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DENTAL PROVIDER MANUAL
NEW JERSEY
Dental Provider Manual 2009 1
Welcome to AmeriChoice of New Jersey
Dental Health Services
AmeriChoice of New Jersey (AmeriChoice) welcomes you as a participating Dental Provider.
AmeriChoice is contracted with New Jersey State to provide dental care to include NJ
FamilyCare/Medicaid members.
The goals of AmeriChoice are to provide accessible, quality comprehensive dental care to its members in
the most cost-effective and efficient manner. AmeriChoice is committed to working with our providers to
achieve that success. You are an important part of our program and we look forward to working with you
to ensure your success.
This Provider Manual is designed as a comprehensive reference guide. We will provide periodic updates
and quick reference guides, as well as forms and other information necessary for you to participate
effectively with AmeriChoice. We recommend you insert these bulletins and updates in your Provider
Manual.
If you have any questions or concerns about information contained in your Provider Manual, please
contact AmeriChoice at 1-888-362-3368.
Thank you.
AmeriChoice of New Jersey
Dental Provider Manual 2009
2
Table of Contents
SECTION 1: PROVIDER SERVICES
1.1 Provider Services Department
1.2 Provider Helpline
SECTION 2: PROVIDER TYPES AND RESPONSIBILITIES
2.1 Role of the Network Dentist (Primary Care Dentist and Specialty Dentist)
2.2 Responsibilities of the Network Dentist
2.3 Dental Office Standards
2.4 Appointment Scheduling Standards
2.5 Walk–In Appointment Standards
2.6 24-Hour Coverage
2.7 Dental Records and Charting Standards of Care
2.8 Dental Standards of Care
2.9 Early and Periodic Screening, Diagnostic and Treatment Services (EPSDT)
2.10 Special Needs
2.11 Contracts
SECTION 3: DENTAL CLAIM SUBMISSIONS
3.1 Dental Claim Submission Guidelines
3.2 Dental Claim Filing and Adjustments
SECTION 4: COMPENSATION AND CLAIMS
4.1 Fee-For-Service
4.2 Payment for Covered Services
4.3 Coordination of Benefits
4.4 Subrogation
SECTION 5: ACCESS AND APPEALS PROCESS
5.1 General (Primary Care) Dentist and Specialty Dentist Selection
5.2 Continuity of Care
5.3 Membership Card and Eligibility Verification
5.4 Member Complaints and Appeals
SECTION 6: COVERED SERVICES
6.1 Covered Services
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SECTION 7: PRIOR AUTHORIZATION
7.1 Procedure for Obtaining Prior Authorization
7.2 Services Requiring Prior Authorization
SECTION 8: QUALITY MANAGEMENT PROGRAM
8.1 Purpose
8.2 Goals
8.3 Provider Credentialing/Recredentialing
8.4 Monitoring Quality Of Care
8.5 Corrective Action
8.6 Member Satisfaction/Grievance
8.7 Utilization Management and Appeals
8.8 Office Site Visits
8.9 Office Standards
8.10 Dental Record Audits
8.11 Provider Education
8.12 Termination of Providers
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SECTION 1: PROVIDER SERVICES
1.1 Provider Services Department
AmeriChoice assists dentists and their staff with all aspects of their involvement. A Dental Provider
Services Representatives is assigned to New Jersey and is available to the provider when needed.
Responsibilities:
• Orientation of the dentist and office staff to AmeriChoice’s policy and procedures
• Timely response to questions and concerns from the dentist and or staff
• Ongoing educational support and training
• Point of contact with AmeriChoice for the provider and staff
1.2 Provider Helpline
The Provider Helpline is available to providers for routing claims inquiries and concerns through the
Customer Service Center 24 hours, seven days as week at: 1-800-822-5353.
SECTION 2: PROVIDER TYPES AND RESPONSIBILITIES
2.1 Role of the Network Dentist
(General Dentist and Specialty Dentist)
Network General Dentists and Specialty Care Dentists are involved in a critical role in the dental delivery
system, ensuring that members receive appropriate access, prevention, continuity of care and treatment
services. For this reason, all dentists must be available to AmeriChoice members 24 hours a day, 7 days-
a-week, and are responsible for assisting in the coordination of dental treatment services. Members have
open access to network providers.
Comprehensive dental care services may be provided in the dentist’s office, a health care facility or
hospital-based practice. The dentist is reimbursed on a fee-for-service basis and agrees to maintain
standards set forth in the Participating Provider Agreement. Well-maintained dental records provide
documentation of care.
If the member needs specialty care, the Primary Care Dentist can recommend a network specialty dentist
or the member can self-select a specialist from our provider directory, visit our web site or by calling
customer service at 1-800-941-4647. Referrals shall be made to qualified specialists who are participating
within the AmeriChoice provider network. No written referrals are needed for Specialty Dental Care.
2.2 Responsibilities of the Network Dentist
The network dentist ensures that the member receives appropriate and necessary dental treatment and
follow-up services. The responsibilities include:
• Accept the AmeriChoice reimbursement as payment in full for all covered dental services,
agreeing never to bill members.
Dental Provider Manual 2009
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• Discuss information on available treatment options for alternate courses of care with members
while maintaining complete confidentiality.
• Offer access to office visits in conformance with AmeriChoice standards.
• Conduct a comprehensive examination during the member’s initial appointment.
• Transfer dental records upon request. Copies of the dental records must be provided to the
member upon request at no charge.
• Document all EPSDT services to members 3 through 20.
• To enable the member to contact the provider or covering provider.
• Respond to emergency needs of members 24-hours a day, 7 days a week, and must have an
answering service or a pre-recorded telephone answering machine message.
• Provide all covered benefits in a manner consistent with the best available scientific evidence.
• Document procedures for monitoring members’ missed appointments as well as outreach
attempts to residual missed appointments.
2.3 Dental Office Standards
AmeriChoice requires a clean and structurally sound office that meets applicable State OSHA and ADA
standards. Periodic site visits to dental offices are conducted under the supervision of the Chief Dental
Officer. If a provider is considering an address change, AmeriChoice must perform a site visit of the new
facility before the change can be approved.
AmeriChoice will conduct periodic site surveys of all facilities. Site surveys will include review of the
office facility and staff, sterilization, infection control, radiation safety, hazard control, emergency
procedures and preparedness, overall treatment and patient records.
2.4 Appointment Scheduling Standards
AmeriChoice is committed to assuring that its providers are accessible and available to their members for
the full range of services specified in the AmeriChoice provider agreement and provider manual.
Participating providers should meet or exceed the following state mandated or plan requirements:
*Urgent or Emergency Care Appointments: Immediately or within 24 hours
*Elective or Routine Care Appointments: Offered within 28 days
AmeriChoice shall monitor compliance with these access and availability standards through a variety of
methods, including review of appointment books, spot checks of waiting room activity, investigation of
member complaints, and random calls to provider offices. Any noted concerns are discussed with the
participating provider(s). If necessary, the findings may be presented to AmeriChoice’s Quality
Committee for further discussion and development of a corrective action plan.
*Providers are encouraged to schedule members appropriately to avoid inconveniencing the
members with long wait times in excess of thirty (30) minutes. Members should be notified of
anticipated wait times and given the option to reschedule their appointment.
2.5 Walk-In Appointments Standards
Dental offices that operate by “walk-in” or “first come, first served” appointments are monitored for
access and waiting times, where applicable.
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2.6 24-Hour Coverage
All network dental providers must be available to members telephonically 24 hours a day, 7 days a week.
If the provider is unavailable, the provider must have telephone coverage by another network
participating dentist or advise the member to call AmeriChoice for referral to a network dentist. Network
dentists are expected to respond to after-hour member calls within one (1) hour of receiving the call.
Member Services, Provider Services and Quality Management staff monitor and document all instances
of provider unavailability to ensure continuity of care. AmeriChoice conducts periodic surveys to ensure
access and availability standards for members are in compliance. Network dentists are required to
participate in all activities related to these surveys.
2.7 Dental Records and Charting Standards of Care
Network dentists must maintain and be in compliance with all regulatory requirements. There shall be a
dental record system that permits easy retrieval of information. Records must be legible, permanently and
accurately documented, comprehensive, and readily available to AmeriChoice, Federal and State agencies
and any external quality review organization for purposes of assessing the quality of care rendered.
AmeriChoice has adopted the record keeping and charting quality standards recommended by the
National Committee for Quality Assurance. Compliance with the following standards is expected of all
dental providers:
Dentists shall maintain a dental record for each AmeriChoice member in accordance with the following
requirements:
1. The record must contain biographic/personal data, such as age, date of birth, sex, race/ethnicity, and
marital status/social supports.
2. The record must contain a tooth chart indicating the condition of the patient’s teeth as observed on the
initial oral examination. The dentist shall clearly indicate on the tooth chart:
a) Missing permanent/primary teeth.
b) Permanent or primary teeth that need to be extracted.
c) Teeth to be restored because of either caries or defective restorations by surface.
d) Restorations previously placed by another dental provider
e) Documention of oral hygiene and preventive dental care instructions
3. The record must note the condition of the oral supporting tissues with full mouth charting when
appropriate. If initial examination of oral soft tissues, tempro-mandibular joint, occlusion, and
periodontium are within normal limits (WNL), provider should make a notation on chart to that effect
for each of these items.
a) The record must contain an appropriate and organized medical history including the patient’s
smoking habit, a history of alcohol use and/or substance abuse. The provider should indicate
on either the medical history form or in the treatment notes the date the medical history was
reviewed. The medical history should also be reviewed at each subsequent visit and noted on
the chart. Allergies and adverse reactions to medications must be prominently displayed on
the front of the patient’s record.
b) A treatment plan must be provided to the member. The provider should indicate if the
member accepts or rejects the proposed treatment plan. Provider, and if possible the member,
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should sign patient record that the treatment plan was proposed and the outcome. All pages
of the record must contain the patient’s name and identification number.
c) Consultations documented in the record must be appropriate given patient characteristics,
history, and presenting problems. The record must document appropriate coordination of
care between the general dentist and dental specialists.
4. For each service rendered, the record must note:
a) The type of service.
b) The date the service was rendered.
c) The tooth number or letter, if applicable.
d) The surface(s) restored, if applicable.
e) The types of materials used in the final restoration, if applicable.
f) The type, concentration and amount of any anesthetic agent used.
g) Any related problems that occurred while the service was being provided.
h) At end of service, the dentist/hygienist must sign or initial the treatment record.
5. If dental radiographs are taken, they must be part of the patient’s record and must be properly
processed, dated and identified with the patient’s name. All radiographs must be of diagnostic quality
and submission of non-diagnostic films may result in withholding of the radiographic fees and/or pre-
authorization for requested services. It is expected that a sufficient number of radiographs will be
taken to allow for the comprehensive examination of all clinical crowns, roots and apices of teeth,
edentulous areas, supporting bone structure, impactions, and other pathology. Full radiographic
series on dentulous patients are to include bitewings.
6. If the services of a dental technician and/or a dental laboratory are used, the dentist must furnish the
dental technician or dental laboratory with a written prescription, which shall contain the following
items:
a) The name and address of the dental laboratory or dental technician.
b) The patient’s name.
c) The date on which the prescription was written.
d) A prescription of the work to be done with diagrams if necessary.
e) A specification of the type and quality of materials to be used.
f) The signature of the dentist and the dentist’s license number.
g) A copy of the prescription shall be maintained as part of the patient’s record.
7. The record must be legible, as judged by the auditor (illegibility of records may result in the need for
provider assistance in completing the rest of the audit).
8. All drugs administered or prescribed, along with amounts and patient instructions (if applicable),
must be documented in record.
9. All records must contain a date of return visit and/or follow up plan for each encounter. Record
should reflect that unresolved problems from previous visit have been addressed.
10. Patient education/oral hygiene instruction should be documented in record.
Providers also are expected to be in compliance with all medical assistance regulations regarding chart
and documentation standards.
Dental Provider Manual 2009
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All dental records must be maintained and readily accessible for a minimum of ten (10) years beyond the
patient’s last date of service or the termination of the provider’s participation agreement, which ever is
greater. For sites with paper files, files must be maintained in paper form for a minimum of 2 years
before they may be converted to another format for the remaining 5 years of required retention.
2.8 Dental Standards Of Care
A. Accessibility of Routine Preventive Care
AmeriChoice. is committed to providing full and open access for its members to access the
necessary and appropriate dental providers. This commitment is fundamental to the success and
goal of a total comprehensive healthcare plan. Routine member office check-up should be
scheduled for every six (6) months for children and adults. There should be an active recall system
in place.
B. Scope of Clinical Activities
Primary Care Dentists (PCD’s) provide members with complete diagnosis and treatment plans. In
addition, PCD’S are required to refer members to primary care provider(s) for routine examinations,
medical clearance and specific medical problems, maintain comprehensive health history, and refer to
dental specialists when appropriate. Medicaid guidelines are the minimum accepted treatment plan
standards.
Note: Please see Attachment A for a comprehensive list of covered services
2.9 Early and Periodic Screening, Diagnostic and Treatment Services
Preventive care is critical to the health of AmeriChoice. members and is therefore a key area of focus for
the Quality Management Program. The Early and Periodic Screening, Diagnostic and Treatment (EPSDT)
guidelines are a federally mandated comprehensive child health program for Medicaid recipients from
birth through 20 years of age.
There is no age minimum for a child to see a Primary Care Dentist or Pedodontist, however it is
recommended that all children be seen at the time of the first tooth eruption or at age 1, whichever comes
first and are required to visit the dentist annually. No referrals are needed for any dental treatment with
the exception of hospital O.R. services.
2.10 Special Needs
AmeriChoice will provide access for comprehensive, quality dental services for the special needs
enrollee. Emphasis will be placed on providing coordinated care managed dental services with the goal of
decreasing the member susceptibility to caries and periodontal disease.
Program Goals:
• Improve special needs members’ access to quality comprehensive dental care through a network
of providers with expertise with developmental disabilities.
• Coordination of access and delivery with Primary Care Provider(s) linkages and community
based organizations.
• Creation of dental management services and expanded benefits for comprehensive dental care
Dental Provider Manual 2009
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within the framework of comprehensive total treatment planning and preventive care delivery.
Objectives:
• The dental care management coordinator will monitor linkages with care managers, community
based organizations and the Primary Care Provider to emphasize preventive education
• Quality utilization management and improvement of the program using national and internally
developed benchmark standards will be monitored by the Chief Dental Officer.
• Provider directories will identify dentists that meet the treatment requirements of the special
needs member.
• The special needs dental coordinator will assist members with special needs in all aspects of
dental treatment.
Requirements:
• The provider network includes dentisists that offer expertise in the dental management of
enrollees with developmental disabilities.
In addition to the covered services offered by AmeriChoice, special needs enrollees have the following
benefit of increased frequency of visits based on the dental risk assessment. The standard allows up to
four visits annually without prior authorization. All other quality utilization management and
improvement benchmark standards are in effect. Emphasis is placed on establishing linkages with the
Primary Care Physician, care manager, and community organizations.
Informed Consent is required from all patients with developmental disabilities or authorized legal
representative/guardian before all surgical cases are treated in the operating room.
The care manager of an enrollee shall coordinate authorizations for dental required
hospitalizations in conjunction with the AmeriChoice dental consultant team.
Dental Services Review, Audits and Monitoring
The special needs program will be reviewed, audited and monitored using the utilization
management and quality improvement measures established by AmeriChoice.
Dentists Management Fee
Providers are paid a dental management fee for initial and follow up dental visits, which may
require up to sixty (60) minutes for a comprehensive assessment.
2.11 Contracts
Dental Provider Manual 2009
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Any provider who signs a contract with AmeriChoice agrees to accept assignment of AmeriChoice
benefits for all covered services. Providers are prohibited from balance billing any members for covered
services. Providers also agree to advise members of services not covered under AmeriChoice and their
financial obligation for those services prior to rendering service.
Providers agree to accept and treat members without regard to race, age, sex, sexual preference, national
origin, religion, health status, economic status or physical disabilities. Providers also agree to participate
in, and abide by, the policies and procedures of AmeriChoice’s Quality Management program.
SECTION 3: DENTAL CLAIMS SUBMISSIONS
3.1 Dental Claims Submissions Guidelines
Network dentists are required to submit either an American Dental Association (ADA) form (2006
version or later) or a CMS 1500 form upon completion of treatment. Codes utilized must be CDT 2007 –
2010, consistent with HIPAA compliance.
One form should be used for each member and should be legible (preferably typed) in order to avoid
delays in processing. Claims can also be submitted electronically to AmeriChoice’s claims vendor (DBP)
under Payor I.D. number 52133. If you need further help with the process, please contact DBP’s call
center at 1-800-822-5353.
As stated above; CDT 2007 - 2010 codes are to be utilized and the claim form must have all necessary
fields populated. Claims must be legible (Typed whenever possible) in order to be scanned into the
adjudication system.
*Claims without attachments should be mailed to:
AMERICHOICE OF NEW JERSEY
P.O. BOX 30765
SALT LAKE CITY, UT 84130-0765
ATTN: DENTAL CLAIMS
*Claims requiring attachments should be mailed to:
AMERICHOICE OF NEW JERSEY
P.O. BOX 200299
NEWARK, NJ 07102
ATTN: DENTAL CLAIMS
3.1.1 All claims must be submitted within ninety (90) days following the date of service.
3.1.2 Standard 2006 ADA Form Minimum Requirements (with required field for NPI):
The following legible member and provider information must be submitted on all claims:
• Member’s name (*box 12)
• Member’s address (*box 12)
• Member’s date of birth (*box 13)
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• AmeriChoice issued member identification/recipient number (*box 15)
• Date(s) of service (*box 24)
• Place of Service (Ex. Office, Hospital) (*box 38)
• Terminology for procedure and CDT procedure codes (Also include surface(s) restored and tooth
number for permanent teeth and Alpha letters for primary teeth and/or arch or quadrant
designations) (*box 25-30)
• Actual provider charge for each service (total provider fee must be entered in the “total fee
charged” area. (*box 31)
• Other insurance information (*box 4-11)
• Provider’s name (This should appear exactly as it does on your contract/credentialing application)
(*box 48)
• Provider’s Individual NPI (*box 54)
• Provider’s tax ID or SSN (*box 51)
• Provider address and phone number (*box 52)
• Prior-authorization number if applicable (*box 2)
*Item or box number found on standard 2006 ADA claim form.
3.1.3 Provider’s signature: (All unsigned claim forms will be returned to your office) Claims should
reflect only one provider for services rendered per billing form.
3.1.4 Standard CMS 1500 form Requirements:
The following legible member and provider information must be submitted on all claims:
• Member’s name (**box 2)
• Member’s address (**box 5)
• Member’s date of birth (**box 3)
• Member identification/recipient number (**box 1a)
• Date(s) of service (**box 24)
• Place of Service (Ex. Office, Hospital) (**box 24b)
• Terminology for procedure and CDT procedure codes (Also include surface(s) restored and
tooth number for permanent teeth and Alpha letters for primary teeth and/or arch or quadrant
designations) (**box 24d)
• Actual provider charge for each service (total provider fee must be entered in the “total fee
charged” area. (**box 24f, 28)
• Other insurance information (**box 9a-d, 11d)
• Provider’s name (This should appear exactly as it does on your contract/credentialing
application) (**box 33)
• Provider’s NPI (**box 33a)
• Provider’s tax ID or SSN (**box 25)
• Provider address and phone number (**box 32)
• Prior-authorization number if applicable (*box 2)
** Item or box number found on standard CMS 1500 claim form.
3.2 Dental Claim Filing and Adjustments
All Dental Claims must be submitted within ninety (90) days from the date of service. All adjustments or
requests for reprocessing must be made within sixty days (60) form receipt of payment. An adjustment
Dental Provider Manual 2009
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can be requested telephonically by calling AmeriChoice’s claims vendor (DBP) at (800) 822-5353 or by
contacting your Provider Representative.
SECTION 4: COMPENSATION AND OTHER CLAIM SUBMISSION
4.1 Fee- for-Service
Network providers are compensated on a fee-for-service basis at agreed upon rates. The reimbursement
will be based on the AmeriChoice’s fee schedule contained within your provider contract.
4.2 Payment for Covered Services
As agreed to in the Participating Provider Agreement, providers shall not bill, charge, collect a deposit
from, seek compensation, remuneration or reimbursement from, or have recourse against enrollees or
persons acting on their behalf for covered services. The network dentist and any of his/her employees
shall not accept fees or gratuities from, or on behalf of, enrollees for any covered services.
4.3 Coordination of Benefits (COB)
Coordination of Benefits (COB) is used when a member is covered by more than one dental insurance
policy. By coordinating benefit payments, the member receives maximum benefits available under each
plan. Coordination of Benefit rules are mandated by the Department of Banking and Insurance (DOBI)
and it is each provider’s responsibility to correctly coordinate benefits. In general, Medicaid payers, such
as AmeriChoice when acting on behalf of a Medicaid program, are considered secondary payers. When
COB is present in this situation, providers should bill the appropriate primary carrier first, then submit to
AmeriChoice for any additional payment along with primary payer’s Explanation of Benefits (EOB).
AmeriChoice shall not be liable for payment if the third party refuses payment due to a determination that
services provided were not medically necessary.
4.4 Subrogation
If the Member’s medical expenses are covered by a third-party settlement, satisfied judgment or other
means, and AmeriChoice has made payment to the provider for those expenses, AmeriChoice will require
the provider to return all benefits paid for illness or injury up to the amount received from the third party
settlement, satisfied judgment or other means.
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SECTION 5: MEMBERS AND ACCESS
5.1 General (Primary Care) Dentist and Specialty Dentist Selection
When members enroll with AmeriChoice, they select network dentists from the directory, which
includes office location(s), hours of service and languages spoken. If assistance is needed,
Member Services Representatives can assist them in the selection of a Primary Care Dentist. Per
your participation agreement, network dentists must inform AmeriChoice of any changes of
telephone number, office hours, site relocations, etc. within 30 days of the change. This ensures
that up-to-date information is provided to members.
5.2 Continuity of Care
NEW MEMBERS
New members can call the Member Services for information on selecting a provider in their
locale.
PROVIDER LEAVES THE NETWORK
If a network provider leaves the network, AmeriChoice can arrange for the member to find a new
dentist. AmeriChoice will allow dental services to be completed within 90 days of the provider
leaving the network. The Chief Dental Officer can extend this time for completion of care upon
written request from the provider.
5.3 Membership Card and Eligibility Verification
AmeriChoice issues a membership card to all its enrollees. When various members of a family
enroll, separate cards are issued to each family member. The membership card is customized with
the AmeriChoice LOGO, and includes the toll-free Customer Service number, the PCP’s name
and telephone number. It also includes the member’s AmeriChoice I.D. number. The back of the
card has instructions for both members (how to access care) and providers (eligibility
verification). The member should present the card whenever he or she obtains covered services.
Eligible members should have a membership card that has been issued by AmeriChoice but it is
the responsibility of the provider to verify that members are eligible at the time of service. This
can be done either by calling AmeriChoice at 1-800-941-4647 www.americhoice.com or DBP at
1-800-822-5353 www.dbp.com.
5.4 Member Complaints and Appeals
AmeriChoice has a multi-level mechanism to process inquires, complaints and appeals. Members
have the right to a timely response to inquires and complaints; and, if dissatisfied with the
resolution of any complaint, the right to file an appeal with AmeriChoice. No member who
exercises the right to file a complaint or appeal will be subject to disenrollment or otherwise
Dental Provider Manual 2009 14
penalized because of the complaint or appeal.
If a member has a concern with the provision of dental care, he or she may file a complaint by
calling the toll-free Member Services number on the back of the member’s ID card or send a
written complaint letter to the Member Services Department. Complaints are collected and
documented daily and forwarded to the Quality Management Department. AmeriChoice members
or providers acting on behalf of such members (with the member’s written consent), have the
right to file an appeal within sixty (60) days of receipt of AmeriChoice's notice of action The
Quality Management Department reviews and tracks all member complaints and grievances
identified by the Member Services Department as potential quality issues and provides corrective
action when necessary. The provider must assist in the resolution of any concern by furnishing
documentation and other requested information to the plan.
SECTION 6: COVERED SERVICES
6.1 Covered Services
AmeriChoice will inform the member which services are covered and which services are not
covered by category of eligibility, i.e. Medicaid, NJ FamilyCare A, B, C or D.
Please see Attachment A for a listing of covered services
SECTION 7: UTILIZATION MANAGEMENT PROGRAM
7.1 Procedure for Obtaining Prior Authorization
Prior authorization for services should be mailed to AmeriChoice at a designated P.O. Box (see
address below) for review. The requests are evaluated by licensed dental consultants and are
issued tracking numbers and filed for easy retrieval.
Prior authorization requests for hospital pre-certifications are approved or denied by the dental
consultant, issued a tracking number then evaluated by the Pre-Certification Department for
medical necessity and appropriateness. Two pre-certification numbers are generally issued for
this type of request, facility and provider. Approvals/denials are mailed to the providers and
tracked and filed by the Dental Department.
7.2 Services that Require Prior Authorization
Typically services requiring prior authorization are orthodontics, periodontics, root canals,
crowns, denture, partials and hospital certification surgical cases. Providers should reference
Attachement A for detail on specific procedure codes that require prior authorization.
Providers are encouraged to call AmeriChoice at 888-362-3368 with questions regarding prior
authorization services prior to treatment and emergency care.
Prior authorization requests are to be sent to:
AmeriChoice Pre Authorization Unit
P.O. Box 200299
Newark, NJ 07102
All documentation should be properly labeled and radiographs must be mounted with member’s
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name, date of radiographs and radiographs copies should indicate right or left side.
SECTION 8: QUALITY MANAGEMENT PROGRAM
8.1 Purpose
The purpose of the Quality Management (QM) program is to assure the delivery of quality care to
all members. To achieve this goal, AmeriChoice has implemented a systematic, inter-
departmental, organization-wide approach to Quality Management. AmeriChoice works with
network dentists and monitors continuous quality improvements, identifies service deficiencies
and opportunities for improvement.
The Quality Improvement Program (QIP) includes policies and procedures to address all aspects
of dental QM activities at AmeriChoice, including credentialing and recredentialing, provider site
visits, data collection and analysis of procedures for quality indicators.
The AmeriChoice Board of Directors has the overall responsibility for the QM program.
Responsibility for the dental component has been delegated to the Chief Dental Officer. A
Subcommittee for Dental Affairs exists which is composed of the Chief Dental Officer, Medical
Director, Director of Quality Management and a minimum of 12 participating network dentists
that includes special needs providers.
8.2 Goals
The Quality Management Approach
The objective of the QM Program is to ensure that quality of care is being reviewed, that
problems are being identified and that follow-up is planned where indicated. The QM Program is
directed by all state and federal policies that ensure member quality outcomes The QM Program
addresses various service elements including accessibility, availability and continuity of care. It
also monitors the provisions and utilization of services to ensure they meet professionally
recognized standards of care. The QM Program is reviewed and updated annually.
The QM Program includes, but is not limited to the following goals:
1. To measure, monitor, trend and analyze the quality of patient care delivery against
performance goals and/or recognized benchmarks.
2. To foster continuous quality improvement in the delivery of patient care by
identifying aberrant practice patterns and opportunities for improvement
3. To evaluate the effectiveness of implemented changes to the QM Program.
4. To reduce or minimize opportunity for adverse impact to members.
5. To improve efficiency, cost effectiveness, value and productivity in the delivery of
oral health services.
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6. To promote effective communications, awareness and cooperation between members,
participating providers and AmeriChoice.
7. To comply with all pertinent legal, professional and regulatory standards.
8. To foster the provision of appropriate dental care according to professionally
recognized standards.
9. To ensure that written policies and procedures are established and maintained by
AmeriChoice to ensure that quality dental care is provided to the members.
8.3 Provider Credentialing/Recredentialing
All network providers must comply with the National Committee for Quality Assurance (NCQA)
guidelines to ensure the members have access to quality dental care. Strict monitoring efforts are
followed to ensure that all participating Dentists are properly credentialed, have passed the initial
facility review, and meet state access standards.
Providers must maintain licenses and certifications required for participation with AmeriChoice
and meet state requirements. The provider must submit copies when requested for credentialing
and recredentialing.
To initiate the credentialing process providers must call the National Credentialing Center at 1-
877-842-3210, options 5, then 1 and 2. You are required to say or enter your Tax Identification
Number to proceed. The credentialing process will include an initial site visit to assess the office
environment and a review of dental records to determine adherence to charting standards.
Network dentists are recredentialed every three years. Office standards are reviewed using criteria
such as: member complaints, chart audits (a minimum of ten are reviewed) utilization profiles,
office hours and environment. On-going monitoring is part of the recredentialing process.
The provider must submit a signed affirmation regarding the existence of any new medical
condition and or conviction of a crime in the State of New Jersey. All candidates are reviewed by
the National Credentialing Committee and report to the Clinical Affairs Committee and finally to
the Quality Improvement Committee.
8.4 Monitoring Quality of Care
AmeriChoice conducts a range of activities designed to ensure that dentists provide accessible,
appropriate, quality dental care in a timely and respectful manner. AmeriChoice utilizes a wide
range of activities, including but not limited to:
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• A thorough credentialing and recredentialing process;
• Provider on-site facility review;
• Provider on-site patient chart review;
• Accessibility and availability monitoring;
• Member grievance and appeals;
• New Jersey specific quality metric indicators
Ongoing monitoring of utilization information and other clinical indicators such as preventive
health; and evaluation of dental health outcomes and quality of care processes comparisons
against group performance and recognized benchmarks where they are available.
8.5 Corrective Action
All confirmed quality issues are subject to corrective action, including provider sanction where
appropriate. As cases with potential quality concerns are identified through the monitoring
activities, the Chief Dental Officer reviews them. Investigation by appropriate staff will assign
and resolve the issue based on levels of severity. Within five business days, the Chief Dental
Officer will respond with a letter detailing the action steps to the provider, the status is tracked to
resolution and so documented in the provider file.
8.6 Member Satisfaction and Grievance
Member satisfaction is a key outcome measurement for the QM program. Dentists shall provide
services to members in a courteous, prompt manner with staff that are mindful of the members’
need for dignity, respect and confidentiality.
AmeriChoice has a process for reviewing and resolving member quality of dental care and service
complaints and grievances. Additionally, AmeriChoice tracks and trends member perceptions of
the quality of care delivered to them.
8.7 Utilization Management Appeals
AmeriChoice operates an internal appeals process to review appeals by members (or a member’s
designee) who are dissatisfied with AmeriChoice’s utilization management decisions.
AmeriChoice members in New Jersey also have the right to an external appeal once the internal
appeal process has been exhausted.
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A. Types of Internal UM Appeals
There are two types of internal UM appeals:
1. Medical Decision Appeals. These appeals contest AmeriChoice’s determination of
medical necessity.
2. UM Administrative Appeals. These are appeals of denials of an admission, extension
of stay or other health care service due to reasons such as late notification of hospital
admission or lack of complete or accurate information.
B. Internal UM Appeals for Medicaid and NJ FamilyCare
Any member, or a member’s designee, who is dissatisfied with any aspect of
AmeriChoice’s utilization management decisions has a right to file a UM appeal. A
provider may file on behalf of a member but must have the member’s written consent.
An internal appeal can be initiated as follows:
• A call from the member (or member’s designee) or the health care provider to the
UM Appeals Department (1-888-456-0218)
• A call from the member (or member’s designee) to Member Helpline (1-800-941-
4647) where the call is recorded and forwarded to the UM Appeals Coordinator
• A written request for appeal from the member (or member’s designee) or health care
provider on behalf of the member with the member’s written consent.
• A verbal appeal must be followed by a written, signed appeal except when the
request is for expedited resolution.
• AmeriChoice will comply with all of the provisions of P.L. 2007, Chapter 259 as
pertains to the regulation of dental decisions by insurers and third party
administrators, providing for limited professional registration certificates, and
supplementing Titles 17 and 45 of the Revised Statutes.
All medical decision and UM administrative appeals must be written and received by
AmeriChoice within 60 days from the date that AmeriChoice notified the member or provider of
the adverse determination. The appeal should contain the following information:
• Member Name and AmeriChoice member identification (ID) number
• Provider Name and AmeriChoice provider number
• Provider’s address and phone number
• Requested procedure or service
• Date of denial (if known)
• Diagnosis and medical justification for the procedure or service
• A copy of the original denial letter
• A copy of the member’s consent if the provider is appealing on behalf of the
member.
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Mail or fax the appeal to:
AmeriChoice of New Jersey, Inc.
Attention: UM Appeals Coordinator
P.O. Box 200179
One Riverfront Plaza Station
Newark, NJ 07102
Fax: 1-973-565-5269
Internal UM Appeal Process (Stage 1)
The Chief Dental Officer rendering an appeal decision will respond in writing either to reinstate
some or all of the denied procedures or to affirm the denial.
All Stage 1 appeals shall be concluded as soon as possible after receipt by AmeriChoice in
accordance with the medical exigencies of the case. AmeriChoice will review the decision and
respond to the member within 72 hours.
A member, or provider acting on behalf of a member, who is dissatisfied with any UM
determination shall have the opportunity to discuss and appeal that determination with the Chief
Dental Officer.
Internal UM Appeal Process (Stage 2)
If the member, or provider acting on behalf of the member with the member’s consent, disagrees
with AmeriChoice’s Stage 1 appeal decision, the member or provider, acting on behalf of the
member, can file a formal second stage internal appeal.
A panel of AmeriChoice dental health care professionals not involved in the initial UM
determination will review the Stage 2 appeal.
AmeriChoice will acknowledge Stage 2 appeals in writing to the member, or provider filing the
appeal on behalf of the member, within 10 business days of receipt.
All Stage 2 appeals shall be concluded as soon as possible after receipt by AmeriChoice in
accordance with the medical exigencies of the case, which shall not exceed 72 hours in the case
of appeals from determinations regarding urgent or emergent care, or 20 business days in the case
of all other appeals, after the receipt of all necessary information. AmeriChoice will notify the
member, or provider acting on behalf of the member, of the Stage 2 appeal decision in writing.
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AmeriChoice will render a decision either to reinstate some or all of the denied days or other
health care service or to affirm the denial.
C. Expedited Appeals for Medicaid and NJ FamilyCare
An appeal is to be expedited if a delay would significantly increase the risk to a member’s health.
AmeriChoice will render a decision on the expedited appeal within 72 hours of receipt of the
appeal and provide a written notification at the same time to all appealing parties.
To facilitate the expedited resolution of an appeal, AmeriChoice will encourage the health care
provider to work collaboratively, including but not limited to, sharing information via telephone
or fax.
Expedited appeals that do not result in a resolution satisfactory to the appealing party may be
further appealed through the standard appeal process or through the external appeal process.
D. External Appeal Process for Medicaid and NJ FamilyCare (Stage 3)
An AmeriChoice Medicaid or NJ FamilyCare member, and any provider acting on behalf of a
member, with the member’s consent, who is dissatisfied with the results of the internal appeal
process, has the right to pursue his/her appeal to an independent utilization review organization
(“IURO”) in accordance with the procedures set forth in a Stage 3 Appeal described in this
section. The right to an external appeal is contingent on the completion of the first and second
stages of internal review. A request to bypass the first and/or second stage of internal review
must be based on AmeriChoice’s waiver of the requirement for the member to pursue the first or
second stage of appeal, or if AmeriChoice fails to comply with any of the deadlines for
completion of the internal utilization management determination appeals or if AmeriChoice
waives its rights to an internal review of any appeal
To initiate an external appeal, a member and/or provider with member’s written consent shall
within 60 days from the receipt of the written determination of the Stage 2 internal appeal panel,
file a written request with the New Jersey Department of Banking and Insurance. The request
shall be filed on the form automatically provided to the member with the Stage 2 internal appeal
determination. The fee specified and a general release executed by the member for all medical
records pertinent to the appeal needs to be included.
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Requests are mailed to:
Department of Banking and Insurance
Consumer Protection Services
Office of Managed Care
P.O. Box 325
Trenton, NJ 08625-0325
The fee for filing an appeal shall be $25, payable by check or money order to the New Jersey
Department of Banking and Insurance. Upon a determination of financial hardship, the fee may
be reduced to $2. Financial hardship may be demonstrated by the member through evidence that
one or more members of the household is receiving assistance or benefits under the
Pharmaceutical Assistance to the Aged and Disabled, Medicaid, NJ FamilyCare, General
Assistance, SSI or New Jersey Unemployment Assistance.
Upon receipt of the appeal, together with the executed release and appropriate fee, the
Department of Banking and Insurance will assign the appeal to an IURO in accordance with New
Jersey Administrative Code for review. Additionally, upon receipt of the request for appeal from
the Department, the IURO will conduct a preliminary review of the appeal and accept it for
processing if it determines that:
1. The individual was or is a member of AmeriChoice;
2. The service which is the subject of the complaint or appeal reasonably appears to be a
covered service under the benefits provided by contract to the member;
3. Except as set forth at New Jersey Administrative Code N.J.A.C. 11:24-8.6(g), the
member has fully complied with both the Stage 1 and Stage 2 appeals.
4. The member or provider has provided all information required by the IURO and the
Department to make the preliminary determination including the appeal form and a
copy of any information provided by AmeriChoice regarding its decision to deny,
reduce, or terminate the covered service, and a fully executed release to obtain any
necessary medical records from AmeriChoice and any other relevant health care
provider.
The IURO completes its review and issues its recommended decision as soon as possible in
accordance with the medical exigencies of the case which unless under certain circumstances will
not exceed 30 business days from the receipt of all documentation necessary to complete the
review. If the appeal involves care for an urgent or emergency case, the IURO shall complete its
review no more than 48 hours following its receipt of the appeal. The IURO’s decision shall be
binding upon AmeriChoice.
If the provider or the member needs assistance regarding the external appeal process, he or she
should call the AmeriChoice Appeals Department at 1-888-456-0218.
E. Fair Hearing Rights for Medicaid and Certain NJ FamilyCare Members
The New Jersey State Fair Hearing process is only available to New Jersey Medicaid and certain
NJ FamilyCare program members who are not satisfied with any AmeriChoice decision. A
member, or individual acting on behalf of the member with the member’s written consent, can
request a Medicaid Fair Hearing by writing to:
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Fair Hearing Section
Division of Medical Assistance and Health Services
P.O. Box 712
Trenton, NJ 08625
For further information, call the Managed Care Hotline at 1-800-356-1561.
8.8 Office Site Visits
Dentists may receive an initial assessment as part of the Credentialing process and subsequent site
visits as required. While it is a comprehensive survey the site visit focuses primarily on: dental
record keeping, patient accessibility, infectious disease control, emergency preparedness and
radiation safety. Results of site reviews will be shared with the dental office. Any failures will
result in a review by the Clinical Affairs Committee, dental consultant or the Chief Dental Officer
leading to a corrective action plan or possible termination. If terminated, the dentist can reapply
for network participation once a second review has been completed and a passing score has been
achieved
To assure high quality dental participation, AmeriChoice is responsible for overseeing all on site
visits at each proposed dental offices and periodic visitations to all dental providers. The site
survey includes, patient record reviews, patient recall systems inspection of the overall physical
premise, handicap accessibility, emergency preparedness, compliance with sterilization and
asepsis, hazardous waste disposal and radiation safety.
8.9 Office Standards
AmeriChoice requires a clean and structurally sound office that meets industry standards. Site
reviews may be completed at any time. They may be done prior to activation of an office or
periodically as part of the recredentialing process to ensure that standards are maintained. In
addition, focused reviews can be performed based on quality indicators. If a provider is
considering an address change, AmeriChoice must be informed and a site visit of the new facility
may be conducted before the new address is approved for participation.
8.10 Dental Record Audits
Network dentists are audited in conjunction with site reviews and on an ongoing basis, with
appropriate remediation, tracking and sanctions for providers who are deficient in the audit
process outcome. Dental care evaluations and aggregated utilization data are used to assess, track,
trend and evaluate the quality of dental care and services delivered to members. Providers are
expected to cooperate with all data collection and quality improvement efforts. Such cooperation
includes, but not limited to: complying with requests for photocopied records, agreeing to office
visits for inspection and record reviews, and making other reasonable efforts to help with data
collection.
AmeriChoice understands member data is confidential and as such must be safeguarded from
inappropriate public disclosure. AmeriChoice accepts this responsibility and will respect all
federal, state and local laws governing the confidentiality of member dental records and data.
Network dentists are contractually obligated to respect these laws regarding confidentiality of
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dental records and data well. Provider audits results are used in the QI process to identify trigger
points for evaluation and to assist providers in improving the quality of dental delivery.
The completed audit work sheets and scoring are placed in the provider credential file. The re-
audits of sites take place within 90 days of the original audit to ensure compliance. If the dentist
fails the re-audit, the Chief Dental Officer will initiate the sanctions process.
Provider dental records are essential sources of data for a continuous monitoring process in the
Quality Utilization Management Program. AmeriChoice conducts periodic dental audits and
encourages the dentist to facilitate and cooperate with the audit process by providing access to his
or her office and to the member dental records.
8.11 Provider Education
The Quality Management Department understands that quality improvement starts with the
knowledge and cooperation of network dentists. AmeriChoice makes every effort to educate
providers regarding the Quality Management process.
8.12 Termination of Providers
Providers who are terminated are given written explanations of the reasons and the opportunity
for an appeal Hearings are not typically offered until routine appeal rights have been exhausted.
In cases involving “imminent harm to patient care” or a determination by a state licensing board
or other agency that impairs a provider’s ability to practice, AmeriChoice may terminate
immediately.
Notices of termination include the reasons for termination and notice of right to request a hearing
or review before a panel appointed by AmeriChoice. A provider may request in writing a hearing
within ten (10) business days of receiving the notice of termination, and the hearing will be held
within thirty (30) days after AmeriChoice receives the written request. The hearing will have no
less than three members on the panel. At least one member of the panel will be a clinical peer in
the same discipline or specialty as the provider requesting the hearing. The panel will then render
a decision in writing within 30 (thirty) days of the close of the hearing to terminate, reinstate, or
issue provisional reinstatement subject to conditions set forth by AmeriChoice. The termination,
if upheld by the hearing panel or unchallenged by the provider, will take effect no earlier than
sixty (60) days after the provider receives the notice of termination.
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