CDA provides guidance on navigating Adult Denti-Cal

The partial restoration of California's adult Medi-Cal dental program and information on how to navigate its complexities was the topic of a packed lecture hall at the recent CDA Presents in Anaheim.

Although federally required adult dental services have been available to beneficiaries of Medi-Cal, adult optional Medi-Cal dental benefits were eliminated in July 2009, except for beneficiaries who are pregnant or residing in a skilled nursing facility or intermediate care facility.

With many benefits for adults restored May 1, the timely lecture entitled Adult Denti-Cal Services: Navigating the Renewal Program, sponsored by the CDA Policy Development Council, explained the treatment options and requirements of newly reestablished Denti-Cal benefits for adults. Presenters Tom Holloway, DDS, Nagaraja Murthy, DDS, and Nirmala Prabhu, DMD, offered valuable information concerning common denial codes in treatment authorization requests and claims, ways to reduce unnecessary denials and specific criteria for common restored procedures.

"We need the providers to come back to Medi-Cal," said Prabhu, a Denti-Cal consultant employed by Delta Dental, who offers training seminars for providers and their staff. "Once you get through the learning curve, Denti-Cal works."

The state eliminated funding for most adult Medi-Cal dental services other than mainly emergency care in 2009, and since then, many Medi-Cal providers, including dentists, due to the budget deficit, were hit with reimbursement rate cuts, including a 10 percent cut last October. In bringing back a program for adult beneficiaries, the state has restored funding at $77 million and is covering fewer services than in 2009. Restored benefits cover examinations, dental cleanings with fluoride treatments, basic restorative procedures, endodontic therapy for anterior teeth and return to function through the provision of some prosthodontic services.

The intent of the restoration of these adult dental benefits is to bring a patient back to a basic level of dental health by restoring existing teeth rather than extracting them. It is important for both fee-for-service and dental managed care providers to familiarize themselves with the benefits available to adults since the scope of services available under the Medi-Cal dental program has changed.

Pregnant adult beneficiaries, through 60 days after delivery, have benefits as required by the U.S. Centers for Medicare & Medicaid Services, in addition to the scope of restored adult benefits. That enhanced scope relates mainly to periodontal surgery and other perio procedures. A full list of specific dental procedures covered under the Medi-Cal dental program can be found at denti-cal.ca.gov.

As required under the provisions of the Affordable Care Act, the Department of Health Care Services (DHCS) must revalidate the enrollment of all providers at minimum once every five years which will require providers to submit a new enrollment application package in order to continue participation in the Medi-Cal Dental program. Revalidation is being done in a phased approach, and providers will receive written notification of their reenrollment when it is due. Providers should not submit a new enrollment application until they have been notified by a letter to do so. A practice owner should ensure that all of his or her rendering providers are enrolled in the Medi-Cal dental program prior to treating Medi-Cal patients.

In addition, dental offices should check on a patient's eligibility before providing treatment.

"One of the things you must be concerned about is whether the patient is eligible," said Holloway, also a Denti-Cal dental consultant for Delta Dental. "It's determined monthly based upon the patient's income, so you need to check eligibility."

Understanding the rules of the Denti-Cal program can be challenging to new and returning providers. Prabhu recommends dentists and their staff take advantage of seminars being offered as well as reading the monthly Denti-Cal Bulletin posted online that contains information about enrollment, eligibility, and changes to the program.

Prabhu adds that the state is working to review processes and make changes to Denti-Cal that benefit the program, members, and providers.

"If patients have had bad, decayed teeth, we no longer require prior authorization," said Prabhu. "They can provide the treatment and then submit the claim. That's a step we took to streamline the process and make it easier."

Due to the popularity of the Denti-Cal seminar, not all attendees who tried to sit in on the lecture were able to do so. A similar lecture will also be held at CDA Presents in San Francisco on Friday, Sept. 5.

For more information on the September lecture, view page 52 of the CDA Presents San Francisco Preliminary Program.