Dental

The provisions outlined in these Plan Specifics shall prevail over any provision in the Centene Dental Provider Manual that may conflict or appear inconsistent with any provision contained in this document.

Envolve Dental, doing business as Centene Dental Services, administers dental benefits Nebraska Total Care. Nebraska Medicaid members are eligible for clinically indicated dental services within the scope of Nebraska’s fee-for-service Medicaid program, as detailed below.

The following Nebraska DHHS Medicaid member eligibility categories are included:

• Medicaid Children ages 0-20
• Medicaid CHIP (CHIP) Children ages 0-19
• Medicaid Adult ages 21+
• Nebraska HHA Expansion Program members

BENEFIT AND ELIGIBILITY INFORMATION AVAILABLE 24/7

• For specific individual benefits and eligibility, access our Provider Web Portal (PWP).
• You may also call 844-813-6769 to reach Centene Dental’s automated eligibility-verification system.

COVERED DENTAL SERVICES

Dental coverage is consistent with DHHS benefits, limits, and exclusions: dhhs.ne.gov. For detailed coverage and coding information, please visit our Dental Code Search Tool and visit our Provider Web Portal (PWP).

Medicaid Dental Benefit Summary

Nebraska Total Care Medicaid Eligibility

Dental Benefit Summary

Children 0-20 CHIP 0-19 Adults 21+ Nebraska HHA Expansion Program Members

1 oral exam every 180 days 1 cleaning every 180 days, ages 21+ 2 cleanings every 365 days, ages 0-20 4 bitewings (1 series) per date of service Fluoride for all ages two times every 365 days Full-mouth radiograph series (D0210, includes bitewings) or panoramic x-rays (D0330) once every 36 months Periodontal services, including scaling and root planing Sealants through age 20 (1 per tooth every 730 days) Minor restorative services, such as fillings Major restorative services, such as crowns Tooth extractions (based on medical necessity) Orthodontia through age 20 (based on medical necessity) Dentures, partials, and repairs (with limits) Dental surgery (with limits) Emergency dental services

DENTAL PRACTICE VISIT

Nebraska Total Care and Centene Dental offer a value-added dental benefit to members of all ages with special health care needs. The purpose of the benefit is to increase preventive dental visits by supporting members with special health care needs to feel comfortable in the dental office setting. All providers are eligible and encouraged to participate. The benefit should be billed with D9430—Office visit for observation, but it will be promoted to members as a “practice visit,” where members go to the dental office to simulate a full dental exam. The benefit may be utilized four times per member, per lifetime. D9430 may not be billed on the same date of service as an exam, cleaning, or other procedure.

APPOINTMENT WAIT TIMES

If the member cannot be seen within 30 minutes of their scheduled appointment time, the office shall advise the member and offer the option to reschedule the appointment. Wait times for scheduled appointments should not routinely exceed 45 minutes, including time spent in the waiting room and the examining room, unless the provider is unavailable or delayed because of an emergency. If a provider is delayed, the member should be notified immediately. If a wait of more than 90 minutes is anticipated, the member should be offered a new appointment.

DENTAL CLINICAL POLICIES

Centene Dental Services considers all benefits and applies clinical standards to them, outlining for providers what conditions must be present for covered benefits to apply. Please be sure to review our clinical policy guidelines and criteria found on our website prior to providing services. Providers should measure intended services to stated clinical criteria before treatment begins to assure proposed services meet medical necessity and appropriateness of care criteria. These policies also include listings of required documentation to support services provided.

AUTHORIZATION REQUIREMENTS

Some services require prior authorization to be obtained prior to rendering treatment. Other services are subject to pre-payment review with claim submission. To view the requirements per covered code, visit the Dental Code Search Tool.

Members may receive an expedited/fast decision when life, health or ability to regain function may be jeopardized. In an emergency, a provider should not wait for prior authorization to provide treatment to the member. When possible, standard authorization requests should be received at least 14 calendar days in advance via:

• Centene Dental Provider Web Portal
• Electronic clearinghouses, using payor ID number 46278
• Alternate, pre-arranged, HIPAA-compliant electronic files
• Paper submissions mailed to the address indicated in the Provider Quick Reference (last page)
  • Requests must be submitted on a current (2012 or later) ADA original claim form
  • Copies, handwritten or faxed forms are not accepted

For urgent requests, please mark your authorization request “Expedited Request” in the Centene Dental PWP or on your clearinghouse or paper submission. For emergencies without prior authorization, please contact Customer Service for claim submission instructions within 2 business days of rendering emergency care.

Please note: Expedited requests not meeting urgent medical standards or lacking sufficient information for fast decision may be downgraded to standard processing times.

Prior authorization decisions for non-urgent services shall be made within two business days, those that require additional information will be contacted and given up to 7 calendar days to review to allow provider response.

ORTHODONTIC CONTINUITY OF CARE

In-Network Providers should submit a continuation of care prior authorization request to Centene Dental Utilization Management with the following:

• A copy of the prior health plan or carrier authorization;
• A copy of the provider’s ledger showing reimbursement of all services provided to the member, including all remits/EOPs received; and
• A narrative detailing the remaining treatment plan and request for continuing care.

Out-of-Network Providers should email Centene Dental Case Management and provide the following:

• A copy of the prior health plan or carrier authorization;
• A copy of the provider’s ledger showing reimbursement of all services provided to the member, including all remits/EOPs received;
• A narrative detailing the remaining treatment plan and request for continuing care

Centene Dental will coordinate the request to determine the remaining treatments allowed per the benefit plan. A written notice will be sent to the requesting orthodontic provider when a determination is made.

HOSPITAL OR OUTPATIENT FACILITY AUTHORIZATIONS

Centene Dental participating providers are not required to submit authorizations for dental care performed at Nebraska Total Car in-network outpatient and hospital facilities. Professional claims submitted to us for services performed in these facilities should contain D9420 for tracking purposes. For out-of-network facilities, authorization should be submitted to Nebraska Total Care. To obtain the most recent listing of in-network facilities in your area:

• Visit NebraskaTotalCare.com
• Call Nebraska Total Care Provider Services: 1-844-385-2192 TTY: 711

CLAIM SUBMISSION

The timely filing requirement is 180 days. No reimbursement will be made for claims received beyond this date. Claims received after the timely filing deadline will be considered a provider liability, and member may not be billed for services. Include applicable arch, quadrant or tooth identifiers as applicable when billing for dental services. Clean claims will be processed within state guidelines of receipt. Claims with retrospective review requirements may take additional processing time. Submit claims in one of these formats:

• Centene Dental Provider Web Portal
• Electronic clearinghouses, using payor ID number 46278
• Alternate, pre-arranged, HIPAA-compliant electronic submissions
• Paper submissions mailed to the address indicated in the Provider Quick Reference (last page)
  • Requests must be submitted on a current (2019 or later) ADA original claim form
  • Copies, handwritten or faxed forms are not accepted

Billing for Fixed and Removable Prosthodontics, and Root Canals

For fixed prosthodontics, the date of service must be billed according to the cementation date. For removable prosthodontics, the billed date of service must be the “seat date”/ date of insertion. For root canals, the billed date of service must be date of final fill of the root canal.

APPEALS & GRIEVANCES

Provider grievances are any dissatisfactions regarding Nebraska Total Care policies, procedures or any aspect of Nebraska Total Care’s administrative function other than administrative review matters.

Member grievances are defined as dissatisfaction about any matter. This does not include matters that constitute an “action.”

All grievances will be sent an acknowledgment letter, which includes a description of the grievance procedures and resolution time frames, within 10 calendar days of receipt. Notification of the grievance resolution shall be made in writing within 90 days of receipt of the grievance.

If the member is dissatisfied with the decision of Nebraska Total Care, a written or oral notice of appeal may be made within 60 calendar days of the Adverse Benefit Determination.

An appeal is the request for review of a denial or limited authorization of a requested service.

Claim appeals must be filed within 60 days from the date of notification of payment or denial and will be resolved within 30 calendar days.

For a standard appeal, Nebraska Total Care will review, resolve and provide written or electronic notification of the appeal decision as quickly as the member’s health condition requires but no later than 30 calendar days after the request for a review. A member has the right to request an expedited appeal. Expedited appeals may be filed when Nebraska Total Care or the member’s provider determines that the time expended in a standard resolution could seriously jeopardize the member’s life or health or ability to attain, maintain, or regain maximum function. Decisions for expedited appeals are issued within 72 hours from the date of the Adverse Benefit Determination.

To file a provider claim appeal or grievance, providers may:

• Call 844-813-6769
• Email dentalappeals@centene.com or dentalgrievances@centene.com as applicable
• Mail paper submissions to the address indicated in the Provider Quick Reference (last page)

Members (or providers on behalf of members) must submit prior authorization appeals within 60 calendar days in writing to:

Nebraska Total Care

Attn: Appeals

2525 N 117th Ave, Suite 100

Omaha, NE 68164

Or call 1-844-385-2192 TTY: 711

State Fair Hearing:

If the member is dissatisfied with Nebraska Total Care’s decision to deny, reduce, change or terminate payment for health care services, the member can request a State Fair Hearing. A Nebraska Total Care member, or a provider acting as the member’s authorized representative, can request a State Fair Hearing only after receiving notice that Nebraska Total Care is upholding the adverse benefit determination within the Adverse Benefit Determination. Any adverse action or appeal that is not resolved wholly in favor of the member by Nebraska Total Care may be appealed by the member or the member’s authorized representative. Adverse actions include reductions in service, suspensions, terminations, and denials. State Fair Hearing appeals must be requested in writing by the member or the member’s representative not more than 120 calendar days of the member’s receipt of the adverse benefit determination.

Requests for a State Fair Hearing should be in writing and sent to:

Nebraska Department of Health and Human Services

MLTC Appeal Coordinator

PO Box 94967

Lincoln, NE 68509-4967

Nebraska Total Care shall comply with the State Fair Hearing decision. The decision in these matters shall be final and shall not be subject to appeal.

Nebraska Total Care Medicaid Dental Benefits Provider Quick Reference

Provider Web Portal (PWP)	Verify member benefits and eligibility File claims and review claim status Download, research, and reprint EOPs Request/submit secure, HIPAA compliant prior authorization Access important provider information Covered dental codes and details Clinical policy guidelines Provider manuals, training, bulletins
CenteneDental.com	View member ID card examples Update provider forms, including: Electronic Funds Transfers (EFT) Disclosure of Ownership (DOO) Credentialing documents Read timely provider news and newsletters
Electronic Clearinghouse Authorizations and Claims	Centene Dental Payor ID Number 46278
Paper Authorizations, Claims, Provider Appeals	Centene Dental PO Box 25974 Tampa, FL 33622-5974
Automated Member Eligibility Verification System 24 hours/7 days a week Customer Service Phone Number Monday through Friday 8 am – 5 pm local time	844-813-6769
Provider Relations (for questions not related to member benefits/eligibility)	Email Provider Relations: dentalproviderrelations@centene.com
Member ID Card	Please visit our website to view health plan ID card examples.