Direct Data Entry (DDE) Dental Claims in ProviderOne

Direct Data Entry (DDE) Dental Claims in ProviderOne


Welcome to the direct data entry webinar training
for dental claims submitted through the ProviderOne Portal. We are conducting this webinar due to the
policy change at the WA Health Care Authority where we are no longer accepting paper claims
unless you have an approved waiver. This was implemented on October 1, 2016 and
we are hoping to reach those providers who have only submitted paper claims and need
to transition to electronic billing. This training will focus on billing electronically
through the Direct Data Entry system in ProviderOne and will not cover HIPAA/EDI claims. For more information on HIPAA billing, please
visit the following webpage: www.hca.wa.gov/billers-providers and click on the 3rd link under the blue Claims
and Billing bar titled, HIPAA Electronic Data Interchange. I am Marci Thietje here with my coworker,
Matt Ashton. We will be reviewing our PowerPoint slideshow
first and break down each field required to submit the claim and then show a live demonstration
of entering a dental claim through ProviderOne. Any questions received during this webinar
will be collected and answers to those questions will be posted after this webinar, along with
a recording of this presentation. Only questions related to direct data entry
billing will be responded to. After this training, you will be able to submit
fee-for-service claims through the ProviderOne Portal and submit claims for clients who have
commercial insurance. Before we get started there are some important
settings on your PC that need to be verified before you begin. Make sure your pop-up blockers are turned
off. The process to turn off pop-ups is different
depending on what browser you are using. ProviderOne uses pop-ups throughout the claim
form and must be turned off to finalize the claim. ProviderOne is a HIPAA-compliant program that
gives you the ability to enter claims directly into the payment system and all fields that
can be entered on a paper claim can be billed through direct data entry. It is easy to use and does not cost anything
to do so. As long as you have the correct profile and
access to your domain in ProviderOne, you can bill as many claims as needed using multiple
pc’s if necessary. You can correct and resubmit denied or voided
claims, or adjust or void previously paid claims. Corrections and resubmissions will not be
covered during this session, however see the contact email for Provider Relations on the
last slide if you need to reach out for assistance on these functions. Once you have entered your domain, user name
and password, you need to choose a profile. There are several profiles that allow for
claim submission. The most frequently used is the EXT Provider
Super User profile. This profile allows the worker to do all functions
in the system, except for managing user permissions. If an incorrect profile was chosen, ProviderOne
gives you 2 ways to change it by using either the My InBox tab or dropdown, or by hovering
over the user name in the upper left corner of the portal. For this session, we will choose the EXT Provider
Super User profile. Once you have chosen the correct profile,
you would then choose On-line Claims Entry from the provider portal. You would then choose the claim type you would
like to enter. A dental claim submission would be the same
as the ADA 2012 dental claim form with all the same fields available for entry. Here is a snapshot of the first half of the
Direct Data Entry screen. The claim itself is broken down into 4 different
sections: Billing Provider, Subscriber or Client information, the Claim level (or header
information) and the Service Line level. There are also some basics on navigation that
we should discuss. Do not click your back arrow on your browser
but use the hyperlinks and buttons on the screen itself to navigate. You also must complete any question or field
with a red asterisk and if you expand an area by clicking any of the red plus signs, you
must either enter the detail required or close that area by clicking on the minus sign otherwise
ProviderOne will be looking for entries in these expanded areas. Here is the second half of the claim form
showing the required entries. We will break down each section and show each
field and what is required to submit a claim. Let’s start with Section 1, Provider Information. The first thing to do is tell ProviderOne
who the billing provider is by entering the National Provider Identifier or NPI. The billing provider is where payment will
be sent to or who is getting paid for the service. You will also need to enter a taxonomy code
that is attached to the billing NPI and applicable to the service you are billing for. The taxonomy code tells ProviderOne what type
of provider is submitting the claim. Note the red asterisks, as these are required
entries. Now you have come to the first question that
must be answered. Is the Billing Provider also the Rendering
Provider? This represents the provider actually performing
the service. If you answer this question Yes you are saying
that you are both the billing provider and the provider rendering the service, otherwise
you would answer this question No. Answering the question No opens up the Rendering
or Performing provider area where you would enter the NPI and taxonomy for that provider. That completes the first section and we are
now in Section 2, Subscriber or Client Information. This is where you will tell ProviderOne what
Apple Health client received the service you are billing for. This is the ID number noted on the ProviderOne
Services card that each client receives. You must enter the WA, but it does not need
to be capitalized. The next step is to expand the Additional
Subscriber/Client Information by clicking on the red + sign. This is where you would tell ProviderOne the
Apple Health client’s name, date of birth, and gender. You will note that the First Name field is
not required, or marked with the red asterisk. This information must match what is in the
client’s file in ProviderOne. If the Apple Health client has a commercial
payer as their primary insurance for dental services, you will need to complete the Other
Insurance Information fields by clicking the red + sign to open this section. Click the very next + sign for Other Payer
Insurance Information. In the Payer/Insurance Organization Name,
enter the commercial payer name. Once complete, expand the red plus sign for
the Additional Other Payer Information section. Only 2 fields are required here, the ID and
the ID type dropdown. The ID needs to be the insurance carrier code
that is listed on the client’s eligibility file which we will show on the next slide. The ID Type dropdown should always be PI for
Payer Identification. This is a snapshot of a Coordination of Benefits
segment from the client eligibility screen in ProviderOne where you will find the Insurance
Carrier Code or the “ID number” from the previous slide. If you need more assistance on finding the
carrier code in ProviderOne, please review our Fact Sheet titled Successful Eligibility
Checks using ProviderOne at the web address noted on the slide. The next entry is to tell ProviderOne how
much the commercial insurance paid by entering the amount in the COB Payer Paid Amount field. This amount can be entered without decimals
if it is a whole dollar amount. If the insurance denied the service, you would
enter a 0 here. ProviderOne requires the use of HIPAA compliant
adjustment reason codes. These codes will be entered by expanding the
Claim Level Adjustments section. Once expanded, you would enter a Group Code,
reason code, and dollar amount applicable to the reason code entered. The HIPAA compliant reason codes can be found
at the WPC’s website at the address noted in the green box. The next section to complete is Section 3
Claim Information. This is also called the claim header detail
information that covers the entire claim. The first field to complete under Claim Data
is for the Patient Account number. This is not required but can be used by your
office to identify the client using your own identifier or account number. This number will be carried forward to the
weekly HCA remittance advice to assist in reconciling accounts. Next you need to tell ProviderOne what date
you saw the client. These dates must be entered in complete digits
as noted on the screen, such as using a 4 digit year. The date of service can also be entered on
each individual service line, however if only one DOS is being added to the claim, you only
need to enter it one time at the Claim Level. The next entry is to choose your place of
service. Most often you are choosing office, so you
can use the number 1 to easily jump down to place of service 11, or use the dropdown to
select from the list. Additional Claim Data is needed only if the
Apple Health client has a spenddown liability they owe that needs to be reported on the
claim. You would choose the red plus sign and enter
the liability amount in the Patient Paid Amount field. The next area for entry is the Prior Authorization
section. You would click the red plus sign and enter
it here if the service you are billing for requires a prior authorization or an expedited
authorization number (EPA) provided in the program billing guides. If no authorization is needed for the service,
skip this area. Entering the authorization or EPA number here
would apply to the entire claim. If you have more than one authorization number
to bill with, this will be covered later in the slide show. Recent system changes to ProviderOne have
changed how claim notes are read. If a specific program or service requires
you to enter a claim note as instructed in a program billing guide, they will still be
read by ProviderOne. If no claim note is needed, skip this option. Here is the last required question on the
dental claim form. You will always answer the question “Is
this claim accident related?” as No. If an Apple Health Medicaid client has a casualty-related
claim, it is handled by a specific unit in our Coordination of Benefits office. That completes section 3 and now we will review
Section 4 Basic Service Line Items, again covering each required entry. The first item to enter on the service line
is the Procedure Code. Enter the CDT code from the most current coding
manuals and always enter the D in front of the procedure. You would then enter the amount you are billing
for in the Submitted Charges field. Again, if this amount is a whole number, no
decimal point is needed. We always recommend that providers bill their
usual and customary amounts here. However, if the service you are billing for
required a prior authorization, you must bill the amount that you requested in the authorization. The place of service is not required on the
line level so can be skipped, as well as modifiers and diagnosis as these are also not required
on a dental claim. If the CDT code you are billing with requires
a tooth number, you would click the red plus sign to expand that area and enter the tooth
number. This is also where you would enter a tooth
surface if required. You will note that the Add Another hyperlink
is crossed out on this slide, because you should only bill for one tooth per service
line. Each procedure you entered will require units. Enter the number of units you are billing
in this field. It is necessary to call out that you would
not bill minutes for anesthesia in the units field. Using an anesthesia procedure code, each 15
minute increment equals a unit of service. Please see the dental program billing guide
for more information on anesthesia services. Also, if you are billing more than one date
of service on this claim and are entering it at the line level, you need to make sure
you billed the first or earliest date in the claim level area or you will receive the error
message noted on this slide. If the procedure you are billing requires
a quad or arch designation, you would enter it here using the drop down boxes. If the authorization number for the procedure
being entered is different than the one listed at the Claim Level or header area, click the
red plus to expand the Prior Authorization area and enter that number here. Skip the Additional Service Line Information
section. Once you have entered all the required information
for the service line, click the Add Service Line Item button to add the service line to
the claim. It will remove the information from the service
line area and populate the columns below the gray bar similar to an ADA 2012 claim form. If there are additional service lines that
need to be added to the claim, you can quickly return to the service line area by clicking
on the service hyperlink shown here and follow the instructions from the previous slides. If the service line was entered incorrectly
and needs to be updated, you would click on the service line number. This will repopulate the service line boxes
for you to make any corrections. Once your changes or corrections are completed,
click on the Update Service Line Item button to add the service line back on the claim. If you added a service line in error and now
need to remove it, you can simply click the Delete hyperlink to the right of the service
line and it will delete that service line and return you to the top of the claim screen. Once all service lines have been added and
you are ready to submit your claim to ProviderOne, click the Submit Claim at the top of the claim
screen. If your pop-ups are turned off, you will receive
this dialogue box . If you have backup documentation that needs to be attached to the claim, click
the Ok button. Simply click Cancel if there is no backup
being sent. If you had no backup to attach and you clicked
Cancel on the dialogue box, you will come to the Submitted Dental Claim Details page. This provides you with your claim number and
a summary of the charges being submitted. When you receive this confirmation screen,
this means ProviderOne has all the required data needed. To finalize the claim, you must hit the final
Submit button to send it to ProviderOne. Once this final step is complete, you will
be returned to a blank claim form. If you had answered Ok to the question “Do
you want to submit backup to the claim”, you have the option of attaching the backup
directly to the claim. To do this you would use the dropdown for
“Attachment Type” and select the appropriate option from the list. Then you must choose a Transmission Code from
the next dropdown box as EL for Electronic Only or Electronic file. Skip the Line No. box dropdown completely. You can then click the browse button to search
for the electronic file you want to attach to your claim. Once attached, click the Ok button to return
to the Submitted Dental Claim Details page. Scanning and attaching your backup electronically,
could result in quicker processing and adjudication of your claims. If you are faxing or mailing the backup documentation,
complete only the Attachment Type dropdown and the Transmission Code dropdown will be
either BM for By Mail or FX for Fax. Click Ok to return to the Submitted Dental
Claim Details page. The next step for mailing or faxing your backup
documentation is to create a cover sheet so that your backup can be matched up to your
claim in ProviderOne. The information noted on this screen is used
to complete the required cover sheet. Click the Print Cover Page button. This cover sheet will come up as a separate
screen from ProviderOne as a PDF file. Complete the first dropdown to choose the
Provider ID “NPI” and enter that number in the Provider ID field. Tab to the TCN field and enter the claim number
you received on your Submitted Dental Claims Detail screen. Tab to the Date of Service field and click
the dropdown to bring up the calendar. Use the calendar to choose the date of service
you are billing for. If there is more than one date of service
on your claim, you must use the earliest or oldest date in this field. Tab to the ProviderOne Client ID field and
enter the 9-digit ProviderOne Services card ID number, including the WA. You will need to tab twice after entering
the client ID to expand the barcode so that it can be properly read by the ProviderOne
scanner. Click the Print Cover Sheet button and either
mail or fax in the backup, depending on what option you chose on the backup screen. Your DDE claim will be held for 3 to 5 days
waiting for the backup to be received to attach to your claim. Now that you have completed the cover sheet
for your backup, you must click the final Submit button to send your claim to ProviderOne
for processing. Once this final step is complete, you will
be returned to a blank claim form. This slide provides some useful links for
accessing resources on the new HCA website and for submitting questions on submitted
claims through our contact us form. There are also 2 helpful email addresses noted
if you need to reach out to the dental program manager, or need assistance on using the provider
portal. We have come to the end of the slide show
portion of entering a dental claim using the direct data entry feature of ProviderOne. Now I’m going to demonstrate entering a
live dental claim using this same process. Hi everyone, this is Matt here. I will narrate for Marci as she walks us through
the DDE screen. Once you have accessed ProviderOne, you will
need to select the appropriate profile for submitting claims. Marci is going to choose the EXT Provider
System Administrator profile from the dropdown list. Next she will choose the On-line Claims Entry
option on the Provider Portal. You will notice she received an error telling
her she does not have sufficient rights to access the link. After clicking close on the error page, Marci
is going to demonstrate how you can change your profile from the Provider Portal screen. She will click on the My Inbox dropdown at
the top left of the screen. She will choose Change Profile and is now
returned to the Select a profile screen. Marci will choose one of the correct profiles
for submitting claims, the EXT Provider Super User profile, and click Go. Now she will click on the On-line Claims Entry
option on the portal. This takes you to the Claim Submission screen
where Marci will choose Submit Dental. The first required field she will complete
is the NPI and taxonomy code for the billing provider. The next step is to answer the question Is
the Billing Provider also the Rendering Provider? Marci will click no and enter a Rendering/Performing/Servicing
provider NPI and taxonomy code. You will notice that ProviderOne moves your
cursor for you from field to field. Next up is telling ProviderOne who the service
was provided to, so Marci will enter a client id number from the ProviderOne Services Card
including the WA. For this demonstration, this is a generic
ID for test purposes. She will expand the Additional Subscriber/Client
Information area by clicking the red plus. Marci will enter the last name, date of birth
and gender. This client has no commercial insurance, so
she will skip the Other Insurance Information area and move to the Claim Information section. She will tell ProviderOne what date the service
is for and choose a place of service. The last required question is “Is this claim
accident related?” Marci will click the No radio button. Moving to the Basic Service Line Items, she
will tell ProviderOne what service code she is billing for and then enter the submitted
charges. She next must enter the number of units. For the purposes of this demonstration we
will skip the remaining areas and add the service line to the claim, by clicking the
Add Service Line Item button. ProviderOne returns you to the top of the
claim screen and Marci will use the service hyperlink to return to the service line area
to verify her entries. She is happy with her entries so she will
return to the top of the claim screen to submit the claim by clicking the Submit Claim button. ProviderOne is asking if there is any backup
documentation to attach to this claim. Marci will click Cancel. This is a good time to make a note of the
TCN number assigned to your claim for future reference and you can verify the dates and
billed amount. Marci will finalize this claim by clicking
the Submit button in the bottom right corner. The system returns you to the top of the claim
form and clears out all the information entered. The claim form is ready for you to submit
another claim if needed. This completes the live demonstration of submitting
a dental claim using the Direct Data Entry feature of ProviderOne.

Author: Kevin Mason

Leave a Reply

Your email address will not be published. Required fields are marked *