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WV Children’s Health Insurance Program Dental Provider Guide 2012-2013

The provider payment system has become output-based, and payment mechanisms are geared to the type of service provided rather than the type of institution responsible for provision. Family doctor services are paid through capitation, outpatient specialist care through a fee-for-service point system, acute inpatient services through a payment system based on diagnosis-related groups (DRGs) and chronic care through per diem rates. Special rules apply to certain services, such as emergency patient transfers. Physicians are either salaried employees or private entrepreneurs contracted by the NHIFA, whereas other health professionals are mostly paid by salary. . | WV Children s Health Insurance Program Dental Provider Guide 2012-2013 Precertification 1-800-356-2392 Option 3 WVCHIP Helpline 1-877-982-2447 www.chip.wv.gov 1 Table of Contents Letter to Dental Providers.3 Dental Services Plan Descriptions.4 WVCHIP Benefit Groups.5 Dental Services not requiring Precertification.6-7 Preventive Diagnostic.6 Restorative.6 Endodontics Root Canal Periodontics.6 Surgery Extractions.7 Other Basic Expenses.7 Dental Services Requiring Precertification.7-9 Prosthodontics.8 Restorative Periodontics.8 Accident related Dental Services.8 Emergency Dental Services.8 Orthodontic Services.9 Examples of American Academy of Orthodontics Dental Photographs.10 Dental Services not Covered.11 Timely Filing.12 Claims Filing Instructions.12 Appeal Process.13-15 WVCHIP Sample Member Cards.16 Appendix A Dental Provider Information Form .17-18 Appendix B Covered ADA Procedure Codes and Co-Pay Information .19-36 Appendix C Orthodontic Treatment Precertification Form .37-38 Appendix D Sample ADA Dental Claim Form .39-40 2 DEAR DENTAL PROVIDER IMPORTANT You assure dental access to kids by updating our website. Since passage of the Children s Health Insurance Program Reauthorization Act CHIPRA in 2009 all CHIP and Medicaid programs are required to provide an electronic list of dental providers to post on a public website. The listing helps CHIP members identify local dental providers who are available to provide services. The initial posting of an electronic list was on the InsureKidsNow.gov website in August 2009. In the past our state maintained unpublicized lists so we could help refer members to a dentist who participates in CHIP and or Medicaid in their local area. An electronic list now allows the public to access this information and dental practices can show if they are currently accepting new CHIP and or Medicaid patients. TO PROVIDE PRACTICE UPDATES Please review your listing on the InsureKidsNow.gov website. Copy and fill out the form in Appendix A .