Customer Service Overview Flashcards
Where can I find the aid codes?
Aid Code Master Chart
What are the aid codes for?
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
What are the different benefit types?
Full scope, limited or restricted scope, and emergency only, pregnancy and postpartum coverage
What does full scope coverage include?
Dental services, all services list in the Manual of Criteria
What does limited or restricted scope include?
Limited to specific (non-dental) programs/benefits
What does emergency only coverage include?
Routine dental visits and preventative services (does not include cleaning and fluoride)
What does pregnancy and postpartum coverage include?
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
What is share of cost?
An amount a member must pay out of pocket each month before Medi-Cal Dental will pay for covered services
Where can a member apply for Medi-Cal?
Department of Health Care Services (DHCS) website, Covered CA website, or call their county office
What dental plans does Medi-Cal Dental offer?
Fee-For-Service (FFS) and Dental Managed Care (DMC)
Who determines a member eligibility?
County Social Services
Where can I find “Common Questions”?
Smile, California website
What does BIC mean and what is it for?
Benefits Identification Card and it is a member’s identification card for Medi-Cal which we use to verify
When is no identification verification required:
When a member is 17 years of age or younger, receiving emergency services, or resident in long-term care facility
The Smile California website can used to
Find a dentist or download member forms
On the Medi-Cal Dental provider homepage, which of the following links are found under Publications?
Provider Handbook, Medi-Cal Dental Manual or Criteria (MOC), and Schedule of Maximum Allowance
What does PAVE stand for what it is for?
Provider Application and Validation for Enrollment
Enrollment and disenrollment for providers
What does Cal-AIM stand for?
California Advancing and Innovating Medi-Cal
What information about the caller should be entered in the CRM?
Name, Relationship to Member, Caller Type
What PHI does a member need to provide for authorization for a call?
- Caller’s name and relationship to member
- Medi-Cal ID or SSN of member
- First and last name of member
- Date of birth of member
What PHI does a provider need to provide for authorization for a call?
- NPI (National Provider Identifier)
- Address of office
If the provider is call about a member, what PHI do they need to provide
- Medi-Cal ID or SSN of member
- First and last name of member
- Date of birth of member
What is Cal-AIM for?
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
What does OBRA stand for?
Omnibus Budget Reconciliation Act
What two pieces of information can you obtain from the Aid Codes?
Benefits and Share of Cost
Regarding the Month of Eligibility, how would you write December 2023?
You would use the Julian Date of 2312 (23 representing the year and 12 representing the month)
What are the 4 alternative English language formats can a member ask for?
Large print, braille, audio CD, and data CD
The toll free number for members to call is
1-800-322-6384
What is a personal representative?
Authority to act as the member and requires legal status or documentation
Example would be a parent of a minor or legal guardian
What is an authorized representative?
- 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
What is adjudication?
The final resolution of a claim in the CD-MMIS
Name three possible adjudication determinations
Allow, modify, or deny
What is an EOB (Explanation of Benefits) form for?
Explains the claims and NOAs are paid and tracks all activity on documents for accounting purposes
What are the two types of transportation services?
Non-medical transportation (NMT) and Non-emergency medical transportation (NEMT)
What is non-medical transportation (NMT) for?
Services for people who do not have another way to get to their appointment
What is non-emergency medical transportation (NEMT) for?
Services are available to eligible members based on medical need
A quality of care complaint may be filed when:
A member is dissatisfied with dental treatment done by a Medi-Cal
Quality of care complaints may be filed:
Over the telephone, by email, by mail
When a member receives a bill but not pay for the covered services, it is referred to as
Improper billing
When a member pays for covered services, it is referred to as
A Conlan case
Where can a member find a complaint form?
On Smile CA, under the members tab and select forms
What form must be submitted or improper billing?
Documenting Aged TAR
Clinical screening can be only scheduled once, true or false?
True
Clinical screening are schedule for what type of procedure complaints?
Removable prosthetics and crowns
You have ________ after the date of the Notice of Medi-Cal Dental Action to request a State Hearing.
90 days
What are the reasons for a State Hearing to be requested?
TAR was denied or modified, member’s reimbursement request was denied, or provider was told they must reimburse the member
Provider must revalidate (re-enroll) every ________ and where ________.
5 years; on PAVE
What form for Providers use to change their status if they choose not to accept new patients?
Medi-Cal Dental Referral Form
Why would a First Level Appeal (FLA) be submitted?
If a Provider is dissatisfied with the denial of a Claim/CIF or TAR/NOA
How long does a Provider have to submit a First Level Appeal (FLA)?
90 days
