May I charge a Denti-Cal patient for an alternative procedure that is not a covered benefit of Denti-Cal ?

The Denti-Cal provider handbook states that a provider and beneficiary may enter into a private agreement to have the patient pay for dental work only under two conditions:

  • You and the beneficiary have agreed to a specific treatment that is outside the Denti-Cal program (and you have not verified patient eligibility or submitted a claim or a TAR for the planned treatment).
  • You have submitted a specific treatment procedure on a TAR and Denti-Cal has denied it on the basis that either it is not a Denti-Cal benefit or it is outside the frequency limitations for the specific covered procedure.

In these cases, you should establish a written contract with the beneficiary for treatment before rendering nonreimbursed Denti-Cal treatment and you should attempt to secure the proper Denti-Cal denial in regard to the second condition.

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