. It is not medical advice and should not be substituted for regular consultation with your health care provider. Pregnant women: Pregnant women should see a dentist at least one time during pregnancy. Help from a registered dietitian and nutritionist. $0 premiums, deductibles, and co-insurance. FH# 6478476L (available here), Example: Appellant was approved for placement of an upper denture but was denied for a lower partial denture. Information about the transition of the pharmacy benefit from MetroPlusHealth to NYRx, the Medicaid Pharmacy Program can be found here. Message DentaQuest through secure messaging. OnBoard is an application that is accessed from the Medical Portal. Claims submitted for the treatment of deciduous cuspids and molars for children ten (10) years of age or older, or for deciduous incisors in children five (5) years of age or older will be pended for professional review. MyChart allows you to: Learn about all of the free preventive services for adults, women and children. Reimbursement for unlisted codes may not be payable and can be subject to the prerogative of the insurer. For children under 7 years of age, ask the dentist or primary care doctor about fluoride varnish. %PDF-1.6 % 2023 Medicare and PDP Compare Plans and Enroll Now Notice of Non-Discrimination We comply with applicable Federal civil rights laws and do not discriminate on the basis of race, color, national origin, age, sex, or disability. Learn more on our Children and Family Support Services pagehere. A dental visit should include a professional cleaning. This means that every time you visit this website you will need to enable or disable cookies again. Other supporting documentation for the request may be submitted including x-rays. Credible testimony by the appellant alone is not sufficient in these types of cases. Orthodontic exam and evaluation and treatment will be billed using the dental fee schedule.*. %%EOF The Medicaid dental benefit is limited and includes only essential services. Can I require workers compensation patients to pay up front for dental work before the work is performed, or bill a workers compensation patient for services rendered? Interested in learning more aboutPreventive Dental Care? See Plan information, Health Rewards, and Messages, Find someone in your neighborhood and in your language. Find a plan that's right for you. How will I be reimbursed for procedures included under CPT but not CDT codes? PEF Dental and/or Vision Only. **You must participate in the Preferred network to also participate in the Spectrum network. OnBoard will be used by dental providers to submit Form HP-1.0 requests for arbitration and to request prior authorization for medications, durable medical equipment, non-MTG procedure(s) costing more than $1000, or under or equal to $1000. Member and Provider FAQs - Pharmacy Benefit Carve-Out. . The NYS Department of Financial Services has adopted the Dental Fee Schedule as its fees for all dental treatment provided to victims of motor vehicle accidents through its NoFault program. % 118 0 obj <> endobj You can perform a search on the internet or use local telephone resources. You do not need a referral from your PCP to see a dentist. 122 Fulton St, 2nd Floor, New York, NY 10038 4.71 65 verified reviews At Nassau Street Dental, our practice strives to achieve excellence in all aspects of dentistry especially cosmetic and our goal is to perfect your smile. New York State is making this change in the initial assessment process to make it easier to get the services you need. Payers may use the charges you submit to determine maximum-allowable fees. If you are turning 65 within the next 3 months or you are 65 years of age or older, you may be entitled to additional medical benefits through the Medicare program. endobj %PDF-1.7 endstream endobj 119 0 obj <. Treatment of deciduous teeth (primary or baby teeth) when exfoliation (when the primary teeth shed and the permanent teeth come in) is reasonably imminent will not be routinely reimbursable. Find the specific content you are looking for from our extensive Provider Manual. The Medicaid Orthodontic Benefit is for children under 21 years old with severe physically handicapping malocclusions (a malocclusion is imperfect positioning of the teeth when the jaws are closed). Provision of orthodontic treatment will require Plan approval. What should I do? On December 28, 2016 the Agency determined to deny the request on the grounds that the service is not covered by the Agency. This dental fee schedule also applies to No-Fault claims. We use cookies to make your experience better. You may be required to submit proof that you have applied for Medicare so please keep your award or denial letter from SSA or your on line receipt from SSA. See Plan information, Health Rewards, and Messages, Find someone in your neighborhood and in your language. If you have any questions, call one of our Member Services Representatives. @Rt CXCP%CBH@Rf[(t CQhz#0 Zl`O828.p|OX We also want to ensure you arrive at your appointment timely without having to rely on family or friends for your transportation. Members who receive care at NYC Health + Hospital facilities now have access to MyChart. a) decides a proposed or delivered health care service which would otherwise be covered under the covered individual's Subscriber's Policy . Your benefits include dental check-ups, cleaning, x-rays, fillings and follow-up care. 12287 0 obj<>stream School Based Health Center dental services will continue to be carved out of Managed Care and will remain billable Fee-for- Service. To make the transition as transparent and seamless as possible for both the provider and patient. This limited coverage makes it important for advocates to understand the exceptions to different coverage limitations. SeeDental Policy and Procedure Code Manual,page 59. Dental providers (along with other health care providers) are required to register for OnBoard via the Boards Medical Portal in order to submit Form HP-1.0 requests and/or requests for prior authorization. /N 3 Learn more about Medicaid and how to enroll with MetroPlusHealth below: Beginning April 1, 2023, all Medicaid members enrolled in MetroPlusHealth Medicaid, Partnership In Care, and Enhanced (HARP) plans will receive their prescription drugs through NYRx, the Medicaid Pharmacy Program. WHAT DENTAL SERVICES ARE COVERED UNDER MEDICAID? Contact: Legal Aid Society Health Hotline (212) 577-3575 or email . FH# 7360626Q(available here), Example: Fidelis (by DentaQuest) determined to deny the Appellant's dentist's prior approval request for a root canal on teeth numbers 2 and 18 on the ground that the service is not covered for members age 21 or older and that the service could be covered if pulling the tooth cannot be done because of a medical illness or if the tooth is needed for a bridge or a partial denture the Appellant already has. Effective January 1, 2019, new mental health and substance use services are available with NYS Childrens Medicaid. SeeDental Policy and Procedure Code Manual, page 24. Start a NEW Online Credentialing Application Continue an ALREADY STARTED Online Credentialing Application Submit Electronic Claims and Dental Claim Forms. /Length 2596 Early treatment prevents them from getting worse. They also want to speak with Medicaid-eligible individuals who require any other dental treatments that are not covered by Medicaid including root canals, immediate dentures, osseous surgery. Child Health Plus cover routine, preventive and emergency dental services through DentaQuest. Dental care and "exam and evaluation for orthodontic treatment" without Plan approval. "Dental care in the medical assistance program shall include only preventive, prophylactic and other routine dental care, services and supplies, and dental prosthetic and orthodontic appliances required to alleviate a serious health condition including one which affects employability.. 0000003851 00000 n MetroPlusHealthMedicaid Managed Care offers low- or no-cost health coverage to New Yorkers who live anywhere in New York City. According to the Dental Policy manual, when considering if services are essential, eight posterior natural or prosthetic molars and/or bicuspids in occlusion will be considered adequate for functional purposes. Dr. To choose a Primary Care Dentist (PCD) or if you need help finding a dentist in your area, call DentaQuest at 844-284-8819. StartingJuly 1, 2021, MetroPlusHealth will cover Article 29-I Voluntary Foster Care Agency (VFCA) Health Facility services for children and youths under age 21 in foster careand other special populations, as indicated. The Board does not authorize dental providers and does not provide lists of dental providers as referrals. If the total number of teeth which require, or are likely to require, treatment would be considered excessive or when maintenance of the tooth is not considered essential or appropriate in view of the overall dental status of the recipient, treatment will not be covered. The SFC program is managed by Dentaquest. To learn more, check out these resources: Fidelis Care members with dental coverage have their benefits covered through DentaQuest. Explore Qualified Health Plans (QHP) through the NY State of Health, The Official Health Plan Marketplace. This means that four maxillary (upper jawbone) and four mandibular (lower jawbone) teeth in functional contact with each other are considered adequate. Requests will be reviewed for necessity based upon the presence/absence of eight points of natural or prosthetic occlusal contact in the mouth (bicuspid/molar contact). [/ICCBased 3 0 R] Example: Appellants dentist submitted a prior authorization for root canal therapy on Appellants tooth number 18 (molar). 0000003098 00000 n See pages 25-26 of the Dental Policy and Procedure Code Manual for a chart of the decisive appointments for various services. FH# 6655671H(available here), Denture Replacement - REVISIONS EFFECTIVE NOV. 12, 2018. Claims must be submitted when the product or service is completed and delivered to the recipient with the appropriate procedure code using the date that the service was actually completed and delivered as the date of service. NEW YORK Healthcare done well. Strictly Necessary Cookie should be enabled at all times so that we can save your preferences for cookie settings. For more information about what services are included, see the state regulation. If you are turning 65 within the next 3 months or you are 65 years of age or older, you may be entitled to additional medical benefits through the Medicare program. Adverse determination: a utilization review decision by the Plan, or a health care provider acting on behalf of the Plan that: . MetroPlusHealth has offered low-cost, quality health care for New Yorkers for more than 35 years. Learn morehere. For Medicaid recipients 21 or older who need additional resources for behavioral health. FOR Qualified New Yorkers MetroPlusHealth Gold $0 premiums, deductibles, and co-insurance. Meet our leadership, join our team, or get in touch with MetroPlusHealth. Our Member Handbook explains the details of your MetroPlusHealth Medicaid coverage, including your benefits, the rules of the plan, and information about how to receive care. Theyalso want to speak with Medicaid-eligible individuals who require any other dental treatments that are not covered by Medicaid including root canals, immediate dentures, osseous surgery. For beneficiaries age 21 and older, molar endodontic therapy will be considered when (1) the tooth in question is a critical abutment for an existing functional prosthesis and (2) the tooth cannot be extracted and replaced with a new prosthesis. Under Medicaid, dental benefits exist, but the coverage is limited. Medicaid Orthodontic Benefit. StartingMay 16, 2022, the way Personal Care Services and Consumer Directed Personal Assistance Services (PCS/CDPAS) are initially assessed will be changing. 12285 13 Members who need dental care should be directed to our Find a Doctor directory. You can choose your own primary care physician (PCP). Lack of Dental Coverage Hampers Medicaid Recipients, Suit Says, EFFECTIVE NOV. 12, 2018 the new policy on denture replacement is, Dental and Orthodontic Services to be Included in the Medicaid Managed Care Benefit Package. The decisive appointment for active orthodontic treatment is the time at which the total appliance(s) is/are completely placed and activated. @~ (* {d+}G}WL$cGD2QZ4 E@@ A(q`1D `'u46ptc48.`R0) How can I get this information? All relevant billing forms and treatment notes should be sent to the workers' compensation insurer. Physical activity is one of the simplest ways to stay healthy, and Healthfirst makes it even more rewarding! A verbal statement by the recipient that is then included by the provider on the prior approval request would generally not be considered sufficient. FH #6755535N(available here), Example: Appellants dentist requested prior authorization for denture replacement prior to the 8 year waiting period. Contact DentaQuest at 1-888-912-3456 or search the DentaQuest website to find a listing of dentists who accept Medicaid in your zip code. A yearly cleaning at your dentists office helps prevent gum disease. Upload necessary documentation. If replacement dentures are requested within the eight year period after they have already been replaced once, then supporting documentation must include an explanation of preventative measures instituted to alleviate the need for further replacements. This service requires prior approval. DQUSA.TX.IND.POL 2.15 4 Part I Definitions . Legal Aid Society asks you to let themknow if you are working with Medicaid-eligible individuals who require dental implants or replacement dentures, including those whose care may not be covered based on the revised policy. Their dental network is 65% larger than what we have been offering, with more dentists and specialists available than before. Provider Update ALSO OF INTEREST Top Undrafted Rookie FAs. The 2023 bump in pay extends throughout the draft. Use the American Dental Associations and New York State Dental Associations published materials to show that the Medicaid Manual is not following professional standards, such as a tooth is still viable and extracting it will cause health complications. %PDF-1.4 % Can I refuse to treat a workers compensation patient for dental services? To choose a Primary Care Dentist (PCD) or if you need help finding a dentist in your area, call DentaQuest at 844-284-8819. Starting July 1, 2022, you can join a no-cost Medically Tailored Meals program that provides healthy meals straight to your home. See EPSDT/CTHP Provider Manual for Child Health Plus A (Medicaid), page 12 https://www.emedny.org/ProviderManuals/EPSDTCTHP/PDFS/EPSDT-CTHP.pdf. Learn more about Monkeypox, including prevention and treatment,here. Yes, any dental provider can refuse to treat a workers compensation patient for dental services. View 2022-Fee Schedule - Dentaquest.docx from EGL 111 at Oakton Community College, Skokie. 0000001103 00000 n Good practice is to review your contracted fee schedules annually. 56.5 mi. The workers compensation insurer is liable only for reimbursement for treatment necessitated by the work-related accident. Plus, when you join our Preferred network you automatically become a participant of our discounted Dental Access Program,and the Preferred Premier plan. Where possible, the provider should use similar listed codes found on the Dental Fee Schedule and bill accordingly. Essential Services. Video visits. The fee schedules are typically part of the Plans must allow new member to continue treatment with non-participating provider for up to 60 days or until the current treatment plan is complete, whichever is sooner, when: A treatment plan is in progress but has not been completed as of date of enrollment; The provider agrees to accept Plan reimbursement as payment in full, adhere to Plans quality assurance and encounter data submission requirements and otherwise adhere to Plans policies and procedures. These networks are separate and unrelated and each has distinct patient enrollment and reimbursement schedules. L. 111-148).. EFFECTIVE NOV. 12, 2018 the new policy on denture replacement is: Full and /or partial dentures are covered by Medicaid when they are required to alleviate a serious health condition or one that affects employability. Submitting provider notified of determination, Provide information on transition timelines, Explain procedures for existing and new cases, Dental Coverage Transition from Fee for Service (FFS) to Medicaid Managed Care (MMC), Process of Approval of Orthodontia Services, Prior Approval Requests and Claims (FFS only), Dental (other than orthodontia) mandatory as of 7/2/12, Health Insurance Plan of Greater New York. Check benefits. Resources. Dental providers are required to register for the Medical Portal and submit a request for prior authorization using OnBoard. For New Yorkers living with HIV/AIDS and other select groups. Reimbursement for services listed in the New York State Fee Schedule for Dental Services is limited to the lower of the fee indicated for the specific service or the provider's usual and customary charge to the general public when there is a significant difference between the two fees. OnBoard: Limited Release is the first phase of OnBoard, designed to move key processes for health care providers and claim administrators from paper to online, including the submission of Request for Decision on Unpaid Medical Bill(s) (Form HP-1.0) and the prior authorization request (PAR) process for medication, durable medical equipment and medical treatment/testing. SeeDental Policy and Procedure Code Manualpage 24. If there are no similar listed dental codes, the provider should use CDT code 09999 "Unlisted Adjunctive Procedure By Report", where the provider should establish a fee consistent in relativity with the other fees listed in the dental fee schedule. Annual trainings are updated annually in the Fall and should be completed each year no later than December 31st. During your appointments, the dentist can find any cavities early and treat them. Contact: Legal Aid Society Health Hotline (212) 577-3575or, Full and /or partial dentures are covered by Medicaid when they are required to alleviate a serious health condition or one that affects employability. OR. 0000001777 00000 n The dental provider must have a valid NYS dental license. MFk t,:.FW8c1L&9aX: rbl1 Participants meet a high credentialing standard and agree to treat covered patients at the fees detailed in our fee schedules. Rookie FA signings by team. No copays. This means that every time you visit this website you will need to enable or disable cookies again. All bills submitted using CDT code D9999 should be accompanied by a report providing the reasons why such procedures are necessary. Do I need to be authorized by the Board to provide dental treatment to workers compensation patients? If you would like a hard copy of this handbook, you can submit a request onlinehereor call us at 1-800-303-9626 (TTY: 711). Please be sure to tell us which plan handbook for example, Medicaid you need. Childrens Dental Benefit. When reviewing requests for services the following general guidelines are used: Treatment will often not be approved when functional replacement with less costly restorative materials, including prosthetic replacement, is possible. One of our representatives will reach out to you ASAP to review your plan options. Revised policy effective November 12, 2018 - click on these links: VI. Decisions are often remanded, or sent back to the plan to make another determination, when the plan fails to provide support for their basis of denial. Find our Quality Improvement programs and resources here. The placement of the component parts (e.g. Contact: Legal Aid Society Health Hotline (212) 577-3575or email . Welcome. Groups range in size from as few as five employees to thousands of covered patients. Dental services for the state's poor moved into managed care on July 1. Revised policy effective November 12, 2018 - click on these links: VI. If the patient was working at the time of the accident, it should be treated as a workers' compensation claim. In accordance with section 13a(5) of the Workers' Compensation Law, if the cost of the procedure(s) will exceed $1,000 (according to the dental fee schedule) the dental provider is required to request prior authorization. A letter from the patients physician must explain how implants will alleviate the patients medical condition. Trainings last updated: October 2022. Prior approval requests for such replacements will not be reviewed without supporting documentation. Learn more here. StartingJanuary 1, 2023, MetroPlusHealth will cover Gambling Disorder Treatment provided by Office of Addiction Services and Supports (OASAS) certified programs. FH# 7261543K(available here), Example: Agency denied appellants request for a lower partial denture because the appellant had 8 points of contact without the denture. Medicaid Managed Care has a year-round open enrollment period. Theyalso want to speak with Medicaid-eligible individuals who require any other dental treatments that are not covered by Medicaid including root canals, immediate dentures, osseous surgery. SBHC services are identified by the following FFS rate codes: Free-standing FQHCs (not in APGs) - 1627, 1628, Hospital FQHCs (not in APGs) - 2888, 2889. Also startingJuly 1, 2021, some children and youth must join a Medicaid managed care plan, including: Some children and youth placed in foster care cannot join a Medicaid managed care plan. Provider must be participating and agree to provide services. Contact DentaQuest Member Services. The 31st . Remember to bring your new ID card when you visit your dentist. In addition, dental providers may use OnBoard to request dental-related DME and medications, and to submit Form HP-1.0. Any dental billing forms with the appropriate code and fee as found in this dental fee schedule can be used. The Great Expressions Difference. Talk To Us About Any Questions or Concerns. (available here), Example: Appellant requested replacement of broken denture prior to the 8 year waiting period. Calendar. . Important notice about your Medicaid managed care plan benefits. Navigators and Certified Application Counselors, NY State of Health, The Official Health Plan Marketplace, online at. Ask the dentist to testify during the fair hearing or to provide a written statement of a denials impact on the clients health. Learn how to use this new tool (and more) by attending one of our scheduled WebEx trainings. How do I request prior authorization for treatment? %%EOF The plan must reimburse the clinic for covered dental services provided to enrollees at approved Medicaid clinic rates. Appellant testified he was taking the denture out at night to clean when he accidentally dropped it on the floor and two of the teeth broke off. New York, NY 10004 Note to Out-of-Network Providers: This schedule displays reimbursements for commonly utilized services on an out-of-network basis only. Check member eligibility status. This website uses cookies so that we can provide you with the best user experience possible. Workers' Compensation Law does not require dental providers to be authorized by the Board. Just quality health care. Use your next visit as a chance to go over how to floss and brush the right way. 18 NYCRR 506.3: Authorization for dental services and supplies: The identification card issued to persons eligible for medical assistance shall constitute full authorization for providing a select list of dental services and supplies and no special or prior authorization shall be required for these services. 2 0 obj We use cookies to make your experience better. MetroPlusHealth Virtual Visit is available anytime, from anywhere in New York State, 24/7 and in your language. Form HP-1.0 should be submitted, along with any necessary attachments, such as copies of medical bills, through OnBoard. However, the dental provider must have a valid NYS dental license. However, the appellant failed to established that other treatments, even if less cosmetically ideal, would not eliminate the pain. The Workers' Compensation Law does not permit a dental provider to collect from, or bill, a workers compensation patient for services rendered, unless a decision is issued by the Workers' Compensation Board indicating the patient failed to prosecute their claim, the claim is denied, the treatment is not causally related to the work injury, or a Section 32 agreement has been approved relieving the insurer of liability for medical expenses. Dental implants will be covered by Medicaid when medically necessary. A dental visit should include a professional cleaning. Dental providers may use OnBoard to submit prior authorization requests for treatment. The denial was overturned because the Agency packet failed to include any information showing how the Agency made the factual finding as to the points of contact in Appellants mouth. All Rights Reserved. Contains dental best-practices, parenting tips, and preventative guidance sourced from accredited institutions on each of the following topics: Dental Preventative Care Dental Care Tips for Moms Diagnosis & Treatment for Gum Disease and Tooth Decay Children's Dental Health Timeline Guidance, from Newborn to Gradeschooler. FH# 7315399K(available here), Exception: Under certain circumstances the Agency will approve replacement of a lost partial denture, such as for a recipient whose mouth had undergone significant changes subsequent to the incident -- for example the loss of teeth. FH 6394357J(available here). We can even enroll you over the phone. Implant Services (revised Nov. 12, 2018. endobj FH #6755535N. Contact ExerciseRewards at 1-877-810-2746 to learn more . See Dental Policy and Procedure Code Manual, page 24. At the fair hearing the appellants testimony of how she was unable to chew properly because of the constant pain and how that pain interfered with her capacity to perform the duties of her job was found to be credible.
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