Capitol Dental Care (CDC) is committed to providing effective evidence-based clinical guidelines to support efforts of CDC contracted providers in delivering appropriate treatment to achieve positive outcomes. CDC has established these guidelines based on the Oregon Health Plan (Medicaid) population it serves in conjunction with reviews of available clinical information. CDC makes known through its Provider Agreement and the Clinical Guidelines Policy those guidelines it is required to follow in delivery of care to CDC members, as well as the clinical practice guidelines utilized by CDC Administrative Staff when making dental determinations. CDC ensures there is more than one avenue of dissemination of the Clinical Practice Guidelines to providers and/or members.
DISSEMINATION OF PRACTICE GUIDELINES PROCEDURES TO PROVIDERS
The CDC Quality Improvement (QI) Committee is responsible for the review, adoption and approval of Clinical Practice Guidelines and updates these guidelines on a regular basis in response to changes within the dental profession, changes in OHP and CMS/Medicaid requirements and changes relating to CDC’s membership demographic.
Clinical guidelines fall into four areas:
Professional standards of care that dentists and dental hygienists are required to comply with to maintain necessary licensing within the state of Oregon.
Guidelines that determine what treatments and services are covered under the Oregon Health Plan and which treatments and services may be ”dentally appropriate” but not covered.
A sub-category of guidelines that govern CDC clinical review of Pre-Authorizations and Referrals to confirm providers are referring cases and requesting PAs consistent with OHP standards.
Guidelines and protocols that govern “Special Needs” members served by Exceptional Needs Dentistry Services (ENDS) as well as other specialized providers.
The following guidelines are the standard for the provision of quality care to its membership, and include measures for referral reviews and prior authorization of procedures:
ADA Practice Parameters www.ada.org/en/.../practice-resources/
Exceptional Needs Dental Services (ENDS) Clinic Protocols for Special Needs Patients..
ADA Center for Evidence-Based Dentistry www.ada.org/en/science-research/.
FDA Guidelines for Prescribing Dental Radiographs www.fda.gov/.../MedicalX-Rays/ucm1165/
American Dental Hygienists Association Practice parameters http://www.adha.org/practice-parameters/
Association of State and Territorial Dental Directors Best Practices
Health Insurance Portability and Accountability Act (HIPAA ) 45 CFR Part 160 and Subparts A and E of Part 164
A copy of the ENDS Clinic Protocols and OHP Dental Services Rulebook are included as exhibits to the Provider Guide, which is provided to the provider upon enrollment. Due to size limitations, other guidelines noted above are referenced by website with the Provider directed to review guidelines. In addition, the CDC Clinical Director discusses verbally and/or in writing relevant guidelines with the referring Provider at the time of review if the referral request or Pre-authorization request does not meet criteria for approval.
DISSEMINATION OF PRACTICE GUIDELINES PROCEDURES TO MEMBERS
Upon request, members are provided with a copy of the Oregon Dental Services Rulebook in response to any coverage issues. In addition, should a “special needs” member or legal guardian of a “special needs” member request guidelines relating to the ENDS providers, the member or legal guardian will be provided with a copy of ENDS clinic protocols.
In addition, where members have filed a grievance or complaint (or verbalize their dissatisfaction relating to coverage issues, CDC Administrative staff will direct the member to the CDC website where a copy of the Member Handbook (explaining coverage) is available. Administrative staff offer to mail a copy of the Dental Services Rulebook electronically or mail by postal service a copy of the Dental Services Rulebook for those members that indicate a lack of access to the Internet.
CDC’s website also offers to members state contact information where additional resources may be found.