L. 111-148).. Provision of orthodontic treatment will require Plan approval. Preventive care includes immunizations, physical exams, lab tests and prescriptions. Copies of bills and treatment plans should also be: I do not know the patients workers compensation insurer. In both cases, a Workers' Compensation Law Judge will decide the dispute. 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. No copays. Find DentaQuest Dentists in Queens, New York & make an appointment online instantly! 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. SoMetroPlusHealth is happy to announce that effective immediately, Medical Answering Services, LLC (MAS) will be responsible for providing you with non-emergency medical transportation services for eligible Medicaid beneficiaries living in the five boroughs of New York City. Get inspired on our Blog, find answers to your questions in our FAQs, and explore our health library. 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. For more information about what services are included, see the state regulation. 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. You do not need a referral from your PCP to see a dentist. Find MetroPlusHealth offices, events, and local family care sites right near you. [/ICCBased 3 0 R] 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. Revised policy effective November 12, 2018 - click on these links: VI. 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. Dental services at these clinics may be accessed without prior approval and without regard to network participation. The limited extended coverage is provided through FFS for up to a six-month period following loss of Medicaid eligibility. $0 premiums, deductibles, and co-insurance. 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. The coverage is limited to three years of treatment and one year of retention care. Child Health Plus cover routine, preventive and emergency dental services through DentaQuest. ACA: The Patient Protection and Affordable Care Act of 2010 (Pub. 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. Dr. Visit . For Medicaid recipients who meet certain income, resource, age, or disability requirements. Navigators and Certified Application Counselors, NY State of Health, The Official Health Plan Marketplace, online at. We respect the contributions of our providers. 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. This service requires prior approval. 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. Review claims status. Please be sure to tell us which plan handbook for example, Medicaid you need. %PDF-1.7 Several payers set fees based on market rates. 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. MetroPlusHealth members can access the Member Portal, find doctors, specialists, and pharmacies, and view member benefits. 1 0 obj These changes, described below and in this document, will take effect on November 12, 2018. Our 24/7 Customer Service Hotline will answer your call at other times and on holidays. To schedule your first appointment within our teaching clinic, please call the Dental Care Center between 8:30am and 5pm, Monday through Friday. 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. 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. Copies of bills and treatment plans should also be: Please review instructions found on How To Submit Claims-Related Forms and Documents to WCB. Yes, any dental provider can refuse to treat a workers compensation patient for dental services. 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. In the event that the recipient has a record of not successfully wearing prosthetic replacements in the past, or has gone an extended period of time (three years or longer) without wearing a prosthetic replacement, the prognosis is poor. By clicking on these links, you will leave the Fidelis Care website. 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. @Rt CXCP%CBH@Rf[(t CQhz#0 Zl`O828.p|OX General information about NYRx, the Medicaid Pharmacy Program can be found here along with information for Members and Providers. Just clickhereto find a representative in your neighborhood who speaks your language and is ready to help. If you have more questions, please call our Customer Services team at1-800-303-9626. xwTS7PkhRH H. 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). Can I refuse to treat a workers compensation patient for dental services? NEW YORK Healthcare done well. We also want to ensure you arrive at your appointment timely without having to rely on family or friends for your transportation. 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. Please click here to access the training schedule. Provide the highest level of healthcare in New York and save up to 20% with our narrow network. Cookie information is stored in your browser and performs functions such as recognising you when you return to our website and helping our team to understand which sections of the website you find most interesting and useful. An insurer can controvert a claim, claiming they are not liable for lost wage payments or medical expenses. Treatment occurs where the examination and evaluation was done (submitting provider), Providers continue to perform exam and evaluations for both FFS and MMC patients and submit prior approval requests for review and determination by FFS Dental Bureau, Last day for providers to submit prior approval requests for MMC patients to FFS for review and determination, Continue to submit requests for clients that are FFS (not enrolled in a MMC plan) to SDOH for review and determination, Submit emergency/urgent cases (MMC enrolled) to SDOH for review and determination, Submit any new cases where the client is enrolled in a MMC Plan directly to the Plan for review after, To be paid for initial placement (D8070, D8080 or D8090) through FFS the provider will need an eMedNY PA, To be paid for ongoing orthodontic treatment FFS (quarterly payments(D8670), retention (D8680 etc. Our dental network partner is changing in 2022 from DentaQuest to Healthplex for certain dental products. They will keep getting services through regular Medicaid. 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. How to Access Your Member Portal Procedure codes and billing guidelines will follow. Search based on your schedule. Dental work for cosmetic reasons or because of the personal preference of the recipient or provider; Although Medicaid Dental is limited to essential services, if you believe your claim has been improperly denied, you may request a plan appeal (in Medicaid managed care) or a Fair Hearing. Do I need to be specialized in order provide treatment to workers compensation patients? 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. 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. Message DentaQuest through secure messaging. At DentaQuest, we are committed to improving oral health by redefining prevention and care. Form HP-1.0 should be submitted, along with any necessary attachments, such as copies of medical bills, through OnBoard. Include several previously exempt and excluded populations, *Enrollment numbers are based on May 2012 data. 157 0 obj <>stream /N 3 For beneficiaries age 21 and older, molar endodontic therapy will be considered when (1) the tooth in question is a critical abutment for an existing functional prosthesis and (2) the tooth cannot be extracted and replaced with a new prosthesis. 0 Health & Safety in the Home, Workplace & Outdoors, Clinical Guidelines, Standards & Quality of Care, All Health Care Professionals & Patient Safety, Transition of Dental and Orthodontia Coverage Power Point, https://www.emedny.org/ProviderManuals/Dental/index.aspx, https://www.emedny.org/Listserv/eMedNY_Email_Alert_System.aspx, https://www.emedny.org/meipass/index.aspx, James V. McDonald, M.D., M.P.H., Acting Commissioner, Multisystem Inflammatory Syndrome in Children (MIS-C), Addressing the Opioid Epidemic in New York State, Health Care and Mental Hygiene Worker Bonus Program, Maternal Mortality & Disparate Racial Outcomes, Help Increasing the Text Size in Your Web Browser, "Examination and Evaluation" performed by ANY orthodontist or clinic participating in Medicaid FFS for both FFS and MMC enrollees. Contact ExerciseRewards at 1-877-810-2746 to learn more . Dental services for the state's poor moved into managed care on July 1. hbbd```b``z"g E,r D2`i`v X.X1X$ LNH`Xed_@d:H=D bg`ig ^ In addition to the treatment due to the patient's accident at work, the patient also needs full mouth periodontal treatment and additional root canal and restorative treatment. Dr. Deborah Simmers, DMD. You can only obtain legal advice from a lawyer. 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. MyChart is a free secure portal you can use to manage your health information. Please note in order to be eligible for Medicaid transportation benefits your provider must complete Form 2015 which is verification of Medicaid Transportation Abilities. 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. . See Dental Policy and Procedure Code Manual, page 24. Procedure Fee Files & CPT Codes . 50 Water Street, 7thFloor IMPORTANT NOTICE FOR OUR MEDICAID MEMBERS AGED 18 YEARS AND OLDER. Update Your Practice Records. Under Medicaid, dental benefits exist, but the coverage is limited. 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. During the 1st month no new participants joined, but 10 people under 65 in group A and 5 people over 65 in . /Length 2596 Welcome to Our Web Portal! *You must participate in the Preferred network to also participate in the Dental Access Plan. When an individual changes insurers (either fee-for-service to Medicaid managed care (MMC) or changes plans) in the midst of a course of treatment, the insurer at the time of the decisive appointment is responsible for the payment for the entire treatment. This person is a food and nutrition expert and will help give guidance and support in choosing healthy foods. All relevant billing forms and treatment notes should be sent to the workers' compensation insurer. A dental visit should include a professional cleaning. Under this program, children can receive periodic oral evaluations and preventive, restorative, and emergency dental care. You can perform a search on the internet or use local telephone resources. Resources. Upload necessary documentation. Neighborhood Health Providers, LLC; . The new rule on replacement dentures imposes new documentation requirements and will be a step backward for some. 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. This allows you to submit and maintain your credentialing information at one location rather than filing with many organizations. % Note: The HP-1.0 form is submitted through OnBoard but the rest of the process remains the same. Payers may use the charges you submit to determine maximum-allowable fees. Zocdoc helps you find Dentists in Queens and other locations with verified patient reviews and appointment availability that accept DentaQuest and other insurances. Find a Dentist in New York 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. 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. Submit claims and authorizations. The dental provider submitted a bill with codes that are not listed on the Dental Fee Schedule. What is the current version of the Dental Fee Schedule? 12287 0 obj<>stream 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. Orthodontic treatment will require SDOH approval. Can I charge the patient the balance between my fee and the workers compensation dental fee? Also, this information is not intended to imply that services or treatments described in the information are covered benefits under your plan. Starting July 1, 2022, you can join a no-cost Medically Tailored Meals program that provides healthy meals straight to your home. Check member eligibility status. Please refer to your Membership Agreement, Certificate of Coverage, Benefit Summary, or other plan documents for specific information about your benefits coverage. Your oral health is important to us. Please contact the Medical Directors Office at 1-800-781-2362 or [email protected]. Beyond representing an act of public service in your community, we want your participation in our network to represent a sound business decision. Were here to help. Claims submitted by a dental provider to the insurer shall be paid within fortyfive calendar days of receipt of the claim. Where should I send the dental billing forms? Submit Electronic Claims and Dental Claim Forms. Meet our leadership, join our team, or get in touch with MetroPlusHealth. /Filter /FlateDecode 0 If there are no similar listed dental codes, the provider should use CDT code 09999 "Unlisted Adjunctive Procedure By Report", where the provider should establish a fee consistent in relativity with the other fees listed in the dental fee schedule. Meet our leadership, join our team, or get in touch with MetroPlusHealth. See Dental Policy and Procedure Code Manual, page 24. Members who need dental care should be directed to our Find a Doctor directory. CPT Procedures would be billed out according to the prevailing workers compensation medical fee schedule for the region in which the services are performed. Find our Quality Improvement programs and resources here. 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. Dental implants and related services (BUT THIS WILL CHANGE NOV. 12, 2018 to the following policy: VIII. At DentaQuest, we are committed to improving oral health by redefining prevention and care. Please call the DentaQuest Provider Hotline (888) 308-2508. The Appellant stated that with the denture being broken, he is left without any teeth, natural or otherwise, in his mouth. Find a plan that's right for you. Orthodontic exam and evaluation and treatment will be billed using the dental fee schedule. FH# 6478476L (available here), Example: Appellant was approved for placement of an upper denture but was denied for a lower partial denture. Childrens Dental Benefit. MFk t,:.FW8c1L&9aX: rbl1 Provide as much documentation as possible to show that the procedure was (1) medically necessary and (2) that an insufficient number of teeth met the points of contact rule. StartingJanuary 1, 2023, MetroPlusHealth will cover Gambling Disorder Treatment provided by Office of Addiction Services and Supports (OASAS) certified programs. If you have any concerns about your health, please contact your health care provider's office. General suggestions for succeeding at a fair hearing: Establish, through evidence, that the procedure is medically necessary. FH #6755535N. 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. Upload necessary documentation. 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. With over 25K providers, 100+ hospitals, 5K practices, 250+ urgent & ambulatory care centers, Fidelis Care is here to support your team's needs. During your appointments, the dentist can find any cavities early and treat them. My dental provider does not want to treat and/or accept workers compensation patients. Learn more on our Children and Family Support Services pagehere. Member and Provider FAQs - Pharmacy Benefit Carve-Out. The denial was reversed. Start a NEW Online Credentialing Application Continue an ALREADY STARTED Online Credentialing Application Adverse determination: a utilization review decision by the Plan, or a health care provider acting on behalf of the Plan that: . 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. SeeDental Policy and Procedure Code Manual, page 24. We use cookies to make your experience better. Covered services range from emergency visits to prenatal care. Not all dental codes are listed on the Dental Fee Schedule. The Great Expressions Difference. Your benefits include dental check-ups, cleaning, x-rays, fillings and follow-up care. Strictly Necessary Cookie should be enabled at all times so that we can save your preferences for cookie settings. Contact Number. Prior approval requests for implants must have supporting documentation from the patients physician and dentist. If it has been over a year since you have seen a dentist, we recommend that you make an appointment to see one as soon as possible. Where possible, the provider should use similar listed codes found on the Dental Fee Schedule and bill accordingly. 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. For Medicaid recipients 21 or older who need additional resources for behavioral health. How do I request prior authorization for treatment? endstream endobj startxref Recently, we sent you an announcement along with your new ID Card about our new partnership with DentaQuest, a dental vendor. How would I charge for procedures not listed on the dental fee schedule? startxref 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. 56.5 mi. Learn more here. Medicare members can call us 24/7 at1.866.986.0356(TTY: 711). Basic plan is FREE for NYC workers and their families! Accordingly, there is often coverage for replacing but not treating a tooth. What should I do? 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. For information regarding No-Fault Insurance, contact the NYS Department of Financial Services. Tooth sensitivity to heat, cold or sweets. Is this allowed? %PDF-1.6 % If you disable this cookie, we will not be able to save your preferences. The Fair Hearings described below were decided based on the OLD denture Policy, which expires Nov. 11, 2018. Provider Update ALSO OF INTEREST 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. The insurer did not respond to within the established time limits, OR, did not pay my dental bill in full. 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. PEF Dental and/or Vision Only. Dental care and "exam and evaluation for orthodontic treatment" without Plan approval. 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. 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. The insurer can also dispute the necessity for dental treatment or that the injuries were not related to the patient's employment. To make the transition as transparent and seamless as possible for both the provider and patient. 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? Our comprehensive, innovative programs, are designed to control costs and assure quality care. Nofault rules and regulations can be found at the. Medicaid Orthodontic Benefit. 118 0 obj <> endobj 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.
dentaquest fee schedule new york
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