Nevada Medicaid

Dental Program

Member Handbook

LIBERTY Dental Plan is committed to being the industry leader in providing quality, advanced and affordable dental benefits, focusing on member satisfaction.

IMPORTANTE: ¿Puede leer este aviso? Si no, alguien le puede ayudar a leerla. Además,

es posible que recital este aviso

Call us at 1-866-609-0418 por escrito en su propio idioma. Para obtener ayuda gratuita, llame ahora mismo al 1-866- 609-0418

LIBERTY Dental Plan of Nevada, Inc.

Making members shine, one smile at a timeTM

www.libertydentalplan.com

Nevada Medicaid Dental Program Member Handbook © 2018 LIBERTY Dental Plan of Nevada, Inc.

6385 S. Rainbow Blvd, Suite 200 Las Vegas, NV 89118

THIS HANDBOOK IS NOT A

CERTIFICATE OF INSURANCE AND SHALL NOT BE CONSTRUED OR INTERPRETED AS EVIDENCE OF INSURANCE COVERAGE BETWEEN LIBERTY AND THE RECIPIENT.

Welcome to LIBERTY Dental Plan

The LIBERTY Dental Plan Difference

At LIBERTY Dental Plan (“LIBERTY”), our goal is to provide you with local access to quality dental care. We use tools to help improve and maintain your overall dental health.

We are here to help guide you in making the most of your dental benefits. LIBERTY pledges to support you through the excellent customer service you deserve.

You have joined the State of Nevada’s Medicaid Dental Program. Your dental care is received through LIBERTY’s network of dentists. As a member of this dental Plan, we encourage you to take an active part in the success of your dental health. LIBERTY advises you to see your dentist on a regular basis. You may choose a network dentist from our list of participating providers to be your Dental Home and will receive any essential covered dental care services at that location. LIBERTY and our participating dentists are here to help arrange dental care services for you.

We want you to understand your dental program and its benefits/services.

We are also here to assist you with information about non-dental services, such as how to obtain transportation to and from your dental office if you are unable to get to your appointments.

This handbook is a summary of the dental services available to you. Please keep this handbook for your reference as it contains

important information regarding LIBERTY and its operations. Any questions you have regarding coverage on any of the following specific provisions, or to change your Dental Home, please call our Member Services Department at 1-866-609-0418 or visit us online at www.libertydentalplan.com/NVMedicaid.

Our pledge to you

LIBERTY is committed to being the industry leader in providing quality and innovative dental benefits with the utmost focus on member satisfaction.

We look forward to serving you!

Notice of Nondiscrimination

Discrimination is against the law. LIBERTY Dental Plan (“LIBERTY”) complies with all applicable Federal civil rights laws and does not discriminate, exclude people or treat them differently on the basis of race, color, national origin, age, disability, or sex.

LIBERTY provides free aids and services to people with disabilities, and free language services to people whose primary language is not English such as:

•Qualified interpreters, including sign language interpreters

•Written information in other languages and formats, including large print, audio, accessible electronic formats, etc.

If you need these services, please contact us at 1-866-609-0418.

If you believe LIBERTY has failed to provide these services or has discriminated on the basis of race, color, national origin, age, disability, or sex, you can file a grievance with LIBERTY’s Civil Rights Coordinator:

•Phone: 1-888-704-9833

•TTY: 1-800-735-2929

•Online: https://www.libertydentalplan.com/About-LIBERTY- Dental/Compliance/Contact-Compliance.aspx

If you need help filing a grievance, LIBERTY’s Civil Rights Coordinator is available to help you. You can also file a civil rights complaint with the U.S. Department of Health and Human Services, Office for Civil Rights:

U.S. Department of Health and Human Services

200 Independence Avenue, SW

Room 509F, HHH Building

Washington, D.C. 20201

1-800-368-1019, 1-800-537-7697 (TDD)

Or you can contact the Nevada Regional Office at:

Michael Leoz, Regional Manager Office for Civil Rights

U.S. Department of Health and Human Services

907th Street, Suite 4-100 San Francisco, CA 94103

Customer Response Center: 1-800-368-1019

Fax: 1-202-619-3818

TDD: 1-800-537-7697

Email: ocrmail@hhs.gov

Online at: https://ocrportal.hhs.gov/ocr/portal/lobby.jsf Complaint forms are available at http://www.hhs.gov/ocr/office/file/index.html

Notice of Language Assistance

If you, or someone you support, have questions about LIBERTY Dental

Plan, you have the right to get help and information in your language at no cost. To speak to an interpreter, call 1-866-609-0418. (English)

ርስዎ፣ ወይም እርስዎ የሚያግዙት ግለሰብ፣ ስለ LIBERTY Dental Plan ጥያቄ ካላችሁ፣ ያለ ምንም ክፍያ በቋንቋዎ እርዳታና መረጃ የማግኘት መብት አላችሁ። ከአስተርጓሚ ጋር ለመነጋገር፣ 1-866-609-0418 ይደውሉ።. (Amharic)

LIBERTY Dental Plan ﻦﻋ تارﺎﺴﻔﺘﺳا ﺔﯾأ هﺪﻋﺎﺴﺗ ﺎﻣ ﺺﺨﺷ وأ ﻚﯾﺪﻟ نﺎﻛ اذإ ﻢﺟﺮﺘﻣ ﻰﻟإ ثﺪﺤﺘﻠﻟ. ًﺎﻧﺎﺠﻣ ﻚﺘﻐﻠﺑ تﺎﻣﻮﻠﻌﻤﻟاو ةﺪﻋﺎﺴﻤﻟا ﻲﻘﻠﺗ ﻲﻓ ﻖﺤﻟا ﻚﯾﺪﻟ (Arabic) 1-866-609-0418 ﻢﻗﺮﻟا ﻰﻠﻋ ﻞﺼﺗا ،يرﻮﻓ

如果您，或您正在幫助的人，有關於 LIBERTY Dental Plan

方面的問題，您有權利免費以您的母語得到幫助和訊息. 想要跟一 位翻譯員通話, 請致電 1-866-609-0418. (Chinese)

LIBERTY Dental Plan درﻮﻣ رد ﯽﺗﻻاﺆﺳ ،ﺪﯿﻨﮐ ﯽﻣ ﮏﻤﮐ یو ﮫﺑ ﮫﮐ ﯽﺼﺨﺷ ﺎﯾ ﺎﻤﺷ ﺮﮔا یاﺮﺑ. ﺪﯿﻨﮐ ﺖﻓﺎﯾرد نﺎﮕﯾار رﻮط ﮫﺑ و نﺎﺗدﻮﺧ نﺎﺑز ﮫﺑ ار تﺎﻋﻼطا و ﮏﻤﮐ ﮫﮐ ﺪﯾراد ﻖﺣ ﺎﻤﺷ ،ﺪﯾراد (Farsi) 1-866-609-0418 ﺪﯾﺮﯿﮕﺑ سﺎﻤﺗ هرﺎﻤﺷ ﺎﺑ ،ﯽھﺎﻔﺷ ﻢﺟﺮﺘﻣ ﺎﺑ ﻮﮕﺘﻔﮔ

Si vous, ou quelqu'un que vous êtes en train d’aider, a des questions à propos de LIBERTY Dental Plan, vous avez le droit d'obtenir de l'aide et l'information dans votre langue à aucun coût. Pour parler à un interprète, appelez 1-866-609-0418. (French)

Falls Sie oder jemand, dem Sie helfen, Fragen zum LIBERTY Dental Plan haben, haben Sie das Recht, kostenlose Hilfe und Informationen in Ihrer Sprache zu erhalten. Um mit einem Dolmetscher zu sprechen, rufen Sie bitte die Nummer 1-866-609-0418 an. (German)

No dakayo, wenno maysa a tao a tultulunganyo, ket adda kayatyo a saludsoden maipanggep iti LIBERTY Dental Plan, adda karbenganyo a dumawat iti tulong ken impormasion iti bukodyo a pagsasao nga awan ti bayadanyo. Tapno makipatang iti maysa a mangipatarus iti pagsasao, tumawag iti numero nga 1-866-609-0418. (Ilocano)

ご本人様、またはお客様の身の回りの方でもLIBERTY Dental Plan につ いてご質問がございましたら、ご希望の言語でサポートを受けたり、 情報を入手したりすることができます。料金はかかりません。通訳と お話される場合1-866-609-0418までお電話ください (Japanese)

만약 귀하 또는 귀하가 돕고 있는 어떤 사람이 LIBERTY Dental Plan 에 관해서 질문이 있다면 귀하는 그러한 도움과 정보를 귀하의 언어로 비용 부담없이 얻을 수 있는권리가 있습니다. 그렇게 통역사와 얘기하기 위해서는 1-866-609-0418 로 전화하십시오.(Korean)

Если у вас или лица, которому вы помогаете, имеются вопросы по поводу LIBERTY Dental Plan, то вы имеете право на бесплатное получение помощи и информации на вашем языке. Для разговора с переводчиком позвоните по телефону 1-866-609-0418 (Russian)

Si usted, o alguien a quien usted está ayudando, tiene preguntas acerca de LIBERTY Dental Plan, tiene derecho a obtener ayuda e información en su idioma sin costo alguno. Para hablar con un intérprete, llame al 1- 866-609-0418. (Spanish)

‘Afai olo’o iai se fesili iate oe, po o se tasi olo’o e fesoasoani i ai, e uiga i le LIBERTY Dental Plan polokalame, o iai iate oe le aia tatau e maua atu ai i se fesoasoani po o se fa’atamalaga e uiga i lena polokalame i le gagana fa’asamoa, auno ma se togiga o tupe. Ina ia talatalanoa i se tagata ua malamalama ai i le gagana fa’asoma, po o se tagata fa’aliliu gagana, vili atu e lau telefoni 1-866-609-0418. (Samoan)

Kung ikaw, o ang iyong tinutulangan, ay may mga katanungan tungkol sa LIBERTY Dental Plan may karapatan ka na makakuha ng tulong at impormasyon sa iyong wika ng walang gastos. Upang makausap ang isang tagasalin, tumawag sa 1-866-609-0418. (Tagalog)

หากคุณหรือคนที่คุณกาลังชํ่วยเหลือมีคําถามเกี่ยวบั LIBERTY Dental Plan, คุณมีสิทธิที่จะได้รับความชวยเหลือและข้อมูลในภาษาของคุณได้โดยไม่มีค่าใช้จ่าย พูดคุยกบลั่าม โทร 1-866-609-0418. (Thai)

Nếu quý vị, hay người mà quý vị đang giúp đỡ, có câu hỏi về LIBERTY Dental Plan, quý vị sẽ có quyền được giúp và có thêm thông tin bằng ngôn ngữ của mình miễn phí. Để nói chuyện với một thông dịch viên, xin gọi 1-866-609-0418. (Vietnamese)

Contacting LIBERTY

How to reach LIBERTY:

If you have questions regarding your dental benefits, locating a participating provider, or for help scheduling an appointment, please contact LIBERTY’s Member Services Department toll-free at 1-866- 609-0418. Business hours are Monday through Friday 5:00 am to 5:00 pm Pacific Standard Time.

Hearing or speech impaired members may call 1-877-855- 8039.

Our Address:

LIBERTY Dental Plan of Nevada, Inc. 6385 S. Rainbow Blvd., Suite 200 Las Vegas, NV 89118

Fax: 1-888-401-1129

You can also contact us online at: www.libertydentalplan.com/NVMedicaid

LIBERTY’s Mobile App and Online Services:

LIBERTY’s Mobile App and Online Services offers a quick and easy way for you to access your account information. This puts our most popular online features at your fingertips.

LIBERTY’s Mobile App features include:

• Check your Usage

• Check Eligibility

• Frequently Asked Questions (FAQ’s)

• Check Utilization

• View Claim Status

• Dental Health Questionnaire

Nevada Medicaid Eligibility:

Phone: 1-800-992-0900

Website: https://www.medicaid.nv.gov

Medical/Dental Emergency:

LIBERTY covers emergency dental care. You can get emergency dental care 24 hours a day, 7 days a week at any in or out of network office. Emergency care can be for pain, bleeding, or swelling.

Call: Your Dental Home for instructions on how to proceed. If you cannot reach your Dental Home, call LIBERTY at 1-866-609-0418 (TTY 1-877-855-8039). LIBERTY’s 24 hour on call service will help you.

Medical Emergencies Call: 911

Member Rights and Responsibilities

LIBERTY must comply with any applicable Federal and State laws that pertain to member rights, and ensure that our staff and affiliated providers take those rights into account when providing services to Medicaid Members, as required by the Code of Federal Regulations, Enrollee Rights, 42 CFR § 438.100, which is available online at: http://www.ecfr.Gov.

Upon enrollment, members are provided the written Member Rights and Responsibilities included in this handbook.

As a LIBERTY member, you have the right:

•To be treated with respect

•To your privacy

•To maintain confidentiality of your medical and dental information

•To be provided with information about the Plan and its services

•To be able to choose your Primary Care Dentist/Dental Home within the Plan’s network

•To change your Primary Care Dentist/Dental Home upon request for any reason and as frequently as needed

•To take part in making decisions about your dental care

•To refuse treatment or dental services

•To have access to the grievance and appeal system and pursue resolution of grievances and appeals about LIBERTY, our Network Providers or care provided

•To request an appeal

•To formulate advance directives

•To have access to your dental records in accordance with applicable federal and state laws and to request that your dental records be amended or corrected

•To be free from any form of restraint or seclusion used as a means of coercion, discipline, convenience, or retaliation

•To receive information on available treatment options and alternatives, presented in a way you can understand

•To be notified of your right to request and obtain a copy of your member handbook at least once per year, or upon request, at no cost to you

As a LIBERTY member, you have the responsibility to:

•Present your Nevada Medicaid issued Medicaid ID card and/or LIBERTY issued ID card when using dental services

•Not permit the use of your ID Card (s) by any other person

•Provide the State of Nevada Medicaid office with changes in your family that might affect eligibility or enrollment, as well as any name, telephone number, or address changes

•Take an active part in ensuring the success of your dental health by seeing your dentist on a regular basis and following a mutually acceptable course of treatment

•Understand your dental program and its benefits, the services you can receive, the services that are not covered, and any limitations on covered services

•Treat your Dental Home, dentist and office staff, as well as LIBERTY staff, with respect and courtesy

•Provide dentists with accurate and complete dental information

•Arrive to your dental appointment on time. If you cannot keep your appointment, contact your Dental Office at least twenty- four (24) hours in advance to reschedule your appointment.

•Ask questions of providers to determine the potential risks, benefits, consequences, and cost of treatment and non- treatment and all relevant alternatives

•Cooperate with your Dental Home in following a prescribed course of treatment, or letting the dentist know the reasons the treatment cannot be followed, as soon as possible

•Call or contact LIBERTY for any questions or information regarding the Plan

•Follow LIBERTY’s internal grievance and appeals process to resolve a disagreement or dissatisfaction with a provider or Plan decision

•Live a healthy lifestyle and stay clear of behaviors known to be detrimental to your health

•Notify LIBERTY if you have any other dental insurance or coverage

•Be aware of and follow the organization’s guidelines in seeking dental care

Notice of Privacy Practice

A statement describing LIBERTY’s policies and procedures for preserving the confidentiality of dental records is available and will be provided to you upon request.

As required by law, this notice is about your rights, our legal duties, and privacy practices with respect to the privacy of Personal Health Information (PHI). This notice also talks about the way we may collect, use, and disclose your PHI. We must follow the orders of the notice currently in effect. We keep the right to make changes to this notice from time to time and to make the changed notice effective for all PHI we keep. You can find our most current privacy notice on our website at:

https://www.libertydentalplan.com/About-LIBERTY/Compliance/HIPAA- Privacy-Notice

You may also call Member Services at 1-866-609-0418 (TTY/TDD 1- 877-855-8039) to request a written copy of this notice at no cost to you.

Eligibility and Enrollment

LIBERTY Dental Plan is a dental plan for people who qualify for Medicaid in Washoe and Clark County, Nevada. Payments are sent directly to the dental care provider for services provided to members.

Who can become a member?

You are eligible for LIBERTY Dental Plan because you qualify for Medicaid and live in Washoe or Clark County. The Division of Welfare and Supportive Services determines Medicaid and Nevada Check Up eligibility for Nevadans. Online applications can be completed using Access Nevada at www.dwss.nv.gov.

Can I disenroll?

Nevada Medicaid recipients enrolled in a medical managed care organization (MCO) are automatically enrolled in LIBERTY’s dental plan. You will be automatically disenrolled if any of the following conditions occur:

•You are no longer eligible for Medicaid

•You move to a part of the state that is not covered by an MCO

•If you ‘opt out’ of your MCO

If there is not an adequate network provider in your area, LIBERTY will arrange for services at an out-of-network office. If you experience poor quality of care, you can change your provider at any time and you can exercise your right to the grievance process.

For questions about enrollment or disenrollment you can call the Nevada Medicaid District Office at:

Northern Nevada: 1-775-687-1900 or 1-800-992-0900

Southern Nevada: 1-702-668-4200 or 1-800-992-0900

Member ID Cards

Each covered member will receive an identification (ID) card issued by Nevada Medicaid and an identification (ID) card issued by LIBERTY. You are responsible for bringing your ID card(s) with you to all dental appointments. If you misplaced your ID card or need to correct any information on the card, you may call LIBERTY at 1-866-609-0418 to ask for a new ID card.

Sample of what your LIBERTY Dental Insurance ID Card will look like:

LIBERTY Dental Plan of Nevada, Inc.

http://www.libertydentalplan.com/NVMedicaid

866.609.0418

NAME: First Name, Last Name

PRV# 001234 Dental Home Name

Dental Home Address

City. State, Zip Code

TEL# (XXX) XXX-XXXX

STATE OF NEVADA MEDICAID TEL# 1-800-992-0900

Your LIBERTY Dental Insurance ID card will include:

•Your Medicaid ID number

•Your first name and last name

•The name, location, and telephone number of your chosen Dental Home

•Your effective date with LIBERTY

•What to do if you need emergency dental care

•The number to call to speak to LIBERTY’s Member Services

Department or to file a grievance (complaint)

•The number to call to report any suspected fraud, waste or abuse

LIBERTY will send you a new card when:

•You become eligible

•You request one

•You change or correct the spelling of a name

To request a new ID card, call Member Services at 1-866-609-0418, request one online at www.libertydentalplan.com/NVMedicaid, or through the free LIBERTY mobile application on your smart phone. ID cards are mailed within 5 working days from the date requested.

Transportation Services

Do you need a ride to your appointment?

Non-Emergency Transportation (NET) is provided to Nevada Medicaid members to get necessary covered services. Nevada Check Up members are not eligible for NET services.

How do I schedule transportation?

Transportation services are managed through MTM to provide you with non-emergency transportation to your dental appointments. If you have questions or need assistance setting up transportation you may call MTM at 1-844-879-7341, or you may contact LIBERTY’s Member Services at 1-866-609-0418 to help coordinate transportation for you.

When do I have to call?

You must call at least five working days before your non-urgent appointment to set up transportation. If you have less than 5 days before your appointment you should still call MTM at 1-844-879-7341 for assistance. MTM schedules routine trips Monday through Friday from 7 a.m. to 5 p.m. Pacific Time.

What information do I need to know when I call?

•The street address, including city and zip code of your pick up and drop off locations, and telephone number

•If you have a Nevada Medicaid ID number, please have it ready for the reservation specialist

•Minors under age 18 must travel with an adult 18-year-old or

older. Members 15-17 years of age may travel alone if MTM has an approved Parental Consent Form on file. Minors under age 18 that are legally married, emancipated, or obtaining family planning services are able to travel alone

•Transportation is only available when you choose to have services at the nearest appropriate network provider

What if I have a complaint about transportation?

You can file a complaint if you:

•Do not agree with a decision made by MTM

•Are not happy with any services received

•Are not happy about any other part of MTM’s transportation services

To file a complaint, call MTM’s ‘We Care Line’ at 1-866-436-0457 or you can go online at: http://www.mtm-inc.net/nevada/.

Interpreter/Translation Services

We want to make sure you fully understand your dental benefits. If English is not your first language LIBERTY will provide interpretation and translation services in your preferred language at no cost to you. To ask for language services call 1-866-609-0418. If you have a preferred language, please notify us by calling 1-866-609-0418.

Who do I call for an interpreter?

Call LIBERTY’s Member Service Department at 1-866-609-0418 to request any interpreter services you may need.

The Member Service Department can help if you:

•Have problems hearing, please call TTY/TDD 1-877-855-8039

•Have problems seeing or reading

•Need materials in other formats

•Do not speak English

•Do not read English

How can I find a dentist who speaks my language?

The provider directory lists all languages spoken at each provider location and if the office is accepting new members. For help locating a provider who speaks your language, or if you need a free provider directory, call Member Services at 1-866-609-0418 and we will mail one to you. You can also view an up-to-date and searchable provider directory anytime by visiting us online at www.libertydentalplan.com/NVMedicaid.

If you are unable to locate or access a provider office that speaks your language, interpreter services can be provided to you at no cost.

How can I get a face-to-face interpreter for my dental appointment?

To ensure that you are able to communicate with your dentist during your appointment, we can arrange for interpreter services during your dental appointments, at no cost to you.

To arrange face-to-face interpretation you must:

•Call LIBERTY at 1-866-609-0418

•Call at least 48 hours before the appointment

•Provide the language that you speak

•Provide details on the provider office where you will have services

•Provide details on your appointment date/time

How to Get Dental Care

How can I find a Dentist?

A list of dentists in your area can be found in LIBERTY’s Provider Directory. This directory will also give you information about each dentist that is part of the Plan’s network.

The LIBERTY Provider Directory lists dentists and Federally Qualified Health Centers (FQHCs). The Provider Directory tells you if the provider is taking new patients and includes the following:

•Names

•Addresses

•Phone numbers

•Business hours

•Languages spoken

The Provider Directory is available online at: www.libertydentalplan.com/NVMedicaid; click on ‘Find & Select a Dentist’ to do a search.

If you need a printed Provider Directory, call 1-866-609-0418 (TTY 1- 877-855-8039).

How do I change my dentist (Dental Home)?

You may call our Member Services Department at 1-866-609-0418 to change your Dental Home. A Member Service Representative will assist you in locating a network provider over the phone. You can also locate providers online at www.libertydentalplan.com/NVMedicaid; click on ‘Find & Select a Dentist’ to do a search.

How do I make an appointment?

When you call your Dental Home identify yourself as a LIBERTY member. Let them know you are calling to make an appointment with the dentist and see which dates and times are convenient for you. Write down the date and time of the appointment on your calendar. Please be sure to be on time to your appointment to avoid having to reschedule. On the date of your appointment, present your LIBERTY

ID card and/or your Medicaid ID Card. The ID numbers on both cards are the same.

What is a Dental Home?

A Dental Home is the Primary Care Dentist or Pediatric Dentist that you have been assigned to for your dental care needs. A Dental Home should be established by 12 months of age. A Dental Home is a dentist you see regularly to provide dental care and will always be available to you. Your Dental Home will help you care for your teeth by providing dental guidance and appropriate dental treatment as needed, including referrals for specialty care when needed.

If you have been to a dental office in the past, please ensure the office participates in LIBERTY’s network. To locate a Dental Home suitable to you and your family, call our Member Services Department at 1-866- 609-0418.

Your Dental Home will work with you and your family to stay healthy. It is important to follow the treatment plan recommended by your dentist.

What if I choose to have services at an office that is not my Dental Home?

Call our Member Services Department at 1-866-609-0418 to change your Dental Home prior to having services. Our Member Services Department will assist you in changing your Dental Home. Members have the freedom to be assigned to any dentist in the network.

How do I get services from a dental Specialist?

Your Dental Home must submit a referral request to LIBERTY for approval to see a dental Specialist such as an Endodontist, Oral Surgeon, Periodontist and/or a Prosthodontist. Only services that have been prior authorized for you by LIBERTY, may be performed by a dental Specialist. Your specialist will submit a request for prior approval if you need more services. Services rendered by a Pediatric Dentist (Pedodontist) do not require a specialist referral. If you would like services by a Pediatric Dentist you can call our Member Services Department to change your Dental Home to the child pediatric dentist office.

What are in-network and out-of-network dentists?

In-network dentists have agreed to join LIBERTY’s network of dentists to treat our members. Out-of-network dentists have not joined our

network. Benefits will not be paid for services performed by an out-of- network dentist, except for certain emergency situations.

What if I choose to have services with a dentist that is out-of- network?

You will have to pay for any out-of-network services not pre-approved by LIBERTY, except for covered services needed as an emergency.

Benefits and Services

What your dental plan covers

Here, we explain all your covered services as a member of the Plan. Your covered services are free to you if they are medically necessary (needed). Care is medically necessary if it is to stop and remove dental disease, illness, and pain, to return the form and function of the dentition, and to correct facial disfiguration or dysfunction.

We offer these types of dental services:

Read the summary of benefits below and each of the sections on the following pages to learn more about the exact services you can get.

Summary of Benefits:

Summary of Covered Services by Age/Category

1Non-Pregnant adults age 21 and over receive coverage under LIBERTY Dental’s value-added services.

2Adults age 21 and over receive coverage under special circumstances and services must be prior-approved (authorized) by LIBERTY to be covered.

What does your dental plan cover?

Nevada Medicaid covers the following dental services for members under age 21 that do not require prior approval:

•Periodic examinations covered once every 11 consecutive months

•Limited examinations covered up to 3 times every 6 months

•Comprehensive examinations covered once every 12 months

•Full mouth x-ray(s) covered once every 12 consecutive months

•Periapical x-ray(s) covered up to a maximum of 13 every year

•Bite-wing x-ray(s) covered once every 6 consecutive months

•Panoramic x-ray(s) covered once every 3 years

•Teeth cleaning (prophylaxis) covered once every 6 months

•Fluoride is covered once every 6 consecutive months

•Fluoride varnish is covered two times every 12 months

•Dental sealants covered once per tooth per lifetime

•Fillings covered once per tooth every 36 months

•Crowns covered once per tooth per lifetime

•Pulpotomies covered once per tooth every 36 months

•Root canal procedures for restorable teeth covered once per tooth per lifetime

•Periodontal scaling/root planning (deep cleaning) covered up to four units every 12 months

•Osseous surgery (surgery of the gums) covered up to 4 units every 60 months

•Extractions covered once per tooth per lifetime

•Alveoloplasty

•Full and partial dentures once every 60 months

•Denture adjustments once every 6 months

•Denture repair and relines

•Incision & drainage of abscess

•Emergency palliative treatment

•General anesthesia for covered services and when medically necessary, covered up to 5 units per day

As a member of LIBERTY Dental Plan under age 21, you also receive these additional value-added services:

•One additional fluoride service every 12 months at a Primary Care Physician or Mobile Unit

•Caries risk assessments covered once per 12 months

•Screenings and Assessment at a Primary Care Physician to facilitate Fluoride Varnish

Nevada Medicaid covers limited emergency services for adults age 21 and over including the following dental services that do not require prior approval:

•Limited Examination up to 3 times every 6 months

•Focused oral exam once every 6 months

•Full mouth x-ray(s) covered once every 12 consecutive months

•Periapical x-ray(s) covered up to a maximum of 13 every year

•Bite-wing x-ray(s) covered once every 6 consecutive months

•Panoramic x-ray(s) covered once every 3 years

•Full and partial dentures once every 60 months

•Denture adjustments once every 6 months

•Denture repair and relines

•Incision & drainage of abscess

•Alveoloplasty

•Extractions covered once per tooth per lifetime

•General anesthesia for covered services and when medically necessary, covered up to 5 units per day

Nevada Medicaid also covers these dental services for adult members over the age of 21 under certain circumstances, but prior approval/authorization from LIBERTY is required:

•Fillings are covered once per tooth every 36 months, for teeth that are needed for a partial denture

•Crowns are covered once per lifetime per tooth, for teeth that are needed for a partial denture

•Immediate dentures covered once in a lifetime

As a member of LIBERTY Dental Plan, age 21 and over, you also receive these additional value-added services:

•Periodic exams covered once every 12 months

•Teeth cleaning (prophylaxis) covered once every 12 months

•X-rays

Nevada Medicaid covers these additional services for adults over age 21 that are pregnant:

•Comprehensive examinations covered once every 12 months

•Teeth cleaning (prophylaxis) covered once every 6 months

•Topical fluoride covered once every 6 consecutive months

•Gingivectomy or gingivoplasty, up to 4 units every 60 months

•Periodontal scaling/root planing (deep cleaning) covered up to four units every 12 months

•Periodontal maintenance covered once every 3 months

As a member of LIBERTY Dental Plan who is pregnant and age 21 and over, you also receive these additional value-added services at your Dental Home:

•Two additional cleanings (prophylaxis) every 12 months

What services are not covered?

There are some services that neither LIBERTY nor Medicaid will cover, including:

•Non-dental related services

•Any dental procedure that is not specifically listed as covered under this dental plan

•Procedures, appliances or restorations to treat Temporomandibular Joint Dysfunction (TMJ)

•Services for cosmetic purposes

•Procedures which are determined not to be medically necessary

•Procedures performed to restore tooth structure lost from abrasion, erosion, attrition or abfraction

•Procedures to increase vertical dimension and restore occlusion

•Any services performed outside of your Dental Home office, unless expressly authorized by LIBERTY or covered as an emergency

•Any routine dental service performed by a dentist or dental Specialist in an inpatient/outpatient hospital setting

LIBERTY understands there may be other treatment options that can be offered to you; however, your Dental Home is responsible for providing covered services as listed by your Plan. If you choose to have any non-covered service(s) you will be responsible for all the associated costs of the non-covered service(s), LIBERTY will not pay or cover any non-covered service.

Do I have to get prior authorization for services?

There are some services that are covered but you must get prior authorized before you can get them done.

Prior authorization, also called pre-approval, means that LIBERTY has reviewed the services your Dental Home or Specialist has requested and agrees that the care is medically necessary (needed). For services that require pre-approval, your Dental Home will send LIBERTY the request with the needed information to decide if the services are medically necessary. The request will be reviewed by LIBERTY and you and your Dental Home will be notified in writing of the decision to approve or deny the services. Only a licensed dentist can deny services due to medical necessity. Standard prior authorizations are processed within 14 calendar days of receipt and urgent prior- authorization requests are processed within 72 hours of receipt. You, your provider or LIBERTY may request up to 14 additional calendar days if more time is needed, and it is in your best interest.

Newborns through age 20 require the following services to be prior authorized:

•Any service not listed under section ‘What Does Your Dental Plan Cover?’ must be prior authorized

•All services performed by a dental Specialist require a referral and prior approval. Services rendered by a Pediatric Dentist (Pedodontist) do not require a specialist referral. If you would like services by a Pediatric Dentist you can call our Member Services Department to change your Dental Home to the child pediatric dentist office.

Adults ages 21 and over require the following services to be prior authorized:

•All services performed by a dental Specialist require a referral and prior approval

•Fillings

•Crowns

•Immediate dentures

•Periodontal Maintenance (for pregnant adults)

•Periodontal scaling/root planning (deep cleaning) (for pregnant adults)

Treatment Plan and Care

Once your oral evaluation has been performed at your Dental Home, you will be provided with a treatment plan. Your dentist will discuss the benefits and importance of treatment versus non- treatment along with any alternative treatment options. You have

the right to receive information on available treatment options and alternatives and to participate in decisions regarding your health care including the right to refuse treatment.

What if I want a second opinion?

You may request a second opinion if you are unhappy with your dentist, or disagree with their opinion about your treatment plan. You can get a second opinion at no cost from another LIBERTY dentist or an out-of-network dentist for any reason.

To request a second opinion, please call our Member Services Department at 1-866-609-0418.

Your Dental Home may also request a second opinion on your behalf. They will submit the appropriate forms with supporting x-rays.

All requests for second opinions are handled by LIBERTY within five (5) business days of receipt of the request. If you believe there is an imminent and serious threat to your health, LIBERTY will handle your case within 72 hours of receipt. LIBERTY will organize the appropriate steps with your Dental Home about your concerns. Once you have been advised that your second opinion is approved, you may schedule an appointment. You may request a copy of LIBERTY's policy description for a second opinion, at no cost to you.

Do I need to submit claims?

You are not required to file claims directly with LIBERTY. Claims or encounters are submitted by your Dental Home on your behalf. Services provided by a Specialist are reported to LIBERTY by the Specialist. If you receive services out-of-network due to an emergency after-hours or out-of-area situation, please see page 31.

What if I have other insurance coverage?

As a member, you are responsible for reporting any other health insurance (third party liability). If you or anyone in your family has other dental insurance, you must tell LIBERTY and your dentist. Any other insurance coverage is considered primary to your coverage with LIBERTY and must pay first.

You may have other dental insurance through your job or your children may have other dental insurance through another parent. You must tell

LIBERTY if you have any other coverage, by calling Member Services at 1-866-609-0418, TTY/TDD 1-877-855-8039. When you visit your

Dental Home, you must also let them know about any other insurance coverage. This will help us make sure all your services get paid for.

How can I report suspected fraud, waste or abuse?

LIBERTY is committed to conducting its business in an honest and ethical manner. We seek to operate in strict compliance with all regulatory requirements that relate to and govern our business and dealings with employees, members, providers, business associates, suppliers, competitors, and government agencies.

Health care fraud includes but is not limited to, the making of intentional false statements, misrepresentations, or deliberate omissions of material facts from any record, bill, claim, or any other form for the purpose of obtaining payment, services, or any type of compensation for health care services for which you are not entitled.

Health care fraud, waste, and abuse costs taxpayers billions of dollars each year. You can help stop fraud by reporting it. Some types of health care fraud are:

•Using someone else’s ID card to get a service or product

•Loaning, selling, or giving your ID card to someone

•Doctors billing for a service not performed, or billing for a service or product that is not needed

•Falsifying eligibility information in order to gain coverage

To report possible unethical business practices or potential illegal activity regarding our Health Plan, our providers, vendors, or members, you may contact LIBERTY:

Compliance Hotline: 1-888-704-9833

E-mail: compliance@libertydentalplan.com

You may remain anonymous if you prefer. All information received will be treated as confidential, and the results of investigations will be discussed only with persons having a legitimate reason to receive the information.

How can I take part in reviewing and making public policies? LIBERTY has a group called the Dental Advisory Committee. This group is made up of members, providers, dentists in our network, our Dental Director and LIBERTY support staff.

The group talks about how to improve LIBERTY’s policies and is responsible for:

•Offering ideas to improve how we service members

•Reviewing quality reports, including complaints

•Suggesting ways to improve the Plan’s programs

•Reviewing financial reports

If you would like to be a part of this group, please call the Member Services Department at 1-866-609-0418 or contact LIBERTY’s Quality Management Department at QM@libertydentalplan.com.

What kind of quality control or improvement is done by LIBERTY? We have many quality programs in place to ensure you get the

care you need. Some examples of our quality programs include:

•Member and provider surveys used to measure satisfaction

•Monitoring members that have been identified as ‘at risk’ and helping with the coordination of their care

•Educating members through newsletters, health fairs, and other means

•Reviewing the types and quality of services given to members

•Giving members access to various education materials and tools online

•Measuring various access standards like how long it takes for a member to get an appointment

Phone calls are also monitored to make sure calls are answered timely and that all information provided is accurate and complete.

All member complaints are reviewed and tracked for any trends or opportunities for improvement.

All of LIBERTY’s contracted dentists have gone through strict

credentialing procedures, background checks and office reviews. Each dentist must follow strict contractual rules. All dentists are reviewed on a regular basis. We monitor our providers to assure compliance with state and federal laws.

For more information about LIBERTY’s quality programs, call our Member Services Department at 1-866-609-0418.

Early Periodic Screening, Diagnosis and Treatment (EPSDT)

In Nevada, the Early Periodic Screening Diagnosis and Treatment (EPSDT) program is called Healthy Kids. Children under the age of 21 qualify for EPSDT benefits when covered under Medicaid. EPSDT services identify health care issues early to prevent the decline of a child’s health. The EPSDT program recommends that all children have an established Dental Home by 12 months of age to help with early intervention. Children that need services that are not part of their benefits may get them under EPSDT.

LIBERTY will decide medical necessity (need) based on materials your Dental Home sends us. EPSDT services are provided at no cost to you and are listed under your ‘Benefits and Services’ on pages 22-29 of this handbook. Call LIBERTY at 1-866-609-0418 for more information.

Emergency Services

Emergency care is covered anywhere in the world. If you reasonably believe that not getting immediate care could be dangerous to your life or to a part of your body, call 911 or go to the nearest hospital. Emergency care may include care for a bad injury, severe pain, or a sudden serious dental illness.

All follow-up care should be done at your Dental Home. Do not go back to the emergency room for follow up dental care.

You do not need prior authorization to receive emergency/urgent dental services from any in-network or out-of-network provider. You have the right to use any provider for emergency/urgent services. You can also call LIBERTY’s Member Services at 1-866-609-0418; LIBERTY’s 24 hour on call service will help you.

You may also visit www.libertydentalplan.com/NVMedicaid to find a dentist and location where emergency/urgent dental care is provided.

Your Dental Home will inform you about their after-hours urgent dental care policy, including how to contact a dental provider 24 hours a day, 7 days a week for emergency/urgent services.

Directions for what to do in an emergency

If you require emergency dental care, call your Dental Home to schedule an immediate appointment.

For urgent or unexpected dental conditions that occur after-hours or on weekends, contact your Dental Home for instructions on how to proceed.

If your Dental Home is not available, or you are out of the area and cannot contact LIBERTY to redirect you to another contracted dental office, you may contact any licensed dentist to receive emergency care. The dentist may need you to pay in full for the emergency dental care. LIBERTY will refund you for covered dental emergency services that you paid for.

If you pay a bill for emergency care, send a copy within 90 days to: LIBERTY Dental Plan of Nevada

Claims Department

6385 S. Rainbow Blvd., Suite 200 Las Vegas, NV 89118

You should let LIBERTY know as soon as possible after receipt of emergency dental services.

What services are covered under emergency care?

The Plan will cover emergency dental services only if services are needed. LIBERTY will also cover these services if you believe that the condition, if left untreated, may lead to disability, dysfunction or death. If you encounter a situation in which there is an imminent and serious threat to your health, you may wish to call 911. The use of such system should be done so responsibly.

Emergency dental services covered by LIBERTY include dental screenings, examination, and evaluation by a Dentist or dental Specialist. The dentist will determine the emergency services necessary to alleviate any emergency symptoms. Medical emergencies are not covered by LIBERTY if the services are rendered in a hospital setting which are covered by a Medical Plan, or if LIBERTY determines the services were not dental in nature.

Grievances (Complaints)

If you have a problem with LIBERTY, a dentist, or with your dental services, you have the right to file a grievance/complaint to your Dental Plan.

A grievance is a formal statement expressing dissatisfaction with LIBERTY, a dentist, or your dental services. Grievances are not eligible for the Fair Hearing process.

How do I submit a grievance (complaint)?

You may submit your complaint over the phone by calling LIBERTY’s Member Services Department at 1-866-609-0418. You can also send your complaint:

By facsimile to: 1-833-250-1814, or

Through our online grievance filing process by visiting: www.libertydentalplan.com/NVMedicaid

Grievance forms are also available on our website, https://www.libertydentalplan.com/Members/Forms-Literature, by calling LIBERTY’s Member Services Department or by asking your provider. A grievance form is not required to submit a grievance. LIBERTY will review a grievance submitted in any format.

If someone other than you submits a grievance on your behalf, they must have your written consent.

If you need help filing your complaint, we can help you. We can give

you free language services. Please call the Member Services Department at 1-866-609-0418 or TTY/TDD 1-877-855-8039.

When will I get a response to my grievance?

LIBERTY will review your concern and make every effort to get you an answer within 30 calendar days.

If you need a fast decision because 30 days would put your life, health, or ability to function in danger, you can ask for an expedited (fast) review. To ask for an expedited (fast) review, please call 1-866-609-

0418 or TTY/TDD 1-877-855-8039. A decision will be made within 72 hours of receipt of the complaint.

You will not be discriminated against in any way by LIBERTY or your Provider for filing a grievance.

Appeals

If we sent you a Notice of Action (NOA) letter and you do not agree with the outcome, you can file an appeal. Your dentist can file an appeal on your behalf as well. You must complete LIBERTY’s appeals process before you can request a Fair Hearing.

How do I submit an appeal?

You or your dentist, on your behalf, may submit an appeal to LIBERTY. If someone other than you submits an appeal on your behalf, they must have your written consent. All appeals must be submitted within 60 calendar days from the date on the notice you received. Appeals may be submitted verbally or in writing.

We will start working on your verbal appeal the first day that it is received. We will also send you a letter within 5 calendar days to tell you that we received your appeal. The letter will include a form that we need you to complete and return to us. If you need help completing the form, please call our Member Services Department at 1-866-609-0418 or TTY 1-877- 855-8039.

All submitted appeals must include the following:

•Your Medicaid ID number

•Your date of birth

•Your provider’s name

•The date of service

•Your mailing address

•An explanation of why you feel the decision should be reversed

•Any supporting documents or records

If you feel that the standard time frame for an appeal could cause serious harm or jeopardy to your dental health, you may request an expedited (fast) appeal. LIBERTY will not take any actions against you if you request an expedited appeal. LIBERTY will also provide you with the chance to review the case file before and after the processing of

your appeal.

LIBERTY will continue your dental benefits during the appeals process, when the criteria listed in the Fair Hearing section relating to continued benefits is met, until one of the following has been met:

•You withdraw your appeal

•10 calendar days have passed since LIBERTY issued the final notice of appeal as unfavorable to you, unless within that time you have requested a State Fair Hearing with continuation of benefits

•A State Fair Hearing Office makes a decision that is not in your favor

Appeals can be sent in writing to one of the following:

Facsimile to: 1-833-250-1814,

Through our online Grievance filing process by visiting: www.libertydentalplan.com/NVMedicaid

Appeal forms are also available on our website, https://www.libertydentalplan.com/Members/Forms-Literature, by calling LIBERTY’s Member Services Department or by asking your provider.

When will I get a response to my appeal?

A group that consists of appropriate level staff and dental care professionals will review your appeal. You will receive a response within 30 calendar days.

For a fast decision, you will receive a response within 72 hours of receipt. It is important that you provide LIBERTY with documentation to support your expedited appeal as soon as possible. You may request an extension of up to 14 calendar days for the expedited review. LIBERTY may also request an extension of up to 14 calendar days if we need additional information and it would be in your best interest. LIBERTY will provide you with a written notice explaining the reasoning for the delay.

What if I am not satisfied with the response to my appeal?

If you are not satisfied with the resolution to your appeal, you may

contact the Hearings Unit with the Division of Health Care Financing and Policy at 1-775-684-3604 or 1-800-992-0900, extension 43604 to

request a Fair Hearing. A copy of the Fair Hearing request form is also included with the Notice of Appeals Resolution letter sent to you.

You will not be discriminated against in any way by LIBERTY or your Provider for filing an appeal.

Can I get a copy of my records from my grievance or appeal? You can ask for a copy of your records that were used during the review of your active grievance or appeal at any time. Once we receive your request, we will provide you a copy of your records within 5 business days.

Fair Hearing

You or your dental provider have the right to ask for a Fair Hearing from the state after you have gone through LIBERTY’s internal appeal process. If someone other than you asks for a Fair Hearing on your behalf, they must have your written consent. If you are not satisfied with the resolution to your appeal, you may contact the Hearings Unit with the Division of Health Care Financing and Policy at 1-775-684- 3604 or 1-800-992-0900, extension 43604.

You can request a Fair Hearing by mail by completing and sending the Fair Hearing request form on page 48 of this member handbook (and attached your Notice of Appeals Resolution letter) to:

Nevada Division of Health Care Financing and Policy, Hearings Unit

1100 East William Street, Suite 101 Carson City, NV 89701

You can also go online to access the recipient Fair Hearings request form at http://dhcfp.nv.gov/resources/PI/Hearings/.

You or your dental provider must ask for this hearing within 120 days of receiving the final notice from LIBERTY. You may designate a person to act on your behalf and file a Fair Hearing in writing.

LIBERTY will continue your dental benefits during the Fair Hearing process, if the following standards are met:

•Your Fair Hearing Request is received within 10 days after LIBERTY’s notice of action or the proposed effective date

•Your Fair Hearing Request is about the termination, suspension, or reduction of previously approved services

•Your Fair Hearing Request is about services ordered by a LIBERTY dental provider

•You specifically requested to have your benefits extended

Please note that if the outcome of the State Fair Hearing is not in your favor, you may have to pay the cost of continued benefits received.

If you need information or help, call the State Medicaid Office at:

Northern Nevada: 1-775-687-1900 or 1-800-992-0900

Southern Nevada: 1-702-668-4200 or 1-800-992-0900

If you need legal assistance, call the Nevada Legal Services Program:

Clark County: 1-702-386-0404 or 1-866-432-0404

Washoe County: 1-775-284-3491 or 1-800-323-8666

If you need information or help, call us at:

Toll-Free: 1-866-609-0418

TTY/TTD: 1-877-855-8039

Member Participation

Dental Advisory Committee

LIBERTY wants to hear from you. Once a quarter, we meet to discuss how well we are performing and how we can improve.

The Committee is made up of members, LIBERTY’s Dental Director and other support staff. We are looking for members who would like to join our Committee. You will take part in:

•Reviewing quality reports, such as complaints

•Suggesting ways to improve the Plan’s programs and services

•Reviewing reports on the Plan’s finances

•Helping to set policies that affect you

You will be paid for every meeting you attend. If you’re interested in the chance to participate, please contact LIBERTY at:

Phone: 1-866-609-0418, and ask about taking part in the Dental Advisory Committee

Or you can email us at:

QM@libertydentalplan.com

Important Dental Tips

Oral Health is critical to whole body health, especially for children. Dental visits can provide key diagnostics by identifying diabetes and other chronic diseases. Taking care of your mouth is one of the best ways to prevent a wide range of health problems. Here are some ailments that are linked to poor oral health - so take care of your pearly whites!

•Heart Disease: Those with gum disease are 2X more likely to have heart disease.

•Stroke and Blood Clots: Gum disease is one of the most common, preventable diseases in adults that increases susceptibility of stroke and blood clots.

•Respiratory Disease: Bad bacteria from the mouth can be an agent for pneumonia and bronchitis.

•Diabetes: Gum disease disrupts the control of blood sugar.

•Kidney Disease: Harmful bacteria from poor oral hygiene can

weaken kidneys.

Thorough daily oral hygiene lays the base for a healthy smile. Regular brushing, flossing and dental visits can be enough to help prevent tooth decay, gum disease and bad breath.

The importance of flossing

•Cleaning between your teeth is every bit as important as brushing. Since brushing cannot effectively clean between teeth, it’s important to use floss to get to those areas.

•Other items also are available to help you clean between your teeth. Ask your dentist which ones to use.

•Floss between your teeth once a day and brush your teeth at least twice a day.

Brushing up on technique

Since there are various techniques for brushing your teeth, it’s a good idea to ask your dentist which one to use. Included below are a few tips to help you develop a good brushing routine.

Brushing your teeth

•Brush your teeth at least twice a day – once in the morning and once before bed

•When brushing, use a gentle touch to avoid injuring your gum tissue

•Use a toothpaste with fluoride to help prevent tooth decay

•Concentrate on brushing all surfaces

•Use a gentle touch - it doesn’t take much pressure to remove the plaque from your teeth, and a vigorous scrubbing could

irritate your gums

Brushing gums

•Hold your toothbrush at a slight angle toward the gums when brushing along the gum line

Brushing your tongue

•Brushing your tongue gently can help remove bacteria that cause bad breath

The Benefits of a Dental Home

•Having a Dental Home helps you keep a healthy smile

•Families are encouraged to build a relationship with their Dental Home

•A great Dental Home encourages members to schedule regular dental checkups

Benefits of establishing a Dental Home:

•Patients become familiar with the dentist, their staff and the office

•Promotes early and regular access to preventive and routine dental services

•Increases continuity of care, prevention, dental and overall health

•Decreases duplication of dental services caused by seeking dental care from multiple dental offices

The American Academy of Pediatrics (AAP), the American Dental Association (ADA), and the American Academy of Pediatric Dentistry (AAPD) recommend establishing a “Dental Home” for your child by one year of age. Children who have a Dental Home are more likely to receive appropriate preventive and routine care. A well-established Dental Home also includes appropriate referrals to dental Specialists.

With the rising incidence of tooth decay among young children, having a Dental Home can be essential in promoting preventive care. In addition to implementing lifelong oral health at home, establishing and

maintaining an ongoing relationship between the dentist and the patient is imperative. The Dental Home is an open door to all aspects of oral health care delivered in a comprehensive, continuously accessible, coordinated, and family-centered way.

Definitions and Useful Terms

Action: A decision made by LIBERTY that you have the right to appeal, including:

•Denial or partial denial of a requested service

•Denial, in whole or in part, of payment for a service

•Failure to provide services in a timely manner

•Failure of LIBERTY to act within specified time frames

Appeal: A request for review of a Notice of Action (see ‘Action’).

Authorization: The notification of approval by LIBERTY that you may proceed with treatment requested.

Benefits: the dental health care services available under the Nevada Medicaid Dental Program.

Benefit Plan: The dental benefit plan provided under your Medicaid coverage by LIBERTY.

Covered Services: Those dental services that are covered under your Medicaid benefits.

Dental Home: A Dental Home is the Primary Care Dentist or Pediatric Dentist that you have been assigned to for your dental care needs. The Dental Home is the ongoing relationship between the dentist and you, inclusive of all aspects of oral health care delivered in a comprehensive, continuously accessible, coordinated, and family- centered way. The Dental Home should be established no later than 12 months of age and includes referral to dental Specialists when appropriate. Also known as Primary Care Dentist or Primary Care Provider.

Dental Necessity or Dentally Necessary: A covered service that meets Plan guidelines for appropriateness and reasonableness by virtue of a clinical review of submitted information.

Covered Services may be reviewed for Dental Necessity prior to a signed contract to provide services, or after services are rendered. Payment for services occurs for Covered Services that are deemed Dentally Necessary by the Plan.

Dental Records: Refers to diagnostic intraoral and extra-oral radiographs, written treatment records including but not limited to progress notes, dental and periodontal chartings, treatment plans, consultation reports, or other written material relating to an individual’s medical and dental history, diagnosis, condition, treatment, or evaluation.

DHCFP: is the abbreviation for the State of Nevada Division of Health Care Financing and Policy.

Emergency Care/Emergency Dental Service: Emergency Dental Service and care include (and are covered by LIBERTY) dental screening, examination, evaluation by a Dentist or dental Specialist to determine if an emergency dental condition exists, and to provide care that would be acknowledged as within professionally recognized standards of care and in order to alleviate any emergency symptoms in a dental office. Medical emergencies are not covered by LIBERTY if the services are rendered in a hospital setting which are covered by a Medical Plan, or if LIBERTY determines the services were not dental in nature.

Exclusion: A statement describing one or more services or situations where coverage is not provided for dental services by the Plan.

General Dentist: A licensed dentist who provides general dental services and who does not identify as a Specialist.

Grievance: Any expression of dissatisfaction with any aspect of care other than the appeal of actions.

In-Network Benefits: Benefits available to you when you receive services from a contracted provider.

Non-Participating Provider: A dentist that has no contract to provide services for LIBERTY.

Out-of-Area Coverage: Benefits provided when you are out of the Plan’s Service Area, or away from your Dental Home.

Participating Dental Group, Dental Office, or Provider: A dental facility and its dentists that are under contract to provide services to LIBERTY members in accordance with LIBERTY’s rules and regulations.

Plan: LIBERTY Dental Plan of Nevada, Inc.

Pre-Authorization: A document submitted on your behalf requesting an advance determination and approval to render desired treatment services for you.

Primary Care Dentist: A dentist affiliated with LIBERTY to provide services to covered members of the Plan. The Primary Care Dentist is responsible to provide or arrange for needed dental services. Also known as a Dental Home.

Provider: A contracted dentist providing services under contract with the Plan.

Member: Any presently enrolled Medicaid Member who has completed a Plan membership application and receives Plan benefits through LIBERTY, also known as Enrollee/Recipient.

Service Area: The counties in Nevada where LIBERTY provides coverage.

Specialist: A dentist that has received advanced training in one of the dental specialties approved by the American Dental Association as a dental specialty, and practices as a Specialist. Examples are Endodontists, Oral and Maxillofacial Surgeons and Periodontists.

Urgent Care: See Emergency Care

Us/We/Our: LIBERTY Dental Plan of Nevada, Inc. (LIBERTY)

You/Your/My/I: Member, recipient, or “you”, are equivalent in this document.

Frequently Asked Questions

How can I find a contracted LIBERTY dentist?

Contact LIBERTY at 1-866-609-0418. A Member Service Representative will assist you in locating a dentist near you or you can locate providers online at www.libertydentalplan.com/NVMedicaid; click on ‘Find & Select a Dentist’ to do a search.

I lost my Dental ID card. How can I get another? Contact LIBERTY at 1-866-609-0418 to request an ID card.

Can I change my dentist?

Yes. See page 20 for details.

How do I know what’s covered under my dental plan?

Pages 22-28 of this handbook will provide you with “Benefits and Services”.

What if I don’t have transportation to my dental appointment?

LIBERTY can arrange transportation to your dental appointment. See page 17 for details.

Does LIBERTY offer interpreter services?

Yes. See page 19 for details.

What if I want a second opinion?

You may request a second opinion. See page 28 for details.

FORMS

MEMBER GRIEVANCE AND APPEAL FORM – NEVADA

You can use this form to file a grievance or appeal with LIBERTY Dental Plan (LIBERTY).You can also use this form to give LIBERTY more information to help review your case. You may request an appeal either orally or in writing. Further, unless you request an expedited resolution, an oral appeal must be followed by a written, signed appeal.

If you need help completing this form, call our Member Services Department at (866) 609-0418, or TTY: 1-877-855-8039, Monday through Friday 5:00 a.m. to 5:00 p.m. (PST). W e can give you an interpreter at no cost, if you need one. You or someone you authorize have the right to review your case file at any time. W e’ll give you copies free of charge.

MEMBER INFORMATION (PLEASE PRINT)

AUTHORIZED REPRESENTATIVE INFORMATION, IF APPLICABLE (PLEASE PRINT)

I am authorizing LIBERTY Dental Plan to allow the following person to act on my behalf during the grievance/appeals process

DENTAL OFFICE/PROVIDER INFORMATION (PLEASE PRINT)

I am authorizing LIBERTY Dental Plan to request my information, including chart records and x-rays, if applicable, from the following office:

SUMMARY OF GRIEVANCE OR APPEAL

Please share any information you have about your grievance or appeal. Please give us as many details as you can, if possible, please provide the dates, names and any treatment. Please share with us how you would like to see your grievance or appeal resolved. If needed you can attach an additional page.

*By providing LIBERTY with your signature, you are giving us your written permission to continue with the appeals process. If you do not sign and return this form, LIBERTY cannot continue with your appeal if it was received over the phone.

PLEASE SEND COMPLETED SIGNED FORM TO:

You will receive a letter acknowledging receipt of your grievance or appeal within

5 calendar days of receipt by LIBERTY.

You will receive a written resolution to your grievance or appeal within 30 calendar

days of receipt by LIBERTY.

You may request a copy of your records associated with your active grievance or

appeal in writing to LIBERTY at the address listed above.

Appeals must be filed within 60 days from the date

on your Notice of Action

(Denial Letter)

Grievances can be filed at any time.

Nevada Medicaid Dental Program Member Handbook © 2018 LIBERTY Dental Plan of Nevada, Inc.

6385 S. Rainbow Blvd. Suite 200 Las Vegas, NV 89118