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Medi-Cal Dental > Customer Service Overview > Flashcards

Customer Service Overview Flashcards

1
Q

Where can I find the aid codes?

A

Aid Code Master Chart

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2
Q

What are the aid codes for?

A

Aid codes are assigned by the county and depend on member’s family size, financial status, and/or Social Services or Programs the member is eligible for

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3
Q

What are the different benefit types?

A

Full scope, limited or restricted scope, and emergency only, pregnancy and postpartum coverage

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4
Q

What does full scope coverage include?

A

Dental services, all services list in the Manual of Criteria

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5
Q

What does limited or restricted scope include?

A

Limited to specific (non-dental) programs/benefits

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6
Q

What does emergency only coverage include?

A

Routine dental visits and preventative services (does not include cleaning and fluoride)

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7
Q

What does pregnancy and postpartum coverage include?

A

Members are covered for all medically necessary services during pregnancy and for 12 months past the end of their pregnancy; eligibility will be granted to an individual in an aid code

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8
Q

What is share of cost?

A

An amount a member must pay out of pocket each month before Medi-Cal Dental will pay for covered services

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9
Q

Where can a member apply for Medi-Cal?

A

Department of Health Care Services (DHCS) website, Covered CA website, or call their county office

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9
Q

What dental plans does Medi-Cal Dental offer?

A

Fee-For-Service (FFS) and Dental Managed Care (DMC)

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10
Q

Who determines a member eligibility?

A

County Social Services

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11
Q

Where can I find “Common Questions”?

A

Smile, California website

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12
Q

What does BIC mean and what is it for?

A

Benefits Identification Card and it is a member’s identification card for Medi-Cal which we use to verify

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13
Q

When is no identification verification required:

A

When a member is 17 years of age or younger, receiving emergency services, or resident in long-term care facility

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14
Q

The Smile California website can used to

A

Find a dentist or download member forms

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15
Q

On the Medi-Cal Dental provider homepage, which of the following links are found under Publications?

A

Provider Handbook, Medi-Cal Dental Manual or Criteria (MOC), and Schedule of Maximum Allowance

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16
Q

What does PAVE stand for what it is for?

A

Provider Application and Validation for Enrollment

Enrollment and disenrollment for providers

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17
Q

What does Cal-AIM stand for?

A

California Advancing and Innovating Medi-Cal

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18
Q

What information about the caller should be entered in the CRM?

A

Name, Relationship to Member, Caller Type

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19
Q

What PHI does a member need to provide for authorization for a call?

A
  1. Caller’s name and relationship to member
  2. Medi-Cal ID or SSN of member
  3. First and last name of member
  4. Date of birth of member
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20
Q

What PHI does a provider need to provide for authorization for a call?

A
  1. NPI (National Provider Identifier)
  2. Address of office
21
Q

If the provider is call about a member, what PHI do they need to provide

A
  1. Medi-Cal ID or SSN of member
  2. First and last name of member
  3. Date of birth of member
22
Q

What is Cal-AIM for?

A

An initiative that aims to improve the quality of life and health outcomes of the Medi-Cal population by implementing broad delivery system, program, and payment reform across the Medi-Cal program

23
Q

What does OBRA stand for?

A

Omnibus Budget Reconciliation Act

24
Q

What two pieces of information can you obtain from the Aid Codes?

A

Benefits and Share of Cost

25
Q

Regarding the Month of Eligibility, how would you write December 2023?

A

You would use the Julian Date of 2312 (23 representing the year and 12 representing the month)

26
Q

What are the 4 alternative English language formats can a member ask for?

A

Large print, braille, audio CD, and data CD

27
Q

The toll free number for members to call is

A

1-800-322-6384

28
Q

What is a personal representative?

A

Authority to act as the member and requires legal status or documentation

Example would be a parent of a minor or legal guardian

29
Q

What is an authorized representative?

A
  • Someone who is appointed, changed, or revoked by the member and has limited authority
  • Requires submission of signed form from the member
  • Example would be like a spouse or attorney
30
Q

What is adjudication?

A

The final resolution of a claim in the CD-MMIS

31
Q

Name three possible adjudication determinations

A

Allow, modify, or deny

32
Q

What is an EOB (Explanation of Benefits) form for?

A

Explains the claims and NOAs are paid and tracks all activity on documents for accounting purposes

33
Q

What are the two types of transportation services?

A

Non-medical transportation (NMT) and Non-emergency medical transportation (NEMT)

34
Q

What is non-medical transportation (NMT) for?

A

Services for people who do not have another way to get to their appointment

35
Q

What is non-emergency medical transportation (NEMT) for?

A

Services are available to eligible members based on medical need

36
Q

A quality of care complaint may be filed when:

A

A member is dissatisfied with dental treatment done by a Medi-Cal

37
Q

Quality of care complaints may be filed:

A

Over the telephone, by email, by mail

38
Q

When a member receives a bill but not pay for the covered services, it is referred to as

A

Improper billing

39
Q

When a member pays for covered services, it is referred to as

A

A Conlan case

40
Q

Where can a member find a complaint form?

A

On Smile CA, under the members tab and select forms

41
Q

What form must be submitted or improper billing?

A

Documenting Aged TAR

42
Q

Clinical screening can be only scheduled once, true or false?

A

True

43
Q

Clinical screening are schedule for what type of procedure complaints?

A

Removable prosthetics and crowns

44
Q

You have ________ after the date of the Notice of Medi-Cal Dental Action to request a State Hearing.

A

90 days

45
Q

What are the reasons for a State Hearing to be requested?

A

TAR was denied or modified, member’s reimbursement request was denied, or provider was told they must reimburse the member

46
Q

Provider must revalidate (re-enroll) every ________ and where ________.

A

5 years; on PAVE

47
Q

What form for Providers use to change their status if they choose not to accept new patients?

A

Medi-Cal Dental Referral Form

48
Q

Why would a First Level Appeal (FLA) be submitted?

A

If a Provider is dissatisfied with the denial of a Claim/CIF or TAR/NOA

49
Q

How long does a Provider have to submit a First Level Appeal (FLA)?

A

90 days

Medi-Cal Dental (3 decks)

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