69
Denti - Cal Safety Net Clinic Seminar Outreach Team B-OUT-TRN-007.C 03/13/18 1
Denti-Cal
Safety Net Clinic
Seminar
Outreach Team
B-OUT-TRN-007.C 03/13/18 1
B-OUT-TRN-007.C 03/13/18 2
This packet has been designed as a
training tool. The information in this
packet contains only some of the
Denti-Cal policies, procedures, criteria
and does not reflect any Medi-Cal
processing or error codes. It is not
intended to replace the detailed
information covered in the Denti-
Cal/Medi-Cal Provider Handbook. This
information is subject to change.
Providers are notified of changes to the
Denti-Cal program via Denti-Cal
Bulletins.
Thank You
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Denti-Cal Outreach
Services offered
Denti-Cal Criteria
Universities
Encounter/Fee for Services Match
Health Fairs; Beneficiary Enhancements
The primary objective of the California Medi-Cal Dental
Program is to create a better dental care system and
increase the quality of services available to those individuals
and families who rely on public assistance to help meet their
health care needs.
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Encounter Rate Fee For Service
FQHC**RHC**IHS Provider
Medi-Cal Guidelines
Eligibility
History Check
Program Limitations
Patient Education
Scope of Benefits
Program Limitations
Required X-rays &
Documentation
Patient Education
Front Office Back Office
B-OUT-TRN-007.C 03/13/18 6
The Denti-Cal Website
www.denti-cal.ca.gov
The Denti-Cal Website
www.denti-cal.ca.gov
B-OUT-TRN-007.C 03/13/18 7
The Denti-Cal Website
www.denti-cal.ca.gov
The Denti-Cal Website
www.denti-cal.ca.gov
B-OUT-TRN-007.C 03/13/18 8
Important Phone Numbers & Websites
For Denti-Cal Providers
Providers Toll-Free Line 800-423-0507
Beneficiary Toll-Free Line 800-322-6384
A.E.V.S. / P.O.S. / Internet Help Desk 800-541-5555
Medi-Cal Website (to verify beneficiary Eligibility) www.medi-cal.ca.gov
Denti-Cal Website www.denti-cal.ca.gov
CA Dept. of Public Health
http://hfcis.cdph.ca.gov/servicesandfacilities.aspx
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Eligibility
The County Dept. of Social Services establishes
eligibility
Information is transferred to the Dept. of Health
Care Services (DHCS)
Verify eligibility monthly
Eligibility Verification Confirmation Number (EVC)
The Medi-Cal Benefits Identification Card (BIC)
BenefitsIdentification
Card
State ofCalifornia
ID No. 99999999999999
FIRST M. LAST
M mm dd yyyy Issue Date 04 01 05
First M. LastThis card is for identification ONLY. It does not
guarantee eligibility. Carry this card with you to
your medical provider. DO NOT THROW AWAY
THIS CARD. Misuse of this card is unlawful.
SIGNATURE
Front
Back
B-OUT-TRN-007.C 03/13/18 11
Eligibility
The Medi-Cal program verifies eligibility
3 ways to verify eligibility thru the Point of Service
(POS) Network
1. Touch Tone Telephone (AVES)
2. Internet (www.medi-cal.ca.gov)
3. POS Device
Request a POS Network/Internet Agreement from the
POS/Internet Help Desk or Medi-Cal website
Service Type:Primary Care Physician Phone#:
Recipient County:
Trace Number (Eligibility Verification Confirmation (EVC) Number):
Second Special Aid Code:
HIC Number:
Eligibility Message:
Remaining Spend Down (SOC) Amount:Spend Down Amount (Share of Cost) Obligation:
Name:
Recipient ID:
Date of Service: Date of Birth: Date of Issue:
Primary Aid Code: First Special Aid Code:
XXXXXXXXXX
Web Eligibility
B-OUT-TRN-007.C 03/13/18 12
Additional Information
Aid Code information may
be found in the Denti-Cal
Provider Handbook
Type of Benefits
Share of Cost (SOC)
Aid Codes
Not everyone receiving Medi-Cal has full-scope benefits
Limited Services
Restricted Services
Emergency only Services
DENTI-CALCALIFORNIA MEDI-CAL DENTAL PROGRAM
P.O. BOX 15610SACRAMENTO, CALIFORNIA 95852-0610Phone 800-423-0507
DENTI-CALCALIFORNIA MEDI-CAL DENTAL PROGRAM
P.O. BOX 15610SACRAMENTO, CALIFORNIA 95852-0610Phone 800-423-0507TREATMENT AUTHORIZATION REQUEST (TAR) / CLAIMTREATMENT AUTHORIZATION REQUEST (TAR) / CLAIM
3.SEX
M F
3.SEX
M F
4.PATIENT BIRTHDATE
MO DAY YR
4.PATIENT BIRTHDATE
MO DAY YR5. MEDI-CAL BENEFITS ID NUMBER5. MEDI-CAL BENEFITS ID NUMBER
7. PATIENT DENTAL RECORD NUMBER7. PATIENT DENTAL RECORD NUMBER
ZIP CODEZIP CODE 8. REFERRING PROVIDER NUMBER8. REFERRING PROVIDER NUMBER
1.PATIENT NAME (LAST, FIRST,M.I.)1.PATIENT NAME (LAST, FIRST,M.I.)
6.PATIENT ADDRESS
CITY, STATECITY, STATE
9. YESYESCHECK IFCHECK IF
RADIOGRAPHS ATTACHED?RADIOGRAPHS ATTACHED?
HOW MANY?_____________HOW MANY?_____________
YESYES
11.
ACCIDENT/INJURY?
EMPLOYMENT RELATED?
11.
ACCIDENT/INJURY?
EMPLOYMENT RELATED?
CHECK IFCHECK IF YESYES
YESYES
YESYES
13.
OTHER DENTAL COVERAGE?
13.
OTHER DENTAL COVERAGE?
14.
MEDICARE DENTAL COVERAGE?
14.
MEDICARE DENTAL COVERAGE?
15. RETROACTIVE ELIGIBILITY?
(EXPLAIN IN COMMENTS SECTION)
(SEE PROVIDER MANUAL)
15. RETROACTIVE ELIGIBILITY?
(EXPLAIN IN COMMENTS SECTION)
(SEE PROVIDER MANUAL)
YESYES
YESYES
YESYES
16.16.
17.17.
18.18.
CHDP
CHILD HEALTH AND
DISABILITY PREVENTION?
CHDP
CHILD HEALTH AND
DISABILITY PREVENTION?
ccs
CALIFORNIA CHILDREN SERVICES?
ccs
CALIFORNIA CHILDREN SERVICES?
MF-O
MAXILLOFACIAL - ORTHODONTIC
SERVICES?
MF-O
MAXILLOFACIAL - ORTHODONTIC
SERVICES?
YESYES
YESYES
YESYES
19. BILLING PROVIDER NAME (LAST,FIRST,M.I.)19. BILLING PROVIDER NAME (LAST,FIRST,M.I.) 20. BILLING PROVIDER NUMBER20. BILLING PROVIDER NUMBER
21. MAILING ADDRESS 21. MAILING ADDRESS TELEPHONE NUMBER
( )
TELEPHONE NUMBER
( )CITY, STATE CITY, STATE ZIP CODEZIP CODE
22. PLACE OF SERVICE22. PLACE OF SERVICEOFFICE HOME CLINIC SNF ICF OFFICE HOME CLINIC SNF ICF
HOSPITAL
IN-PATIENT
HOSPITAL
IN-PATIENT
HOSPITAL
OUT-PATIENT
HOSPITAL
OUT-PATIENT
OTHER(PLEASE SPECIFY)
OTHER(PLEASE SPECIFY)
EXAMINATION AND TREATMENTEXAMINATION AND TREATMENT
26.TOOTH#/LTR,
ARCH,QUAD
26.TOOTH#/LTR,
ARCH,QUAD
28.28. 32.
FEE
32.
FEE
33.
RENDERING
PROVIDER NO.
33.
RENDERING
PROVIDER NO.
CHECK IFCHECK IF CHECK IFCHECK IF
11
33
44
55
66
77
88
99
1010
22
34. COMMENTS34. COMMENTS TOTAL FEE
CHARGED
TOTAL FEE
CHARGED
36.36.
37.37.
38.38. DATE
BILLED
DATE
BILLED
IMPORTANT NOTE:IMPORTANT NOTICE:
In order to process your TAR/Claim an X-ray envelope containing your
radiographs, if applicable, MUST be attached to this form. The X-Ray
envelopes (DC-214A and DC-214B) are available free of charge from
the Denti-Cal Forms Supplier.SIGNATURE DATE
SIGNATURE OF PROVIDER OR PERSON AUTHORIZED BY PROVIDER TO BIND PROVIDER BY ABOVE SIGNATURE TO
STATEMENTS AND CONDITIONS CONTAINED ON THIS FORM.
X
DO NOT WRITE IN THIS AREA
MF-OMAXILLOFACIAL - ORTHODONTIC
SERVICES?
MF-OMAXILLOFACIAL - ORTHODONTIC
SERVICES?
12.ELIGIBILITY PENDING?
(SEE PROVIDER MANUAL)
12.ELIGIBILITY PENDING?
(SEE PROVIDER MANUAL)
10.
OTHER ATTACHMENTS?
10.
OTHER ATTACHMENTS?
BIC Issue Date:
EVC #:
BIC Issue Date:
EVC #:
1 2 3 4 5 6 7 8 1 2 3 4 5 6 7 8
DESCRIPTION OF SERVICE
(INCLUDING X-RAYS, PROPHYLAXIS, MATERIALS USED, ETC.)
DESCRIPTION OF SERVICE
(INCLUDING X-RAYS, PROPHYLAXIS, MATERIALS USED, ETC.)
27.
SURFACES
27.
SURFACES
30.
QUANTITY
30.
QUANTITY
31.
PROCEDURE
NUMBER
31.
PROCEDURE
NUMBER
29.
DATE SERVICE
PERFORMED
29.
DATE SERVICE
PERFORMED
PATIENT
SHARE- OF- COST
AMOUNT
PATIENT
SHARE- OF- COST
AMOUNT
35.35.
39. THIS IS TO CERTIFY THAT TO THE BEST OF MY KNOWLEDGE THE INFORMATION CONTAINED ABOVE AND ANY ATTACHMENTS
ROVIDED IS TRUE, ACCURATE, AND COMPLETE AND THE REQUESTED SERVICES ARE NECESSARY TO THE HEALTH OF THE
PATIENT. THE PROVIDER HAS READ, UNDERSTANDS, AND AGREES TO BE BOUND BY AND COMPLY WITH THE STATEMENTS
AND CONDITIONS CONTAINED ON THE BACK OF THIS FORM.
OTHER
COVERAGE
AMOUNT
OTHER
COVERAGE
AMOUNT
DC-217 (R09/09)
Last , First x mm dd yy 99999999999999
Address
Address 00000
ADAMS, JAMES DDS 1234567891
30 CENTER STREET xxx xxx-xxxx
ANYTOWN, CA 95814 123456CN12
#8 Pain & swelling – periapical abscess.John Smith, DDS
Mary Smith 03 03 11
03/03/11
8 Extraction of erupted tooth 03 03 11 D7140 85.00 1111111112
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Other Insurance Coverage
Managed Care Plans
Other Coverage
Indemnity Plans
Medi-Cal / Denti-Cal is always secondary carrier / Other
coverage must be billed first
Share of Cost
Is a pre-set amount determined by DHCS for an individual
or family
Any Health Care Services may be used
Non Covered Services may be used to meet SOC
Update SOC
Case Numbers
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Eligibility Check List
Patient Last Name____________________ First Name____________________
BIC #__________________________ Issue Date _________________________
Birthdate (mmddyy) _______________ Date of Service (mmddyy) _____________
Month/Year Checked:
_________
JAN
FEB
MAR
APR
MAY
JUN
JUL
AUG
SEPT
OCT
NOV
DEC
Aid Code _____ Scope of Benefits--Full / Restricted / No benefits
Emergency Services only? Yes No
Share of Cost? Yes No
SOC Amount $_______
SOC Remaining $_______
Must complete SOC transaction
Other Coverage? Yes No
Type- Indemnity A. Regular B. Capitation
Medi-Cal A. HMO B. PHPC. MCP
EVC # ______________________________
* Check Scope of Coverage: “D”= DentalOr
* Call _______________ if number is given
*Is dental coverageincluded?
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Program Overview
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Encounter / Visit
A “visit” is a face-to-face encounter between an FQHC,RHC, or IHS patient and a physician*,
physician assistant, nurse practitioner, certified nurse midwife, clinical psychologist, licensed
clinical social worker or visiting nurse (as defined in Code of Federal Regulation, Title 42,
Section 405.2416), referred to as a “health professional,” to the extent the services are
reimbursable under the State Plan.
*Physician Defined:
A doctor of medicine or osteopathy
A doctor of podiatry
A doctor of optometry
A doctor of chiropractics
A doctor of dental surgery (dentist)
Source: Medi-Cal website: http://www.medi-cal.ca.gov Rural Health Clinics (RHCs) and Federally Qualified Health Centers (FQHCs): Outpatient Services 452, May 2012
Rendering Providers
Rendering Providers not
currently active in the
Medi-Cal Dental Program,
must submit a Medi-Cal
Rendering Provider
Application (DHCS 6216)
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Qualifying Visits
“Clinic visits at which the patient receives services “incident to”
physician services (for example, a laboratory or X-ray
appointment) do not qualify as reimbursable visits.”
Source: Medi-Cal website: http://www.medi-cal.ca.gov Rural Health Clinics (RHCs) and Federally Qualified Health Centers (FQHCs): Outpatient Services 452, May 2012
Records
Treatment Authorization Requests (TARs) are not required for servicesrendered by FQHC, RHC and IHS clinics.
What takes the place of a TAR?
Having the dentist ‘authorize’ the treatment
and
Maintaining the patient’s medical record, using the same level ofdocumentation that is needed for prior authorization approval. (i.e.,radiographs, DC054 form, written narrative, etc)
B-OUT-TRN-007.C 03/13/18 20
Criteria~ Most Commonly Used Procedures ~
Resource
Medi-Cal Dental Program Provider HandbookWebsite: https://www.denti-cal.ca.gov/Dental_Providers/Denti-Cal/Provider_Handbook/
Section 5- Manual of Criteria and Schedule of Maximum Allowances:
https://www.denti-cal.ca.gov/DC_documents/providers/provider_handbook/handbook.pdf#page=135
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DIAGNOSTICD0100 – D0999
Comprehensive Oral Evaluation D0150
A benefit
Once per patient per billing provider for initial
evaluation
For beneficiaries age 3 and older
Additional D0150 allowable if no D0120 or D0150 paid to
same billing provider within previous 36 months
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Periodic Oral Evaluation D0120
A benefit
Once every 6 months per billing provider for beneficiaries
age 3 through 20
At least 6 months following comprehensive oralevaluation (D0150) by same billing provider
Once every 12 months per billing provider for
beneficiaries age 21 and older
At least 12 months following comprehensive oral
evaluation (D0150) by same billing provider
A benefit
Under the age of 3
Once every 3 months per billing provider
For recording history, caries susceptibility, developing
appropriate oral health regimen, and counseling of the
child’s parent, legal guardian and/or primary caregiver
ORAL EVALUATION FOR A PATIENT UNDER AGE 3 AND COUNSELING WITH PRIMARY
CAREGIVER
D0145
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Radiographs /Photos
Are considered current if taken:
Within 8 months for children
Within 14 months for adults
Within 36 months for arch integrity films
Arch integrity films are not required
for patients under 21
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PREVENTIVED1000 - D1999
CHILD – UNDER AGE 21
D1120 – Prophylaxis
D1208 – Fluoride
D1206 – Fluoride Topical Fluoride Varnish
Benefit once in a 6-month period per patient without prior
authorization
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ADULT – AGE 21 & OLDER
D1110 – Prophylaxis
D1208 – Fluoride
D1206 – Topical Fluoride Varnish
Benefit once in a 12-month period per patient without prior
authorization
Sealants D1351
A benefit under the age 21 for 1st & 2nd permanent molars
Occlusal surface must be caries/restoration free
Occlusal surface must be sealed
Indicate tooth # & tooth surfaces being sealed
Original provider is responsible for replacement for 36
months
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Preventive Resin D1352
A benefit under the age 21 for 1st & 2nd permanent molars
Indicate tooth # & tooth surfaces being sealed
Only for an active carious lesion in pit or fissure thatdoes not cross the DEJ
Once per 36 months per provider regardless of surfacessealed
Original provider is responsible for replacement within36 months
Space Maintainers
Requires quadrant code or arch code as applicable
Requires pre-operative radiograph depicting:
Developing bicuspid
Adequate eruption space
Bicuspid not near eruption
Acceptable Pre-operative radiograph(s)
Before extraction
After the extraction but before placement of the space
maintainer
Not a benefit for the anterior region or for congenitallymissing teeth
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Space Maintainers
D1550 – Recementation of Fixed Space Maintainer
D1555 – Removal of Fixed Space Maintainer
Requires quadrant code or arch code as applicable
Requires pre-operative radiograph depicting:
Adequate eruption space
Bicuspid not near eruption
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RESTORATIVED2000 - D2999
This law applies to children age 3 and under, and the developmentally
disabled person of any age who is a
“Registered Consumer of the Department of Developmental Services.”
(Age 21 years & older must reside in a qualifying
ICF or SNF or clinic must bill Denti-Cal)
The law states that one current diagnostic radiograph or photo showing
caries through the DEJ on at least one tooth surface will be sufficient to
allow all restorations and/or prefabricated crowns on the same claim or
TAR.
The requirement for arch films will be waived for prefabricated crowns on
permanent teeth.
Senate Bill - 1403
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Amalgam & Composite RestorationsD2140 – D2394
Original provider is responsible for:
12 months for primary teeth
36 months for permanent teeth
Loss due to circumstances beyond provider's controlmust be documented
Four or more restorations per patient in a 12-month periodrequire radiographs
*SB – 1403 exceptions apply
Photos are optional
Note: Posterior composite codes are available
Laboratory Crowns
Prior authorization is required
A PA of the tooth + arch integrity films (if over 21)
Longevity
Periodontal condition
Restorability
Reasonable occlusal plane
A benefit:
Permanent teeth only
Once in a 5-year period
Not a benefit:
Patients under 13 years of age
3rd molars unless meets criteria and occupying 1st or 2nd molar position
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Laboratory Crowns~ Criteria ~
Anteriors
Destruction of 4 or more tooth surfaces including incisal
angle, or destruction of more than 50% of the clinical
crown
Bicuspids
3 or more tooth surfaces including 1 cusp
Molars
4 or more surfaces including 2 cusps
Laboratory Crowns~ Bicuspids & Molars ~
Posterior crowns are a benefit for age 21 & over only when thetooth meets existing crown criteria & is:
An abutment for a removable prosthesis with cast clasps orrests
or
When the treatment plan includes an abutment crown andremovable cast metal partial
Radiographs/photos depicting existing appliance
Noble Metals are Not a Benefit of the Denti-Cal program
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POSTERIOR CROWNS
Alternative treatment age 21 or older
Prefabricated crown
Amalgam or composite
Private-pay patient for lab crown
Recement CrownD2920
Not a benefit within 12-months of initial placement by the
original provider
Not a benefit within 12-months of a previous
recementation
Requires a tooth code
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Prefabricated Crowns~ Primary Teeth ~
D2929 – Porcelain (primary tooth)
D2930 – Stainless Steel Crown
D2932 – Resin Crown
D2933 – SS with Resin Window
A pre-op radiograph
*SB – 1403 Exception applies
A benefit once in a 12-month period
Criteria:
Three or more tooth surfaces
or
Extensive two-surface interproximal preparation
or
In conjunction with a pulpotomy
Prefabricated Crowns~ Permanent Teeth ~
D2931 – Stainless Steel Crown
D2932 – Resin Crown
D2933 – SS with Resin Window
A pre-op radiograph + arch integrity films (if over 21)
*SB -1403 Exception applies
A benefit once in a 36-month period
Criteria:
Same tooth type criteria as laboratory crowns
or
If used to restore an endodontically treated bicuspid
or molar
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Protective RestorationD2940
For use as temporary restoration
Requires a pre-op radiograph
Requires a tooth code & written documentation indicating
the rationale for placement
A benefit once per tooth in a 6-month period
Not a benefit for Root Canal treated tooth/teeth
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ENDODONTICSD3000 – D3999
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ROOT CANAL THERAPYGENERAL POLICIES
Prior authorization is required
A PA of the tooth + arch integrity films (if over 21)
Longevity
Periodontal condition
Restorability
RCT is not a benefit for 3rd molars
Exceptions
Tooth occupying 1st or 2nd molar position
If an abutment to an existing fixed bridge or existing
removable partial denture with cast clasps or rests
Root Canal Therapy
Effective January 1st, 2018, all root canal therapy and
root canal therapy re-treat codes are a benefit for
adults
D3310 D3320 D3330
D3346 D3347 D3348
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Benefit once per tooth
For the relief of acute pain prior to
conventional root canal therapy
Not to be used for root canal therapy visits
Additional emergency visit - use D9110
PULPAL DEBRIDEMENTPRIMARY AND PERMANENT - D3221
(Initial Open & Drain)
PULPAL DEBRIDEMENTPRIMARY AND PERMANENT - D3221
(Initial Open & Drain)
Benefit for initial Open & Drain
Prior authorization not required
Written documentation or radiograph not required for
payment
For permanent teeth or over-retained primary teeth
with no successor
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PERIODONTICS
D4000 – D4999
Prior authorization is required
Documentation:
Current PA's of involved areas + arch integrity films (if
over 21) for scaling & root planing and osseous surgery
procedures
Photographs are required for gingivectomy &
gingivoplasty procedures
A benefit for age 13 years & older
Exceptions
Aggressive Periodontitis or Drug-induced Hyperplasia
Periodontics General Policies
B-OUT-TRN-007.C 03/13/18 38
A benefit once per quadrant in a 24-month period
Prior authorization requires:
Quadrant code
PA's of all involved teeth in quadrant + arch integrity
films (if over 21)
Each qualifying tooth must show radiographic evidence of:
Significant amount of bone loss
Presence of calculus deposits (on root surfaces)
Restorability
Arch integrity
SCALING AND ROOT PLANINGFour or more teeth D4341 Three or fewer teeth D4342
Effective January 1st, 2018, Periodontal
Maintenance is a benefit for all beneficiaries.
Note: Previously only a benefit for residents of a SNF/ICF
Does not require
Prior authorization
Periodontal chart
Radiographs
PERIODONTAL MAINTENANCE
D4910
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Benefit as full-mouth treatment when root
planing has been paid within the last 24 months
Payable once per calendar quarter for up to
7 calendar quarters following root planing
Not a benefit in same calendar quarter as root
planing
Not a benefit in same calendar quarter as a
prophylaxis by the same provider
PERIODONTAL MAINTENANCE
D4910
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PROSTHODONTICS
D5000 – D5999
REMOVABLE
PROSTHODONTICS
Complete Dentures
D5110 – Complete Denture – MaxillaryD5120 – Complete Denture – Mandibular
Immediate Dentures
D5130 – Immediate Denture – MaxillaryD5140 – Immediate Denture – Mandibular
Partial Dentures
D5211 – Maxillary Partial Denture – Resin BaseD5212 – Mandibular Partial Denture – Resin BaseD5213 – Maxillary Partial Denture – Cast Metal FrameworkD5214 – Mandibular Partial Denture – Cast Metal Framework
B-OUT-TRN-007.C 03/13/18 41
REMOVABLE
PROSTHODONTICS Prosthetic appliances require prior authorization
A benefit only once in a 5-year period
Requires radiographs of all remaining teeth
Requires a properly completed DC-054 form or equivalent
Dentures lost or stolen requires a police report to receive a
replacement. If loss is due to fire a report from the fire
department.
PARTIAL DENTURES
Resin Base
A benefit when
Replacing a permanent anterior tooth/teeth
or
The arch lacks posterior balanced occlusion
Resin Base partial does not need to
oppose a complete denture
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PARTIAL DENTURESCast Metal Framework
A benefit only when
Opposing a full denture
and
The arch lacks posterior balanced occlusion
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1
32
31
30
29
28
27 2625 24
23 22
21
20
19
18
17
3
9 1011
12
13
14
15
16
2
4
5
687
3 3
1
32
31
30
29
28
27 2625 24
23 22
21
20
19
18
17
3
9 1011
12
13
14
15
16
2
4
5
687
3 3
1
32
31
30
29
28
27 2625 24
23 22
21
20
19
18
17
3
9 1011
12
13
14
15
16
2
4
5
687
3 3
LACK OF POSTERIOR BALANCED OCCLUSIONFor Partial Dentures (Resin Base or Cast Metal Framework)
The 1st & 2nd molars and the 2nd
bicuspid are missing on the same side. 3 All four 1st and 2nd molars are
missing.4
Total of five posterior permanent teeth
are missing (excluding 3rd molars).5
= 3rd Molars = Anteriors
3rd Molars• Are not counted for balanced occlusion
• May act as abutments for a partial denture
Resin Base Partial Denture• Does not need to oppose a complete denture
• A benefit when arch lacks posteriorbalanced occlusion
• A benefit when replacing a permanentanterior tooth
• Posterior teeth may be included in thepartial denture when replacing an anteriortooth
Cast Metal Framework Partial Denture• Must oppose a complete denture
• A benefit when opposing arch lacksposterior balanced occlusion
3
FUD
FUD
FUD
36
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Requires arch code
A benefit once in a 12-month period
6 months after date of service for an immediate
denture or an overdenture or partial denture that
required extractions
12 months after date of service for a complete
denture, overdenture or partial denture that did not
require extractions
RELINES
Chairside Relines
Maxillary Complete Denture
Mandibular Complete Denture
Maxillary Partial Denture
Mandibular Partial Denture
Laboratory Relines
(A laboratory reline is not a benefit for a resin base partial
denture)
Maxillary Complete Denture
Mandibular Complete Denture
Maxillary Partial Denture
Mandibular Partial Denture
RELINES
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DENTURE ADJUSTMENTSComplete Denture and Removable Partial
Payable once per date of service per billing provider
Allowed twice per appliance in a 12-month period per
billing provider
Not payable to same provider for 6 months after
Delivery of denture
Reline - Laboratory or Chairside
Repair - Same appliance
Tissue Conditioning
DENTURE REPAIRSComplete Denture and Removable Partial
Do not require Prior authorization Radiographs Documentation
Payable once per date of service per provider
Allowed twice per appliance in a 12-month period
per provider
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EXTRACTIONS
EXTRACTION PROCEDURES
D7111 – Coronal Remnant (deciduous tooth)
D7140 – Extraction of erupted tooth or exposed root
D7210 – Surgical removal of erupted tooth
D7250 – Surgical removal of residual root (cutting procedure)
D7220 – Impacted (soft tissue)
D7230 – Impacted (partial bony)
D7240 – Impacted (complete bony)
D7241 – Impacted (complete bony with surgical complications)
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ORAL SURGERY
3rd Molar Extractions
Document specific condition or medical necessity foreach tooth identified for extraction
Current radiograph depicting the entire tooth
Prophylactic removal for some adverse condition that may ormay not occur in the future is not a benefit
TREATMENT COMPLICATIONS –
D9930(Post-Surgical) Unusual Circumstances
A benefit within 30 days of extraction for
Dry Socket
Excessive bleeding
Removal of bony fragment
Infection
Life threatening allergy related to recent extraction
Requires documentation –use formula for emergency visit
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EMERGENCYPROCEDURES
EMERGENCY PROCEDURES
Written documentation must include:
Chief Complaint
Diagnosis (including the tooth/area)
Treatment Provided
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PALLIATIVE EMERGENCY TREATMENT
OF DENTAL PAIN D9110
A "Hands-On" visit
A minor procedure to relieve patient of pain
No other services are being provided exceptradiographs/photos
Payable once per patient, per day
Requires written documentation
Examples might be:
Perio related emergencies
Removal of foreign object
OFFICE VISIT FOR OBSERVATION
D9430(during regular office hours) – No other services preformed
A "Hands-Off" visit
For observation only
No other services are being provided exceptradiographs/photos
Payable once per patient, per day
Requires written documentation
Examples might be
Prescription
Reappointing
Referring patient
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APPLICATION OF DESENSITIZING
MEDICAMENT
D9910
Requires documentation
Tooth/teeth
Specific treatment provided
A Benefit
Once per date of service
Once in a 12 month period per provider
For permanent teeth only
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RESIDENTS OF
SNFs & ICFs
FULL MOUTH DEBRIDEMENT
D4355
Once in 12-month period
Excessive plaque or calculus
that inhibits ability to perform
comprehensive evaluation
Not a benefit same date of
service as Root planing, prophy
or perio maintenance and within
24 months following Root planing
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NEED MORE INFORMATION?
New/Modified Procedures for SNF/ICF Residents
CDT Code Procedure Rate*
D1110 Prophylaxis – adult $40.00
D1120 Prophylaxis – child $30.00
D1206 Topical application of fluoride varnish - adult 21 and over $6.00
D1208 Topical application of fluoride - adult $6.00
D4341 Periodontal scaling and root planing – four or more teeth per quadrant (for beneficiaries in a SNF or ICF) $70.00
D4342 Periodontal scaling and root planing – one to three teeth, per quadrant (for beneficiaries in a SNF or ICF) $50.00
D4355 Full mouth debridement to enable comprehensive evaluation and diagnosis $75.00
D4910 Periodontal maintenance $55.00
Date/Time: Location: County:
Los Angeles County
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PREGNANT
WOMEN
PREGNANT BENEFICIARIES AND
60 DAYS POSTPARTUM
Pregnant beneficiaries regardless of age, aid code
and/or scope of benefits are now eligible to receive all
procedures listed in the Manual of Criteria as long as all
procedure requirements and criteria are met.
Refer to Denti-Cal Bulletin for additional information:
November 2014, Volume 30, Number 17
www.denti-cal.ca.gov
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PREGNANCY
Scaling & Root Planing (D4341 - D4342)
Indicate ‘Pregnant’ or ‘Postpartum’
Requires quadrant codes
Periapical radiographs of all involved areas
(Arch integrity films are waived)
For the above procedures that require radiographs, no payment will be made if the radiographs are not
submitted. “Patient refused x-rays” will not be acceptable documentation for non-submission of radiographs.
Additional information regarding dental care during pregnancy can be found at the CDA Foundation web site
:http://www.cdafoundation.org/learn/perinatal_oral_health
PREGNANT BENEFICIARIESBulletin: June 2010 - Volume 26 , Number 12
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Thank You
for
Supporting
the
Denti-Cal Program!
Denti-Cal Outreach Team
11155 International Dr., C25
Rancho Cordova, CA 95670
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We value your opinion regarding the content and presentation of this training. Please takea moment to answer the questions below and make suggestions on subjects for future seminars.
FQHC/RHC/IHS TRAINING Evaluation Form
1. Do you have Internet access to utilize the Denti-Cal website? ( ) Yes ( ) No
2. How valuable was the information on the location and content of the Denti-Cal website?( ) Very Valuable ( ) Above Average ( ) Average ( ) Below Average
3. How valuable was the information presented on the Diagnostic procedures?( ) Very Valuable ( ) Above Average ( ) Average ( ) Below Average
4. How valuable was the information presented on the Restorative procedures?( ) Very Valuable ( ) Above Average ( ) Average ( ) Below Average
5. How valuable was the information presented on the Endodontic procedures?( ) Very Valuable ( ) Above Average ( ) Average ( ) Below Average
6. How valuable was the information presented on the Periodontal procedures?( ) Very Valuable ( ) Above Average ( ) Average ( ) Below Average
7. How valuable was the information presented on the Prosthodontic procedures?( ) Very Valuable ( ) Above Average ( ) Average ( ) Below Average
8. How valuable was the information presented on the Oral Surgery procedures?( ) Very Valuable ( ) Above Average ( ) Average ( ) Below Average
9. How effective was the trainer in presenting this seminar?( ) Very Effective ( ) Above Average ( ) Average ( ) Below Average
10. What was your overall evaluation of the seminar in acquainting you with the Denti-Calprogram?( ) Very Valuable ( ) Above Average ( ) Average ( ) Below Average
What helpful information will you take back to your office? ______________________________
________________________________________________________________________________
General comments or suggestions: ___________________________________________________
________________________________________________________________________________
Please provide your contact information:
Facility Name: Phone #:
Phone #: Email Address:
( ) Yes, I would like a representative to contact me for assistance with questions I still have.
Best time to call: Contact Person:
C-OUT-FRM-031.A
