Medi-Cal Dental Program Provider Handbook
The California Medi-Cal Dental Program Provider Handbook, also known as the Denti-Cal Handbook is updated with the information from the Denti-Cal Bulletins each quarter.
The Denti-Cal Handbook is provided to you in a Table of Contents format. It is also provided to you in Adobe Acrobat Reader. If you do not have this software installed, you can easily download this software by selecting Get Adobe Acrobat Reader.
- Hard Copy Discontinuation Letter
- Letter to the Doctor
- Preface
- How to use this Handbook
- To download the entire handbook in one document, please click on the Handbook zip file. The zip file contains an Adobe Acrobat document of the Handbook in its entirety - click on it and you will be prompted to either open or save it to your computer.
- Handbook Updates. Here you will find a pdf file containing the most recent Handbook updates.
| SECTION | CONTENT |
|---|---|
| TOC | Main Table of Contents |
| SECTION 1 | Introduction |
| Program Background | |
| Program Objectives | |
| Regulations | |
| Current Dental Terminology (CDT) Copyright | |
| SECTION 2 | Program Overview |
| Provider Participation in the California Medi-Cal Dental (Denti-Cal) Program | |
| Compliance the Denti-Cal Program | |
| Out-of-State Coverage | |
| Written Correspondence | |
| Suspended and Ineligible Providers | |
| Enrollment Denied for Failure to Disclose Fraud or Abuse, or Failure to Remediate Deficiencies | |
| General Telephone Information | |
| Contact Listings for Denti-Cal | |
| Internet Access and Web Sites | |
| Training Program | |
| Provider Appeals Process | |
| Health Insurance Portability and Accountability Act (HIPAA) and the National Provider Identifier (NPI) | |
| Freedom of Information Act (FOIA)-Disclosable Data | |
| Electronic Data Interchange (EDI) | |
| Overview of TAR and Claim Processing | |
| Prior Authorization | |
| Billing and Payment Policies | |
| Time Limitations for Billing | |
| Interim Payments | |
| Retroactive Reimbursement for Medi-Cal Beneficiaries for Out-of-Pocket Expenses | |
| Medicare/Medi-Cal Crossover Claims | |
| Orthodontic Services Program | |
| Dental Restorations for Children Under Age Four and for Developmentally Disabled Beneficiaries of Any Age | |
| Hospital (Special) Cases | |
| SECTION 3 | Enrollment Requirements |
| Provider Application and Disclosure Forms | |
| Rendering Provider Enrollment Process | |
| Provisional Provider Status | |
| Tax Identification Number | |
| No Claim Activity for 12 Months | |
| Voluntary Termination of Provider Participation | |
| Enrollment of Billing Intermediaries | |
| Electronic Claims Submission and Payment Services | |
| Medi-Cal Dental Patient Referral Service | |
| Electronic Funds Transfer | |
| SECTION 4 | Treating Beneficiaries |
| Beneficiary Identification | |
| Verifying Beneficiary Identification | |
| Denti-Cal Beneficiary Eligibility | |
| Verifying Beneficiary Eligibility | |
| Share of Cost (SOC) | |
| Interactive Voice Response System (IVR) | |
| Beneficiary Coverage | |
| Copayment Requirements for Denti-Cal Services | |
| Limited Dental Benefits for Pregnant Women | |
| Other Health Coverage | |
| Prepaid Health Plan (PHP)/Health Maintenance Organization (HMO) | |
| Child Health and Disability Prevention (CHDP) Gateway | |
| Altered Cards and Other Abuses of the Denti-Cal Program | |
| Prevention of Identity Theft | |
| Beneficiary Complaint or Grievance Procedures | |
| Grievance and Complaint Procedures to the Department of Managed Health Care | |
| State Hearing | |
| Aid Codes | |
| SECTION 5 | Manual of Criteria and Schedule of Maximum Allowances |
| Current Dental Terminology 13 (CDT 13) Codes – Preface | |
| CDT 13-14 Codes | |
| Denti-Cal Schedule of Maximum Allowances | |
| SECTION 6 | Forms |
| Denti-Cal Forms | |
| Ordering Forms | |
| Optical Character Recognition (OCR)/Intelligent Character Recognition (ICR) | |
| Correct Use of Denti-Cal Envelopes | |
| Treatment Authorization Request (TAR)/Claim Forms | |
| Notice of Authorization (NOA)(DC-301, Rev. 10/06) | |
| Notice of Denti-Cal Action | |
| Resubmission Turnaround Document (RTD)(DC-102, Rev.07/93) | |
| Claim Inquiry Form (CIF)(DC-003, Rev. 07/09) | |
| Claim Inquiry Response (CIR) | |
| Checklists | |
| Reminders | |
| Time Limitations for NOAs | |
| Justification of Need for Prosthesis (DC054, Rev 10/05) | |
| Sample Handicapping Labio-Lingual Deviation (HLD) Index California Modification Score Sheet (DC-016, Rev 04/07) | |
| Explanation of Benefits (EOB) | |
| SECTION 7 | Codes |
| Adjudication Reason Codes | |
| Claim in Process Reason Codes | |
| Accounts Payable/Accounts Receivable Codes | |
| Readjudication Codes | |
| Resubmission Turnaround Document (RTD) Codes and Messages | |
| TAR/Claim Policy Codes and Messages | |
| Claim Inquiry Response (CIR) Status Codes and Messages/Claim Inquiry Form (CIF) Action Codes and Messages | |
| Prepaid Health Plans (PHP) and Codes | |
| SECTION 8 | Fraud, Abuse and Quality of Care |
| Surveillance and Utilization Review Subsystem (S/URS) | |
| Statutes and Regulations Pertaining to Providers | |
| Billing Denti-Cal | |
| Prohibition of Rebate, Refund, or Discount | |
| Overpayment Recovery | |
| Civil Money Penalties | |
| Utilization Controls | |
| Administrative Hearings | |
| Beneficiary Fraud | |
| SECTION 9 | Special Programs |
| California Children's Services (CCS) | |
| Genetically Handicapped Person's Program (GHPP) | |
| CCS-only and CCS/Healthy Families Benefits | |
| Contact Listings for Denti-Cal, Medi-Cal Eligibility, GHPP, and CCS | |
| Orthodontic Services Program | |
| Initial Orthodontic Evaluation and Completion of the HLD Index Score Sheet | |
| Early and Periodic Screening, Diagnosis, and Treatment (EPSDT) Services | |
| SECTION 10 | CDT 13 Tables |
| SECTION 11 | Glossary |
| SECTION 12 | Bulletin Index |
| SECTION 13 | Index |