DENTAL and ORTHODONTIC UPDATE

1. DENTAL and ORTHODONTIC UPDATE March 1, 2006

2. Appeals and Fair Hearings Orthodontic Appeal and Fair Hearing Process • HLD scored forms under 26 points • HLD scored forms 26 or more points

3. Appeals and Fair Hearings • HLD scored forms under 26 points with no automatic qualifying condition: • This Computes # 155 REVISED • Child was determined CCS program eligible • SAR was issued to orthodontist with SCG S02 • Drop down message added, “Fax/send completed HLD Index scored forms with less than 26 points and no automatic qualifying condition to this CCS office”

4. Appeals and Fair Hearings • Child is found not to be medically eligible • Orthodontic provider sends HLD scored form under 26 points to CCS office • CCS sends Notice of Action (NOA) to family • If family appeals, second orthodontist is issued a SAR with SCG S02

5. Appeals and Fair Hearings • What if there is no second orthodontist? • Hunt for one! • For instance: If first orthodontist is from Western Dental and there are no other orthodontists, get a second orthodontist from Western Dental • If hunt is futile: • Request override from State Dental Hygienist Consultant for study models. • Send study models to State Orthodontic Consultant

6. Appeals and Fair Hearings • If second orthodontist (or State Orthodontic Consultant) also scores under 26 points • Client shall be offered a fair hearing by the county • Normal county/regional office fair hearing process • Why? • Scored form was not sent to Denti-Cal • CCS only reviewed

7. Appeals and Fair Hearings • HLD scored forms 26 or more points or automatic qualifying condition • System change at Delta to accommodate CCS appeal and fair hearing process…takes time • Interim process necessary

8. Appeals and Fair Hearings • Interim process: • Client follows directions for fair hearing on back of “TARNOT” denial letter sent from Denti-Cal • Once Denti-Cal is notified of request, study models and scored HLD forms are sent to State CCS Orthodontic Consultant for measurement and report is written • Documentation is sent to State Dental Hygienist Consultant • Decision is made

9. Appeals and Fair Hearings • Denti-Cal decision overridden: • Memo sent from CMS Branch to Medi-Cal Dental Services Branch to authorize • Copy of memo sent to county • County sends copy of memo to orthodontic provider • Provider attaches memo to future TARs and claims sent to Denti-Cal • County notifies family • County keeps SAR with SCG S02 active

10. Appeals and Fair Hearings • Denti-Cal decision upheld • Notification from CMS Branch to family (cc to county) • Treated as a first level appeal • Family can request fair hearing • County signs State representation form and sends to regional office • Regional office sends to DHS legal department for representation at fair hearing • Fair hearing held locally

11. Appeals and Fair Hearings Proposed for the future: • System change at Delta/Denti-Cal • New denial letter designed by CMS for first level appeal to be sent from Denti-Cal • Family will appeal directly to CCS/CMS Branch • Appeal/Case will be reviewed • If denied, family can request a fair hearing • Fair hearing process will follow

12. Appeals and Fair Hearings Questions???