Articles
October 16 HIPAA Deadline Nears
Delta Dental to Accept Only CDT-4 Codes
Delta Dental of CA's New Address
D4381 Coding Change
New Jersey Adopts Tough New Insurance Fraud Law
Professional Relations Reminder
Matheny Opens Dental Center to Treat Persons with Disabilities

October 16 HIPAA Deadline Nears

Will you be ready to bill Delta Dental starting October 16? That is the deadline to comply with Health Insurance Portability and Accountability Act (HIPAA) provisions for electronic transactions and code sets. 

If you are not ready to use the HIPAA standard transaction and code sets by October 16, you may not get paid!

HIPAA is more than a privacy law. It touches many aspects of health care, including the claims you submit electronically to all health insurers, including Medicare. Effective October 16, 2003, all electronic transactions covered by HIPAA must comply with these standards for format and content. For example, the electronic claim that a dentist sends to a health or dental plan must be compliant; any noncompliant claims submitted after the October deadline could be returned to you, unpaid. 

Delta Dental and our clearinghouse WebMD (Envoy and MedE America) are eager to help you through this transition. Testing is required to assure that you and your business partners can send and receive HIPAA-compliant transactions. Working with your practice management vendor is vital to a successful transition. Following Centers for Medicare & Medicaid Services (CMS) guidelines, for an interim period, we will work closely with our vendors toward a smooth transition into a state of 100% compliance.

Although we have all been working hard to achieve HIPAA compliance and the benefits it will bring, there is still much to be done. Time is growing short; please be sure to test sending and receiving HIPAA-compliant transactions with your vendor and clearinghouse as early as possible to avoid any last-minute problems.

Delta Dental to Accept Only CDT-4 Codes

As of October 16, 2003, Delta Dental will no longer be accepting procedure codes other than CDT-4 codes on electronic claims submitted to our offices. Claims with non-CDT-4 codes will be rejected and returned to your office.

As of November 1, 2003, Delta Dental will no longer be accepting procedure codes other than CDT-4 codes on paper claims submitted to our offices. Claims with non-CDT-4 codes will be rejected and returned to your office.

Delta Dental Plan of CA's New Address

Delta Dental Plan of California has a new post office box for its commercial claims (DeltaPremier and DeltaPreferred Option). Claims should now be sent to:

Delta Dental Plan of California
P.O. Box 997330
Sacramento, CA 95899-7330

D4381 Coding Change

Effective October 16, 2003 Delta Dental Plan of New Jersey, Inc. (DDPNJ) will solely use CDT-4 Code D4381 (localized delivery of chemotherapeutic agents via a controlled release vehicle into diseased crevicular tissue, per tooth, by report) to process all claims for these procedures regardless of the type of chemotherapeutic agent placed in the crevice. 

Codes 04382, 04383 and 04384, which were used to differentiate the types of therapeutic agents, will be discontinued. 

Dentists should submit only code D4381 regardless of the type of agent. The procedure is to be reported per tooth and must be accompanied by periodontal charting and radiographs. The use of chemotherapeutic agents is considered an adjunctive procedure for specific sites with pocket depths 5mm or greater that are unresponsive to conventional therapy or for cases in which systemic disease precludes conventional or surgical therapy. 

This procedure does not replace conventional or surgical therapy required for debridement, resective procedures or for regenerative therapy. DDPNJ processing policies for these procedures have not changed and are listed below for your convenience.

• Patient must have had scaling and root planing (D4341, D4342) and/or a periodontal maintenance procedure (D4910) six weeks to six months prior to the treatment.
• Retreatment of an area is not benefited within 24 months from the original treatment.
• Traditional surgery is not benefited within 12 months of original treatment.
• Benefits will be provided for up to two teeth per quadrant. Fees for the treatment of any additional teeth in the same quadrant within the same episode of treatment are disallowed and not collectable from the patient.
• If different teeth within the same quadrant are treated with this procedure within 24 months of the original treatment, the procedure is denied and the approved amount is collectable from the patient.

New Jersey Adopts Tough New Insurance Fraud Law

On June 9, 2003, New Jersey Governor James McGreevey signed into law a comprehensive reform package relating, among other things, to insurance fraud. The new law is L. 2003, Chapter 89. It is accessible on the Web at http://www.njleg.state.nj.us/2002/Bills/PL03/89_.HTM.

The new law creates a new crime of "insurance fraud." In brief, any person (including an insured or a licensed practitioner) who knowingly makes or causes to make a false or misleading statement of material fact to an insurance company (including medical and dental insurers, automobile insurers and professional liability insurers as well as self-funded plans and the State Health Plan) is guilty of "the crime of insurance fraud" if such statement is made in connection with any of the following: a claim for payment or reimbursement; an application for coverage; and any payment made or to be made in accordance with the terms of an insurance policy. L.2003, c.87, § 73 (codified at N.J.S.A. 17:33A-33).

The new law recites that it is intended to aggressively confront the problem of insurance fraud by facilitating the detection, investigation and prosecution of such fraud. L. 2003, c.87, § 71(b). Among the features of the bill are provisions that make it a second degree crime: "if the person knowingly commits five or more acts of insurance fraud, including acts of healthcare claims
fraud, ... and if the aggregate value of [the benefit] obtained or sought to be obtained is at least $1,000." L.2003, c.89, § 73(b) (codified at N.J.S.A. 17:33A-33(b).)

In determining whether the $1,000 threshold has been met, the amounts involved in separate claims may be aggregated and the fraud need not have succeeded; the amounts involved in attempted (unsuccessful) frauds are also includible. This means that a covered person and/or practitioner who submits five claims with knowingly misleading or false information material to the claim ("material" means it's relevant -- an incorrect address which is irrelevant to the insurer's action would not be material) of $200 each could be convicted of a second-degree offense. Second-degree theft offenses in New Jersey are serious crimes; previously, $75,000 was the minimum threshold to constitute a second-degree theft.

The clear message is that the State of New Jersey will be tough on persons who engage in a pattern of insurance fraud, even if the claims are relatively small. Although there must be five frauds to constitute a pattern, they can all occur in one claim form, e.g. a claim for five separate services that deliberately misrepresent the fees charged or services actually rendered. L.2003, c.89, § 73(b) (codified at N.J.S.A. 17:33A-33(b).) The crime is a third-degree offense if there are fewer than five claims or if the $1,000 threshold is not met.

A similar provision has been on the books for healthcare claim fraud of licensees for the last five years. The State of New Jersey has increasingly utilized that law since its enactment. This law complements the health care claim fraud law, increases the stakes for both practitioners and non-practitioners, and expands it beyond health insurance.

The new law has also "upped the ante" against insurance fraud by creating a system to provide financial rewards to those individuals who provide "information leading to the arrest, prosecution, and conviction of persons or entities who have committed healthcare claims fraud, insurance fraud or any other criminal offense related to an insurance transaction." L. 2003, c.89, § 74(d) (codified at N.J.S.A. 17:33A-34(d).) Patients who suspect their provider is overbilling, office staff who suspect upcoding, or former employees who have pertinent information about similar misconduct can now receive a reward of up to $25,000.

Now, more than ever, is the time to review your claim preparation and submission practices to assure that your claims are accurate and that your personnel understand the stakes involved in submitting false information to dental or medical carriers (as well as other carriers such as automobile insurers and professional liability insurers).

This is not legal advice. We recommend that you confer with your legal counsel for advice concerning this and other laws.

Professional Relations Reminder

Professional Relations requests that you notify Delta Dental if your practice experiences any of the following changes:

• Another dentist joins your practice
• A dentist leaves your practice
• An additional office location
• An office location eliminated
• Changes to Taxpayer Identification Number
• Name for IRS form 1099 reporting
• Changes to the name, address or telephone number of the practice
• Any fee updates and/or corrections

Please submit any changes in writing to:
Professional Relations
Delta Dental Plan of New Jersey, Inc.
P.O. Box 222
Parsippany, NJ 07054-0222

Changes may also be faxed to (973) 285-4192.

Matheny Opens Dental Center to Treat Persons with Disabilities

The Matheny School and Hospital, a facility for children and adults with developmental disabilities, has opened a new Dental Center as part of the Matheny Center of Medicine and Dentistry. The new Dental Center provides ongoing preventive treatment to persons with disabilities, a vulnerable and underserved population that often has difficulty finding satisfactory dental care. The Center is a partnership with The University of Medicine and Dentistry of New Jersey (UMDNJ)-New Jersey Dental School, with funding support from Delta Dental Plan of New Jersey Foundation and the New Jersey Health Initiatives Program of the Robert Wood Johnson Foundation.

Services include: cleaning, treatment of cavities, obtaining x-rays, behavioral management and simple extractions. Treatment is provided by dentists on the faculty of UMDNJ-New Jersey Dental School. Techniques for behavioral management and knowledge of special medical issues for this population (i.e., swallowing, positioning, drug interactions, etc.) is provided by physicians and therapists at Matheny.

A secondary objective of the Dental Center is to improve access to care by including a training component. Matheny's Dental Center serves as a training site for third- and fourth-year dental students, first-year residents from the New Jersey Dental School and dental hygiene students from the UMDNJ School of Health Related Professions. The goal of this training is to increase the number of dentists and hygienists out in the community who are capable of providing quality dental care to persons with disabilities. The long-term plan is to develop a dental residency program in disability dentistry.

If you know of individuals with disabilities who need specialized dental care, please refer them to the Matheny Center of Medicine and Dentistry, (908) 234-0011, ext. 771.