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  Frequently Asked Questions
 
 
General Information   Eligibility   EFT
ACS   Benefits   Orthodontics
Peach State Health Plan   Pre-Treatment Estimate   Enrollment
Provider Services   Prior Approval   Specialty/Referral
 
 
  General Information
   
Which Care Management Organization is Avesis associated with?
Avesis is associated with Peach State Health Plan.
   
What is the relationship between Avesis and Peach State Health Plan?

Avesis has contracted with Peach State Health Plan to provide dental services to Peach State Health Plan Medicaid and PeachCare Members.
   
Do I contract with Avesis or Peach State Health Plan?
Avesis will make payment for eligible CDT codes. Providers who bill utilizing CPT codes should present those requests for payment to the appropriate CMO.
   
Why are there three different CMO's?
Ten (10) health plans bid on the Georgia State Medicaid and PeachCare for Kids program. Three (3) were awarded that business by the State of Georgia.
   
Will third party liability still be the same?
Medicaid 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 Explanation of Benefits, you will submit a claim to Avesis with the primary payer’s EOB within 90 days of the date on the EOB.
   
Will we get new provider numbers?
You will keep your current Medicaid number. If you do not have a Medicaid number, you will need to apply for one. You should apply for your Medicaid number using the state’s Medicaid Application. At the time you submit your application, the State will issue you a “pending” Medicaid ID number. In addition to the Medicaid application, the NPI Application must be completed. You will need a NPI number by May 23, 2007. 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.
   
Does Avesis pay on a Fee for Service Schedule?
Yes. Avesis will pay a maximum of 100% of the prevailing Georgia Medicaid fees in effect on the member’s date of service.
   
How will Peach State Health Plan Members locate an Avesis dental provider?
An Avesis dental provider can be found:
  1. In a printed Provider Directory given to each Peach State Health Plan Member.

  2. By contacting Member Services at Peach State Health Plan

  3. On the Peach State Health Plan website at www.pshpgeorgia.com
   
Can Peach State Health Plan Members change to another CMO?
Yes, a Medicaid Member may switch CMO’s during the first ninety (90) days of the program effective date in their region. After that time frame, the Member is locked in for one year. Members will also have the option of changing their CMO choice once per year.
   
Will Peach State Health Plan Members have to choose a primary care dentist?
No, the Peach State Health Plan Member may go to any dentist in the Avesis provider network.
 
  ACS
   
My understanding is that ACS will pay Adult Medicaid when the new program begins?
ACS will continue to pay claims for the SSI portion of the Medicaid population along with dual eligible’s, waivers, and foster children. The remaining population will move to the managed care format with either Peach State Health Plan, WellCare, or Amerigroup. Avesis will be paying dental claims for Peach State Health Plan and Doral will be paying dental claims for WellCare, and Amerigroup. ACS, Avesis and Doral will pay Adult Medicaid claims.
 
  Peach State Health Plan
   
Is Peach State Health Plan a 21 and over program?
No, Peach State Health Plan is a CMO contracted by the State to render services to Medicaid enrollees under this program.
   
Can we 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 CMO or Avesis for a Peach State Health Plan 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) 231-0979 Monday through Friday from 7 AM until 7 PM, except observed holidays.
 
  Eligibility
   
How will I know that the Member has chosen to participate with Peach State Health Plan?
The Member will present with a Peach State Health Plan identification card.
   
When are children considered adults under this program?
The State of Georgia 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: (866) 522-5923
   
Do I need to verify eligibility each time a Member presents?
Yes, due to the unique qualifications for Georgia Medicaid, it is in your best interests to verify eligibility for each visit.
   
Will eligibility obtained be "real time" information?
At this time, Avesis is scheduled to receive eligibility updates monthly.
 
  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?
No, both Nitrous Oxide and intervenes sedation are covered without prior approval.
   
What are the parameters for behavior management for pediatric patients?
Behavior management (D9920) is covered twice per year up to their third birthday. For children age three and over, there must be documentation supporting physical or medical challenge.
   
  Are partial dentures ever a covered benefit?
For Anterior replacement of a single tooth only, D5213 or D5214 are a covered benefit.
   
What is the clinical guideline for perio?
Perio-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 Endo?
Endo does require prior approval and bitewings. Endo is not considered with the presence of rampant cavities or multiple missing teeth.
   
Are the PeachCare benefits that were taken away July 1, 2005 going to be reinstated?
Not at this time. It is, however, important to note that this program may be subject to change.
   
Is the PeachCare for Kids program still to age 19 only?
Yes, the age guideline for this program has not changed.
   
We have received a number of denials for sealants. How will we know when sealants have been performed?
Benefits are linked to our Claims Processing System. This system works in real time, so we recommend that you check eligibility prior to rendering services to Members. Eligibility verification is not a guarantee of payment. Payment is determined upon receipt of a claim.
   
We currently have a sealant program with the school system. Will we have the capability to verify benefits?
We recommend that you verify eligibility prior to each appointment. You may not provide preventative/diagnostic services without providing restorative services. If we determine upon reviewing utilization data that preventative/diagnostic services are performed without providing restorative services, then the Chief Dental Officer for Avesis will contact the practice to educate. If the situation is not rectified, Avesis will penalize the practice.
   
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 ninety (90) days from the date of service to file a claim.
   
Does Avesis require radiographs on everything?
No, the Covered Benefits and Maximum Allowable Schedule clearly states when radiographs are required.
   
Is there a dental fee schedule?
Eligible claims will be paid a maximum of the prevailing Medicaid reimbursement rate with the exception of CDT 2140, 2150, 2160, 2391, 2392, 2394 which are 50 percent of the primary dentition and 50 percent of the permanent dentition for a total of 100%.
 
  EFT
   
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.
 
  Pre-Treatment Estimate/Prior Approval
   
What is the Avesis Pre-Treatment Estimate/Prior Approval 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/Prior Approval?
Avesis will communicate the decision to you within 2 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.
 
  Orthodontics
   
Are Orthodontics ever a covered benefit?
Only approved medically necessary orthodontics (D8660 and D8080) 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 Peach State Health Plan. Avesis is a licensed third party administrator in Georgia and will work closely with Peach State Health Plan to ensure that claims are paid correctly and in a timely manner. Under Georgia 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. Peach State Health Plan’s parent company, Centene Corporation, is traded on NYSE (CNC). Centene’s financial information can be viewed at www.centene.com.
   
What if an Adult Medicaid Member requests Non-Covered Services?
If, in the course of the exam, you determine that the Member requires services not covered by the Medicaid 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. Providers are required to reduce the members financial obligation by 20%.
   
What happens if I perform an extraction on a tooth and inadvertently leave a piece of the root behind, and a second provider later removes the piece of root left behind and submits a claim for the removal of the same tooth?
Avesis would pay your claim initially, however once the claim is received from the second provider indicating what transpired, Avesis would move to recover the amount paid on the initial claim.
   
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.
   
Is the Non-Covered Services 80% of UCR or Medicaid rates?
Non-covered Services are to be billed at 80% of the providers UCR.
   
Does the Enhanced Adult program have co-pays?
No, there are no co-pays on the program.
   
What is the bitewing coverage for the Enhanced Adult benefit?
The CDT codes allowed are D0270, D0272, D274, D0272 and D0274.
   
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 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 Peach State Health Plan honor the Georgia prompt pay law requiring that all eligible clean claims be processed and paid within fifteen (15) business days. Avesis will pay eligible clean dental claims on a weekly basis.
 
  Enrollment
   
How will Medicaid enrollees select a CMO?
Maximus has been contracted by the State of Georgia to educate Medicaid enrollees on the three CMO’s and the differences between them to aid them in selecting a CMO. Enrollees that do not select a CMO will be assigned to one by the State.
   
Are the Enhanced Adult benefits available on all plans?
No, the benefits detailed in the Provider Manual and on the Avesis website are specific to Peach State Health Plan.
   
Is the matrix available on the Avesis website?
No it is not. The matrix can be found at: www.gahealthyfamilies.com.
 
  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) 231-0979 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 Medicaid Members.
   
Is the referral form online?
Yes, click here to obtain the Specialty Referral Form. It can also be found within the Provider Manual.
   
Is the referral form used for a General/Pediatric Dentist to refer to a specialist?
Yes, this is a General/Pediatric Dentistry program.
   
 

 
   
   
 
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