Cal. Code Regs. Tit. 17, § 6843 - Referral to Dentist
(a) Availability.
(1) A direct referral to a dentist shall be
made for eligible Medi-Cal beneficiaries three years of age and older unless
dental services have been declined. The dental referral is for the purpose of
diagnosis and treatment. Dental treatment consists of dental care needed for
relief of pain and infections, restoration of teeth and maintenance of dental
health.
(2) An inspection of the
teeth, gums and mouth is part of the health assessment, and referral to a
dentist shall be made if appropriate.
(b) Informing and training responsibilities.
The provisions of Section
6824 also apply to the information
and training responsibilities of the state and community child health and
disability prevention programs regarding informing Medi-Cal beneficiaries of
the availability of dental services, how the services may be obtained, and of
the assistance available with transportation and scheduling
appointments.
(c) Frequency. An
annual referral to a dentist for dental services shall be offered each eligible
Medi-Cal recipient three years of age and older.
Dental providers, approved for participation in the Medi-Cal program, shall be reimbursed for diagnosis resulting from this annual referral, and for dental care needed for relief of pain and infections, restoration of teeth and maintenance of dental health.
(d) Offer of assistance with transportation
and scheduling appointments. Medi-Cal beneficiaries shall be offered assistance
with transportation and scheduling appointments for initial and periodic dental
examinations. The response to this offer shall be recorded, and this assistance
shall be provided if requested by the beneficiary.
(e) Completion of referral. All reasonable
steps shall be taken to ensure that Medi-Cal beneficiaries eligible to receive
an initial or a periodic dental examination, and who request a referral,
complete the referral. An initial dental examination shall normally be
completed within 120 days from either the date the beneficiary requests the
referral, or the date the beneficiary was certified eligible to receive
Medi-Cal benefits, whichever occurs later. A periodic dental examination shall
normally be completed within 120 days from either the date the beneficiary
requests the referral, or the last day of the month in which the annual dental
examination was due, whichever occurs earlier.
(f) Referral sources. The first source of
referral for dental services shall be the person's usual source of licensed
dental care. If no usual source of licensed dental care can be identified, the
person shall be given, without prejudice for or against any one source, the
names and locations of at least three sources of dental care, when available,
which have been approved as providers of dental services by the California
Medical Assistance Program. Although the family or recipient may choose to
receive dental diagnostic and treatment services from a provider of its choice,
to be eligible for state reimbursement, these services shall be provided by
Medi-Cal approved providers and in accordance with the provisions of the
California Administrative Code, Title 22, Division 3 and subject to any
applicable Medi-Cal program limitations.
(g) Documentation. If initial or periodic
dental services were not provided to a Medi-Cal beneficiary who had requested
such services and who also had requested assistance with transportation or
scheduling appointments for services, documentation must exist showing that the
family or person lost eligibility, could not be located despite a good faith
effort to do so, or the person's failure to receive the services was due to an
action or decision by the family or person, rather than a failure by the
community child health and disability prevention program to meet requirements
of this subchapter, including the requirement to offer and provide assistance
with transportation and scheduling appointments for services.
Notes
2. Certificate of Compliance filed 3-27-80 (Register 80, No. 13). 3. Amendment of subsection (a)(1) filed 5-22-80; effective thirtieth day thereafter (Register 80, No. 21).
3. Amendment of subsection (a) (1) filed 5-22-80; effective thirtieth day thereafter (Register 80, No. 21).
Note: Authority cited: Sections 208 and 321, Health and Safety Code. Reference: Sections 321.2, 322.7 and 323.7, Health and Safety Code.
2. Certificate of Compliance filed 3-27-80 (Register 80, No. 13). 3. Amendment of subsection (a)(1) filed 5-22-80; effective thirtieth day thereafter (Register 80, No. 21).
3. Amendment of subsection (a) (1) filed 5-22-80; effective thirtieth day thereafter (Register 80, No. 21).
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