Presentation prepared for

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Presentation prepared for
Avesis UPMC Dental Providers Staff
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Who is Avesis?

• Mission Statement
• Building long term partnerships to deliver
  valued, Innovative Healthcare Solutions one
  member at a time.
• Dental and Vision Plan Administrator working with
  employer groups and health plans nationally
• Over 30 years experience in the dental and vision
  insurance industry

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Who is Avesis Dental?

• Dental Networks - over 30,000 dentists in 41
  States
• Experienced Administrator 30 years serving
  corporate and government clients
• Avesis administers Medicaid plans in 4 states and
  Medicare Advantage plans in 20 states

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Avesis is National

• Executive Offices in Baltimore, MD
• Operations located in Phoenix, AZ
• Southeast regional office in Atlanta, GA
• Local representatives located in Pennsylvania

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Avesis Staff Contact Information

• Nichole Mitchell VP, Health Plan Services
• nmitchell_at_avesis.com (800) 522 0258, ext. 296
• Dale Woodie PA State Program Manager
  dwoodie_at_avesis.com (800) 522 0258, ext. 135
• Lori Retort PA Provider Services and Dental
  Field Representative
• lretort_at_avesis.com (800) 522 0258, ext. 161

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Avesis Staff for UPMC

• Carolyn Wright Utilization Management
• cwright_at_avesis.com (800) 522 0258, ext. 294
• Provider Services
• ( 888) 209 - 1243

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Avesis Clinical Professionals

• Dr. Fred Sharpe Chief Dental Officer fsharpe_at_ave
  sis.com
• Dr. Rick Celko Regional Dental Director
• rcelko_at_avesis.com
• Dr. Dan Pituch Avesis PA Medical Director

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Avesis Advisory Boards

• Committee of licensed PA Dentists and Avesis
  staff
• Act in an advisory capacity to UPMC Health Plan
  and Avesis in all matters pertaining to the UPMC
  Dental Programs
• Help to ensure quality communications between PA
  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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Avesis Dental Advisory Board

• Dental Community Representatives include
• Dr. Howard Elson
• Dr. Kurt Laemmer
• Dr. Christopher Martone
• Dr. Adam Mychak
• Dr. Leon Williams
• Dr. Michael Wolff
• Dr. Ronald Zatman

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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

•  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 Members 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 Member that requires help in
  securing dental treatment, Avesis is able to
  assist you in ensuring that the Members needs are
  met by assisting in coordinating an appropriate
  referral to a dental Provider who is able to meet
  the Members needs.

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ELIGIBILITY
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Eligibility

• It is strongly encouraged that you verify
  eligibility for each Members 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
  actual payment is based on the terms and
  conditions of the plan in force once the claim is
  received.

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Eligibility

• You may obtain eligibility verification four
  ways
• IVR Please bear in mind that this only provides
  you with information as to whether or not the
  member is eligible on the date of service. It
  does not provide utilization data
• Website This method provides you with
  information as to whether or not the member is
  eligible on the date of service and allow you to
  view the members utilization history.

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Eligibility

• Customer service Customer service is able to
  provide you with both eligibility confirmation as
  well as utilization data.
• Fax You may utilize the form found of the
  following slide for eligibility confirmation.
  This form will provide you with both eligibility
  confirmation and utilization data.

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Eligibility Verification Form
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BENEFITS
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Benefits

• UPMC has several programs and the benefits vary
  according to the program in which the Member is
  enrolled.

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UPMC Health Plans

• UPMC for You
  
  
• UPMC for Life
• UPMC for Life Options
• UPMC for Kids (CHIP)

• UPMC for Life Specialty Plan
• Federal Employees Health Benefit Plan
• UPMC for You Advantage
  
  

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General Overview

• 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 Childrens 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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General Overview

• UPMC for Life Specialty Plan 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.
• 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.

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General Overview

• 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.

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General Overview

• Covered Services
• Covered services will be paid according to the
  plan fee schedule
• Non-Covered Services
• Non-Covered Services will be the responsibility
  of the member
• Member must be notified of financial
  responsibility prior to services being rendered
• Benefit Exception Process
• Benefit 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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Non-Covered Services Disclosure Form
Member pays 80 of Usual and Customary Fees
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Benefits

• There were two new plans for UPMC effective
  January 1, 2012 which are UPMC for You Advantage
  and UPMC for Life Options. These plans will be
  detailed on the following slides.
• There were changes to UPMC for Kids effective
  January 1, 2012.
• For calendar year 2012, Members enrolled in UPMC
  for Kids will have access to an expanded dental
  benefit in the amount of 1,000 that is separate
  and apart from their 1,500 annual maximum.

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Benefits

• UPMC for You Advantage
• Medicare Advantage plan for dual eligible members
  
• Members will also have Medical Assistance
  (ACCESS)
• 0 copayment for the following preventive
  services
• oral exams up to 1 visit(s) every six months
• cleanings up to 1 visit(s) every six months
• dental x-rays up to 1 visit(s) every six months
• Additional comprehensive benefits fillings and
  simple tooth extractions only.
• Members enrolled in UPMC for You Advantage also
  have Medical Assistance (ACCESS) coverage

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Benefits

• UPMC for Life Options (Medicare Advantage)
• Medicare Advantage plan
• 0 copayment for the following preventive
  services
• oral exams up to 1 visit(s) every six months
• cleanings up to 1 visit(s) every six months
• dental x-rays up to 1 visit(s) every six months
• No fillings or simple tooth extractions.
• No comprehensive dental allowance.

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Benefits

• The UPMC for You adult benefits are changing
  effective 5/1/2012. These benefits and the
  Benefit Limit Exception (BLE) process will be
  outlined further in the following slides.
• The Adult Partial benefits under the UPMC for You
  plan will end 4/30/2012.
• The Adult Palliative benefits under the UPMC for
  You plan will be effective 5/1/2012 and are
  outlined on the following slide.

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Benefits

• UPMC for You Adult Palliative Benefits
• Members 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
• Oral surgery and impacted teeth removal if the
  nature of the procedure or the members
  compromising condition would cause undue risk if
  performed on an outpatient basis or
• 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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Benefit Limits

• Effective May 1, 2012, UPMC for You adult members
  (age 21 and older) will experience a change to
  their dental benefit that will limit the
  following dental services
• Periodic oral evaluations (D0120)
• Prophylaxis, adult (D1110)
• Dentures, both complete and partial (D5110,
  D5120, D5130, D5140, D5211, D5212, D5213, D5214)
• Services provided beyond a Members benefit
  limits are not covered unless a BLE is requested
  and approved by Avesis.

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Benefit Limits

• The Benefit Limits are as listed below
• Periodic oral evaluations (D0120) will be limited
  to one (1) per 180 days per adult Member. NOTE
  Providers will not be paid for a periodic oral
  evaluation (D0120) and a comprehensive oral
  evaluation (D0150) within the same 180 day time
  period.
• Prophylaxis, adult (D1110) will be limited to one
  (1) per 180 days per adult Member.
• Dentures will be limited to one per upper arch,
  full or partial, regardless of procedure code
  (D5110, D5130, D5211, D5213) and one per lower
  arch, full or partial, regardless of procedure
  code (D5120, D5140, D5212, D5214), per lifetime.
  Avesis will review claim payment history for
  dates of service on and after March 1, 2004 to
  determine if the Member previously received a
  denture for the arch.

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Benefit Limits

• 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)

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Benefit Limits

• 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
  (ICF/MR) or an intermediate care facility for
  persons with other related conditions (ICF/ORC).

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EPSDT Services

• The Early and Periodic Screening, Diagnostic, and
  Treatment (EPSDT) service is Medical Assistance's
  comprehensive and preventive child health program
  for individuals under the age of 21.
• EPSDT includes periodic screening, vision,
  dental, and hearing services.

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EPSDT 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 screens performed.
  
• All relevant medical information, including the
  results of the EPSDT screens, are to be
  incorporated into the Members primary medical
  record.

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EPSDT Services

• 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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CLAIMS
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Claim Submission

• Claims may be submitted one of three ways
• Through your practice management software using a
  clearinghouse
• On an ADA claim form - please submit to the
  following address
• Avesis Dental Claims
• PO Box 7777
• Phoenix, AZ 85011 7777
• 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
• You may check claim status on the Avesis website
  at www.avesis.com.
• You may contact our provider services department
  at (888) 209 1243 to check claim status.

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Corrected Claims

• Submission
• If you are missing information (i.e. tooth number
  or quadrant number) or you have submitted
  incorrect information (wrong code, wrong tooth
  number, etc) you may edit the claim on the Avesis
  website regardless of the method of submission.
• If you wish to submit a corrected claim on an ADA
  claim form you will need to do the following
• 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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Claim Payment

• Check runs WEEKLY
• CLEAN CLAIMS processed and adjudicated within 15
  business days
• Electronic Funds Transfer available for all
  claims submissions or resubmissions
• EFT payments deposited weekly

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Electronic Funds Transfer Agreement
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PRIOR AUTHORIZATION

• PRE-TREATMENT ESTIMATES
• BENEFIT EXCEPTIONS

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Avesis Pre-Treatment Estimate/Prior Approval

• Services requiring prior approval are listed in
  detail in the Provider manual
• Providers may submit both pre-treatment estimates
  and requests for benefit exceptions on an ADA
  claim form to our Phoenix address or via the
  Avesis website at www.avesis.com with all
  pertinent clinical information to accompany the
  request.

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Avesis Pre-Treatment Estimate/Prior Approval

• Avesis accepts electronic attachments via the
  Avesis web portal.
• Prior authorization and benefit exception
  requests are processed within 2 business days of
  the receipt of all required information.
• Both the Provider and Member will receive a
  written notice of the approval or denial of the
  request. Denials of service will contain an
  explanation as to the reason for the denial.

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Requesting a Benefit Limit Exception

• Avesis will grant benefit limit exceptions to the
  dental benefits when one of the following
  criteria are met
• Avesis determines the Member has a serious
  chronic systemic illness or other serious health
  condition and denial of the exception will
  jeopardize the life of the Member.
• Avesis determines the Member has a serious
  chronic systemic illness or other serious health
  condition and denial of the exception will result
  in the rapid, serious deterioration of the health
  of the recipient.

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Requesting a Benefit Limit Exception

• Avesis will grant benefit limit exceptions to the
  dental benefits when one of following criteria
  are met
• Avesis determines that granting a specific
  exception is a cost effective alternative.
• Avesis determines that granting an exception is
  necessary in order to comply with Federal law.

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Requesting a Benefit Limit Exception

• In order to request a dental BLE, dentists must
  submit the following information to Avesis
•  An American Dental Association (ADA) claim form
  completed in its entirety. Providers must include
  their NPI number on the claim form. Failure to do
  so will result in your request being sent back to
  the requesting office as not being able to be
  processed.
• A completed Avesis Dental BLE request form.

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Requesting a Benefit Limit Exception

• Providers may require a BLE prospectively (prior
  to services being rendered) or retrospectively
  (after services are rendered).
• Retrospective BLE requests must be submitted no
  later than 60 days from the date Avesis denies
  the claim because the service is over the benefit
  limit.
• Retrospective BLE requests received on or after
  the 61st day from the date of the claim rejection
  will be denied.
•  

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Requesting a Benefit Limit Exception

• Avesis will respond to prospective BLE requests
  within 21 days after the request is received.
• Avesis will respond to a retrospective BLE
  request within 30 days after the request is
  received. Both the provider and Member will
  receive a written notice of the approval or
  denial of the dental BLE request.
• When Avesis denies a BLE request, both the
  provider and Member will receive a written notice
  of the decision that explains the reason for the
  denial.

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CHART REVIEWS
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Avesis Office Visits

• Avesis conducts office reviews for our dental
  provider networks
• Your office will be contacted in order for Avesis
  to schedule a time to come out
• 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

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PROVIDER SERVICES
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Services to Providers

• Avesis is primary for Member and Provider
  Services
• Toll free phones staffed by experienced and
  knowledgeable representatives from 7am 7pm EST
• State and National professionals involved in
  professional decisions regarding care and
  referrals

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Services to Providers (Cont.)

• Local Avesis Personnel
• Regional meetings and training sessions scheduled
  for providers
• Quarterly Provider Newsletters
• On-site assistance in your office when available
• Peer to peer interaction for Providers

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Other Avenues for 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
• Eligibility verification
• Claim submission with real time claims processing
• Claim status and editing
• Remittance advice information
• Pre-treatment Estimate
• Interactive Voice Response (IVR)
• Eligibility
• Benefits

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Committed to Technology

• Avesis offers online assistance with website
  navigation. Providers may access tutorials that
  show how to create an account, confirm
  eligibility and submit claims on the Avesis
  website at http//www.avesis.com/Provider_videos.h
  tml
• Providers may also contact Avesis for a web
  demonstration and training session by calling
  [phone].

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Thank You

• Thank you for your time attention.
• We at Avesis look forward to
• continuing to work with you and your team.