Kentucky Dental Avesis by liaoqinmei


									An Educational Presentation

Prepared For:
Avesis/Wellcare of
Kentucky Dental
Providers & Staff

Presented by: Avesis

September 2012
             Mission Statement
     Building long term partnerships to deliver valued, innovative
     healthcare solutions… one member at a time.

Kentucky Dental
Who We Are

 Dental, Vision, and     Over 30 years         Covering over 4.5
 Hearing Plan            experience in the     million members
 Administrator working   dental, vision, and   throughout the
 with employer groups    hearing insurance     country
 and health plans        industry

Kentucky Dental
Avesis Dental

   Dental Networks

        Over 30,000 dentists in 41 States

   Experienced Administrator

        30 years serving corporate and government clients

   Avesis administers Medicaid dental plans in 4 states and Medicare
    Advantage dental plans in 11 states

Kentucky Dental
Avesis is National

   Executive Offices in Baltimore, MD

   Operations located in Phoenix, AZ

   Southeast regional office in Atlanta, GA

Kentucky Dental
Points of Contact

        Renee Ruggiero
         Assistant Director of Health Plan Services
         (800) 522-0258 x753

        Emori Campbell
         Dental Provider Relations
         (800) 522-0258 x178

        Carolyn Wright
         Utilization Management
         (800) 522-0258 x294

Kentucky Dental
Points of Contact

        Robin Mays
         Manager, Dental Provider Contracting
         (800) 522-0258 x136

        Angela Bridges
         Provider Contracting Specialist
         (800) 522-0258 x156

        General Provider Inquiries
         (855) 214-6776

Kentucky Dental
Clinical Professionals

        Dr. Fred Sharpe
         Chief Dental Officer

        Dr. Rick Celko
         Regional Dental Director

        Dr. Terrence Poole
         Avesis KY/OH Dental Director

Kentucky Dental
Avesis Dental Advisory Board

   Committee of Kentucky licensed Dentists and Avesis staff

   Acts in an advisory capacity to Wellcare of Kentucky and Avesis in all
    matters pertaining to the Avesis/Wellcare of Kentucky Dental Programs

Kentucky Dental
Avesis Dental Advisory Board

   Help to ensure quality communications between Kentucky provider
    community, Avesis, and Wellcare of Kentucky

   Forum for providers to submit recommendations and feedback regarding
    the programs and their administration

Kentucky Dental

Kentucky Dental

   It is strongly encouraged that you verify eligibility for each Member’s
    appointment the business day prior to rendering services unless the next
    business day is the first day of a new month.
   Please note that verification of benefits or eligibility is not a guarantee of
    payment: actual payment is based on the terms and conditions of the
    plan in force once the claim is received.

Kentucky Dental
You may obtain eligibility verification four ways:
1.   IVR – Please bear in mind that this only provides you with information as to
     whether or not the member is eligible on the date of service. It does not provide
     utilization data
2.   Website – This method provides you with information as to whether or not the
     member is eligible on the date of service and allow you to view the members
     utilization history. ( or check the state website
3.   Customer Service – Customer service is able to provide you with both eligibility
     confirmation as well as utilization data. You may call 855.214.6776 to reach the
     Customer service department.
4.   Fax – You may utilize the form found of the following slide for eligibility
     confirmation. This form will provide you with both eligibility confirmation and
     utilization data.

Kentucky Dental
Fax Eligibility Verification

Kentucky Dental

Kentucky Dental
Benefits Overview

   Covered Services
      • Covered services will be paid according to the plan fee schedule

   Non-Covered Services
      • Non-Covered Services may be the responsibility of the member if and only if
        the Member is notified of and agrees to financial responsibility prior to
        services being rendered

Kentucky Dental
Benefits Overview

   There are two Medicaid programs under Wellcare of Kentucky:
       • Global Choices
       • Family Choice

   Benefits for children (Members ages 20 and under) are the same in each of the plans

   Benefits for adults (Members ages 21 and over) vary according to the program in
    which the Member is enrolled.

Kentucky Dental
The Global Choices Program

Global Choices is the benefit plan for most Kentucky Medicaid members.
This plan covers basic medical and dental services. There are no co-pays
for any dental services for Wellcare of Kentucky members enrolled in
Global choices. Some service limits can be increased if the service is
medically necessary (requires prior approval).

Kentucky Dental
Benefits for Global Choices

   Global Choices benefits include but are not limited to:
       • Children under 21:
         • 2 cleanings per 12-month period
         • 1 set of x-rays per 12-month period
         • Extractions and fillings
         • Other dental services are available

       • Adults 21 and over:
         • 1 cleaning per 12-month period
         • Limited to one dental visit per month
         • 1 set of x-rays per 12-month period
         • Extractions and fillings

Kentucky Dental
The Family Choices Program

Family Choices is the Kentucky Medicaid benefit plan for most children. This
plan covers basic medical and dental services. Kentucky Children’s Health
Insurance Program (KCHIP) is part of the Family Choices Plan. This is not a
complete list of services. Some benefit limits can be increased if the service is
medically necessary (requires prior approval).

Kentucky Dental
Benefits for Family Choices

   Family Choices benefits include but are not limited to:
       • Children under 21:
         • 2 cleanings per 12-month period
         • 1 set of x-rays per 12-month period
         • Extractions and fillings
         • Other dental services are available

Kentucky Dental
General Benefits

   Benefit Exception/EPSDT Process
      •   Benefit exception occurs when a provider contacts Avesis requesting
          services that are non-covered for medical necessity
      •   Benefits are either exhausted or not a covered benefit
      •   Requests will be reviewed by Utilization Management and a decision will be
          made with in two (2) business days.

   Emergency Services
      •   Members seeking emergency services may need to be referred back to
          Wellcare of Kentucky for medical benefits

Kentucky Dental
Non-Covered Services Disclosure Form

                                       This form is for your protection
                                       and the Member pays Usual
                                       and Customary Fees

Kentucky Dental

Kentucky Dental
Claim Submission

Claims may be submitted one of three ways:

   Through your practice management software using a clearinghouse

       •   The Avesis payer identification number is 86098

   On an ADA claim form - please submit to the following address:

      Avesis Dental Claims
      PO Box 7777
      Phoenix, AZ 85011 – 7777

   Utilizing our website at

Kentucky Dental
Claims Follow-up

Providers receive remittance advices detailing claims both paid and
denied. If you believe you have not received status on a claim, you may
check the status of submitted claims two ways:

      • You may check claim status on the Avesis website at

      • You may contact our provider services department at (855) 214-6776 to
        check claim status

Kentucky Dental
Corrected Claims


•   If you are missing information (i.e. tooth number or quadrant number) or you have
    submitted incorrect information (wrong code, wrong tooth number, etc.) you may edit
    the claim on the Avesis website regardless of the method of submission.

•   If you wish to submit a corrected claim on an ADA claim form you will need to do the

       • Write corrected claim on the top of the ADA claim form in blue or black ink. The
         scanner does not read red ink

       • Please do not highlight notes on the claim in blue or green highlighter. The
         scanner reads these colors as black so what ever they highlight is blacked out

Kentucky Dental
Avesis Claims Payment

   Check runs weekly

   CLEAN CLAIMS processed and adjudicated within 15 business days

   Electronic Funds Transfer available for all claims submissions or

   EFT payments deposited weekly

Kentucky Dental
Electronic Funds Transfer Agreement

Kentucky Dental
            Prior Authorization
          Pre-treatment Estimates & Benefit Exceptions

Kentucky Dental
Avesis Prior Approval Requirements

   Services requiring prior approval are listed in detail in the provider manual
    and on the covered benefits schedule.
   Providers may submit pre-treatment estimates on an ADA claim form to
    our Phoenix address or via the Avesis website at
   Avesis accepts electronic attachments via the Avesis web portal.

Kentucky Dental
                  Chart Reviews

Kentucky Dental
Avesis Office Visits

   Avesis conducts office reviews for our dental provider networks

   Your office will be contacted in order for Avesis to schedule a time to come

   In addition to a facility walk through, providers will be furnished a list of
    charts prior to the visit to have available for review

   After the visit, your office will be sent a letter regarding the findings of our

Kentucky Dental
             Provider Services

Kentucky Dental
Services to Providers

   Avesis is primary for Member and Provider Services
   Toll free phones staffed by experienced and knowledgeable representatives
    from 7am – 7pm EST at 855-214-6776.
   State and National professionals involved in professional decisions
    regarding care and referrals
   Regional meetings and training sessions scheduled for providers
   Quarterly Provider Newsletters
   On-site assistance in your office when available
   Peer to peer interaction for Providers

Kentucky Dental
Additional Assistance

   Schedule a conference call

   Schedule a web demo

   Schedule an onsite visit

Kentucky Dental
Committed to Technology

24/7 Access to information:
   Web Based
       • Eligibility verification
       • Claim submission with real time claims processing
       • Claim status and editing
       • Remittance advice information
       • Pre-treatment Estimate

   Interactive Voice Response (IVR)
       • Eligibility
       • Benefits

Kentucky Dental
           Thank You For Your Time
    We at Avesis look forward to working with you and your team.

Kentucky Dental

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