PHI/HIPPA
TO VALIDATE PHI,FULL NAME, DOB AND ID IS NEEDED FOR WHO
WHO IS : MEMBER
TYPES OF TIER 1 AND TIER 2 CALLS
PICK TWO
Eligibility
Benefits
Finding a dentist for a member
Main Dental Home (MDH) changes for Texas members
Primary Care Dentist (PCD) changes for New York members
Scheduling a dental appointment for a member and a dental office
Authorizations
Organization Determinations for Medicare members
Member and provider web portal Issue
WINDAWARD (WW) ,KNOWLEDGEBASE (KB) AND OFFICE REFERNECE MANUAL(ORM) IS WHERE YOU FIND WHAT INFORMATION FOR THE MEMBER
WHAT IS : BENEFITS
THE PROVIDER OWNER WE USE WHEN PULLING UP THE PROVIDERS IN WW
WHAT IS : DENTAQUEST
WE USE THIS IN WW TO KEEP CALL NOTES CONSISTANT
WHAT IS : A CALL NOTE TEMPLATE
CALLER NAME
RELATION
TAG LINE OF ELIGIBILITY
REASON FOR CALL
CALL RESOLUTION
MEMBERS,MEMBER REPRESENTATIVES,DENTISTS,DENTAL OFFICE STAFF AND HEALTH PLANS
WHAT ARE : THE PEOPLE THAT A CUSTOMER SERVICE REPRESETATIVE WITH DENTAQUEST WILL TALK TO
DENTAQUEST ALWAYS SENDS ID CARDS TO EVERY MEMBER
WHAT IS : FALSE, WE HAVE TO PULL UP THE MEMBERS GROUP NUMBER IN KB TO SEE IF DQ CAND SEND OR IF THE MEMBER WILL HAVE TO REFER BACK TO HEALTH PLAN
WHEN VALIDATE A PROVIDER YOU MUST ASK FOR _____________________
WHAT IS: NPI/TIN, PROVIDERS FIRST AND LAST NAME
THERE ARE TWO WEB SITES FOR FINDING A DENTIST
TRUE OR FALSE
WHAT IS :TRUE
Two web sites are available to also find dentists for members: a. NON MassHealth members: www.dentaquest.com. b. MH Medicaid members: www.masshealth-dental.net.
YOU LOOK HERE TO SEE IF DENTAQUEST IN CONTRACTUALLY REQUIRED TO MAKE AN APPOINTMENT FOR A MEMBER
WHAT IS: (KB) KNOWLEDGBASE
This rule establishes national standards to protect individuals' medical records and other personal health information and applies to health plans, health care clearinghouses, and those health care providers that conduct certain health care transactions electronically.
WHAT IS: HIPAA
You MUST access THIS on every call so that you ensure correct information is being provided to your callers as it is updated daily.
WHAT IS: KB OR KNOWLEDGEBASE
ARTICLE________ IS WHERE THE PAYER ID IS FOUND
WHAT IS : ARTICLE 1801
"Common Questions and Answers for Provider Benefit Breakdown Calls"
THE DIFFERENCE BETWEEN PAR AND NON PAR ARE
WHAT IS:
Par – Participating dentist, accepts members insurance
o Non-Par – Does not participate and member cannot be seen at this office unless they have out of network benefits.
What this means while on a call, is when a provider office calls to get an eligibility check and/or benefit breakdown, they might not be aware whether they accept the members insurance or not.
It is part of our job to make sure that all providers are aware of a member benefits as well as if they accept that members insurance.
THE HISTORY SEARCH LINK SHOWS WHAT INFORMATION
WHAT IS : This view lists each LINE of a claim. They are sorted from the past being on top to the present at the bottom.
information that directly identifies the individual [e.g., name, member ID] or from which there is a reasonable basis to believe the information can be used to identify the individual [indirect identifier such as date of birth]
WHAT IS: Protected Health Information (PHI)
A DATABASE WHERE WE HOUSE CUSTOMER AND PROVIDER INFORMATION AS WELL AS DOCUMENT CALLS
WHAT IS: WW OR WINDWARD
A FEW TYPICALLY STANDARD THINGS WHEN IT COMES TO INSURANCE,DENTAL BENEFITS AND BILLING, NAME TWO
• Limitations on the number of times a member can receive procedures such as routine dental cleanings, exams, and x-rays.
• Insurance may not cover every dental service that a dentist suggests, and commonly provides a lower reimbursement rate for more expensive procedures such as root canals, crowns, and bridges.
• Time limits and waiting periods for the replacement of a filling, crown, or dentures.
• Services such as orthodontics and fluoride treatments may be reimbursed only for children under the age of 19.
ARTICLE NUMBER FOR FINDING TYPES OF DENTISTS
WHAT IS : 1561
PER ARTICLE 2050 WE CAN FIND THE COB WHERE ON THE (WW) WINDWARD PAGE
WHAT IS :From the member account in Windward, view Family Member Summary section. IT WILL INDICATE N WHEN MEMBER ONLY HAS DENTAQUEST AND Y WHEN MEMBER HAS MORE.
A CALL THAT COULD "FLAG ' A MEMBER AS BEING IN SOME SORT OF PROTECTIVE CARE ENVIRONMENT.
WHAT IS: A CONFIDENTAIL CALL
Windward is divided into sections or_______, based on the Health Plan of a member or provider.
WHAT IS :BUSINESS UNITS
THE BENEFITS TAB IS FOUND IN WW UNDER WHAT SECTION
PER ARTICLE 1835 WHAT DO YOU DO IF A MEMBER IS FROM WISCONSON AND LOOKING FOR AN ORTHODONTIST FOR THEIR CHILD
WHAT IS : Explain to the caller: “To see an orthodontist, the general dentist needs to submit a written referral request. Please speak with the general dentist about the treatment plan. Would you like the inquiry number for this call? Is there anything else that I can help you with today? Thank you for calling member services, have a great day.” and go to step 4.
COB OR CORDINATION OF BENEFITS REQUIRES THAT ALL HEALTH PLANS ND OTHER PAYERS (e.g. MEDICAID AND MEDICARE) DO WHAT
WHAT IS : coordinate benefits to eliminate duplication of payment and help patients receive the maximum benefit they are allowed.