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Medi-Cal Dental Program Provider Handbook

The California Medi-Cal Dental Program Provider Handbook, also known as the Denti-Cal Handbook is updated with the information from the Denti-Cal Bulletins each quarter.

The Denti-Cal Handbook is provided to you in a Table of Contents format. It is also provided to you in Adobe Acrobat Reader. If you do not have this software installed, you can easily download this software by selecting Get Adobe Acrobat Reader.

TOC Main Table of Contents
SECTION 1 Introduction
Program Background
Program Objectives
Current Dental Terminology (CDT) Copyright
SECTION 2 Program Overview
Provider Participation in the California Medi-Cal Dental (Denti-Cal) Program
Compliance the Denti-Cal Program
Out-of-State Coverage
Written Correspondence
Suspended and Ineligible Providers
Enrollment Denied for Failure to Disclose Fraud or Abuse, or Failure to Remediate Deficiencies
General Telephone Information
Contact Listings for Denti-Cal
Internet Access and Web Sites
Training Program
Provider Appeals Process
Health Insurance Portability and Accountability Act (HIPAA) and the National Provider Identifier (NPI)
Freedom of Information Act (FOIA)-Disclosable Data
Electronic Data Interchange (EDI)
Overview of TAR and Claim Processing
Prior Authorization
Billing and Payment Policies
Time Limitations for Billing
Interim Payments
Retroactive Reimbursement for Medi-Cal Beneficiaries for Out-of-Pocket Expenses
Medicare/Medi-Cal Crossover Claims
Orthodontic Services Program
Dental Restorations for Children Under Age Four and for Developmentally Disabled Beneficiaries of Any Age
Hospital (Special) Cases
SECTION 3 Enrollment Requirements
Provider Application and Disclosure Forms
Rendering Provider Enrollment Process
Provisional Provider Status
Tax Identification Number
No Claim Activity for 12 Months
Voluntary Termination of Provider Participation
Enrollment of Billing Intermediaries
Electronic Claims Submission and Payment Services
Medi-Cal Dental Patient Referral Service
Electronic Funds Transfer
SECTION 4 Treating Beneficiaries
Beneficiary Identification
Verifying Beneficiary Identification
Denti-Cal Beneficiary Eligibility
Verifying Beneficiary Eligibility
Share of Cost (SOC)
Interactive Voice Response System (IVR)
Beneficiary Coverage
Copayment Requirements for Denti-Cal Services
Limited Dental Benefits for Pregnant Women
Other Health Coverage
Prepaid Health Plan (PHP)/Health Maintenance Organization (HMO)
Child Health and Disability Prevention (CHDP) Gateway
Altered Cards and Other Abuses of the Denti-Cal Program
Prevention of Identity Theft
Beneficiary Complaint or Grievance Procedures
Grievance and Complaint Procedures to the Department of Managed Health Care
State Hearing
Aid Codes
SECTION 5 Manual of Criteria and Schedule of Maximum Allowances
Current Dental Terminology 13 (CDT 13) Codes – Preface
CDT 13-14 Codes
Denti-Cal Schedule of Maximum Allowances
Denti-Cal Forms
Ordering Forms
Optical Character Recognition (OCR)/Intelligent Character Recognition (ICR)
Correct Use of Denti-Cal Envelopes
Treatment Authorization Request (TAR)/Claim Forms
Notice of Authorization (NOA)(DC-301, Rev. 10/06)
Notice of Denti-Cal Action
Resubmission Turnaround Document (RTD)(DC-102, Rev.07/93)
Claim Inquiry Form (CIF)(DC-003, Rev. 07/09)
Claim Inquiry Response (CIR)
Time Limitations for NOAs
Justification of Need for Prosthesis (DC054, Rev 10/05)
Sample Handicapping Labio-Lingual Deviation (HLD) Index California Modification Score Sheet (DC-016, Rev 04/07)
Explanation of Benefits (EOB)
Adjudication Reason Codes
Claim in Process Reason Codes
Accounts Payable/Accounts Receivable Codes
Readjudication Codes
Resubmission Turnaround Document (RTD) Codes and Messages
TAR/Claim Policy Codes and Messages
Claim Inquiry Response (CIR) Status Codes and Messages/Claim Inquiry Form (CIF) Action Codes and Messages
Prepaid Health Plans (PHP) and Codes
SECTION 8 Fraud, Abuse and Quality of Care
Surveillance and Utilization Review Subsystem (S/URS)
Statutes and Regulations Pertaining to Providers
Billing Denti-Cal
Prohibition of Rebate, Refund, or Discount
Overpayment Recovery
Civil Money Penalties
Utilization Controls
Administrative Hearings
Beneficiary Fraud
SECTION 9 Special Programs
California Children's Services (CCS)
Genetically Handicapped Person's Program (GHPP)
CCS-only and CCS/Healthy Families Benefits
Contact Listings for Denti-Cal, Medi-Cal Eligibility, GHPP, and CCS
Orthodontic Services Program
Initial Orthodontic Evaluation and Completion of the HLD Index Score Sheet
Early and Periodic Screening, Diagnosis, and Treatment (EPSDT) Services
SECTION 10 CDT 13 Tables
SECTION 11 Glossary
SECTION 12 Bulletin Index
SECTION 13 Index
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