 Welcome, to all of you, as we celebrate another milestone for the Oklahoma Health Care Authority (OHCA) – the launch of our new Dental Newsletter. It is our intent to provide you with targeted information in "bite size chunks,” which will enable you to better partner with OHCA.
Aristotle tells us that we are the sum of our actions and motivation. We are all destined to make choices, and those choices do largely control our actions. OHCA appreciates your partnership and is aware that an individual’s cumulative actions can result in a fantastic group product. I know that our OHCA staff works hard, sharing any information and knowledge they have to assist our dental partners.
I am most fortunate and grateful that I have broad support that allows this additional effort to communicate with you. I give my warmest welcome to you – one and all.
Leon D. Bragg, DDS, MEd
Chief Dental Officer
|
OHCA works
to keep providers and their staff informed about the latest happenings in
SoonerCare. Be sure to check that all dental providers, administrative staff,
business departments and other appropriate parties have access to this
E-newsletter by forwarding it today!
Information contained within is
subject to change. Be sure to check OHCA Provider Letters, Global Messages and
Web Alerts at www.okhca.org for the most up-to-date information.
Recently, the OHCA Dental Unit offered the free webinar “How to submit a dental prior authorization (PA) on the Provider Portal” online at www.okhca.org. The presentation is a step-by-step explanation of how to submit PAs on the secure site and is recommended for the following provider types: 27 – Dentist, 86 – Dental Clinic, 271 – General Dentistry, 272 – Oral Surgeon, 273 – Orthodontist, and 274 – Pediatric Dentist.
The demonstration is now available in PDF form for your convenience. Click here to download.
To learn more about SoonerCare dental PAs, please visit our website.
A component of OHCA’s administrative duties is to maintain oversight of the SoonerCare program. OHCA’s Program Integrity & Accountability Unit fulfills this requirement. Program integrity (PI) is essential to any successful business venture; it plays a critical role in ensuring that the agency meets the directed mission, securing the trust of business stakeholders, and verifying that operations run efficiently, effectively and comply with applicable laws. When taxpayer dollars fund the business venture, as with the SoonerCare program, it becomes even more vital. OHCA is accountable to the public to ensure these funds are spent appropriately. Provider audits/reviews are one way we accomplish this.
What is a provider audit?
The OHCA Program Integrity Unit uses provider audits/reviews to determine if services billed by a provider are appropriate and allowable. These audits are necessary to certify the SoonerCare program is billed by legitimate providers for correct amounts and for medically appropriate services to eligible members. All OHCA providers are subject to review.
As with any other type of review, the outcome is based on the results of examining service documentation with applicable rules and regulations, provider billings, industry coding and payment guides.
Why is an audit conducted?
Review begins when a questionable issue surfaces. OHCA identifies issues through methods such as data analytics, referrals, exception processing and explanation of benefits. We also review CMS fraud and abuse alerts, Office of Inspector General work plans and reports, and other external sources to stay abreast of emerging issues.
Once we identify a potential issue, we perform a preliminary investigation. The results of this investigation go before a case internal selection committee who determines if an audit is necessary. If the committee votes yes, the audit is started; if no, the issue is closed. We maintain documentation in the case file.
Who performs the audits?
OHCA PI and dental staff conduct dental PI audits; PI staff consists of a dental hygienist and registered nurses, all of whom are certified coders. Additionally, OHCA dental staff is consulted throughout the dental review process. OHCA dentists have final review of informal reconsiderations.
How is an audit performed?
We conduct audits through the collection and examination of provider service records, reviewing them against applicable criteria and drawing an audit conclusion. PI staff validates that appropriate payments are made:
· to legitimate providers,
· for medically necessary services, and
· to eligible members.
The audit is a comprehensive review of dental records for the service rendered. PI staff examines treatment plans and treatment notes, and reviews radiographs for type to determine if services are compensable. Upon completion, we submit an initial audit report to the provider notifying them of the audit findings and what actions they may take.
What actions can a provider take to address audit findings?
Providers may submit an informal reconsideration to address audit findings. Providers can submit additional documentation/explanation to support the billed service. Dentists review all informal reconsiderations. Upon completion, OHCA submits a final audit report to the provider notifying them of the results and that they may file a formal appeal.
At this time, providers may file an appeal with OHCA and present their case to an administrative law judge.
 OHCA got very exciting news that Insure Oklahoma (IO) has received another one-year extension from the federal government and will be operational through December 31, 2015 and hopefully beyond. OHCA will continue to promote IO as an effective solution to the health care needs of thousands of low-income Oklahomans. OHCA looks forward to working with Oklahomans, small businesses, brokers, agents and media outlets to ensure that folks are well informed about program eligibility and benefits, as well as how to sign up for coverage.
No eligibility guidelines, benefits or requirements will change from the current program. As is the case today, the employer-sponsored plan (ESI) remains available for qualified small businesses with fewer than 99 employees whose family income is at or below 200 percent of the Federal Poverty Level (FPL). Eligibility for the individual plan (IP) remains at 100 percent of FPL. Existing copay requirements remain the same.
|
OHCA is pleased to announce its new “green”
provider notification process. In going “green,” OHCA will only offer providers
paperless sources of communication. These options are: electronic mail (email),
electronic data interchange (EDI), and the Provider Portal (secure site).
Providers will receive all official correspondence
from the agency by email. This includes Provider Letters, contract change and
renewal correspondence, newsletters, and other OHCA business communications.
This new electronic communications policy is
effective Nov. 1, 2014. Please verify or update your provider contact information
by logging in to the OHCA secure site and following these
instructions:
1.
Select “Update Provider File,” and then select the “Address and
Contacts” tab.
2.
Verify your information (make corrections or changes as allowed).
3.
Click the “Submit” button.
Complete details can be found in OHCA Provider
Letter 2014-44.
Leon D. Bragg, DDS, MEd, Chief Dental Officer
During the year 2010, I began conversations in hopes of developing a “sounding board” of dentists to assist me in the development of the SoonerCare Dental Program. In the last quarter of that year, the OHCA Dental Focus Group (DFG) was formed. This group is composed of contracted partners who represent various areas of the state and its community of dentists. Upon establishment of the DFG, members were exposed to the various units and operations that comprise OHCA.
In the DFG, we have had discussions regarding logical ways to establish a 3-year plan to enhance programmatic rules that will move forward accessible, comprehensive oral health care services for SoonerCare and Insure Oklahoma (IO) members. Our goals have included:
- Strengthening the OHCA’s dental infrastructure;
- Identifying current problems and developing a long-range strategic plan;
- Developing ways to establish a SoonerCare oral health care standard by listing specific approaches OHCA should utilize;
- Development of a priority list of subjects identified as good, better and best aspects of SoonerCare;
- Development of specific strategies that should be undertaken by OHCA to ensure the continuation of a dominant public health dental program for Oklahoma’s population; and
-
Assimilation of information; transferal of lessons learned; updating of guidelines; and development of best practice descriptions, identification of research and/or practice evaluation and policy implications.
Members are of the DFG are:
Emile Farha, DDS – Oklahoma City
Richard Gilman, DMD - Norman
Bernard Rhone, DDS – Oklahoma City
Deborah Corwin, DDS - Bristow
Don Cheatham, DDS - Edmond
Emilie Stahler, DDS - Marietta
Floyd Simon, DDS - Clinton
Geoff Roubik, DDS – Oklahoma City
Glen Mead, DDS - Purcell
Heath Whitfield, DDS - Edmond
Janna McIntosh, DDS - McAlester
Randall Graham, DDS - Tulsa
Robert Herman, DDS - Tulsa
Ron Austin, DDS - Tishomingo
Stephen Virtue, DDS – Oklahoma City
Steven Sullivan, DDS – Oklahoma City
Most of our partners are only aware of how they practice dentistry on a daily basis; members of the DFG have been exposed to actions by other dentists that contradict their expectations of dentists in our state. The exposure and education of this group to the internal workings of OHCA has been successful and valuable for the SoonerCare dental program. It was difficult for some to accept that not all dentists are providing medically necessary, appropriate and high-quality dentistry to the SoonerCare population. Now that DFG members have a new understanding of what occurs at this level of administration, I can have discussions with them regarding certain issues, knowing that the issues and feedback are relevant and will be kept confidential.
It has been beneficial for me to know the feedback I receive is based on an understanding of the difficulties in developing appropriate OHCA policy. The DFG understands why OHCA undertakes certain actions or the need for attention that is required of a small percentage of contracted dentists. They better understand various activities that, if left unchecked, could harm the SoonerCare program and its pediatric members. Guidance and ideas from the DFG will be shared in future issues of this newsletter.
 Dental imaging is an important component of children's overall health care, but it’s important to remember that one size does not fit all when it comes to this technology. On September 24, the dental community was welcomed to growing movement of medical professionals committed to safety in pediatric imaging – the Image Gently® campaign. The campaign is supported by the American Dental Association, the American Academy of Oral and Maxillofacial Radiology and other dental specialty groups, in conjunction with the Alliance for Radiation Safety in Pediatric Imaging.
The campaign encourages providers to image gently during pediatric dental procedures and to keep in mind these six best practices1:
1. Select x-rays for a patient’s individual needs, not as a routine.
2. Use the fastest image receptor possible: E- or F-speed film or digital sensors.
3. Collimate the x-ray beam to only expose the area of interest.
4. Always use thyroid collars.
5. Child-size the exposure time.
6. Use cone-beam CT only when necessary.
Detailed information can be found in this PDF.
The mission of the Alliance for Radiation Safety in Pediatric Image Imaging (the Image Gently Alliance) is to improve the safety and effectiveness of the imaging care of children worldwide. This is achieved through increased awareness, education and advocacy on the need for the appropriate examination and amount of radiation dose when imaging children.
The Alliance’s Image Gently® Website has many useful resources specifically for dental professionals. You can access them by clicking here.
OHCA encourages you to take the pledge to Image Gently® today! Our SoonerCare patients and their parents will thank you for your commitment to patient safety.
1. White SC, Scarfe WC, Schulze RKW, et al. The Image Gently in Dentistry campaign: promotion of responsible use of maxillofacial radiology in dentistry for children. Oral Surg Oral Med Oral Pathol Oral Radiol. 2014;118:257-61. Available at: http://ac.els-cdn.com/S2212440314005239/1-s2.0-S2212440314005239-main.pdf?_tid=8e53f73e-3ce8-11e4-9a7b-00000aab0f26&acdnat=1410793204_584ff9c85ed88186e16af50f4a696be5.
|
 1. What is a comprehensive treatment plan and why must I provide one with all requests for prior authorization (PA)?
A comprehensive treatment plan identifies all dental treatment needs of the member. This includes services that require prior authorization (PA) as well as those that do not. OHCA requires a comprehensive treatment plan in order to obtain the “full scope” of treatment the dentist plans for the member, not just the current, immediate plan of treatment.
2. What is a CDT and why should my office have one?
The CDT (Current Dental Terminology) is a reference manual published annually by the American Dental Association (ADA). It is a complete listing of all current dental procedure codes, including a narrative describing each procedure code. OHCA encourages each office to own the current reference manual in order to ensure procedures are billed accurately, in accordance with the ADA.
3. Where can I find OHCA’s dental fee schedule?
All SoonerCare fee schedules are available on our public website, www.okhca.org. Click here to access.
Be sure to watch for additional FAQs in each dental newsletter.
Dates to remember
November 13 OHCA Board Meeting @ OHCA
December 11 OHCA Board Meeting in Tulsa
Here’s a
brief look at recent news and updates affecting our dental providers that have
been published on the OHCA website. Please follow the appropriate links for more in-depth
information.
Provider Letters:
Global Messages:
· Commonly Used SoonerCare Dental Forms
· Dental Periodicity Schedule
· SoonerCare Fee Schedules (includes dental)
· OHCA Quick Reference Guide (PDF)
· Provider Resources: Useful contact information
· EVS Guide: Oklahoma Client Eligibility Verification System
· ePocrates: Oklahoma SoonerCare drug list and Medicare Part D formularies
· Medicaid on the Web: Oklahoma Medicaid Management Information System (OKMMIS) Provider Training Manual
· Provider Directory (PDF for members in Patient-centered Medical Homes)
· Additional Provider Directories (Behavioral Health, Dental, Vision, DME, etc.)
· Online provider training (Webinars, provider workshop schedules, etc.)
· Statistics & Data (access Fast Facts on providers and services)
· Free OHCA publications: Ordering from our website
OHCA Provider Helpline: 800-522-0114
Dental Prior Authorization Unit: 405-522-7401
WWW.okhca.org/dental
Contact:
Leon
Bragg, DDS, MEd
Chief
Dental Officer
Oklahoma Health Care Authority
4345 N. Lincoln Blvd.
Oklahoma City, OK 73105
405-522-7592
Leon.Bragg@okhca.org
| 
