Verification of Coverage

In the event an employee indicates that a dental claim for services has been denied, it is possible that there is a problem with the employee's enrollment and the employee is not reflected on the dental carrier's eligibility files. If this occurs, departments should do the following:

1. Verify that the correct dental plan name is reflected on the employee's pay warrant.

2. Ensure that the claim denial was not prior to the 5th or the 20th of the month because the carriers receive eligibility information from SCO via electronic download on these dates. The employee may want to have his/her dentist resubmit the claim.

3. Confirm with the employee that the correct Social Security Number was entered on the claim form.

4. Review the file copy of the STD. 692 for accuracy.
   • If the STD. 692 is correct, contact the SCO Deductions Liaison Unit to verify when the document was processed and premiums paid.
   • If any of the following items are incorrect on the STD. 692, contact the SCO Deductions Liaison Unit:

     Section A -	Items 1, 2 or 4
     Section B -	Item 1; Item 3 does not correspond to Section E, Item 4
     Section D -	Form not signed/dated
     Section E -	Item 1; Item 2 does not correspond to Items 7 and 8 and/or Section B-1

Change of Dentist

Employees enrolled in a State-sponsored prepaid plan (DeltaCare USA or SafeGuard) are allowed to change to a different dentist within the dental plan's provider network. This type of change must be done through the dental carrier. Please refer the employee appropriately.

Employee Complaints

All the dental carriers have an internal complaint/grievance process in the event an employee is not satisfied with the services or benefits he/she receives. An employee with such a complaint should be advised to contact his/her dental carrier directly.

In addition, all the dental carriers are required to be licensed under the Knox-Keene Health Care Act of 1975, which is now administered by the Department of Managed Health Care. An employee who has exhausted his/her dental carrier's grievance/complaint process and is not satisfied with how the matter has been handled or resolved can contact the Department of Managed Health Care, Complaint Hotline at (888) HMO-2219 or (877) 688-9891 (TDD), or through their web site at http://www.dmhc.ca.gov/gethelp/.

Claim Forms

Claim forms are not required by DeltaCare USA or SafeGuard. Claim forms for Delta Dental are generally not necessary because of direct claims submission by the provider to Delta Dental. For out-of-network claims for reimbursement for services rendered by a non-Delta Dental provider, claim forms may be obtained directly form Delta Dental. Employees in Units 5 and 6 should contact their respective union for information on how to obtain claim forms.

Dental Carrier Address/Phone Information for State-Sponsored Dental Plans

Delta Dental of California
P.O. Box 429086
San Francisco, CA 94142-9086
1-800-225-3368
(415) 972-8300

DeltaCare USA
12898 Towne Center Drive
Cerritos, CA 90703
1-800-422-4234
FAX: (562) 924-8311

SafeGuard Health Plans
95 Enterprise
Aliso Viejo, CA 92656
1-800-880-1800
FAX: (949) 425-4149

Dental Carrier Direct Payment Address Information for State-Sponsored Dental Plans (excluding COBRA)

Delta Dental of California
Attn: Linda Clark MS:6N
P.O. Box 429086
San Francisco, CA 94142-9086
1-800-225-3368
(415) 972-8300

DeltaCare USA
12898 Towne Center Drive
Cerritos, CA 90703
1-800-422-4234
(562) 924-8311

SafeGuard Health Plans
P.O. Box 8095
Laguna Hills, CA 92654
1-800-880-1800
FAX (949) 425-4149
extension 4186

Dental Carrier COBRA Payment Address Information for State-Sponsored Dental Plans

For Delta Dental of California, mail STD 692 to:
Wolfpack Insurance Services, Inc.
P.O. Box 833
Belmont, CA 94002-0833
1-800-296-0192

DeltaCare USA
Attn: COBRA Unit
12898 Towne Center Drive
Cerritos, CA 90703
1-800-422-4234
(562) 924-8311

SafeGuard Health Plans
Attn: Cielo Gomez - COBRA Unit
95 Enterprise
Aliso Viejo, CA. 92656
1-800-880-1800
FAX (949) 425-4149
extension 4186