Transcript Overcoming Financial Barriers to Oral Care

Lynn Nolf Estrada, Administrator
Geriatric Dental Group of South Texas
San Antonio, TX
Learning Objectives
 To understand who is eligible for each program
 To recognize the required forms needed for each
program
 To understand the required processes for each
program
 Recognize the pitfalls that can endanger the successful
utilization of each program
Financial Options for Senior Care
 Form H1263-B Medicaid Process
 Full Vendor Program
 Self-pay
Form H1263-B
 Receive a completed Form H1263B from the nursing
facility social worker
 You must have original signature of the MD, DO, NP,
PA or Clinical nurse specialist on the first page
 The 2nd page needs the signature of the resident or
their responsible party (RP)
 The form must be entirely filled out.
 The resident must reside in and a licensed Nursing
Facility
Business Manager Checklist
 Applied income
 Nursing Home Medicaid #14 effective date
 Medical POA or RP and their relation to the resident
 Who manages the funding/trust
 Spouse in the community
 Good standing with the facility
 Hospice
Verified Eligibility
 Contact the nurse and request the following:
 Face Sheet
 MARs (Medical Administration Resources)
 Advance Directive
 History & Physical
 Most recent lab work
 Set appointment with the nurse
 Courtesy call to the RP
Initial dental appointment
Develop treatment plan based upon the findings from:
 Complete Oral Examination
 Full Mouth X-rays / Panorex
 Debridement
RP Consents
 Contact the Responsible Party for consents
•
•
Treatment Plan
Oral Surgery Consents
Bisphosphonate Consents
Sedation, etc

Memorandum of Understanding
•
•
Completed Treatment
Once the medically necessary treatment has been
completed. Submit the claim to the Nursing Facility
ME worker
 Mail original Form H1263-B
 Itemized Claim form of all completed treatment
 Date
 ADA Code
 Fee
*Average processing time is about 30 to 45 days
Income Adjustment
 The ME worker approves treatment
 The adjustment is entered in the MESAV system
 The MESAV reflects the increase in funds available
 This notifies the nursing facility of an approval
 The practice will receive one or two forms showing the
approval. This notifies us of the billing direction.
3 possibilities for payments
 Form H1259 – Back-dated payments will come from
the nursing facility
 Forms H1259 AND H4808 – a mixture of back-dated
funds from the NF and future monthly payments from
the fund manager
 Form H4808 – Payments to come in consecutive
monthly intervals
** Form H1259 changing to H1053
Billing
Form H1259
Form H4808
 Bill the nursing facility
 Statement
 Itemized Invoice
 Copy of the 1259
 Bill the Responsible
Party
 Statement
Additional forms
 H1052-IME
 Action Needed




Signatures missing
Signature not original
Description of signer
Coding incorrect, etc
 H1054-IME
 Proof Needed

Questionable treatment
rendered. State
requesting verification
that treatment was
received.
Full Vendor Program Eligibility
 There is no applied income (their SSI is =/< $60 per
month)
 Nursing Facility Medicaid #14
 Must be in dental pain
 Reside in a licensed Nursing Facility
Necessary Full Vendor Forms
 Form 2463
 Physician Order stating “Dental Pain”
 Itemized invoice from the dental office
** There is a 1 year submission deadline.
Full Vendor fee schedule
Dental Codes and Rates
D0140
D9110
D0220
D0230
D7140
D7250
D7210
D7220
D7230
D7240
D7241
D7250
D7510
D7520
D9215
D9220
D9221
Emergency Oral Exam
Emergency Palliative Exam
X-Rays First Exam
X-Rays Second and Each Film
Simple Extraction Single Tooth
Extraction Root Removal – Exposed Roots
Surgical Removal of Erupted Tooth
Removal of Impacted Tooth-Soft Tissue
Removal of Impacted Tooth – Partially Bony
Removal of Impacted Tooth – Completely Bony
Removal of Impacted Tooth – Completely Bony with Complications
Surgical Removal of Resident Tooth Roots
Incision and Drainage of Abscess-Intraoral Soft Tissue
Incision and Drainage of Abscess-Exta oral Soft Tissue
Local Anesthesia
General Anesthesia – First 30 Minutes
General Anesthesia – Each Additional 15 Minutes
$19.16
$18.75
$12.82
$11.74
$67.04
$92.50
$102.81
$157.50
$180.00
$300.00
$156.25
$92.50
$37.50
$125.00
$12.50
$87.50
$31.25
Self Pay
 Resident has no Medicaid or the Medicaid is pending
 Work with the trust fund manager
 Credit card/checks
 CareCredit
 Once Medicaid is approved, if it is retro-dated, you can
submit the Form H1263-B for their reimbursement
Thank you!
Lynn Nolf Estrada, Administrator
Phone: 210.617.4446
Fax: 210.617.5572
admin @ geriatricdentalgroup.com
www.geriatricdentalgroup.com