The portal system grants participating providers access to eligibility along with information pertaining to claims and pre-determinations The Argus Dental portal
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I HEREBY AUTHORIZE PAYMENT DIRECTLY TO THE BELOW NAMED DENTIST OF THE GROUP INSURANCE BENEFITS OTHERWISE PAYABLE TO ME
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1 © 2013 Argus Dental Plan, Proprietary & Confidential
Argus Dental Plan, Inc.
Provider Manual
Argus Dental Plan, Inc.
Provider Manual
Please refer to your Participation Agreement for plans in which you contract.Argus Dental Plan, Inc.
4010 West State Street
Tampa, FL 33609
www.argusdental.com This document contains proprietary and confidential information and may not be disclosed to others without written permission. 2 © 2013 Argus Dental Plan, Proprietary & ConfidentialArgus Dental Plan, Inc.
Provider Manual
Contact Information
Department Phone Numbers
813-831-4522 Compliance
877-864-0625 Customer Service - Toll
813-864-0625 Customer Service - Local
Department Faxes:
Appeals: 813-283-4259
Claims: 813-400-1783
Compliance /FWA/SIU: 813-283-2411
Credentialing: 813-400-1781
Grievances: 813-283-2457
Pretreat - Emergency: 813-283-2412
Pretreat -Standard: 813-283-2441
Provider Relations: 813-400-1782
Quality: 813-283-2405
Department Emails:
Compliance: compliance@argusdental.com -
Credentialing: credentialing@argusdental.com
Management Information Systems:
mis@argusdental.com Pre - Authorization: pre-authorization@argusdental.comProvider Relations: pr@argusdental.com
Quality: quality@argusdental.com
Sales & Marketing: sales.marketing@argusdental.com 3 © 2013 Argus Dental Plan, Proprietary & ConfidentialArgus Dental Plan, Inc.
Provider Manual
The Florida Patient's Bill of Rights and ResponsibilitiesFlorida law requires that your health care provider or health care facility recognizes your rights while
you are receiǀing dental care and that you respect the health care proǀider's or health care facility's
right to expect certain behavior on the part of you the patient. You may request a copy of the full text of
this law from your health care provider or health care facility. A summary of your rights and responsibilities are as follows:9 A patient has the right to be treated with courtesy and respect, with appreciation of his or her individual
dignity, and with protection of his or her need for privacy.9 A patient has the right to a prompt and reasonable response to questions and requests.
9 A patient has the right to know who is providing dental services and who is responsible for his or her
care.9 A patient has the right to know what patient support services are available, including whether an
interpreter is available if he or she does not speak English.9 A patient has the right to know what rules and regulations apply to his or her conduct.
9 A patient has the right to be given by the dental care provider, information concerning diagnosis,
planned course of treatment, alternatives, risks and prognosis.9 A patient has the right to refuse any treatment, except as otherwise provided by law.
9 A patient has the right to be given, upon request, full information and necessary counseling on the
availability of known financial resources for his or her care.9 A patient has the right to receive, upon request, prior to treatment, a reasonable estimate of charges for
dental care.9 A patient has the right to receive a copy of a reasonably clear and understandable, itemized bill and, upon
request, to have the charges explained.9 A patient has the right to impartial access to dental treatment or accommodations, regardless of
race, national origin, religion, physical handicap, or source of payment.9 A patient has the right to treatment for any emergency dental condition that will deteriorate from
failure to receive treatment.9 A patient has the right to know if dental treatment is for purposes of experimental research and to give
his or her consent or refusal to participate in such experimental research.9 A patient has the right to express grievances regarding any violation of his or her rights, as stated in
Florida law, through the grievance process of the dental care provider or dental care facility which served
the patient and to the appropriate state licensing agency.9 A patient is responsible for providing to his or her dental care provider, to the best of his or her
knowledge, accurate and complete information about present complaints, past illnesses, hospitalizations, medications, and other matters related to his or her health.9 A patient is responsible for reporting unexpected changes in his or her condition to the dental care
provider.9 A patient is responsible for reporting to his or her dental care provider whether he or she comprehends a
contemplated course of action and what is expected of him or her.9 A patient is responsible for following the treatment plan recommended by his or her dental care provider.
4 © 2013 Argus Dental Plan, Proprietary & ConfidentialArgus Dental Plan, Inc.
Provider Manual
9 A patient is responsible for keeping appointments and, when he or she is unable to do so for any
reason, for notifying the dental care provider or dental care facility.9 A patient is responsible for his or her actions if he or she refuses treatment or does not follow the dental
care proǀider's instructions.9 A patient is responsible for assuring that the financial obligations of his or her dental care are fulfilled as
promptly as possible.9 A patient is responsible for following dental care facility rules and regulations affecting patient conduct
Statement of Provider Rights and Responsibilities
Disclaimer:
changes to this document.The Plan strives to provide the most accurate, up-to-date and reliable information within this document,
however the Plan reserves the right to update this document as needed.Providers shall have the right to:
1) Communicate with their patients regarding dental treatment options.
2) Recommend a course of appropriate treatment for the patient.
3) File an appeal or complaint pursuant to the procedures of Plan.
4) Supply accurate, relevant, factual information to the patient or designee in connection with
an appeal or complaint.5) Dispute policies, procedures, or decisions made by Plan.
6) If a recommended course of treatment is not covered, e.g., not approved by Plan, the
participating Provider must notify the member in writing and obtain a signature of waiver if the Provider intends to charge the member for such a non-compensable service.7) Upon request, providers shall be informed of their credentialing application status. .
8) Participating Providers are responsible for verifying that members are eligible prior to services
being rendered, and to determine if recipients have other dental coverage. 5 © 2013 Argus Dental Plan, Proprietary & ConfidentialArgus Dental Plan, Inc.
Provider Manual
TABLE OF CONTENTS
Plan Eligibility and Member ID Card ...................................... p.7 Specialist Referral ............................................................. p.8-12 Emergency Referral ............................................................. p.12 Claim Submission ........................................................... p.13-15 Coordination of Benefits ................................................ p.15-17 Grievance and Appeals ................................................... p.17-18 Utilization Management Program ....................................... p.19 Quality Improvement Program ........................................... p.20 Credentialing ....................................................................... p.21 6 © 2013 Argus Dental Plan, Proprietary & ConfidentialArgus Dental Plan, Inc.
Provider Manual
The Patient Record ......................................................... p.21-25 Compliance .......................................................................... p.25 Patient Recall System & Compliance Verification .......... p.25-26 Community Practice ............................................................ p.26 Discipline of Providers ......................................................... p.27 Radiology Requirements ................................................ p.27-29 Clinical Criteria ............................................................... p.30-37 Cultural Competency Program ............................................ p.37 Reimbursement of Services Rendered ................................ p.38 Website links to online HIPAA Resources....................... p.38-39 7 © 2013 Argus Dental Plan, Proprietary & ConfidentialArgus Dental Plan, Inc.
Provider Manual
Plan Eligibility
Any person enrolled in the Plan program is eligible for benefits under the certificate.Member Identification Card
Members will receive a plan ID card. Participating providers are responsible for verifying that members
are eligible prior to the services being rendered and to determine if recipients have other dental coverage.Please note that due to possible eligibility status changes, this information does not guarantee payment
and is subject to change without notice.Argus Dental's Eligibility Systems
The Plan offers three options to providers needing to obtain eligibility information. Those options are an
Interactive Voice Response (IVR), faxback line and web portal system.Interactive Voice Response (IVR)
Upon calling the Argus Dental toll-free number 888.978.9513, providers are presented with threeoptions for assistance. After dialing the toll free number, option 1 guides participating providers to the
Argus Dental portal system. Option 2 directs providers to the Argus Dental faxback line. Providers can
press option 3 to discuss matters with an Argus Dental agent. 8 © 2013 Argus Dental Plan, Proprietary & ConfidentialArgus Dental Plan, Inc.
Provider Manual
IVR Faxback Eligibility System
Upon calling the Argus Dental toll-free number 888.978.9513, providers are presented with threeoptions for assistance. After dialing the toll-free number, option 1 guides participating providers to the
Argus Dental portal system. Option 2 directs providers to the Argus Dental faxback line. Providers can
press option 3 to discuss matters with an Argus Dental agent.Access eligibility information via Internet:
Participating providers can access the Argus Dental portal system by logging onto http://argusdental.com/portal.htm by registering with their tax identification number and NPI. Theportal system grants participating providers access to eligibility along with information pertaining to
claims and pre-determinations. The Argus Dental portal system also allows participating providers to submit claims and pre-determinations directly to Argus Dental.The portal system currently allows Providers to verify a member's eligibility as well as submit claims
directly to the Plan.1. Go to : http://argusdental.com/portal.htm
2. Press the Register button
4. Please enter your Name, TIN, NPI and phone number.
5. Please enter your username, password, email and security question/answer
6. From here you will be granted access to view patient eligibility, claim information, and even
upload claims if you wish!7. Questions can be sent to mis@argusdental.com
We will require your TIN, NPI and phone number along with the proǀider's name and and/or practice name. From here, we can grant you access to your members eligibility and claim information.Please note that due to possible eligibility status changes, the information provided by either system
does not guarantee payment.If you are having difficulty accessing either the IVR or website, please contact the member services at
1.888.978.9513. They will be able to assist you in utilizing either system.
Website: Provider Section
Providers can access the Argus Dental website provider section to important plan information and required documents. 9 © 2013 Argus Dental Plan, Proprietary & ConfidentialArgus Dental Plan, Inc.
Provider Manual
Specialist Referral Process
The Plan requires a primary care dentist to contact the Dental's Case Manager if the primary care dentist
determines that the member needs to be referred to a specialist. The primary care dentist shall provide
the reason for the referral and any pertinent member information required in order for the specialist to
see the member.Specialists include:
Endodontist
Orthodontist
Oral Surgeon
Periodontist
Prosthodontist
Specialist Referral Process and Form
Primary Care dentist will provide most of the dental treatment that Members need but when a Primary Care dentist determines that the dental services a Member needs is outside the scope of their capabilities, the dentist will submit a specialist referral to Argus on the Member's behalf. Argus will determine if the treatment outlined in the referral is necessary depending on the documentation provided by the primary care dentist and the authorization guidelines. Once it is determined that the treatment is necessary, an Argus case coordinator will locate and contact an in-network Specialist and inform the office of the pending member's name and referral purpose. The Argus
case coordinator will then contact the Member and advise them of the Specialist to contact for the referred procedures. The specialist referral form can be found on p. xx in the back of the manual. You may also download online at www.argusdental.com/providers/fhk/ Password: dental (lowercase)Pediatric Dentists
The Plan requires a referral to a pediatric dentist, only if the pediatric dentist is acting as a specialist, and
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