0000003098 00000 n Claims submitted by a dental provider to the insurer shall be paid within fortyfive calendar days of receipt of the claim. Prospective Vision Providers. 0000003891 00000 n Then the child needs a dental checkup every 6 months or as determined by the childs dentist. Services provided absent a negotiated rate with a managed care plan will be reimbursed by the plan at the FFS Medicaid rate.*. /Length 2596 New York State is making this change in the initial assessment process to make it easier to get the services you need. 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. Treatment of deciduous teeth (primary or baby teeth) when exfoliation (when the primary teeth shed and the permanent teeth come in) is reasonably imminent will not be routinely reimbursable. By providing you with advanced technological tools, we eliminate the administrative burden associated with participating in government-sponsored programs. 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. Medicaid Dental Coverage includes only essential services, rather than comprehensive care. Under Medicaid, dental benefits exist, but the coverage is limited. Find DentaQuest Dentists in Queens, New York & make an appointment online instantly! No. Call us at1-855-809-4073or visit us at our Virtual Office. Groups range in size from as few as five employees to thousands of covered patients. Welcome to Our Web Portal! MyNYSHIP - Employee Self-Service. Click hereto visit the CAQH website. Whether you have a medical appointment near your home or across town, MetroPlusHealthwants to ensure you get the care you need when you need it without the stress of getting there. 0000001459 00000 n In these cases, you shouldnt be charged more than your plans copayments, coinsurance and/or deductible. American Dental Association: http://www.ada.org/en/, New York State Dental Association: http://www.nysdental.org/. Basic plan is FREE for NYC workers and their families! Search based on your schedule. Where the insurer has failed to pay a claim or make reasonable request for additional information within fortyfive calendar days, the insurer is deemed to have waived any objection to liability for the claim and shall pay the claim. \% 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 MetroPlusHealth members can access the Member Portal, find doctors, specialists, and pharmacies, and view member benefits. Message DentaQuest through secure messaging. Our comprehensive, innovative programs, are designed to control costs and assure quality care. No premiums. Without a referral, our members can seek care from any general dentist or dental specialist who participates with their dental plan. The 31st . See Dental Policy and Procedure Code Manual, page 8. However, the appellant failed to established that other treatments, even if less cosmetically ideal, would not eliminate the pain. Nofault cases are subject to different policy interpretations. ***You must participate in the Preferred network to also participate in the Preferred Premier plan. MetroPlus Health Plan The Dental Fee Schedule became effective on 3/1/2009. Procedure Fee Files & CPT Codes . Visit . 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. Find important information about the EmblemHealth Bridge Program. These changes, described below and in this document, will take effect on November 12, 2018. Check out our blog post! If additional assistance is needed, please contact Healthplex at 888-468-2183, Monday to Friday from 8 a.m. to 5 p.m. 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. 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. The dental provider can use any usual and customary dental billing forms. The letter from the physician must explain how dentures would alleviate the patients serious health condition or improve employability. Best of all, MetroPlusHealth Medicaid Managed Care comes with no monthly premiums or copays. Using Your Benefits. Members who have an ongoing prescription including medications, certain supplies such as pen needles, test strips, continuous glucose monitors, and blood glucose test strips at a Walgreens or Duane Reade should call their health care providers to get a new prescription to be sent to a different pharmacy. FH #6755535N. 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. A child is defined as anyone under the age of 21. 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 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. Dr. Abdul told TDMR that he found out that DentaQuest had instituted their own waiver coverage for Webb county and gave it a fee schedule not only lower than the previous Liberty fee schedule but even lower than DentaQuest's regular waiver fee schedule. 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. If the bill is disputed, insurer must provide a response and can request additional information. 0000000575 00000 n The SFC program is managed by Dentaquest. They will keep getting services through regular Medicaid. Beyond representing an act of public service in your community, we want your participation in our network to represent a sound business decision. We offer five dental plans to employer groups throughout New York State and to their employees who live in or out of the state. 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 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. Regulardental visits helpkeep your smile healthy. The Appellant failed to establish that tooth number 18 is necessary to support a bridge or denture. 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. 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. Do I need to be specialized in order provide treatment to workers compensation patients? Copies of bills and treatment plans should also be: I do not know the patients workers compensation insurer. 0000000016 00000 n 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) decides a proposed or delivered health care service which would otherwise be covered under the covered individual's Subscriber's Policy . Dental services at these clinics may be accessed without prior approval and without regard to network participation. Childrens Dental Benefit. 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. Monkeypox cases are rising in NYC. This person is a food and nutrition expert and will help give guidance and support in choosing healthy foods. Plus, when you join our Preferred network you automatically become a participant of our discounted Dental Access Program,and the Preferred Premier plan. Interrupted Treatment Policy. The Board does not authorize dental providers and does not provide lists of dental providers as referrals. You can find any other dental provider that is willing to perform this service and accept the Dental Fee Schedule. Revised policy effective November 12, 2018 - click on these links: VI. 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. Just quality health care. 0000002741 00000 n During your appointments, the dentist can find any cavities early and treat them. Dental implants will be covered by Medicaid when medically necessary. Ask the dentist to testify during the fair hearing or to provide a written statement of a denials impact on the clients health. We respect the contributions of our providers. These networks are separate and unrelated and each has distinct patient enrollment and reimbursement schedules. *You must participate in the Preferred network to also participate in the Dental Access Plan. A letter from the patients physician must explain how implants will alleviate the patients medical condition. Is this allowed? * *The fee schedule amount for "orthodontic exam and evaluation" codes D8660, D0340,D0330 . The letter from the physician must explain how dentures would alleviate the patients serious health condition or improve employability. Find our Quality Improvement programs and resources here. Any service billed under these rate codes is carved out of Managed Care. % Requests will be reviewed for necessity based upon the presence/absence of eight points of natural or prosthetic occlusal contact in the mouth (bicuspid/molar contact). We offer a state of the art dental facility, utilizing the most advanced technology in cosmetic dentistry. Copies of bills and treatment plans should also be: Please review instructions found on How To Submit Claims-Related Forms and Documents to WCB. OnBoard is an application that is accessed from the Medical Portal. "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.. See article in New York Times, August 2, 2018, "Lack of Dental Coverage Hampers Medicaid Recipients, Suit Says." How will I be reimbursed for procedures included under CPT but not CDT codes? %PDF-1.6 % 2020 EmblemHealth. 0000003050 00000 n 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. Credible testimony by the appellant alone is not sufficient in these types of cases. 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. If you have any concerns about your health, please contact your health care provider's office. Appellant testified that she lost her lower denture at home. %%EOF She was forced to eat by pressing food against her upper palate with her thumb. 1 0 obj 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. endstream endobj startxref Contact: Legal Aid Society Health Hotline (212) 577-3575or email . FH# 6655671H(available here), Denture Replacement - REVISIONS EFFECTIVE NOV. 12, 2018. All relevant treatment plans should also be attached with the dental billing forms. StartingJanuary 1, 2023, MetroPlusHealth will cover Gambling Disorder Treatment provided by Office of Addiction Services and Supports (OASAS) certified programs. Study Resources. It is not medical advice and should not be substituted for regular consultation with your health care provider. 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. 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. When it comes to other doctors, you can pick from a comprehensive list of providers in all five boroughs. 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. MetroPlusHealthMedicaid Managed Care offers low- or no-cost health coverage to New Yorkers who live anywhere in New York City. trailer Early treatment prevents them from getting worse. About 3.8 million . View up-to-date payment information. In both cases, a Workers' Compensation Law Judge will decide the dispute. schedule of allowable fees **please refer to office reference manual on dentaquest's website for covered services** code description fee . See, e.g., FH #6254420Y. Upload necessary documentation. What should I do? The rules and limitations for different dental services are included in the policy manual. You may not accept a fee from a patient for services relating to an on-the-job injury. 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. 118 0 obj <> endobj 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). Please refer to your Membership Agreement, Certificate of Coverage, Benefit Summary, or other plan documents for specific information about your benefits coverage. Review claims status. The Medicaid Orthodontic Benefit is for children under 21 years old with severe physically handicapping malocclusions (a malocclusion is imperfect positioning of the teeth when the jaws are closed). 0000002971 00000 n Welcome. A D5110 denture was now $656.20, D5213 $676.60, D5214 $676.60. Our Member Handbook explains the details of your MetroPlusHealth Medicaid coverage, including your benefits, the rules of the plan, and information about how to receive care. The Appellant stated that with the denture being broken, he is left without any teeth, natural or otherwise, in his mouth. xb```b``y ,@Q{ TjJ|UY=9sA6VK|ox9vdhLuaZ9r3?sfAf128 pVb"/@beSi1bL=> Zocdoc helps you find Dentists in Queens and other locations with verified patient reviews and appointment availability that accept DentaQuest and other insurances. The limited extended coverage is provided through FFS for up to a six-month period following loss of Medicaid eligibility. Learn morehere. Participants meet a high credentialing standard and agree to treat covered patients at the fees detailed in our fee schedules. This will help smooth relationships with patients when it comes to billing for out-of-pocket expenses. * These plans are preferred provider organizations (PPO) and are underwritten by EmblemHealth. 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. 12285 0 obj<> endobj A letter from the patients dentist must explain the specific circumstances that necessitates replacement of the denture. 807 Spring Forest Rd, Ste 600, Raleigh, NC 27609. 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. Children: A childs first dental exam should occur around the time of the childs first tooth and no later than 12 months (1 year) of age. 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? The Great Expressions Difference. How would I charge for procedures not listed on the dental fee schedule? 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. Physical activity is one of the simplest ways to stay healthy, and Healthfirst makes it even more rewarding! Services are provided at home or in the community. This service requires prior approval. Provide the highest level of healthcare in New York and save up to 20% with our narrow network. Submit claims and authorizations. Mental Health and Substance Use Services for Children. ?:0FBx$ !i@H[EE1PLV6QP>U(j Dental clinics are reimbursed on a rate basis or through Ambulatory Patient Groups (APGs) such as hospital outpatient departments, diagnostic and treatment centers, and dental schools, are required to follow the policies stated in the Dental Provider Manual. In addition, your use of this site does not create an attorney-client relationship. If you disable this cookie, we will not be able to save your preferences. 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. Watch the video below for an overview of the new dental health coverage for adults. 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. See Dental Policy and Procedure Code Manual, page 38. Consequently, she could only use the left side of her mouth to eat. 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. How can I get this information? To learn more, check out these resources: Fidelis Care members with dental coverage have their benefits covered through DentaQuest. Qualified New Yorkers Essential Plan $0 premiums for all who qualify, and no deductible, so it pays for your care right away. Medicare members can call us 24/7 at1.866.986.0356(TTY: 711). I would like to object to the dental bill. 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. Starting July 1, 2022, you can join a no-cost Medically Tailored Meals program that provides healthy meals straight to your home. StartingMay 16, 2022, the way Personal Care Services and Consumer Directed Personal Assistance Services (PCS/CDPAS) are initially assessed will be changing. Contact: Legal Aid Society Health Hotline (212) 577-3575or, Full and /or partial dentures are covered by Medicaid when they are required to alleviate a serious health condition or one that affects employability. For more information about what services are included, see the state regulation. Here are some good practices to follow to ensure proper oral hygiene. 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). What should I do? 5 verified reviews. Home Provider Enrollment. Orthodontic exam and evaluation and treatment will be billed using the dental fee schedule.*. On December 28, 2016 the Agency determined to deny the request on the grounds that the service is not covered by the Agency. FH# 7261543K(available here), Example: Agency denied appellants request for a lower partial denture because the appellant had 8 points of contact without the denture. 142 0 obj <>/Filter/FlateDecode/ID[<50BF235CB0813E4C89D853A2B2492B60><1D4202BFC1803A4BB7FE6E056AB3B3AE>]/Index[118 40]/Info 117 0 R/Length 115/Prev 160342/Root 119 0 R/Size 158/Type/XRef/W[1 3 1]>>stream With over 25K providers, 100+ hospitals, 5K practices, 250+ urgent & ambulatory care centers, Fidelis Care is here to support your team's needs. 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. Contact: Legal Aid Society Health Hotline (212) 577-3575 or email . Check member eligibility status. Find a plan that's right for you. No. Covered services range from emergency visits to prenatal care. When was the Dental Fee Schedule established? Video visits. 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). Early treatment prevents them from getting worse. SeeDental Policy and Procedure Code Manual,page 24. General suggestions for succeeding at a fair hearing: Establish, through evidence, that the procedure is medically necessary. $0 premiums, deductibles, and co-insurance. <]>> The dental provider should ask the patient at the first visit if their injuries sustained in a motor vehicle accident occurred while working. For children under 7 years of age, ask the dentist or primary care doctor about fluoride varnish. However, the dental provider must have a valid NYS dental license. Placement of the upper denture was expected to improve appellants chewing ability. You can only obtain legal advice from a lawyer. By understanding the nuances of the benefit, advocates can help get their clients the coverage they need. We are here Monday through Saturday from 8:00AM to 8:00PM. 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. With the Active&Fit ExerciseRewards program, you can earn $200 every six months if you visit a qualifying fitness center at least 50 days during the same six-month reward period. 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. 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. 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. To make the transition as transparent and seamless as possible for both the provider and patient. Provide as much evidence and medical documentation as possible of the need for and benefit of the work. DQUSA.TX.IND.POL 2.15 4 Part I Definitions . 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/. xwTS7PkhRH H. Just clickhereto find a representative in your neighborhood who speaks your language and is ready to help. See Dental Policy and Procedure Code Manual,page 24. Tooth sensitivity to heat, cold or sweets. You do not need a referral from your PCP to see a dentist. 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. You may be required to submit proof that you have applied for Medicare so please keep your award or denial letter from SSA or your on line receipt from SSA. (available here), Example: Appellant requested replacement of broken denture prior to the 8 year waiting period. There is a strong relationship between your oral health and your overall health. Our dental network partner is changing in 2022 from DentaQuest to Healthplex for certain dental products. Talk To Us About Any Questions or Concerns. @Rt CXCP%CBH@Rf[(t CQhz#0 Zl`O828.p|OX Aug. 28, 2012. Their dental network is 65% larger than what we have been offering, with more dentists and specialists available than before. 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. Request for Decision on Unpaid Bills (Form HP-1.0) is used by a health care provider to ask the Board to make a determination whether a claim administrator should pay a medical bill, which they previously declined to pay in full, or in part, for services rendered to a patient who has a workers' compensation case. If you are interested in applying to become a participating provider in our Dental Plan Network, please Annual trainings are updated annually in the Fall and should be completed each year no later than December 31st.
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