Transcription
iNevada MedicaidProvider Reference Guidewww.libertydentalplan.com/NVMedicaid
TABLE OF CONTENTSSECTION 1. LIBERTY DENTAL PLAN INFORMATION . 5INTRODUCTION . 5OUR MISSION FOR THE MEDICAID PROGRAM AND MEDICAID MEMBERS . 5PROVIDER CONTACT & INFORMATION GUIDE . 6SECTION 2. PROVIDER RELATIONS AND TRAINING . 7PROVIDER COMPLIANCE AND TRAINING . 8SECTION 3. ONLINE SELF-SERVICE TOOLS . 9ON-LINE ACCOUNT ACCESS . 9SYSTEM REQUIREMENTS . 9DIRECTORY INFORMATION VERIFICATION (DIV) ONLINE . 10SECTION 4. ELIGIBILITY . 11PRIMARY CARE DENTAL HOME ASSIGNMENT . 11HOW TO VERIFY ELIGIBILITY . 11MEMBER IDENTIFICATION CARDS . 12CARE FOR MEMBERS WITH SPECIAL NEEDS . 12SECTION 5. CLAIMS AND BILLING . 13MEDICAID REIMBURSEMENT . 13HIPAA COMPLIANT 837D FILE . 13ELECTRONIC SUBMISSION . 14PAPER CLAIMS . 14“CLEAN” CLAIMS . 14CLAIMS SUBMISSION PROTOCOLS AND STANDARDS . 15DATE OF INSERTION . 15ICD-10 CODES . 15CLAIMS STATUS INQUIRY . 16CLAIMS STATUS EXPLANATIONS . 16CLAIMS RESUBMISSION. 16CLAIMS OVERPAYMENT . 17PROMPT PAYMENT OF CLAIMS . 17ELECTRONIC FUNDS TRANSFER (EFT) . 17PAPER CHECKS . 18PEER-TO-PEER COMMUNICATION. 18
SECTION 6. COORDINATION OF BENEFITS . 19IDENTIFYING THE PRIMARY CARRIER . 19SECTION 7. PROFESSIONAL GUIDELINES AND STANDARDS OF CARE . 21PRIMARY CARE DENTIST PROVIDER RESPONSIBILITIES AND RIGHTS . 21SPECIALTY CARE PROVIDERS RESPONSIBILITIES & RIGHTS . 22MEMBER RIGHTS AND RESPONSIBILITIES . 22ANTI-DISCRIMINATION . 23NATIONAL PROVIDER IDENTIFIER (NPI) . 25VOLUNTARY PROVIDER CONTRACT TERMINATION . 25APPOINTMENT AVAILABIILTY AND ACCESSIBILITY STANDARD . 25AFTER HOURS AND EMERGENCY SERVICES AVAILABILITY . 27APPOINTMENT RESCHEDULING . 27RECALL, FAILED OR CANCELLED APPOINTMENTS . 27COMPLIANCE WITH THE STANDARDS OF ACCESSIBILITY AND AVAILABILITY . 27PRIOR AUTHORIZATION GUIDELINES FOR PRIMARY CARE DENTISTS . 27FACILITY PHYSICAL ACCESS FOR THE DISABLED . 28DEFINITION OF MEDICAL NECESSITY . 28TREATMENT PLAN GUIDELINES . 28SECOND OPINIONS . 29CONTINUITY AND COORDINATION OF CARE . 29EARLY AND PERIODIC SCREENING, DIAGNOSTIC AND TREATMENT (EPSDT) BENEFITS . 29TREATMENT OF MINORS . 30CARIES RISK ASSESSMENT . 30INFECTION CONTROL . 30DENTAL RECORDS STANDARDS . 30CULTURALLY COMPETENT CARE . 32LANGUAGE ASSISTANCE SERVICES. 32HEALTH INSURANCE PORTABILITY AND ACCOUNTABILITY ACT (HIPAA) . 33SAFEGUARDING PROTECTED HEALTH INFORMATION (PHI) . 34SECTION 8. CLINICAL DENTISTRY PRACTICE PARAMETERS . 36CLINICAL ORAL EVALUATIONS . 37INFORMED CONSENT . 38PRE-DIAGNOSTIC SERVICES . 38DIAGNOSTIC IMAGING . 38TESTS, EXAMINATIONS AND REPORTS. 39PREVENTIVE TREATMENT . 39RESTORATIVE TREATMENT . 40ENDODONTICS . 43
PERIODONTICS . 44REMOVABLE PROSTHETICS . 49ORAL SURGERY . 51ADJUNCTIVE SERVICES . 53RETROSPECTIVE REVIEW . 56SECTION 9. SPECIALTY CARE REFERRAL GUIDELINES . 57NON-EMERGENCY SPECIALTY REFERRAL SUBMISSION AND INQUIRIES . 57EMERGENCY REFERRAL . 58REFERRAL GUIDELINES FOR THE PRIMARY CARE DENTIST . 58REFERRAL GUIDELINES FOR SPECIALIST . 58SECTION 10. QUALITY MANAGEMENT . 59PURPOSE, GOALS AND OBJECTIVES . 59PROGRAM CONTENT AND COMMITTEES . 60UTILIZATION MANAGEMENT . 61MEMBER GRIEVANCES AND APPEALS . 64CONTINUATION OF BENEFITS . 64STATE FAIR HEARING . 65PROVIDER GRIEVANCES AND APPEALS . 65SECTION 11. FRAUD, WASTE AND ABUSE; AND OVERPAYMENT . 67SECTION 12. FORMS AND RESOURCES . 73SECTION 13. NEVADA MEDICAID SCHEDULE OF BENEFITS . 74
SECTION 1. LIBERTY DENTAL PLAN INFORMATIONINTRODUCTIONWelcome to LIBERTY Dental Plan’s (“LIBERTY’s”) Medicaid network of Participating Providers for the Divisionof Health Care and Financing Policy (“DHCFP”) Medicaid Program. We are proud to maintain a broadnetwork of qualified dental providers who offer both general and specialized treatment, guaranteeingwidespread access to our members.This Provider Reference Guide serves only as a summary of certain terms of the Provider Agreement betweenyou (or the contracting dental office/facility) and LIBERTY, and additional terms and conditions of theProvider Agreement may apply. In the event of a conflict between a term of this Provider Reference Guideand a term of the Provider Agreement, the term of the Provider Agreement shall control. You received acopy of the fully executed Provider Agreement when you joined LIBERTY’s network or during orientation,however, you may also obtain a copy of the Provider Agreement at any time by submitting a request toProvider@libertydentalplan.com or by contacting the Provider Relations Department at 888.700.0643.LIBERTY shall not refuse to contract with, or pay, an otherwise eligible dental office for the provision of coveredservices solely because such dental office has in good faith communicated with, or advocated on behalfof, one or more of his or her prospective, current, or former patients regarding the provisions, terms orrequirements of the member’s LIBERTY benefit plan.To provide the most current information, updates to the Provider Reference Guide will be available bylogging on to LIBERTY’s website at http://www.libertydentalplan.com/NVMedicaid.OUR MISSION FOR THE MEDICAID PROGRAM AND MEDICAID MEMBERSLIBERTY’s mission is to be the industry leader in improving access to quality oral health care services for theNevada Medicaid population. LIBERTY seeks to increase annual patient visits and improve the overall healthof the Medicaid population through member outreach and education. Our continued expansion is anoutgrowth of our commitment to exceptional service and expertise in our industry while providing a positive,rewarding, and enjoyable professional relationship with our network providers, Medicaid members, andLIBERTY staff members.Revised: 03.10.2021www.libertydentalplan.comSECTION 1. LIBERTY DENTAL PLAN INFORMATIONPAGE 5 of 74
PROVIDER CONTACT & INFORMATION GUIDENEVADA MEDICAID PROVIDER CONTACT & INFORMATION GUIDEIMPORTANT PHONENUMBERS& GENERAL INFORMATIONToll Free888.700.0643Eligibility & Benefits: Option 1Claims: Option 2Pre-Estimates: Option 3ELIGIBILITY & BENEFITSVERIFICATIONProvider PortalProvider PHONE888.700.0643Option 2TELEPHONE888.700.0643Option 1FAX888.700.1727Referrals & SpecialtyPre-Authorizations: Option4Request Materials: Option 5General Information: Option 6HOURSLive representatives areavailable866.609.0418PRE-APPROVAL,SUBMISSION & INQUIRIESCLAIMS SUBMISSIONSProvider /TELEPHONEProvider /EDIPayor ID #: CX0838 a.m. – 5 p.m. PSTPROVIDER lan.comEMAILclaims@libertydentalplan.comRegular Referrals by MailTELEPHONE833.276.0851General InformationOption 6888.700.0643Fax: 949.313.0766LIBERTY Dental PlanAttn: Provider RelationsP.O. Box 401086Las Vegas, NV 89140LIBERTY Dental PlanAttn: Referral DepartmentP.O. Box 401086Las Vegas, NV 89140EMAILProvider@libertydentalplan.comUrgent Referralsand HotlineDIRECTORY INFORMATIONVERIFICATION888.700.0643Option 4www.libertydentalplan.com/ProviderDIVFax: 888.334.6033MEMBER GRIEVANCE& APPEALSHoursMonday- Friday8 a.m. – 5 p.m. PSTLIBERTY Dental PlanAttn: Grievances and AppealsP.O. Box 26110Santa Ana, CA .com/LIBERTY Dental Plan offers 24/7 realtime access to important informationand tools through our secure onlinesystem Electronic Claims SubmissionClaims InquiriesReal-time Eligibility VerificationMember Benefit InformationPre-approval SubmissionPre-approval StatusPlease visit:888.700.0643Option 4Monday – Friday,PROVIDER WEB PORTALCLAIMS INQUIRIESFax: 888.700.1727Paper Claims by MailorCorrected Claims by MailLIBERTY Dental PlanAttn: Claims DepartmentP.O. Box 401086Las Vegas, NV 89140Corrected Claims by Fax888.700.1727Provider Portalto register as a new user and/or login.Your Office Number and Access Codecan be found on your LIBERTYWelcome Letter. If you cannot locateyour office number and/or accesscode, or need help with the loginprocess, please call 888.700.0643 forassistance. For technical m.PROVIDER COMPLAINTS& APPEALSProviders have the right to file a nonclaim related complaint or appealregarding provider payment orcontractual issues.Complaints and Appeals must be inwriting and mailed to:LIBERTY Dental PlanAttn: Grievance & AppealsP.O. Box 26110Santa Ana, CA 92799-6110Toll Free Number866.609.0418Fax: nday - Friday8 a.m. – 5 p.m. PSTToll Free Number866.609.0418Fax: onday - Friday8 a.m. – 5 p.m. PSTRevised: 03.10.2021www.libertydentalplan.comSECTION 1. LIBERTY DENTAL PLAN INFORMATIONPAGE 6 of 74
SECTION 2. PROVIDER RELATIONS AND TRAININGLIBERTY’s team of Network Managers is responsible for recruiting, contracting, servicing, and maintaining ournetwork of Providers. We encourage our Providers to communicate directly with their designated NetworkManager to assist with the following: Plan contracting Escalated claim payment issues Education on LIBERTY Policies and Member Benefits Provider Trainings and Orientations Directory Validation Changes in Office Demographics Opening, Changing, or Closing a Location Adding or Terminating Associates Credentialing and Recredentialing of an owner and an associate dentist inquiry Change in name or ownership Taxpayer Identification Number (TIN) change Changes in office hoursTo ensure that your information is displayed accurately, and claims are processed efficiently, please submit allchanges within 30 days in advance by email or in writing. Provider Relations will address your inquiry withinthree (3) business days of receipt.LIBERTY Dental PlanATTN: Provider RelationsP.O. Box 401086Las Vegas, NV 89140Provider RelationsM-F from 8 am – 5 pm (Pacific)888.700.0643Email at Provider@libertydentalplan.comRevised: 03.10.2021www.libertydentalplan.comSECTION 2. PROVIDER RELATIONS AND TRAININGPAGE 7 of 74
PROVIDER COMPLIANCE AND TRAININGLIBERTY provides initial orientation and training to all new offices within 30 days of activation. Additional trainingis provided for new staff, when changes in the program occur, or when there is a change in provider utilizationand/or other activity. Further, LIBERTY may provide training through webinars, as well as telephonic and in-personmeetings.All trainings regarding the requirements, including any Contract amendments and special needs of membersare available to providers and their staff. Providers are trained on identifying adverse incidents and requirementsto report adverse incidents to LIBERTY within forty-eight (48) hours of the incident.Providers must maintain supporting documentation for a period of ten (10) years after training for all officepersonnel supporting LIBERTY’s government business and can furnish the documentation upon request.You may utilize LIBERTY’s training modules (or your own comparable content) and attest that all associates andstaff have completed required training.Training modules are also available online der-Training-1.aspx.Training programs include, but are not limited to: Critical Incident Awareness Code of Business Ethics & Conduct Cultural Competency Fraud, Waste & Abuse General Compliance HIPAARevised: 03.10.2021www.libertydentalplan.comSECTION 2. PROVIDER RELATIONS AND TRAININGPAGE 8 of 74
SECTION 3. ONLINE SELF-SERVICE TOOLSLIBERTY is dedicated to meeting the needs of our providers by utilizing leading technology to increase youroffice’s efficiency. Online tools are available for billing, eligibility, claim inquiries, referrals and other transactionsrelated to the operation of your dental practice.We offer 24/7 real-time access to important information and tools free of charge through our secure onlineprovider portal.Registered users will be able to: Submit electronic claims Requests for prior authorizations Verify member eligibility and benefits View office and contract information Submit referrals and check status Access benefit plans Print monthly eligibility rosters Perform a provider searchON-LINE ACCOUNT �saccount,visittheAll contracted network dental offices are issued a unique Office Number and Access Code. These numbers canbe found on your LIBERTY Dental Plan Welcome Letter and are required to register your office on LIBERTY’s onlineProvider Portal.The designated Office Administrator should be the user to set up the account on behalf of all providers/staff. TheOffice Administrator will be responsible for adding, editing, and terminating users within the office.If you are unable to locate your Office Number and/or Access Code, please contact the Member ServicesDepartment for assistance. For technical assistance, email portalsupport@libertydentalplan.com.For more detailed instructions on how to utilize the provider portal, Documents/ma Office Portal User Guide.pdf.referenceSYSTEM REQUIREMENTS Internet Connection compatible with Microsoft Edge, Google Chrome, and Mozilla Firefox Adobe Acrobat ReaderRevised: 03.10.2021www.libertydentalplan.comSECTION 3. ONLINE SELF-SERVICE TOOLSPAGE 9 of 74the
DIRECTORY INFORMATION VERIFICATION (DIV) ONLINELIBERTY actively works to verify and maintain the accuracy of our provider directories which are available tomembers and the public. It is required that we maintain current office information to ensure the informationprovided to our members reflects both your current office demographic information and associate dentist thatare available to LIBERTY members.There is an easier way to update your information through our Provider Directory Information Verification (DIV)website at me you have changes, including, but not limited to appointment times, office hours, address, phonenumber, fax number, associate dentist, etc. You’ll be able to update or attest that no changes were made. Thisshould be completed no less than every quarter. We also highly recommend that you set a calendar reminderin your system to go to the website every 85 days and validate the information.Why do I need to update my provider information? Prevent and minimize costly claims payment delays Stop time consuming calls to validate your directory information Fix what’s wrong with the click of a button No filling out paper forms and faxing or emailing Provide the most up-to-date information to existing and new members so they can make educationaldecisions about their provider office choicesYou will need to have your office Access Code to use the online feature. This number can be found in yourLIBERTY Welcome Letter. If you are unable to locate your Access Code, please contact the Provider RelationsDepartment at 888.700.0643 or email Provider@libertydentalplan.com for assistance.Revised: 03.10.2021www.libertydentalplan.comSECTION 3. ONLINE SELF-SERVICE TOOLSPAGE 10 of 74
SECTION 4. ELIGIBILITYAnti-Discrimination Notice: LIBERTY complies with applicable federal civil rights laws and does not discriminatebased on race, color, national origin, age, disability, or sex.PRIMARY CARE DENTAL HOME ASSIGNMENTDental home is the ongoing relationship between the dentist and the member, inclusive of all aspects of oralhealth care delivered in a comprehensive, continuously accessible, coordinated, and family-centered way. Thedental home should be established no later than 12 months of age to help children and their families institute alifetime of good oral health. A dental home addresses anticipatory guidance and preventive, acute, andcomprehensive oral health care and includes referral to dental specialists when appropriate.All Medicaid members must be assigned to their primary care dental home prior to treatment. Dental homesinclude general and pediatric offices also known as Primary Care Dentists (PCD).Members will be assigned to a dental home (a dental home or Primary Care Dentist “PCD”) consists of generaldentists and pediatric dentists. Upon initial enrollment, LIBERTY will assign members to the nearest Primary CareDentist based on such factors as language, cultural preference, previous history of the member or another familymember, etc. Members can change Primary Care Dentists at any time by either calling LIBERTY or going ontothe LIBERTY website.Providers are responsible for verifying member eligibility prior to scheduling an appointment. Checking eligibilitywill allow providers to complete medically necessary procedures and reduce the risk of denied claims.HOW TO VERIFY ELIGIBILITYOptions available to verify eligibility:1. Provider Portal: https://providerportal.libertydentalplan.com/(We recommend using Member’s Last Name, First Name and Date of Birth for best results)2. Calling LIBERTY’s Member Services Department to speak with a live representative, Monday through Fridayfrom 8 a.m. to 5 p.m. PST.If a Medicaid member has not selected your office as their dental home prior to treatment, the claim may notbe payable unless a dental emergency is identified.In the event a member does not appear on the monthly roster, please contact LIBERTY’s Member ServicesDepartment.Revised: 03.10.2021www.libertydentalplan.comSECTION 4. ELIGIBILITYPAGE 11 of 74
Eligibility RostersAt the beginning of each month, LIBERTY will post a member roster in the “My Resources” section of the ProviderPortal. This list will provide your office with the following information in alphabetical order: Member Name Member Telephone Number Member Identification Number Date of Birth Group Type of Coverage (Plan number/name) Effective Date of CoverageMEMBER IDENTIFICATION CARDSMembers should present their ID card at each appointment.Members can print an ID card from LIBERTY’s website. Providersare encouraged to validate the identity of the personpresenting an ID card by requesting some form of photoidentification. The presentation of an ID card does notguarantee eligibility and/or payment of benefits. In such cases,providers should check a photo ID and check against aneligibility list or contact Member Services or visit the online webportal for verification of eligibility. Please note that due topossible eligibility status changes, this information does notguarantee payment and is subject to change without notice.Verification of network participation: Offices may be linked to child and/or adult programs. If you are unsurewhich programs you are currently linked to, please contact your local Network Manager.CARE FOR MEMBERS WITH SPECIAL NEEDSWe offer care management services to children andOur care management programs are offered to members who:adultswithspecialhealthcareneeds. Are developmentally disabled Are home-bound Are identified as needing assistance in accessing or using services; and Have long-term or complex health conditions, like asthma, diabetes, HIV/AIDS, and high-risk pregnancyOur care managers are trained to help providers, children and adults to arrange services (including referrals tospecial care facilities for highly specialized care) that are needed to manage illness. Our goal is to help memberswith special needs understand how to take control of themselves and maintain good oral health.Our care management programs offer children and adults a care manager and other outreach workers. They’llwork one-on-one to help coordinate oral health care needs. To do this, they: May ask questions to get more information about a member’s health conditions Will work with PCPs to arrange services needed and to help members understand their illness Will provide information to help members understand how to care for themselves and how to accessservices, including local resourceRevised: 03.10.2021www.libertydentalplan.comSECTION 4. ELIGIBILITYPAGE 12 of 74
SECTION 5. CLAIMS AND BILLINGAll claims
Revised: 03.10.2021 SECTION 1. LIBERTY DENTAL PLAN INFORMATION PAGE 5 of 74 www.libertydentalplan.com SECTION 1. LIBERTY DENTAL PLAN INFORMATION INTRODUCTION Welcome to LIBERTY Dental Plan's ("LIBERTY's") Medicaid network of Participating Providers for the Division
