Colorado Medicaid Dental Program Member Handbook July 2014

DentaQuest’s Dental Care Plan for the
Colorado Medicaid Dental Program
Member Handbook July 2014
www.DentaQuest.com
Member Services: 1- 855-225-1729, TTY: 711
1
ID Card
Your ID card is inside the envelope. Take it out and keep it with you at all
times. Remember to bring the ID card to all of your and/or your child’s
dental appointments. Call DentaQuest at 1-855-225-1729, TTY: 711
and press 2 to ask for a new ID card if you lose it or if any information is
wrong.
Who is covered?
The Colorado Medicaid Dental Program covers children age 20 years
and under, pregnant women and adults age 21 and over. When we say
“you” in this member handbook it refers to members who are eligible for
the Colorado Medicaid Dental Program and/or the guardian of a child
who is covered under the Colorado Medicaid Dental Program.
Hearing Impaired
If you are Deaf or hearing impaired, please call AT&T Relay Service toll
free at the phone numbers below for assistance.
English: 1-855-225-1729, TTY: 711
Other languages: 1-855-225-1729, TTY: 711
Other Communication
DentaQuest has staff who speak English and Spanish. We can also help
you in other languages.
Member Handbook Information
This handbook is available in Spanish, large print or as an audio
recording. Please call DentaQuest member services if you need a
special format. We want to make sure you understand your benefits.
Información Del Manual Del Cliente
Esta Guía está disponible en Español, en imprenta grande o como una
grabación de audio. Por favor llame al departamento de Servicio al
Cliente de DentaQuest si usted necesita un formato especial. Queremos
asegurarnos que usted entiende sus beneficios para poder ayudarlos
con cualquier pregunta que tenga.
www.DentaQuest.com
Member Services: 1- 855-225-1729, TTY: 711
1
Dear Colorado Medicaid Dental Program Member,
Table of Contents
Welcome to DentaQuest. You have been enrolled with DentaQuest on
behalf of the Colorado Medicaid Dental Program. We work with the
Colorado Medicaid dental provider network of general dentists and
specialists to serve our Colorado Medicaid members.
Member Handbook Information.................................................................1
Welcome to Colorado Medicaid Dental Program and DentaQuest...........2
Your Rights and Responsibilities...............................................................4
Covered Services......................................................................................5
EPSDT Services........................................................................................6
Getting Started..........................................................................................7
Your Dental Home.....................................................................................6
How to Find a Dental Home Dentist using our Website............................8
Suggest a Dental Home Dentist................................................................8
Member ID Card........................................................................................9
• How to Use Your ID Card.................................................................9
• How to Replace Your Card if Lost....................................................9
• Do Not Abuse Your ID Card.............................................................9
Can I Get a Ride to My Dental Appointment?.........................................10
To Cancel a Dental Appointment............................................................. 11
What Is the Difference Between a General Dentist and a Specialist?..... 11
Referrals..................................................................................................12
What If I Want a Second Opinion?..........................................................12
What Do I Have To Pay?.........................................................................12
Emergency Care.....................................................................................12
• What Is a Dental Emergency?.......................................................12
• What If My Child Has a Dental Emergency?.................................13
• When Should My Child Go to the Emergency
Room or Call 911?.........................................................................13
Out-of-Network Services.........................................................................14
Status Change.........................................................................................14
Loss of Medicaid Eligibility......................................................................15
Member Services....................................................................................15
Complaints, Grievance and Appeal Process...........................................15
Urgent Grievances..................................................................................17
How to Report Fraud and Abuse.............................................................18
Dental Terms...........................................................................................19
Exclusions and Limitations......................................................................21
Confidentiality..........................................................................................24
Dental Health Tips...................................................................................24
We follow strict rules to make sure you receive the best dental care.
This handbook has everything you need to use these dental benefits.
Please read it to understand the details of the Colorado Medicaid Dental
Program.
Continuing Care: You may be in the middle of dental treatment with a
non-Colorado Medicaid dentist. If this is true, you must call DentaQuest
and let us know before you continue with that dental care. DentaQuest
will make sure you get the care you need. If you do not contact us before
you continue your dental care with a non-Colorado Medicaid dentist, the
dentist may not be able to give you care, or they may charge you directly
for that care.
Dental Home: A Dental Home is a dentist that you will see regularly.
Please call your Dental Home dentist to plan your first regular 6-month
dental checkup. The dentist at your Dental Home will provide the care
you need and help you stay healthy.
You can find a Dental Home two ways:
1. Call us at 1-855-225-1729, TTY: 711. A member services person will
help you find a Dental Home closest to you.
2. Visit our website at www.DentaQuest.com and choose
“Find-a-Dentist” from the top line and select Medicare/Medicaid.
Then follow the directions to find a Dental Home.
Good dental health is important to us. We hope you use the dental
benefits provided by Colorado Medicaid and serviced by DentaQuest.
We look forward to serving you!
Yours in good dental health,
DentaQuest
www.DentaQuest.com
Member Services: 1- 855-225-1729, TTY: 711
3
Your Rights and Responsibilities
•
Your Colorado Medicaid Dental Benefits
This handbook explains how to get dental care and what you need to
know as a Colorado Medicaid DentaQuest member. Call DentaQuest if
you have any questions about how this plan works.
•
Covered Services and Limits
The summary on page x of this member handbook gives you an
overview of some of the services available to children age 20 years and
under, pregnant women and adults age 21 and over in the Colorado
Medicaid Dental Program. Other services may be covered. Please speak
with your dental provider about services you may need. If you have
questions about what is covered, please contact DentaQuest.
Please see page 5 for a summary of covered services.
Your Rights
•
•
•
•
•
•
•
•
•
•
•
•
•
To be treated with kindness, respect, and dignity.
To have you and your child’s privacy protected.
To know what services are available.
To be helped quickly and politely.
To know who your and your child’s Dental Home dentist is.
To be able to change your Dental Home dentist.
To get complete information from the dentist about your and your
child’s treatment.
To refuse treatment and to ask your and your child’s dentist what
may happen if you refuse treatment.
To access dental services for you and/or your child without regard
to race, national origin, religion or physical handicap.
To access information about your and your child’s dental plan.
To complain or file a grievance about DentaQuest or the dental
services you or your child have received.
To help in making decisions with the dentist about your and your
child’s dental care.
To access a copy of your and your child’s medical records.
Your Responsibilities
•
To read the member handbook and get to know everything about
your and your child’s dental plan.
www.DentaQuest.com
Member Services: 1- 855-225-1729, TTY: 711
•
•
•
•
•
•
•
•
To cooperate with and be respectful of the dentist and dental office
staff.
To give the dentist and staff the facts needed to care for you or
your child.
To keep your and your child’s scheduled appointments and be on
time.
To call the dental office as soon as possible when you can’t keep
an appointment.
To respect the rights of other patients.
To follow the treatment and dental care plan you and or your child’s
dentist agreed upon.
To show your and your child’s DentaQuest ID card before getting
dental services.
To pay all charges for services not covered by the dental plan.
To follow the dental office’s rules about care and conduct.
To only go to a Medicaid participating dentist except in an emergency.
DentaQuest follows the following federal regulations: 42 CFR 438.10 (f).
and 42 CFR 438.10 (f)(2) which requires DentaQuest to inform members
every year of their right to ask for and get information about the plan.
Covered Services for Children ages 0 through 20
This is a summary of covered services. Your Colorado Medicaid dentist
will perform these services at no cost. Before treatment, please ask the
dentist if the needed services are covered by the plan. These are some
of the covered services within the plan. Go to page 19 for a list of dental
terms to help explain some of the services below.
•
•
•
•
•
•
•
•
•
•
•
•
•
•
Office Visits
Teeth Cleanings
Fluoride Application
Dental Sealants
Space Maintainers
Oral Examinations
X-rays
Dental Fillings
Crowns
Oral Surgery Procedures
Extractions
Root Canal Treatment
Gum Treatment
Dentures (False Teeth)
5
•
•
•
Braces are only covered when the condition of the child’s teeth or
jaw affects the child’s growth.
Sedation, limited to children who need it to receive dental care
safely.
Hospitalization is covered if the child cannot be safely treated in
the dental office.
Covered Services for Adults ages 21 and older
This is a summary of covered procedures. Your Colorado Medicaid
dentist will perform these services at no cost up to the annual limit of
$1,000. Emergency dental services and dentures (false teeth) are
covered when medically necessary and are not counted towards your
$1,000 benefit annual limit. Before treatment, please ask the dentist if
the needed procedures are covered by the plan. There are many
services covered by the Colorado
Medicaid Dental Plan, and below are some examples of services you can
receive. Go to page 19 for a list of dental terms to help explain some of
the services below.
•
•
•
•
•
•
•
•
•
•
•
Office Visits
Teeth Cleanings
Oral Examinations
X-rays
Dental Fillings
Crowns
Oral Surgery Procedures
Extractions
Root Canal Treatment
Gum Treatment
Dentures (False Teeth)
EPSDT Services (Early Periodic Screening, Diagnostic and
Treatment)
Every child and teen needs regular dental health check-ups every six
months, even if they seem healthy.
These visits help your child’s dentist find and treat problems early.
Medicaid pays for all medically necessary care to treat problems found
www.DentaQuest.com
Member Services: 1- 855-225-1729, TTY: 711
at the check-up. The check-up exam will be used to see if other services
are needed.
If your child hasn’t had a check-up lately, call your Dental Home dentist
today for an appointment. Ask for a check-up. Your dentist will tell you if a
service is going to be paid by Medicaid before he or she treats you.
If your child’s dentist finds anything wrong, Colorado Medicaid will
provide your child the dental treatment that he or she needs.
Getting Started
When you call to make a first appointment, it is important to tell us and
our providers if you have a special need. Some of our members may
need special help to get the most from their dental health services. If you
have a disability and need special assistance, please let us know when
you call for an appointment. Also let us know if you need an interpreter
for a non-English language or someone who knows sign language.
Follow these steps to get dental benefits:
1. Call DentaQuest if you need to choose or do not know who your
Dental Home dentist is. Our member services staff can help you.
2. Don’t go to a dentist until you know the dental office accepts Colorado Medicaid.
3. Call the dental office for your first check-up appointment. Tell them
that you are a member of Colorado Medicaid.
4. On the day of the appointment, show your DentaQuest ID card to the
dental office.
Your Dental Home
For a healthy smile, choose a Dental Home today! A Dental Home is a
dentist you will see regularly every six months. This dentist will provide
care for you and will always be available.
Your Dental Home will work with you so you can stay healthy. It is
important to go back to the same Dental Home for each appointment.
Your dentist will:
• Be in charge of your records, your treatment and coordinating your
care.
• Help you create your service (treatment) plan.
• Ask you to sign releases of information for other providers, if needed.
• Help you identify any special needs you may have.
• Provide follow-up.
7
•
•
•
•
•
•
•
•
When choosing a Dental Home, ask yourself these questions:
Am I comfortable with the dental provider?
Can I ask the dentist questions?
Will the dental provider help me get special care if I need it?
Is the office clean and neat?
Is the office easy to get to?
Do appointment times work for me?
Am I treated with kindness, respect and dignity?
Healthy teeth and gums are an important part of overall health. For a
longer, healthier life, schedule regular checkups every six months.
Children should see the dentist starting at age one.
So don’t wait! Find a dentist in your community today and establish a
dental home for you.
Remember a dental home provides you:
• Complete dental care
• A dental health plan designed for you
• Guidance about growth and diet
• How to correctly care for your teeth
So make an appointment today at your Dental Home. If you need to
establish a Dental Home call DentaQuest dental program member
services toll free 1-855-225-1729, TTY: 711 or visit our website at
www.DentaQuest.com.
Remember: Once you choose a Dental Home it is important to keep all
of your appointments and always arrive on time. If you are moving or
need to change your Dental Home please call member service for help.
How to Find a Dentist Using Our Website
Visit our website at www.DentaQuest.com and Choose “Find-a-Dentist”
on the top line, then select “Medicare/Medicaid”
Choose COLORADO as the state you live in and click on “GO.” A “Find
a Dentist” page will come up; fill out the criteria on the page, including
your zip code. This will bring up a list of all dentists participating within
30 miles. If you would like a list of general dentists or specialists please
choose that option under provider specialty.
www.DentaQuest.com
Member Services: 1- 855-225-1729, TTY: 711
Suggest a Dental Home Dentist
Do you have a favorite dentist that is not a Colorado Medicaid plan
dentist? Please let us know. We will try to enroll them with the plan.
Member Identification (ID) Card:
All members are given a member ID card:
• This card has important information about your dental benefits
• Only you can use your member ID card for dental services.
• No one else can use your member ID card to get services.
• If so:
• That person will be charged for the services he or she
receives.
• DentaQuest may not be able to keep you in the plan if
someone else uses your member ID card.
How to Read Your Card
The following describes how to read your member ID card:
1. Member Name
2. Member ID# - is your Medicaid ID number.
3. Plan Name - shows that you are enrolled in the Colorado Medicaid
Dental Program.
4. Effective Date - is the date your Colorado Medicaid Dental Program
coverage started.
How to Use Your Card
To use your card:
1. Have your ID card ready when calling our member call center.
2. Bring your ID with you when you go to your Dental Home.
3. Show your member ID card when you see the dentist.
4. Your dentist needs your member ID card to check your eligibility and
benefits.
How to Replace Your Card If Lost
Please call us if you have not received your and/or your child’s member
ID card or if you lost it. Contact our member services call center at 1-855225-1729, TTY: 711.
Do not Abuse the ID Card
Do not let someone else use your and/or your child’s DentaQuest ID
card!
You could lose your Medicaid benefits.
9
Can I get a ride to my dental appointment?
Non-Emergent Medical Transportation (NEMT)
Non-Emergent Medical Transportation (NEMT) is transportation to and/
or from Medicaid medical appointments or services. It is available to
Colorado Medicaid recipients only when a client has no other means of
transportation.
Types of NEMT transportation available include:
• Public Transportation
• Private Vehicle
• Train
• Mobility Vehicle
• Wheelchair Van
• Stretcher Van
• Ambulance
• Plane
• Reimbursement also may be provided for gas, bus tokens and bus
passes.
What services are not covered?
•
Transportation anywhere other than a Medicaid medical appointment or service with an authorized Medicaid provider.
Who is eligible?
• Most Medicaid clients who have no other means of transportation
may qualify
• Clients under the following Medicaid programs do not
qualify:
• Old Age Pension – State Medical Program (OAP
SMP)
• Qualified Individual – 1 Medicare (QI-1)
• Qualified Medicare Beneficiary (QMB)
• Special Low-Income Medicare Beneficiary (SLMB)
• Though not considered a Medicaid program,
clients in the Child Health Plan Plus (CHP+)
program do not qualify for Non-Emergent
Medical Transportation.
How do I schedule NEMT services?
You must contact First Transit, if you live in the following counties:
• Adams
• Arapahoe
• Boulder
www.DentaQuest.com
Member Services: 1- 855-225-1729, TTY: 711
•
•
•
•
•
•
Broomfield
Denver
Douglas
Jefferson
Larimer
Weld
Note: Clients call 855-264-6368; Providers call the 855-264-6368 and
select option 3.
If you live in a county that is not listed above, contact your local county
office.
For more information contact the Colorado Medicaid Customer Contact
Center at 1-800-221-3943.
When I call, what information will I need to provide?
• Name
• Member/Medicaid Identification Number
• One other type of personal information, such as birth date
• Date of the ride is required
• Actual address of pick-up location
• Name of medical provider
Is there transportation for non-medical appointments or services?
If you are enrolled in a Home and Community Based Services (HCBS)
Waiver program, some non-medical transportation may be available to
you. For additional information call the Single Entry Point located in your
county.
To Cancel a Dental Appointment
If you have to cancel an appointment, please call the Dental Home
dentist at least one (1) day before the appointment. This will help you
reschedule a new appointment.
What is the difference between a general dentist and a
specialist?
A general dentist can perform most of the services you will need. There
may be times when you need extra attention for things such as
extractions (pulling out a tooth).
11
Specialists focus on certain areas. Oral surgeons pull teeth.
Periodontists treat gums. Endodontists do root canals. Orthodontists
apply and adjust braces. Your Dental Home dentist will tell you if s/he
cannot do the service and you need a specialist.
What if I or my child has a dental emergency?
If you have a dental emergency, please call your Dental Home dentist
first. If you can’t reach the dentist, go to any hospital or urgent care or
you can call 911. You can also call DentaQuest for help. You do not need
approval to take care of a dental emergency.
Referrals
You may need follow-up care from your dentist after the emergency has
been treated. The dental services for follow-up care do not need
approval however, the services must be covered under the plan.
Colorado Medicaid has dental specialists in all fields. If your Dental
Home general dentist decides special care is needed, you will be
referred to a Colorado Medicaid specialist in your area. Your general
dentist must contact DentaQuest to refer you to a specialist. DentaQuest
will review the referral and then approve or deny the request. You and
the dentist will receive a letter from DentaQuest to inform you of our
decision. DentaQuest will review any possible exceptions for treatment in
progress.
There are no limits on the number of referrals or on the number of visits
to the specialist.
What if I want a second opinion?
You can always get a second opinion from another dentist whenever you
have questions. Call DentaQuest and we will find you a network dentist
or a dentist outside Colorado’s Medicaid dental network for a second
opinion. There is no cost for a second opinion.
What do I have to pay?
You do not have to pay anything for any covered services for you as long
as the services remain under the $1,000 annual benefit limit for adult
members (age 21 years and over). There is no annual limit on dental
services for members who are children age 20 years and under.
Emergency Care
What is a Dental Emergency?
• Constant pain of teeth or gums
• Uncontrollable bleeding in mouth area
• A painful infection
• Severe pain that cannot be controlled
• Sharp edges caused by broken teeth or damaged braces
• Tears or cuts inside the mouth
• Broken jaw and/or facial bones
• Dislocated jaw
www.DentaQuest.com
Member Services: 1- 855-225-1729, TTY: 711
If you are away from home and not near your Colorado Medicaid dentist,
you can still receive emergency dental care. DentaQuest will help you
find a dentist if you are away from home and not near your Medicaid
dentist. Please call DentaQuest to help you find a dentist. When
DentaQuest finds a dentist, DentaQuest will need to call the office to set
up payment with the dentist who treats you. The services you receive
must be covered under the plan.
Call your Dental Home dentist if you have questions about going to the
hospital. You can also call DentaQuest for help.
Out-Of-Network Services
You should only visit dentists in the Colorado Medicaid Dental Program
network because Colorado Medicaid will only cover the costs of dental
care you receive from a Colorado Medicaid dental provider. If you need
help finding a Dental Home for your child, call DentaQuest’s member
services department.
In some cases, a Medicaid dentist might not be available in your area.
You may also need a second opinion. DentaQuest must help find a
participating dentist or an out-of-network dentist.
For an emergency, please call DentaQuest to find a dentist. If
DentaQuest or your dentist is not available at the time of your
emergency, you and your child may go to a non-network, out of area
dentist. If you visit a non-network, out of area dentist, please call
DentaQuest to let us know.
Status Change
Your family’s address or phone number may change. If a change occurs,
contact DentaQuest’s member services department.
13
You may receive other health care coverage. This includes other
government programs or private insurance. If this is the case, please
inform us by calling DentaQuest or the Colorado Department of Health
Care Policy and Financing at 1-800-221-3943.
If you are calling to complain, our staff will:
•
Put together all of the facts.
•
Review the case privately.
•
Help to find an answer for you.
•
Explain the answer to you.
Loss of Medicaid Eligibility
Most issues can be fixed by DentaQuest’s member services staff. If we
cannot fix your problem within 24 hours, we will send your complaint
to our Grievances and Appeals Department for further review and your
complaint will be processed as a formal grievance.
Anyone can lose Medicaid. You could lose your benefits if you move or
do not re-certify on time. If you or your child loses your Medicaid benefits,
you lose DentaQuest.
Member Services
DentaQuest’s member services representatives are available to assist
you Monday through Friday from 7:30 a.m. to 5:00 p.m. Mountain Time.
English and Spanish speaking representatives are available toll free:
1-855-225-1729, TTY: 711. Self-service assistance is available via
Interactive Voice Response (IVR) 24 hours a day, 7 days a week.
DentaQuest member services representatives are trained and educated
on dental terminology and your Colorado Medicaid plan benefits and can
help you with:
• Choosing/Changing your Dentist
• ID Card Replacements
• Explaining Your Benefits
• Understanding Your Treatment Plan
• Referrals to a Dentist Specialist
• Eligibility Verification
Complaints, Grievance and Appeals Process
As a member of Colorado Medicaid/DentaQuest, you have the right to
file a complaint, grievance, reconsideration or client appeal.
Complaints
If you have questions about your dental plan or DentaQuest’s services,
please call us toll free at 1-855-225-1729, TTY: 711. We will try to handle
your questions and complaints quickly. Most questions can be answered
by DentaQuest’s member services staff.
www.DentaQuest.com
Member Services: 1- 855-225-1729, TTY: 711
Grievance Process
A grievance is when you are not happy with the service you are getting or
you feel you and/or your child has not been treated well. You can tell us
about a grievance verbally or in writing within 30 days of the incident. We
will look at your grievance and when we finish, we will send you a letter.
This process will take no more than ten (10) calendar days.
Your dentist, a friend or a family member can make a grievance for
you as long as you approve it in writing. We will need a letter with your
name, member ID, telephone number, address, and your signature
telling us this person can act for you. If you want to put your grievance
in writing, you can write your own letter or ask for a grievance form from
our member service department by calling 1-855-225-1729, TTY: 711
Monday through Friday, from 7:30 a.m. to 5:00 p.m. Mountain Time. The
member services representative can help you complete it or the form will
be mailed to you in 3 business days. Your dentist will also have a copy of
the DentaQuest grievance form. Mail or fax the letter or the form to:
DentaQuest
Attn: Colorado Medicaid Reconsideration Specialist
12121 North Corporate Parkway
Mequon, WI 53092
You can give us more information about your grievance at any time
during the process. This can be done on the phone, or in writing. You
also have the right to look at your case file and any other documents
involved in the process. Call DentaQuest’s member services
department.
You can ask for an extension to add up to 14 calendar days to the
process. You can ask for this extra time by writing or calling us. We can
also take an extra 14 calendar days if we need more time to get more
information that will help us make a decision in your favor. We will send
you a letter if we need extra time. The letter will tell you why we need
more time.
15
Our Grievance and Appeals Department can be reached at
1-855-225-1729, TTY: 711 Monday through Friday, from 7:30 a.m. to
5:00 p.m. Mountain Time.
Reconsideration Process
A reconsideration is when you have your dentist ask DentaQuest to
review a denial of services within 10 calendar days after you get our
letter about your denial. This process will take no more than 10 calendar
days from the date we receive your reconsideration request either on
the phone or in writing. If you request a reconsideration verbally, you
need to send us a letter within 10 calendar days from the date you talk
to us, or you can have your dentist request a reconsideration on your
behalf. We will look at the reconsideration request and we will send you
and your dentist a letter within 10 days from when the reconsideration
was requested. The letter will tell you what we decided and why. You
may request to continue receiving the benefits being denied during the
reconsideration process. If the reconsideration decision is not in your
favor, you may have to pay us back for the services received during this
time. You can ask your dentist how much the services would cost if the
decision is not in your favor.
You or your dentist can give us more information about your
reconsideration at any time during the process. This can be done
verbally or in writing. You also have the right to look at your case file and
any other documents involved in the process. Call DentaQuest’s member
services at 1-855-225-1729, TTY: 711.
Expedited Reconsideration
You or your dentist may call or write to DentaQuest to ask for an
expedited review of your reconsideration if you think your child’s health
is at risk. DentaQuest may not approve the request for an urgent or
expedited reconsideration if we feel you and/or your child will not be
harmed if the decision is not made in 3 business days.
DentaQuest will answer your request within 3 business days, either by
phone, or fax or mail if we cannot reach you by phone. If the request for
an expedited reconsideration is not approved, the appeal will be handled
as a standard reconsideration and this process will take no more than 10
calendar days from the date we receive your reconsideration request.
Your benefits will not end while we review the request. You may request
to continue receiving the benefits being denied during the
reconsideration process. If the reconsideration decision is not in your
favor, you may have to pay us back for the services received during this
time. You can ask your dentist how much the services would cost if the
www.DentaQuest.com
Member Services: 1- 855-225-1729, TTY: 711
decision is not in your favor. The benefits will end if the child is taken out
of Medicaid (dis-enrolled) for any of the reasons in this book.
CLIENT APPEALS RIGHTS
If you agree with the decision, you do not need to take any further action.
If you think the decision is wrong, you can appeal and ask for a hearing.
You may have an appeal hearing with an Administrative Law Judge. You
may represent yourself, or have a lawyer, a relative, a friend or other
spokesperson assist you as your authorized representative.
How to Appeal:
1. You must ask for a hearing in writing. This is called a LETTER OF
APPEAL.
2. Your letter of appeal must include:
a. Your name, address, phone number and Medicaid number;
b. Why you want a hearing; and
c. A copy of the front page of the notice of action you are
appealing.
3. You may ask for a telephone hearing rather than appear in person.
4. Mail or fax your letter of appeals to:
OFFICE OF ADMINISTRATIVE COURTS
1525 SHERMAN STREET, 4TH Floor
DENVER, CO 80203
FAX 303-866-5909
5. Your letter of appeal must be received by the Office of Administrative
Courts no later than thirty (30) calendar days from the date of this
notice of action. The date of the notice of action is located on the
front of this notice.
6. The Office of Administrative Courts will contact you by mail with the
date, time and place for your hearing with the Administrative Law
Judge.
Continued Benefits: To continue receiving the denied services listed
on the notice, you must file your request for a hearing in writing before
the effective date on the front of this notice. You may continue receiving
services while you are waiting for a decision on your appeal. If you lose
your appeal, you must pay back the cost of the services you received
during the appeal. If you win your appeal, the State will pay your provider
for the service(s) you received during your appeal process. Your provider
is responsible for reimbursing you for the amount you paid them during
your appeal.
17
If you have questions about this process, please call:
CUSTOMER SERVICE: 1-800-221-3943
Se Habla Español
DISCRIMINATION
If you believe that you have been discriminated against because of race,
color, sex, age, religion, national origin, or disability, you have the right to
file a complaint with: the U.S. Department of Health & Human Services,
Office for Civil Rights, 999 18th Street, Suite 417, Denver, CO 80202. If
you have any questions, or need help to file your complaint, call OCR
toll-free at 1-800-368-1019 (voice) or 1-800-537-7697 (TDD). You may
also send an email to [email protected].
STATEMENT OF PENALTIES
If you make a willfully false statement or representation, or use other
fraudulent methods to obtain public assistance or medical assistance you
are not entitled to, you could be prosecuted for theft under state and/or
federal law. If you are convicted by a court for fraudulently obtaining such
assistance, you could be subject to a fine and/or imprisonment for theft.
How to Report Fraud and Abuse
Fraud means lying or misrepresenting the truth in order to receive some
undeserved benefit, for yourself or for someone else. There are many
forms of fraud. Examples of fraud committed by Medicaid providers may
include:
• Billing Medicaid for office visits, medical procedures, drugs, or
supplies that were not provided to the client.
• Billing for the same service twice.
• Examples of fraud committed by Medicaid recipients may include:
• Providing false information on applications in order to receive
benefits.
• Loaning your Medicaid ID card to others.
Abuse means any activity that causes an unnecessary cost to Colorado
Medicaid.
If you think your dentist has committed fraud or abuse, please contact
DentaQuest’s member services toll-free number at 1-855-225-1729.
You can also contact the State Medicaid Department.
• Call the Colorado Department of Health Care Policy and Financing
toll free at 855-375-2500
• Send an email to [email protected]
www.DentaQuest.com
Member Services: 1- 855-225-1729, TTY: 711
•
•
Send a fax to 303-866-4411, or
Mail information to:
Department of Health Care Policy and Financing
Attn: Program Integrity Section
1570 Grant Street
Denver, Colorado 80213
You can find this form at the end of the handbook.
Dental Terms
Abscess: A place in the mouth that is swollen and sore. May be caused
by infection in the bone or gums.
Amalgam Filling: Silver colored filling used to fill holes in teeth caused
by decay.
Analgesia: A drug, usually nitrous oxide, given by the dentist to a patient
to temporarily stop the feeling of pain while the person is awake.
Anesthetic: A drug which causes a local or general loss of feeling, including pain. General anesthesia causes loss of consciousness, usually
to relieve the pain of surgery. Local anesthesia causes loss of feeling in
one area of the body.
Anterior: Front teeth. Includes the canines and the teeth in the center
front of the mouth.
Apicoectomy: Surgery to remove the end of a tooth root.
Biopsy: A medical test to remove skin, tissues, cells, or fluids from a
living person to test for disease.
Bridge: A custom-made false tooth or teeth that is permanently placed
between two healthy teeth, filling in the area left by a missing tooth or
teeth.
Cavity/Caries: A hole in a tooth caused by decay.
Composite Filling: Also called a resin filling. White colored filling used to
fill holes in teeth caused by decay. Usually used in front teeth.
Crown: Also called a cap. A lab-fabricated (made in a lab) false tooth
used to restore a tooth that has heavy decay, a fracture or a root canal.
Decay: The breakdown of a tooth because of food and bacteria left on
the teeth.
Denture: Also called false teeth. A complete set of either upper or lower
teeth. Used when all teeth must be removed due to damage, decay or
disease. Dentures are made in a lab.
Extraction: Removing a tooth by pulling or cutting it from the gum and
bone.
Fluoride: Fluoride helps prevent tooth decay by making the top layer of
the tooth stronger.
19
Gingival flap procedure: Surgery for gum treatment. The gums are
separated from the teeth and folded back to let a dentist reach the root of
the tooth and the bone.
Gingivectomy: Surgery for gum disease. Removes and reshapes loose,
diseased gum tissue to get rid of pockets between the teeth and gums.
Gingivitis: Redness and swelling of the gums. This is the first sign of
gum disease.
Impacted Tooth: A tooth that has grown under the gum and cannot
reach its normal place in the mouth. Intraoral: The inside of the mouth.
Intravenous: A drug given to a patient through an IV. The IV is inserted
into the patient’s vein.
Partial denture: Teeth made in a lab to fill in the spaces made by
missing teeth. Keeps other teeth from moving. The partial denture can be
removed from the mouth.
Periapical: The area around the tip of a tooth root.
Periodontal: Periodontal diseases or gum diseases are serious
infections that can lead to tooth loss if not treated. The word periodontal
means “around the tooth.” Periodontal diseases affect the gums and
bone supporting the teeth.
Plaque: A sticky, white film of bacteria that forms on teeth. It causes
tooth decay, swelling of the gums, periodontal disease and bad breath.
Prefabricated: Made in a lab.
Posterior: Back teeth. Includes bicuspids and molars. Prophylaxis/
Cleaning: The process used to remove plaque, tartar and stains from
teeth above the gum line. Includes professional brushing, scraping and
polishing of the teeth.
Pulp: The blood vessels and nerves that are inside of a tooth.
Pulpotomy: Removal of the top portion of the pulp.
Root Canal: Removal of the pulp inside a tooth due to deep decay and/
or fracture.
Scaling and root planning: Deep cleaning below the gum line.
Sealant: Plastic coating that covers the grooves in healthy teeth.
Protects teeth from decay.
Sedation: The dentist may give a patient a drug called a sedative to help
them relax during dental visits. Sometimes used with a local anesthetic.
Sedatives can be given before, during or after dental treatment by
mouth, inhalation or injection. Deep sedation causes a loss of feeling and
reduced consciousness to stop both pain and anxiety.
Space Maintainer: A space maintainer is put in a child’s mouth to keep
the teeth in place when a baby tooth is lost too soon.
X-rays/Radiographs: A picture of the teeth and gums that helps the
dentist learn the condition of the teeth and decide what treatment is
needed.
www.DentaQuest.com
Member Services: 1- 855-225-1729, TTY: 711
Colorado Medicaid Dental Program Medicaid Exclusions
and Limitations
Service Requirements
The Colorado Medicaid Dental Program covers medically necessary
services. Services already performed by another dentist are not covered.
Services completed before you became a member of the Colorado
Medicaid/DentaQuest dental program are not covered.
The Services:
• Must be specific to your needs. They must match your treatment
needs. They must not be more than you need;
• Must not be experimental or investigational;
• Must be at a level that can be safely done. There must not be an
equal, more conservative, or lower priced treatment available; and
• Must not be done simply because it is easy for the member and/
or the member’s child, the child’s parent/guardian, or the dental
provider.
Children:
Exclusions and limitations for children are defined by Medicaid and are
sometimes subject to review.
Exclusions
These dental benefits are not normally covered for children or offered by
DentaQuest:
• Putting fluoride as part of the service, on a tooth when it is getting
a filling, root canal or crown.
• Fillings or crowns on baby teeth if loss is expected in 6 months.
• Fillings, crowns, orthodontics (braces) etc. only for cosmetic reasons.
• Fixed, non-removable bridges.
• Using dental implants to replace individual teeth.
• Any dental procedure that is seen as experimental by Colorado
Medicaid.
• Any treatment paid for by Workers’ Compensation or employer’s liability laws or any treatment paid by a federal, state, city, or county government agency or other than Medicaid.
• Any non-approved dental treatment by a non-participating general
dentist or specialist except in an emergency.
• Dental treatment that was not approved by Medicaid before the
child was with DentaQuest (DentaQuest will review these on a
case by case basis).
• Exams for non-covered benefits.
21
•
•
•
•
•
Removing teeth, when the teeth do not have any problems. May
include but is not limited to the removal of third molars (“wisdom
teeth”).
Removing healthy baby teeth when they are going to fall out.
Injuries covered by the child’s Medicaid Health Care plan.
A sealant cannot be done when teeth have cavities or fillings.
Partial dentures are not covered to replace just one tooth unless it
is a missing front tooth.
Limitations
• Orthodontic benefits (Braces): Braces are not covered for non-medical or cosmetic reasons. Braces are only covered when
the child’s teeth and/or jaw are bad enough to affect the child’s
physical development. DentaQuest follows Medicaid’s rules for
braces.
• DentaQuest must approve the braces first. Some treatment will not
be approved if it is:
• Part of early or minor treatment before braces are placed (also
called interceptive treatment, split phase treatment or Phase I
treatment), except for cleft palate cases; or
• to mostly change the child’s looks (cosmetic).
• Orthodontic care is covered for members who had braces approved by Medicaid before they were with DentaQuest. DentaQuest does not need to approve the care if Medicaid has
already approved the braces. Either 24 monthly care visits or 36
months of treatment are allowed.
• Each surface of a tooth can only be filled once every 3 years.
• A tooth can only have a sealant applied one time every 3 years.
• Sealants are only covered on permanent first and second molars.
This includes tooth numbers: 2, 3, 14, 15, 18, 19, 30, and 31.
• Space maintainers that can be removed are not covered. The
space maintainer will not be covered if the space will be maintained for less than 6 months.
• Covered care to relieve pain in an emergency is called palliative
treatment. This treatment is offered when the client’s status will not
allow more specific care.
• Root canals are covered when
• There is enough tooth and bone support to be fixed
• The root canal will work on the tooth, and
• If a baby tooth, it should not fall out in the next 18 months.
Adults:
All available dental benefits are subject to the $1000 annual limitation on
adult dental services as defined by Medicaid. Only emergency services
to relieve pain and infection, and complete dentures and partial dentures
www.DentaQuest.com
Member Services: 1- 855-225-1729, TTY: 711
are not subject to the $1000 annual limitation.
Exclusions
These dental benefits for adults are not covered or offered by DentaQuest:
• Putting fluoride on teeth except for adults considered “high risk”
due to certain medical conditions or other circumstances
• Dental sealants
• Fillings, crowns, etc. placed only for cosmetic reasons.
• Fixed, non-removable bridges.
• Using implants to replace individual teeth.
• Any dental procedure that is seen as experimental by Colorado
Medicaid.
• Any treatment paid for by Workers’ Compensation or employer’s liability laws or any treatment paid by a federal, state, city, or county government agency or other than Medicaid.
• Any non-approved dental treatment by a non-participating general
dentist or specialist except in an emergency.
• Exams for non-covered benefits.
• Removing teeth, when the teeth do not have any problems. May
include but is not limited to the removal of third molars (“wisdom
teeth”).
• Injuries covered by the adult’s Medicaid Health Care plan.
• Partial dentures are not covered to replace just one tooth unless it
is a missing front tooth.
• Certain other services listed by Medicaid.
Limitations
• Each surface of a tooth can only be filled once every 3 years.
• Covered care to relieve pain in an emergency is called palliative
treatment. This treatment is offered when the client’s status will not
allow more specific care.
• Root canals are covered when
• There is enough tooth and bone support to be fixed, and;
• The root canal will work on the tooth
• DentaQuest must approve partial and full, or complete dentures
before they are made.
• DentaQuest will only pay for a denture one time every seven (7)
years
• Denture and partial denture relines are covered once per denture
per 60 months.
• When dentures are placed, changes to the dentures are not covered after 6 months. All assessment, maintenance and adjustments, including repairs and relines are subject to the $1000
annual limitation on adult dental services.
23
Confidentiality
• Any information about your dental health is called “protected health
information” or PHI. We will only use your PHI to make sure that
you get good dental health care and for activities of payment.
• For example, we can only use PHI:
• For treatment. We may share your health information with people
involved in providing your health care.
• For coordinating your care between providers or for coordinating
care between a provider and an insurance company.
• To communicate with providers who have given you services so we
can pay claims.
• To look at how our members use services. This helps us to provide
better care.
• When required by law. We will share PHI when federal, state or
local law requires it. We will share PHI if we get a court order or if
your records are subpoenaed.
• To collect information about disease or injury to report it to a public
health authority.
• To avoid a serious threat to health or safety. We may share PHI
with law enforcement or other persons if we think it will prevent or
reduce the threat of harm.
10. The dentist is a doctor who is specially trained to care for teeth. The
dentist looks at your teeth and gums to check for any problems and
cleans and polishes your teeth.
11. Kids have 20 baby (or primary) teeth and adults have 32 permanent
teeth. So keep those teeth clean and strong!
Dental Health Tips
1. Did you know that some snacks are good for your teeth? Fresh fruits
and veggies like apples and carrots are healthy snacks!
2. A small, soft toothbrush used twice a day can keep your teeth
healthy and stop tooth decay!
3. Dental floss finds the stuff that can’t be reached by a toothbrush. So
floss the teeth you want to keep!
4. Toothpaste and fluoride help to clean your teeth and keep them
strong and healthy.
5. Too many sweets are not good for your teeth. Watch out for starch
and sugar!
6. Your teeth are important! Strong, healthy teeth help you chew the
food you need to help you grow. Teeth also help you speak clearly
and look your best.
7. A healthy smile should last a lifetime!
8. Your mouth is a busy place. Bacteria - tiny groups of living things are
always on your teeth, gums, lips and tongue. So brush your teeth for
at least two (2) minutes!
9. Don’t forget to brush your tongue. This helps keep your whole mouth
clean and makes your breath smell good!
www.DentaQuest.com
Member Services: 1- 855-225-1729, TTY: 711
25
12121 N. Corporate Parkway
Mequon, WI 53092
07/2014
www.DentaQuest.com
Member Services: 1- 855-225-1729, TTY: 711