CA DMHC Day 2

PDO’s receive monthly capitation for each member assigned to its office. The PDO agrees to only accept the set capitation and the member’s copays as payment in full, so the PDO does not send claims to Dental NET for reimbursement.

• Claims Based PDO’s

• PDO Capitation

• Encounter Forms

• Supplemental Compensation

If the patient is 35 miles or more away from their assigned PDO, the member can go to an out of network provider in an emergency without calling Dental Net.

• In Area Emergencies

• Limited Provider Access

• Out of Area Emergencies

• None of the above.

In cases when multiple treatment options are available, the plan pays for the least expensive treatment. The more expensive is optional.

• Noble or High Noble Alloys

• Optional Alternative Fee

• Posterior Composites

• Ortho Special Deal Offices

If the PDO direct refers a patient to a specialist, then the Dental Net specialist submits a claim along with the direct referral from the Assigned PDO for reimbursement of the services he or she provided.

• Special Reimbursement

• Member’s Copay on Claim

• Regional or Standard HMO Fees

• Specialty Referral Process

We will route the request to have the appropriate from completed based on the Member’s contract code and then it will be forwarded to the Member. We will provide the Member with a list of Contracted Orthodontists. The Member will take the letter to the contracted Orthodontist as a direct referral form from the PDO is not necessary.

• Specialty Referral Process

• Emergency Specialty Referral

• Ortho Referral Letters

• Special Reimbursement

The only Dental Net plan that has an OOP Maximum.

• Dental Net 3000M

• Dental Net 2000

• Dental Net

• Dental Net 3000

Dental Net encourages the PDO office to submit an Encounter Claim/Patient Visit Record (PVR).

• Specialty Referral Process

• Supplemental Compensation

• Dental Net Pediatric Maximums

• Dental Net Waiting Periods

Dental Net reimburses specialists from their standard or regional HMO fees if they do not have negotiated file fees on file.

• Regional or Standard HMO Fees

• Claims Processing

• Special Reimbursement

• Encounter Forms

Pediatric Specialist Coverage age limit for Dental Net.

• Up to 7 years

• Through 5 years

• Up to 5 years

• No coverage

Claims processors key and adjust claims for providers with special financial arrangements in plan code?

• 075

• 025

• 050

• 090