Referrals are required for services considered to be specialty treatments. The following is a brief explanation of specialty guidelines of the Access Dental Plan. The Primary Care Dentist requesting the referral must submit an Access specialty referral form. You can obtain this form under Provider Forms.
Decisions authorizing referrals for specialty services are based on information provided by your office to Access Dental Plan. Access’ Dental Consultants make the final decisions regarding authorization for specialty services. The Dental Consultant or his/her designee, who is a California licensed dentist, reviews all referral decisions requiring professional judgment, including all potential denials.
Referrals are valid for 90 days from the date of approval by Access.
You can review details of the specialty referral guidelines below:
Regular Specialty Referral
Access Dental Plan
Attn: Specialty Referral
8890 Cal Center Drive
Sacramento, CA 95826
Determinations of referrals are based on submitted documentation and the benefit as outlined in Title 22 and Title 10 and the Department of Health Services Medi-Cal Manual of Criteria for Dental Services. A copy of the approved Specialty Referral form is sent to the specialist and the member and the PCD. In addition, the PCD and member receive a letter notifying them of the approval and advising them, when appropriate, that follow-up treatment needs to be performed by the PCD.
Specialty referrals may be denied for any of the following reasons:
- Lack of eligibility.
- Procedure not a benefit.
- Insufficient documentation.
- Dental necessity for procedure not evident.
- Poor prognosis or longevity questionable.
- Procedure requested is within the scope of the PCD.
Decisions resulting in denial, delay or modification of all or part of the requested dental services shall be communicated to the member in writing within two business days and to the member’s treating provider within 24 hours of the decision.
Denial notification includes the rationale for the denial as well as the member’s right to appeal the decision and the appeal process, including timeframes for submitting an appeal. Members are also advised of their right to seek a second or third opinion at no charge. The Referral/Case Management Coordinator assists the member in obtaining a second or third opinion.
When a referral for a member under the age of 21 is denied based on Medi-Cal benefits, the member’s parent or legal guardian will be contacted and advised to seek assistance through the Child Health and Disability Program (CHDP), California Children’s Services (CCS) or Early and Periodic Screening, Diagnosis and Treatment (EPSDT) program.
When a referral is denied because the services fall within the scope of the PCD, the member is instructed to return to their PCD for treatment. The Plan will follow up with the PCD on completion of the services within thirty (30) days.
Emergency Specialty Referrals
We will respond to an emergency referral request within twenty-four (24) hours from the time the request is received in our offices. If the request for emergency referral is approved, Access will contact the specialty provider to inform him/her of the patient’s urgent need for treatment and authorization by Access. The PCD office must forward a written referral request to Access after obtaining verbal approval from the Referral Department.
Access’ Referral Department will make decisions on emergency authorizations based on the information provided by the referring provider over the phone or by fax. The accuracy of this information will be verified based on the written referral request submitted by the referring provider. If the written referral request and supporting documentation does not substantiate the need for a referral, Access will charge the cost of the referral services back to the referring provider.
While emergency specialty referrals do not require prior authorization, specialty providers are requested, whenever possible during office hours, to notify Access prior to treating the member. This is done to ensure that the provider understands Access’ program and does not provide routine non-emergent dental services for which he or she may not be reimbursed. Dental emergency (emergent) services are defined as those required for alleviation of severe pain, severe swelling, bleeding or immediate diagnosis and treatment of unforeseen dental conditions, which, if not immediately diagnosed and treated, would lead to disability or harm to the member.
Timelines for Referrals
Decision to approve, modify, or deny requests by providers prior to, or concurrent with, the provision of dental care services to members shall be made in a timely fashion appropriate to the nature of the member’s condition, not to exceed five (5) business days from Access receipt of the information reasonably necessary and requested by Access to make the determination.
In cases where the review is retrospective, the decision shall be communicated to the individual who received services within 30 days of the receipt of the information that is reasonably necessary to make the determination. This information shall also be communicated to the provider.
When the member’s condition is such that the member faces an imminent and serious threat to his or her health including, but not limited to, loss of life, or other major bodily function, the decision to approve, modify or deny requests by providers shall be made in a timely manner appropriate for the nature of the member’s condition, not to exceed 72 hours after Access’ receipt of the information reasonably necessary and requested by Access to make the determination.
Decision to approve, modify or deny requests by providers for authorization prior to, or concurrent with, the provision of dental care services to members shall be communicated to the requesting provider within 24 hours of the decision.
Except for concurrent review decisions pertaining to dental care that is underway, which shall be communicated to the enrollee’s treating provider within 24 hours, decisions resulting in denial, delay, or modification of all or a part of the requested dental services, shall be communicated to the member in writing within two business days of the decision. In the case of concurrent review, dental care shall not be discontinued until the member’s treating provider has been notified of Access’ decision, and a care plan has been agreed upon by the treating provider that is appropriate for the dental needs of that patient.
In the event that Access cannot make a decision to approve, modify, or deny the request for authorization within the timeframes specified above because Access has not received all the needed information, Access shall then notify the provider and the member in writing that Access cannot make a decision to approve, modify or deny the request for authorization within the specified timeframe and specify the information requested but not received. Access shall also notify the provider and the member of the anticipated date on which a decision may be rendered.
Specialty Referrals by Category
Primary Care Dentists (PCD) are expected to administer all phases of periodontal treatments with the exception of periodontal surgeries. Before a referral can be authorized, a complete periodontal work-up must be completed by the PCD through a non-surgical approach. After healing is completed, if the PCD determines that oral hygiene is acceptable and pocket depths are unmaintainable, a referral can be requested from Access. Surgeries must be done by a panel provider after authorization is received from Access. When requesting a periodontist referral, the PCD must submit the following documentation:
- Case history.
- Areas or tooth numbers where surgery is required.
- Pre-scaling pocket depth charting.
- FMX.
- A copy of the patient chart indicating the dates on which periodontal services were rendered.
- Documentation indicating the dates the PCD provided full mouth root planing for the member.
- A post-scaling (3-6 months after initial root planing) pocket depth charting.
- The PCD is responsible for providing the following treatments: root planing, diagnosis, x-rays, pocket depth charting, curettage, occlusal adjustment, prophylaxis, oral hygiene instructions and emergency abscess treatments.
- Grafting, splinting and treatments on teeth with a poor periodontal prognosis are not benefits under Access Dental Plan.
Specialty Referral for Endodontics
Performing endodontic treatments on all teeth, including molar teeth is the responsibility of the PCD. Referral to an endodontist without prior authorization from Access, is the financial responsibility of the PCD.
The PCD is responsible for providing all palliative emergency treatments on teeth, even teeth that might need treatment from an endodontist due to a complication. If, for any reason, the PCD determines that the palliative treatment must be done by an endodontist, the PCD must obtain an emergency treatment authorization from Access. The PCD must thoroughly document the patient chart regarding the condition and why therapy cannot be done at the PCD’s office.
For Access Dental Plan to bear financial responsibility for the endodontic treatment, the following must exist:
The tooth must be critically important to the integrity of the oral condition of the patient.
Specific reasons must exist for making the treatments by the PCD contradictory (i.e. failure of an existing root canal, calcified canals indicated through radiographs depicting an endodontic file in the blocked canal, broken instruments and periapical pathology remaining after standard therapy.)
The following documents must be submitted with a referral request for referral to an endodontist:
- Reason why the treatment cannot be performed at the PCD’s office.
- FMX or bilateral bite wings.
- All working x-rays with rubber dam and files in place demonstrating complications such as calcification of the canals preventing proper access for instrumentation.
- Prognosis of the tooth.
- Documentation of the complication in the chart.
- Date of the previous root canal, if applicable.
- Symptoms.
Inadequate access to perform the procedure or lack of proper instruments to perform the procedure are not acceptable reasons for referral to an endodontist. All requests for referral to an endodontist are reviewed by the Dental Consultant to determine whether the financial responsibility lies with Access Dental Plan or with the PCD.
Specialty Referral for Oral Surgery
Oral surgery services are expected to be delivered by the PCD with exceptions for partial bony, full bony extractions, biopsies or any surgery on a patient whose physician will not allow the PCD to perform the procedure at the PCD’s office (documentation from the physician is required.)
Requests for referral to an oral surgeon must be accompanied by a diagnostic x-ray completely depicting the apical area of the tooth. If the x-ray is non-diagnostic, the x-ray charges from the specialist office will be charged back to the PCD’s office.
Access will cover extractions of impacted teeth only with an existing pathology. Extraction of immature, erupting third molars, which are currently impacted (usually on patients 18 years of age or younger) is not a covered benefit. Extraction of impacted, asymptomatic teeth with no pathology on adult patients is not a covered benefit.
Specialty Referral for Pedodontics
PCDs are responsible for providing all necessary pedodontic care to their assigned enrollees, so long as that care is within their clinical competency. A complete narrative description of the case must be submitted to Access with the referral request. Documentation of two attempts at treatment by the PCD must be submitted with date of service for the referral request. If the PCD is unable to provide appropriate pedodontic care because of the age of the patient or the complexity of treatment required, or because of the existence of significant management or behavioral problems, the PCD may request that the patient be referred to a pedodontist. Cases of rampant caries or baby bottle syndrome are not reasons for referral unless the patient is demonstrating significant behavioral problems that the PCD cannot handle. Pedodontic referrals for GMC and LAPHP are not available to children age of 11 years and older under the LAPHP and GMC programs.
Referral Follow-up
Denial of Referral Due to Inadequate Information
Second Opinion
If a member requests a second opinion, your office should contact Access and request a referral to another provider. Access will then provide the member with an authorization to obtain a second opinion.
If a member is requesting a second opinion about care from his or her PCD, the second opinion shall be provided by an appropriately qualified dental provider of the member’s choice within Access’ network. An appropriately qualified health care professional means a primary care dentist, specialist, or other licensed health care provider who meets these requirements.
If a member is requesting a second opinion about care from a specialist, the second opinion shall be provided by any provider of the member’s choice within Access’ network of the same or comparable specialty. If the specialist is not within Access’ network, Access shall incur the cost or negotiate the fee arrangements of that second opinion, beyond the applicable co-payments paid by the member. If there is no participating Access provider within the network who is an appropriately qualified dentist, Access shall authorize a second opinion by an appropriately qualified dentist outside of Access’ provider network. Access shall take into account the ability of the member to travel to the provider. The cost of obtaining the second opinion will be borne by Access. Providers also who are treating members can request second opinions.
The reasons for a second opinion shall include, but are not limited to the following reasons:
- Member questions the reasonableness or necessity of the recommended procedures.
- Member questions the diagnosis or plan of care for a condition that threatens loss of life, substantial impairment, including a serious chronic condition.
- The clinical indications are not clear, the provider is unable to diagnose the condition or the diagnosis is unclear due to conflicting test results and the Subscriber requests additional diagnosis.
- The treatment plan in progress is not improving the dental condition of the member within an appropriate period of time given the diagnosis and the member requests a second opinion regarding the diagnosis or continuance of treatment.
- Member has attempted to follow the plan of care or consulted with the initial provider concerning serious concerns about the diagnosis or plan of care.
Access shall review the reasons for the request of a second opinion and provide an authorization or a denial in an expeditious manner. The second opinion will be rendered within 72-hours from Access’ receipt of request where the member’s condition poses imminent and serious threat to the member’s life.
Access shall require the provider who is rendering the second opinion to provide the member and the initial provider with a consultation report, including any recommended procedures or tests that this second provider deems appropriate.
In the event that Access denies a request by a member or a treating provider for a second opinion, Access shall notify the member and the provider in writing of the reasons for the denial and shall inform the member and the provider of the right to file a grievance with Access.
