For New Yorkers living with HIV/AIDS and other select groups. If the patient was not working at the time of the accident, the nofault insurer should be billed. No. Plus, when you join our Preferred network you automatically become a participant of our discounted Dental Access Program,and the Preferred Premier plan. Use your next visit as a chance to go over how to floss and brush the right way. Your participation in both networks may prove beneficial to your practice. The Medicaid dental benefit is limited and includes only essential services. Essential Services. 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. Note: The HP-1.0 form is submitted through OnBoard but the rest of the process remains the same. We use cookies to make your experience better. 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. Provision of orthodontic treatment will require Plan approval. To choose a Primary Care Dentist (PCD) or if you need help finding a dentist in your area, call DentaQuest at 844-284-8819. These changes, described below and in this document, will take effect on November 12, 2018. Orthodontic exam and evaluation and treatment will be billed using the dental fee schedule.*. If you have any concerns about your health, please contact your health care provider's office. 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. Learn more here. The 31st . 56.5 mi. What is the current version of the Dental Fee Schedule? >> 0000002197 00000 n MetroPlusHealth Medicaid Managed Care is our plan for people eligible for Medicaid, a government assistance program. One of our representatives will reach out to you ASAP to review your plan options. 5 verified reviews. 0000001777 00000 n Talk To Us About Any Questions or Concerns. SBHC services are identified by the following FFS rate codes: Free-standing FQHCs (not in APGs) - 1627, 1628, Hospital FQHCs (not in APGs) - 2888, 2889. Log into your account, view patient information, and more. Copies of bills and treatment plans should also be: Please review instructions found on How To Submit Claims-Related Forms and Documents to WCB. MetroPlusHealth has offered low-cost, quality health care for New Yorkers for more than 35 years. Welcome to Our Web Portal! The insurer did not respond to within the established time limits, OR, did not pay my dental bill in full. See Dental Policy and Procedure Code Manual, page 24. Mitigating factors surrounding these circumstances should be included with the prior approval request. FH #6755535N. Orthodontic treatment will require SDOH approval. See Dental Policy and Procedure Code Manual, page 8. If you have Medicaid, you MUST apply for Medicare as a condition of continuing eligibility. /Length 2596 UnitedHealthcare of New York, Inc. Dentaquest Empire Health Choice HMO, Inc. Fidelis Care New York; Healthfirst PHSP, Inc. With the 2023 NFL Draft in the books . No, any dental provider with any type of dental specialization can treat workers compensation patients. 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. CPT Procedures would be billed out according to the prevailing workers compensation medical fee schedule for the region in which the services are performed. << Dentist. Members who need dental care should be directed to our Find a Doctor directory. Members can find a list of network pharmacies or use our online provider search tool. Your benefits include dental check-ups, cleaning, x-rays, fillings and follow-up care. $0 premiums for all who qualify, and no deductible, so it pays for your care right away. Our four dental networks consist of over 8,000 dentists and dental specialists practicing in New York and New Jersey. Before continuing using our website you agree and accept our cookie policy & privacy. 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. See Dental Policy and Procedure Code Manualpage 24. You may be able to continue receiving meals as long as you are eligible for this program. Not all dental codes are listed on the Dental Fee Schedule. Monkeypox cases are rising in NYC. No copays. Upload necessary documentation. Manage Your Health Online With MyChart. Nor was she able to establish that extraction of tooth number 18 is contraindicated for health reasons. See Dental Policy and Procedure Code Manual, page 43. Servicing members for more than one state. StartingJanuary 1, 2023, MetroPlusHealth will cover Gambling Disorder Treatment provided by Office of Addiction Services and Supports (OASAS) certified programs. Dental services at these clinics may be accessed without prior approval and without regard to network participation. About 3.8 million . Published: Apr 29, 2023 at 07:08 PM Updated: Apr 29, 2023 at 07:36 PM. provider and client notified of denial and rights to appeal. Prior authorize treatment on or after October 1, 2012, Contract with a sufficient array of providers, Conduct quality of care reviews at least annually. Do I need to be authorized by the Board to provide dental treatment to workers compensation patients? 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. 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. 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 No, if you accept a workers' compensation patient, you must charge the fees as indicated in the Dental Fee Schedule. 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. For more information about what services are included, see the state regulation. The workers compensation insurer is liable only for reimbursement for treatment necessitated by the work-related accident. xwTS7PkhRH H. There is a strong relationship between your oral health and your overall health. 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). endstream endobj 12297 0 obj<>/W[1 1 1]/Type/XRef/Index[255 12030]>>stream Find MetroPlusHealth offices, events, and local family care sites right near you. Though the Appellant accidentally broke the lower denture, dentures which are broken will not be replaced unless they become unserviceable through trauma, disease or extensive physiological change. All bills submitted using CDT code D9999 should be accompanied by a report providing the reasons why such procedures are necessary. The appellant did not dispute that she had the 8 points of contact. Prior approval requests for replacement dentures prior to eight years must include a letter from the patients physician and dentist. 22 - 24, If "Decisive Appointment" prior to enrollment, insurer on date of decisive appointment pays for entire procedure, Applies to new members enrolling from FFS or another Plan. You do not need a referral from your PCP to see a dentist. Learn more about your new dental benefit here. The placement of the component parts (e.g. 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. A D5110 denture was now $656.20, D5213 $676.60, D5214 $676.60. Payments can also be sent electronically via "Electronic Funds Transfer (EFT)". A yearly cleaning at your dentists office helps prevent gum disease. Available today. Meet our leadership, join our team, or get in touch with MetroPlusHealth. 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. I need a dental provider for treatment for a work injury. What do I do if I get my medications from Walgreens or Duane Reade? Participants meet a high credentialing standard and agree to treat covered patients at the fees detailed in our fee schedules. Services are provided at home or in the community. A plan for New Yorkers who have or are eligible for Medicaid. Then the child needs a dental checkup every 6 months or as determined by the childs dentist. Explore Qualified Health Plans (QHP) through the NY State of Health, The Official Health Plan Marketplace. Can I charge the patient the balance between my fee and the workers compensation dental fee? 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. An insurer can controvert a claim, claiming they are not liable for lost wage payments or medical expenses. Learn how to use this new tool (and more) by attending one of our scheduled WebEx trainings. Without a referral, our members can seek care from any general dentist or dental specialist who participates with their dental plan. Lack of Dental Coverage Hampers Medicaid Recipients, Suit Says, EFFECTIVE NOV. 12, 2018 the new policy on denture replacement is, Dental and Orthodontic Services to be Included in the Medicaid Managed Care Benefit Package. 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. 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. 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. Join Our Dental Networks. This means that four maxillary (upper jawbone) and four mandibular (lower jawbone) teeth in functional contact with each other are considered adequate. Learn more below, in the Plan Materials section. %%EOF Do I need to request for prior authorization to the workers compensation insurer for dental treatment? What type of workers compensation form should the dental provider use to bill for treatment? They also 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. This means that every time you visit this website you will need to enable or disable cookies again. 807 Spring Forest Rd, Ste 600, Raleigh, NC 27609. These meals are tailored for your specific health needs and can help you gain access to healthy, nutritious foods. 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. A letter from the patients dentist must explain the specific circumstances that necessitates replacement of the denture. Whether you are looking for a new customized dental plan for your group, wish to have your existing dental program redesigned, or simply want to lower your overall dental costs, Healthplex can offer you a spectrum of flexible, affordable options. At DentaQuest, we are committed to improving oral health by redefining prevention and care. You do not need a referral from your PCP to see a dentist. Appellant testified he was taking the denture out at night to clean when he accidentally dropped it on the floor and two of the teeth broke off. Just call1.800.303.9626(TTY:711). We use cookies to make your experience better. Procedure codes and billing guidelines will follow. The letter from the physician must explain how dentures would alleviate the patients serious health condition or improve employability. Find the specific content you are looking for from our extensive Provider Manual. You can perform a search on the internet or use local telephone resources. The agencys denial was affirmed because although the appellants testimony indicated that she might have qualified for the partial lower denture, the appellant failed to present any medical documentation that proved her medical condition. 2020 EmblemHealth. [/ICCBased 3 0 R] 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). Get inspired on our Blog, find answers to your questions in our FAQs, and explore our health library. DENTAL FEE SCHEDULE 1. Welcome to EmblemHealth Dental Find a Dental Specialist Benefit From Network Participation. American Dental Association: http://www.ada.org/en/, New York State Dental Association: http://www.nysdental.org/. Our Preferred and Preferred Plus Networks 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. Early treatment prevents them from getting worse. During the 1st month no new participants joined, but 10 people under 65 in group A and 5 people over 65 in . 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. 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. Procedure Fee Files & CPT Codes . 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. Preventive care includes immunizations, physical exams, lab tests and prescriptions. 0 Please refer to your Membership Agreement, Certificate of Coverage, Benefit Summary, or other plan documents for specific information about your benefits coverage. SeeDental Policy and Procedure Code Manual,page 59. Important notice about your Medicaid managed care plan benefits. Find our Quality Improvement programs and resources here. Learn more on our Children and Family Support Services pagehere. 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. 0 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. The Dental Fee Schedule became effective on 3/1/2009. See all PARs submitted by dental providers. 0000003098 00000 n 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. Dental services for children are provided as part of Medicaids Early Periodic Screening, Diagnosis and Treatment (EPSDT) program. Please click here to access the training schedule. The dental provider can use any usual and customary dental billing forms. Agency denial upheld. No. Dental implants will be covered by Medicaid when medically necessary. I have a patient who is seeking dental treatment as a result of a motor vehicle accident, do I bill the NoFault insurer or the workers compensation insurer? You do not need a referral from your PCP to see a dentist. 0000000016 00000 n 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. 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. Claims submitted for the treatment of deciduous cuspids and molars for children ten (10) years of age or older, or for deciduous incisors in children five (5) years of age or older will be pended for professional review. Even though appellant could not eat the food she required for her diabetes, appellant presented no objective medical evidence to support her contention that her lack of the lower denture will cause her health to be compromised. If the patient was working at the time of the accident, it should be treated as a workers' compensation claim. Our Member Services team is always here to help. xb```b``y ,@Q{ TjJ|UY=9sA6VK|ox9vdhLuaZ9r3?sfAf128 pVb"/@beSi1bL=> 0000003050 00000 n This website uses cookies so that we can provide you with the best user experience possible. 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. If you disable this cookie, we will not be able to save your preferences. 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. General information about NYRx, the Medicaid Pharmacy Program can be found here along with information for Members and Providers. Covered services range from emergency visits to prenatal care. FH # 7484720Z(available here). 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. Appellant testified that she lost her lower denture at home. To choose a Primary Care Dentist (PCD) or if you need help finding a dentist in your area, call DentaQuest at 844-284-8819. You may not accept a fee from a patient for services relating to an on-the-job injury. There is no cost to file an application with CAQH and it can be completed online. MetroPlusHealthMedicaid Managed Care offers low- or no-cost health coverage to New Yorkers who live anywhere in New York City. Implant Services (revised Nov. 12, 2018. Contact: Legal Aid Society Health Hotline (212) 577-3575or email . Our comprehensive, innovative programs, are designed to control costs and assure quality care. Decisions are often remanded, or sent back to the plan to make another determination, when the plan fails to provide support for their basis of denial. More Information Coronavirus (COVID-19) Keep yourself informed about Coronavirus (COVID-19.) Update Your Practice Records. Dental providers may use OnBoard to submit prior authorization requests for treatment. The dental provider can use any usual and customary dental billing forms. Provider Enrollment - DentaQuest. For children under 19 who are not eligible for Medicaid and have little or no health insurance. Dental Care Regular dental visits help keep your smile healthy. Check benefits. Zocdoc helps you find Dentists in Queens and other locations with verified patient reviews and appointment availability that accept DentaQuest and other insurances. See Dental Policy and Procedure Code Manual, page 38. 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. /Filter /FlateDecode We respect the contributions of our providers. Pregnant women: Pregnant women should see a dentist at least one time during pregnancy. We are here Monday through Saturday from 8:00AM to 8:00PM. If you have questions, please call Customer Services team at 1-800-303-9626. Before continuing using our website you agree and accept our cookie policy & privacy. A dental visit should include a professional cleaning. Please be sure to tell us which plan handbook for example, Medicaid you need. hbbd```b``z"g E,r D2`i`v X.X1X$ LNH`Xed_@d:H=D bg`ig ^ The denial was reversed. L. 111-148).. Physical activity is one of the simplest ways to stay healthy, and Healthfirst makes it even more rewarding! Tell us more about yourself to find qualifying plans and estimate costs. Medicaid members can access dental care using their MetroPlusHealth ID card. For information regarding No-Fault Insurance, contact the NYS Department of Financial Services. Dental care and "exam and evaluation for orthodontic treatment" without Plan approval. 0000000575 00000 n 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 To schedule your first appointment within our teaching clinic, please call the Dental Care Center between 8:30am and 5pm, Monday through Friday. No. The dental provider must have a valid NYS dental license. Dr. Deborah Simmers, DMD. 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. Start a NEW Online Credentialing Application Continue an ALREADY STARTED Online Credentialing Application 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. All Rights Reserved. Any information provided on this Website is for informational purposes only. What type of workers compensation form should I use to bill for dental treatment? . 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. Any dental billing forms with the appropriate code and fee as found in this dental fee schedule can be used. Nofault rules and regulations can be found at the. xref **You must participate in the Preferred network to also participate in the Spectrum network. School Based Health Center dental services will continue to be carved out of Managed Care and will remain billable Fee-for- Service. PEF Dental and/or Vision Only. brackets, bands) does not constitute complete appliance insertion or active treatment. See Plan information, Health Rewards, and Messages, Find someone in your neighborhood and in your language. During your appointments, the dentist can find any cavities early and treat them. Good practice is to review your contracted fee schedules annually.
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