Download Quick Reference Guide Hoosier Healthwise

Quick Reference Guide
Hoosier Healthwise
Coordination of Care:
– DentaQuest will honor all previous care authorizations from the member’s enrollment in the
Hoosier Healthwise program from a previous health plan.
• From January 1, 2017, through March 31, 2017, DentaQuest will accept previous
authorizations from the newly eligible member’s previous health plan for 90 calendar
days.
• As of April 1, 2017, DentaQuest will accept previous authorizations from the newly
eligible member’s previous health plan for 30 calendar days.
• Contracted or non-contracted IHCP providers should submit the previous care
authorization as an attachment with the claim.
Patient Eligibility Verification
Providers are encouraged to check eligibility through the IHCP eligibility check process. Web InterChange at:
https://interchange.indianamedicaid.com/Member/EligInquiryHIPAA.aspx
The enrollment information contained within this website will be considered the source of truth and should
be used as the primary source of eligibility verification.
Claims Submission:
Beginning January 1, 2017, please submit all Hoosier Healthwise dental claims and authorization requests for dates
of service on or after January 1, 2017, directly to DentaQuest. All claims for dates of service before January 1,
2017, should follow the established process and continue to be submitted to Indiana Medicaid for processing.
Claims should be submitted via the provider portal:
1) Register and Sign in for the new provider portal: https://provider.dentaquest.com/providerlogin
2) Go to “Claims/Pre-Authorizations”
3) Populate the information to submit a claim
Electronic claims should be sent to:
Via Clearinghouse – Payer ID CX014
Include address on electronic claims:
DentaQuest, LLC
PO Box 2906
Milwaukee, Wisconsin 53201-2906
Paper claims should be sent to:
DentaQuest, LLC- Indiana
Attn: Claims
PO Box 2906
Milwaukee, Wisconsin 53201-2906
Provider claim appeals should be sent to:
DentaQuest, LLC- Indiana
Attn: Appeals
PO Box 2906
Milwaukee, Wisconsin 53201-2906
DentaQuest Authorization Submission:
Authorizations should be submitted via the provider portal:
AINPEC-1117-16 December 2016, P0834 (11/16)
1) Register and Sign in for the new provider portal: https://provider.dentaquest.com/providerlogin
2) Go to “Claims/Pre-Authorizations”
3) Populate the information to submit an authorization
Authorization requests should be sent via mail to:
DentaQuest, LLC- Indiana
Attn: Authorizations
PO Box 2906
Milwaukee, Wisconsin 53201-2906
Once a provider is contracted and credentialed with DentaQuest, they can submit claims and authorization requests
securely online via our provider portal at https://provider.dentaquest.com/providerlogin or
https://govservices.dentaquest.com/.
New Provider Portal:
As a DentaQuest participating provider, you have access to a new provider portal that allows you to easily support
your members and manage your practice. All providers must create a new login and password to use the new portal,
and applies even if you have registered for our previous portal. If you do not register, you will lose online access to
DentaQuest, as our old portal will no longer be active after December 31, 2016.
To register for the new portal, visit www.dentaquest.com/indiana and click on the provider login link. Then
choose the Register link and follow the directions.
For your education, a provider portal user guide for the new portal has been uploaded to the following website:
http://www.dentaquest.com/state-plans/regions/indiana/dentist-page/
Network Open All IHCP Providers:
The Hoosier Healthwise network will remain open until it has been deemed fully compliant by the state of Indiana.
DentaQuest will allow members to see dentists contracted with the State of Indiana until a change in the process is
approved by the State of Indiana. We encourage you to complete the contracting and credentialing process
immediately to ensure you and your staff are enrolled and credentialed.
Additional Information:
Claims Questions: denclaims@dentaquest.com or 855.453.5286
Authorization Questions: 855.453.5286
Eligibility or Benefit Questions: denelig.benefits@dentaquest.com or 855.453.5286
Customer Service/ Member Services
888.291.3762– Anthem
844.231.8310 – MDwise
Hearing Impaired/TTY: 800.466.7566
DentaQuest’s Provider Engagement Representative Territories:
AINPEC-1117-16 December 2016, P0834 (11/16)
For information on Hoosier Healthwise, DentaQuest, claims submission, contracting/credentialing, provider portal
training, request for an onsite visit, or any other inquiry, please contact your DentaQuest Provider Engagement
representative or DentaQuest’s Provider Services at 855.453.5286.
Benefit Information Overview:
Hoosier Healthwise is a program sponsored by the State and covers children, pregnant women and low income
parents/caretakers of children under the age of 18. There are no dental copays for the Hoosier Healthwise program.
AINPEC-1117-16 December 2016, P0834 (11/16)
Hoosier Healthwise Covered Benefits:
Code
D0120
D0140
D0145
D0150
D0160
D0170
D0210
D0220
D0230
D0240
D0250
D0251
D0270
D0272
D0273
D0274
D0277
D0290
D0310
D0330
D0340
D0486
D1110
D1120
D1206
D1208
D1351
D1352
D1354
D1510
D1515
D1520
D1525
D1550
D1555
D1999
D2140
D2150
Procedure Name
periodic oral evaluation - established patient
limited oral evaluation-problem focused
oral evaluation for a patient under three
years of age and counseling with primary
caregiver
comprehensive oral evaluation - new or
established patient
detailed and extensive oral eval-problem
focused, by report
re-evaluation, limited problem focused
intraoral - complete series of radiographic
images
intraoral - periapical first radiographic image
intraoral - periapical each additional
radiographic image
intraoral - occlusal radiographic image
extra-oral – 2D projection radiographic
image created using a stationary radiation
source, and detector
extra-oral posterior dental radiographic image
bitewing - single radiographic image
bitewings - two radiographic images
bitewings - three radiographic images
bitewings - four radiographic images
vertical bitewings - 7 to 8 films
posterior-anterior or lateral skull and facial
bone survey radiographic image
sialography
panoramic radiographic image
cephalometric radiographic image
accession of exfoliative cytological smears,
microscopic examination, preparation and
transmission of written report
prophylaxis - adult
prophylaxis - child
topical application of fluoride varnish
topical application of fluoride - excluding
varnish
sealant - per tooth
Preventive resin restoration is a mod. to high
caries risk patient perm tooth conservative
interim caries arresting medicament
application
space maintainer-fixed-unilateral
space maintainer - fixed - bilateral
space maintainer-removable-unilateral
space maintainer-removable-bilateral
re-cement or re-bond space maintainer
removal of fixed space maintainer
Unspecified preventive procedure, by report
Amalgam - one surface, primary or
permanent
Amalgam - two surfaces, primary or
permanent
AINPEC-1117-16 December 2016, P0834 (11/16)
Package A - Child
covered
covered
Package A - Adult
covered
covered
Package C - CHIP
covered
covered
covered
NOT COVERED
covered
covered
covered
covered
covered
covered
covered
covered
covered
covered
covered
covered
covered
covered
covered
covered
covered
covered
covered
covered
covered
covered
covered
covered
covered
covered
covered
covered
covered
covered
covered
covered
covered
covered
covered
covered
covered
covered
covered
covered
covered
covered
covered
covered
covered
covered
covered
covered
covered
covered
covered
covered
covered
covered
covered
covered
covered
covered
covered
covered
covered
NOT COVERED
NOT COVERED
covered
covered
covered
covered
covered
covered
NOT COVERED
NOT COVERED
covered
covered
covered
NOT COVERED
covered
covered
covered
covered
covered
covered
covered
covered
covered
NOT COVERED
NOT COVERED
NOT COVERED
NOT COVERED
NOT COVERED
NOT COVERED
covered
covered
covered
covered
covered
covered
covered
covered
covered
covered
covered
covered
covered
covered
covered
covered
Code
D2160
D2161
D2330
D2331
D2332
D2335
D2390
D2391
D2392
D2393
D2394
D2910
D2920
D2921
D2930
D2931
D2932
D2933
D2934
D2940
D2941
D2949
D2951
D2980
D2990
D3220
D3222
D3230
D3240
Procedure Name
Package A - Child
amalgam - three surfaces, primary or
covered
permanent
amalgam - four or more surfaces, primary or
covered
permanent
resin-based composite - one surface, anterior
covered
resin-based composite - two surfaces,
covered
anterior
resin-based composite - three surfaces,
anterior
covered
resin-based composite - four or more
covered
surfaces or involving incisal angle (anterior)
resin-based composite crown, anterior
covered
resin-based composite - one surface,
posterior
covered
resin-based composite - two surfaces,
posterior
covered
resin-based composite - three surfaces,
posterior
covered
resin-based composite - four or more
surfaces, posterior
covered
re-cement or re-bond inlay, onlay, veneer or
partial coverage restoration
covered
re-cement or re-bond crown
covered
Reattachment of tooth fragment, incisal
edge or cusp
covered
prefabricated stainless steel crown - primary
tooth
covered
prefabricated stainless steel crownpermanent tooth
covered
prefabricated resin crown
covered
prefabricated stainless steel crown with
resin window
covered
prefabricated esthetic coated stainless steel
crown - primary tooth
covered
protective restoration
covered
Interim therapeutic restoration - primary
dentition
covered
Restorative foundation for an indirect
restoration
covered
pin retention - per tooth, in addition to
restoration
NOT COVERED
crown repair, by report
covered
Resin infiltration of incipient smooth surface
lesions
covered
therapeutic pulpotomy (excluding final
restoration) - removal of pulp coronal to the
dentinocemental junction and application of
covered
medicament
partial pulpotomy for apexogenesis permanent tooth with incomplete root
covered
development
pulpal therapy (resorbable filling) - anterior,
primary tooth (excluding final restoration)
covered
pulpal therapy (resorbable filling) - posterior,
primary tooth (excluding final restoration)
covered
AINPEC-1117-16 December 2016, P0834 (11/16)
Package A - Adult
Package C - CHIP
covered
covered
covered
covered
covered
covered
covered
covered
covered
covered
covered
covered
covered
covered
covered
covered
covered
covered
covered
covered
covered
covered
covered
covered
covered
covered
covered
covered
covered
covered
covered
NOT COVERED
covered
covered
NOT COVERED
covered
covered
covered
covered
covered
covered
covered
covered
covered
NOT COVERED
covered
covered
covered
covered
covered
covered
covered
covered
covered
covered
covered
covered
covered
Code
D3310
D3320
D3330
D3346
D3347
D3348
D3351
D3352
D3353
D3410
D3421
D3425
D3426
D3427
D3430
D4210
D4211
D4212
D4240
D4241
D4260
D4341
D4342
D4355
D4910
D5110
D5120
D5130
D5140
Procedure Name
endodontic therapy, anterior tooth (excluding
final restoration)
endodontic therapy, bicuspid tooth
(excluding final restoration)
endodontic therapy, molar (excluding final
restoration)
retreatment of previous root canal therapyanterior
retreatment of previous root canal therapybicuspid
retreatment of previous root canal therapymolar
apexification/recalcification - initial visit
(apical closure / calcific repair of
perforations, root resorption, etc.)
apexification/recalcification - interim
medication replacement
apexification/recalcification - final visit
(includes completed root canal therapy apical closure/calcific repair of perforations,
root resorption, etc.)
apicoectomy - anterior
apicoectomy - bicuspid (first root)
apicoectomy - molar (first root)
apicoectomy (each additional root)
Periradicular surgery without apicoectomy
retrograde filling - per root
gingivectomy or gingivoplasty - four or more
contiguous teeth or tooth bounded spaces
per quadrant
gingivectomy or gingivoplasty - one to three
contiguous teeth or tooth bounded spaces
per quadrant
Gingivectomy or gingivoplasty to allow
access for restorative procedure, per tooth
gingival flap procedure, including root planing
- four or more contiguous teeth or tooth
bounded spaces per quadrant
gingival flap procedure, including root planing
- one to three contiguous teeth or tooth
bounded spaces per quadrant
osseous surgery (including elevation of a full
thickness flap and closure) - four or more
contiguous teeth or tooth bounded spaces
per quadrant
periodontal scaling and root planing - four or
more teeth per quadrant
periodontal scaling and root planing - one to
three teeth per quadrant
full mouth debridement to enable
comprehensive evaluation and diagnosis
periodontal maintenance procedures
complete denture - maxillary
complete denture - mandibular
immediate denture - maxillary
immediate denture - mandibular
AINPEC-1117-16 December 2016, P0834 (11/16)
Package A - Child
Package A - Adult
Package C - CHIP
covered
NOT COVERED
covered
covered
NOT COVERED
covered
covered
NOT COVERED
covered
covered
NOT COVERED
covered
covered
NOT COVERED
covered
covered
NOT COVERED
covered
covered
NOT COVERED
covered
covered
NOT COVERED
covered
covered
covered
covered
covered
covered
covered
covered
NOT COVERED
NOT COVERED
NOT COVERED
NOT COVERED
NOT COVERED
NOT COVERED
NOT COVERED
covered
covered
covered
covered
covered
covered
covered
covered
covered
covered
covered
covered
covered
covered
covered
covered
covered
covered
covered
covered
covered
covered
covered
covered
covered
covered
covered
covered
covered
covered
covered
covered
covered
covered
covered
NOT COVERED
NOT COVERED
covered
covered
covered
covered
covered
covered
covered
covered
covered
covered
NOT COVERED
NOT COVERED
Code
D5211
D5212
D5213
D5214
D5225
D5226
D5281
D5510
D5520
D5610
D5620
D5630
D5640
D5650
D5660
D5730
D5731
D5740
D5741
D5750
D5751
D5760
D5761
D5951
D5952
D5993
D6930
D6980
D7111
D7140
D7210
D7220
D7230
D7240
Package A - Child
Package A - Adult
Package C - CHIP
covered
covered
covered
covered
covered
covered
covered
covered
covered
covered
covered
covered
covered
covered
covered
covered
covered
covered
covered
covered
covered
covered
NOT COVERED
covered
covered
covered
covered
covered
covered
covered
covered
covered
covered
covered
covered
covered
covered
covered
covered
covered
covered
covered
covered
covered
covered
covered
reline complete mandibular denture
(chairside)
covered
reline maxillary partial denture (chairside)
covered
reline mandibular partial denture (chairside) covered
reline complete maxillary denture (laboratory)
covered
reline complete mandibular denture
(laboratory)
covered
reline maxillary partial denture (laboratory)
covered
reline mandibular partial denture (laboratory)
covered
covered
feeding aid
covered
speech aid prosthesis, pediatric
Maintenance and cleaning of a maxillofacial
prosthesis (extra or intraoral) other than
required adjustments.
covered
covered
re-cement or re-bond fixed partial denture
fixed partial denture repair
covered
extraction, coronal remnants - deciduous
tooth
covered
extraction, erupted tooth or exposed root
(elevation and/or forceps removal)
covered
surgical removal of erupted tooth requiring
removal of bone and/or sectioning of tooth,
and including elevation of mucoperiosteal
flap if indicated
covered
removal of impacted tooth-soft tissue
covered
covered
removal of impacted tooth-partially bony
removal of impacted tooth-completely bony
covered
covered
covered
covered
covered
covered
covered
covered
covered
covered
NOT COVERED
covered
covered
covered
NOT COVERED
covered
NOT COVERED
NOT COVERED
NOT COVERED
covered
covered
NOT COVERED
NOT COVERED
NOT COVERED
covered
covered
covered
covered
covered
covered
covered
covered
covered
covered
covered
covered
covered
covered
covered
Procedure Name
maxillary partial denture - resin base
(including any conventional clasps, rests
and teeth)
mandibular partial denture - resin base
(including any conventional clasps, rests
and teeth)
maxillary partial denture - cast metal
framework with resin denture bases
(including any conventional clasps, rests
and teeth)
mandibular partial denture - cast metal
framework with resin denture bases
(including any conventional clasps, rests
and teeth)
maxillary partial denture-flexible base
mandibular partial denture-flexible base
removable unilateral partial denture - one
piece cast metal
repair broken complete denture base
replace missing or broken teeth - complete
denture (each tooth)
repair resin denture base
repair cast framework
repair or replace broken clasp
replace broken teeth-per tooth
add tooth to existing partial denture
add clasp to existing partial denture
reline complete maxillary denture (chairside)
AINPEC-1117-16 December 2016, P0834 (11/16)
Code
D7241
D7250
D7251
D7260
D7261
D7270
D7280
D7282
D7285
D7286
D7288
D7295
D7310
D7311
D7320
D7321
D7410
D7411
D7412
D7413
D7414
D7415
D7440
D7441
D7450
D7451
D7460
Procedure Name
Package A - Child
removal of impacted tooth-completely bony,
with unusual surgical complications
covered
surgical removal of residual tooth roots
(cutting procedure)
covered
Coronectomy-intentional partial tooth
removal is performed when a neurovascular
complication is likely if the entire impacted
tooth is removed.
covered
oroantral fistula closure
covered
primary closure of a sinus perforation
Subsequent to surgical removal of tooth,
exposure of sinus requiring
repair, or immediate closure of oroantral or
oralnasal communication in
absence of fistulus tract.
covered
tooth reimplantation and/or stabilization of
accidentally evulsed or displaced tooth
covered
Surgical access of an unerupted tooth
covered
mobilization of erupted or malpositioned
tooth to aid eruption
covered
incisional biopsy of oral tissue-hard (bone,
tooth)
covered
incisional biopsy of oral tissue-soft
covered
brush biopsy - transepithelial sample
collection
covered
Harvest of bone for use in autogenous
grafting procedure
covered
alveoloplasty in conjunction with extractions four or more teeth or tooth spaces, per
quadrant
covered
alveoloplasty in conjunction with extractions one to three teeth or tooth spaces, per
quadrant
covered
alveoloplasty not in conjunction with
extractions - four or more teeth or tooth
spaces, per quadrant
covered
alveoloplasty not in conjunction with
extractions - one to three teeth or tooth
spaces, per quadrant
covered
radical excision - lesion diameter up to
1.25cm
covered
excision of benign lesion greater than 1.25
cm
covered
excision of benign lesion, complicated
covered
excision of malignant lesion up to 1.25 cm
covered
excision of malignant lesion greater than
1.25 cm
covered
excision of malignant lesion, complicated
covered
excision of malignant tumor - lesion
diameter up to 1.25cm
covered
excision of malignant tumor - lesion
diameter greater than 1.25cm
covered
removal of odontogenic cyst or tumor lesion diameter up to 1.25cm
covered
removal of odontogenic cyst or tumor lesion greater than 1.25cm
covered
removal of nonodontogenic cyst or tumor lesion diameter up to 1.25cm
covered
AINPEC-1117-16 December 2016, P0834 (11/16)
Package A - Adult
Package C - CHIP
covered
covered
covered
covered
covered
covered
covered
covered
covered
covered
covered
covered
covered
covered
covered
covered
covered
covered
covered
covered
covered
covered
covered
covered
covered
covered
covered
covered
covered
covered
covered
covered
covered
covered
covered
covered
covered
covered
covered
covered
covered
covered
covered
covered
covered
covered
covered
covered
covered
covered
covered
covered
covered
covered
Code
D7461
D7471
D7472
D7473
D7485
D7510
D7511
D7520
D7521
D7560
D7610
D7620
D7630
D7640
D7650
D7660
D7670
D7671
D7680
D7710
D7720
D7730
D7740
D7750
D7760
D7770
D7771
D7780
D7810
D7820
D7910
D7911
D7912
D7960
D7972
D7980
D7982
D7983
Procedure Name
removal of nonodontogenic cyst or tumor lesion greater than 1.25cm
removal of exostosis - per site
removal of torus palatinus
removal of torus mandibularis
surgical reduction of osseous tuberosity
incision and drainage of abscess - intraoral
soft tissue
incision and drainage of abscess - intraoral
soft tissue - complicated (includes drainage
of multiple fascial spaces)
incision and drainage of abscess - extraoral
soft tissue
incision and drainage of abscess - extraoral
soft tissue - complicated (includes drainage
of multiple fascial spaces)
Package A - Child
Package A - Adult
Package C - CHIP
covered
covered
covered
covered
covered
covered
covered
covered
covered
covered
covered
covered
covered
covered
covered
covered
covered
covered
covered
covered
covered
covered
covered
covered
covered
covered
covered
covered
covered
covered
covered
covered
covered
covered
covered
covered
covered
covered
covered
covered
covered
covered
covered
covered
covered
covered
covered
covered
covered
covered
covered
covered
covered
covered
covered
covered
covered
covered
covered
covered
covered
covered
covered
covered
covered
covered
covered
covered
covered
covered
malar and/or zygomatic arch-closed
reduction
covered
alveolus-stabilization of teeth, open
reduction splinting
covered
alveolus, closed reduction stabilization of
teeth
covered
facial bones - complicated reduction with
covered
fixation and multiple surgical approaches
open reduction of dislocation
covered
closed reduction dislocation
covered
suture small wounds up to 5 cm
covered
complicated suture-up to 5 cm
covered
complex suture - greater than 5cm
covered
frenulectomy – also known as frenectomy or
frenotomy – separate procedure not
incidental to another procedure
covered
surgical reduction of fibrous tuberosity
covered
sialolithotomy
covered
sialodochoplasty
covered
closure of salivary fistula
covered
covered
covered
covered
covered
covered
covered
covered
covered
covered
covered
covered
covered
covered
covered
covered
covered
covered
covered
covered
covered
covered
covered
covered
covered
covered
covered
covered
covered
covered
covered
maxillary sinusotomy for removal of tooth
fragment or foreign body
maxilla - open reduction
maxilla - closed reduction
mandible - open reduction (teeth
immobilized, if present)
mandible - closed reduction
malar and/or zygomatic arch-open reduction
malar and/or zygomatic arch-closed
alveolus stabilization of teeth, closed
reduction splinting
alveolus - open reduction, may include
stabilization of teeth
facial bones - complicated reduction with
fixation and multiple surgical approaches
maxilla - open reduction
maxilla - closed reduction
mandible - open reduction
mandible - closed reduction
malar and/or zygomatic arch-open reduction
AINPEC-1117-16 December 2016, P0834 (11/16)
Code
D7999
D8010
D8020
D8030
D8040
D8050
D8060
D8070
D8080
D8090
D8210
D8220
D9120
D9223
D9230
D9243
D9248
D9920
Procedure Name
Package A - Child
unspecified oral surgery procedure, by report
covered
limited orthodontic treatment of the primary
covered
dentition
limited orthodontic treatment of the
covered
transitional dentition
Limited orthodontic treatment of the
covered
adolescent dentition
limited orthodontic treatment of the adult
covered
dentition
interceptive orthodontic treatment of the
covered
primary dentition
Interceptive orthodontic treatment of the
transitional dentition
covered
comprehensive orthodontic treatment of the
transitional dentition
covered
Comprehensive orthodontic treatment of the
adolescent dentition
covered
comprehensive orthodontic treatment of the
covered
adult dentition
removable appliance therapy
covered
fixed appliance therapy (includes appliances
for thumb sucking and tongue thrusting)
fixed partial denture sectioning
deep sedation/general anesthesia – each 15
minute increment
inhalation of nitrous oxide/analgesia,
anxiolysis
intravenous moderate (conscious)
sedation/analgesia – each 15 minute
increment
non-intravenous moderate (conscious)
sedation
behavior management, by report
AINPEC-1117-16 December 2016, P0834 (11/16)
Package A - Adult
Package C - CHIP
covered
covered
NOT COVERED
covered
NOT COVERED
covered
NOT COVERED
covered
NOT COVERED
covered
NOT COVERED
covered
NOT COVERED
covered
NOT COVERED
covered
NOT COVERED
covered
NOT COVERED
NOT COVERED
covered
covered
covered
covered
covered
covered
covered
covered
covered
NOT COVERED
covered
covered
NOT COVERED
covered
covered
covered
covered
covered
covered
NOT COVERED
NOT COVERED
covered
covered