Envolve Dental Medicaid is a program that uses tools to improve the information sharing between Medicaid agencies, healthcare providers, and Envolve. With these tools, Envolve can effectively manage care, conduct regular check-ups, and prevent fraud and abuse. The system also allows sharing of important medical information with the necessary healthcare providers, leading to more straightforward and effective personalized healthcare treatment plans. Envolve Dental Medicaid utilizes these tools to improve the overall efficiency and effectiveness of Medicaid services, resulting in better outcomes for Medicaid beneficiaries.
Envolve Dental Program Overview
Envolve Dental is a Medicaid managed dental care program that provides comprehensive dental coverage to eligible children, adults, and pregnant women in New Jersey. This program is designed to improve access to quality dental care for Medicaid recipients and ensure they receive necessary treatments for maintaining good oral health.
The Envolve Dental program is administered by Magellan Healthcare, a national managed care organization with extensive experience in providing healthcare services. Magellan Dental provides a comprehensive range of dental services through its network of participating dental providers in the state.
Envolve Dental offers various benefits to its members, including:
- Preventive care: Routine cleanings, exams, fluoride treatments, and sealants.
- Diagnostic services: X-rays, CT scans, and pulp tests.
- Restorative care: Fillings, crowns, bridges, dentures, and extractions.
- Orthodontic care: Braces and other orthodontic treatments.
- Emergency care: Access to emergency dental services 24/7.
The Envolve Dental program also offers several unique features that enhance its value to members:
- Dental Home Model: The program encourages the establishment of a dental home, where members can receive ongoing care from a dedicated dentist who understands their oral health history and needs.
- Case Management: Members with complex oral health conditions or special needs can receive case management support to coordinate their care and ensure they receive the appropriate services.
- Transportation Assistance: Envolve Dental provides transportation assistance to members who need help getting to their dental appointments.
To be eligible for the Envolve Dental program, individuals must meet certain criteria:
- Be a New Jersey resident.
- Be enrolled in Medicaid.
- Be under the age of 21 (for children) or be pregnant or a parent of a child under the age of 19 (for adults).
Enrolling in the Envolve Dental program is easy. Individuals can enroll online, by phone, or through a participating dental provider. For more information about the Envolve Dental program, please visit the Magellan Healthcare website or call the customer service line.
| Program | Benefits | Eligibility | Enrollment |
|---|---|---|---|
| Envolve Dental | Comprehensive dental coverage, including preventive care, diagnostic services, restorative care, orthodontic care, emergency care, dental home model, case management, and transportation assistance. | New Jersey residents enrolled in Medicaid, under 21 years of age (for children), or pregnant or a parent of a child under 19 years of age (for adults). | Online, by phone, or through a participating dental provider. |
Medicaid Eligibility and Coverage
Medicaid is a comprehensive health insurance program funded by federal and state governments. It provides health coverage to millions of low-income individuals and families, including children, pregnant women, and individuals with disabilities. Medicaid is administered by state and county agencies, and eligibility requirements and coverage vary from state to state.
To be eligible for Medicaid, individuals must meet certain income and resource requirements. Income limits are based on a percentage of the federal poverty level (FPL). Resource limits vary from state to state, but typically include assets such as bank accounts, vehicles, and real estate.
In addition to income and resource requirements, individuals may also be eligible for Medicaid if they meet other criteria, such as being pregnant, having a disability, or being a child in a low-income family. Individuals who qualify for Supplemental Security Income (SSI) are automatically eligible for Medicaid.
Medicaid Coverage
Medicaid coverage varies from state to state, but typically includes the following services:
- Preventive care, such as well-child visits, immunizations, and cancer screenings
- Doctor visits and hospital stays
- Prescription drugs
- Mental health and substance abuse treatment
- Long-term care services, such as nursing home care and home health care
Some states also offer additional benefits, such as dental care, vision care, and transportation to medical appointments. To find out what Medicaid benefits are available in your state, you can contact your state Medicaid agency.
| State | Medicaid Dental Coverage |
|---|---|
| California | Children and adults with Medicaid are eligible for comprehensive dental coverage, including preventive, restorative, and emergency services. |
| Florida | Children with Medicaid are eligible for comprehensive dental coverage, including preventive, restorative, and emergency services. Adults with Medicaid are eligible for limited dental coverage, including preventive services and emergency services. |
| Texas | Children and adults with Medicaid are eligible for limited dental coverage, including preventive services and emergency services. |
Envolve Dental Provider Participation
To ascertain whether a dental provider participates in Envolve Dental Medicaid, individuals can utilize the following methods:
- Online Provider Directory: Patients can access the Envolve Dental website and utilize the provider search tool by inputting their ZIP code or the provider’s name to locate participating dentists in their vicinity.
- Contact Envolve Dental Customer Service: Individuals can contact Envolve Dental’s customer service department by dialing the phone number provided on their Medicaid card or visiting their website to inquire about participating providers.
- Provider Outreach: Patients can directly contact dental providers in their area to ascertain whether they accept Envolve Dental Medicaid. It is advisable to inquire about their participation status prior to scheduling an appointment.
It is recommended for individuals to confirm the provider’s participation status with Envolve Dental directly, as the information provided by the provider may not be up to date or accurate.
Envolve Dental Provider Reimbursement
Envolve Dental compensates providers for services rendered to Medicaid beneficiaries through a variety of methods, including:
- Fee-for-Service: Under this model, providers are reimbursed based on a predetermined fee schedule for each service they provide to Medicaid patients.
- Capitation: In this arrangement, providers receive a fixed monthly payment for each Medicaid patient they agree to care for, regardless of the number of services provided.
- Managed Care: Through managed care organizations (MCOs), providers are reimbursed based on a predetermined fee schedule or capitation, but they may also receive additional payments for meeting certain quality metrics or achieving specific health outcomes.
The specific reimbursement method used by Envolve Dental may vary depending on the state in which the services are provided and the type of provider.
Envolve Dental Provider Requirements
To participate in the Envolve Dental Medicaid program, providers must meet certain requirements, including:
- Licensure and Certification: Providers must possess a valid license and any necessary certifications to practice dentistry in the state where they are located.
- Provider Enrollament: Providers must enroll with Envolve Dental and complete the required application process, which may include submitting documentation of their qualifications and agreeing to comply with program rules and regulations.
- Quality Assurance: Providers must participate in quality assurance activities, such as performance reviews and continuing education, to ensure they are delivering high-quality care to Medicaid beneficiaries.
Envolve Dental may also have additional requirements for providers, such as specific training or experience, depending on the services they are providing.
Envolve Dental Provider Complaints
Individuals who have concerns or complaints about an Envolve Dental provider can take the following steps:
- Contact the Provider Directly: Patients may attempt to resolve the issue directly with the provider by discussing their concerns and attempting to reach a resolution.
- File a Complaint with Envolve Dental: Beneficiaries can file a complaint with Envolve Dental by contacting their customer service department or by submitting a complaint form online. Envolve Dental will investigate the complaint and take appropriate action, which may include conducting an audit or taking disciplinary action against the provider.
- Contact the State Medicaid Agency: Individuals can also contact the state Medicaid agency responsible for overseeing Envolve Dental to file a complaint. The state agency will investigate the complaint and may take action to address the issue.
It is important for individuals to report any concerns or complaints they have about an Envolve Dental provider to ensure that appropriate action is taken to address the issue and protect the health and safety of Medicaid beneficiaries.
Envolve Dental Provider Terminations
Envolve Dental may terminate a provider’s participation in the Medicaid program for various reasons, including:
- Failure to Meet Quality Standards: If a provider fails to meet the quality standards set by Envolve Dental, such as failing to provide appropriate care or meeting performance metrics, their participation may be terminated.
- Fraud or Abuse: Engaging in fraudulent or abusive activities, such as billing for services not rendered or providing unnecessary treatments, can result in termination from the program.
- Criminal Convictions: Providers who are convicted of certain crimes, such as Medicaid fraud or patient abuse, may be terminated from the program.
- Non-Compliance with Program Rules: Failure to comply with Envolve Dental’s rules and regulations, such as failing to maintain proper documentation or refusing to participate in quality assurance activities, can lead to termination.
When a provider is terminated from the Envolve Dental Medicaid program, they will be notified in writing and given an opportunity to appeal the decision.
Envolve Dental Medicaid Program
Envolve Dental is a dental Medicaid program that provides dental care to eligible individuals in certain states. The program is designed to help low-income individuals and families access affordable dental care.
Envolve Dental Claims
Dental providers who participate in the Envolve Dental program must submit claims for reimbursement for services provided to Medicaid-eligible patients. Claims must be submitted electronically through the Envolve Dental Provider Portal. Claims must include the following information:
- Patient’s name, date of birth, and Medicaid ID number
- Date of service
- Procedure code
- Tooth number (if applicable)
- Quantity of service
- Fee charged
Claims must be submitted within 120 days of the date of service.
Envolve Dental Reimbursement
Envolve Dental reimburses providers for covered services at a set rate. The reimbursement rate is based on the provider’s geographic location and the type of service provided. Providers can view the reimbursement rates for each procedure in the Envolve Dental Provider Manual.
Envolve Dental typically processes claims within 30 days of receipt. Providers can track the status of their claims through the Envolve Dental Provider Portal.
| Procedure Code | Description | Reimbursement Rate |
|---|---|---|
| D0120 | Comprehensive oral evaluation | $50 |
| D0150 | Periodic oral evaluation | $30 |
| D0210 | Prophylaxis – adult | $20 |
| D0220 | Prophylaxis – child | $15 |
| D2150 | Amalgam restoration – one surface, primary tooth | $50 |
| D2160 | Amalgam restoration – two surfaces, primary tooth | $60 |
| D2170 | Amalgam restoration – three or more surfaces, primary tooth | $70 |
Hey folks, thanks for sticking with me through this journey of exploring whether or not Envolve Dental is part of Medicaid. I appreciate you taking the time to dive into the details with me. Remember, healthcare can be a complex topic, so if you have more specific questions, don’t hesitate to reach out to your healthcare provider or a qualified professional. Keep an eye out for more informative and engaging content coming your way. Until next time, stay healthy and keep smiling!