Who’s Eligible and How to Apply?

Who’s Eligible and How to Apply?

• To participate in Smiles For Children (SFC), recipients must first be eligible for Medicaid, FAMIS or FAMIS Plus.

• Once eligible, recipients are automatically enrolled in the SFC program and receive a Member Handbook.

• Recipients do not receive a SFC ID card. Recipients may use:

• Commonwealth of Virginia (blue and white) plastic identification
• MCO identification card

• For questions regarding Medicaid eligibility, recipients should:

• Visit their local Department of Social Services
• http://www.dss.virginia.gov/

• For questions regarding FAMIS or FAMIS Plus eligibility, recipients should:

• Go online and visit: www.famis.org; or
• Call 1-866-87FAMIS (1-866-873-2647)

Enrollee Eligibility

• Doral uses the 12-digit Medicaid ID number as the enrollee ID Number.

• Eligibility may be confirmed using:

• Doral website
• By calling 1-888-912-3456
• DMAS MediCall voice response system at 1-800-884-9730 or 1-800-772-9996.

• If DMAS Medicall voice response system is used, providers are cautioned to listen to the entire message. Members may be in a waiver program, such as the Family Planning Waiver, and may not be eligible for dental benefits.

Interactive Phone System

• AVAILABLE 24 HOURS A DAY!

• By dialing 1-888-912-3456 and choosing option 1 providers can access:

• Patient Eligibility
• Limited Claims History
• Fax Back Confirmation of eIVR call
• Spanish Call Handling

• Patients eligibility can be verified on the eIVR along with limited claim history (codes: D0120, D0150, D0210, D0272, D0274, D0330, D1110, D1120, D1201, D1203, D1204, D1205, D1351, D5110, D5120, D5130 and D5140)

• Confirmation fax of the eIVR available to providers who use the system

• Option to choose Spanish or English

Enrollee Eligibility – FAMIS MOMS

• FAMIS MOMS receive comprehensive health care benefits during pregnancy and for two months following the end of pregnancy-this includes SFC dental benefits if under twenty one years of age. Detailed information is available at www.famis.org.

• Providers are encouraged to contact Doral to verify eligibility prior to rendering services.

Benefits For Enrollees Under Age 21

• SFC provides comprehensive dental benefits for enrollees under the age of 21:

• Diagnostic
• Preventive
• Restorative
• Endodontics
• Periodontics
• Prosthodontics Removable
• Prosthodontics Fixed
• Oral Surgery
• Orthodontics
• Adjunctive General

• A full explanation of benefits can be found in the Office Reference Manual, Exhibit A.

Benefits For Enrollees Age 21 and Older

• Coverage for adults, age 21 or older, is limited to medically necessary oral surgery and associated diagnostic services.

• Diagnostic services include the oral examination and selected radiographs needed to assess the oral health, diagnose oral pathology, and develop an adequate treatment plan.

• Extractions for adults must be medically necessary and be complicating the patient’s general health as documented by the dentist or medical provider:

• Severe periodontal infection which causes acute pain, loss of appetite or weight due to pain or infection
• Exacerbates a medical condition/medical management such as diabetes, heart valve condition

Benefits For Enrollees Age 21 and Older

• Services for adults require Prepayment Review:

• Services requiring prepayment review, require that proper documentation be submitted with the claim following treatment in order for the claim to be considered for reimbursement.

• For all services that require Prepayment Review, Providers have the option of requesting prior authorization:

• Services requiring prior authorization/pre-determination require that documentation regarding the medical necessity of the proposed treatment be submitted and authorization from Doral be obtained before the services are rendered.

• A full explanation of benefits can be found in the Office Reference Manual, Exhibit B.

• Oral surgery procedures not listed in Exhibit B may be covered under the member’s medical benefits through the Medicaid, FAMIS, or FAMIS Plus fee-for-service or managed care organization (MCO) program.

Office Reference Manual

• Policies and procedures

• Instructions for claims filing

• Benefits and limitations

• Instructions regarding services that require prior authorization

• Orthodontia criteria

• Outreach services

• American Academy of Pediatric Dentistry (AAPD) dental care guidelines

• Important phone numbers and addresses

• The Office Reference Manual (ORM) is available on line:

• Go to www.doralusa.com. Click on “Providers.” After logging in, “View Documents”

• or

• Download a copy from the DMAS website at http://www.dmas.virginia.gov

Provider Web Portal (PWP)

• Meets accessibility standards put forth by the ADA (Americans with Disabilities).

• Users can use any browser – no longer limited to “Internet Explorer.”

• New improved look for ease of use.

• Easy to read menu.

• Email form for streamlined communication.

• Payment release dates so Providers can easily track payment dates.

• Location information displayed for the office staff to check accuracy and update the information via a contact form.

• Claims and authorization entry still available with accurate reporting and tracking information.

Enrollee Outreach Initiatives

Broken Appointments

• Broken appointments:

• A major concern for DMAS, VDA, ODDS, and Doral
• Recognized as expensive for dentists
• Lead to dentists unwillingness to participate in the program

• In December 2005, Doral implemented the Broken Appointment Tracking Initiative in order to collect data to better track, trend, and understand the issue

• Doral uses the information to:

• Educate families regarding the importance of appointments and compliance with treatment plans

Broken Appointment Initiative

• Broken Appointment Tracking Log Outcomes

• Over 10,000 broken appointments from SFC participating dentists have been received since Fall 2006.

• Enhancements to the Broken Appointment Tracking Form

• Missed appointment - a missed appointment where the member or member representative did not call to cancel
• Late Notice Cancellation (LNC) - a missed appointment with a cancellation less than 24 hours prior to the appointment time
• Reason codes - 1) forgot about appointment., 2) conflict with schedule, 3) transportation 4) illness, 5) other.

• Next Steps:

• Broken Appointment Best Practices Questionnaire
• Broken Appointment Focused Survey
• SFC Broken Appointment Pilot Program

SFC Transportation Complaint Form

• Analyses of data related to broken appointments indicate problems with transportation as one reason for broken appointments.

• Providers are encouraged to report problems with transportation to DMAS. The SFC Transportation Complaint Form can now be used to report problems.

Interpreter Services- Pending Implementation

• Title XIX of the Social Security Act requires Medicaid providers to provide non-discriminatory services to its clients including those with limited English proficiency.

• In order to help providers with this requirement, DMAS has implemented a provision for reimbursement of interpreter services under the SFC program when there is a need and it relates to the treatment.

• In order for the SFC dentist to be reimbursed for interpreter services performed at the dental office, the provider must submit documentation (invoice) of the services provided by and paid to a professional interpreter. The following elements must included in the documentation:

• Date(s) of Service
• Patient name and ID number
• Copy of the invoice showing the name, address and telephone number of the professional interpreter service, the type and length of service, and the amount paid

• Mail the SFC Professional Interpreter Service Invoice Form along with the above documentation to:

• Doral Dental

• ATTN: Lori Howley

• 12121 N. Corporate Parkway

• Mequon, WI 53092

• An interpreter services resource listing will be located on the DMAS website, http://www.dmas.virginia.gov. A copy of the resource listing will also be available upon request.

How to Locate a Provider

Provider Directory

• Contents:

• Provider name

• Practice name

• Office address(es)

• Telephone number(s)

• Provider specialty

• Panel status

• Office hours

• Languages spoken

• Any other panel limitations

Doral Dental USA Website

• Open Microsoft Internet Explorer and access www.doralusa.com.

• Click on the “Find A Provider” button to continue.

Find A Provider

Find A Provider Search Results

Contact Information

• DMAS Smiles For Children Staff:

• Sandra Brown, MSW:

• Dental Program Manager

• Direct Line: [phone]

• Fax: [phone]

• Email: [e-mail]

• Dr. Marjorie Chema, DDS:

• Dental Consultant

• Direct Line: [phone]

• Fax: [phone]

• Email: [e-mail]

• Lisa Bilik:

• Dental Contract Monitor

• Direct Line: [phone]

• Fax: [phone]

• Email: [e-mail]

Thank You!