June 2014

Prepared For:

UPMC Health PlanDental Providers and Staff

Presented by Avesis

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Mission Statement

Building long term partnerships to deliver valued, Innovative healthcare solutions ... one member at a time

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Who We Are

Dental, Vision, and Hearing Plan Administrator working with employer groups and health plans nationally

Over 30 years experience in the dental, vision, and hearing insurance industry

Covering over 4.5 million members throughout the country

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• Dental Networks

Over 30,000 dentists in 41 States

• Experienced Administrator

31 years serving corporate and government clients

• Avesis administers Medicaid dental plans in 4 states and Medicare Advantage dental plans in 18 states

Avesis Dental

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Avesis is National

• Executive Offices in Owings Mills (Baltimore area), MD

• Operations located in Phoenix, AZ

• Southeast regional office in Atlanta, GA

• Local Provider Representatives serving all of Pennsylvania

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Points of Contact

•Dora Wilson Executive Vice President of Health Plan Services dwilson@avesis.com (800) 522-0258 x11794

• Renee RuggieroAssistant Director of Health Plan Servicesrruggiero@avesis.com(800) 522-0258 x11753

• Shauntrai JonesUtilization Managementsjones@avesis.com(800) 522-0258 x11294

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Points of Contact cont’d

•Donna Phillips UPMC Dental Provider Relations, Western PA dphillips@avesis.com (800) 522-0258 x11830

• Kelley OwensUPMC Dental Provider Relations, Eastern PAkowens@avesis.com(800) 522-0258 x11738

• Lori RetortDental Provider Relations, Team Leadlretort@avesis.com(800) 522-0258 x11161

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Points of Contact cont’d

•Robin Mays Manager, Dental Provider Contracting rburroughs@avesis.com (800) 522-0258 x11136

• Angela RawlingsProvider Contracting Specialistarawlings@avesis.com(800) 522-0258 x11291

•Lanae Wilson Provider Contracting Specialist lwilson@avesis.com (800) 522-0258 x12335

• General Provider(866) 909-1083

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Clinical Professionals

• Fred Sharpe, DDS, JD Chief Dental Officer fsharpe@avesis.com • Daniel Pituch, DMD, MD Medical Director

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Avesis Dental Advisory Board

• Committee of Pennsylvania licensed Dentists: Dr. Adam Mychak; Dr. Howard Elson; Dr. Kurt Laemmer; Dr. Leon Williams Jr; Dr. Michael Wolff; Dr Ronald Zatman and Avesis Staff.

• Acts in an advisory capacity to UPMC Health Plan and Avesis in all matters pertaining to the Dental Program.

• Helps to ensure quality communications between Pennsylvania provider community, Avesis and UPMC Health Plan.

• Forum for providers to submit recommendations and feedback regarding the programs and their administration.

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Cultural Competency

As a company dedicated to providing clients with superior service, Avesis fully recognizes the importance of serving Members in a culturally and linguistically appropriate manner. We know from direct experience that:

• Some Members have limited proficiency with the English language including some Members whose native language is English but who are not fully literate.

• Some Members have disabilities and/or cognitive impairments that impede their communicating with us and using health care services.

• Some Members come from other cultures that view health-related behaviors and health care differently than the dominant culture.

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Cultural Competency cont’d

To be culturally competent, Providers shall:

• Work with Members so that once Members are identified that may have cultural or linguistic barriers alternative communication methods can be made available.

• Utilize culturally sensitive and appropriate educational materials based on the Member’s race, ethnicity and primary language spoken.

• Ensure that resources are available to overcome the language barriers and communication barriers that exist in the Member population.

• Make certain that you recognize the culturally diverse needs of the population.• Teach staff to value the diversity of both their co-workers inside the organization and the

population served, and to behave accordingly.

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Special Needs

• Avesis works in coordination with the Special Needs Unit at the Health Plan to ensure that the dental needs of every Member are met.

• If you have a Special Needs Member that requires help in securing dental treatment, Avesis can assist in coordinating an appropriate referral to a dental Provider who is able to meet the Member’s specific needs.

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Eligibility

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Eligibility

You may obtain eligibility verification three ways:

1. Website – This method provides you with information as to whether or not the member is eligible in our system on the date of service and allows you to view the members utilization history. (www.Avesis.com or check the state website http://promise.dpw.state.pa.us/)

2. Customer Service – Customer service is able to provide you with both eligibility confirmation as well as utilization data. You may call (866) 909-1083 to reach the Customer Service department.

3. Fax – You may utilize the form found in the Provider Manual and on the secure login for eligibility confirmation. This form will provide you with both eligibility confirmation and utilization data.

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Fax Eligibility Verification

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Eligibility

• It is strongly encouraged that you verify eligibility for each Member’s appointment the business day prior to rendering services unless the next business day is the first day of a new month.

• Please note that verification of benefits or eligibility is not a guarantee of payment.

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UPMC Plans

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UPMC Plans

UPMC Plans Include:

• UPMC for You, affiliate program of UPMC Health Plan, offers affordable dental care to eligible Medical Assistance recipients in the UPMC Health Plan service area.

• UPMC for Kids is available through a contract with the Children's Health Insurance Program (CHIP) of Pennsylvania. CHIP is a State and Federally funded program to provide health insurance for uninsured children from birth until they reach the age of 19. In 2007, Pennsylvania CHIP was expanded to offer health insurance to children and teens who are not eligible for Medical Assistance, regardless of family income. Enrollment eligibility is evaluated every 12 months.

• UPMC for Life HMO and PPO offer choices for more enhanced services and care options than are available through traditional Medicare, including routine dental services.

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UPMC Plans cont’d

• UPMC Community Care offers dual eligible members (Medicaid/Medicare) choices for more enhanced dental services and care options that are available through traditional Medicare including routine dental services.

• UPMC for Life Options Plan offers dual eligible members (Medicaid/Medicare), who demonstrate long-term care needs, choices for more enhanced dental services and care options that are available through traditional Medicare, including routine dental services.

• UPMC for You Advantage offers dual eligible members (Medicaid/Medicare) choices for more enhanced dental services and care options that are available through traditional Medicare, including routine dental services.

• Federal & Postal Employee Health Benefits (FEHB) Plan offers two levels of limited dental coverage to enrolled members. The first level includes routine, diagnostic, and preventive services that are provided at no cost to the member. The second level lists all of the other covered services and the corresponding fee due from the member according to standing office policies. Procedures not listed are the responsibility of the member.

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UPMC Benefits

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Benefits and Fee Reimbursements

Benefits and Fee Schedules for UPMC can be found on the Avesis portal: www.avesis.com

After logging in, to the right, click on Related Documents. You are then able to view, print or download a copy of the Benefit Grids, Fee Schedules and Provider Manual.

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Benefit Changes

2014 Benefit Changes

There were changes to UPMC for You Options Plan effective January 1, 2014.

Addition of a $500.00 allowance for dentures, crowns and bridges. Please note that some of these services require prior authorization.

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Program Exception

Program Exception Process

• A program exception occurs when a provider contacts Avesis requesting services that are non-covered for medical necessity.

• Benefits are either exhausted or not a covered benefit.

• Requests will be reviewed by Utilization Management and a decision will be made with in two (2) business days.

Emergency Services• Members seeking emergency services may need to be referred back to UPMC for

medical benefits.

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Benefit Limit Exception

Benefit Limit Exception Process:

Effective May 1, 2012, UPMC for You adult members (age 21 and older) will be eligible for the following services only if Avesis approves a BLE request:

• Crowns and adjunctive services (D2710, D2721, D2740, D2751, D2791, D2910, D2915, D2920, D2952, D2954, D2980)

• Periodontic services (D4210, D4341, D4355, D4910)• Endodontic services (D3310, D3320, D3330, D3410, D3421, D3425, D3426)

NOTE: The dental benefit changes do not apply to children under 21 years of age or to adults who reside in a nursing facility, an intermediate care facility for persons with mental retardation (IFC/MR) or an intermediate care facility for persons with other related conditions (IFC/ORC)

• Requests will be reviewed by Utilization Management and a decision will be made within twenty one (21) business days.

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Benefit Limit Exception cont’d

Benefit Limit Exception Per DPW

Consistent with 55 Pa.Code § 1101.31 (F)(2)(viii), the provider may not bill the MA recipient for payment for services rendered in excess of the dental limits unless:

1. The provider informs the recipient before the service is rendered that the service requires a BLE and the recipient is liable for the payment if the request for an exception is denied; and,

2. The provider requests an exception to the limit and the Department denies the request.

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UPMC for You Palliative Plan

Also beginning on May 1, 2012, members with limited dental benefits (who are 21 years of age and older and do not reside in a nursing home or intermediate care facility) will only be

eligible for the following services:

• Palliative care, (the emergency treatment of dental pain).• Dental Care provided in a Short Procedure Unit (SPU), Ambulatory Surgical

Center (ASC) or Inpatient Hospital. The following dental care may be covered: 1. Oral surgery and impacted teeth removal if the nature of the procedure or the member’s compromising condition would cause undue risk if performed on an Outpatient basis; or 2. Teeth extraction and dental restorative services for a member who is unmanageable and requires general anesthesia by an anesthesiologist, not the dentist, due to a severe mental and/or physical condition.

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Covered and Non-Covered

• Covered Services

• Covered services will be paid according to the plan fee schedule.

• Non-Covered Services

• Non-Covered Services may be the responsibility of the member if and only if the Member is notified of and agrees to financial responsibility prior to services being rendered.

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Non-Covered Disclosure Form

A member receiving a non-covered Service must sign and date a disclosure form prior to rendering treatment and must include the date of service, procedure code, description of service and fee.

The chargeable fee is:• The fee listed on the Fee Reimbursement

Schedule or• 20% under the Provider’s Usual and Customary fee if the code is not listed on the Fee Reimbursement Schedule.

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Claims

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Claims Submission

Claims may be submitted one of three ways:

1. Through your practice management software using a clearinghouse

• The Avesis payer identification number is 86098

2. On an ADA claim form - please submit to the following address:

Avesis Dental ClaimsPO Box 7777Phoenix, AZ 85011 – 7777

3. Utilizing our website at www.avesis.com

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Claims Follow-Up

Providers receive remittance advices detailing claims both paid and denied. If you believe you have not received status on a claim, you may check the status of submitted claims two ways:

1. You may check claim status on the Avesis website at www.avesis.com

2. You may contact our Customer Service department at (866) 909-1083 to check claim status

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Corrected Claims

Submission

• If you are missing information (i.e. tooth number or area) or you have submitted incorrect information (wrong code, wrong tooth number, etc.) you may edit the ADA claim form and send marked as ‘corrected’ with the claim number, if a claim number has been assigned, to the Phoenix, Az office.

• Write Corrected Claim on the top of the ADA claim form in blue or black ink. The scanner does not read red ink

• Please do not highlight notes on the claim in blue or green highlighter. The scanner reads these colors as black so what ever they highlight is blacked out

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Appeals

Provider Appeal Process for Denial of Claim(s)

Procedure Levels:

• Administrative-involves adverse determination for reasons other than medical necessity (e.g. timeliness of filing, no prior authorization, etc.)

• Medically Necessary Appeals-involves adverse determination finding that there was no medically necessary reason to pay the claim.

a. Written request stating that it is an appeal within thirty (30) days of denial. b. Address to the Phoenix office; clearly mark the envelope Attn: Appealsc. Appeal decision is determined and provider notified if upheld or paid if the initial

determination is reversed and to be paid out.

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Avesis Claims Payment

• Check runs are weekly

• Electronic Funds Transfer (EFT) payments deposited weekly

• Card Payment Services (CPS) transactions completed weekly

CLEAN CLAIMS are processed and adjudicated within 15 business days.State guidelines are within 30 days

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Electronic Funds Transfer Agreement

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Prior Authorization

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Avesis Prior Approval Requirements

Services requiring prior approval are listed in detail on the covered benefits schedule and describe the required attachments.

• Providers may submit pre-treatment estimates on an ADA claim form to our Phoenix address or via the Avesis website at www.avesis.com.

• Avesis accepts electronic attachments via the Avesis web portal or through NEA (National Electronic Attachment)

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EPSDTEarly and Periodic Screening, Diagnostic and Treatment

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EPSDT Defined

The Early and Periodic Screening, Diagnostic and Treatment (EPSDT) benefit provides comprehensive and preventive health care services for children under age 21 who are enrolled in Medicaid. EPSDT is key to ensuring that children and adolescents receive appropriate preventive, clinical, dental, mental health, and developmental and specialty services.

In December 2010, the Centers for Medicare and Medicaid Services (CMS) convened a Workgroup that includes state representatives, children’s health providers, consumer representatives, and other experts in the areas of maternal and child health, Medicaid, and data analysis.

The group helps CMS identify the most critical areas for improvement of EPSDT, and provides ideas on how CMS can work with states and other partners to increase awareness and access to services, and improve data reporting to improve the quality of care provided to children.

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EPSDT

• EPSDT includes periodic screening, vision, dental, and hearing services

• If a Provider is unable to conduct the necessary EPSDT screens for Members under age 21, the Provider is responsible for making a referral to another Participating Provider to ensure the Member has the necessary EPSDT screening performed.

• All relevant medical information, including the results of the EPSDT screening, are to be incorporated into the Member’s primary medical record.

• Based upon the requirements of the EPSDT program, each Avesis Provider office is required to maintain and document the Member recall policies and procedures for all UPMC for You and UPMC for Kids members.

• Additional information on the EPSDT program can be found at www.cms.hhs.gov/Medicaid/epsdt.

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Chart Reviews

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Avesis conducts office reviews for our dental provider networks

• Your office will be contacted in order for Avesis to schedule a time to visit

• In addition to a facility walk through, providers will be furnished a list of charts prior to the visit to have available for review

• After the visit, your office will be sent a letter regarding the findings of our review

Avesis Office Reviews

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Avesis Facility Review

1-ACCESS Street SignageParkingHandicappedEntryEntry Signage

2-WAITING AREA Number of SeatsMagazines, TV / VideoGame Area Sufficient Size

3-RECEPTION AREA AccessGreetingManualsSufficient Size

4-STAFF

5-TREATMENT AREAS Number of OpsDDS / Hygiene License displayedLab on SiteClean & Neat

 6-X-RAY MACHINES Number of PA UnitsPanoramic UnitInspection DateExam prior to X-rayLead ApronDarkroom BadgesDaylight Developer

 7-STERILIZATION SterilizersSteam/ChemicalCold SterilizationMeets OSHA rules

8-INFECTION CONTROL Gloves wornMasks wornScrubs wornHand washingWater line flushingSharps ContainersSpore TestingAnti-back Flow ValvesBarrier Techniques

 9-MISCELLANEOUS Nitrous AvailableFire ExtinguishersCPR TrainingEmergency TrainingEmergency KitMedicines Up to Date

AED Equipment  

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Avesis Chart Review

Individual Chart per Patient

HIPAA Statement

Medical HistorySigned & dated by Doctor or staffSigned & dated by memberReviewed within 1 yearAllergies NotedMedications ReviewedPhysician ListedMedical Alerts Obvious

RadiographsMounted & Dated

Patient RecordMissing teethCaries &/or current restorationsTreatment PlanSigned authorization for txReferrals to specialistsPrescriptions given

Chart Documentation Quality of Care - Standard of CareTooth # billed matches chartCodes billed matches chartDOS billed matches chartBilling DDS matchesTx billed supported by documentationTx appears appropriateX-rays taken support treatment

Recall SystemFrequency

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Provider Services

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Services to Providers

• Avesis is primary for Provider Services

• Toll free phones staffed by experienced and knowledgeable representatives from 7am – 7pm EST at 888-209-1243

• State and National professionals are involved in professional decisions regarding care and referrals

• Regional meetings and training sessions are scheduled for providers

• Quarterly Provider Newsletters are sent

• On-site assistance in your office is scheduled , according to availability

• Peer to peer interaction is available for Providers

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Additional Assistance

• Schedule a conference call

• Schedule a web demo

• Schedule an onsite visit

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Committed to Technology

24/7 Access to information:

• Web Based

o Eligibility verification

o Claim submission with real time claims processing

o Claim status and editing

o Remittance advice information

o Pre-treatment Estimate

o On line training and education materials at www.avesis.com

• Interactive Voice Response (IVR)

o Eligibility

o Benefits

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Thank You For Your Time!Questions?

We at Avesis look forward to working with you and your team.