However, the appellant stated that she suffered from Multiple Sclerosis, which paralyzed the right side of her mouth. Accordingly, there is often coverage for replacing but not treating a tooth. See, e.g., FH #6254420Y. In addition, dental providers may use OnBoard to request dental-related DME and medications, and to submit Form HP-1.0. Home Provider Enrollment. A dental visit should include a professional cleaning. 5. Please also provide ample time for your appointment to be scheduled. Implant Services (revised Nov. 12, 2018. Example: Appellants dentist submitted a prior authorization for root canal therapy on Appellants tooth number 18 (molar). 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). Their dental network is 65% larger than what we have been offering, with more dentists and specialists available than before. There are no relevant workers compensation forms for billing purposes. Benefits | Essential Plan - Molina Healthcare If the cost of the dental treatment will exceed $1,000, the dental provider may be required to obtain prior authorization from the appropriate insurer. Our four dental networks consist of over 8,000 dentists and dental specialists practicing in New York and New Jersey. 0000003851 00000 n FH# 7062037L(available here), Example: On December 28, 2016 the Appellants dentist requested prior authorization for a root canal on tooth number 15 (code D3330). The Agency denial was upheld because the placement of the upper denture satisfied the 8 point of contact rule between the upper and lower back teeth. 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. New York | Wellcare Diagnosis & Treatment for Gum Disease and Tooth Decay , Children's Dental Health Timeline Guidance, from Newborn to Gradeschooler, FIDELIS and FIDELIS CARE are trademarks of Centene Corporation, The Centers for Disease Control Oral Health Page, Transparency in Coverage Machine Readable Files. 0 Good practice is to review your contracted fee schedules annually. If the bill is disputed, insurer must provide a response and can request additional information. Early treatment prevents them from getting worse. FH# 6478476L (available here), Example: Appellant was approved for placement of an upper denture but was denied for a lower partial denture. 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). The coverage is limited to three years of treatment and one year of retention care. What type of workers compensation form should I use to bill for dental treatment? Your benefits include dental check-ups, cleaning, x-rays, fillings and follow-up care. ), there will have to be a claims history for initial placement, Prior Approval Request for MMC enrollees will be subject to Plan procedures - future discussion, Free HIPAA compliant software available through CSC (ePACES), Speed and efficiency- immediate feed back if an error is made, No paper forms to obtain, fill out and store, Photographs and x-rays can be submitted electronically with the request*. The current policy states effective until Nov. 12, 2018, "Full and/or partial dentures are covered when required to alleviate a serious health condition or a condition that affects employability. Great Expressions Dental Centers participates with most dental insurance plans in Connecticut, Florida, Georgia, Massachusetts, Michigan, New Jersey, New York, Ohio, and Texas. No copays. xb```b``y ,@Q{ TjJ|UY=9sA6VK|ox9vdhLuaZ9r3?sfAf128 pVb"/@beSi1bL=> See Dental Policy and Procedure Code Manual, page 43. * These plans are preferred provider organizations (PPO) and are underwritten by EmblemHealth. endobj "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.. We offer a state of the art dental facility, utilizing the most advanced technology in cosmetic dentistry. If additional assistance is needed, please contact Healthplex at 888-468-2183, Monday to Friday from 8 a.m. to 5 p.m. Early treatment prevents them from getting worse. Member and Provider FAQs - Pharmacy Benefit Carve-Out. Cases prior approved under MA FFS, including NYCORP, FFS responsible for duration of treatment/retention, Limited extended coverage for patients enrolled in either FFS or MMC if eligibility is lost, If patient is in FFS (i.e., not enrolled in managed care), if appliances are placed and active treatment begun, member receives a maximum of six months of treatment paid for via FFS, For Medicaid managed care enrollees, this process will also be handled FFS, Plan Member changes plan or newly eligible. Contact: Legal Aid Society Health Hotline (212) 577-3575or email . Because the tooth was not necessary to support any prosthetics, the Plans determination to deny the requested root canal for tooth number 18 was upheld. Strictly Necessary Cookie should be enabled at all times so that we can save your preferences for cookie settings. NFL.com. UnitedHealthcare of New York, Inc. Dentaquest Empire Health Choice HMO, Inc. Fidelis Care New York; Healthfirst PHSP, Inc. Manage Your Health Online With MyChart. See Dental Policy and Procedure Code Manual, page 24. NY Essential Plans | Healthfirst [/ICCBased 3 0 R] The dental provider must have a valid NYS dental license. The dental provider should ask the patient at the first visit if their injuries sustained in a motor vehicle accident occurred while working. Though the Appellant accidentally broke the lower denture, dentures which are broken will not be replaced unless they become unserviceable through trauma, disease or extensive physiological change. Nor was she able to establish that extraction of tooth number 18 is contraindicated for health reasons. Medicaid Dental Coverage includes only essential services, rather than comprehensive care. All Rights Reserved. Workers' Compensation Law does not require dental providers to be authorized by the Board. MetroPlusHealth members can access the Member Portal, find doctors, specialists, and pharmacies, and view member benefits. For information on which services do and do not require prior approval and authorization, click on this link to the regulation: For information on orthodontic care coverage, click on thislink to the regulation. Example: Agency denial was based on its determination that Appellant had 8 points of biting contact and the service requested was not covered due to the 8 points of contact rule, and not medically necessary. If you disable this cookie, we will not be able to save your preferences. Her looks and speech were unaffected but the lack of lower dentures were detrimental to her health because she was unable to eat the healthy diet required as an insulin-dependent diabetic. Please note in order to be eligible for Medicaid transportation benefits your provider must complete Form 2015 which is verification of Medicaid Transportation Abilities. DENTAQUEST 2022 Procedure Code Ages Effective Jan 1 2022 D0120 0-20 $ 28.00 D0120 21-999 $ Expert Help. Medicaid members can access dental care using their MetroPlusHealth . Become a Patient | Stony Brook University School of Dental Medicine MetroPlusHealth has offered low-cost, quality health care for New Yorkers for more than 35 years. Welcome. The letter from the physician must explain how dentures would alleviate the patients serious health condition or improve employability. %PDF-1.7 Treatment such as endodontics (repeat root canal treatment) or crowns will not be approved in association with an existing or proposed prosthesis (artificial replacement) in the same arch, unless the tooth is a critical abutment (needed to attach a denture to) for a prosthesis provided through the NYS Medicaid program, or unless replacement by addition to an existing prosthesis or new prosthesis is not feasible.

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