VOL 67 | OCT 2022 | QTR 4
TEXAS ROUNDUP
Program Updates for Texas Dentists
IN THIS ISSUE
Appeals vs Claim Resubmission - Do's and Don'ts
Appeal:
An appeal is a request to review an adverse benefit determination. Appeals should be submitted for the following:
- No additional information is being submitted for review on pre-authorization. Provider is asking for an additional review of initial submission. This must be appealed.
- Claim denies and provider makes no changes to the initial claim, or the claim is no longer considered timely. Timely is 95 days from the original date of service. Appeals can be submitted up to 120 days from last denial date. This must be appealed.
Example:
- Claim denies for medical necessity and provider does not have any additional information to add. The provider wishes to appeal the decision based on original submission.
- Claim denies and provider wishes to make changes and / or submit new information; however, the claim is outside the timely filing limit (95 days from date of service). Upon further review, the claim is still within 120 days from the denial date. Provider would need to submit appeal for reconsideration.
An appeal will be processed within 30 calendar days from the receipt date. A physical resolution letter will be mailed with the determination of the appeal. An appeal should not be utilized if a claim that is still timely or authorization is denied for missing information.
Resubmission:
A resubmission is a second claim or pre-authorization submitted with additional or corrected information. Claims should be resubmitted if within 95 days from the original date of service. A claim within 95 days from the date of service should be resubmitted for the following:
- Claim changes such as revision of a code, adding missing information such as TID, x-rays, narrative, primary insurance…etc.
- Pre-authorization with additional information submitted or codes being added, changed, or deleted
- Please place keyword in Box 35 (remarks / comments) to identify the claim as a resubmission of the original.
- Suggested keywords: resubmission, re-submit, correction or corrected.
Example:
- Claim denies for missing caries risk assessment code and is still considered timely. Provider resubmits the claim and adds the appropriate caries risk assessment code. This should not be appealed.
- Pre-authorization denies and provider expands the narrative to include additional information for consideration. Provider would resubmit the auth with all additional information. This should not be appealed.
The resubmission process follows the normal process for claims adjudication and pre-authorization determination which is timelier and more efficient than the appeal process. This is an advantage to the provider as the 30-day appeal timeline is reduced considerably through the resubmission process. If you are unsure of when to appeal or resubmit, please contact your Regional Provider Partner with any questions.
Caries Risk Assessment Claim Submission Requirements
The entire claim submission will deny when a caries risk assessment procedure code (D0601, D0602 or D0603) is not submitted on the same date of service and same claim submission, as the dental examination procedure code (D0120, D0145, and D0150). The member’s dental condition(s) that justifies the risk assessment classification submitted with the claim must be maintained by the provider in the member’s dental record and be clearly documented using a caries risk assessment tool or in a narrative charting addressing clinical and biological factors or based on a professionally recognized assessment tool. Dentists have the flexibility, using his or her professional judgment, to utilize the caries risk assessment tools with which the dentist is most comfortable. Any denial due to missing caries risk assessment code should be resubmitted with appropriate code within 95 days from the original date of service. Please do not submit as an appeal unless the claim is no longer timely.
Reminder: Online Main Dental Home Change Form
As of May 1, 2022, DentaQuest no longer accepts Main Dentist change forms via fax. The fax line has been discontinued and all Main Dental Home provider changes must now be submitted by the Member's Head of Household using the online tool.
Texas Medicaid and Texas CHIP members can now change their Main Dental Home provider online at www.dentaquest.com/texas. As a reminder, Main Dentist changes can only be made by the Member's Head of Household.
- Make changes faster than a call, 24/7
- No need to log in to the Member portal
- Use the same system our Member Services team uses
- Members show up on your patient roster within minutes
- 16-digit reference number provided on the confirmation page
Member's Head of Household can use this QR code to change their main dentist now!
Reminder - Interim Care Transfer (ICT)
As part of its core mission, DentaQuest is deeply engaged in all of the Texas communities in which they serve, with a particular focus on the most underserved and neediest populations. As part of this community engagement, DentaQuest continually monitors developments that may impact the delivery of dental care to those who need it most.
As part of your agreement with DentaQuest to provide care for its members, you must comply with state and federal laws, rules and regulations governing marketing, as well as the Health and Human Services Commission’s (HHSC) marketing policies and procedures, including their Uniform Managed Care Manual. Included in these rules are restrictions prohibiting providers from offering cash, gifts or other items to Medicaid members to influence their health care decisions, either directly or through a third party. This includes hiring individuals and marketing firms to solicit Medicaid eligible children.
Texas Provider Marketing Guidelines
As part of its core mission, DentaQuest is deeply engaged in all of the Texas communities in which they serve, with a particular focus on the most underserved and neediest populations. As part of this community engagement, DentaQuest continually monitors developments that may impact the delivery of dental care to those who need it most.
As part of your agreement with DentaQuest to provide care for its members, you must comply with state and federal laws, rules and regulations governing marketing, as well as the Health and Human Services Commission’s (HHSC) marketing policies and procedures, including their Uniform Managed Care Manual. Included in these rules are restrictions prohibiting providers from offering cash, gifts or other items to Medicaid members to influence their health care decisions, either directly or through a third party. This includes hiring individuals and marketing firms to solicit Medicaid eligible children.
Any violations of this policy will result in termination from the DentaQuest network and may also result in Federal and state civil and criminal penalties. DentaQuest takes violations of its policies and procedures seriously, especially when children and other vulnerable individuals are impacted. DentaQuest investigates all reported allegations and takes appropriate action on all provider behavior that is inconsistent with policies and procedures regarding the solicitation of members.
For additional information, please refer to the Office of Inspector General (OIG) website.
Important Reminders
Provider Resource Documents
The following documents are listed on the Provider Resources page:
DentaQuest Holiday Closures
In observance of the Thanksgiving, Christmas, and New Year holidays, DentaQuest will be closed for the following days:
- Thursday, November 24
- Friday, November 25
- Monday, December 26
- Monday, January 2
Visit the Provider Relations Contacts page to locate your regional partner.
