Update on eDental payment and prior approval modernisation project - October 2019

Our monthly update on the project to modernise payment and prior approvals as part of the eDental programme, covering:

  • eDental downtime notification - all services
  • eDental payment update
  • ePrior approval update
  • eOrthodontic payment and approval – mandated from 1 January 2020
    • PMS supplier update for eOrtho
    • GP17PR(O) forms and electronic signatures

 

eDental downtime notification - all services

On Wednesday 23 October 2019 between 4pm and 6pm, our services will be down for a new release. The details of changes are shown in the various sections below. Please avoid using any of the following services, as you will experience errors during this time if you attempt to do so:

  • CHI patient lookup
  • ePayments
  • ePrior approval
  • eOrtho

 

eDental payment update

We’re continuing to notice that some practices are not using the correct functionality provided with eDental in relation to the following points. By not following the correct process, practices may experience delays to claims being processed and paid:

  • Including unnecessary observations in cases. For example, patient failed to return but no fee is being requested (PFTR), referrals and continuation cases. New functionality is available in your practice management system (PMS) and the web form to provide the relevant information, without the need to add observations. These are all explained in the 'Summary of changes to observations' section in the PMS guide available on our website.
  • MIDAS reply letter. If we’ve rejected a claim and returned it to you on paper (this is known as a MIDAS reply letter; MIDAS is our payment system), the claim must be adjusted in either your PMS or the web form, and returned via eDental. Please do not send the paper MIDAS reply letter back. If you believe two patients have been linked incorrectly, for example, in the case of twins, then a 287 registration adjustment form should be downloaded from our website and sent to the customer administration team.
  • When claiming an incomplete 10(C), we ask that you include the following information:
    • the number of active treatment visits
    • if the active treatment is complete
    • the number of teeth that have been treated
    • the number of sextants that are involved

We currently need to adopt a workaround for submission of incomplete fees requested for patient failed to return (PFTR), in order to prevent payment adjustment scenarios.

When you have marked a claim as requesting a PFTR incomplete treatment fee, please add information to both the PFTR observation section and general observations.

If you are having issues with the payments aspect, please take a look at the eDental guidance in the first instance.

 

Payment rule changes

Previously, you may have received a Dental workflow return to dentist letter from us if you submitted a claim to us which took you over the maximum allowable treatments in an 11 month period for Item 44G. This is now being moved into the eDental rules engine, which means you would now receive the following rejection if you  trigger that rule:

  • E000853 “You have claimed more than the maximum number of treatments allowed within a given period for this patient.” In additional information – “No more than 2 claims for item 44(G) can be claimed for the same patient within an 11 month period” 

If a domiciliary dentist claims more than 2 Item 1E treatments in a 12 month period, the claim will be rejected:

  • E000853 - “You have claimed more than the maximum number of treatments allowed within a given period for this patient.” In additional information – “No more than 2 claims for item 1(E) can be claimed for the same patient within an 11 month period” 

Two rules have been refined so that if we receive a claim with a date of acceptance prior to 1 October 2018, it must have the Prior Approval date if there is a prior approval item on the claim, or reaches or exceeds the prior approval limit.  If the date of acceptance is on or after 1 Oct 2018, the Prior Approval date and Prior Approval reference must be supplied. The rules that have been refined include: 

  • E000696 - “One or more treatments require prior approval but no prior approval authorisation details have been specified.”
  • E000801 - “A valid Prior Approval reference number and/or Approval Date is required because one or more treatment items on the claim require prior approval. If the case was granted approval on paper, the approval date must be added to the claim. Electronic approvals require both the prior approval reference number and the approval date to be submitted on the claim.”


ePrior Approval

The majority of PMS suppliers are accredited to submit electronically. Please see the PMS supplier page for up to date information on each supplier’s position.

We’ve noticed in some instances that where a practice has moved to electronic submission, from having used the web form, some dentists have not gone back into the web form to pick up any updates on their outstanding prior approval cases. If you started a prior approval in the web form before moving to your electronic system to system solution, please log back in to the web form to check update responses on your outstanding web form cases. You may be required to take further action.

Our clinical team have advised that there are some common issues being experienced in ePrior Approval:

  • Practitioners are updating observations and advising of changes in treatment, but not updating the charting section. The charting section must be updated, or the request will be returned.
  • There appears to be a number of practitioners claiming fillings and crowns on the same tooth within the same course of treatment. This is not allowable under the Statement of Dental Remuneration, where only one can be claimed.
  • Physical evidence is being sent in, but the electronic request has not been updated to indicate physical evidence has been sent, and thereafter, resubmitted.

Our prior approval guidance remains available online, in addition to online videos and frequently asked questions. If you are receiving error messages you do not understand, please review the guidance on the web site in the first instance before contacting our Customer Services team, as many calls can be answered by looking at the guidance. If there are areas you feel would benefit from further guidance or require changes/further clarification, contact our Customer Services team via email at nss.psddental@nhs.net 

 

Prior Approval rule changes

A request submitted without any examination treatments was previously returned if the No Examination Reason was not included. This meant practices had to undertake a workaround for patients under 18, ensuring they added something into the text field. The rule has now been amended so it only applies to those over 18 years of age:

  • E001117 - “No exam reason field MUST be populated if not exams on claim and patient is over 18.” 

 

eOrthodontic payment and approval – mandated from 1 January 2020

As practitioners will be aware, the submission of orthodontic prior approval requests and payments must be submitted electronically from an accredited practice management system (PMS) from 1 January 2020. Practices are reminded that there is no web form solution available for Orthodontics, therefore if you undertake orthodontic activity, you must ensure you have a PMS which has been accredited for electronic orthodontic payment and approvals in order to be able to submit from 1 January 2020.

The Scottish Government have issued 2 PCAs in September, and then in October which relate to Orthodontic electronic submission:

  • PCA 2019(D)11 contains information relating to the phasing out of the GP17-O form and the introduction of the GP17PR(O) form.
  • PCA 2019(D)12 contains clarification of paragraph 4 of the above PCA with regards to electronic submission of Orthodontic payment claims and prior approval requests from 1 January 2020. It also gives details of the fee increase commencing 1 November 2019.

 

Update to existing eOrtho rule

An existing rule has been refined so that for interim payment, discontinued and final payment claims, when there is a prior approval item or the prior approval limit is reached or exceeded, if the date of acceptance is before 1 Jan 2020, the Prior Approval date must be supplied.  If the date is on or after 1 Jan 2020, the prior approval date and the prior approval reference must be supplied.  The following rule has been refined:

  • E000801 - “A valid Prior Approval reference number and/or Approval Date is required because one or more treatment items on the claim require prior approval. If the case was granted approval on paper, the approval date must be added to the claim. Electronic approvals require both the prior approval reference number and the approval date to be submitted on the claim.”


eOrtho Transition

From the practices who have transitioned across already for eOrtho, we have some learnings and top tips we can share that will help you avoid any delays in processing:

  • When submitting physical evidence, mark on the box submitted, “eOrtho”.
  • Only send the updated electronic submission request to us when you have sent the physical evidence to us.
  • If you receive a response requesting evidence for an IOTN 5 case, please ensure you supply all relevant photographs and radiographs.
  • If using discretionary code 3999 01, you must add observations.
  • If you are submitting electronically, do not submit the paper GP17-O as duplicate.

In addition, the team are aware that some GP17-O’s are being sent to our offices in Bain Square, Livingston. This will cause delays in processing. All paper correspondence relating to GP17-Os should be sent to:

        Dental Prior Approval Team
        South Gyle
        1 South Gyle Crescent
        Edinburgh
        EH12 9EB


PMS supplier update for eOrtho

Two PMS suppliers are currently accredited with eOrtho. For the current and up to date position of each PMS supplier, please check our eOrthodontic PMS supplier page

PMS Supplier testing will be undertaken in two parts. Part one is fit for purpose (Ffp) testing, which tests the technical connections and communication channels between the PMS and ourselves. The second part of supplier testing is accreditation and this takes place following a successful Ffp.  Accreditation is a verification process that allows us to test a set of valid business scenarios, which the PMS supplier must create as a dentist would, thus ensuring a level of satisfaction that their software will perform as expected. We generally allow around a month for Ffp and a further month for Accreditation, and ask that PMS suppliers take this into account when they plan their timescales.

 

GP17PR(O) PR forms and electronic signatures

The GP17PR(O) form has been developed to support the capturing of patient signatures.  These forms have been printed and issued to NHS Board stores. Any practice providing Orthodontic treatment, and not yet submitting payment claims and prior approval requests electronically should request supplies of the GP17PR(O) form from their NHS Board store as they transition from paper to electronic submission. Practices should retain these forms (either as electronic copy or paper format), and ensure that they are made available when requested to do so.

The GP17PR(O) electronic signature specification has now been made available to PMS suppliers, allowing them the opportunity to develop the changes required to capture patient signatures electronically using a digital signature pad or tablet. Electronic signatures are optional for PMS suppliers who wish to offer that service to their customers. Any PMS supplier wishing to offer the service must complete an accreditation process.  We’ve now added a table detailing the status of PMS suppliers with respect to electronic signatures on the Orthodontic PMS supplier web page. 

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