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98 Pages·2015·1.97 MB·English

California Dental Network, Inc.,
DBA DentaQuest, LLC

Please Refer to Your Participation Agreement for Plans You are Contracted For

Molina Healthcare of California
Pediatric Exchange Programs

Molina Essential Health Benefits (EHB)

Office Reference Manual

12121 North Corporate Parkway
Mequon, WI 53092
855-230-5764
www.dentaquestgov.com

This document contains proprietary and confidential information and
may not be disclosed to others without written permission.
Copyright 2014. All rights reserv ed.
DentaQuest, LLC May 4, 2015
Current Dental Terminology © American Dental Association. All Rights Reserved.
California Dental Network, Inc., DBA DentaQuest
California Dental Network, Inc. DBA DentaQuest (CDN/DQ)
Address and Telephone Numbers

Provider Services Credentialing
CDN/DQ CDN/DQ
12121 North Corporate Parkway 23291 Mill Creek Drive, Suite 100
Mequon, WI 53092 Laguna Hills, CA 92653
855.230.5764
Fax numbers: Claims should be sent to:
Claims/payment issues: 262.241.7379 CDN/DQ - Claims
Claims to be processed: 262.834.3589 12121 North Corporate Parkway
All other: 262.834.3450 Mequon, WI 53092
Claims Questions:
California Dental Network, Inc. DBA DentaQuest 3

California Dental Network, Inc. DBA DentaQuest
Statement of Members Rights and Responsibilities
The mission of California Dental Network, Inc., DBA DentaQuest is to expand access to high-quality,
compassionate healthcare services within the allocated resources. We are committed to ensuring
that all Members are treated in a manner that respects their rights and acknowledges its
expectations of Member’s responsibilities. The following is a statement of Member’s rights and
responsibilities.
1) Available and accessible services including emergency services, as defined in member’s
contract, 24 hours a day and seven days a week;
2) Be informed of health problems, and to receive information regarding medically necessary
treatment options and risks which is sufficient to assure informed choice, regardless of cost
or benefit coverage. You have the right to have all Your questions about Your health
answered;
3) Help make decisions about Your health care. You have the right to ask for a second opinion
about Your health condition, you have the right to refuse treatment, and the right to privacy of
medical and financial records maintained by Molina Healthcare and its health care providers,
in accordance with existing law;
4) Complain about Molina Healthcare of complain about Your care. You can call, fax, email or
write to Molina Healthcare’s Customer Support Center to initiate a complaint or grievance.
“Grievance” means a written or oral expression of dissatisfaction regarding the plan and/or
provider, including quality of care concerns, and includes any complaint, dispute, request for
reconsideration or appeal made by you or your representative. Where the plan is unable to
distinguish between a grievance and an inquiry, it will be considered a grievance;
5) Receive information about Molina Healthcare, its services, its practitioners and providers and
your rights and responsibilities;
6) Be treated with respect and recognition of your dignity and your right to privacy;
7) Participate with your providers in making health care decisions. You have the right to see
Your medical record. You also have the right to get a copy of and correct Your medical record
where legally allowed;
8) Appeal Molina Healthcare’s decisions. You have the right to have someone speak for You
during Your grievance;
9) Dis-enroll from Molina Healthcare (leave the Molina Healthcare health plan);

DentaQuest, LLC May 4, 2015
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California Dental Network, Inc. DBA DentaQuest 4
10) Get interpreter services on a 24 hour basis at no cost to help You talk with Your doctor or us
if You prefer to speak a language other than English;
11) Not be asked to bring a minor, friend, or family member with You to act as your interpreter;
12) Get information about Molina Healthcare, Your providers or Your health in the language You
prefer;
13) File a complaint if You believe Your linguistic needs were not met by Molina Healthcare; and
14) Make recommendations regarding the organization’s member rights and responsibilities
policy.
As a Molina Healthcare member of this plan, members have the responsibility to:
1) Supply information (to the extent possible) that the organization and its providers need in
order to provide care;
2) Follow plans and instructions for care that you have agreed to with your providers to sustain
and manage your health;
3) Understand your health needs and problems and participate in developing mutually
agreed-upon treatment goals to the degree possible. If you have a question about Your
benefits, You may call: 855-230-5530; and
4) Pay copayments at the time of service and promptly pay deductibles, and if applicable,
additional charges for non-covered services.

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California Dental Network, Inc. DBA DentaQuest 5

California Dental Network, Inc., DBA DentaQuest
Statement of Provider Rights and Responsibilities

Providers shall have the right to:
1) Communicate with patients, including Members regarding dental treatment options.
2) Recommend a course of treatment to a Member, even if the course of treatment is not a
covered benefit, or approved by Plan or California Dental Network, Inc., DBA DentaQuest.
3) File an appeal or complaint pursuant to the procedures of Plan or California Dental Network,
Inc., DBA DentaQuest.
4) Supply accurate, relevant, factual information to a Member in connection with an appeal or
complaint filed by the Member.
5) Object to policies, procedures, or decisions made by Plan or California Dental Network, Inc.,
DBA DentaQuest.
6) If a recommended course of treatment is not covered, e.g., not approved by Plan or California
Dental Network, Inc., DBA DentaQuest, the participating Provider must notify the Member in
writing and obtain a signature of waiver if the Provider intends to charge the Member for such
a non-compensable service.
7) To be informed of the status of their credentialing or re-credentialing application, upon
request.

* * *

California Dental Network, Inc., DBA DentaQuest makes every effort to maintain accurate information
in this manual; however will not be held liable for any damages directly or indirectly due to
typographical errors. Please contact us should you discover an error.

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California Dental Network, Inc. DBA DentaQuest 6
Office Reference Manual
Table of Contents
Section Page

1.00 Patient Eligibility Verification Procedures................................................................... 8
1.01 Plan Eligibility ..................................................................................................... 8
1.02 Member Identification Card ................................................................................. 8
1.03 California Dental Network, Inc. DBA DentaQuest Eligibility Systems ................... 8
1.04 Eligibility Verification System (EVS) .................................................................... 9
1.05 Specialist Referral Process .................................................................................. 9
1.06 Specialty Referral Form......................................................................................10
1.07 Molina Healthcare Interpreter Services ..............................................................11
2.00 Authorization of Treatment ........................................................................................13
2.01 Member Cost Sharing Responsibilities ...............................................................13
2.02 Dental Treatment Requiring Authorization .........................................................21
2.03 Electronic Attachments .......................................................................................23
3.00 Participating Hospitals ...............................................................................................24
4.00 Claim Submission Procedures (claim filing options) ..................................................24
4.01 Submitting Authorization or Claims with X-Rays ................................................24
4.02 Electronic Claim Submission Utilizing DentaQuest’s Internet Website ...............25
4.03 Electronic Authorization Submission Utilizing DentaQuest's Internet Website ....25
4.04 Electronic Claim Submission via Clearinghouse ................................................25
4.05 HIPAA Compliant 837D File.................................................................................25
4.06 NPI Requirements for Submission of Electronic Claims ......................................26
4.07 Paper Claim Submission ....................................................................................26
4.08 Dental Claim Form..............................................................................................29
4.09 Coordination of Benefits (COB) ...........................................................................31
4.10 Filing Limits ........................................................................................................32
4.11 Receipt and Audit of Claims ...............................................................................32
5.00 Health Insurance Portability and Accountability Act (HIPAA) .....................................33
5.01 HIPAA Companion Guide....................................................................................33
6.00 Complaints and Appeals (Policies 200.001, 200.002, 200.003, 200.004, 200.005, 200.006,
200.007, 200.008, 200.009, 200. 010.) .......................................................................................34
7.00 Utilization Management Program (Policies 500 Series)..............................................36
7.01 Introduction ........................................................................................................36
7.02 Community Practice Patterns .............................................................................36
7.03 Evaluation...........................................................................................................36
7.05 Fraud and Abuse (Policies 700 Series)................................................................37
8.00 Quality Improvement Program (Policies 1100 Series) ...............................................38
9.00 Credentialing (Policies 300 Series)............................................................................39
10.00 The Patient Record ....................................................................................................40
11.00 Patient Recall System Requirements .........................................................................45
12.00 Radiology Requirements ............................................................................................46

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California Dental Network, Inc. DBA DentaQuest 7
13.00 Health Guidelines – Ages 0-18 Years ..........................................................................50
14.00 Clinical Criteria ........................................................................................................... 1
14.01 Criteria for Dental Extractions.............................................................................. 2
14.02 Criteria for Cast Crowns ....................................................................................... 3
14.03 Criteria for Endodontics ....................................................................................... 4
14.04 Criteria for Stainless Steel Crowns ...................................................................... 5
14.05 Criteria for Authorization of Operating Room (OR) Cases .................................... 7
14.06 Criteria for Removable Prosthodontics (Full and Partial Dentures)...................... 8
14.07 Criteria for the Excision of Bone Tissue ............................................................... 9
14.08 Criteria for the Determination of a Non-Restorable Tooth...................................10
14.09 Criteria for General Anesthesia and Intravenous (IV) Sedation ..........................10
14.10 Criteria for Periodontal Treatment......................................................................11
14.11 Criteria for Medically Necessary Orthodontic Services .......................................12

APPENDIX A Attachments

General Definitions...................................................................................................... A-1
Additional Resources .................................................................................................. A-3

APPENDIX B Covered Benefits
Covered Benefits......................................................................................................... B-1
Member Benefit Plan Summary.................................................................................... B-2
Exhibits .......................................................................................................................... 50

DentaQuest, LLC May 4, 2015
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California Dental Network, Inc. DBA DentaQuest 8
1.00 Patient Eligibility Verification Procedures

1.01 Plan Eligibility

Any person who is enrolled in a Plan’s program is eligible for benefits under the Plan certificate.

1.02 Member Identification Card

Health Plan Members receive identification cards from the Plans. Participating Providers are responsible for
verifying that Members are eligible at the time services are rendered and to determine if recipients have other
health insurance. See Section 1.03 to review a variety of options available to provider to confirm member
eligibility.

Please note that due to possible eligibility status changes, this information does not guarantee payment and is subject
to change without notice. Members will receive a Health Plan ID Card.

California Dental Network, Inc., DBA DentaQuest recommends that each dental office make a photocopy of the
Member’s identification card each time treatment is provided. It is important to note that the Health Plan
identification card is not dated and it does not need to be returned to the Health Plan should a Member lose
eligibility. Therefore, an identification card in itself does not guarantee that a person is currently
enrolled in the Health Plan.

1.03 California Dental Network, Inc. DBA DentaQuest Eligibility Systems

Participating Providers may access Member eligibility information by reviewing their CDN/DQ member roster,
through our Interactive Voice Response (IVR) system or through the “Providers Only” section of CDN/DQ’s
website at www.dentaquestgov.com.The eligibility information received from either system will be the same
information you would receive by calling CDN/DQ’s Customer Service department; however, by utilizing either
system you can get information 24 hours a day, 7 days a week without having to wait for an available
Customer Service Representative.

Access to eligibility information via the Internet
CDN/DQ’s Internet currently allows Providers to verify a Member’s eligibility as well as submit claims directly
to CDN/DQ. You can verify the Member’s eligibility on-line by entering the Member’s date of birth, the
expected date of service and the Member’s identification number or last name and first initial. To access the
eligibility information via the website, simply log on to the website at www.dentaquestgov.com. Once you have
entered the website, click on “Dentist”. From there choose your ‘State” and press go. You will then be able to

DentaQuest, LLC May 4, 2015
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California Dental Network, Inc. DBA DentaQuest 9
log in using your password and ID. First time users will have to register by utilizing the Business’s NPI or TIN,
State and Zip Code. If you have not received instruction on how to complete Provider Self Registration contact
CDN/DQ’s Customer Service Department at: 855-230-5764. Once logged in, select “eligibility look up” and
enter the applicable information for each Member you are inquiring about. You are able to check on an
unlimited number of patients and can print off the summary of eligibility given by the sy stem for your records.

Access to eligibility information via the IVR line
To access the IVR, simply call CDN/DQ’s Customer Service Department at 855-230-5764. The IVR system
will be able to answer all of your eligibility questions for as many Members as you wish to check. Once you
have completed your eligibility checks, you will have the option to transfer to a Customer Service
Representative to answer any additional questions, i.e. Member history, which you may have. Using your
telephone keypad, you can request eligibility information on a Medicaid or Medicare Member by entering your
6-digit CDN/DQ location number, the Member’s recipient identification number and an expected date of service.
Specific directions for utilizing the IVR to check eligibility are listed below. After our system analyzes the
information, the patient’s eligibility for coverage of dental services will be verified. If the system is unable to
verify the Member information you entered, you will be transferred to a Customer Service Representative.

Directions for using CDN/DQ’s IVR to verify eligibility:

Entering system with Tax and Location ID’s

1. Cal l CDN/DQ’sC ustomer Service at8: 55-230-5764.

2. After the greeting, s tay on the l ine for Engl iosrh press 1 for Spanish .

3. When prompted, press or say 2 for El igibi l i t y.
4. When prompted, press or say 1 i f you know your NPI (National Provider Identi fi cation
number) and Tax ID numbe r .
5. If you do not have thi s information, press or say W2.hen prompted ,enter your User ID
(previous ly referred to as Location ID) and the last 4 digi ts of your Tax ID num ber.
6. Does the Member’s ID haven umbers and letter sin i t? I f so, press or say 1. When
prompted, enter the Member I D.

7. Does the Member’s ID havoe nly numbers in i t? I f so, press or say 2. When prompted, enter

the Member ID .

8. Upon system veri fi cation of the Member’s el igibi l i ty, you wi l l be prompted to repeat the

information given, veri fy the el igibi l i ty of another Member, get benefi t informagtieot n,

l imi ted claim history on this Member, or get fax confi rmation of thi s cal l .

9. If you choose to veri fy the el igibi l i ty of an addi tionMael mber(s), you wi l l be asked to

repeat step 5 above for eacMh ember.

10. .

Please note that due to possible eligibility status changes, the information provided by either system
does not guarantee payment.

If you are having difficulty accessing either the IVR or website, please contac t the Customer Service
Department at: 855-230-5764. They will be able to assist you in utilizing either system.

1.04 Eligibility Verification System (EVS)

If you are having difficulty verifying eligibility via the IVR or website, please contact CDN/DQ’s Customer
Service Department at: 855-230-5764

1.05 Specialist Referral Process

DentaQuest, LLC May 4, 2015
Current Dental Terminology © mA eraci n eD ntal sA soaic toi n . lA l thgiR s eR serev d.
California Dental Network, Inc. DBA DentaQuest 10

To see a Dental Specialist, a patient must go to their assigned Primary Dentist first, and if services by a dental
specialist are needed, the Primary Dentist must provide a referral to CDN/DQ to request a referral to a dental
specialist. The Dental Specialist is responsible for obtaining prior authorization for services according to
Appendix B of this manual. A sample template of the Specialist Referral form may be found on the following
page. Or, you may call our Customer Service Department at: 855-230-5764 to obtain paper copies of the
Specialist Referral Form.

Periodontics: The Primary Dentist is responsible for all Phase I therapy and periodontal emergencies.
Patients must have completed Phase I therapy within the past year and have been seen regularly for
periodontal maintenance.
Endodontics: The Primary Dentist is responsible for the diagnosis and treatment of all anterior, bicuspid, and
routine molar endodontics and for providing palliative treatment (pulpotomy, pulpectomy, incise and drain,
antibiotics and/or analgesics) even if tooth must be referred out for definitive treatment. Patients referred for
diagnostic purposes will be referred back to the Primary Dentist for treatment once the endodontist has
confirmed the diagnosis.

Pedodontics: For unmanageable patients under age six. Medically comprised or developmentally disabled
patients age six and over will be subject to plan review.

Oral Surgery: The Primary Dentist is responsible for routine, simple surgical and soft tissue impaction
extractions. There is no coverage for preventive extractions of asymptomatic, nonpathologic erupted or
impacted teeth or extractions for orthodontic purposes. Oral surgery referral is considered for individual
symptomatic or pathologically involved partial or full bony impactions and difficult surgical or soft tissue
extractions of pathologic/sumptomatic teeth.

1.06 Specialty Referral Form

DentaQuest, LLC May 4, 2015
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