PROVIDER WEBINARS June 2011
AGENDA § What’s New § What’s Changing § What’s NOT Changing § Administrative Reminders § Web Portal Registration and User Set–Up Process § Web Portal Overview § Questions and Answers 2 2
What’s New … 3 3
What’s New § New Web Portal Features } } Upload attachments and x-rays free of charge Ability to communicate via secure messaging Ability to obtain status of claims and authorizations much quicker Ability to enter broken/missed appointment information via the web § Claims Processing } State-of-the-art claims processing system } Claims decisions made nearly instantaneously so claims and authorizations can be viewed much quicker on the portal -usually within 24 hours § New and Improved Automated Phone System } Ability to verify benefits and eligibility and obtain a procedure history } Ability to have information faxed back to you } Once member information (such as membership number or date of birth) is entered, you will be able to jump between menus without re-entering that information. 4 4
What’s New § Electronic EOBs } EOBs will be posted to the web portal for easy access and viewing. § Electronic Notifications } Notices will be posted to the web portal for immediate distribution including regulatory updates, newsletters, meeting notices and contractual changes. 5 5
What’s Changing … 6 6
Examples of Changes § When we migrate to the new system, current provider user id and password will no longer be valid. } Providers must register on the new web portal. } Providers may pre-register the week of June 27 – July 3, 2011 and the week of July 4 – 11, 2011. § Improved security features that allow tiered access and increased provider control. § NPI numbers will be used on all correspondence. Provider ID numbers will no longer be used. § Provider Remittance Advice will have a different look. 7 7
Cases for EPSDT Review § The Early and Periodic Screening Diagnosis and Treatment (EPSDT) program is a comprehensive and preventive child health program for individuals under the age of 21. § EPSDT requires that any medically necessary health care services be provided when the service is needed to correct or ameliorate a dental condition. § Coverage is available under EPSDT for services even if the service is not available under the Smiles For Children to the rest of the Smiles For Children population. 8 8
Cases for EPSDT Review § § (cont. ) Effective July 11, 2011, all services that exceed the benefit limitation or 2011 frequency and any service that is listed as not available, must be submitted for Prior Authorization. } Provider must check Box #1 – EPSDT/Title XIX of the 2006 ADA Claim Form. } Provider must submit the claim using the actual treatment code. Use of D 9999 for EPSDT cases will be discontinued. If the appropriate box is not checked, the request will be denied. 9 9
Remittance Advice (EOB) DENTAQUEST, LLC Payee ID: 123_456 Patient Name: Subscriber/Member: DOB: Office Reference No: EOB Date: 7/11/2011 Group #: 099 Payee Name: AMERICA KIDS Dental Care LLC SMITH, JOHN 00000123456789 11/08/1998 Provider Name: ABC HEALTHCARE Provider/Loc NPI: Business NPI: 1770597627 Group: USA HEALTHCRE Sub-Group: USA HEALTHCARE -Arizona Medicaid Children BILLED ALLOWED PAID PAYABLE PATIENT AMOUNT QTY AMOUNT POS QTY CODE AMT PAY SUBMITTED ITM CODE/TH/SUR DESCRIPTION DOS 1 D 0220 05/06/09 11 1 $21. 00 1 $0. 00 D 0220 $0. 00 2 D 0120 05/06/09 11 1 $40. 00 1 $0. 00 D 0120 $0. 00 3 4 D 1120 D 1330 05/06/09 11 11 1 1 $50. 00 1 1 $0. 00 D 1120 D 1330 10/14/09 11 1 $50. 00 1 $0. 00 D 1330 PERIAPICAL XRAY PERIODIC ORAL EXAM CLEANING, CHILD ORAL HYGEINE Claim#: Referral Date: OTHER INSUR 200930335069800 NET AMT PROCESSING POLICIES $0. 00 2118 $0. 00 2016, 2046 $0. 00 $0. 00 2016 2004, 2016 $0. 00 2002 INSTRUC 5 D 1330 ORAL HYGEINE INSTRUC 2002 The claim and/or records indicate other coverage. Please provide the subscriber's name, date of birth, d effective ate, and name of the other carrier on this EOB and resubmit for processing. 2016 This procedure has been submitted after the timely filing limit. 2046 Service conflicts with previous service in patient's history. 2118 Service has been bundled to a more cost effective full mouth series § Processing Policy numbers (if applicable) will be listed at the end of each service line. The full description will be listed at the bottom of the page. § The submitted code and the paid code will now be listed on the same service line. § NPI numbers will now be used versus the provider ID numbers. 10
What’s NOT Changing … 11
What’s NOT Changing … § Current Web Portal Features (adding enhancements) } } } Verify Member Eligibility Quick and easy claim and authorization entry (free of charge) View status of claims and authorizations Obtain member claim history Review documents such as Office Reference Manual (ORM) § Electronic Data Interchange (EDI): } Electronic claims submission § Same phone numbers and addresses § Same payment cycle 12 12
Administrative Reminders § Submission of electronic claims is highly recommended via our web portal or through a clearing house. § If submitting paper claims, they must be submitted on a 2006 or newer ADA claim form, which can be found at www. ada. org. § To ensure your claims are not returned to you, be sure to: } } } Enter the appropriate NPI numbers in box #49 and #54. Include the treating dentist signature in box #53. Acceptable signatures include: “Signature on file”, electronic name and typed names. Indicate in box #4 if the member has other insurance. Check the appropriate Place of Treatment in box #38. If you are submitting an adjustment, void or resubmission of a claim, enter “adjustment”, “void” or “resubmission” in the remark field box #35. § Do not send in marked up pre-authorization determination letters when submitting the services for payment. The services must be submitted on an appropriate ADA claim form. § When submitting claims/authorizations via regular mail, do not also submit the request electronically. Sending both creates duplicate requests. 13 13
Administrative Reminders § Methods of submitting claims and authorization (refer to your ORM for further details) } } § Electronic via Denta. Quest’s web portal Electronic via Clearinghouse HIPPA compliant 837 D File Paper Claims If you are interested in using NEA (National Electronic Attachments) for attachments, we have secured a special deal for you: } By mentioning promotion code DQSTSZ when registering (www. nea-fast. com) NEA will waive the $200 registration fee if you sign up by July 31, 2011 § Direct Deposit } As a benefit to participating Providers, Denta. Quest offers Direct Deposit for claims payments. This process improves payment turnaround times as funds are directly deposited into your banking account. Please refer to your Office Reference Manual (ORM) for detailed instructions. 14 14
Administrative Reminders X-ray Policy § § We require that x-rays be mounted. Claims received with more than 4 un-mounted x-rays will be returned for mounting. X-rays must be of diagnostic quality, properly mounted, dated and identified with the member's name. Below are the options in which you can submit x-rays to us. These are (in order of preference): } } § Electronically using NEA (National Electronic Attachment) Mail duplicate x-rays with your ADA form Send original x-rays, your ADA form, and a self addressed stamped envelope (SASE) so that we may return the x-rays to you. We are unable to return x-rays received without a SASE. X-rays without a SASE will be scanned and recycled. Refer to your Office Reference Manual to determine if the submission of x-rays is required. 15 15
Administrative Reminders Electronic Communications PURL § § PURL = Personalized URL PURL site provides: } } } § Personalized communication 24/7 access to relevant program information via the website Less paper and waste Secure access Your communications is password protected Visit the PURL site at: www. DQInfosource. com 16 16
Registration Process Overview 17 17
New Web Portal Security The Primary Administrator (Super User): Responsible for setting up the users for the provider group and determining what access they should be allowed. This is determined based on what tier you assign them to and what security role you grant them. Provider Tiers: Each provider group will be set up with 3 separate tiers. The tier will control which offices and providers the user will have access to. User Id’s are allowed to be set up at Tier 1 and Tier 2. A user assigned to the…. Will be able to access information…. Business Entity (Tier 1) Note: This tier should be assigned security roles 1 through 3. for all providers at all locations. A user is assigned at this level if you want them to be able to view and/or maintain information for your entire organization (all service offices/locations and providers). Service Office (Tier 2) Note: This tier should be assigned security roles 1 through 3. for all providers in a specific location. A user is assigned at this level if you have different staff members who view and/or maintain information for a specific service office/location. User can only view the providers assigned to the specific service office/location. Individual Provider (Tier 3) User Id’s are not allowed to be set up at this Tier level. 18 18
Security Role The Security Role will control what functions the user will be allowed to do: If a user is assigned the role of…. At the tier they have been assigned they will be able to…. Provider Super User (Role 1) § § § Create and manage user IDs for staff Perform Member Eligibility searches View Remit Advices Check status of Claims and Pre-authorizations Enter and submit Claims and Pre-authorizations Provider office User (Role 2) § § Perform Member Eligibility searches View Remit Advices Check status of Claims and Pre-authorizations Enter and submit Claims and Pre-authorizations Provider Office User, No Remit (Role 3) § § § Perform Member Eligibility searches Check status of Claims and Pre-authorizations Enter and submit Claims and Pre-authorizations 19 19
Web Portal Overview 20 20
Change in Claims Adjudication Schedule § In the weeks leading up to the migration, providers may receive larger than normal checks. § As a result of the July 11, 2011 migration, providers will not receive a reimbursement check during the week of July 25, 2011. § Providers may continue to submit claims through the current web portal through July 10, 2011. Providers should plan accordingly and prepare for this delay in claims payment. DMAS and Denta. Quest will not issue advance pays associated with this delay. § 21 21
A copy of this presentation can be found on the home page of the current Provider Web Portal (PWP). QUESTIONS AND ANSWERS 22 22
Скачать презентацию PROVIDER WEBINARS June 2011 AGENDA What s
ff88e007347a9037538ecf60dfc1542d.ppt