Member Services Guide

Capitol Dental Care
3000 Market Street Plaza NE
Suite 228
Salem, Oregon 97301
(800) 525–6800 or (503) 585–5205
www.CapitolDentalCare.com

Welcome to Capitol Dental Care (CDC)!

We are pleased to be your dental plan under the Oregon Health Plan (OHP).

Summary of Contents:
     Alternate format of Members Services Guide
      Appointments
      Complaints, Appeals & Hearings
      Dental Care and You
      Dis-enrollment
      DMAP Medical Care Identification Sheet
      Emergencies & Urgent Care
      Hearing Impaired
      Interpreter Services
      Keeping Appointments
      Member Rights and Responsibilities
      Phased Treatment Planning
      Primary Care Dentist (choosing or changing)
      Sight Impaired
      Special Needs
      Specialty Care

Remember!

• DO take a few minutes to read this guide carefully. It will answer many questions you may have about how to use our plan.
• DO tell your Department of Human Services (DHS) worker if you move out of your current county.
• DO call CDC with your questions.
• DO NOT go to the emergency room for something that is not an emergency.

Alternate Format of Guide

If you need our materials in another format, such as other language, large print, computer disk, Braille, audio tape or oral presentation, please call our Customer Service Department at 503-585-5205, 1-800-525-6800 or for TTY 1-800-735-2900 to request the format you need. (English)

Si ud. necesita nuestro material en español o en un formato alternativo, tal como Letra grande, Disco, Braille, Audio casete, Presentación oral, llame, por favor, al departamento de información y reclamaciones al 503-585-5205, 1-800-525-6800, o para TTY (para sordos) al 1-800-735-2900. (Spanish)

Если вам нужны наши материалы на русском языке или в другом варианте, например Крупным шрифтом, На компьютерной дискете, Шрифтом Брайля, На аудиокассете, pассказать устнопозвоните, пожалуйста, в наш Отдел бслуживания по тел. 503-585-5205, 1- 800-525-6800, для плохослышащих 1-800-735-2900.(Russian)

Neu qui vi can nhung tai lieu cua chung toi bang tieng Viet nam hay bang mot phuong phap thay the khac, chang han nhu Chu in lon, Bang ghi hinh, Dia cua may dien toan, Trinh bay qua dam thoai, Chu danh cho nguoi khiem thi, xin qui vi goi den Van Phong Phuc Vu Khach Hang chung toi o so dien thoai mien phi 503-585-5205, 1-800-525-6800 hay so dien thoai danh cho nguoi bi diec 1-800-735-2900.(Vietnamese)

Sight Impaired

If you are sight impaired and need the guide in larger print or on an audio tape, let us know.
   
Interpreter Services

If you do not speak English and need assistance with your dental care, let us know.  If an interpreter is needed for a dental appointment, let your dentist know.  Your dentist will call us ahead of time to arrange for interpreting services.

Hearing Impaired

If you are deaf or hearing impaired and need phone relay assistance to call CDC or your dentist, call the Oregon Telecommunication Relay Service.  This service is offered 24 hours a day and at no cost to the caller.  Dial TTY/Voice 1-800-735-2900, give the operator the number you are calling, and it will be relayed.  Calls are confidential.  Long distance calls are billed accordingly.

If you are deaf or hearing impaired and need an interpreter for a dental appointment let your dentist know.  Your dentist will call us ahead of time to arrange for one.

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Appointments

We are a managed dental care plan, and we use dentists who are on our Plan for your dental care.

The dentists on our Plan will care for you at a scheduled appointment time. Once you are ready to make an appointment, please call our member service department, for the name of a primary care dentist (PCD) located in your area. Then call the dentist and ask for an appointment.

If you have been unable to obtain an appointment on your own, call our member service department for help.

Going to a dentist not on our Plan (without approval by CDC) could result in your bill not being paid. This may mean you would have to pay the bill.

Arrive at your appointment on time. Keep all your appointments. If you won’t be able to make it to an appointment, call and cancel at least 24 hours before your appointment time. CDC takes missed appointments very seriously.

Keeping Appointments

Your choices affect not only you, but also others.  The number one reason dental providers give for not wanting to see OHP members is missed or late canceled appointments.   Arrive at your appointment on time.  Keep all of your appointments.  If you must cancel an appointment give at least 24 hours notice. 

Failure to keep your appointments can result in a provider dismissing you and your family.   It can result in CDC asking the state to dis-enroll (remove) you and your family from our plan.  Or it can result in a provider deciding to no longer see any future CDC members.

Dis-enrollment

• You may be dis-enrolled (removed) from a dental plan for various reasons:
   
• If you move outside of the service area of the dental plan.
   
• If your personal situation change and you are no longer eligible for the Oregon Health Plan (OHP).
   
• If you missed too many appointments.

Phased Treatment Planning

Under the OHP non-emergency restorative treatment (i.e. fillings, crowns, dentures) in the Plus package is limited.  Treatment must have a good prognosis (expected result) and must be dentally appropriate, cost effective, and practical.   
 
The cause of dental disease is almost always preventable.  It can be prevented with good oral hygiene, diet, and regular check-ups and cleanings.  In considering non-emergency restorative treatment, we review if the cause of the oral disease and rampant caries is under control.  Also your PCD will be asked if you are following through on oral hygiene.   (We understand young children and disabled adults may need special consideration in phased treatment).

CDC promotes phased treatment planning.  Phased treatment planning is an order of doing dental services to get the best outcome.

1. Pain and infection is treated.
2. Routine exams, cleaning, or gum care are done as needed.
3. Oral hygiene instructions are given.
4. Oral hygiene follow-through is noted.
5. Non-emergency restorative services are considered.     

Primary Care Dentist (PCD)

CDC is a managed care dental plan. This means each member of your family needs to have a primary care dentist/provider (PCD) to manage dental care.  In selecting a PCD, you need to choose a participating provider with our plan.  Your PCD will take care of most of your dental care needs.
   
Choosing a PCD

When you are ready to make an appointment, you may call us for names of PCDs open to new patients.  Or use the PCD list and call a provider noted open to “new” patients.  Let the provider know you are covered by CDC and would like to make an appointment.  Whether a provider is open or not to accepting new CDC patients can change.  So if the PCD you called is not open, select another PCD on the list to call.  Should you have difficulty selecting a PCD, call us for help.

Only members without live teeth may select a denturist as a PCD.  All members with live teeth MUST select a primary care dentist as a PCD. 

Changing Dentists

It is important to develop a relationship with your PCD.  Going to a different PCD should be thought over carefully.  CDC allows a member to change twice without our approval.  A third change requires a request to CDC with a valid reason -- and with our approval.

Be Sure to Call Your PCD First

Be sure to call your primary care dentist (PCD) first for all your dental care needs. The dentist who will be your PCD has a special role in managing your dental care. Sometimes members need more than basic dental care. Your PCD will, if necessary, refer you to a specialist.

Going to a specialist without a referral from your PCD could result in your bill not being paid. This may mean you would have to pay the bill.

Specialty Care

Your PCD, if necessary, may request a referral to a specialist.   Going to a specialist without a referral and approval from CDC could result in you paying the bill.

Keeping an appointment is important with any dental provider, even more so with a specialty care appointment.  There are few specialty care providers available.  A failed appointment can mean the specialty care provider will not be willing to see you for a future appointment.
 

DMAP Medical Care Identification Sheet

The Division of Medical Assistance Programs (DMAP) will issue you a medical care identification sheet for each month.  This sheet is a full sheet of paper printed on both sides.  You must keep this form with you and show it to your plan representative and your PCD.  If you lose your DMAP Medical Care Identification Sheet, contact your Department of Human Services (DHS) worker.

Covered Services Under the OHP

What is covered? The OHP covers “basic dental care.” Many services have limits, and others need prior approval before treatment. Your dentist will talk to you about what is covered at the time of your visit. See Covered OHP dental procedures

Dental Care and You

The success of your dental care depends on you. Follow your PCD’s instructions in home care by brushing and flossing regularly. Return to your PCD for preventive dental care such as cleanings and checkups. See Dental Health Tips

Under OHP Coverage guidelines, dental services may not be approved when the prognosis (outcome) is unfavorable. Your oral health and follow-through in home care will be a factor in coverage decisions.

 Emergencies and Urgent Care

Emergency dental care is dental care that requires treatment within 24 hours or sooner.

Examples of an emergency include:

• A severe toothache
• Dental pain keeping you awake, not relieved by over the counter medications
• Infection in gums or a tooth
• A tooth that has been knocked out
• Severe swelling of the gums around a tooth.

If you have a dental emergency, call your primary care dentist. If unable to reach your primary care dentist or you do not have one, call CDC ‘s toll-free number, 1-800-525-6800 or TTY/voice number (800) 735-2900 or AT&T Operation Service for TTY (800) 855-1155. An on-call dentist will be available to help you.

Do not call after hours unless you have a dental emergency.
Calls for routine or urgent dental care needs should be made during regular business hours.

If you have trouble breathing or swallowing, that is a medical emergency--not a dental emergency. You should follow the emergency guidelines of your health plan.

Emergency While Away

For an emergency while you are away from home, call CDC before you obtain services, if possible. If you receive emergency dental care out of the area have the dentist send us an itemized billing and chart notes showing a dental emergency. Information must verify that a dentist on our Plan was not available to provide the dental care.

For an emergency while you are away from home, call CDC if possible.  We will let your dental provider know what services are covered.  Covered OHP services to stabilize the emergency will be considered.  Follow-up care is NOT an emergency.  Call your primary care dentist or CDC for follow-up care, if needed.

Urgent Dental Care

Urgent dental care is dental care that needs prompt but not immediate treatment.  Examples of urgent dental care are:

• A toothache
• Swollen gums
• Lost filling

For dental urgent care, call your primary care dentist (PCD).  If unable to reach your PCD or you do not have a PCD, call CDC.  Generally you will be seen within 1-2 weeks depending on your condition.

  Complaints, Appeals and Hearings

CDC and the dentists on our Plan want to give you the best dental care possible. If you have a complaint with any part of your treatment, follow these steps.

1. Contact your dentist or a CDC member service representative by phone or in writing. The staff will look into both dental and non-dental problems.
2. We will get back to you within 5 working days.
3. We have 30 days to give you a decision.
4. You need to give us consent to investigate your complaint. Without this consent, we may not be able to help you.
5. All information about your complaint is confidential.
6. If you have been denied a service, you may request an appeal, or you may request an administrative hearing through DMAP within 45 days from the date of the decision notice.
7. CDC will review your appeal and give you a decision within 16 days.
8. If you disagree with our appeal decision, an administrative hearing can be requested within 45 days of the notice.
9. If at any step in this process, your problem is solved, you need to contact the DMAP Hearings Representative.
10. If you believe your dental complaint or appeal is an emergency and cannot wait for review, let CDC know or call your DHS worker.

Changing Dentists

Going to a different dentist should be a decision thought over carefully. CDC allows a member to change twice without an approval. A third change requires a request to CDC with a valid reason -- and with our approval.

Changing Dental Plans

To change to another Dental Care Organization (DCO) Plan, you must contact your DHS worker.

How Can We Help?

We can help if you do not speak English, are deaf or hearing impaired or otherwise need assistance. Call CDC and let us know what assistance you need. If an interpreter is needed for an appointment, let your dentist know. Your dentist will call us ahead of time to arrange one.

A member who is deaf, or hearing impaired can call their dentist or CDC through the Oregon Telecommunications Relay Service. This communication service links deaf and hearing impaired with others via the telephone. Dial TTY/Voice (1-800-735-2900) or AT&T Operator Service for TTY (1-800-855-1155) to use this service. Give the operator the phone number you are calling and the call will be relayed. All calls and information are confidential, and the service is offered 24 hours a day at no cost to callers. Long distance calls will be billed accordingly.

A member who is sight-impaired can call us at 1-800-525-6800 for an audio tape of this guide, or to discuss any concerns you might have in how to obtain dental care.

  If You Have a Special Need

If you have a special need making it difficult for you to obtain dental care under our Plan, call us for assistance. We work with our partner Exceptional Needs Dental Services (www.endsor.com) to address some of our special needs dental care.

Member Rights and Responsibilities

The OHP member guide lists member rights.   CDC has listed a few that are very important.  You have a right to:

• Be treated with dignity and respect
• Be involved in the development of your treatment plan
• Consent to treatment or refuse services and be told the consequences of that decision.
• Receive necessary and reasonable services to diagnose the presenting condition.

The OHP member guide lists member responsibilities.  CDC has listed a few that are very important.  You have a responsibility to:

• To treat the plan’s providers and clinic’s staff with respect.
• Be on time for appointments made with providers.  Call if going to be late; or to cancel if unable to keep the appointment.  (See CDC’s Member Guide on Keeping Appointments for more information).
• Show your Medical Care Identification card at every appointment.
• Ask your provider if a service is covered under OHP, before getting the service.
• Use urgent and emergency care appropriately.
• Follow prescribed, agreed-upon treatment plans.
• Pay for non-covered services you receive.

For a complete list of member rights and responsibilities, please refer to the Oregon Health Plan client handbook.