Smiles For Children, Virginia’s Dental Program for Medicaid, FAMIS, and FAMIS Plus Children – Effective July 1, 2005Download PDF
Effective July 1, 2005, the Department of Medical Assistance Services (DMAS) will be implementing a new dental program, Smiles For Children, for Medicaid, FAMIS, and FAMIS Plus children. Doral Dental USA (Doral), the new DMAS Dental Benefits Administrator, will administer the new program. DMAS has been working closely with the Virginia Dental Association (VDA), the Old Dominion Dental Society (ODDS), the Dental Advisory Committee (DAC), and other interested groups to develop the Smiles For Children dental program. Smiles For Children is designed to improve access to and increase utilization of dental services. The major components of the program include:
- Consolidation of pediatric dental services for approximately 400,000 Medicaid, FAMIS, and FAMIS Plus children enrolled in fee-for-service (FFS) and managed care organizations (MCOs);
- An unprecedented 30 percent overall increase in funding for dental fees approved by the 2005 General Assembly. The bulk of the fee increase (28%) goes into effect July 1, 2005 (the remaining 2% increase goes into effect on May 1, 2006); specific fees are provided in Attachment I; and
- Simplified program administration that includes conforming to industry standards, flexible claims filing options, timely reimbursement, minimal authorization requirements, a dedicated call center with provider relations staff, and expanded outreach to dental providers.
DMAS is currently working with Doral to make the transition to the Smiles For Children program as seamless as possible for recipients and providers. The key issues are briefly summarized below:
- Providers currently enrolled with DMAS and the managed care organizations’ (MCOs) dental plans will be enrolled in the Smiles For Children network according to the DMAS Smiles For Children credential requirements, which can be found on the DMAS website at www.dmas.virginia.gov. Dentists enrolled in the Smiles For Children program will be listed in the Smiles For Children provider directory. Please visit the DMAS website (www.dmas.virginia.gov) for more details.
- Doral will be sending all participating providers a welcome letter, a Smiles For Children Office Reference Manual, and a provider identification number as well as some information on provider training sessions.
- The Smiles For Children Office Reference Manual outlines procedures that dental providers should follow for services rendered on or after July 1, 2005. This manual and other important information can be accessed on Doral’s website at www.doralusa.com.
- Smiles For Children covers all children under age 21. Recipients age 21 and over will receive the same limited oral surgery benefits that are currently provided under the Medicaid program. If you provide oral surgery services, you will receive a separate Medicaid Memo.
- Recipients will not receive a separate Smiles For Children ID card for dental services. Since Medicaid, FAMIS, and FAMIS Plus eligible recipients will receive dental coverage under Smiles For Children regardless of their MCO enrollment status, recipients may use their Commonwealth of Virginia (blue and white) plastic identification card or any of the following MCO cards: Virginia Premier Health Plan, Optima Health Family Care, UniCare Health Plan of Virginia, CareNet by Southern Health, AMERIGROUP (as of September 1, 2005), Anthem HealthKeepers Plus, Anthem HealthKeepers Plus by Peninsula, and Anthem HealthKeepers Plus by Priority. (Although dental services have been carved out from the MCO contracts, all MCO ID cards list the 12-digit Medicaid, FAMIS, and FAMIS Plus ID number for eligibility verification purposes.)
- Under Smiles For Children, the number of services requiring prior authorization or pre- payment review is significantly reduced. (Please see Attachment I or the DMAS website at www.dmas.virginia.gov for the list of covered services and those requiring prior authorization or pre-payment review.)
- Payment for services which have been prior authorized or have been provided prior to July 1, 2005, will continue to be processed according to procedures in place prior to July 1, 2005. Effective with dates of service on July 1, 2005 and thereafter, Doral will process all dental claims. Paper claims should be submitted to the following address:
Doral Dental USA, LLC VA Claims
12121 N Corporate Parkway Mequon, WI 53092
- For more information and billing options for submitting Smiles For Children electronic claims, call Smiles For Children at 1-800-341-8478 and press for option #6. Information on billing options is also available on Doral’s website at www.doralusa.com.
- Orthodontists will receive a separate letter with information on how Smiles For Children
will manage the transition of patients in treatment to the Smiles For Children program.
- Providers may submit Smiles For Children grievances to Doral at the following address: Doral Dental USA, LLC
Smiles For Children
ATTN: Provider Grievances and Appeals 12121 N Corporate Parkway
Mequon, WI 53092
Providers may submit Smiles For Children appeals to Doral at the above address and then to the DMAS Appeals Division at the address below:
Director, Division of Provider Appeals Department of Medical Assistance Services 600 E Broad Street
Richmond, VA 23219
DMAS is working closely with Doral and dental providers to ensure that Medicaid, FAMIS, and FAMIS Plus children have access to quality dental care. You may have already received or you may be receiving information from Doral about Smiles For Children. In addition, Doral and DMAS will be conducting a series of information sessions around Virginia to discuss the Smiles For Children program with dental providers (please see Attachment II for more information about these meetings).
If you have any questions regarding the Smiles For Children program and how it will affect your practice, please call the Provider Relations Department at Doral at 1-888-912-3456 or go to Doral’s website at www.doralusa.com.
SMILES FOR CHILDREN CALL CENTER
If you have any dental service questions, please contact the Smiles For Children Call Center at 1-888-912-3456. Doral has dedicated provider relations staff to answer any questions you may have regarding the Smiles For Children program. The Smiles For Children Call Center is available Monday through Friday from 8:00 a.m. to 6:00 p.m. (Eastern Time), except on state holidays, to answer questions.
ELIGIBILITY AND CLAIMS STATUS INFORMATION
Providers may access recipient eligibility information through Doral’s Interactive Voice Response (IVR) system by calling 1-888-912-3456 or online through the “Providers Only”
section of Doral’s website at www.doralusa.com. Both options are available 24 hours a day, seven days a week at no cost to the provider.
COPIES OF MANUALS
The Smiles For Children Office Reference Manual outlines policies and procedures that dental providers should follow for services rendered on or after July 1, 2005, under the Smiles For Children program. Doral will be sending all participating providers an Office Reference Manual. This manual and other important information can also be accessed on Doral’s website at www.doralusa.com.
DMAS will continue to make its Dental Provider Manual available to providers on the DMAS website at www.dmas.virginia.gov. Please refer to this manual for procedures that should be followed for services rendered prior to July 1, 2005. If you do not have access to the Internet or would like a paper copy of the DMAS Dental Provider Manual, you can order it by contacting Commonwealth-Martin at 804-780-0076. A fee will be charged for the printing and mailing of the manuals and manual updates requested.
PROVIDER E-NEWSLETTER SIGN-UP
DMAS is pleased to inform providers about the creation of a new Provider E-Newsletter. This newsletter will contain information pertinent to all providers and various aspects of the Medicaid and FAMIS programs, not just the dental program. The intent of this electronic newsletter is to inform, communicate, and share important program information with providers. Covered topics will include upcoming changes in claims processing, common problems with billing, new programs or changes in existing programs, and other information that may directly affect providers. If you would like to receive the electronic newsletter, please sign up at www.dmas.virginia.gov/pr-provider_newletter.asp.
Please note that the Provider E-Newsletter is not intended to take the place of Medicaid Memos, Medicaid Provider Manuals, or any other official correspondence from DMAS.