Frequently Asked Questions

Which Care Management Organization (CMO) is Avesis associated with?

Avesis is associated with Absolute Total Care by Total Care Carolina.

What is the relationship between Avesis and Peach State Health Plan?

Avesis has contracted with Absolute Total Care to provide enhanced dental services to Absolute Total Care Medicaid Members ages 21 and over.

Do Providers contract with Avesis or Absolute Total Care?

Providers seeking reimbursement for non-emergent eligible CDT codes for Absolute Total Care Members ages 21 and over should contract with Avesis directly.

Will third party liability still be the same?

Medicaid is the payer of last resort. If the Member has other health insurance, claims must be filed with that payer first. Upon receipt of the primary Remittance Advice (RA), you will submit a claim to Avesis with the primary payerís RA within 90 days of the date on the RA.

Will Providers get new provider numbers?

Providers will keep their current Medicaid number issued by the State of South Carolina. Providers will also be issued an Avesis Provider number. If a Provider does not currently have a Medicaid number, he/she will need to apply for one prior to becoming contracted with Avesis.

What is an NPI number?

The Health Insurance Portability and Accountability Act of 1996 (HIPPA) mandated that the Secretary of Health and Human Services adopt a standard unique health identifier for health care providers. On January 23, 2004, the Secretary published a Final Rule that adopted the National Provider Identifier (NPI) as this identifier. NPI is a unique identification number for health care providers that will be used by all health plans. Health care providers and all health plans and health care clearinghouses will use the NPI in the administrative and financial transactions specified by HIPAA. The NPI contains no embedded intelligence; that is, it contains no information about the health care provider such as the type of health care provider or State where the health care provider is located. The NPI must be used in connection with the electronic transactions identified in HIPAA. The NPI will not:

Source:
http://www.cms.hhs.gov/MLNMattersArticles/downloads/SE0528.pdf
http://aspe.hhs.gov/admnsimp/faqnpi.htm
http://www.ada.org/prof/resources/topics/npi.asp

Does Avesis pay on a Fee for Service Schedule?

Yes. Avesis will pay 100% of the Providerís contracted rate in effect on the Memberís date of service.

How will Absolute Total Care Members locate an Avesis dental provider?

An Avesis dental provider can be found: In a printed Provider Directory given to each Total Care Carolina Member. By contacting Member Services at Total Care Carolina

Will Absolute Total Care Members have to choose a primary care dentist?

No, the Absolute Total Care Member may go to any dentist in the Avesis provider network.

Is Absolute Total Care a 21 and over program?

No, Absolute Total Care is a CMO contracted by the State to render services to Medicaid enrollees both under and over 21 years of age. However, only Absolute Total Care Members ages 21 and over will have enhanced dental benefits with Avesis.

Can a Provider refuse to see a patient that does not have an identification card that comes into the office?

It is not necessary to refuse treatment to a Member because they do not present with their identification card. Eligibility can be verified with Absolute Total Care or Avesis for an Absolute Total Care member.

Is there a number to call where Providers can reach an actual person for assistance?

Avesis Provider Services is available to assist Providers at (800) 327-4462 Monday through Friday from 7 AM until 7 PM, except observed holidays.

Are the Enhanced Adult benefits available on all plans?

No, the benefits detailed in this manual and on the Avesis website are specific to Absolute Total Care.

How will I know that the Member has chosen to participate with Absolute Total Care?

The Member will present with an Absolute Total Care identification card.

When are Members considered adults for the purpose of this program?

The first day of the month following their 21st birthday is considered to be adulthood.

Will Providers have the capability to verify benefits?

Avesis recommends that Providers verify eligibility prior to each appointment.

How will Providers obtain eligibility information?

Providers have three options to obtain eligibility information:

Will Providers be able to view the Memberís benefits online?

Full benefit information is available on the Avesis website.

Do Providers need to verify eligibility each time a Member presents?

Yes, it is in the Providersí best interests to verify eligibility for each visit.

Will eligibility obtained be ďreal timeĒ information?

At this time, Avesis is scheduled to receive eligibility updates monthly.

Does Avesis process claims in real time?

Claims are processed in real time. The first clean claim received would have the highest likelihood for payment. Providers have ninety (90) days from the date of service to file a claim.

Is there a dental fee schedule?

Yes, the South Carolina Covered Fees and Benefits schedule can be found on the Avesis website and in the Provider Manual.

Does Avesis have a referral process?

Referrals are not required in this program.

Are Providers required to obtain Pre-Treatment Estimates in this progam?

Currently there are no services in the program that require pre-treatment estimate.

What if an Absolute Total Care Member ages 21 or over requests Non-Covered Services?

If, in the course of the exam, you determine that the Member requires services not covered by the Medicaid program you will be expected to discuss possible options with the Member. Should the Member choose to receive Non-Covered Services, the Non-Covered Services Form will be completed and signed by the provider and the Member.

Should I send a copy of the Non-Covered Services Form to Avesis?

No, this form becomes part of the Memberís permanent record.

Can the Non-Covered Services Form be completed online?

No, that is not possible since the form requires signatures.

Does the Enhanced Adult program have co-pays?

No, there are no co-pays on the program.

Will SCDHHS pay any benefits for Adults enrolled in Absolute Total Care?

SCDHHS will continue to pay claims for emergency services for members ages 21 and over. Only claims for covered, non Ė emergent services for which the Member is eligible should be filed to Avesis for those Absolute Total Care Members ages 21 and over.

Will Providers need to send a check with the EFT agreement?

Yes, providers interested in electronic remittance will need to provide Avesis a voided check with the completed EFT form which can be found in the manual.

Where do Providers send EFT Agreements?

Please mail the EFT Agreement and voided check to:

Avesis Third Party Administrators, Inc.
Attn: Finance
PO Box 782
Owings Mills, MD 21117

How are claims submitted to Avesis?

In one of three ways:

Will Avesis accept faxed claims?

No, Avesis does not accept faxed claims at this time.

Will Avesis accept HIPAA compliant electronic claims (837)?

Yes, Avesis will accept HIPAA compliant 837 claims.

How often are claims paid?

Avesis processes and pays all clean claims within fifteen (15) business days. Avesis will pay eligible clean dental claims on a weekly basis.

How do I get reimbursed if an Absolute Total Care Member has a dental emergency?

Providers who see Members on an emergency basis should submit their claim for payment to the SCDHHS.