dentaquest fee schedule new york

. All bills submitted using CDT code D9999 should be accompanied by a report providing the reasons why such procedures are necessary. The fee schedules are typically part of the Important Notice:Effective October 1, 2021, our members now access their behavioral health services through MetroPlusHealth. . Any dental billing forms with the appropriate code and fee as found in this dental fee schedule can be used. 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 Appellant failed to establish that tooth number 18 is necessary to support a bridge or denture. 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. 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. If you have questions, please call Customer Services team at 1-800-303-9626. Ask the dentist to testify during the fair hearing or to provide a written statement of a denials impact on the clients health. Partnering with DentaQuest, we are able to bring their experience and passion for improving oral health care to you. Medicaid Dental Coverage includes only essential services, rather than comprehensive care. schedule of allowable fees **please refer to office reference manual on dentaquest's website for covered services** code description fee . OnBoard: Limited Release is the first phase of OnBoard, designed to move key processes for health care providers and claim administrators from paper to online, including the submission of Request for Decision on Unpaid Medical Bill(s) (Form HP-1.0) and the prior authorization request (PAR) process for medication, durable medical equipment and medical treatment/testing. Rookie FA signings by team. If you have any questions, please call the CVS CaremarkCustomer Care Team at1-(855) 656-0361 for Medicaid Managed Care and Child Health Plus members or 1-(855) 383-9426 for Exchange Plan members. To make the transition as transparent and seamless as possible for both the provider and patient. endobj For information regarding No-Fault Insurance, contact the NYS Department of Financial Services. 118 0 obj <> endobj Video visits. <]>> Is this allowed? A letter from the patients dentist must explain the specific circumstances that necessitates replacement of the denture. Sign in to make the most of your day with the new provider portal from DentaQuest. How to Access Your Member Portal Please call the DentaQuest Provider Hotline (888) 308-2508. Check member eligibility status. More Information Coronavirus (COVID-19) Keep yourself informed about Coronavirus (COVID-19.) No, any dental provider with any type of dental specialization can treat workers compensation patients. Where possible, the provider should use similar listed codes found on the Dental Fee Schedule and bill accordingly. You may join one or both networks the choice is yours. . View 2022-Fee Schedule - Dentaquest.docx from EGL 111 at Oakton Community College, Skokie. See Dental Policy and Procedure Code Manual, page 24. DENTAL FEE SCHEDULE 1. OnBoard will be used by dental providers to submit Form HP-1.0 requests for arbitration and to request prior authorization for medications, durable medical equipment, non-MTG procedure(s) costing more than $1000, or under or equal to $1000. FOR Qualified New Yorkers MetroPlusHealth Gold $0 premiums, deductibles, and co-insurance. \% 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 Orthodontic treatment will require SDOH approval. startxref Workers' Compensation Law does not require dental providers to be authorized by the Board. The placement of the component parts (e.g. Capital District Physicians Health Plan, Inc. Yes- Bronx, Kings, New York, Queens, Nassau, Richmond. On December 28, 2016 the Agency determined to deny the request on the grounds that the service is not covered by the Agency. Tell us more about yourself to find qualifying plans and estimate costs. Dental implants will be covered by Medicaid when medically necessary. MFk t,:.FW8c1L&9aX: rbl1 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. or by completing our Contact form by clickinghere. %PDF-1.7 "Dental care in the medical assistance program shall include only preventive, prophylactic and other routine dental care, services and supplies, and dental prosthetic and orthodontic appliances required to alleviate a serious health condition including one which affects employability.. 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). Our four dental networks consist of over 8,000 dentists and dental specialists practicing in New York and New Jersey. A yearly cleaning at your dentist's office helps prevent gum disease. CPT Procedures would be billed out according to the prevailing workers compensation medical fee schedule for the region in which the services are performed. Brush twice a day with fluoride toothpaste. 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. Starting January 1, 2022, Walgreens and Duane Reade will no longer be in the pharmacy network for members of these plans: Where can I find a list of participating network pharmacies? StartingJuly 1, 2021, MetroPlusHealth will cover Article 29-I Voluntary Foster Care Agency (VFCA) Health Facility services for children and youths under age 21 in foster careand other special populations, as indicated. Note: The HP-1.0 form is submitted through OnBoard but the rest of the process remains the same. To learn more, check out these resources: Fidelis Care members with dental coverage have their benefits covered through DentaQuest. 0000001459 00000 n DENTAQUEST 2022 Procedure Code Ages Effective Jan 1 2022 D0120 0-20 $ 28.00 D0120 21-999 $ Expert Help. View up-to-date payment information. Basic plan is FREE for NYC workers and their families! If you have Medicaid, you MUST apply for Medicare as a condition of continuing eligibility. Here are some good practices to follow to ensure proper oral hygiene: Child Health Plus cover routine, preventive and emergency dental services through DentaQuest. A dental visit should include a professional cleaning. Our Preferred and Preferred Plus Networks Her looks and speech were unaffected but the lack of lower dentures were detrimental to her health because she was unable to eat the healthy diet required as an insulin-dependent diabetic. Welcome to Our Web Portal! Review the ADA Checklist. Covered services range from emergency visits to prenatal care. xb```b``y ,@Q{ TjJ|UY=9sA6VK|ox9vdhLuaZ9r3?sfAf128 pVb"/@beSi1bL=> Dental providers (along with other health care providers) are required to register for OnBoard via the Boards Medical Portal. 0000003891 00000 n MetroPlusHealth has offered low-cost, quality health care for New Yorkers for more than 35 years. No copays. The Medicaid dental benefit is limited and includes only essential services. In these cases, you shouldnt be charged more than your plans copayments, coinsurance and/or deductible. A. Pregnant women: Pregnant women should see a dentist at least one time during pregnancy. ADCs will continue to be "free access" providers. Basic plan is FREE for NYC workers and their families! Yes, any dental provider can refuse to treat a workers compensation patient for dental services. No premiums. Medicaid members can access dental care using their MetroPlusHealth ID card. Member and Provider FAQs - Pharmacy Benefit Carve-Out. Appellant testified that she lost her lower denture at home. When it comes to other doctors, you can pick from a comprehensive list of providers in all five boroughs. If you would like a hard copy of this handbook, you can submit a request onlinehereor call us at 1-800-303-9626 (TTY: 711). Dr. Dental providers may use OnBoard to submit prior authorization requests for treatment. UnitedHealthcare of New York, Inc. Dentaquest Empire Health Choice HMO, Inc. Fidelis Care New York; Healthfirst PHSP, Inc. Home Provider Enrollment. MetroPlusHealth Virtual Visit is the fast, easy way for our members to see a provider for common physical, mental, emotional, and behavioral health issues that are not emergencies. Form HP-1.0 should be submitted, along with any necessary attachments, such as copies of medical bills, through OnBoard. 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. See Dental Policy and Procedure Code Manual, page 24. Adult Patient Program: (631) 632-8989, select prompt #4; Child (Under age 17) Patient Program: (631) 632-8967; Orthodontic Program: (631) 632-8906 All bills submitted using CDT code D9999 should be accompanied by a report providing the reasons why such procedures are necessary. Mental Health and Substance Use Services for Children. Preventive care includes immunizations, physical exams, lab tests and prescriptions. xA 04e\GcwzC. 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. 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. The limited extended coverage is provided through FFS for up to a six-month period following loss of Medicaid eligibility. To schedule your first appointment within our teaching clinic, please call the Dental Care Center between 8:30am and 5pm, Monday through Friday. Submit Electronic Claims and Dental Claim Forms. A plan for New Yorkers who have or are eligible for Medicaid. See Dental Policy and Procedure Code Manual,page 24. Agency denial upheld. Any information provided on this Website is for informational purposes only. We use cookies to make your experience better. Learn more below, in the Plan Materials section. Provide as much evidence and medical documentation as possible of the need for and benefit of the work. 0000002971 00000 n Not all dental codes are listed on the Dental Fee Schedule. The NYS Department of Financial Services has adopted the Dental Fee Schedule as its fees for all dental treatment provided to victims of motor vehicle accidents through its NoFault program. hbbd```b``z"g E,r D2`i`v X.X1X$ LNH`Xed_@d:H=D bg`ig ^ How do dental providers submit a Request for Decision on Unpaid Medical Bill(s) (Form HP-1.0) via OnBoard? 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. You can apply for Medicare by calling the Social Security Administration at1-800-772-1213or by applying on-line at:https://www.ssa.gov/medicare/. You can contact any dental provider in your local area to perform workers compensation dental service. The new rule on replacement dentures imposes new documentation requirements and will be a step backward for some. There is no cost to file an application with CAQH and it can be completed online. 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. No-Fault cases may be subject to differing interpretations. The 31st . 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. hb```g``Zpj1 X{ y `` Before continuing using our website you agree and accept our cookie policy & privacy. Dental providers are required to register for the Medical Portal and submit a request for prior authorization using OnBoard. Business Name *. 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. * These plans are preferred provider organizations (PPO) and are underwritten by EmblemHealth. Transitional care rules apply and member will transition to participating provider after 60 days or after treatment is complete, whichever comes first. The plan further determined to deny the Appellants dentists prior approval request for a crown (D2751) on the same teeth on the ground that the root canal treatment was not approved. Review claims status. The Agency denial was upheld because the placement of the upper denture satisfied the 8 point of contact rule between the upper and lower back teeth. 0000000016 00000 n We encourage our member to take advantage of this benefit in order to ensure that services are provided. Disease or extensive physiological change can include additional lost teeth, especially if an abutment for the current denture is lost or damaged. OR. Treatment not completed within the maximum allowed period must be continued to completion without additional compensation for the NYS Medicaid program, the recipient, or the family. Resources. The SFC program is managed by Dentaquest. /Filter /FlateDecode There are no relevant workers compensation forms for billing purposes. School Based Health Center dental services will continue to be carved out of Managed Care and will remain billable Fee-for- Service. Dental services for children are provided as part of Medicaids Early Periodic Screening, Diagnosis and Treatment (EPSDT) program. These meals are tailored for your specific health needs and can help you gain access to healthy, nutritious foods. 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. Nor was she able to establish that extraction of tooth number 18 is contraindicated for health reasons. MyChart is a free secure portal you can use to manage your health information. If you have any questions, call one of our Member Services Representatives. Members who receive care at NYC Health + Hospital facilities now have access to MyChart. During the 1st month no new participants joined, but 10 people under 65 in group A and 5 people over 65 in . Procedure Fee Files & CPT Codes . Managed care plans, providers, and ALJs rely on the manual in determinations about dental coverage. Provider Update ALSO OF INTEREST 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. In addition, dental providers may use OnBoard to request dental-related DME and medications, and to submit Form HP-1.0. Interrupted Treatment Policy. Low-cost plans for daycare workers in New York City. This means that four maxillary (upper jawbone) and four mandibular (lower jawbone) teeth in functional contact with each other are considered adequate. 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. A dental visit should include a professional cleaning. One missing maxillary anterior tooth (upper jawbone front tooth) or two missing mandibular anterior teeth (lower jaw front tooth) may be considered an esthetic problem that warrants a prosthetic replacement. If you have more questions, please call our Customer Services team at1-800-303-9626. DentaQuest has a NEW and improved Online Enrollment and Credentialing Tool! It is important for everyone over the age of 1 to visit the dentist at least one time every year in order to help keep your teeth and gums healthy. Search based on your schedule. We offer five dental plans to employer groups throughout New York State and to their employees who live in or out of the state. . Participants meet a high credentialing standard and agree to treat covered patients at the fees detailed in our fee schedules. Learn more about Monkeypox, including prevention and treatment,here. Join Our Dental Networks. Services are provided at home or in the community. 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. 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. 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 Commitment to Health Equity Orthodontic exam and evaluation and treatment will be billed using the dental fee schedule.*. At DentaQuest, we are committed to improving oral health by redefining prevention and care. For New Yorkers living with HIV/AIDS and other select groups. 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. 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. However, the dental provider must have a valid NYS dental license. $0 premiums for all who qualify, and no deductible, so it pays for your care right away. MetroPlusHealth Virtual Visit is available anytime, from anywhere in New York State, 24/7 and in your language. Dental services at these clinics may be accessed without prior approval and without regard to network participation. All relevant treatment plans should also be attached with the dental billing forms. Contact the patient or patients legal representative for this information. Prospective Vision Providers. (available here). Explore Qualified Health Plans (QHP) through the NY State of Health, The Official Health Plan Marketplace. To choose a Primary Care Dentist (PCD) or if you need help finding a dentist in your area, call DentaQuest at 844-284-8819. Best of all, MetroPlusHealth Medicaid Managed Care comes with no monthly premiums or copays. Agency denial upheld. New York, NY 10004 Please refer to your Membership Agreement, Certificate of Coverage, Benefit Summary, or other plan documents for specific information about your benefits coverage. xwTS7PkhRH H. Medicaid Managed Care has a year-round open enrollment period. The insurer did not respond to within the established time limits, OR, did not pay my dental bill in full. Welcome to EmblemHealth Dental Find a Dental Specialist Benefit From Network Participation. 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. Furthermore, the record failed to establish that the upper denture had yet been placed. Contact Number. Contact: Legal Aid Society Health Hotline (212) 577-3575or email . Members can find a list of network pharmacies or use our online provider search tool. How do I request prior authorization for treatment? 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. 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. You do not need a referral from your PCP to see a dentist. 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 These services give children/youth (under age 21) and their families the power to improve their health, well-being and quality of life, strengthening families and helping them make informed decisions about their care. Strictly Necessary Cookie should be enabled at all times so that we can save your preferences for cookie settings. Find our Quality Improvement programs and resources here. FH # 7484720Z(available here). Plans must allow new member to continue treatment with non-participating provider for up to 60 days or until the current treatment plan is complete, whichever is sooner, when: A treatment plan is in progress but has not been completed as of date of enrollment; The provider agrees to accept Plan reimbursement as payment in full, adhere to Plans quality assurance and encounter data submission requirements and otherwise adhere to Plans policies and procedures. 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. There is a strong relationship between your oral health and your overall health. The denial was overturned because the Agency packet failed to include any information showing how the Agency made the factual finding as to the points of contact in Appellants mouth. A verbal statement by the recipient that is then included by the provider on the prior approval request would generally not be considered sufficient. FH #6755535N(available here), Example: Appellants dentist requested prior authorization for denture replacement prior to the 8 year waiting period. This allows you to submit and maintain your credentialing information at one location rather than filing with many organizations. Complete dentures and partial dentures will not be replaced for a minimum of eight years from initial placement except when they become unserviceable through trauma, disease, or extensive physiological change. Learn how to use this new tool (and more) by attending one of our scheduled WebEx trainings. Procedure codes and billing guidelines will follow. 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. ***You must participate in the Preferred network to also participate in the Preferred Premier plan. Nofault rules and regulations can be found at the. Our dental networks are: EmblemHealth Preferred Dental EmblemHealth Preferred Plus Dental This person is a food and nutrition expert and will help give guidance and support in choosing healthy foods. Your oral health is important to us.

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