edental payment and approval modernisation Guidance for submitting prior approval requests via the edental web form.

Transcription

1 edental payment and approval modernisation Guidance for submitting prior approval requests via the edental web form. v1.0 September 2018

2 Contents Accessing and managing your account 3 Homepage. 5 Patient search... 6 Patient Details and Patient Acceptance tabs Prior Approval Details tab and sub-tabs Claim Details tab.. 17 Continuation cases Treatment tab and sub-tabs 19 Observations tab.. 24 Submission tab. 25 Dealing with errors 26 List Claims/Prior Approval table. 28 Description of statuses 29 Providing further information upon request.. 30 Approval granted.. 35 Re-approval

3 If you require your account to be unlocked or forget your password, contact our Customer Services team on (select option 4) or You must inform us of staff changes, where someone no longer requires access to the web form, by ing inserting web form access leaver into the subject field of the . Open the web form by clicking on the web address below or copy & paste the link into your browser: On entering your username and password in the login screen for the first time you will be asked to change your password. 3

4 When you are logged in, the ribbon at the top of the screen will show you as being logged in, along with the name of your practice and the date and time of your last login. Your name and list number are also displayed, but if you have more than one list number at the practice, you must select the list number you are creating a new prior approval request for from the drop-down list. If you work at more than one practice, where you will be required to use the web form to submit prior approvals, you will need a separate user account for use at each practice. 4

5 You will only use the Create Prior Approval link, as you will continue to submit payment claims from your practice management system. Click the View Prior Approvals link to view the List Claims/Prior Approvals table, which details all prior approvals for the practice. You can change your password at any time, by clicking the Change Password link. Passwords are valid for 90 days and if it expires, you will be taken to the change password page when you log in. You cannot use one of the 5 previously used passwords. Selecting Create Prior Approval from the Homepage will present the patient search screen, which is always the first step to creating a prior approval request. 5

6 All fields throughout the web form marked with a red asterisk are mandatory, so must be completed. Enter mandatory details for the patient search, which are surname, forename, date of birth, sex and the first line of the address. Enter any other details you have, ie postcode, as this will improve the accuracy of the search. Previous surname should only be entered if the patient s name has changed since their last visit. Matching your patient to the patient records we hold improves the accuracy and validity of claimed treatment. It also prevents patients being incorrectly linked; reducing the number of duplicate records created. If a patient has changed their gender and received a new Community Health Index (CHI) number, submit a Patient Detail Amendment form, Dental 287, before submitting a request with the patient s new details. Once we have changed our records, the details you enter when carrying out a patient search should match to the amended record in our system. If you submitted a prior approval request with the patient s original details, but submit the payment claim with the patient s new details, you will need to add observations to the claim, as well as the prior approval reference number and date. The observations should include the patient s date of birth, previous names, sex and CHI number. 6

7 The patient search will present one of two outcomes. The first is an exact match, where the details you entered match with only one record in our system. If you are happy that the details returned are for your patient, select Create Prior Approval and these details will be used for the request. If not, select Back and search again. The date of the patient s last examination, regardless of where they had that examination, is also returned and may be a 1a, 1b or 1c examination. 7

8 The other outcome is where the details you provided do not match exactly to one record. You will be presented with a list of potential matches. Select the details that match your patient and hit Search. The details for this patient will be presented to you in the same way as an exact match. If your patient is on the list, but the details are slightly different to those you hold, select that patient to create the request. You should then submit a Dental 287 form, asking us to update that patient s record with the correct details. If your patient is not on the list, select None of the above and hit Search. A message will be presented to say patient not found and you can create your approval with your original details. Only select None of the above if you are sure the patient has never received NHS treatment in Scotland, as if they do, we will hold a record for them and you should carry out another search. 8

9 Once you have the correct patient details, click Create Prior Approval and a pop-up will be presented. By selecting Confirm, you are taking responsibility for providing care and treatment to that patient The ribbon at the top of the screen will remain present as you navigate through the web form. The patient details will now have been added to the ribbon. The prior approval request form has a simple tab system. You can move between tabs by clicking on the tab you want to view or by using the Next and Back buttons at the bottom of each tab. The Cancel button cancels the request completely (you will receive a pop-up to confirm you wish to cancel) and returns you to the Homepage. The Save button saves the information entered to that point and places the request on the List of Claims/Prior Approvals table, with a status of saved, allowing you to complete it later. If you are part way through entering a request and are called away, you should save what you have done up to that point, as the web form will time-out if not used for a certain amount of time and any information not saved will be lost, meaning you will have to begin the request from the start. 9

10 The first tab is called Patient Details and is pre-populated with the patient information you confirmed during the Patient Search. You do not need to complete anything else on this tab. The next tab is Patient Acceptance. The patient must sign part 1a of the paper GP17(PR) form (or electronic signature pad) before treatment starts and these details should be reflected here by selecting from the drop-down menus: All fields throughout the web form marked with a red asterisk are mandatory, so must be completed. 10

11 If HC3 exemption is selected, the HC3 certificate number must be entered in the relevant box on the right. 11

12 The Prior Approval Details tab has 6 sub-tabs, the first one being Examination Details. All questions on this tab are mandatory and a selection must be made for each one. If you answer No to the question I have examined the patient, you must enter a reason in the box provided. 12

13 In the Medical History tab, if you answer Yes to the question Does patient have a medical condition or taking medication pertinent to their oral health, you must enter details in the comments box provided. The other two questions are on this tab are lifestyle questions. These questions are not mandatory, but the information is useful when prior approval is being considered. This guide to alcoholic units is provided to assist you with the alcohol intake question. 13

14 On the General Condition tab, if you answer Yes to Is there any evidence of non cariogenic tooth surface loss, you must enter details in the box provided. You must also then answer the question below it, Does this require treatment. If you answer Yes to Are there any other pertinent intra oral features or conditions, you must enter details in the box provided. The last three questions relate to dentures. If you select Upper or Lower for Does patient currently wear dentures, you require to select the material. If you select Both for this question, you do not require to select a material. 14

15 All questions on the Radiograph Details tab are mandatory. The teeth shown in the intraoral radiographs must be detailed on the chart on the right hand side of the screen. If a vitality test is available, you must enter + or for each tooth present on the Vitality Test tab. 15

16 On the Prior Approval Arrangement tab, if you answer Yes to Is it proposed that any items of treatment will be provided privately, you must enter details in the box provided. If treatment is to be carried out under sedation, but is not being administered by the operator, the name of the person administering the sedation must be entered in the box provided. 16

17 In the Claim Details tab, if you are claiming Special Needs or External Trauma to the mouth, simply tick the relevant box - no observations are required. If claiming Referral, select the reason for referral, either Facilities, Experience or Expertise. 17

18 You only need to answer the Radiographs Available question when one or more of the treatment codes on your request has a proviso in the Statement of Dental Remuneration (SDR) stating that No fee shall be payable except where appropriate radiographs are available, for example, for the provision of a bridge (item 18). If you have radiographs available, select Yes. Where it is not appropriate to take radiographs, for example, pregnancy, select No. You must enter a reason in the box provided. If none of the items claimed require radiographs, as stated in the SDR, there is no need to select anything for this question. Continuation cases: A continuation case is where one dentist starts treatment and a different dentist within the same practice takes over the treatment. In these cases, the Previous Claim ID and Continuation Part Number are required. The previous claim ID can be located on the list of claims/prior approvals table, under the column named Reference. Note: The same date of acceptance must be used on all parts of a continuation case, to reflect that it is one course of treatment. If the case was previously granted approval electronically, via the web form, the Previous Prior Approval Reference Number and Approval Date must be entered in the appropriate fields. These can be found on the Submission tab of your prior approval request. If the case was previously granted approval on paper, the Approval Date from the previous request must be entered in observations. 18

19 The Treatment tab has five sub tabs and the first one is Chart. All permanent teeth are defaulted to P for Present. For permanent teeth not present, you need to change the P to one of the other options listed at the bottom of the tab, M - Missing, U - Unerupted or Z - Missing and space closed. If all permanent teeth are missing, you can click the All Permanent Teeth Missing button to change all entries from P to M. Indicate the presence of Deciduous and/or Supernumerary teeth by selecting the relevant tick-boxes in the chart. 19

20 Enter all non-tooth specific treatments on the Other Treatment tab. You can select some common non-tooth specific items by clicking the tick-box beside that item at the top of the tab. Enter the number of Radiographs and Photographs in the boxes provided. There is a checkbox for Chronic Periodontal 10(C) on this tab, but it should not be selected. If claiming item 10(C), you must enter this on the tooth specific tab. This item will be removed from this tab in the near future. For other non-tooth specific items, enter the 4 digit Treatment Code from the Statement of Dental Remuneration (SDR) and the Quantity in the relevant boxes. Click the Add button to add the treatment to the table on the right. If you add a treatment to the table in error, it can be removed by clicking Delete. Follow that same procedure for all other non-tooth specific treatments. There is no maximum number of treatments that can be added to the table. 20

21 On the Tooth Specific Treatment tab, treatments are entered using the 4 digit SDR Treatment Code and the Tooth Number, using FDI World Dental Federation notation. As well as the 4 digit SDR code and tooth number, if the item of treatment is a Filling, you must also select the Annotation Code, Surface(s) and Material. For Gold Inlays, you must also select the Annotation code and Surface(s). The Annotation Code drop-down list contains six entries, but you only ever need to use two. For Fillings, select F Filling and for Gold Inlays, select IN Gold inlay. 21

22 Do not select an Annotation Code for any other type of treatment, only the treatment codes listed below: If your treatment code is not a Filling or Gold Inlay, you only need to enter the four digit treatment code and tooth number, then click Add. Clicking the Add button adds the treatment onto the table. There is no maximum number of treatments that can be added to the table. If you add a treatment to the table in error, it can be removed by clicking Delete. If an item of treatment is being done on a supernumerary tooth, indicate this by selecting Yes for Supernumerary before adding to the table. For free replacement items, select Yes for Free Replacement before adding to the table. Note: Free replacement can only be claimed in conjunction with trauma. 22

23 You must always go to the Value Summary tab and click the Get SDR Values and Refresh Table button. This will populate the table with the information from the Other Treatment and Tooth Specific Treatment tabs. The total value of the request is shown, along with the total patient charge. Note: The patient charge is for information only and is only relevant if the patient pays for treatment. The actual patient contribution must be entered on the Patient Completion tab. The maximum patient charge still applies, even although it may be shown as greater on this tab. If you go back to the Tooth Specific Treatment or Other Treatment tabs and add, remove or amend any treatment, you must return to this tab and click the button again to refresh the table and monetary values. 23

24 The BPE is mandatory for all prior approval requests. Acceptable entries are: single number 0-4 a single number 0-4 followed by asterisk a dash (-) with no number an X with no number Observations should only be added to provide additional information on your treatment plan and/or instructions pertinent to the prior approval request. 24

25 You are now ready to submit your prior approval request, from the Submission tab. The Approval Date and Prior Approval Reference will only be populated after the request has been approved. If your request does not require approval, but you would like a Dental Adviser s opinion on your treatment plan, select Request a Review. When you click Submit, the web form will carry out in-form validation. If there are no errors, a pop-up will appear to enter your PIN and accept the declaration. If there are errors, these will be highlighted to you, as shown below. 25

26 The in-form validation checks that all mandatory fields are completed and all dates are in the correct format. Tabs with errors are highlighted in red. Note: The red highlight will not disappear once the errors are fixed. 26 The field(s) containing the error will be highlighted in red. A message, explaining the reason for the failure will also appear at the bottom of the tab. Once you have fixed the errors, return to the Submission tab and click the Submit button.

27 When there are no in-form validation errors and you have submitted the request using your PIN, the validation in our rules engine will be run. This validation is rules based and if the request fails any of the rules, the request will be returned with a new tab, called Failure. This tab is highlighted red and will provide you with the error codes and specific reasons for failure. Correct the errors and submit the request again. If errors are still present when you re-submit the request, you will again be presented with the failure tab to indicate the errors. If you have corrected all the errors and the form is successfully submitted, the form will be displayed in the List Claims/Prior Approvals table, with a status of Accepted. We will then review the request and make a decision on the case presented. Prior approval requests can only be submitted one at a time and your PIN must be entered for each request submitted. You only need to submit attachments if we request attachments or further information, by returning the request to you. See below for details of the Communications tab. 27 Note: The Failure tab will not disappear when you have corrected the error(s).

28 You can view all the requests for the practice on the List Claims/Prior Approvals table. The Status column tells you where the request is in the process. See below for an explanation of all statuses. Sort the list, using the various filters, to search for your own requests. Click the Refresh button to refresh table. 28

29 Note: Accepted only means we have received the request. If the request is granted approval, the status will read Approved. 29

30 If we require additional information, in order to properly review your request, we will return it to you. It will appear on your List Claims/Prior Approval table with a status of Request. When you view the request, there will be a new tab called Communications, coloured orange. Select correspondence to read from the left hand table and the details will appear in the reading pane at the top right. Any responses you have sent are also available to view in this way. You can only respond or upload attachments when viewing our latest correspondence. If we only require written clarification on something, you can type your response in the Response Area. You must then go to the Submission tab and re-submit the request. 30

31 If we have asked you to submit attachments, and you have electronic files available, click the Upload Attachments button in the Communications tab. This will take you to a secure web page, where you can upload your digital attachments. Your list number and practice reference number (this is the claim reference number) are shown at the top of the page. When you click the Add file(s) button, this will allow you to choose the attachments you wish to upload by selecting the files you have saved on your computer. We can accept the following file extensions: doc docx jpeg jpg pdf tif tiff bmp png xls xlsx 31

32 When several files are selected for upload, they will stack on top of each other and the page will scroll, if required. You must select the Attachment type for each one from the drop-down menu. When a field requires completion, it will be highlighted orange at the left hand side. Once you have completed a field the colour will change to green. 32

33 All images must be positioned correctly and correctly oriented before they are uploaded. If you select Intraoral Radiograph or Clinical Photograph as the Attachment type, you must also: enter the date they were taken; and a description of the teeth or area of the mouth the image shows. If you have selected other, you must also complete the description box. When you have completed all the required fields, click the Upload file(s) button Note: The Upload file(s) button will not be accessible if any required fields have not been completed. A pop-up box will be presented, asking you to confirm you would like to upload the listed files. You cannot remove any files once they have been uploaded. 33

34 Once all your listed files have been uploaded, you will receive confirmation that the upload has been successful. You must then go to the Submission tab and indicate what attachments you have sent. If you have uploaded digital images, tick the box for Electronic Attachment Uploaded If you have submitted physical evidence, tick the box beside each bit of physical evidence sent in, so we know what to expect in the post. Important note: You must re-submit the request at this point. Your case cannot proceed for review without this action. 34

35 All physical evidence sent to us must have the patient s name, date of birth and the web form prior approval Case ID number attached. When we receive the physical evidence, we will send you a message to confirm we have them. If we do not receive a reply to our request after 28 days, we will send you a reminder. If we have still not received a reply after a further 14 days, the case will be closed and the status of the request on the List Claims/Prior Approval table will change to Closed. If you still wish to apply for approval for this course of treatment, you will need to submit a brand new request. If prior approval is no longer required, you must specify this on the Submission tab, by ticking the appropriate box. You must also indicate whether it was the patient or dentist who initiated this and include the reason in the box provided. You must then re-submit the request. If your request has been approved, the status on your List Claims/Prior Approval table will change to Approved. The Submission tab will now be populated with the Approval Date and Prior Approval Reference. This is the date and prior approval reference you will need to add to your claim when submitting for payment. 35

36 Re-Approvals: If you change your treatment plan after your request has been approved using the web form, you will need to apply for re-approval. Make the necessary changes to your treatment plan and add observations explaining why re-approval is required and what exactly has changed in the treatment plan. Go to the Submission tab and re-submit the request in the usual way. If you are seeking re-approval for a request previously approved on paper, create a new prior approval request in the web form, with the amended treatment details. Add observations explaining why re-approval is required and what exactly has changed in the treatment plan. You must also state the approval date from the previous paper approval. When you submit your payment claim electronically using your practice management system, the Approval Date and Prior Approval Reference from the Submission tab of the web form must be copied into the appropriate fields within your system, before the payment claim is submitted. 36