, LLC 12121 N Corporate Parkway Mequon, WI 53092 DentaQuest Customer Service/Member Services For Amerigroup Community Care members 800.895.2218 Fraud Hotline 800.237.9139 TTY/TDD Amerigroup 711 relay Provider Enrollment - DentaQuest. The provider manual clarifies that this means children should receive routine preventive dental care every six months, and additional visits should be based upon the dentists assessment of the childs individual needs. Dental providers must be licensed and currently registered by the New York State Education Department (NYSED), or, if in practice in another state, by the appropriate agency of that state, and must be enrolled as providers in the New York State Medicaid program. If you are interested in applying to become a participating provider in our Dental Plan Network, please On December 28, 2016 the Agency determined to deny the request on the grounds that the service is not covered by the Agency. Servicing members for more than one state. Adults: Adults should establish a dental home and see the dentist as often as the dentist recommends. See article in New York Times, August 2, 2018, "Lack of Dental Coverage Hampers Medicaid Recipients, Suit Says." These changes, described below and in this document, will take effect on November 12, 2018. Great Expressions Dental Centers participates with most dental insurance plans in Connecticut, Florida, Georgia, Massachusetts, Michigan, New Jersey, New York, Ohio, and Texas. Manage Your Health Online With MyChart. This website uses cookies so that we can provide you with the best user experience possible. If a recipient's health would be adversely affected by the absence of a prosthetic replacement, and the recipient could successfully wear a prosthetic replacement, such a replacement will be considered. Copies of bills and treatment plans should also be: I do not know the patients workers compensation insurer. X, 19Ys = L L.NP) t\&=L L ;u In addition, your use of this site does not create an attorney-client relationship. Your benefits include dental check-ups, cleaning, x-rays, fillings and follow-up care. I need a dental provider for treatment for a work injury. 5.00. Important Notice:Effective October 1, 2021, our members now access their behavioral health services through MetroPlusHealth. We encourage our member to take advantage of this benefit in order to ensure that services are provided. Dental providers (along with other health care providers) are required to register for OnBoard via the Boards Medical Portal in order to submit Form HP-1.0 requests and/or requests for prior authorization. Include several previously exempt and excluded populations, *Enrollment numbers are based on May 2012 data. 2020 EmblemHealth. Any dental billing forms with the appropriate code and fee as found in this dental fee schedule can be used. Because the tooth was not necessary to support any prosthetics, the Plans determination to deny the requested root canal for tooth number 18 was upheld. Welcome to EmblemHealth Dental Find a Dental Specialist Benefit From Network Participation. Do I need to be authorized by the Board to provide dental treatment to workers compensation patients? If the recipient can provide documentation that reasonable care has been exercised in the maintenance of the prosthetic appliance, and it did not become unserviceable or lost through negligence, a replacement may be considered. How to Access Your Member Portal Good practice is to review your contracted fee schedules annually. The workers compensation dental fee for my patient's treatment is less than my usual fees. Extraction of deciduous teeth will only be reimbursed if injection of a local anesthetic is required. <> Disease or extensive physiological change can include additional lost teeth, especially if an abutment for the current denture is lost or damaged. Please call the DentaQuest Provider Hotline (888) 308-2508. The plan must reimburse the clinic for covered dental services provided to enrollees at approved Medicaid clinic rates. Tooth sensitivity to heat, cold or sweets. There are no relevant workers compensation forms for billing purposes. If you disable this cookie, we will not be able to save your preferences. Do I need to request for prior authorization to the workers compensation insurer for dental treatment? Your oral health is important to us. No-Fault cases may be subject to differing interpretations. 0000003050 00000 n By understanding the nuances of the benefit, advocates can help get their clients the coverage they need. No premiums. Yes, any dental provider can refuse to treat a workers compensation patient for dental services. 0000002197 00000 n The decisive appointment for active orthodontic treatment is the time at which the total appliance(s) is/are completely placed and activated. When you get emergency care or are treated by an out-of-network provider at an in-network hospital or ambulatory surgical center, you are protected from balance billing. Where should I send the dental billing forms? The insurer can also dispute the necessity for dental treatment or that the injuries were not related to the patient's employment. According to the Dental Policy manual, when considering if services are essential, eight posterior natural or prosthetic molars and/or bicuspids in occlusion will be considered adequate for functional purposes. Social Services law defines medical necessity as medical, dental, and remedial care, services and supplies which are necessary to prevent, diagnose, and correct or cure conditions in the person that may cause acute suffering, endanger life, result in illness or infirmity, interfere with such persons capacity for normal activity or threaten some significant handicap.- Social Services Law 365-a(2).