As part of an effort to simplify providers’ participation in the state’s Medi-Cal Dental Benefits Program (Denti-Cal), CDA, with the cooperation of the State Department of Health Care Services’ Dental Services Department, has developed a guide to working within the program.
The Denti-Cal program is highly regulated in statute and DHCS rules. The department offers a detailed Provider Handbook, available on its website for dentists participating in the program that discusses provider enrollment, the scope of benefits, proper claim submission requirements, radiograph and other documentation requirements, and the like. The Handbook is the definitive and detailed guide for complying with the program’s requirements. However, given the Handbook’s size (nearly 500 pages), CDA considered that the development of a shorter guide or checklist that summarizes the major requirements of the program would be helpful to providers in the program.
The guide, entitled “Denti-Cal Provider Guide,” is divided into two main sections: Processing a Denti-Cal Patient Through the Dental Practice; and the Denti-Cal Billing Process. Summary information in the guide includes:
- The basic requirement of the program: providers treating Denti-Cal beneficiaries must be enrolled as providers in the program. References are available in the Dentist Handbook on becoming enrolled as a provider.
- How to verify a patient’s eligibility and enrollment in the Denti-Cal program.
- What information and diagnostic documentation is required on the Denti-Cal Treatment Authorization Request (TAR) and claim form.
- What benefits are covered by the program, and in particular, what benefits require prior authorization from Denti-Cal.
- Specific reference to recent revisions to benefits, such as third-molar extractions; allowed services to adults as required by federal requirements, including services to pregnant adults, to adults in residential care facilities and regional centers for developmentally disabled beneficiaries.
- Reference to specific information required on the TAR/claim form.
- What details are sent in response to a claim if additional information is required before Denti-Cal can process it.
- What details are on the Evidence of Benefits (EOB) form when Denti-Cal sends a check for services.
- The common reasons that an authorization request or claim are denied and how to avoid denials.
- What documentation is required when submitting a claim for treatment that has been preauthorized.
- What to do if a claim is denied, either in terms of resubmission of a claim, or appeal of the denial.
The Denti-Cal Provider Guide was recently made available for downloading and printing on the CDA Compass.