Dental Services - Service Specific Probe Review Findings - JE Part B

Current Review Results

In order to fulfill its contractual obligation with CMS, Noridian Healthcare Solutions (Noridian), your Medicare Contractor, performs pre-payment reviews in accordance with CMS direction. CMS is required by the Social Security Act to ensure that payment is made only for those medical services that are reasonable and necessary. Medical review assesses submitted documentation to validate provider compliance with Medicare payment rules and regulations, including coverage, coding and billing guidelines.

This is to update providers of the claim review findings for Dental Services. The results of this focused review are not a reflection on providers’ competence as a health care professional or the quality of care provided to patients. Specifically, the results are based on the documentation requested by Medicare and/or your facility’s compliance with the required documentation.

Summary of Findings

Since the initiation of this review, 126 claims were reviewed from July 31, 2023, thru October 10, 2024, revealing an error rate of 75.38%. The breakdown of those findings are as follows:

• 43 claims were allowed.
• 83 claims were denied in full for the following reasons:
  • The service billed is not a covered Medicare benefit or is an excluded service
  • Failure to return records
  • The documentation submitted does not support services were rendered as billed

The overall error rate since the initiation of this service specific probe review is 60.29%. The error rate is calculated by dividing the dollar amount of charges billed in error (minus any confirmed under-billed charges) by the total amount of charges for services medically reviewed. If you disagree with a claim determination, the normal appeal process may be followed as directed on the Noridian website under Appeals or as directed in your claim remittance advice, although this will not affect the error rate of the pre-payment review.

Education

Under Medicare Part B, no payment will be made for any services or expenses in connection with care, treatment, filling, removal, or replacement of teeth or structures supporting teeth. Structures supporting teeth include periodontium, which includes the gingivae, dentogingival junction, periodontal membrane, cementum of the teeth, and alveolar process. The hospitalization or non-hospitalization of a patient has no direct bearing on the coverage or exclusion of a given dental procedure. Refer to the Code of Federal Regulation Title 42 Section 440.100 & 411.15(i); Title XVIII Social Security Act Section 1862(a)(12); Internet Only Manual (IOM), Publication (Pub) 100-02, Medicare Benefit Policy Manual, chapter 15, section 150; and IOM Pub 100-02, Medicare Benefit Policy Manual, chapter 16, section 140.

The ordering or prescribing physician or Non-Physician Practitioner (NPP) must sign a document indicating their knowledge, approval, acceptance, or obligation to services provided or certified. Keep in mind that signature requirements are applicable to orders and other medical documentation used to support medical necessity of the service provided.

The documentation requested must support that the services were rendered as billed. A claim will be denied when the documentation does not support the services billed were performed. Refer to IOM-Pub 100-08, Medicare Program Integrity Manual, Chapter 3, Section 3.6.2.5(A).

Resources

• Failure to Return Records
• Why Is My Claim Denied

For additional educational resources, please visit our Education and Outreach department.

Provider Action Required

Providers should review individual claim determinations.

To review individual claim comments via the Noridian Medicare Portal, complete the following steps:

• Log into Noridian Medicare Portal
• Choose Claim Status from the menu bar.
• On the Claim Status Inquiry page:
• Fill in all Provider/Supplier Details.
• Select MEDB under Program drop down box
• Fill in all Beneficiary Details
• Fill in Claim Details.
• Click the Submit Inquiry button at the bottom of the form.
• On the Claim Status Results page
• Choose View Claim.
• On the right side of the page will the heading: Related Inquiries
• Choose Noridian Comments.
• Scroll down the page and under the Claim Status Line Details the comment will display.

Note: If documentation was sent late (>45 days from the date of the ADR), the claim may have been reopened by the examiner. These reviews are not currently available on the portal.

Initial documentation must be sent by fax, mail or esMD. Additional documentation requested can be submitted fax, mail or Noridian Medicare Portal.

Further provider action recommended includes:

• Provide education regarding errors noted to applicable staff members.
• Verify documentation supports medical necessity of Dental Services
• Ensure ADR submissions are timely, complete, and include all documentation to support medical necessity and a valid physician order.
• If records supporting the services on the claim are located at another facility, as the billing provider, your facility is responsible for obtaining those records for review.

Summary

This service specific review will continue until medical review results demonstrate provider compliance with Medicare guidelines and education provided. This file is reviewed at least quarterly; providers with low/no errors after a reasonable sample will no longer be reviewed for this file. Remaining providers will continue to be reviewed.

If you would like to receive information regarding findings specific to your facility prior to the completion of the review, send an email to medicalreviewpartb@noridian.com. In order to facilitate the response, follow these instructions:

• Complete the Subject line with the following information: Results request for Dental Services widespread review
• In the body of the email, include the following elements:
  • Your name, title, and telephone number
  • The facility name
  • NPI Number
  • Short description of information you would like to receive
  • Indicate if you would like to receive results via phone call, fax or US Mail and include a fax number or mailing address as applicable.
    • Upon request receipt, Noridian Medical Review will respond as timely as possible. Requests may take up to two weeks to be completed.

If you have any questions, contact the (JE) Provider Contact Center