DENTAL and ORTHODONTIC DENTAL and ORTHODONTIC UPDATEUPDATE

March 1, 2006March 1, 2006

Appeals and Fair HearingsAppeals and Fair Hearings

Orthodontic Appeal and Fair Hearing Orthodontic Appeal and Fair Hearing ProcessProcess

HLD scored forms under 26 pointsHLD scored forms under 26 points HLD scored forms 26 or more pointsHLD scored forms 26 or more points

Appeals and Fair HearingsAppeals and Fair Hearings

HLD scored forms HLD scored forms under 26 pointsunder 26 points with no with no automatic qualifying condition:automatic qualifying condition:– This Computes # 155 REVISEDThis Computes # 155 REVISED

Child was determined CCS program eligibleChild was determined CCS program eligible SAR was issued to orthodontist with SCG SAR was issued to orthodontist with SCG

S02S02–Drop down message added, “Fax/send Drop down message added, “Fax/send

completed HLD Index scored forms with completed HLD Index scored forms with less than 26 points and no automatic less than 26 points and no automatic qualifying condition to this CCS office”qualifying condition to this CCS office”

Appeals and Fair HearingsAppeals and Fair Hearings

Child is found not to be medically eligibleChild is found not to be medically eligible Orthodontic provider sends HLD scored Orthodontic provider sends HLD scored

form under 26 points to CCS officeform under 26 points to CCS office CCS sends Notice of Action (NOA) to familyCCS sends Notice of Action (NOA) to family If family appeals, second orthodontist is If family appeals, second orthodontist is

issued a SAR with SCG S02issued a SAR with SCG S02

Appeals and Fair HearingsAppeals and Fair Hearings

What if there is no second orthodontist?What if there is no second orthodontist?– Hunt for one!Hunt for one!

For instance: If first orthodontist is from Western For instance: If first orthodontist is from Western Dental and there are no other orthodontists, get a Dental and there are no other orthodontists, get a second orthodontist from Western Dentalsecond orthodontist from Western Dental

– If hunt is futile:If hunt is futile: Request override from State Dental Hygienist Request override from State Dental Hygienist

Consultant for study models.Consultant for study models. Send study models to State Orthodontic ConsultantSend study models to State Orthodontic Consultant

Appeals and Fair HearingsAppeals and Fair Hearings

If second orthodontist (or State Orthodontic If second orthodontist (or State Orthodontic Consultant) also scores under 26 pointsConsultant) also scores under 26 points– Client shall be offered a fair hearing by the Client shall be offered a fair hearing by the

countycounty– Normal county/regional office fair hearing Normal county/regional office fair hearing

processprocess Why?Why? Scored form was not sent to Denti-CalScored form was not sent to Denti-Cal CCS only reviewed CCS only reviewed

Appeals and Fair HearingsAppeals and Fair Hearings

HLD scored forms HLD scored forms 26 or more points26 or more points or or automatic qualifying conditionautomatic qualifying condition

– System change at Delta to accommodate CCS System change at Delta to accommodate CCS appeal and fair hearing process…takes timeappeal and fair hearing process…takes time

– Interim process necessaryInterim process necessary

Appeals and Fair HearingsAppeals and Fair Hearings

Interim process:Interim process:– Client follows directions for fair hearing on back Client follows directions for fair hearing on back

of “TARNOT” denial letter sent from Denti-Calof “TARNOT” denial letter sent from Denti-Cal– Once Denti-Cal is notified of request, study Once Denti-Cal is notified of request, study

models and scored HLD forms are sent to State models and scored HLD forms are sent to State CCS Orthodontic Consultant for measurement CCS Orthodontic Consultant for measurement and report is writtenand report is written

– Documentation is sent to State Dental Hygienist Documentation is sent to State Dental Hygienist Consultant Consultant

– Decision is madeDecision is made

Appeals and Fair HearingsAppeals and Fair Hearings

Denti-Cal decision overridden:Denti-Cal decision overridden:– Memo sent from CMS Branch to Medi-Cal Memo sent from CMS Branch to Medi-Cal

Dental Services Branch to authorizeDental Services Branch to authorize– Copy of memo sent to countyCopy of memo sent to county

County sends copy of memo to orthodontic County sends copy of memo to orthodontic providerprovider

–Provider attaches memo to future TARs Provider attaches memo to future TARs and claims sent to Denti-Caland claims sent to Denti-Cal

County notifies family County notifies family County keeps SAR with SCG S02 activeCounty keeps SAR with SCG S02 active

Appeals and Fair HearingsAppeals and Fair Hearings

Denti-Cal decision upheldDenti-Cal decision upheld– Notification from CMS Branch to family Notification from CMS Branch to family

(cc to county)(cc to county)– Treated as a first level appealTreated as a first level appeal– Family can request fair hearingFamily can request fair hearing– County signs State representation form and County signs State representation form and

sends to regional officesends to regional office– Regional office sends to DHS legal department Regional office sends to DHS legal department

for representation at fair hearingfor representation at fair hearing– Fair hearing held locallyFair hearing held locally

Appeals and Fair HearingsAppeals and Fair Hearings

Proposed for the future:Proposed for the future: System change at Delta/Denti-CalSystem change at Delta/Denti-Cal

– New denial letter designed by CMS for first level New denial letter designed by CMS for first level appeal to be sent from Denti-Cal appeal to be sent from Denti-Cal

– Family will appeal directly to CCS/CMS BranchFamily will appeal directly to CCS/CMS Branch– Appeal/Case will be reviewed Appeal/Case will be reviewed – If denied, family can request a fair hearingIf denied, family can request a fair hearing– Fair hearing process will followFair hearing process will follow

Appeals and Fair HearingsAppeals and Fair Hearings

Questions???Questions???