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Legal Resources | Code of Regulations, Title 17 |  T17  6843  

Subchapter 13. Child Health And Disability Prevention Program. Article 4. Required Services. Referral to Dentist.   

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(a) Availability.

(1) A direct referral to a dentist shall be made for eligible Medi-Cal beneficiaries three years of age and older unless dental services have been declined. The dental referral is for the purpose of diagnosis and treatment. Dental treatment consists of dental care needed for relief of pain and infections, restoration of teeth and maintenance of dental health.

(2) An inspection of the teeth, gums and mouth is part of the health assessment, and referral to a dentist shall be made if appropriate.

(b) Informing and training responsibilities. The provisions of Section 6824 also apply to the information and training responsibilities of the state and community child health and disability prevention programs regarding informing Medi-Cal beneficiaries of the availability of dental services, how the services may be obtained, and of the assistance available with transportation and scheduling appointments.

(c) Frequency. An annual referral to a dentist for dental services shall be offered each eligible Medi-Cal recipient three years of age and older. Dental providers, approved for participation in the Medi-Cal program, shall be reimbursed for diagnosis resulting from this annual referral, and for dental care needed for relief of pain and infections, restoration of teeth and maintenance of dental health.

(d) Offer of assistance with transportation and scheduling appointments. Medi-Cal beneficiaries shall be offered assistance with transportation and scheduling appointments for initial and periodic dental examinations. The response to this offer shall be recorded, and this assistance shall be provided if requested by the beneficiary.

(e) Completion of referral. All reasonable steps shall be taken to ensure that Medi-Cal beneficiaries eligible to receive an initial or a periodic dental examination, and who request a referral, complete the referral. An initial dental examination shall normally be completed within 120 days from either the date the beneficiary requests the referral, or the date the beneficiary was certified eligible to receive Medi-Cal benefits, whichever occurs later. A periodic dental examination shall normally be completed within 120 days from either the date the beneficiary requests the referral, or the last day of the month in which the annual dental examination was due, whichever occurs earlier.

(f) Referral sources. The first source of referral for dental services shall be the person's usual source of licensed dental care. If no usual source of licensed dental care can be identified, the person shall be given, without prejudice for or against any one source, the names and locations of at least three sources of dental care, when available, which have been approved as providers of dental services by the California Medical Assistance Program. Although the family or recipient may choose to receive dental diagnostic and treatment services from a provider of its choice, to be eligible for state reimbursement, these services shall be provided by Medi-Cal approved providers and in accordance with the provisions of the California Administrative Code, Title 22, Division 3 and subject to any applicable Medi-Cal program limitations.

(g) Documentation. If initial or periodic dental services were not provided to a Medi-Cal beneficiary who had requested such services and who also had requested assistance with transportation or scheduling appointments for services, documentation must exist showing that the family or person lost eligibility, could not be located despite a good faith effort to do so, or the person's failure to receive the services was due to an action or decision by the family or person, rather than a failure by the community child health and disability prevention program to meet requirements of this subchapter, including the requirement to offer and provide assistance with transportation and scheduling appointments for services.

Authority cited:

Health and Safety Code 208

Health and Safety Code 321

Reference:

Health and Safety Code 321.2

Health and Safety Code 322.7

Health and Safety Code 323.7

(Register 80, No. 21.)