About 3.8 million . When you get emergency care or are treated by an out-of-network provider at an in-network hospital or ambulatory surgical center, you are protected from balance billing. startxref hb```g``Zpj1 X{ y `` The insurer did not respond to within the established time limits, OR, did not pay my dental bill in full. Paper checks and rosters are being phased out and EFT will become mandatory Paper Submission, Prior Approval Request Form eMedNY361401 and Claim Form A are obtained through CSC at: (800) 343-9000. Medicare members can call us 24/7 at1.866.986.0356(TTY: 711). Check benefits. <]>> Online Scheduling Exam Fees Eye Exam Starting Fee $80.00 Contact Lens Starting Fee $129.00 Dilation Fee $40.00 Insurance/Discount Plans We accept most insurances, including: Aetna Avesis Cigna Dentaquest Envolve Payment Types Visa Mastercard Discover American Express Applepay Cash Check Languages English Spanish Location Location Information . Can I refuse to treat a workers compensation patient for dental services? 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. ATTENTION: QM Health Risk Assessment Unit Tooth sensitivity to heat, cold or sweets. Live customer service representatives who speak your language, Regular check-ups and office visits with your own Primary Care Provider (PCP), Behavioral health and mental health services. It is important for everyone over the age of 1 to visit the dentist at least one time every year in order to help keep your teeth and gums healthy. By providing you with advanced technological tools, we eliminate the administrative burden associated with participating in government-sponsored programs. Please contact the Medical Directors Office at 1-800-781-2362 or provider@wcb.ny.gov. 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. No, if you accept a workers' compensation patient, you must charge the fees as indicated in the Dental Fee Schedule. Medicaid members can access dental care using their MetroPlusHealth . \% ZP`\f)@zYVl@4/0&HJ,oz ],mC`HLZ7Ql!@```l`` GD@"g`6 i eda \D,3)7Rx-dR $?SfiN [VVaS% 'r'P4?P 81q-d23!Z h Where possible, the provider should use similar listed codes found on the Dental Fee Schedule and bill accordingly. To schedule your first appointment within our teaching clinic, please call the Dental Care Center between 8:30am and 5pm, Monday through Friday. 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. Provide the highest level of healthcare in New York and save up to 20% with our narrow network. MetroPlusHealth Virtual Visit is available anytime, from anywhere in New York State, 24/7 and in your language. See Dental Policy and Procedure Code Manual, page 43. Mitigating factors surrounding these circumstances should be included with the prior approval request. Explore Qualified Health Plans (QHP) through the NY State of Health, The Official Health Plan Marketplace. Plan may require prior authorization for services not included in the treatment plan as of the effective date of enrollment, Identify those MMC Plan(s) that provide, or will provide, coverage for your patients, Contact those Plans that you wish to participate with and enroll as a provider, Determine what forms, diagnostics, means of submission, etc. Health & Safety in the Home, Workplace & Outdoors, Clinical Guidelines, Standards & Quality of Care, All Health Care Professionals & Patient Safety, Transition of Dental and Orthodontia Coverage Power Point, https://www.emedny.org/ProviderManuals/Dental/index.aspx, https://www.emedny.org/Listserv/eMedNY_Email_Alert_System.aspx, https://www.emedny.org/meipass/index.aspx, James V. McDonald, M.D., M.P.H., Acting Commissioner, Multisystem Inflammatory Syndrome in Children (MIS-C), Addressing the Opioid Epidemic in New York State, Health Care and Mental Hygiene Worker Bonus Program, Maternal Mortality & Disparate Racial Outcomes, Help Increasing the Text Size in Your Web Browser, "Examination and Evaluation" performed by ANY orthodontist or clinic participating in Medicaid FFS for both FFS and MMC enrollees. The rules and limitations for different dental services are included in the policy manual. No, any dental provider with any type of dental specialization can treat workers compensation patients. 0000003050 00000 n 0000001103 00000 n 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. Find a plan that's right for you. Search based on your schedule. Commitment to Health Equity 5.00. 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. How long must I wait for payment to be made by my patient's workers compensation insurer? Before continuing using our website you agree and accept our cookie policy & privacy. Recently, we sent you an announcement along with your new ID Card about our new partnership with DentaQuest, a dental vendor. Find DentaQuest Dentists in Queens, New York & make an appointment online instantly! MetroPlusHealth Virtual Visit is the fast, easy way for our members to see a provider for common physical, mental, emotional, and behavioral health issues that are not emergencies. This service requires prior approval. Form HP-1.0 should be submitted, along with any necessary attachments, such as copies of medical bills, through OnBoard. Join Our Dental Networks. Consequently, she could only use the left side of her mouth to eat. To choose a Primary Care Dentist (PCD) or if you need help finding a dentist in your area, call DentaQuest at 844-284-8819. Member and Provider FAQs - Pharmacy Benefit Carve-Out. 0000003851 00000 n MetroPlusHealth has offered low-cost, quality health care for New Yorkers for more than 35 years. 0000002197 00000 n Starting January 1, 2022, Walgreens and Duane Reade will no longer be in the pharmacy network for members of these plans: Where can I find a list of participating network pharmacies? If the bill is disputed, insurer must provide a response and can request additional information. 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. Your benefits include dental check-ups, cleaning, x-rays, fillings and follow-up care. See Dental Policy and Procedure Code Manual, page 24. 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. A dental visit should include a professional cleaning. Upload necessary documentation. Contact the patient or patients legal representative for this information. Capital District Physicians Health Plan, Inc. Yes- Bronx, Kings, New York, Queens, Nassau, Richmond. Basic plan is FREE for NYC workers and their families! >> SeeDental Policy and Procedure Code Manual,page 24. WHAT DENTAL SERVICES ARE COVERED UNDER MEDICAID? Check member eligibility status. 807 Spring Forest Rd, Ste 600, Raleigh, NC 27609. You can also contact the NY Dental Association to find a dentist. Is the Dental Fee Schedule the same as the NoFault dental fee schedule? Not all dental codes are listed on the Dental Fee Schedule. Nor was she able to establish that extraction of tooth number 18 is contraindicated for health reasons. Medicaid Managed Care has a year-round open enrollment period. Whether you are looking for a new customized dental plan for your group, wish to have your existing dental program redesigned, or simply want to lower your overall dental costs, Healthplex can offer you a spectrum of flexible, affordable options. 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. American Dental Association: http://www.ada.org/en/, New York State Dental Association: http://www.nysdental.org/. Any dental billing forms with the appropriate code and fee as found in this dental fee schedule can be used. Check member eligibility status. Best of all, MetroPlusHealth Medicaid Managed Care comes with no monthly premiums or copays. Under Medicaid, dental benefits exist, but the coverage is limited. $0 premiums for all who qualify, and no deductible, so it pays for your care right away. Do I need to request for prior authorization to the workers compensation insurer for dental treatment? How will I be reimbursed for procedures included under CPT but not CDT codes? Calendar. Any information provided on this Website is for informational purposes only. %PDF-1.6 % xb```b``y ,@Q{ TjJ|UY=9sA6VK|ox9vdhLuaZ9r3?sfAf128 pVb"/@beSi1bL=> @Rt CXCP%CBH@Rf[(t CQhz#0 Zl`O828.p|OX Beyond representing an act of public service in your community, we want your participation in our network to represent a sound business decision. provider and client notified of denial and rights to appeal. Child Health Plus cover routine, preventive and emergency dental services through DentaQuest. Cleft palate or approved orthognathic surgical cases may be approved for additional treatment time. Please be sure to tell us which plan handbook for example, Medicaid you need. The letter from the physician must explain how dentures would alleviate the patients serious health condition or improve employability. 2 0 obj Then the child needs a dental checkup every 6 months or as determined by the childs dentist. 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. View up-to-date payment information. Dental providers may use OnBoard to submit prior authorization requests for treatment. 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. Basic plan is FREE for NYC workers and their families! Our four dental networks consist of over 8,000 dentists and dental specialists practicing in New York and New Jersey. Without a referral, our members can seek care from any general dentist or dental specialist who participates with their dental plan. I need a dental provider for treatment for a work injury. << NFL.com. Please click here to access the training schedule. Regulardental visits helpkeep your smile healthy. The current Dental Fee Schedule version is dated March 1, 2009. Provision of orthodontic treatment will require Plan approval. Just call1.800.303.9626(TTY:711). Appellant testified that she lost her lower denture at home. Where should I send the dental billing forms? Find our Quality Improvement programs and resources here. If you have more questions, please call our Customer Services team at1-800-303-9626. 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). Complete dentures and partial dentures whether unserviceable, lost, stolen, or broken will not be replaced for a minimum of eight years from initial placement except when determined medically necessary by the Department or its agent. With the Active&Fit ExerciseRewards program, you can earn $200 every six months if you visit a qualifying fitness center at least 50 days during the same six-month reward period. Log into your account, view patient information, and more. When it comes to other doctors, you can pick from a comprehensive list of providers in all five boroughs. Contact ExerciseRewards at 1-877-810-2746 to learn more . 118 0 obj <> endobj For more information about what services are included, see the state regulation. Managed care plans, providers, and ALJs rely on the manual in determinations about dental coverage. Low-cost plans for daycare workers in New York City. Claims submitted by a dental provider to the insurer shall be paid within fortyfive calendar days of receipt of the claim. Find a Dentist in New York The Board does not authorize dental providers and does not provide lists of dental providers as referrals. See all PARs submitted by dental providers. Your participation in both networks may prove beneficial to your practice. Dr. Nofault cases are subject to different policy interpretations. Credible testimony by the appellant alone is not sufficient in these types of cases. Our Preferred and Preferred Plus Networks In addition, dental providers may use OnBoard to request dental-related DME and medications, and to submit Form HP-1.0. In addition to a plans network of dental providers, plan members have the right to access dental services at the five New York Academic Dental Center clinics licensed under Article 28 of the NY Public Health Law. endstream endobj 12297 0 obj<>/W[1 1 1]/Type/XRef/Index[255 12030]>>stream 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. 12285 13 IMPORTANT NOTICE FOR OUR MEDICAID MEMBERS AGED 18 YEARS AND OLDER. 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. StartingMay 16, 2022, the way Personal Care Services and Consumer Directed Personal Assistance Services (PCS/CDPAS) are initially assessed will be changing. This will help smooth relationships with patients when it comes to billing for out-of-pocket expenses. %PDF-1.4 % Participants meet a high credentialing standard and agree to treat covered patients at the fees detailed in our fee schedules. Were here to help. The dental provider can use any usual and customary dental billing forms. When billing for limited extended coverage, submit a paper claim at the end of the period to FFS using procedure code D8999: Limited extended coverage for lost eligibility is only payable one (1) time during the course of orthodontic treatment. Cookie information is stored in your browser and performs functions such as recognising you when you return to our website and helping our team to understand which sections of the website you find most interesting and useful. Interested in learning more aboutPreventive Dental Care? If you need to schedule or inquire about receiving transportation benefits please contact MetroPlusHealthCustomer Service Department at 1-800-303-9626 (TTY: 711) if you need assistance. During the 1st month no new participants joined, but 10 people under 65 in group A and 5 people over 65 in . ADCs will continue to be "free access" providers. Orthodontic exam and evaluation and treatment will be billed using the dental fee schedule.*. If there are no similar listed dental codes, CDT code 09999 "Unlisted Adjunctive Procedure By Report" could be utilized, where the provider should establish a fee consistent relative to the other fees listed in the dental fee schedule.
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