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Frequently Asked Questions
 
General Information   Benefits   Billing and Claims
Bridgeway Health Solutions   Behavior Management   Electronic Funds Transfer
Provider Services   Pre-Treatment Estimate   EPSDT
Eligibility   Specialty/Referral    
 
 
  General Information
   
Which Managed Care Organization (MCO) is Avesis associated with?
Avesis is associated with Bridgeway Health Solutions.
   
What is the relationship between Avesis and Bridgeway Health Solutions?

Avesis has contracted with Bridgeway Health Solutions to provide dental services to Arizona Long Term Care System Members.

   
Do I contract with Avesis or Bridgeway Health Solutions?
You will contract with Avesis.
   
Why are there different MCO's?
Many health plans bid on the Arizona Long Term Care System program. Three (3) health plans were awarded that business in Maricopa County and one (1) health plan in all other counties.
   
Will third party liability still be the same?
ALTCS is the payer of last resort. If the Member has other health insurance, claims must be filed with that payer first. Upon receipt of the primary Remittance Advice (RA), you will submit a claim to Avesis with the primary payer’s RA within 90 days of the date on the RA.
   
Will we get new provider numbers?
You will keep your current AHCCCS Provider number. If you do not have an AHCCCS Provider number, you will need to apply for one. You should apply for your AHCCCS Provider number through the state’s website. Please note that you need a unique number for each location that you render services. After you are credentialed, you will receive an Avesis pin number which will be your Avesis identification number. For your convenience, Click here for information on the National Provider Identifier (NPI) number. This link will provide you with information and an application from the National Plan & Provider Enumeration System (NPPES). You will need this number by May 23, 2007.
   
What is an NPI number?

The Health Insurance Portability and Accountability Act of 1996 (HIPPA) mandated that the Secretary of Health and Human Services adopt a standard unique health identifier for health care providers. On January 23, 2004, the Secretary published a Final Rule that adopted the National Provider Identifier (NPI) as this identifier. NPI is a unique identification number for health care providers that will be used by all health plans. Health care providers and all health plans and health care clearinghouses will use the NPI in the administrative and financial transactions specified by HIPAA. The NPI contains no embedded intelligence; that is, it contains no information about the health care provider such as the type of health care provider or State where the health care provider is located. The NPI must be used in connection with the electronic transactions identified in HIPAA. The NPI will not:

  • Replace the DEA number when required for prescribing controlled substances or other DEA-regulated activities.
  • Replace state-issued licenses and certifications verifying a Provider's licensing or qualifications.
  • Replace Social Security Number, Individual Tax ID, or Employer ID for tax purposes.

Source:
http://www.cms.hhs.gov/MLNMattersArticles/downloads/SE0528.pdf http://aspe.hhs.gov/admnsimp/faqnpi.htm http://www.ada.org/prof/resources/topics/npi.asp

   
Does Avesis pay on a Fee for Service Schedule?
Yes. Avesis will pay 100% of the Covered Benefits and Fee Schedule that Avesis established for the Arizona Long Term Care System (ALTCS) Program.
   
How will Bridgeway Health Solutions Members locate an Avesis dental provider?

An Avesis dental provider can be found:

1. In a printed Provider Directory given to each Bridgeway Health Solutions Member.

2. By contacting Member Services at Bridgeway Health Solutions

3. On the Avesis website at www.avesis.com

   
Will Bridgeway Health Solutions Members have to choose a primary care dentist?
No, the Bridgeway Health Solutions Member may go to any dentist in the Avesis provider network.
   
Who can a Member call if their Provider is unavailable and they believe that their concern is urgent?
The Member may contact NurseWise®, a 24-hour, toll-free phone line through which callers can reach both customer service representatives and bilingual nursing staff. The nurse triage service provides access to a broad range of health-related services.
   
Will Bridgeway Health Solutions Members have to choose a primary care dentist?
No, the Bridgeway Health Solutions Member may go to any dentist in the Avesis provider network.
 
  Bridgeway Health Solutions
   
Is Bridgeway Health Solutions a 21 and over program?
No, Bridgeway Health Solutions is a MCO contracted by the State to render services to ALTCS enrollees under this program.
   
Can our office refuse to see a patient that does not have an identification card that comes into the office?
It is not necessary to refuse treatment to a member because they do not present with their identification card. Eligibility can be verified with the Member’s MCO or Avesis for a Bridgeway Health Solutions Member.
 
  Provider Services
   
Is there a number to call where you can reach an actual person?
Avesis Provider Services is available to assist you at (800) 327-4462 Monday through Friday from 8 AM until 5 PM MST except observed holidays.
 
  Eligibility
   
How will I know that the Member has chosen to participate with Bridgeway Health Solutions?
The Member will present with an AHCCCS identification card which will list the Health Plan.
   
When are children considered adults under this program?
The State of Arizona deems the first day of the month following their 21st birthday to be adulthood.
   
How will I obtain eligibility information?
Your office can:
  • Visit the Avesis website anytime

  • Utilize Avesis IVR anytime at: (866) 234-4806

  • Call Avesis Customer Service at: (800) 327-4462
   
Do I need to verify eligibility each time a Member presents?
Yes, due to the unique qualifications for Arizona ALTCS, it is in your best interest to verify eligibility for each visit.
   
Will eligibility obtained be “real time” information?
At this time, Avesis is scheduled to receive eligibility updates weekly.
 
  Benefits
   
Will we be able to view the member’s benefits online?
Full benefit information will be available on the Avesis website.
   
Are providers required to obtain prior approval for the use of Nitrous Oxide or intervenes sedation?
Prior Approval is not required for one unit of Nitrous Oxide per Member per appointment. Prior Approval is not required for one unit of intravenous sedation per Member per appointment.
   
Are dentures ever a covered benefit?
Dentures are covered for medical necessity only by the Member’s Primary Care Physician.
   
  What is the clinical guideline for Periodontal Therapy?
Subgingival calculus must be present in any covered quadrant and there must be at least 4 areas with a minimum pocket depth of 4mm. D4260 and D4261 require at least 4 areas with a minimum pocket depth requirement of 5mm.
   
What is the requirement for Endodontic Therapy?
Endo does require prior approval and bitewings. Endodontic therapy is not considered with the presence of rampant cavities or multiple missing teeth.
   
If I do a panoramic x-ray today and a second performs the same procedure during the same week; would my claim pay?
Claims are processed in real time. The first clean claim received would have the highest likelihood for payment. Providers have one hundred and eighty (180) days from the date of service to file a claim.
   
Does Avesis require radiographs?
No, the Covered Benefits and Fee Schedule clearly states when radiographs are required.
 
  Behavior Management
   
What is the coverage for behavior management for pediatric patients?

Behavior management by report (D9920) must be requested in 15 minute increments (one unit =15 minute increment). This post review service will be reimbursed if all required attachments per the Covered Benefits and Fee Schedule accompany the claim and Member qualifies under one or more of the three categories:

  • Handicapped,
  • Retarded,
  • Age three or younger who can not be managed or handled in the routine dental office setting through normal office procedures.

Behavior Management is limited to a four hour maximum or sixteen units per Member per calendar year. An explanation of why management time is required must accompany the post approval review request. When submitting for authorization of management time, the entire treatment plan for the Member must accompany your request. Management time is calculated by determining the additional time to be spent beyond the normal time required to complete the service. The minutes or time requested must be for the additional time – NOT THE FULL APPOINTMENT TIME.

You may request behavior management or nitrous oxide or other drugs. With approval, only one of these services will be reimbursed per date of service per Member.

 
  Pre-Treatment Estimate
   
What is the Avesis Pre-Treatment Estimate process?
Providers will submit a completed form as well as all required information to the Specialty/Referral address listed in the Provider Manual.
   
How many days does it take for Pre-Treatment Estimate?
Avesis will communicate the decision to you within ten (10) business days.
   
Can Pre & Post approvals be sent online?
You will be able to submit narratives online. At this time, radiographs need to be mailed. Avesis is working toward an electronic alternative to this process.
 
  Specialty/Referral
   
What happens when you have to refer out of network for a specialist?
Participating providers are required to refer to participating providers. If you can not locate a participating provider, please contact Provider Services at (800) 327-4462 for assistance.
   
If a Pedodontist is not considered a specialty, are we required to service adults?
Providers are not expected to change their scope of practice to accommodate all ALTCS Members.
   
Is the referral form online?
Yes, it can be obtained from this website.
   
Is the referral form used for a General Dentist to refer to a specialist?
Yes, this is a General Dentistry program.
   
Are Orthodontics ever a covered benefit?
Only approved medically necessary orthodontics (D8010, D8020, D8030, D8080, and D8660) are eligible for coverage. They include: overjet >10mm, underjet > 3.5mm, deep bite with tissue trauma, Cleft Palate, anterior open bite – molar occlusion only, thumb sucking, tongue thrust, impacted canine with cystic formation or root resorption.
 
  Billing and Claims
   
How will dentists be assured that Avesis is financially solvent and will pay claims timely?
Avesis is the dental managed care subcontractor for Bridgeway Health Solutions. Avesis is a licensed third party administrator in Arizona and will work closely with Bridgeway Health Solutions to ensure that claims are paid correctly and in a timely manner. Under Arizona insurance law, managed care subcontractors are required to meet specific standards for claims payment. The parent insurance company is, however, ultimately responsible for claims payment. Bridgeway Health Solutions parent company, Centene Corporation, is traded on NYSE (CNC). Centene’s financial information can be viewed at www.centene.com.
   
What if an Adult ALTCS Member requests Non-Covered Services?
If, in the course of the exam, you determine that the Member requires services not covered by the ALTCS program you will be expected to discuss possible options with the Member. Should the Member choose to receive Non-Covered Services, the Non-Covered Services Form will be completed and signed by the provider and the Member.
   
Should I send a copy of the Non-Covered Services Form to Avesis?
No, this form becomes part of the Member’s permanent record.
   
Can the non-covered services form be completed online?
No, that is not possible since the form requires signatures.
   
Can the Non-Covered Services form be completed online?
No, that is not possible since the form requires signatures.
 
  Electronic Funds Transfer
   
Will we need to send a check with the EFT agreement?
Yes, providers interested in electronic remittance will need to provide Avesis a voided check with the completed EFT form which can be found in the manual.
   
Where do I send my EFT Agreement?

Please mail the EFT Agreement and voided check to:

Avesis Third Party Administrators, Inc.
Attn: Finance
PO Box 782
Owings Mills, MD 21117

   
How are claims submitted to Avesis?

In one of three ways:

  • Electronic Data Interchange (EDI)
  • Manually entered on the Avesis website
  • By mail, using the ADA Form
   
Will you accept faxed claims?

No.

   
Will Avesis accept HIPAA compliant electronic claims (837) and provide electronic remittance (835)?

Yes, Avesis will accept HIPAA compliant 837 claims, and will return HIPAA compliant 835 remittance advice for those claims.

   
Will Avesis accept HIPAA compliant electronic eligibility benefit request (270) and provide an electronic response (271)?

Yes, Avesis will accept HIPAA compliant 270 eligibility benefit request, and will return HIPAA compliant 271 benefit information response for those inquiries.

   
How often are claims paid?

Avesis and Bridgeway Health Solutions honor the Arizona payment law requiring that 90% of all clean claims be processed and paid within thirty (30) calendar days of receipt of clean claim and 99% of claims be processed and paid within sixty (60) calendar days of receipt of clean claim. Avesis will pay eligible clean dental claims on a weekly basis.

 
  EPSDT
   
Is there a code to bill Early and Periodic Screening, Diagnosis and Treatment (EPSDT)?

No. There is no CDT code to bill EPSDT. If you are asked to examine a school age child for EPSDT, you will be required to perform a full:

D0150 – Comprehensive Oral Evaluation or
D0120 – Periodic Oral Evaluation
 

 
   
   
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