Denti-Cal is the dental care segment of the Medi-Cal program. Denti-Cal is administered by a private managed care plan, Delta Dental. Delta Dental’s primary function is to process claims and treatment authorization request (TARs) submitted by providers for dental services performed for Medi-Cal beneficiaries. The most recent contract between California Department of Health Services (DHS) and Delta Dental was signed in 1998.
Eligibility, administration and scope of services is governed by Welfare and Institution Code 14000 et seq. And Title 10 and Title 22 of the California Code of Regulations. Additional guidance about the program is provided in the Denti-Cal Provider Manual.
Individuals who are enrolled in the Medi-Cal Program are eligible to receive dental services provided by Denti-Cal. Eligibility is verified through presentation of a Beneficiary Identification Card, known as a BIC card. Certain limitations in access to dental services may apply to the following beneficiaries:
1) individuals enrolled in prepaid health plan which provides dental services;
2) individuals enrolled in another pilot program which provides dental services;
3) individuals who are assigned special aid codes; 4 individuals with minor consent restricted cards.
Upon verifying eligibility in Medi-Cal, a provider cannot bill a beneficiary for any part of the charge for a Medi-Cal covered service, except to collect copayments or share of cost. Providers can request payment of share of cost. Additionally, providers can input information about incurred medical expenses into the AEVS system (Automated Eligibility Verification System), which can help a beneficiary satisfy his/her share of cost obligation.
Generally, Denti-Cal covers inpatient and outpatient services “which are reasonable and necessary for the prevention, diagnosis, and treatment of dental disease, injury or defect.” A number of dental services, including emergency and diagnostic services, including examinations, radiographs, biopsies and dental prophylaxis, are covered without prior authorization. Denti-Cal services are provided through fee-for-service as well as managed care arrangements. In the fee-for-service system, beneficiaries can access any dental provider who participates in Medi-Cal in their geographic area. In managed care, beneficiaries are restricted to those providers participating in the dental plan.
Additionally, in the fee-for-service system, approval of some services must be sought through a Treatment Authorization Request (TAR). In managed, care approval of certain services is provided by the health plan through its pre-authorization process. Some services, such as cosmetic procedures, experimental procedures that increase vertical dimension or restore occlusion, are excluded from coverage by Denti-Cal.