dentaquest fee schedule new york
The Great Expressions Difference. Copies of bills and treatment plans should also be: I do not know the patients workers compensation insurer. PEF Dental and/or Vision Only. 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. Plan may require prior authorization for services not included in the treatment plan as of the effective date of enrollment, Identify those MMC Plan(s) that provide, or will provide, coverage for your patients, Contact those Plans that you wish to participate with and enroll as a provider, Determine what forms, diagnostics, means of submission, etc. Find a Dental Specialist. Annual trainings are updated annually in the Fall and should be completed each year no later than December 31st. Evaluation and diagnostic materials submitted by provider for review and determination. %%EOF **You must participate in the Preferred network to also participate in the Spectrum network. This will help smooth relationships with patients when it comes to billing for out-of-pocket expenses. Without a referral, our members can seek care from any general dentist or dental specialist who participates with their dental plan. Message DentaQuest through secure messaging. The coverage is limited to three years of treatment and one year of retention care. 3 0 obj Credible testimony by the appellant alone is not sufficient in these types of cases. hb```g``Zpj1 X{ y `` We respect the contributions of our providers. Medicare members can call us 24/7 at1.866.986.0356(TTY: 711). When billing for limited extended coverage, submit a paper claim at the end of the period to FFS using procedure code D8999: Limited extended coverage for lost eligibility is only payable one (1) time during the course of orthodontic treatment. SeeDental Policy and Procedure Code Manualpage 24. 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. Complete dentures and partial dentures whether unserviceable, lost, stolen, or broken will not be replaced for a minimum of eight years from initial placement except when determined medically necessary by the Department or its agent. The Dental Fee Schedule became effective on 3/1/2009. FH# 7062037L(available here), Example: On December 28, 2016 the Appellants dentist requested prior authorization for a root canal on tooth number 15 (code D3330). You do not need a referral from your PCP to see a dentist. All Rights Reserved. You can also contact ushere. This website uses cookies so that we can provide you with the best user experience possible. All bills submitted using CDT code D9999 should be accompanied by a report providing the reasons why such procedures are necessary. Good practice is to review your contracted fee schedules annually. Columbia University College of Dental Medicine, Stony Brook University School of Dental Medicine, University of Buffalo School of Dental Medicine, University of Rochester Eastman Dental Center, This site provides general information only. In August, 2018,The Legal Aid Society and Willkie Farr & Gallagher filed Ciaramella v. Zucker (18-cv-06945) to challenge the New York State Department of Healths rules preventing Medicaid coverage for replacement dentures within 8 years from initial placement and the ban on Medicaid coverage for dental implants. Use the American Dental Associations and New York State Dental Associations published materials to show that the Medicaid Manual is not following professional standards, such as a tooth is still viable and extracting it will cause health complications. Explore Qualified Health Plans (QHP) through the NY State of Health, The Official Health Plan Marketplace. No. The limited extended coverage is provided through FFS for up to a six-month period following loss of Medicaid eligibility. Commitment to Health Equity MetroPlusHealth Medicaid Managed Care is our plan for people eligible for Medicaid, a government assistance program. MetroPlus Health Plan General information about NYRx, the Medicaid Pharmacy Program can be found here along with information for Members and Providers. 18 NYCRR 506.3: Authorization for dental services and supplies: The identification card issued to persons eligible for medical assistance shall constitute full authorization for providing a select list of dental services and supplies and no special or prior authorization shall be required for these services. 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. Contact DentaQuest at 1-888-912-3456 or search the DentaQuest website to find a listing of dentists who accept Medicaid in your zip code. 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). Accordingly, there is often coverage for replacing but not treating a tooth. Talk To Us About Any Questions or Concerns. Provide as much documentation as possible to show that the procedure was (1) medically necessary and (2) that an insufficient number of teeth met the points of contact rule. Agency denial upheld. At DentaQuest, we are committed to improving oral health by redefining prevention and care. Live customer service representatives who speak your language, Regular check-ups and office visits with your own Primary Care Provider (PCP), Behavioral health and mental health services. See Dental Policy and Procedure Code Manual,page 24. Please click here to access the training schedule. He further stated that without the lower denture, he cannot use the upper one because he will just be hurting his lower gum. 0000001459 00000 n Where possible, the provider should use similar listed codes found on the Dental Fee Schedule and bill accordingly. Example: Agency denial was based on its determination that Appellant had 8 points of biting contact and the service requested was not covered due to the 8 points of contact rule, and not medically necessary. In response, DOH will be implementing changes to the dental manual to cover dental implants when medically necessary and to change the rules for replacement dentures. If replacement dentures are requested within the eight year period after they have already been replaced once, then supporting documentation must include an explanation of preventative measures instituted to alleviate the need for further repl. Review the ADA Checklist. Reimbursed for procedures performed, typically: Examination and diagnostic workup (D8660), Cephalometric X- ray & Tracing (D0340), FMX (D0330 or D0210), Diagnostic Casts (D0470), and, Photographs (D0350), "Evaluation and diagnostic materials submitted by provider for review and determination to FFS Dental Bureau in Albany, "Submitting provider notified of determination, "Examination and Evaluation" performed by. See Dental Policy and Procedure Code Manual, page 8. Check out our blog post! In addition to a plans network of dental providers, plan members have the right to access dental services at the five New York Academic Dental Center clinics licensed under Article 28 of the NY Public Health Law. When was the Dental Fee Schedule established? You do not need a referral from your PCP to see a dentist. If the total number of teeth which require, or are likely to require, treatment would be considered excessive or when maintenance of the tooth is not considered essential or appropriate in view of the overall dental status of the recipient, treatment will not be covered. In these cases, you shouldnt be charged more than your plans copayments, coinsurance and/or deductible. Learn more here. See article in New York Times, August 2, 2018, "Lack of Dental Coverage Hampers Medicaid Recipients, Suit Says." {{{;}#tp8_\. Cost savings in printing, staff time, postage, etc. Members can find a list of network pharmacies or use our online provider search tool. No premiums. L. 111-148).. Prior approval requests for replacement dentures prior to eight years must include a letter from the patients physician and dentist. 0000001920 00000 n * These plans are preferred provider organizations (PPO) and are underwritten by EmblemHealth. 2020 EmblemHealth. d0120 periodic oral evaluation - established patient $26.20 d0140 limited oral evaluation -problem focused $32.28 d0145 oral evaluation for a patient under three years of age and counseling with primary Furthermore, the record failed to establish that the upper denture had yet been placed. Change Your Group. At the fair hearing the appellants testimony of how she was unable to chew properly because of the constant pain and how that pain interfered with her capacity to perform the duties of her job was found to be credible. Watch the video below for an overview of the new dental health coverage for adults. With over 25K providers, 100+ hospitals, 5K practices, 250+ urgent & ambulatory care centers, Fidelis Care is here to support your team's needs. OR. 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. Agency denial upheld. When it comes to other doctors, you can pick from a comprehensive list of providers in all five boroughs. Resources. Your participation in both networks may prove beneficial to your practice. endstream endobj 12297 0 obj<>/W[1 1 1]/Type/XRef/Index[255 12030]>>stream trailer We can even enroll you over the phone. This means that every time you visit this website you will need to enable or disable cookies again. Strictly Necessary Cookie should be enabled at all times so that we can save your preferences for cookie settings. 18 NYCRR 513.0, provides that prior approval of medical, dental and remedial care, services or supplies is required under the MA program, such prior approval will be granted when the medical, dental and remedial care, services or supplies are shown to be medically necessary to prevent, diagnose, correct or cure a condition of the recipient. School Based Health Center dental services will continue to be carved out of Managed Care and will remain billable Fee-for- Service. For Medicaid recipients who meet certain income, resource, age, or disability requirements. However, the appellant stated that she suffered from Multiple Sclerosis, which paralyzed the right side of her mouth. 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. ), there will have to be a claims history for initial placement, Prior Approval Request for MMC enrollees will be subject to Plan procedures - future discussion, Free HIPAA compliant software available through CSC (ePACES), Speed and efficiency- immediate feed back if an error is made, No paper forms to obtain, fill out and store, Photographs and x-rays can be submitted electronically with the request*. Nofault rules and regulations can be found at the. Upload necessary documentation. If the cost of the dental treatment will exceed $1,000, the dental provider may be required to obtain prior authorization from the appropriate insurer. If the patient was not working at the time of the accident, the nofault insurer should be billed. 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. General suggestions for succeeding at a fair hearing: Establish, through evidence, that the procedure is medically necessary. FH# 7315399K(available here), Exception: Under certain circumstances the Agency will approve replacement of a lost partial denture, such as for a recipient whose mouth had undergone significant changes subsequent to the incident -- for example the loss of teeth. FH 6394357J(available here).