PROVIDER REFERENCE GUIDE CALIFORNIA - LIBERTY Dental …

1 PROVIDER REFERENCE GUIDE CALIFORNIA TABLE OF CONTENTS SECTION 1 LIBERTY Dental PLAN Introduction .. 1 Our Mission .. 1 SECTION 2 PROFESSIONAL RELATIONS ..3 SECTION 3 ONLINE SERVICES ..4 SECTION 4 ELIGIBILITY ..5 How to Verify Eligibility .. 5 Member Identification Cards .. 5 SECTION 5 - SUMMARY OF PLAN OFFERINGS ..6 SECTION 6 CLAIMS AND BILLING ..7 Electronic Submission .. 7 Paper Claims .. 7 Claims Submission Requirements .. 7 Claims Status Inquiry .. 8 Claims Resubmission .. 8 Medicare and Duals Prior-Authorization Outreach .. 8 Claims Overpayment .. 8 SECTION 7 COORDINATION OF BENEFITS.

2 11 SECTION 8 PROFESSIONAL GUIDELINES AND STANDARDS OF CARE .. 16 PROVIDER Responsibilities and Rights .. 16 Specialty Care Providers Responsibilities & 16 Anti-Discrimination .. 16 National PROVIDER Identifier (NPI) .. 17 Voluntary PROVIDER Contract Termination .. 17 Standards of Accessibility .. 18 After Hours and Emergency Services Availability .. 18 Facility Physical Access for the Disabled .. 18 Appointment Rescheduling .. 19 Interpreter Services .. 19 Compliance with the Standards of Accessibility .. 19 Treatment Plan Guidelines .. 19 Second Opinions .. 19 Continuity and Coordination of 19 Member Rights and Responsibilities .. 20 SECTION 9 - CLINICAL DENTISTRY GUIDELINES.

3 22 New Patient Information .. 22 Early and Periodic Screening, Diagnostic and Treatment (EPSDT) Benefits .. 23 Continuity of 23 Infection Control .. 23 Dental Records .. 23 Language Assistance Program (LAP).. 24 Baseline Clinical Evaluation Documentation .. 25 Radiographs .. 25 Prevention .. 26 Treatment Planning .. 27 Request for Pre-Estimate .. 29 Progress Notes .. 29 Endodontics .. 29 Oral Surgery .. 32 Periodontics .. 34 Restorative .. 39 Crowns and Fixed Bridges .. 41 Removable Prosthodontics .. 43 Implants .. 45 SECTION 10 - SPECIALTY CARE REFERRAL GUIDELINES .. 47 Non-Emergency Referral Submission and Inquiries .. 47 Emergency Referral .. 47 Endodontics.

4 48 Oral Surgery .. 51 Orthodontics .. 55 Pediatric Dentistry .. 58 Periodontics .. 60 Prosthodontist .. 64 SECTION 11- QUALITY MANAGEMENT .. 65 Program 65 Committees .. 65 Program Standards and Guidelines .. 68 Credentialing / Recredentialing .. 69 Records Review .. 69 Grievances and appeals .. 70 PROVIDER Dispute Resolutions .. 72 SECTION 12 - FRAUD, WASTE AND ABUSE .. 74 SECTION 13 ALTERNATIVE TREATMENT .. 77 SECTION 14 FORMS .. 79 Alternate Treatment Form .. 79 Grievance Form .. 79 Referral Form .. 79 Section 1 LIBERTY Dental Plan Information P a g e | 1 SECTION 1 LIBERTY Dental PLAN INFORMATION INTRODUCTION Welcome to LIBERTY Dental Plan s network of Participating Providers.

5 We are proud to maintain a broad network of qualified Dental providers who offer both general and specialized treatment, guaranteeing widespread access to our members. The intent of this PROVIDER REFERENCE GUIDE is to aid each Participating PROVIDER and their staff members in becoming familiar with the administration of LIBERTY Dental Plan. Please note that this PROVIDER REFERENCE GUIDE serves only as a summary of certain terms of the PROVIDER Agreement between you (or the contracting Dental office/facility) and LIBERTY Dental Plan and that additional terms and conditions of the PROVIDER Agreement apply. In the event of a conflict between a term of this PROVIDER REFERENCE GUIDE and a term of the PROVIDER Agreement, the term of the PROVIDER Agreement shall control.

6 You will receive a copy of the fully executed PROVIDER Agreement at time of your activation on LIBERTY Dental Plan s network; however, you may also obtain a copy of the PROVIDER Agreement at any time by submitting a request to or by contacting Professional Relations at 800-268-9012. LIBERTY shall not refuse to contract with, or pay, an otherwise eligible Dental Office for the provision of Covered Services solely because such Dental Office has in good faith communicated with, or advocated on behalf of, one or more of his or her prospective, current or former patients regarding the provisions, terms or requirements of the member s LIBERTY benefit plan.

7 To provide the most current information, updates to the PROVIDER REFERENCE GUIDE will be available by logging in to the PROVIDER Portal at OUR MISSION LIBERTY Dental Plan is committed to being the industry leader in providing quality, innovative, and affordable Dental benefits with the utmost focus on member satisfaction. Section 1 LIBERTY Dental Plan Information P a g e | 2 PROVIDER Contact and Information GUIDE LIBERTY Dental Plan Simply Better CoverageIMPORTANT PHONE NUMBERS AND GENERAL INFORMATION ELIGIBILITY & BENEFITS VERIFICATION CLAIMS INQUIRIES PROVIDER WEB PORTAL (i-TRANSACT) LIBERTY PROVIDER SERVICE LINE (800) 268-9012 Eligibility & Benefits for General Dentistry: Press Option 1 Claims: Press Option 2 Pre-Estimates: Press Option 3 Referrals & Specialty Pre-Authorizations: Press Option 4 Request Materials.

8 Press Option 5 HOURS Live representatives are available Monday Friday, 8 PST 5 PST PROFESSIONAL RELATIONS DEPARTMENT (800) 268-9012 (800) 268 0154 (fax) LIBERTY Dental Plan Attn: Professional Relations Box 26110 Santa Ana, CA 92799-6110 PROVIDER Portal (i-Transact) Or TELEPHONE (800) 268-9012 Press Option 1 PROVIDER Portal (i-Transact) Or TELEPHONE (800) 268-9012 Press Option 2 LIBERTY Dental Plan offers 24/7 real-time access to important information and tools through our secure online system Electronic Claims Submission Claims Inquiries Real-time Eligibility Verification Member Benefit Information Referral Submission Referral Status Please visit: to register as a new user and/or login.

9 Your Access Code can be found on your LIBERTY Welcome Letter. If you cannot locate your access code, or need help with the login process, please call (800) 268-9012 for assistance. REFERRAL SUBMISSION & INQUIRIES CLAIMS SUBMISSIONS PROVIDER Portal (i-Transact) TELEPHONE (800) 268-9012 Press Option 4 Regular Referrals by Mail LIBERTY Dental Plan Attn: Referral Department Box 26110 Santa Ana, CA 92799-6110 *Emergency Referrals* All requests for emergency specialty care should be made by calling: (800) 268-9012 Press Option 4 PROVIDER Portal (i-Transact) EDI Payor ID #: CX083 TELEPHONE (800) 268-9012 General Information ( Claims Mailing Address or Payor ID): Press Option 6 Paper Claims by Mail LIBERTY Dental Plan Attn: Claims Department Box 26110 Santa Ana, CA 92799-6110 Rev.

10 201506 Section 2 Professional Relations P a g e | 3 SECTION 2 PROFESSIONAL RELATIONS LIBERTY s team of Network Managers is responsible for recruiting, contracting, servicing and maintaining our network of Providers. We encourage our Providers to communicate directly with their designated Network Manager to assist with the following: Plan Contracting Escalated Claim Payment Issues Education on LIBERTY Members and Benefits Opening, Changing or Closing a Location Adding or Terminating Associates Credentialing Inquiries Change in Name or Ownership Tax Payer Identification Number (TIN) Change To ensure that your information is displayed accurately and claims are processed efficiently, please submit all changes 30 days in advance and in writing to: LIBERTY Dental Plan Box 26110 Santa Ana, CA 92799-6110 Attention.