dentaquest fee schedule new york

endstream endobj startxref Medicaid Dental Coverage includes only essential services, rather than comprehensive care. However, the appellant stated that she suffered from Multiple Sclerosis, which paralyzed the right side of her mouth. Copies of bills and treatment plans should also be: Mailed to: NYS Workers' Compensation Board, PO Box 5205 Binghamton, NY 13902-5205, OR Email: wcbclaimsfiling@wcb.ny.gov, OR Web Upload Early treatment prevents them from getting worse. Cleft palate or approved orthognathic surgical cases may be approved for additional treatment time. Learn morehere. 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. Dental providers are required to register for the Medical Portal and submit a request for prior authorization using OnBoard. 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. WHAT DENTAL SERVICES ARE COVERED UNDER MEDICAID? 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. No. No premiums. 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. Thus, if this is met, services may not be considered essential. General suggestions for succeeding at a fair hearing: Establish, through evidence, that the procedure is medically necessary. There are no relevant workers compensation forms for billing purposes. 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. 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. >> Workers' Compensation Law does not require dental providers to be authorized by the Board. Please call the DentaQuest Provider Hotline (888) 308-2508. Credible testimony by the appellant alone is not sufficient in these types of cases. 0000001459 00000 n You can contact any dental provider in your local area to perform workers compensation dental service. 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. Form HP-1.0 should be submitted, along with any necessary attachments, such as copies of medical bills, through OnBoard. 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. 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. 5 verified reviews. 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. New York, NY 10004 Note to Out-of-Network Providers: This schedule displays reimbursements for commonly utilized services on an out-of-network basis only. Medicaid Orthodontic Benefit. Help from a registered dietitian and nutritionist. Note: The HP-1.0 form is submitted through OnBoard but the rest of the process remains the same. Any information provided on this Website is for informational purposes only. 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. 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. However, the dental provider must have a valid NYS dental license. What type of workers compensation form should the dental provider use to bill for treatment? You can also contact the NY Dental Association to find a dentist. MetroPlusHealth members can access the Member Portal, find doctors, specialists, and pharmacies, and view member benefits. Covered services range from emergency visits to prenatal care. 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. Home Provider Enrollment. 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. Get inspired on our Blog, find answers to your questions in our FAQs, and explore our health library. Review claims status. Consequently, she could only use the left side of her mouth to eat. They will keep getting services through regular Medicaid. Find a plan that's right for you. **You must participate in the Preferred network to also participate in the Spectrum network. By providing you with advanced technological tools, we eliminate the administrative burden associated with participating in government-sponsored programs. Capital District Physicians Health Plan, Inc. Yes- Bronx, Kings, New York, Queens, Nassau, Richmond. See Dental Policy and Procedure Code Manualpage 24. The dental provider can use any usual and customary dental billing forms. Zocdoc helps you find Dentists in Queens and other locations with verified patient reviews and appointment availability that accept DentaQuest and other insurances. How would I charge for procedures not listed on the dental fee schedule? The workers compensation dental fee for my patient's treatment is less than my usual fees. School Based Health Center dental services will continue to be carved out of Managed Care and will remain billable Fee-for- Service. Top Undrafted Rookie FAs. The provider manual clarifies that this means children should receive routine preventive dental care every six months, and additional visits should be based upon the dentists assessment of the childs individual needs. File Notice of Objection to a Payment of a Bill for Treatment Provided (Form C-8.1B), or Notice to Health Care Provider and Claimant of an Insurer's Refusal to Pay All (or a portion) of a Medical Bill Due to Valuation Objection(s) (C-8.4), as appropriate. The letter from the physician must explain how dentures would alleviate the patients serious health condition or improve employability. Around the NFL Staff. 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. You can find any other dental provider that is willing to perform this service and accept the Dental Fee Schedule. View 2022-Fee Schedule - Dentaquest.docx from EGL 111 at Oakton Community College, Skokie. Provider Update ALSO OF INTEREST See EPSDT/CTHP Provider Manual for Child Health Plus A (Medicaid), page 12 https://www.emedny.org/ProviderManuals/EPSDTCTHP/PDFS/EPSDT-CTHP.pdf. endobj Revised policy effective November 12, 2018 - click on these links: VI. In these cases, you shouldnt be charged more than your plans copayments, coinsurance and/or deductible. A dental visit should include a professional cleaning. No, if you accept a workers' compensation patient, you must charge the fees as indicated in the Dental Fee Schedule. Example: Appellants dentist submitted a prior authorization for root canal therapy on Appellants tooth number 18 (molar). 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. Here are some good practices to follow to ensure proper oral hygiene. Starting January 1, 2023, you can begin to use your new ID Card for all your health care needs, including dental services with DentaQuest. When Medicaid eligibility is lost after active orthodontic treatment has been initiated, the FFS or MMC patient may choose to continue treatment as private pay or through commercial insurance, or access Medicaid FFS for. 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. Interested in learning more aboutPreventive Dental Care? Brush twice a day with fluoride toothpaste. Can an insurer deny a workers compensation dental claim? Placement of the upper denture was expected to improve appellants chewing ability. See all PARs submitted by dental providers. Resources. 1 0 obj 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? Information about the transition of the pharmacy benefit from MetroPlusHealth to NYRx, the Medicaid Pharmacy Program can be found here. We can even enroll you over the phone. 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. Adverse determination: a utilization review decision by the Plan, or a health care provider acting on behalf of the Plan that: . By clicking on these links, you will leave the Fidelis Care website. 2020 EmblemHealth. This means that every time you visit this website you will need to enable or disable cookies again. <]>> 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. 50 Water Street, 7thFloor Nofault rules and regulations can be found at the. A yearly cleaning at your dentist's office helps prevent gum disease. About 3.8 million . 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). MetroPlusHealth has offered low-cost, quality health care for New Yorkers for more than 35 years. 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. The dental provider submitted a bill with codes that are not listed on the Dental Fee Schedule. Fixed bridgework, except for cleft palate stabilization, or when a removable prosthesis would be contraindicated; Molar root canal therapy for beneficiaries 21 years of age and over, except when extraction would be medically contraindicated or the tooth is a critical abutment for an existing serviceable prosthesis provided by the NYS Medicaid program; Replacement of partial or full dentures prior to required time periods unless appropriately documented and justified as stated in the Manual -- see changes effective Nov. 12, 2018. The fee schedules are typically part of the Where should I send the dental billing forms? 3 0 obj This service requires prior approval. Is this allowed? Join Our Dental Networks. 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. We offer five dental plans to employer groups throughout New York State and to their employees who live in or out of the state. $0 premiums for all who qualify, and no deductible, so it pays for your care right away. 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. We respect the contributions of our providers. 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. 0000000575 00000 n Your oral health is important to us. Yes, any dental provider can refuse to treat a workers compensation patient for dental services. 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. Services are provided at home or in the community. Where possible, the provider should use similar listed codes found on the Dental Fee Schedule and bill accordingly. Dental Care Regular dental visits help keep your smile healthy. 12285 0 obj<> endobj {{{;}#tp8_\. Beyond representing an act of public service in your community, we want your participation in our network to represent a sound business decision. Important Notice:Effective October 1, 2021, our members now access their behavioral health services through MetroPlusHealth. Dental implants will be covered by Medicaid when medically necessary. Any dental billing forms with the appropriate code and fee as found in this dental fee schedule can be used. Strictly Necessary Cookie should be enabled at all times so that we can save your preferences for cookie settings. MetroPlusHealth has offered low-cost, quality health care for New Yorkers for more than 35 years. View up-to-date payment information. Log in, register for an account, pay your bill, print ID cards, and more. 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. Payments can also be sent electronically via "Electronic Funds Transfer (EFT)". Find our Quality Improvement programs and resources here. The plan must reimburse the clinic for covered dental services provided to enrollees at approved Medicaid clinic rates. In addition, dental providers may use OnBoard to request dental-related DME and medications, and to submit Form HP-1.0. Orthodontic exams and evaluation without SDOH approval. . These networks are separate and unrelated and each has distinct patient enrollment and reimbursement schedules. The Board does not authorize dental providers and does not provide lists of dental providers as referrals. 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. For information on which services do and do not require prior approval and authorization, click on this link to the regulation: For information on orthodontic care coverage, click on thislink to the regulation. Several payers set fees based on market rates. See Dental Policy and Procedure Code Manualpage 24. Accordingly, there is often coverage for replacing but not treating a tooth. 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). Our four dental networks consist of over 8,000 dentists and dental specialists practicing in New York and New Jersey. Extraction of deciduous teeth will only be reimbursed if injection of a local anesthetic is required. See Dental Policy and Procedure Code Manual, page 24. xwTS7PkhRH H. 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. The current policy states effective until Nov. 12, 2018, "Full and/or partial dentures are covered when required to alleviate a serious health condition or a condition that affects employability. A letter from the patients physician must explain how implants will alleviate the patients medical condition. Low-cost plans for daycare workers in New York City. StartingMay 16, 2022, the way Personal Care Services and Consumer Directed Personal Assistance Services (PCS/CDPAS) are initially assessed will be changing. Find MetroPlusHealth offices, events, and local family care sites right near you. Please click here to access the training schedule. See Dental Policy and Procedure Code Manual, page 8. will be required by the Plans, Prepare to submit prior approval requests to the Plans on and after 7/2/2012, Requests for emergency or urgent care can be submitted to FFS, Providers must begin submitting claims and prior approval requests to the beneficiarys plan, All FFS prior approval requests for beneficiaries enrolled in a MMC Plan will be automatically, Any prior approval that has been issued through FFS is. 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, any dental provider with any type of dental specialization can treat workers compensation patients. Before continuing using our website you agree and accept our cookie policy & privacy. Our dental network partner is changing in 2022 from DentaQuest to Healthplex for certain dental products. To choose a Primary Care Dentist (PCD) or if you need help finding a dentist in your area, call DentaQuest at 844-284-8819. We use cookies to make your experience better. What is the current version of the Dental Fee Schedule? Members who receive care at NYC Health + Hospital facilities now have access to MyChart. We are here Monday through Saturday from 8:00AM to 8:00PM. The coverage is limited to three years of treatment and one year of retention care. OR. Partnering with DentaQuest, we are able to bring their experience and passion for improving oral health care to you. Check out our blog post! However, the appellant failed to established that other treatments, even if less cosmetically ideal, would not eliminate the pain. 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). A letter from the patients dentist must explain the specific circumstances that necessitates replacement of the denture. Please be sure to tell us which plan handbook for example, Medicaid you need. 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. The insurer did not respond to within the established time limits, OR, did not pay my dental bill in full. Early treatment prevents them from getting worse. Please contact the Medical Directors Office at 1-800-781-2362 or provider@wcb.ny.gov. $0 premiums, deductibles, and co-insurance. 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. Just quality health care. Physical activity is one of the simplest ways to stay healthy, and Healthfirst makes it even more rewarding! Orthodontic exam and evaluation and treatment will be billed using the dental fee schedule. 12285 13 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). Implant Services (revised Nov. 12, 2018. Include several previously exempt and excluded populations, *Enrollment numbers are based on May 2012 data. If the patient was working at the time of the accident, it should be treated as a workers' compensation claim. *You must participate in the Preferred network to also participate in the Dental Access Plan. How to Access Your Member Portal Claims submitted by a dental provider to the insurer shall be paid within fortyfive calendar days of receipt of the claim. Start a NEW Online Credentialing Application Continue an ALREADY STARTED Online Credentialing Application The dental provider can use any usual and customary dental billing forms. To make the transition as transparent and seamless as possible for both the provider and patient. StartingJanuary 1, 2023, MetroPlusHealth will cover Gambling Disorder Treatment provided by Office of Addiction Services and Supports (OASAS) certified programs. With over 25K providers, 100+ hospitals, 5K practices, 250+ urgent & ambulatory care centers, Fidelis Care is here to support your team's needs. Prior approval requests for implants must have supporting documentation from the patients physician and dentist. Under this program, children can receive periodic oral evaluations and preventive, restorative, and emergency dental care. Message DentaQuest through secure messaging. Here are some good practices to follow to ensure proper oral hygiene: Child Health Plus cover routine, preventive and emergency dental services through DentaQuest. Navigators and Certified Application Counselors, NY State of Health, The Official Health Plan Marketplace, online at. Our comprehensive, innovative programs, are designed to control costs and assure quality care. 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. Contact: Legal Aid Society Health Hotline (212) 577-3575or email . At DentaQuest, we are committed to improving oral health by redefining prevention and care. Member and Provider FAQs - Pharmacy Benefit Carve-Out. 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. * These plans are preferred provider organizations (PPO) and are underwritten by EmblemHealth. Welcome. The decisive appointment for active orthodontic treatment is the time at which the total appliance(s) is/are completely placed and activated. By understanding the nuances of the benefit, advocates can help get their clients the coverage they need. We offer a state of the art dental facility, utilizing the most advanced technology in cosmetic dentistry.

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