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19.24.3 Frequently Asked Questions About Dental Claims
Q |
Why is routine dental treatment not a benefit when performed at the same visit as an emergency visit? |
A |
The following are reasons routine dental treatment is not a benefit when performed at the same visit as an emergency visit: |
• The purpose of an emergency claim is to allow the provider to treat a true emergency without the concern that routine dental procedures may be denied.
•Medicaid program policy guidelines do not allow payment for both types of services to the same provider at the same visit. True emergency claims process through the audit system correctly when "emergency" is checked on either the paper or electronic claim and the Remarks or Narrative section of the claim form describes the nature of the emergency.
Q |
Why are some claims for oral exams and emergency exams on the same date for the same client denied? |
A |
Medicaid program policy does not allow an initial oral exam and an emergency exam to be billed on the same date of service for the same client. An emergency exam performed by the same provider in the same six-month time period as an initial exam may be considered for reimbursement only when the claim for the emergency exam indicates it is an emergency and the emergency block is marked. If the claim is not marked as an emergency, the claim wll be denied. |
Q |
How are orthodontic bracket replacements reimbursed? Can the client be charged for bracket replacements? |
A |
The provider uses orthodontic procedure code D8690 to claim reimbursement. Medical necessity must be documented in the client record. Payment is subject to retrospective review.
The client with current Medicaid eligibility should not be charged for bracket replacement. If the provider charges the client erroneously, the provider refunds any amount paid by the client. |
Q |
Why could an appeal of a denied claim take a long time? |
A |
An appeal can take a long time if TMHP is required to research the denied claim and determine the reason the claim did not go through the system. For faster results, providers should submit appeals as soon as possible and not use the entire 120 days allowed to submit the appeal. |
The following are guidelines on filing claims efficiently:
•Use R&S report dates to track filed claims.
•File claims electronically through TMHP EDI. Electronic billing does not allow a claim with an incorrect date to be accepted and processed, which saves time for the provider submitting claims and TMHP in processing claims. Call 1-888-863-3638, for more information about TMHP EDI.
•File claims with the correct information included. Most denied claims result from the omission of dates, signature, and narrative, or incorrect ID numbers such as client Medicaid numbers or provider identifiers.
Q |
Why are only ten appeals allowed per call? |
A |
There is a limit on appeals per call to allow all providers equal access. |
Q |
Why do reimbursement checks sometimes take a long time to arrive? |
A |
Reimbursement may be delayed if a provider fails to submit claims in a timely manner. |
Q |
Does electronic billing result in delayed payment? |
A |
No. Providers who bill electronically report faster results than billing on paper. Providers are encouraged to use TMHP EDI for claims submission. |
The following are helpful hints to a more efficiently processed claim:
•Ensure the provider identifier is on all claims.
•Include the performing proper's signature on all paper claims.
•Verify client eligibility for procedures.
•Verify if the procedure code requires a narrative on the claim; the narrative is for medical necessity.
•Include the required client information, including name, birth date, and client number.
•Dental auxiliaries cannot enroll in the Texas Medicaid Program; therefore, they cannot bill the Texas Medicaid Program. Any procedure performed by the auxiliary (i.e., the hygienist or the chairside assistant) must be billed by the supervising dentist, using the dentist's provider identifier.
Reminders:
•Procedure code D9630 is not payable for take home fluorides or drugs. Prescriptions should be given to clients to be filled by the pharmacy for these medications as the pharmacy is reimbursed by the Medicaid Vendor Drug Program. D9630 is payable for medications (antibiotics, analgesics, etc.) administered to a client in the provider's office. Documentation of dosage and route of administration must be provided in the Remarks section of the claim.
•Procedure code D8660 is allowed at different age levels, per provider. If D8660 is billed within six months of D8080, the D8080 will be reduced by the amount that was paid for D8660.
•Prior authorization is required with documentation of medical necessity when replacing lost or broken orthodontic retainers (D8680).
•Prior authorization of orthodontic services is nontransferable. If a client changes an orthodontic provider for any reason, the new provider must submit a separate request for prior authorization. The provider requesting and receiving authorization for the service also must perform the service and submit the claim. Codes listed on the authorization letters are the only codes considered for payment. All other codes billed are denied. Providing the authorization number on the submitted claim results in more efficient claims processing.
•General anesthesia (provided in the dentist office, ambulatory service clinic, and inpatient/outpatient hospital settings) does not require prior authorization, but is required to follow the Criteria for Dental Therapy Under General Anesthesia (see page 19-34) to determine if a client meets the minimum required points for general anesthesia. All THSteps dental charts for dental general anesthesia are subject to retrospective, random review for compliance with the Criteria for Dental Therapy Under General Anesthesia and requirements for chart documentation.
•Providers must not bill a client unless a formal denial for the requested item/service has been issued stating the service is not a benefit of the Texas Medicaid Program and the client has signed the Client Acknowledgment Statement for that specific item/service. A provider must not bill Medicaid clients if the provided service is a benefit of the Texas Medicaid Program.
Refer to: "Client Acknowledgment Statement"
THSteps clients must receive:
•Dental services specified in the treatment plan that meet the standards of care established by the laws relating to the practice of dentistry and the rules and regulations of the TSBDE.
•Dental services free from abuse or harm from the provider or the provider's staff.
•Only the treatment required to address documented medical necessity that meets professionally recognized standards of health care.
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