Enhanced benefits from Delta Dental
As we announced to participating and nonparticipating Delta Dental of Michigan, Ohio, and Indiana providers on August 30, we are offering enhanced benefits to clients who wish to take advantage of them on behalf of eligible members with special health care needs.
These benefits provide members with greater coverage of care, and providers with additional treatment options and time with patients to support a positive dental experience.
Who qualifies for this benefit?
Enhanced benefits are being offered to Delta Dental customers, but the ability of covered members to use the benefits depends on the customer’s willingness to educate their members and accept a small amount of additional eligibility management responsibility. Therefore, some employers may decide not to opt in to the benefits. This means that even if you have a patient with special health care needs and Delta Dental group benefits, they may not be eligible for these benefits. It is important to verify coverage.
Before rendering services, providers should check the member’s eligibility file in the Dental Office Toolkit® to verify coverage. If the member has coverage through the enhanced benefits, you will see that a “Special Health Care Needs” attribute is checked in their file. There is no age limit on these benefits.
If a member says they are eligible, but the attribute is not checked, the subscriber must work with their group to have the member’s file updated accordingly.
Note—The “Special Health Care Needs” attribute is different from the “Handicap” attribute.
What is included in this benefit?
Beginning January 1, 2022, the below services will be covered under this enhanced benefit. Use the accompanying procedure codes when submitting a claim.
Providers must include remarks regarding the special health care need benefit on applicable claims to indicate that treatment was provided for a patient with special health care needs.
- Additional visits to the dentist’s office and/or consultations that can be helpful prior to the first treatment to help patients learn what to expect and what is needed for a successful dental appointment.
- Additional exam benefits will be allowed for this purpose
- Procedure codes D0120, D0145, D0150, D0160 and D0180
- Up to four total dental cleanings in a benefit year.
- Procedure codes D1110, D1120, D4910, D4346 and D4355
- The use of silver diamine fluoride (SDF) that can be applied to cavities for patients who can’t tolerate the use of dental instruments.
- Treatment delivery modifications necessary for dental staff to provide oral health care for patients with sensory sensitivities, behavioral challenges, severe anxiety, or other barriers to treatment.
With support from the Delta Dental Foundation, Penn Dental Medicine has established a free continuing education series aimed at building awareness of the barriers to equitable oral health care for individuals with disabilities and developing competency to provide oral health care to this vulnerable population.
Learn more about the Center for Persons with Disabilities Presentation Series.
Click here to view our “Enhanced dental benefit provider directions” flyer. Eligible members will receive this flyer and may bring it with them to their dental appointment when utilizing the enhanced benefits.
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Update on CMS Medicare opt-out status
Starting January 1, 2022, the Centers for Medicare and Medicaid Services (CMS) Medicare opt-out status will no longer apply to supplemental dental services covered by Delta Dental through Medicare Advantage plans.
Accordingly, Medicare Advantage members will be able to receive services even if a provider has opted out of Medicare, and those providers will be included in the Delta Dental directory of participating dentists. Furthermore, the opt-out provision in your provider agreement is hereby removed.
Note—Opt-out is still in effect for services covered under original Medicare.
If you have any questions, please contact your Delta Dental professional services representative.
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Reminder: Switch to HAP ID
As a reminder, HAP transitioned in December 2020 to using a single ID card for their Medicare Advantage members (Group #5653) and D-SNP members (Group #10500) for identification of members’ dental benefits.
When verifying coverage and submitting claims for a patient in this group, remember to use their 11-digit HAP ID number, located on their HAP Medicare Advantage medical card.
Please call the Delta Dental Medicare Advantage™ customer service line at 800-330-2732 if you have any questions.
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As a reminder, all Delta Dental network participating dentists are required to complete Fraud, Waste and Abuse (FWA), Compliance and Cultural Competency Training once each calendar year. This requirement is stipulated in your network participation agreement regardless of whether you treat patients who are Medicaid or Medicare Advantage participants.
This anti-fraud training was developed to inform providers of the overall impact of FWA on the entire health care industry. In addition, it lays out some of the common laws that are relevant to your practice, including The False Claims Act and the Anti-Kickback statute.
Once training is completed, one person in the practice must acknowledge completion of the training for the business entity by completing the Training Acknowledgment Form. Training is tracked by the business tax identification number (TIN) used to submit claims to Delta Dental.
To find the training modules and acknowledgment form, visit www.deltadentalmi.com/CMScompliance.
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HKD access standards
Our Delta Dental Healthy Kids Dental (HKD) participating providers play an important role in addressing children’s oral health gaps. As part of this role, and as required by the Michigan Department of Health and Human Services, Delta Dental HKD dentists must see Delta Dental HKD members within specified time frames based on treatment urgency.
Benchmarks can be found in your contract, or those for general practitioners and pediatric dentists are listed below.
- Urgent care—see within 48 hours
- Routine services—schedule within 21 business days
- Preventive services—schedule within six weeks
- Initial appointment—must schedule within eight weeks
If a participating office does not meet the required access standards as declared in the Addendum to the Delta Dental Premier® Agreement for HKD providers, your Delta Dental professional relations field representative will reach out to you to discuss.
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