Dental Billing

Presented byMina Reynaga & Kristen BriceProvider Field Representatives

Call 505-246-0710 or 800-299-7304 - to directly reach all provider help desks including Provider Relations, Provider Enrollment, the HIPAA/EMC help desk and TPL.For all contact, Claims, and Correspondence Addresses information go to the following link on the New Mexico Medicaid Web Portal:

• https://nmmedicaid.acs-inc.com/nm/general/loadstatic.do?page=ContactUs.htm

• Email: NMPRSupport@xerox.com

Contact Xerox

Important State Websites - Dental

Dental Program Policy:

http://www.hsd.state.nm.us/mad/pdf_files/provmanl/prov83107.pdf

Dental Provider Billing Instructions:

http://www.hsd.state.nm.us/mad/pdf_files/BillingInstructions/83107.pdf

Registers and Supplements:http://www.hsd.state.nm.us/mad/registers/2012.html

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Important State Websites - Dental

Dental Fee Schedule:

http://www.hsd.state.nm.us/mad/pdf_files/FeeSchedules/DENTAL%20CODE%20FEE%20SCHEDULE.pdf

Providers can find a copy of a HLD Index Scoring Sheet, at the link below:

http://www.hsd.state.nm.us/mad/pdf_files/Forms/NM%20HLD%20Form%200000.pdf 

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Xerox Field Representative

Provider Field Representative:

Mina Reynaga (505)246-9988 Ext. 813233Kristen Brice Ext. 8131216

• E-mail: Erminia.reynaga@Xerox.com• E-mail: Kristen.brice@Xerox.com

• Cc: NMPRSUPPORT@Xerox.com

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The Billing Process

Before you bill Medicaid

• Check the beneficiary’s eligibility for Medicaid.

• Check the beneficiary’s eligibility for dental services.

• Check the beneficiary’s service limits.

• Check the procedure code on the dental fee schedule to determine if prior authorization is needed.

• Check for other dental insurance coverage.  

Before you bill Medicaid

• Check the procedure code on the fee schedule to see if New Mexico Medicaid covers that code.

• Check the current version of the ADA’s Current Dental Terminology code book for correct procedure codes.

• Check to see if the procedure code requires tooth, surface, or quadrant indicators.

• Check to see if co-payment is required.

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Ways to Check Eligibility

•On-Line Eligibility Inquiry—Web Portal https://nmmedicaid.acs-inc.com

•Automatic Voice Response System (AVRS) (800) 820-6901

•Xerox Eligibility Help Desk: (800)-705-4452 Monday - Thursday 8:00 a.m. - 5:00 p.m. Friday (Mountain Time) 8:00 a.m. - 4:00 p.m.

Eligibility Inquiry

Eligibility Inquiry – UPDATE w/ Dental Slide TPL

Eligibility Denials

What do I do if I receive a denial pertaining to the client’s eligibility?

• Verify client eligibility for the date of service on the Web Portal.

• Verify correct patient ID, DOB and Name. • Attach an authorization (CMS 309), if CMS client.

Dental services are not covered under these categories:

• 029 – Family Planning• 035 – Pregnancy Related (NAX) when patient is exempt from a

SALUD plan.• 035 (2) – Premium Assistance for Maternity (PAM)• 041, 044 – Qualified Medicare Beneficiary (QMB)• 062, 063 – State Coverage Insurance (SCI)• 072 (2) – Premium assistance for Kids (PAK)

Categories of Eligibility with Co-pays

Clients with these COE’s may owe co-pays for some services. • 071 – CHIP (Children’s Health Insurance Program)

• 074 – WDI (Working Disabled Individuals)

CHIP Copayment Schedule

ServiceOutpatient Physician VisitUrgent Care VisitOutpatient Therapy VisitOther Practitioner VisitDental Office Visit

Co-payment$5.00$5.00$5.00$5.00$5.00 - co-pay does not apply if service is preventative, diagnostic, or orthodontic.

WORKING DISABLED INDIVIDUAL (WDI) CO-PAY AMOUNTS

• $7.00 outpatient therapy and behavioral health services• $20.00 emergency room services $30.00 inpatient hospital services.• $7.00 doctor visit, urgent care or vision visit• $7.00 dentist visit• $5.00 prescriptions

Please note: Native Americans are exempt from CHIP and WDI co-payment requirements.

CMS (Children’s Medical Services) Claims Submission

CMS is the same as billing for a Medicaid client with the following differences:

• Always use the 14 digit CMS client ID number that begins with 07.

• Always enter the PA number in box 2 of the ADA form (if the PA number is 8 digits, add 2 zeroes in front of it).

• When submitting on paper, always attach the 309 form or copy of the Healthier Kids card.

Utilization Review (UR)

How do you determine if/when a PA is required?

• Call the UR Agency Molina TPA at (505) 348-0311 (in Albuquerque) (866) 916-3250 (toll free).

• Provider Relations Helpdesk (800) 299-7304

• Molina TPA can tell you if a PA is required and the procedures for getting a PA.

Prior Authorization Requirements

Services requiring a PA include but are not limited to the following:

• Children’s benefits: Periodontics, braces, crowns, crown repair, root canals, maxillofacial prosthetics, certain maxillofacial repair services.

• Adult benefits: Periodontics, dentures/partials and root canals (front teeth only), maxillofacial prosthetics, certain maxillofacial repair services.

Prior Authorization RequirementsFFS (Fee for Service)Important Information for Fee for Service Dental Services:Prior authorization (PA) requests for dental services for FFS Medicaid recipients must be submitted to DentaQuest at the address listed below.  PA requests are submitted on the ADA form (appropriate ADA codes and tooth numbers/quadrants must be indicated) with appropriate documentation and clinical material, such as x-rays, charting, and study models for orthodontia. 

DentaQuest 12121 North Corporate Parkway

Mequon, WI 53092 http://dentaquest.com

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Prior Authorization RequirementsFFS (Fee for Service)Recommended Steps for Provider Inquiries Regarding the Status of a FFS Dental Prior Authorization:

1. Check the Xerox web portal and confirm the PA numbers.

2. If there is no PA on the web portal, contact DentaQuest at (800) 341-8478 for the status.

3. If you have contacted DentaQuest for a status check and are not able to view the PA on the Xerox web portal, or more information is needed on the PA, contact Molina Healthcare Third Party Assessor Dental Care Coordinator toll-free at (800) 580-2811, ext. 180279 or in Albuquerque at (505) 348-0279 to resolve the issue.

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Prior Authorization RequirementsFFS (Fee for Service)Recommended Steps for Provider Inquiries Regarding the Status of a FFS Dental Prior Authorization ( Continued):4. If you have questions about a dental claim denial, contact Molina Healthcare Third Party Assessor Dental Care Coordinator toll -free at (800) 580-2811, ext. 180279 or in Albuquerque at (505) 348-0279.

5. If after you have followed steps 1-4 (above) and issues are still unresolved, please contact Medical Assistance Division Staff Manager, Devi Gajapathi at (505) 827-6227.

6. If you have clients that have questions regarding PA status, please refer them to Molina Healthcare Dental Care Coordinator, Christopher Salazar at (505) 348-0279.

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Orthodontic Authorizations

To ensure your orthodontic authorizations are processed efficiently and timely, we would like to remind you of the appropriate way to submit orthodontic authorization requests. Per New Mexico Medical Assistance Division Utilization Review instructions 8.310.7 UR Dental Services:

http://www.hsd.state.nm.us/mad/pdf_files/provmanl/8%20310%207%20UR%20draft%20dental%2002%2010%202010%20rev.pdf

 

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Orthodontic Authorizations

The documentation required must include each of the following:

• Diagnostic Casts or digital study models 

• Full mouth or panoramic x-ray • Cephalometric film 

• Diagnostic Photographs

• A completed orthodontic screening form that states the Handicapping Labiolingual Deviation Index (HLD) score and indicates the handicapping malocclusion. The provider may submit either the original or a copy.

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Orthodontic Authorizations

Prior to making a decision, DentaQuest may issue a request for information (RFI) to the provider requesting clarification or additional information, in order to have sufficient information to render an appropriate decision.

The provider must submit the clarification or additional information within 21 calendar days of issuance of the request or a technical denial may be issued (8.350.2 NMAC).

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Orthodontic Authorizations

If your office needs the models returned please include a postage paid container, appropriate to securely return the ortho models or a postage paid label that we can apply to a container that we have available.

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Orthodontic Authorizations

As a reminder, you can receive 24 hour service 7 days a week by using www.dentquestgov.com to check member eligibility, history, submit claims, authorizations and many other features. 

Should you need other assistance, or wish to use our interactive voice response system, please contact DentaQuest at 1.800.483.0031. 

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Procedure Codes and Fee Schedule

Procedures must be reported using the American Dental Association’s dental procedure codes and terminology. For complete code descriptions, terms and definitions, reference the Current Dental Terminology manual.

NM Medicaid Dental Fee Schedule is available:

http://www.hsd.state.nm.us/mad/pdf_files/FeeSchedules/Dental_Codes.pdf

Procedure Codes and Fee Schedule

Dental services must be billed with a “D” and a four digit code.

Oral cavity designations for quadrants are as follows:• 10 – UR• 20 – UL• 30 – LL• 40 - LR

Service Limits – Children’s Services

Certain services are limited in frequency:• Two dental exams per year• Two cleanings every six months• Two fluoride treatments per year

Sealants: • Not covered on pre-molars• Only pay for sealants once every five years• O – Occlusal is the only surface covered

Service Limits – Adult Services

Certain services are limited in frequency:• One dental exam per year• One cleaning per year

Adults are not eligible for braces or crowns.

Service Limits – Dentures and Partials

Dentures and partials require PA• Payment include 2 adjustments during the first 6 months after delivery.

Adjustments are limited to 2 per year.• Repairs are limited to 2 per year for full and partial dentures.• Relining dentures is limited to once every 3 years.• Relining cannot be billed during the six months following the insertion

of the prosthesis.

Service Limits – X-Rays

Full mouth or panoramic x-rays are covered once every 3 years.

Claim Form Requirements

Electronic Claim Submission

All Fee For Service claims within 90 days from the initial date of service that do not require an attachment for payment must be submitted electronically.

For any assistance regarding Electronic Claims Submissions, contact the HIPAA Helpdesk

 HIPAAHelpdesk@acs-inc.com

or call 800-299-7304

Three Ways to Submit Claims Electronically

• Payerpath – Free HIPAA Compliant web-based claims entry system.

The URL to the registration form for Payerpath submissions is:

http://www.hsd.state.nm.us/mad/hipaa.html *Pay attention to the RA Newsletter, for upcoming updates to the Payerpath.

• Through a Clearinghouse

• EDI Gateway The URL for additional information regarding EDI Gateway electronic submissions is:http://www.hsd.state.nm.us/mad//pdf_files/Converting%20from%20TIE%20to%20ACS%20EDI.pdf

Timely Filing Denials

Exceptions to the filing limit:When the provider was not originally enrolled as a MAD provider on the date of service, the filing limit of 90 days is counted from the date the provider was notified of their enrollment, but must not exceed 210 days from the date of service. A provider should submit a provider participation agreement in sufficient time to allow processing and still meet the Medicaid 210 day limit for submitting the claim.

When a claim previously paid by a Medicaid managed care organization is recouped from a provider due to retroactive disenrollment of the client from the managed care organization, the filing limit of 90 days is counted from the date of the managed care organization’s notice or recoupment from the provider.

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Timely Filing Denials

Re-filing Claims and Submitting Adjustments

When resubmitting a claim or requesting an adjustment on a claim that is past the 90 day filing limit but originally met the filing limit, the “TCN” number which appears on the remittance advice (RA) will be used by Xerox to evaluate the claim. The provider must supply that TCN number in order for Xerox to be able to evaluate the claim.

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Timely Filing Denials

Re-filing Claims and Submitting Adjustments

ADA 2006 Dental Claim Form:

Enter the TCN number in Box 35 beginning on the left side.

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ADA 2006 Dental Claim Submission

ADA 2006 Claim Form Requirements

• All claims that do not require an attachment for payment must be submitted electronically.

• Professional claims are submitted on the 837D electronically and the ADA-2006 on paper.

• MAD requires that all paper ADA-2006 claim forms be on the original red claim forms.

• Photocopies of claim forms will be returned to your billing office.

ADA 2006 Claim Submission

The following claim is how a paper ADA 2006 claim form is generally filled out.

Use procedure codes that are specific to your claims.

You can get a copy of the ADA 2006 Claim form instructions for Medicaid requirements.https://nmmedicaid.acs-inc.com/nm/general/loadstatic.do;jsessionid=QhtBzkNyVLD02LTWGGwwy5zJvZYpfjdl5hpGxQQBjTYy027ChpYJ!1711986351?page=ProviderInformation.htm• This will give you box by box information on how to fill out the claim

form for Medicaid primary, TPL primary, or HMO/PPO primary claim variations.

Where to get a copy of claim form instructions

Click on Provider Information

Where to get a copy of claim form instructions

TPL Billing Instructions

• Always attach a copy of the EOB from the other insurance. Always attach the list of EOB code explanations from the other carrier.

• Box 32 needs to be filled in with the paid amount from the primary payer.

TPL Example

45 00 120 00

120.00

paid amount from the primary payer.

Co-pay Billing Instructions

The NM Medicaid program requires a prior payment made by a primary payer to be entered in this field. • If trying to collect a flat copayment amount, the amount entered in box

#32• should be the difference between the total billed and the copayment

amount. • Write “HMO Copayment due” on the claim.

Co-pay Billing Instructions

• Leave blank if there is not a primary payer or if the primary payer did not make a payment on the claim.

*Note: Do not enter previous amounts paid by Medicaid on these services.

• Claims partially paid by Medicaid need to be submitted as adjustments when trying to collect for the unpaid or partially paid services on the claim.

Co-pay Example

120.00

120.00

100.00

Difference between the total billed and the copayment amount. ($20 copay)

Billing Instructions - Reminder

Rendering NPI number is always required!

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Common Denials

0101 – Service Dates Within Managed Care Enrollment Period

The client is in managed care on some or all of the dates of service on the claim.

• Verify eligibility through our Web Portal or AVRS and resubmit to the appropriate MCO.

1361 – Exact Duplicate

Payment has already been made for this claim

• Check the Web Portal under Claim Status to view the claim history to identify when the claim was paid and post it to your accounts.

• If there is an incorrect payment because of a billing error, you must submit an Adjustment Request Form along with your corrected claim form in order to have the claim corrected.

0820 – Timely Filing Limit Not Met

.The initial filing limit has not been met. Please make sure to do the following:

• Verify that the claims was/ was not submitted within the timely filing limit.

• If the claim needs a reconsideration for timely filing, make sure to re-submit with a cover letter explaining the reasons that timely filing may need to be overridden.

0424 – Billing Provider Not Enrolled on Dates of ServiceProvider enrollment status is not active.

The provider can contact the provider enrollment department for additional assistance at:

505-246-0710 or 800-299-7304

1699 – Must Submit Claim Electronic

The provider submitted a paper claim and the provider master database media code does not contain a value of “P” – Paper.

• The provider must submit all claims electronically.

0431 – Procedure Not A Covered CMS Service for Dates of Service

The procedure is not a covered CMS service for the date of service.

0124- From Date of Service is Missing

• Please review the Dental Form instructions for Box 24 and submit accordingly.

0110- Service dates Within Coordination of Long Term Services Enrollment Period• Client is enrolled in a Colts MCO.

• Provider can verify Colts MCO, via New Mexico Medicaid web portal. https://nmmedicaid.acs-inc.com/nm/secure/publicHome.do

0439 – Procedure not a Benefit for Service Date

Verify that claim was processed with correct procedure code ( box 29).

Call provider relations helpdesk, for additional assistance at: 505-246-0710 or 800-299-7304

0362- Tooth Surface Required

The “Tooth Surface” box is empty and the procedure code requires a tooth surface.

Enter a valid tooth surface here• O – Occlusal is the only surface covered.

Provider Enrollment Tips

Most Common Mistakes - Applications• Placing “same” in a box

• Not answering a yes/no answer question

• Missing initials on each page, including the signature page

• The mailing and billing addresses not matching the group on a MAD 312 app

• Not putting in a provider type and/or specialty.  • Not initialing next to the questions on the signature page

• Not including a complete document when a provider declares a ‘yes’ answer on the signature page. 

• Not having insurance for the provider that proves insured while they are working for or at the group listed in box 24 of a MAD 312

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Most Common Mistakes - Applications

• Not initialing next to the questions on the signature page

• Not including a complete document when a provider declares a ‘yes’ answer on the signature page. 

• Not having insurance for the provider that proves insured while they are working for or at the group listed in box 24 of a MAD 312

• Not signing in the correct spot on a MAD 335. 

• Not initialing any strike thru they make on the app.

• Using white out / line out • Faxing an application.

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Most Common Mistakes – TAD’s

• Not completing the ownership pages for all listed as required

• Providers believe that non-profit status exempts them from completing the ownership sections (this includes ss#s and b-dates).  There is nothing on the doc that exempts them based on profit status.

• Not including a complete document when a provider declares a ‘yes’ answer on the signature page.  We need the document to include all aspects as outlined on the TAD; we cannot use a quick sentence written in under the question.

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Most Common Mistakes – TAD’s

• Providers changing a document to match another person/business.  The document belongs to the person/business it is printed for and identified by the provider number on it.  You cannot alter mine to update yours.

• Using white out / line out. • Providers need to print the name of the person signing the doc above

their signature, especially if their signature isn’t legible.

• Providers need to initial next to three questions on signature page.

• Providers cannot fax a TAD.

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Most Common Mistakes – Updates

• Using / completing an application to cross reference an active provider to a group. 

- Applications are for applicants, if you’re already active we just need a letterhead letter signed by all parties involved, proof of license and insurance, DEA if using it. 

• New W-9’s will not get your addresses changed.• Xerox cannot make changes over the phone.• Xerox cannot process multiple people on one letter. 

-If you’re going to disaffiliate several people from your group, each one needs their own letter.  • Include provider numbers on all correspondence. 

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