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Idaho Smiles8Early Dental Home Program - Children ages 0-3 yearsAre you building a “Dental Home” for your patients?Effective March 2014, a Dental Home program was implemented for children ages 0 through 3 in both theBasic and Enhanced Plans.In dentistry, continuity of care is a critical component in ensuring a patient’s oral health and well-being.DentaQuest’s Dental Home program is modeled after the AAPD guidelines and promotes continuity ofcare by encouraging dental providers to manage the preventive, the diagnostic and the restorative dentalneeds of their patients.The Dental Home is a place where a child’s oral health care is delivered in a complete, accessible andfamily-centered manner by a licensed dentist. This concept has been successfully employed by primarycare physicians in developing a “Medical Home” for their patients, and the “Dental Home” concept mirrorsthe “Medical Home” for primary dental and oral health care. If expanded or specialty dental services arerequired, the dentist is not expected to deliver the services, but to coordinate the referral and to monitorthe outcome.The American Academy of Pediatric Dentistry (AAPD) defines dental home as “inclusive of all aspects oforal health that result from the interaction of the patient, parents, non-dental professionals, and dentalprofessionals.” It constitutes the ongoing relationship between the dentist who is the Primary Dental CareProvider and the patient, which includes comprehensive oral health care, beginning no later than age one,pursuant to ADA policy.The Dental Home visit can be initiated as early as 6 months of age and must include the following: Comprehensive oral examinationOral hygiene instruction with primary caregiverDental prophylaxis, if appropriateTopical fluoride varnish application when teeth are presentCaries risk assessmentDental anticipatory guidance.Member AssignmentMembers are assigned to providers based on where they were last seen, where their siblings were lastseen, or to the closest provider accepting new patients.Members are notified of their assigned Dental Home and educated on the program by mail.Although member assignment is to encourage members to use their dental home, they may go to anyparticipating provider. Also, providers may treat any eligible member and be paid for covered benefits.If a provider has selected to be an “Existing Patients Only” provider or have other panel restrictions, theywill not be assigned any additional members.Provider support is essential to effectively employ the Dental Home program for Idaho Smiles members.With assistance and support from dental professionals, a system for improving the overall health ofchildren in Idaho Similes can be achieved.For additional information regarding the Idaho Smiles Dental Home Program, visit the Provider Web Portalunder Related Documents-Dental Home or contact Idaho Smiles Customer Service. You may alsocontact your Provider Relations Representative.DentaQuest LLC November 24, 2015Current Dental Terminology American Dental Association. All Rights Reserved.

9Idaho Smiles1.00Dedicated Call Center for Dental ProvidersIdaho Smiles offers participating dental Providers access to Provider Service Representativeswho specialize in areas such as: Eligibility, covered services and authorizationsClaims, andIntervention ServicesPlease contact these representatives at 800.936.0978 Monday through Friday 8:00 am – 6:00 pmfor assistance.1.01Provider DirectoryIdaho Smiles publishes an on-line Provider directory for Idaho Smiles Participants. TheProvider directory includes: Provider name, practice name (if applicable), officeaddress(s), telephone number(s), and panel status (for example, Providers limiting theirpractice to existing patients only). New Participants receive instructions on how to accessthe directory over the phone and on the internet.The website maintains the most up-to-date information on active Providers. The IdahoSmiles Participants will look to the Find A Provider feature of the website to locate aProvider in their area.It is very important that Providers notify Idaho Smiles of any changes in practiceinformation. Please follow the instructions found in Appendix A (Additional resources) toupdate your information.1.02Specialist Referral ProcessA patient requiring a referral to a dental specialist can be referred directly to any specialistcontracted with Idaho Smiles without authorization from Idaho Smiles. The dentalspecialist is responsible for obtaining prior authorization for services according toAppendix B of this manual. If you are unfamiliar with the Idaho Smiles contractedspecialty network or need assistance locating a certain specialty, please contact IdahoSmiles’ Customer Service Department at 800.936.0978.1.03Transportation for ParticipantsMedicaid will cover transportation for eligible Medicaid participants, including Idaho Smilesparticipants, as a medical benefit. DentaQuest cannot answer any questions abouttransportation services. Transportation to covered dental services will be authorized for eligible Idaho Smilesparticipants, on a case-by-case basis, by Medicaid’s transportation brokerage,American Medical Response (AMR). AMR coordinates and administers all NEMT.Once a participant has a dental appointment arranged, the provider or participant cancall AMR at 877 503-1261 to schedule transportation if the dental treatment iscovered by Idaho Smiles.Additional information about NEMT is available in the August 2010 MedicAide issueof the MedicAide newsletter, pages 18 and 22, ers/Forms/AllItems.aspxDentaQuest LLC November 24, 2015Current Dental Terminology American Dental Association. All Rights Reserved.

10Idaho Smiles1.04Healthy Connections (HC) ProgramHealthy Connections (HC) is Idaho Medicaid’s care management program. Dentalservices, regardless of where they are performed, do not need a Healthy Connectionsreferral.DentaQuest LLC November 24, 2015Current Dental Terminology American Dental Association. All Rights Reserved.

11Idaho Smiles2.00Patient Eligibility Verification Procedures2.01EligibilityAny Participant who is enrolled in the Idaho Smiles program, or covered under theMedicaid Program, is eligible for dental benefits under Idaho Smiles. Participant eligibilityin Idaho Smiles is determined by Idaho Department of Health and Welfare.2.02Participant Identification CardParticipants receive identification cards from Idaho Smiles. Participating Providers areresponsible for verifying that Participants are eligible each time services are rendered andto determine if Participant’s have other health insurance. If you do not have an IdahoSmiles card you may show your Idaho Medicaid card at your dentist’s office. Theidentification numbers are the same on both cards.Please note that due to possible eligibility status changes, this information does notguarantee payment and is subject to change without notice. It is important that you savethe eligibility confirmation from the day of service. This will allow you to be paid in theevent there has been an error in eligibility for the memberParticipants will receive an Idaho Smiles ID Card.Idaho Smiles recommends that each dental office make a photocopy of the Participant’sidentification card each time treatment is provided. It is important to note that theidentification card is not dated and it does not need to be returned to Idaho Smiles shoulda Participant lose eligibility. Therefore, an identification card in itself does notguarantee that a Participant is currently enrolled in the Idaho Smiles program.2.03Eligibility SystemsParticipating Providers may access Participant eligibility information through the IdahoSmiles website, through the Idaho Smiles Interactive Voice Response (IVR) system, orthrough MACS (Medicaid Automatic Communications Services). The eligibilityinformation received from each system will be the same information you would receive bycalling the Idaho Smiles Customer Service department; however, by utilizing theautomated methods, you can get information 24 hours a day, 7 days a week.DentaQuest LLC November 24, 2015Current Dental Terminology American Dental Association. All Rights Reserved.

12Idaho SmilesAccess to eligibility information via the InternetProviders may verify a Participant’s eligibility as well as submit claims directly to IdahoSmiles via the Internet. To access the eligibility information via Idaho Smiles’ website,simply log on to the website at www.dentaquestgov.com and select ‘Dentist’ and click onProvider Web Portal. First time users will have to register by utilizing their 6 digit IdahoSmiles Location ID, office name and office address. Please refer to your welcome letter,payment remittance or contact Idaho Smiles’ Customer Service Department at800.936.0978 to obtain your Location ID. Once logged in, select “eligibility look up” andenter the applicable information for each Participant you are inquiring about. You are ableto check on an unlimited number of patients and can print off the summary of eligibilitygiven by the system for your records.Access to eligibility information via the IVR lineTo access the IVR, simply call Idaho Smiles’ Customer Service department at800.936.0978 and press 1 for eligibility. The IVR system will be able to answer all of youreligibility questions for as many Participants as you wish to check. Once you havecompleted your eligibility checks, you will have the option to transfer to a CustomerService Representative to answer any additional questions (i.e. Participant history) whichyou may have. Specific directions for utilizing the IVR to check eligibility are listed below.After our system analyzes the information, the Participant’s eligibility for coverage ofdental services will be verified. If the system is unable to verify the Participant informationyou entered, you will be transferred to a Customer Service Representative.Directions for using Idaho Smiles’ IVR to verify eligibility:Entering system with Tax and Location ID’s1.2.3.4.5.6.7.8.9.Call Idaho Smiles Customer Service at 800.936.0978.After the greeting, stay on the line for English or press 1 for Spanish.When prompted, press or say 2 for Eligibility.When prompted, press or say 1 if you know your NPI (National Provider Identification number) andTax ID number.If you do not have this information, press or say 2. When prompted, enter your User ID (previouslyreferred to as Location ID) and the last 4 digits of your Tax ID number.Does the Participant’s ID have numbers and letters in it? If so, press or say 1. When prompted,enter the Participant ID.Does the Participant’s ID have only numbers in it? If so, press or say 2. When prompted, enter theParticipant ID.Upon system verification of the Participant’s eligibility, you will be prompted to repeat theinformation given, verify the eligibility of another Participant, get benefit information, get limitedclaim history on this Participant, or get fax confirmation of this call.If you choose to verify the eligibility of an additional Participant(s), you will be asked to repeat step5 above for each Participant.Please note that due to possible eligibility status changes, the informationprovided by either the website or IVR does not guarantee payment.If you are having difficulty accessing either the IVR or website, please contact theCustomer Service Department at 800.936.0978. They will be able to assist you in utilizingeither system.DentaQuest LLC November 24, 2015Current Dental Terminology American Dental Association. All Rights Reserved.

Idaho Smiles3.0013Outreach and Education MaterialsMember and provider education and outreach materials can be found on our website by going towww.dentaquestgov.com. The member materials include documents in both English and Spanishwith topics including “Brushing Tips,” Snack Facts,” Safe Pacifier Tips,” Dental DOs,” and‘Pregnant Women.” On the same website, providers can find access to the Provider Web Portal;current and back issues of our quarterly newsletter (also mailed to offices); FAQs (also found onwww.dentaquestgov.com); and links to prominent oral health resources (ADA, CMS, andwww.NAPD.org). For more information on outreach and education materials, please contactIdaho Smiles’ Customer Service at 800.936.0978.DentaQuest LLC November 24, 2015Current Dental Terminology American Dental Association. All Rights Reserved.

14Idaho Smiles4.00Authorization for Treatment4.01Dental Treatment Requiring AuthorizationIdaho Smiles utilizes specific dental utilization criteria as well as an authorization processto manage utilization of services. Idaho Smiles’ operational focus is to assure compliancewith its utilization criteria. The criteria are included in this manual (see Clinical Criteriasection). Please review these criteria as well as the benefits covered to understand thedecision making process used to determine payment for services rendered. ParticipatingProviders must hold the Participant and Idaho Smiles harmless as set forth in theProvider Participation Agreement if coverage is denied for failure to obtain authorization(either before or after service is rendered).A.Authorization and documentation submitted before treatment begins (Nonemergency).Services that require authorization (non-emergency) should not be started prior tothe determination of coverage (approval or denial of the authorization). Nonemergency treatment started prior to the determination of coverage will beperformed at the financial risk of the Provider office. If coverage is denied, thetreating Provider will be financially responsible and may not bill the Participantand/or Idaho Smiles.Documentation should include:1) Radiographs, narrative, or other information where requested (See Exhibitsfor specifics by code)2) CDT codes on the claim formYour submission should be sent on an ADA approved cla

Idaho Smiles 2 Idaho Smiles Address and Telephone Numbers Provider Services 12121 N. Cor