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). These networks are separate and unrelated and each has distinct patient enrollment and reimbursement schedules. Where possible, the provider should use similar listed codes found on the Dental Fee Schedule and bill accordingly. Can I charge the patient the balance between my fee and the workers compensation dental fee? You can also contact the NY Dental Association to find a dentist. During your appointments, the dentist can find any cavities early and treat them. Dental providers (along with other health care providers) are required to register for OnBoard via the Boards Medical Portal. A yearly cleaning at your dentist's office helps prevent gum disease. See Plan information, Health Rewards, and Messages, Find someone in your neighborhood and in your language. The dental provider should submit all bills and treatment plans to the appropriate insurer. Claims submitted by a dental provider to the insurer shall be paid within fortyfive calendar days of receipt of the claim. <]>> Evaluation and diagnostic materials submitted by provider for review and determination. 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. Click hereto visit the CAQH website. Members who need dental care should be directed to our Find a Doctor directory. By providing you with advanced technological tools, we eliminate the administrative burden associated with participating in government-sponsored programs. Talk To Us About Any Questions or Concerns. How to Access Your Member Portal These meals are tailored for your specific health needs and can help you gain access to healthy, nutritious foods. Provision of orthodontic treatment will require Plan approval. The record establishes that the Appellants oral surgeon had advised by a letter dated March 11, 2015 that the Appellant not have any extractions, because, due to her clenching and TMJ Disorder, any surgical extractions will worsen patient condition.Denial was reversed. The insurer shall have thirty days to pay the claim or provide written notice to the Board, patient, and dental provider explaining why the claim is not being paid. We also want to ensure you arrive at your appointment timely without having to rely on family or friends for your transportation. You can contact any dental provider in your local area to perform workers compensation dental service. The Agency did not review the Appellants request based on whether the dentists request for a root canal falls under the medically necessary guidelines. With the 2023 NFL Draft in the books . Payers may use the charges you submit to determine maximum-allowable fees. See Dental Policy and Procedure Code Manual, page 24. The Dental Fee Schedule became effective on 3/1/2009. To make the transition as transparent and seamless as possible for both the provider and patient. This is not legal advice. 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. Trainings last updated: October 2022. %%EOF Physical activity is one of the simplest ways to stay healthy, and Healthfirst makes it even more rewarding! However, the dental provider must have a valid NYS dental license. How long must I wait for payment to be made by my patient's workers compensation insurer? There is no cost to file an application with CAQH and it can be completed online. Thus, if this is met, services may not be considered essential. WHAT DENTAL SERVICES ARE COVERED UNDER MEDICAID? Dental services at these clinics may be accessed without prior approval and without regard to network participation. Online Scheduling Exam Fees Eye Exam Starting Fee $80.00 Contact Lens Starting Fee $129.00 Dilation Fee $40.00 Insurance/Discount Plans We accept most insurances, including: Aetna Avesis Cigna Dentaquest Envolve Payment Types Visa Mastercard Discover American Express Applepay Cash Check Languages English Spanish Location Location Information 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. Prior approval requests for implants must have supporting documentation from the patients physician and dentist. The 2023 bump in pay extends throughout the draft. Necessary treatment can be provided throughout pregnancy. Dental providers may use OnBoard to submit prior authorization requests for treatment. The denial was reversed. 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. 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. Do I need to request for prior authorization to the workers compensation insurer for dental treatment? Important notice about your Medicaid managed care plan benefits. ), 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*. Provide the highest level of healthcare in New York and save up to 20% with our narrow network. Business Name *. View up-to-date payment information. See Dental Policy and Procedure Code Manual, page 38. Change Your Group. If you have Medicaid, you MUST apply for Medicare as a condition of continuing eligibility. Just quality health care. MetroPlus Health Plan Can I require workers compensation patients to pay up front for dental work before the work is performed, or bill a workers compensation patient for services rendered? One can challenge a determination that there are eight points of contact if the teeth that make up points of contact are damaged, diseased, or have moved. See Dental Policy and Procedure Code Manual, page 43. Procedure codes and billing guidelines will follow. We offer a state of the art dental facility, utilizing the most advanced technology in cosmetic dentistry. 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. provider and client notified of denial and rights to appeal. 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. Our Member Services team is always here to help. Top Undrafted Rookie FAs. Early treatment prevents them from getting worse. You may join one or both networks the choice is yours. Transitional care rules apply and member will transition to participating provider after 60 days or after treatment is complete, whichever comes first. Submitting provider notified of determination, Provide information on transition timelines, Explain procedures for existing and new cases, Dental Coverage Transition from Fee for Service (FFS) to Medicaid Managed Care (MMC), Process of Approval of Orthodontia Services, Prior Approval Requests and Claims (FFS only), Dental (other than orthodontia) mandatory as of 7/2/12, Health Insurance Plan of Greater New York. Adult Patient Program: (631) 632-8989, select prompt #4; Child (Under age 17) Patient Program: (631) 632-8967; Orthodontic Program: (631) 632-8906 This service requires prior approval. 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. A letter from the patients dentist must explain why other covered functional alternatives for prosthetic replacement will not correct the patients dental condition and why the patient requires implants. OR. Her testimony alone was insufficient; objective medical documentation is required. Review claims status. Our Companies, Lines of Business, Networks, and Benefit Plans (PDF), Medicaid, HARP, and CHPlus (State-Sponsored Programs), Cultural Competency Continuing Education and Resources, Medicaid Cultural Competency Certification, Find a center near you, view classes and events, and more, Vendor-Managed Utilization Management Programs, Physical and Occupational Therapy Program, Radiology-Related Programs and Privileging Rules for Non-Radiologists, Pharmacy Medical Preauthorization List (PDF), New Century Health Medical Oncology Policies, UM and Medical Management Pharmacy Services, COVID-19 Updates and Key Information You Need to Know, EmblemHealth Guide for Electronic Claims Submissions, Consolidated Appropriations Act/No Surprise Billing Information, Payment processes unique to our health plans, EmblemHealth Guide for NPIs and Taxonomy Codes, 2023 Provider Networks and Member Benefit Plans, EmblemHealth Spine Surgery and Pain Management Therapies Program, Outpatient Diagnostic Imaging Privileging, Benefits to Participation in Dental Network. {{{;}#tp8_\. %PDF-1.7 Qualified New Yorkers Essential Plan $0 premiums for all who qualify, and no deductible, so it pays for your care right away. See Dental Policy and Procedure Code Manual, page 24. Our comprehensive, innovative programs, are designed to control costs and assure quality care. The current policy states effective until Nov. 12, 2018, "Full and/or partial dentures are covered when required to alleviate a serious health condition or a condition that affects employability. There is a strong relationship between your oral health and your overall health. The Appellant stated that with the denture being broken, he is left without any teeth, natural or otherwise, in his mouth. Complete or partial dentures will not routinely be replaced when they have been provided by the Medicaid program and become unserviceable or are lost within eight years, except when they become unserviceable through extensive physiological change. For information on which services do and do not require prior approval and authorization, click on this link to the regulation: For information on orthodontic care coverage, click on thislink to the regulation. How will I be reimbursed for procedures included under CPT but not CDT codes? Published: Apr 29, 2023 at 07:08 PM Updated: Apr 29, 2023 at 07:36 PM. The Council for Affordable Quality Healthcare (CAQH) offers a single credentialing application and an online database that contains information necessary for insurance companies to credential a provider. MyChart allows you to: Learn about all of the free preventive services for adults, women and children. Basic plan is FREE for NYC workers and their families! Medicaid Orthodontic Benefit. Cost savings in printing, staff time, postage, etc. Message DentaQuest through secure messaging. SeeDental Policy and Procedure Code Manual,page 59. New York State Catholic Health Plan, Inc. Yes- Bronx, Broome, Cayuga, Chenango, Clinton, Columbia, Cortland, Dutchess, Essex, Franklin, Fulton, Greene, Hamilton, Kings, Livingston, Madison, Monroe, Montgomery, Nassau, New York, Niagara, Orange, Oswego, Putnam, Queens, Richmond, Rockland, Schoharie, St. Lawrence, Steuben, Suffolk, Sullivan, Tioga, Ulster, Warren, Wayne, Westchester, No- Albany, Allegany, Cattaraugus, Chautauqua, Chemung, Delaware, Erie, Genesee, Herkimer, Lewis, Oneida, Onondaga, Ontario, Orleans, Otsego, Rensselaer, Saratoga, Schenectady, Schuyler, Tompkins, Washington, Wyoming, Yes- Bronx, Kings, New York, Queens, Nassau, Richmond, Suffolk, No- Broome, Cayuga, Chenango, Clinton, Herkimer, Jefferson, Madison, Oneida, Onondaga, Oswego, Rockland, Tioga, Warren, Westchester, No- Albany, Dutchess, Orange, Rensselaer, Rockland, Ulster, eMedNY Dental Policy and Procedure Manual pp. Additionally, remember that it is very important to report your full fee on the claim form. Using Your Benefits. or by completing our Contact form by clickinghere. DentaQuest has a NEW and improved Online Enrollment and Credentialing Tool! . Example: Appellants dentist submitted a prior authorization for root canal therapy on Appellants tooth number 18 (molar). There is a strong relationship between your oral health and your overall health. 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. Submit Electronic Claims and Dental Claim Forms. New York State is making this change in the initial assessment process to make it easier to get the services you need. 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. With over 25K providers, 100+ hospitals, 5K practices, 250+ urgent & ambulatory care centers, Fidelis Care is here to support your team's needs. File Notice of Objection to a Payment of a Bill for Treatment Provided (Form C-8.1B), or Notice to Health Care Provider and Claimant of an Insurer's Refusal to Pay All (or a portion) of a Medical Bill Due to Valuation Objection(s) (C-8.4), as appropriate. << If you need to schedule or inquire about receiving transportation benefits please contact MetroPlusHealthCustomer Service Department at 1-800-303-9626 (TTY: 711) if you need assistance. Any dental billing forms with the appropriate code and fee as found in this dental fee schedule can be used. Resources. Check benefits. 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. Treatment such as endodontics (repeat root canal treatment) or crowns will not be approved in association with an existing or proposed prosthesis (artificial replacement) in the same arch, unless the tooth is a critical abutment (needed to attach a denture to) for a prosthesis provided through the NYS Medicaid program, or unless replacement by addition to an existing prosthesis or new prosthesis is not feasible. Here are some good practices to follow to ensure proper oral hygiene. Appellant confirmed that she is not missing other teeth, all of her teeth are intact and healthy, and she does not have a bridge or denture for which tooth number 18 would serve as a critical abutment. Not all dental codes are listed on the Dental Fee Schedule. Good practice is to review your contracted fee schedules annually. For more information about what services are included, see the state regulation. For Medicaid recipients who meet certain income, resource, age, or disability requirements. Annual trainings are updated annually in the Fall and should be completed each year no later than December 31, Fraud Waste & Abuse & General Compliance Training, Cultural Sensitivity & Non-Discrimination Training, New York City Department of Health Oral Health Recommendations, Information about the Online Credentialing Application. Participants meet a high credentialing standard and agree to treat covered patients at the fees detailed in our fee schedules. 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. How would I charge for procedures not listed on the dental fee schedule? All relevant treatment plans should be attached with the dental billing forms. Appellant testified that she lost her lower denture at home. Our four dental networks consist of over 8,000 dentists and dental specialists practicing in New York and New Jersey. 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. Learn more about OnBoard. 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. stream 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. A dental visit should include a professional cleaning. 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. DQUSA.TX.IND.POL 2.15 4 Part I Definitions . 2023 Medicare and PDP Compare Plans and Enroll Now Notice of Non-Discrimination We comply with applicable Federal civil rights laws and do not discriminate on the basis of race, color, national origin, age, sex, or disability. 0000000575 00000 n hb```g``Zpj1 X{ y `` The coverage is limited to three years of treatment and one year of retention care. HRA can be returned to: Cases prior approved under MA FFS, including NYCORP, FFS responsible for duration of treatment/retention, Limited extended coverage for patients enrolled in either FFS or MMC if eligibility is lost, If patient is in FFS (i.e., not enrolled in managed care), if appliances are placed and active treatment begun, member receives a maximum of six months of treatment paid for via FFS, For Medicaid managed care enrollees, this process will also be handled FFS, Plan Member changes plan or newly eligible. 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. Vision Benefits. Learn how to use this new tool (and more) by attending one of our scheduled WebEx trainings. 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. *You must participate in the Preferred network to also participate in the Dental Access Plan. 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. Yes. Dr. Deborah Simmers, DMD. If the patient was working at the time of the accident, it should be treated as a workers' compensation claim. Treatment is not considered appropriate when the prognosis of the tooth is questionable or when a reasonable alternative course of treatment would be extraction of the tooth and replacement. A. Managed care plans, providers, and ALJs rely on the manual in determinations about dental coverage. We can even enroll you over the phone. Also startingJuly 1, 2021, some children and youth must join a Medicaid managed care plan, including: Some children and youth placed in foster care cannot join a Medicaid managed care plan. Our dental network partner is changing in 2022 from DentaQuest to Healthplex for certain dental products. Fixed bridgework, except for cleft palate stabilization, or when a removable prosthesis would be contraindicated; Molar root canal therapy for beneficiaries 21 years of age and over, except when extraction would be medically contraindicated or the tooth is a critical abutment for an existing serviceable prosthesis provided by the NYS Medicaid program; Replacement of partial or full dentures prior to required time periods unless appropriately documented and justified as stated in the Manual -- see changes effective Nov. 12, 2018. Please also provide ample time for your appointment to be scheduled. Under Medicaid, dental benefits exist, but the coverage is limited. Nofault rules and regulations can be found at the. Do I submit a claim for all the necessary dental treatment to the workers compensation insurer? Accordingly, there is often coverage for replacing but not treating a tooth. 12285 0 obj<> endobj Before continuing using our website you agree and accept our cookie policy & privacy. Zocdoc helps you find Dentists in Queens and other locations with verified patient reviews and appointment availability that accept DentaQuest and other insurances. /Filter /FlateDecode MetroPlusHealth Virtual Visit is available anytime, from anywhere in New York State, 24/7 and in your language. 56.5 mi. Whether the move makes it easier or harder to find an upstate dentist is open to debate. 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. Watch the video below for an overview of the new dental health coverage for adults. hbbd```b``z"g E,r D2`i`v X.X1X$ LNH`Xed_@d:H=D bg`ig ^ 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. . 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. \% ZP`\f)@zYVl@4/0&HJ,oz ],mC`HLZ7Ql!@```l`` GD@"g`6 i eda \D,3)7Rx-dR $?SfiN [VVaS% 'r'P4?P 81q-d23!Z h Commitment to Health Equity SeeDental Policy and Procedure Code Manual, page 24. 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 The Official New York State Workers Compensation Dental Fee Schedule (Dental Fee Schedule) applies to dental treatment and procedures performed on, or after, March 1, 2009. 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. The plan must reimburse the clinic for covered dental services provided to enrollees at approved Medicaid clinic rates. 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. If you are experiencing a mental health crisis, our Behavioral Health Crisis after hours partner Vibrant Emotional Health can be reached 24/7 at 1.866.728.1885 (SMS capable for the hearing impaired). Welcome to Our Web Portal! EFFECTIVE NOV. 12, 2018 the new policy on denture replacement is: Full and /or partial dentures are covered by Medicaid when they are required to alleviate a serious health condition or one that affects employability. Please contact the Medical Directors Office at 1-800-781-2362 or provider@wcb.ny.gov. 0000003891 00000 n Check out our blog post! The dental provider must have a valid NYS dental license. Dental implants will be covered by Medicaid when medically necessary. In addition, your use of this site does not create an attorney-client relationship. 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. Update Your Practice Records. The Workers' Compensation Law does not permit a dental provider to collect from, or bill, a workers compensation patient for services rendered, unless a decision is issued by the Workers' Compensation Board indicating the patient failed to prosecute their claim, the claim is denied, the treatment is not causally related to the work injury, or a Section 32 agreement has been approved relieving the insurer of liability for medical expenses. 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. Assist patients in identifying orthodontists participating in their Managed Care Plan. Available in the next 3 days . Any dental billing forms with the appropriate code and fee as found in this dental fee schedule can be used. A child is defined as anyone under the age of 21. Before continuing using our website you agree and accept our cookie policy & privacy. To contact a lawyer, visit, Valerie Bogart (New York Legal Assistance Group), In August, 2018,The Legal Aid Society and Willkie Farr & Gallagher filed, 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. Cleft palate or approved orthognathic surgical cases may be approved for additional treatment time. dentaquest.com Superior Vision Phone: 866.810.3312 superiorvision.com CVS Caremark Pharmacy Phone: 855.722.6228 caremark.com Authorization: 800.294.5979 Appeals: 888.543.9069 Laboratory Services BioReference Laboratories Phone: 800.229.5227 GeneDX: 888.729.1206 GenPath Women's Health: 800.633.4522 GenPath Oncology: 800.627.1479 trailer Implant Services (revised Nov. 12, 2018. We respect the contributions of our providers. 157 0 obj <>stream In addition, dental providers may use OnBoard to request dental-related DME and medications, and to submit Form HP-1.0. Orthodontic exam and evaluation and treatment will be billed using the dental fee schedule. L. 111-148).. Find a plan that's right for you. Basic plan is FREE for NYC workers and their families! You may qualify for Medicaid if you have high medical bills, receive Supplemental Security Income (SSI), or meet certain income, resource, age or disability requirements. In the event a dental provider renders dental treatment during the time the patient's workers' compensation case is controverted or disputed, the dental provider is entitled to an additional 25% reimbursement above the fees listed in the dental fee schedule.
