Autorizaciones y reclamaciones dentales
Proceso de Autorización Dental/Ortodoncia
Proceso de Autorización Dental/Ortodoncia
All requests for CCS dental and orthodontic services for CCS Only and CCS Healthy Families clients (CCS does not cover medically handicapping malocclusion for clients with Medi-Cal full-scope no share of cost eligibility; these clients are to be referred to Medi-Cal Dental) must be submitted using a DHS 4516 form, CCS Dental and Orthodontic Client Service Authorization Request (SAR). Once a dental/orthodontic SAR has been received by CCS and entered into the system, all necessary dental/orthodontic procedures will be authorized by Medi-Cal Dental. Only active Medi-Cal Dental Providers may receive authorization to provide CCS program services. Services may be authorized for varying lengths of time during the CCS client’s eligibility period.
Algunos consejos útiles a la hora de presentar un SAR dental/ortodóncico:
- Dental providers must request CCS services using a Dental/Orthodontic SAR form.
- Each SAR submitted to CCS is reviewed for residential and financial eligibility (unless a Healthy Families subscriber) to determine child’s program eligibility.
- Todos los SAR dentales/ortodónticos se emiten a la espera de la revisión de Medi-Cal Dental/Delta Dental para su autorización.
- Medi-Cal Dental no autorizará ningún procedimiento para CCS sin un SAR correspondiente.
- CCS follows all of Medi-Cal Dental’s policies, procedures, and requirements.
- Providers should not proceed with treatment until an authorization is received from Medi-Cal Dental (unless Medi-Cal Dental does not require prior authorization for a specific service–see Medi-Cal Dental Provider Manual Section 4, Program Policy).
- Todos los servicios de ortodoncia requieren autorización previa de Medi-Cal Dental.
Procesamiento de reclamos
Claims for services that have been authorized by CCS or Medi-Cal Dental are to be submitted directly to Medi-Cal Dental.
- Presentar reclamaciones por servicios que fueron aprobados o autorizados por el programa CCS o Medi-Cal Dental. Las reclamaciones por servicios sin la aprobación o autorización previa de CCS o Medi-Cal Dental pueden ser denegadas.
- Presentar solicitudes de reembolso por servicios prestados a un cliente cuyo derecho a recibir prestaciones CCS se haya confirmado. Se denegarán las solicitudes de reembolso de servicios prestados a clientes que no sean CCS o que ya no reúnan los requisitos para recibir prestaciones CCS.
- Presentar reclamaciones a Medi-Cal Dental de manera oportuna.
Presentar reclamaciones por servicios prestados a clientes con otra cobertura de seguro médico con la Explicación de Beneficios (EOB) adjunta a las reclamaciones.
Preguntas sobre facturación
If you have billing questions, please contact Delta Dental at (800) 423-0507. You can also visit the Medi-Cal Dental website for billing procedures and updates.