Member  
Handbook  
What you need to know about your benefits  
LIBERTY Dental Plan of California, Inc.  
Combined Evidence of Coverage and Disclosure Form  
2
019  
Sacramento County  
Geographic Managed Care (GMC)  
Other languages and formats  
Other languages  
and formats  
Other languages  
You can get this Member Handbook and other plan  
materials for free in other languages. Call 800-735-2929.  
The call is free.  
Other formats  
You can get this information for free in other formats, such  
as Braille, large print and audio. Call 877-550-3875 (TTY  
800-735-2929). The call is free.  
Interpreter services  
For free interpreter, linguistic and cultural services and  
help available 24 hours a day, 7 days a week, or to get  
this handbook in a different language, call 877-550-3875  
(TTY 800-735-2929). The call is free.  
Call Member Services at 877-550-3875 (TTY 800-735-2929). We’re here  
Monday through Friday 8:00 a.m. to 5:00 p.m. The call is free.  
Visit us online at www.libertydentalplan.com.  
2
 
 
 
 
Notice of non-discrimination  
Call Member Services at 877-550-3875 (TTY 800-735-2929). We’re here  
Monday through Friday 8:00 a.m. to 5:00 p.m. The call is free.  
Visit us online at www.libertydentalplan.com.  
3
Notice of non-discrimination  
1
Call Member Services at 877-550-3875 (TTY 800-735-2929). We’re here  
Monday through Friday 8:00 a.m. to 5:00 p.m. The call is free.  
Visit us online at www.libertydentalplan.com.  
4
Notice of non-discrimination  
2
Nondiscrimination Notice  
Discrimination is against the law. LIBERTY Dental Plan  
follows state and federal civil rights laws and does not  
unlawfully discriminate, exclude people, or treat them  
differently because of sex, race, color, religion,  
ancestry, national origin, ethnic group identification,  
age, mental disability, physical disability, medical  
condition, genetic information, marital status, gender,  
gender identity, or sexual orientation.  
LIBERTY Dental Plan provides:  
▪
Free aids and services to people with disabilities  
to help them communicate better, such as:  
•
•
Qualified sign language interpreters  
Written information in other formats  
(braille, large print, audio, accessible  
electronic formats, and other formats)  
▪
Free language services to people whose primary  
language is not English, such as:  
•
•
Qualified interpreters  
Information written in other languages  
If you need these services, contact LIBERTY Dental Plan  
between 8:00 a.m. to 5:00 p.m. Monday through Friday by  
calling 877-550-3875. Or, if you cannot hear or speak well,  
please call (TTY 800-735-2929).  
Call Member Services at 877-550-3875 (TTY 800-735-2929). We’re here  
Monday through Friday 8:00 a.m. to 5:00 p.m. The call is free.  
Visit us online at www.libertydentalplan.com.  
5
 
Notice of non-discrimination  
HOW TO FILE A GRIEVANCE  
If you believe that LIBERTY Dental Plan has failed to provide these services or  
unlawfully discriminated in another way on the basis of sex, race, color, religion,  
ancestry, national origin, ethnic group identification, age, mental disability, physical  
disability, medical condition, genetic information, marital status, gender, gender  
identity, or sexual orientation, you can file a grievance with LIBERTY Dental Plan.  
You can file a grievance by phone, in writing, in person, or electronically:  
•
By phone: Contacting LIBERTY Dental Plan between Monday through Friday  
by calling 877-550-3875. Or, if you cannot hear or speak well, please call TTY  
8
00-735-2929.  
In writing: Fill out a complaint form or write a letter and send it to:  
DMC Civil Rights Coordinator]  
•
[
PO Box 26110  
Santa Ana, CA 92799-6110  
Phone 888-704-9833  
•
•
In person: Visit your doctor’s office or LIBERTY Dental Plan and say you want  
to file a grievance.  
Electronically: compliance@libertydentalplan.com  
OFFICE OF CIVIL RIGHTS – CALIFORNIA DEPARTMENT OF HEALTH CARE SERVICES  
You can also file a civil rights complaint with the California Department of Health  
Care Services, Office of Civil Rights by phone, in writing, or electronically:  
•
•
By phone: Call 916-440-7370. If you cannot speak or hear well, please call 711  
Telecommunications Relay Service).  
(
In writing: Fill out a complaint form or send a letter to:  
Office of Civil Rights  
Department of Health Care Services  
Office of Civil Rights  
P.O. Box 997413, MS 0009  
Sacramento, CA 95899-7413  
Complaint forms are available at http://www.dhcs.ca.gov/Pages/Language_Access.aspx.  
Electronically: Send an email to CivilRights@dhcs.ca.gov.  
•
Call Member Services at 877-550-3875 (TTY 800-735-2929). We’re here  
Monday through Friday 8:00 a.m. to 5:00 p.m. The call is free.  
Visit us online at www.libertydentalplan.com.  
6
Notice of non-discrimination  
OFFICE OF CIVIL RIGHTS – U.S. DEPARTMENT OF HEALTH AND HUMAN SERVICES  
If you believe you have been discriminated against on the basis of race, color,  
national origin, age, disability or sex , you can also file a civil rights complaint with the  
U.S. Department of Health and Human Services, Office for Civil Rights by phone, in  
writing, or electronically:  
•
•
By phone: Call 1-800-368-1019. If you cannot speak or hear well, please call TTY/TDD  
-800-537-7697.  
1
In writing: Fill out a complaint form or send a letter to:  
U.S. Department of Health and Human Services  
2
00 Independence Avenue, SW  
Room 509F, HHH Building  
Washington, D.C. 20201  
Complaint forms are available at http://www.hhs.gov/ocr/office/file/index.html.  
•
Electronically: Visit the Office for Civil Rights Complaint Portal at  
https://ocrportal.hhs.gov/ocr/portal/lobby.jsf  
Call Member Services at 877-550-3875 (TTY 800-735-2929). We’re here  
Monday through Friday 8:00 a.m. to 5:00 p.m. The call is free.  
Visit us online at www.libertydentalplan.com.  
7
Welcome to LIBERTY  
Dental Plan!  
Thank you for joining LIBERTY Dental Plan (“LIBERTY ” or the “Plan”. LIBERTY is  
a dental plan for people who have Medi-Cal. We work with the state of California to  
help you get the dental care you need.  
Member Handbook  
This Member Handbook tells you about your coverage under LIBERTY’s  
Sacramento Geographic Managed Care (GMC). Please read it carefully. It will help  
you understand and use your benefits and services. It also explains your rights and  
responsibilities as a member of LIBERTY Dental Plan.  
This Member Handbook is also called the Evidence of Coverage (EOC). It is only a  
summary of LIBERTY’s rules and policies. If you would like to learn the exact terms and  
conditions of coverage, you may request a copy of the contract from Member Services.  
Call 877-550-3875 (TTY 800-735-2929) to ask for a copy of the contract. You may  
also ask for another copy of the Member Handbook at no cost to you or visit our  
website at www.libertydentalplan.com to view the Member Handbook.  
Contact us  
We are here to help. If you have questions, call 877-550-3875 (TTY 800-735-2929).  
We are here Monday through Friday 8:00 a.m. to 5:00 p.m. The call is free.  
You can also visit us online at any time at www.libertydentalplan.com.  
Thank you,  
LIBERTY Dental Plan of California  
P.O. Box 26110  
Santa Ana, CA 92799-6110  
Call Member Services at 877-550-3875 (TTY 800-735-2929). We’re here  
Monday through Friday 8:00 a.m. to 5:00 p.m. The call is free.  
Visit us online at www.libertydentalplan.com.  
8
 
 
 
Table of Contents  
Table of Contents  
Other languages and formats ......................................................................................................... 2  
Other languages................................................................................................................................. 2  
Other formats..................................................................................................................................... 2  
Interpreter services ............................................................................................................................ 2  
Nondiscrimination Notice................................................................................................................ 5  
Welcome to LIBERTY Dental Plan!................................................................................................. 8  
Member Handbook............................................................................................................................. 8  
Contact us.......................................................................................................................................... 8  
Table of Contents............................................................................................................................. 7  
1
. Getting started as a member................................................................................................... 10  
How to get help................................................................................................................................ 10  
Who can become a member............................................................................................................ 10  
Identification (ID) cards .................................................................................................................... 11  
Ways to get involved as a member .................................................................................................. 11  
2
. About your dental plan............................................................................................................ 12  
Dental plan overview........................................................................................................................ 12  
How your dental plan works............................................................................................................. 13  
Changing dental plans ..................................................................................................................... 13  
Continuity of care ............................................................................................................................. 14  
Costs................................................................................................................................................ 15  
Member costs .............................................................................................................................. 15  
How a dentist gets paid .............................................................................................................. 15  
Asking us to pay a bill................................................................................................................. 15  
3
. How to get dental care............................................................................................................. 16  
Getting dental services..................................................................................................................... 16  
Routine dental care..................................................................................................................... 17  
Call Member Services at 877-550-3875 (TTY 800-735-2929). We’re here Monday  
through Friday 8:00 a.m. to 5:00 p.m. The call is free.  
Visit us online at www.libertydentalplan.com.  
7
 
Urgent dental care....................................................................................................................... 18  
Emergency dental care ............................................................................................................... 18  
Where to get dental care.................................................................................................................. 19  
Dental Provider Directory ........................................................................................................... 19  
Dental provider network ................................................................................................................... 19  
In network .................................................................................................................................... 19  
Out of network............................................................................................................................. 20  
Dentists ........................................................................................................................................ 20  
Primary care dentist (PCD) .............................................................................................................. 20  
Choice of Dentists....................................................................................................................... 21  
Appointments and visits............................................................................................................. 22  
Payment ....................................................................................................................................... 22  
Referrals....................................................................................................................................... 22  
Pre-approval ................................................................................................................................ 23  
Second opinions ......................................................................................................................... 23  
Timely Access to Care ................................................................................................................ 24  
4
. Benefits and services.............................................................................................................. 25  
What your dental plan covers........................................................................................................... 25  
Summary of benefits................................................................................................................... 26  
Frequency of services ................................................................................................................ 27  
Additional pediatric dental care services.................................................................................. 27  
Non-Emergency MedicalTransportation ................................................................................... 28  
Non-Medical Transportation....................................................................................................... 29  
What your dental plan does not cover.............................................................................................. 29  
Other programs and services for people with Medi-Cal ......................Error! Bookmark not defined.  
Coordination of benefits ................................................................................................................... 32  
5
. Rights and responsibilities..................................................................................................... 47  
Your rights........................................................................................................................................ 47  
Your responsibilities......................................................................................................................... 49  
Notice of Privacy Practices .............................................................................................................. 49  
Notice about laws............................................................................................................................. 50  
Notice about Medi-Cal as a payer of last resort ............................................................................... 50  
Call Member Services at 877-550-3875 (TTY 800-735-2929). We’re here Monday  
through Friday 8:00 a.m. to 5:00 p.m. The call is free.  
Visit us online at www.libertydentalplan.com.  
8
Notice of Adverse Benefit Determination ......................................................................................... 50  
DMC should insert other legal notices.]..............................................Error! Bookmark not defined.  
[
6
. Reporting and solving problems............................................................................................ 51  
Complaints....................................................................................................................................... 52  
Appeals............................................................................................................................................ 53  
State Hearings ................................................................................................................................. 54  
Fraud, waste and abuse................................................................................................................... 55  
7
. Important numbers and words to know................................................................................. 56  
Important phone numbers................................................................................................................ 56  
Words to know ................................................................................................................................. 56  
[DMC may insert index, if needed.]......................................................Error! Bookmark not defined.  
Call Member Services at 877-550-3875 (TTY 800-735-2929). We’re here Monday  
through Friday 8:00 a.m. to 5:00 p.m. The call is free.  
Visit us online at www.libertydentalplan.com.  
9
1.  
Getting started as  
a member  
How to get help  
We want you to be happy with your dental care. If you have any questions or  
concerns about your care, we want to hear from you!  
Member Services  
LIBERTY’s Member Services is here to help you. We can:  
Answer questions about your dental plan and covered services  
Help you choose a primary care dentist (PCD)  
Tell you where to get the care you need  
Offer interpreter services if you do not speak English  
Offer information in other languages and formats  
If you need help, 877-550-3875 (TTY 800-735-2929). We are here Monday through  
Friday 8:00 a.m. to 5:00 p.m. The call isfree. You can also visit us online at any  
time at www.libertydentalplan.com.  
Who can become a member  
You qualify for LIBERTY Dental Plan because you qualify for Medi-Cal and live in  
Sacramento County. For questions about enrollment, call Health Care Options at 1-800-  
4
30-4263 (TTY 1-800-430-7077). Or visit http://www.healthcareoptions.dhcs.ca.gov.  
You can ask questions about qualifying for Medi-Cal at your local county human  
services office. Find your local office at http://www.dhcs.ca.gov/services/medi-cal or  
call 1-800-300-1506 (TTY) 888 889-4500 to reach Covered California.  
Call Member Services at 877-550-3875 (TTY 800-735-2929). We’re here  
Monday through Friday 8:00 a.m. to 5:00 p.m. The call is free.  
Visit us online at www.libertydentalplan.com.  
1
0
 
 
 
Identification (ID) cards  
As a member of LIBERTY Dental Plan, you will get a dental plan ID card. You must  
show your dental plan ID card and your Medi-Cal Benefits Identification Card (BIC)  
when you get any dental services. You should carry both cards with you at all times.  
Here is a sample dental plan ID card to show you what yours will look like:  
Your dental plan ID card lists your assigned Primary Care Dentist’s name, address  
and phone number. Review your ID card when you receive it. Call Member Services  
at 877-550-3875 (TTY 800-735-2929) to change your dentist or information listed on  
your ID card. If you change your assigned dentist a new ID card will be mailed to you.  
Show your ID card at every dental visit.  
If you do not get your dental plan ID card within a few weeks of enrolling, or if your  
card is damaged, lost or stolen, call Member Services right away. We will send you a  
new card. Call (877-550-3875 (TTY 800-735-2929).  
Ways to get involved as a member  
LIBERTY wants to hear from you. Each year, we have meetings to talk about what is  
working well and how we can improve. Members are invited to attend. Join us and tell  
us what you think!  
LIBERTY’s Public Policy Committee  
We have a group called the Public Policy Committee. This group is made up of  
members, dental providers, support staff and our Dental Director. The group talks  
about how to improve LIBERTY’s policies and is responsible for:  
➢
➢
➢
➢
Offering ideas to improve how we service our 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, call 877-550-3875 (TTY 800-735-2929).  
 
 
2.  
About your  
dental plan  
Dental plan overview  
LIBERTY is a dental plan for people who have Medi-Cal in Sacramento County. We  
work with the state of California to help you get the dental care you need.  
You may talk with one of our Member Services Representatives to learn more about  
the dental plan and how to make it work for you. Call 877-550-3875 (TTY 800-735-  
2
929).  
When your coverage starts and ends  
When you enroll in the Plan, you will receive a LIBERTY Member ID card within seven (7)  
calendar days. Please show this card every time you visit the dentist for any service under your  
plan. This card is proof that you are enrolled with LIBERTY GMC program.  
You must see the dentist listed on your ID card. If you did not choose a Dentist when you  
enrolled, a dentist will be assigned to you. Or call 877-550-3875 (TTY 800-735-2929) to choose a  
different dentist. Your Primary Care Dentist’s name and telephone number are on your ID card.  
You may ask to end your LIBERTY coverage and choose another dental plan at any time.  
You can also ask to end your Medi-Cal. You must follow the Department of Health  
Care Services (DHCS) procedures if you ask to end your coverage.  
Sometimes LIBERTY can no longer serve you. LIBERTY must end your coverage if:  
You move out of the county or are in prison  
You no longer have Medi-Cal  
You request to be disenrolled from the Plan  
You become enrolled as a commercial member of a dental plan  
You verbally mistreat a dentist or the office staff  
You physically hurt a dentist or the office staff  
You let someone else use your dental benefits  
If you are a Native American, you do not have to enroll in a Medi-Cal managed care  
dental plan. If you have been enrolled in LIBERTY, you can ask to leave at any  
time. You can also get dental care at an Indian Health Service (IHS) Division of  
Oral Health (DOH) site.  
 
 
How your dental plan works  
LIBERTY is a dental plan contracted with DHCS. LIBERTY is a dental managed  
care plan. Managed care plans are a cost-effective use of dental care resources that  
improve dental care access and assure quality of care. LIBERTY works with dentists  
and other providers in our service area (our network) to provide dental care to you,  
our member.  
Member Services will tell you how LIBERTY works and how to get the dental care  
you need. Member Services can help you:  
Find a primary care dentist (PCD)  
Schedule an appointment with your PCD  
Get a new LIBERTY Member ID card  
Get information about covered and non-covered services  
Get transportation services  
Understand how to report and solve grievances and appeals  
Get a list of dentists  
Request member materials  
Answer other questions you may have  
To learn more, call 877-550-3875 (TTY 800-735-2929). Or find member service information  
online at www.libertydentalplan.com.  
Changing dental plans  
You may leave LIBERTY and join another dental plan at any time. Call Health Care  
Options at 1-800-430-4263 (TTY 1-800-430-7077) to choose a new plan. You can call  
between 8:00 a.m. and 5:00 p.m. Monday through Friday, or visit  
www.healthcareoptions.dhcs.ca.gov.  
It takes 45 calendar days to process your request to leave the Plan. To find out  
when Health Care Options has approved your request, call 1-800-430-4263 (TTY 1-  
8
00-430-7077).  
If you want to leave LIBERTY sooner, you may ask Health Care Options for an  
expedited (fast) disenrollment. If the reason for your request meets the rules for  
expedited disenrollment, you will get a letter to tell you that you are disenrolled.  
You may ask to leave LIBERTY in person at your local county human services  
office. Find your local office at http://www.dhcs.ca.gov/services/medi-cal or call  
1
-800-300-1506 to reach Covered California. You should continue seeing the  
dentist listed on your LIBERTY Member ID card until you get a letter from Health  
Care Options.  
 
 
Continuity of care  
If you now see dentists who are not in the LIBERTY’s network, you may be able to  
keep seeing them for up to 12 months. If your dentist(s) do not join our network by the  
end of 12 months, you will need to switch to dentists in the LIBERTY’s network.  
You have the right to dental services with a dentist(s) who is not part of LIBERTY’s  
network for certain dental benefits. Call 877-550-3875 (TTY 800-735-2929) to see if  
you qualify for this service, or to get a copy of LIBERTY’s Continuity of Care policy.  
College students who move to a new county  
If you move to a new county to attend college, you may still be able to get LIBERTY  
services, even if the Plan does not serve your new county. Or you may be able to get  
services through regular Medi-Cal, also known as Fee-for-Service (FFS) Medi-Cal.  
This is called continuity of care. LIBERTY provides continuity of care services for  
college students if:  
It is an emergency  
To learn more about continuity of care services, 877-550-3875 (TTY 800-735-2929).  
Dentists who leave LIBERTY  
If your dentist stops working with the Plan, you may be able to keep getting  
services from that dentist. This is another form of continuity of care. LIBERTY  
provides continuity of care services for:  
▪
Services that have not been finished by the dentist before leaving  
LIBERTY  
▪
Services that have not been finished by an out-of-network dentist when you  
became active with LIBERTY  
LIBERTY provides continuity of care services if the following terms are met:  
▪
▪
▪
▪
The services are covered under you dental plan  
The services are dentally necessary  
The services meet our clinical guidelines  
You did not have access to a LIBERTY dental provider  
LIBERTY does not provide continuity of care services if the following terms are  
met:  
▪
▪
▪
▪
The services are not covered under your dental plan  
The services are not dentally necessary  
The services do not meet our clinical guidelines  
You did have access to a LIBERTY Dental Plan provider  
To learn more about continuity of care services, call 877-550-3875 (TTY 800-735-  
929).  
2
 
Costs  
Member costs  
LIBERTY Dental Plan serves people who qualify for Medi-Cal. LIBERTY members do  
not have to pay for covered services. You will not have premiums, co-pays or  
deductibles.  
You may have to pay a portion of your dental care costs each month before  
benefits become effective. This is called your share of cost. The amount of your  
share of cost depends on your income and resources. For questions about share of  
cost, contact your local county human services office. Find your local office at  
http://www.dhcs.ca.gov/services/medi-cal.  
How a dentist gets paid  
LIBERTY pays dentists in these ways:  
▪
Capitation payments  
LIBERTY pays some dentists a set amount of money every month for each  
LIBERTY member. This is called a capitation payment. LIBERTY and  
dentistswork together to decide on the payment amount.  
▪
Fee-for-service payments  
Some dentists give dental care to LIBERTY GMC members and then send  
the Plan a bill for the services they provided. This is called a fee-for-service  
payment. LIBERTY and dentists work together to decide how much each  
service costs.  
To learn more about how LIBERTY pays dentists, call 877-550-3875 (TTY 800-  
35-2929).  
7
Asking us to pay a bill  
If you get a bill for a covered service, call Member Services right away at 877-550-  
3
875 (TTY 800-735-2929).  
If you pay for a service that you think the Plan should cover, file a claim with us. Call  
77-550-3875 (TTY 800-735-2929).to ask for a claim form, or for help to file a claim.  
Use a claim form and tell us in writing why you had to pay.  
8
 
 
 
 
3. How to get dental care  
Getting dental services  
PLEASE READ THE FOLLOWING INFORMATION SO YOU WILL KNOW FROM  
WHOM OR WHAT GROUP OF PROVIDERS DENTAL CARE MAY BE OBTAINED.  
You can begin to get dental care services on your effective date of coverage. Always  
Keep your dental plan ID card and Medi-Cal BIC card with you. Never let anyone else  
use your ID card or BIC card. Dentists are also called dental providers.  
New members must choose a primary care dentist (PCD) in our network. The  
LIBERTY network is a group of dentists who work with us. You must choose a PCD  
within 30 days from the time you become a member in LIBERTY. If you do not  
choose a PCD, we will choose one for you. You may choose the same PCD or  
different PCDs for all family members in LIBERTY.  
If you have a dentist you want to keep, or you want to find a new PCD, you can look in  
the dental Provider Directory. It has a list of all PCDs in our plan network. The dental  
Provider Directory has other information to help you choose. If you need a dental  
Provider Directory, call 877-550-3875 (TTY 800-735-2929). You can also find the  
Provider Directory on our website at www.libertydentalplan.com.  
If you cannot get the care you need from a participating dental provider in our  
network, your PCD must ask LIBERTY for approval to send you to an out-of-network  
provider.  
Read the rest of this chapter to learn more about PCDs, our dental Provider Directory  
and our dental provider network.  
Call Member Services at 877-550-3875 (TTY 800-735-2929). We’re here  
Monday through Friday 8:00 a.m. to 5:00 p.m. The call is free.  
Visit us online at www.libertydentalplan.com.  
16  
 
 
3
| How to get dental care  
When you call for an appointment with your PCD, tell the person who answers the  
phone that you are a member of LIBERTY. Give your dental plan ID number.  
To get the most out of your dental visit:  
▪
▪
▪
▪
▪
▪
Bring your Medi-Cal identification card (BIC)  
Bring your dental plan ID card  
Bring your valid California ID card or driver's license  
Know your Social Security Number  
Bring your list of medications  
Be ready to talk with your PCD about any dental problems you've noticed  
for yourself or your children.  
Be sure to call your PCD’s office if you are going to be late or cannot go to your  
appointment.  
Routine dental care  
Oral health is an important part of overall health and well-being. The Medi-Cal  
Dental program recommends that children begin seeing a dentist by their first tooth  
or their birthday. Routine care is regular dental care. LIBERTY covers routine care  
from your PCD. Some services may be referred to dentists that are specialists, and  
some services may require pre-approval (prior authorization). All dental services  
must meet Medi-Cal Dental program requirements to be covered.  
Dental services that may be covered for children are:  
▪
▪
▪
▪
▪
▪
▪
▪
▪
▪
Exams and x-rays  
Cleanings  
Fluoride treatments  
Sealants  
Fillings  
Crowns  
Tooth extractions  
Root canals  
Braces  
Appliances to replace missing teeth  
Call Member Services at 877-550-3875 (TTY 800-735-2929). We’re here  
Monday through Friday 8:00 a.m. to 5:00 p.m. The call is free.  
Visit us online at www.libertydentalplan.com.  
17  
 
3
| How to get dental care  
Dental services that may be covered for adults are:  
▪
▪
▪
▪
▪
▪
▪
▪
▪
▪
▪
Exams and x-rays  
Cleanings  
Deep Cleanings (scaling and root planing)  
Fluoride treatments  
Fillings  
Laboratory crowns  
Anterior root canals (front teeth)  
Tooth extractions  
Prefabricated crowns  
Full and partial dentures  
Other medically necessary dental services  
For a full list of child and adult dental services, read Chapter 4 in this handbook.  
Urgent dental care  
LIBERTY covers urgent dental care. If you need to see a dentist right away but it is not an  
emergency, urgent care appointments are available within 72 hours.  
During normal office hours, call your dentist for help. If it is after office hours, try calling your  
dentist first. If you cannot reach your dentist, call LIBERTY anytime at 877-550-3875 (TTY 800-  
7
35-2929) for assistance.  
Emergency dental care  
LIBERTY covers emergency dental care. A dental emergency can be pain, bleeding, or swelling  
that can cause harm to you or your teeth if not fixed right away. Emergency dental care is  
available 24 hours a day, 7 days per week. You do not need approval from LIBERTY to get  
emergency care.  
During normal office hours, call your dentist for help. If it is after office hours, try calling your  
dentist first. If you cannot reach your dentist, call LIBERTY anytime at 877-550-3875 (TTY 800-  
7
35-2929) for assistance.  
You may also call 911 or go to the nearest hospital. If you are away from home, you can find a  
dentist that is close to you to get emergency care. Dentists who are not contracted with LIBERTY  
may charge you for emergency care. If you pay for emergency care, we will pay you back.  
Call Member Services at 877-550-3875 (TTY 800-735-2929). We’re here  
Monday through Friday 8:00 a.m. to 5:00 p.m. The call is free.  
Visit us online at www.libertydentalplan.com.  
18  
 
 
3
| How to get dental care  
For medical emergencies, call 911 or go to the nearest emergency room.  
If you need help, call 877-550-3875 (TTY 800-735-2929). We are here Monday  
through Friday 8:00 a.m. to 5:00 p.m. The call is free.  
Where to get dental care  
You will get most of your care from your PCD. Your PCD will give you most of your  
routine dental care. Your PCD will refer (send) you to specialists if you need them.  
Dental Provider Directory  
The LIBERTY Dental Plan Provider Directory lists providers that participate in  
the Plan’s network. The network is the group of providers that work with  
LIBERTY.  
The LIBERTY Provider Directory lists dentists, specialist dentists, Federally  
Qualified Health Centers (FQHCs), Indian Health Centers (IHC) and Native  
American Health Clinics.  
The Provider Directory has names, provider addresses, phone numbers, business  
hours and languages spoken. It tells if the provider is taking new patients. It gives the  
level of physical accessibility for the building.  
You can find the online Provider Directory at www.libertydentalplan.com.  
If you need a printed Provider Directory, call 877-550-3875 (TTY 800-735-2929).  
Dental provider network  
The dental provider network is the group of dentists and specialty dentists that work  
with LIBERTY. You will get your covered services through our network.  
In network  
You will use dentists in the LIBERTY network for your dental care needs. You will get  
preventive and routine care from your PCD. You will also use specialists and other  
providers in our network.  
To get a dental Provider Directory of network providers, call call 877-550-3875 (TTY  
8
00-735-2929). Or you can find our dental Provider Directory online at  
www.libertydentalplan.com.  
For urgent or emergency dental care, call your PCD. If you would like assistance to  
Call Member Services at 877-550-3875 (TTY 800-735-2929). We’re here  
Monday through Friday 8:00 a.m. to 5:00 p.m. The call is free.  
Visit us online at www.libertydentalplan.com.  
19  
 
 
 
 
3
| How to get dental care  
schedule an appointment, or are not in your home area, call 877-550-3875 (TTY  
00-735-2929).  
8
For medical emergency care, call 911 or go to the nearest emergency room.  
Out of network  
Out-of-network providers are those that do not have an agreement to work with  
LIBERTY. Except for urgent or emergency care, you may have to pay for care from  
providers who are out of network. If you need covered dental care services, you may be  
able to get them out of network at no cost to you as long as they are medically  
necessary and not available in the network.  
If you need help with out-of-network services, call 877-550-3875 (TTY 800-735-  
2
929).  
If you are outside of our service area and need care that is not an emergency, call  
your PCD right away. Or call call 877-550-3875 (TTY 800-735-2929).  
If you have questions about out-of-network or out-of-area care, call 877-550-3875  
(TTY 800-735-2929).  
Dentists  
You will choose a Primary Care Dentist (PCD) from the LIBERTY Dental Plan  
Provider Directory. Your PCD must be a participating dentist. This means the dentist  
is in our network. To get a copy of our dental Provider Directory, call 877-550-3875  
(TTY 800-735-2929). You should also call if you want to check to be sure the PCD  
you want is taking new patients.  
If you were seeing a dentist for certain conditions before you were a member of  
LIBERTY, you may be able to keep seeing that dentist. This is called continuity of care.  
To make changes, please call 877-550-3875 (TTY 800-735-2929).  
Primary Care Dentist (PCD)  
New members must choose a PCD within 30 days of enrolling in in the Plan. You  
may choose a general dentist as your PCD.  
You can also choose a Federally Qualified Health Center (FQHC), community  
clinic, Native American Health Clinic or other primary care facility that has dental  
services as your PCD if they are in the LIBERTY network and if you qualify for  
their services. These are centers that are located in areas that do not have many  
dental care services.  
You can choose the same or different PCDs for everyone in your family who is a  
member of LIBERTY.  
Call Member Services at 877-550-3875 (TTY 800-735-2929). We’re here  
Monday through Friday 8:00 a.m. to 5:00 p.m. The call is free.  
Visit us online at www.libertydentalplan.com.  
20  
 
 
 
3
| How to get dental care  
If you do not choose a PCD within 30 days, a dentist who works with member  
care in LIBERTY will choose a PCD for you.  
Your PCD will:  
▪
▪
▪
▪
Get to know your dental needs  
Keep your dental records  
Give you the preventive and routine dental care you need  
Refer (send) you to a specialist if you need one  
You can look in the dental Provider Directory to find a PCD in the LIBERTY network. The  
dental Provider Directory has a list of FQHCs that work with LIBERTY.  
You can find our dental Provider Directory online at www.libertydentalplan.com. Or call 877-  
5
50-3875 (TTY 800-735-2929). You can also call to find out if the PCD you want is taking  
new patients.  
Choice of Dentists  
You know your dental care needs best, so it is best if you choose your PCD.  
It is best to stay with one PCD so he or she can get to know your dental care needs.  
However, if you want to change to a new PCD, you can change one time each month.  
You must choose a PCD who is in the LIBERTY Dental Plan provider network and is  
taking new patients.  
Your new choice will become your PCD on the first day of the next month after you  
make the change.  
To change your PCD, call 877-550-3875 (TTY 800-735-2929).  
We may ask you to change your PCD if the PCD is not taking new patients, has left our  
network, or does not give care to patients your age. LIBERTY or your PCD may also  
ask you to change to a new PCD if you cannot get along with or agree with your PCD,  
or if you miss or are late to appointments. If we need to change your PCD, we will tell  
you in writing.  
If you change PCDs, you will get a new dental plan member ID card in the mail. It will  
have the name of your new PCD. Call Member Services if you have questions about  
getting a new ID card.  
Call Member Services at 877-550-3875 (TTY 800-735-2929). We’re here  
Monday through Friday 8:00 a.m. to 5:00 p.m. The call is free.  
Visit us online at www.libertydentalplan.com.  
21  
 
 
3
| How to get dental care  
Appointments and visits  
When you need dental care:  
▪
▪
▪
▪
▪
▪
▪
▪
Call your PCD  
Have your LIBERTY Member ID number ready on the call  
Leave a message with your name and phone number if the office is closed  
Take your BIC and dental plan ID card to your appointment  
Bring an identification card or driver license  
Be on time for your appointment  
Call right away if you cannot keep your appointment or will be late  
Have your questions ready in case you need them  
Payment  
You do not have to pay any deductibles or co-pays for covered services. You  
should not get a bill from a dentist. You may get an Explanation of Benefits (EOB)  
or a statement from a dentist. EOBs and statements are not bills.  
If you do get a bill, call 877-550-3875 (TTY 800-735-2929). Tell us the amount  
charged, the date of service and reason for the bill.  
If you get a bill or are asked to pay a co-pay, you can also file a claim form. You will  
need to tell us in writing why you had to pay for the item or service. We will read your  
claim and decide if you can get money back. For questions or to ask for a claim form,  
call 877-550-3875 (TTY 800-735-2929).  
Referrals  
Your PCD will give you a referral to send you to a specialist if you need one. A  
specialist is a dentist who has extra education in one area of dentistry. Your PCD will  
work with you to choose a specialist. Your PCD’s office can help you set up a time to  
see the specialist.  
Your PCD may give you a form to take to the specialist dentist. The specialist dentist will fill out  
the form and send it back to your PCD.  
If you want a copy of our referral policy, call 877-550-3875 (TTY 800-735-2929).  
You do not need a referral for:  
▪
▪
PCD visits  
Urgent or emergency care  
Call Member Services at 877-550-3875 (TTY 800-735-2929). We’re here  
Monday through Friday 8:00 a.m. to 5:00 p.m. The call is free.  
Visit us online at www.libertydentalplan.com.  
22  
 
 
3
| How to get dental care  
Pre-approval  
For some types of care, your PCD or specialist dentist will need to ask us before you  
get the care. This is called prior authorization or pre-approval. It means that LIBERTY  
agrees that the care is medically necessary.  
Care is medically necessary if it is to prevent and eliminate orofacial disease,  
infection, and pain, to restore the form and function of the dentition,  
or to correct facial disfiguration or dysfunction. Dental services must meet Medi-Cal  
program rules for medical necessity.  
These dental services need pre-approval, even if you receive them from a provider in the  
LIBERTY network:  
▪
▪
▪
▪
▪
▪
Root canals  
Crowns  
Full dentures  
Denture relines  
Deep cleanings (scaling and root planing)  
General anesthesia and IV sedation  
Other dental services your dentist recommends may also require pre-approval.  
For some services, such as care from a specialist dentist, you need pre-approval if  
you get the care out of network. We will decide within 5 business days, for routine  
service, or 72 hours for urgent care.  
We review the request to decide if the care is medically necessary and covered.  
We do not pay our reviewers to deny coverage or dental services. If we do not  
approve the care, we will tell you why.  
LIBERTY will contact you if we need more information or more time to review  
your request.  
Second opinions  
You might want a second opinion about care your PCD says you need, or about  
your diagnosis or treatment plan. For example, you may want a second opinion if  
you are not sure you need a prescribed treatment or surgery.  
To get a second opinion, call your PCD. Your PCD can refer you to a network  
provider for a second opinion. Or call 877-550-3875 (TTY 800-735-2929).  
Call Member Services at 877-550-3875 (TTY 800-735-2929). We’re here  
Monday through Friday 8:00 a.m. to 5:00 p.m. The call is free.  
Visit us online at www.libertydentalplan.com.  
23  
 
 
3
| How to get dental care  
We will pay for a second opinion if you or your network dentist asks for it and you  
get the second opinion from a network dentist. You do not need permission from  
us to get a second opinion if the dentist you choose for a second opinion is  
approved. If you have urgent request, we will decide within 72 hours.  
Call Member Services at 877-550-3875 (TTY 800-735-2929).  
If we deny your request for a second opinion, you may appeal. To learn more  
about appeals, go to page #53 in this handbook.  
Timely Access to Care  
LIBERTY must provide appointments within the following timeframes:  
▪
▪
Routine appointments (including preventive care) – 4 weeks  
Specialist appointments – 30 business days (ages 21+); 30 calendar days  
(under age 21)  
▪
▪
Urgent care appointments – 72 hours  
Emergency care – Must be available 24 hours, 7 days per week  
Call Member Services at 877-550-3875 (TTY 800-735-2929). We’re here  
Monday through Friday 8:00 a.m. to 5:00 p.m. The call is free.  
Visit us online at www.libertydentalplan.com.  
24  
 
4.  
Benefits and  
services  
What your dental plan covers  
In this section, we explain all of your covered services as a member of the Plan.  
Your covered services are free as long as they are medically necessary. Care is  
medically necessary if it is to prevent and eliminate orofacial disease, infection, and  
pain, to restore the form and function of the dentition, and to correct facial  
disfiguration or dysfunction.  
We offer these types of dental services:  
Type of Service  
Diagnostic  
Examples  
Exams, x-rays  
Preventive  
Cleanings, fluoride treatments, sealants  
Fillings, crowns  
Restorative  
Endodontic  
Pulpotomies, root canals  
Gum surgery  
Periodontal  
Removable Prosthodontics  
Oral and Maxillofacial Surgery  
Orthontices  
Immediate and complete dentures, relines  
Extractions  
Braces  
Adjunctives  
Sedation, general anesthesia  
Read the summary of benefits and each of the sections below to learn more about  
the exact services you can get.  
Call Member Services at 877-550-3875 (TTY 800-735-2929). We’re here  
Monday through Friday 8:00 a.m. to 5:00 p.m. The call is free.  
Visit us online at www.libertydentalplan.com..  
2
5
 
 
4
| Benefits and services  
Summary of benefits  
Below is a summary of dental benefits for adults and children:  
Benefit  
Not a benefit  
Residing in a  
Limited Pregnancy  
Full Scope Scope Related  
Facility  
(SNF/ICF)  
Procedure  
Oral Evaluation (Under age 3 only)  
Initial Exam (Age 3+)  
Periodic Exam (Age 3+)  
Regular Cleanings  
Fluoride  
Restorative Services – Fillings/Crowns  
Crowns*  
Scaling and Root Planing (deep cleaning)**  
Periodontal Maintenance (gums)  
Anterior Root Canals (in front)  
Posterior Root Canals (in back)  
Partial Dentures  
Full Dentures  
Extractions/Oral and Maxillofacial Surgery  
Emergency Services  
Exceptions:  
*
1. Not a benefit under age 13.  
. Over age 21, allowed under special circumstances for back teeth.  
*Not a benefit under age 13. Allowable under special circumstances.  
2
*
Call Member Services at 877-550-3875 (TTY 800-735-2929). We’re here  
Monday through Friday 8:00 a.m. to 5:00 p.m. The call is free.  
Visit us online at www.libertydentalplan.com..  
2
6
 
4
| Benefits and services  
Frequency of services  
Dental services are covered if medically necessary. However, for some services, there are limits  
on how many times you may receive the service within a given period of time. Below are common  
services where there are limits:  
▪
▪
▪
▪
▪
▪
▪
▪
▪
▪
▪
▪
Examinations – Every 6 months (under age 21); Every 12 months (ages 21+)  
Bite-wing x-rays – Every 6 months  
Full mouth x-rays – Every 36 months  
Panoramic x-rays – Every 36 months  
Teeth cleaning – Every 6 months (under age 21); Every 12 months (ages 21+)  
Topical fluoride – Every 6 months (under age 21); Every 12 months (ages 21+)  
Dental sealants – Every 36 months (under age 21 only)  
Fillings – Every 12 months (per baby tooth); Every 36 months (per permanent tooth)  
Crowns – Every 5 years (age 13+)  
Deep cleaning (scaling/root planning) – Every 24 months per quadrant (age 13+)  
Full and partial dentures – Every 5 years  
Denture repair and relines – Twice per year  
Additional pediatric dental care services  
Early and Periodic Screening, Diagnostic and Treatment (EPSDT) services  
We cover EPSDT services. EPSDT services include all services covered by Denti-  
Cal. If you are under 21, you may receive additional services that are not covered  
by Denti-Cal as long as they are medically necessary. These services are in  
addition to the regular Denti-Cal benefits.  
If you need one of these additional services, your dentist will ask us. All requests  
are sent to LIBERTY for approval.  
If you want more information on EPSDT benefits, call 877-550-3875 (TTY 800-  
7
35-2929).  
Call Member Services at 877-550-3875 (TTY 800-735-2929). We’re here  
Monday through Friday 8:00 a.m. to 5:00 p.m. The call is free.  
Visit us online at www.libertydentalplan.com..  
2
7
 
 
4
| Benefits and services  
Non-Emergency MedicalTransportation  
You are entitled to use Non-Emergency Medical Transportation (NEMT) when you  
physically or medically are not able to get to your medical appointment by car, bus,  
train, or taxi, and the plan pays for your dental condition.  
NEMT is an ambulance, litter van, wheelchair van or air transport. NEMT is not a car,  
bus or taxi. LIBERTY allows the lowest cost NEMT for your medical needs when you  
need a ride to your appointment. That means, for example, if you are physically or  
medically able to be transported by a wheelchair van, LIBERTY will not pay for an  
ambulance. You are only entitled to air transport if your medical condition make any  
form of ground transportation not possible.  
NEMT must be used when it is:  
▪
▪
▪
Physically or medically needed as determined with a written prescription by a  
physician; or  
You are not able to physically or medically use a bus, taxi, car or van to get to  
your appointment;  
Approved in advance by LIBERTY with a written prescription by a physician.  
To ask for NEMT, please call LIBERTY at 877-550-3875 (TTY 800-735-2929) at  
least 10 business days (Monday- Friday) before your appointment. For urgent  
appointments, please call as soon as possible. Please have your member ID card  
ready when you call.  
Limits of NEMT  
There are no limits for receiving NEMT to or from dental appointments covered under  
LIBERTY when a provider has prescribed it for you.  
What Does Not Apply?  
If your physical and medical condition allows you to get to your medical appointment by  
car, bus, taxi, or other easily accessible method of transportation. Transportation will  
not be provided if the service is not covered by LIBERTY. A list of covered services is  
in this member handbook.  
Cost to Member  
There is no cost when transportation is authorized by LIBERTY.  
Call Member Services at 877-550-3875 (TTY 800-735-2929). We’re here  
Monday through Friday 8:00 a.m. to 5:00 p.m. The call is free.  
Visit us online at www.libertydentalplan.com..  
2
8
 
4
| Benefits and services  
Non-Medical Transportation  
You can use Non-Medical Transportation (NMT) when you are:  
▪
Traveling to and from an appointment for a LIBERTY covered service prescribed by  
your provider.  
LIBERTY allows you to use a car, taxi, bus, or other public/private way of getting to  
your medical appointment for plan-covered medical services including mileage  
reimbursement when transportation is in a private vehicle arranged by the beneficiary  
and not through a transportation broker, bus passes, taxi vouchers or train tickets.  
LIBERTY allows the lowest cost NMT type for your medical needs that is available at  
the time of your appointment.  
To ask for NMT services, please call LIBERTY at 877-550-3868 or at least 10  
business days (Monday-Friday) before your appointment or call as soon as you can  
when you have an urgent appointment. Please have your member ID card ready when  
you call.  
Limits of NMT  
There are no limits for receiving NMT to or from dental appointments covered under  
LIBERTY when a provider has prescribed it for you.  
What Does Not Apply?  
NMT does not apply if:  
▪
▪
An ambulance, litter van, wheelchair van, or other form of NEMT is medically  
needed to get to a covered service.  
The service is not covered by LIBERTY. A list of covered services is in this  
member handbook.  
Cost to Member  
There is no cost when transportation is allowed by LIBERTY.  
What your dental plan does not cover  
Dental services provided outside of Sacramento County are not covered unless it is an  
emergency.  
Medi-Cal does not cover these dental services, over the age 21:  
▪
▪
Crowns with high noble metal (gold)  
Gingival irrigation  
Call Member Services at 877-550-3875 (TTY 800-735-2929). We’re here  
Monday through Friday 8:00 a.m. to 5:00 p.m. The call is free.  
Visit us online at www.libertydentalplan.com..  
2
9
 
 
4
| Benefits and services  
▪
▪
▪
▪
Flexible base partial dentures  
Specialty dentist consultations  
Orthodontic treatment (braces)  
Laboratory crowns on back teeth that do not support and existing or treatment planned  
denture  
▪
Partial dentures unless there is an existing or treatment planned full denture on the other  
arch  
▪
▪
Implants and implant related services unless exceptional medical conditions are present  
Fixed partial denture (bridge) unless exceptional medical conditions are present  
If you have questions or want to learn more about dental services, call Denti-Cal at 1-  
00-322-6384 (TTY 1-800-735-2922). You may also visit the Denti-Cal website at denti-  
8
cal.ca.gov.  
Services you cannot get through LIBERTY or Medi-Cal  
There are some services that neither LIBERTY nor Medi-Cal will cover, including:  
▪
▪
▪
▪
California Children’s Services(CCS)  
Non-dental related services  
Any dental service that is not covered by the Medi-Cal Dental program  
Dental services started prior to active coverage or after termination of coverage with the  
Plan  
▪
▪
▪
▪
▪
▪
Dental services, procedures, appliances or restorations to treat Temporomandibular  
Joint Dysfunction (TMJ)  
Dental services that are determined to be for cosmetic purposes based on professional  
review  
Dental services that are determined not to be dentally necessary based on professional  
review  
Dental services to restore tooth structure lost from abrasion, erosion, teeth grinding or  
clinching  
Dental services or appliances that are provided by a dentist who specializes in  
Prosthodontics.  
Dental services for the removal of third molar teeth (wisdom teeth) that do not have  
meaningful signs of decay, irreversible pain and infection and/or the teeth are not  
blocking the eruption of other teeth.  
▪
▪
Dental services that would change the way teeth come together to bite and chew  
Any dental service performed outside of your assigned dental office, unless expressly  
Call Member Services at 877-550-3875 (TTY 800-735-2929). We’re here  
Monday through Friday 8:00 a.m. to 5:00 p.m. The call is free.  
Visit us online at www.libertydentalplan.com..  
3
0
4
| Benefits and services  
authorized by LIBERTY  
▪
Any routine dental service performed by a dentist or dentist specialist in an  
inpatient/outpatient hospital setting  
Read each of the sections below to learn more. Or call 877-550-3875 (TTY 800-735-2929).  
California Children’s Services (CCS)  
CCS is a state program that treats children under 21 years of age with certain health  
conditions, diseases or chronic health problems and who meet the CCS program rules.  
If LIBERTY or your PCP believes your child has a CCS condition, he or she will be  
referred to the CCS program.  
CCS program staff will decide if your child qualifies for CCS services. If your child can  
get these types of care, CCS providers will treat him or her for the CCS condition.  
LIBERTY will continue to cover types of service that do not have to do with the CCS  
condition such as physicals, vaccines and well-child checkups.  
LIBERTY does not cover care given by the CCS program. For CCS to cover  
these problems, CCS must approve the provider, services and equipment.  
CCS does not cover all problems. CCS covers most problems that physically disable or  
that need to be treated with medicines, surgery or rehabilitation (rehab). CCS covers  
children with problems such as:  
▪
▪
▪
▪
▪
▪
▪
▪
▪
▪
▪
▪
▪
▪
▪
▪
▪
▪
Congenital heart disease  
Cancers  
Tumors  
Hemophilia  
Sickle cell anemia  
Thyroid problems  
Diabetes  
Serious chronic kidney problems  
Liver disease  
Intestinal disease  
Cleft lip/palate  
Spina bifida  
Hearing loss  
Cataracts  
Cerebral palsy  
Seizures that are not controlled  
Rheumatoid arthritis  
Muscular dystrophy  
Call Member Services at 877-550-3875 (TTY 800-735-2929). We’re here  
Monday through Friday 8:00 a.m. to 5:00 p.m. The call is free.  
Visit us online at www.libertydentalplan.com..  
3
1
4
| Benefits and services  
▪
▪
AIDS  
Severe head, brain or spinal cord injuries  
▪
▪
Severe burns  
Severely crooked teeth  
The state pays for CCS services. If your child is not eligible for CCS program services,  
he or she will keep getting medically necessary care from LIBERTY.  
To learn more about CCS, call 877-550-3875 (TTY 800-735-2929).  
Coordination of benefits  
LIBERTY offers services to help you coordinate your dental care needs at no cost to  
you. If you have questions or concerns about your dental care or the dental care of your  
child, call 877-550-3875 (TTY 800-735-2929).  
Call Member Services at 877-550-3875 (TTY 800-735-2929). We’re here  
Monday through Friday 8:00 a.m. to 5:00 p.m. The call is free.  
Visit us online at www.libertydentalplan.com..  
3
2
 
5
.
Rights and  
responsibilities  
As a member of LIBERTY, you have certain rights and responsibilities. This chapter  
will explain those rights and responsibilities. This chapter will also provide legal  
notices that you have a right to as a member of LIBERTY.  
Your rights  
LIBERTY members have these rights:  
▪
To be treated with respect, giving due consideration to the Member’s right to  
privacy and the need to maintain confidentiality of the Member’s medical and  
dental information.  
▪
To be provided with information about the plan and its services, including Covered  
Services.  
▪
▪
To be able to choose a Primary Care Dentist within the Contractor’s network.  
To participate in decision making regarding their own dental care, including the  
right to refuse treatment.  
▪
To voice grievances, either verbally or in writing, about the organization or the  
care received.  
▪
▪
To receive oral interpretation services for their language.  
To have access to Federally Qualified Health Centers, Indian Health Service  
Facilities, and Emergency Services outside the Contractor’s network pursuant  
to the federal law.  
▪
▪
▪
To request a State Hearing, including information on the circumstances under  
which an expedited hearing is possible.  
To have access to, and where legally appropriate, receive copies of, amend or  
correct their Dental Record.  
To disenroll upon request.  
Call Member Services at 877-550-3875 (TTY 800-735-2929). We’re here  
Monday through Friday 8:00 a.m. to 5:00 p.m. The call is free.  
Visit us online at www.libertydentalplan.com.  
.
4
7
 
 
▪
To receive written Member informing materials in alternative formats (including  
Braille, large size print, and audio format) upon request and in a timely fashion  
appropriate for the format being requested and in accordance with W & I Code  
Section 14182 (b)(12).  
▪
▪
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 manner appropriate to the Member’s condition and ability to understand.  
To receive a copy of his or her dental records, and request that they be amended or  
corrected, as specified in federal regulations.  
▪
▪
The freedom to exercise these rights without adversely affecting how they are  
treated by the Contractor, providers, or the State.  
Your responsibilities  
LIBERTY members have these responsibilities:  
▪
Give your dentist, to the best of your knowledge, correct information about your  
physical and dental health  
▪
▪
Telling your dentist if you have any sudden changes to your physical and dental health  
Telling your dentist that you understand the treatment plan and what is of you required  
of you  
▪
▪
▪
▪
Staying with the treatment plan that you understood and agreed to with your dentist  
Keeping your planned appointments with your dentist  
Telling your dentist ahead of time if you are unable to make your planned appointments  
Your own actions if you refuse treatment or do not follow your dentist’s treatment plan,  
instructions and advise  
▪
▪
Paying any agreed upon fees or monies to your dental office as soon as possible  
Following all of the dental office’s rules about care and conduct  
Notice of Privacy Practices  
A statement describing our policies and procedures for preserving the  
confidentiality of dental records is available and will be furnished to you upon  
request.  
Call Member Services at 877-550-3875 (TTY 800-735-2929). We’re here  
Monday through Friday 8:00 a.m. to 5:00 p.m. The call is free.  
Visit us online at www.libertydentalplan.com.  
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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-Dental/Compliance/Privacy-  
Policy.aspx.  
Call our Member Services at 877-550-3875 (TTY 800-753-2929) Monday through Friday for a  
written copy of this notice  
Notice about laws  
Many laws apply to this Member Handbook. These laws may affect your rights and  
responsibilities even if the laws are not included or explained in this handbook. The  
main laws that apply to this handbook are state and federal laws about the Medi-Cal  
program. Other federal and state laws may apply too.  
Notice about Medi-Cal as a payer of last resort  
Sometimes someone else has to pay first for the services we provide you. For  
example, if you already have affordable health insurance from your employer.  
As a LIBERTY member, you will always received your Medi-Cal benefits.  
However, if you have coverage under a plan or policy from any other health  
Plan, your coverage under this plan is a secondary dental benefit.  
The California Department of Health Care Services has the right and responsibility to  
collect for covered Medi-Cal services for which Medi-Cal is not the first payer.  
The Medi-Cal program complies with state and federal laws and regulations relating to  
the legal liability of third parties for health care services to beneficiaries. We will take all  
reasonable measures to ensure that the Medi-Cal program is the payer of last resort.  
Notice of Adverse Benefit Determination  
We must use the Notice of Adverse Benefit Determination (NABD) form to notify you of  
a denial, termination, and delay or modification in benefits. If you disagree with our  
decision, you can file an appeal with our plan.  
Call Member Services at 877-550-3875 (TTY 800-735-2929). We’re here  
Monday through Friday 8:00 a.m. to 5:00 p.m. The call is free.  
Visit us online at www.libertydentalplan.com.  
50  
 
 
 
6
.
Reporting and  
solving problems  
There are two kinds of problems that you may have with your dental plan:  
▪
A complaint (or grievance) is when you have a problem with LIBERTY, or a  
provider, or with the dental care or treatment you got from a provider  
▪
An appeal is when you don’t agree with [DMC’s] decision not to cover  
services  
You should use the LIBERTY’s grievance and appeal process first to let us know about  
your problem. This does not take away any of your legal rights and remedies. We will  
also not discriminate or retaliate against you for complaining to us. Letting us know  
about your problem will help us improve care for all members. If your grievance is not  
solved, you may file a complaint with the Department of Managed Health Care  
(DMHC). If you disagree with the result of your appeal, you can file a State Fair  
Hearing. You must complete LIBERTY’s appeals process before you can file for a  
State Fair Hearing.  
You may also ask for an Independent Medical Review (IMR) from the DMHC. The  
IMR is an impartial review of a dental plan’s decision.  
The IMR decides medical necessity, coverage, and payment disputes for urgent  
or emergency services. You must apply for an IMR within 6 months after  
LIBERTY sent you a written decision about your appeal.  
If you ask for a State Hearing first, you cannot ask for an Independent Medical Review  
(IMR). But if you ask for an IMR first and are not satisfied with the result, you can ask  
for a State Hearing. You can get help from the California Department of Managed  
Health Care.  
The California Department of Managed Health Care is responsible for regulating health  
care service plans. If you have a grievance against your health plan, you should first  
telephone your health plan at 877-550-3875 (TTY 800-753-2929) and use your health  
plan’s grievance process before contacting the department. Utilizing this grievance  
procedure does not prohibit any potential legal rights or remedies that may be  
available to you. If you need help with a grievance involving an emergency, a  
grievance that has not been satisfactorily resolved by your health plan, or a grievance  
that has remained unresolved for more than 30 days, you may call the department for  
Call Member Services at 877-550-3875 (TTY 800-735-2929). We’re here  
Monday through Friday 8:00 a.m. to 5:00 p.m. The call is free.  
Visit us online at www.libertydentalplan.com.  
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| Reporting and solving grievances  
assistance. You may also be eligible for an Independent Medical Review (IMR). If you  
are eligible for IMR, the IMR process will provide an impartial review of medical  
decisions made by a health plan related to the medical necessity of a proposed service  
or treatment, coverage decisions for treatments that are experimental or investigational  
in nature and payment disputes for emergency or urgent medical services. The  
department also has a toll-free telephone number (1-888-HMO-2219) and a TDD line  
(1-877-688-9891) for the hearing and speech impaired. The department’s Internet Web  
site http://www.hmohelp.ca.gov has complaint forms, IMR application forms and  
instructions online.  
The California Department of Health Care Services (DHCS) Medi-Cal Managed Care  
Ombudsman can also help. The Ombudsman can help with problems the plan has not  
resolved; problems joining, changing or leaving a plan; and other problems with a Medi-  
Cal managed care plan. You can call the Ombudsman at 1-888-452-8609, Monday  
through Friday from 8:00 a.m. to 5:00 p.m.  
You can also file a grievance with your county eligibility office about your Medi-Cal  
eligibility. If you are not sure who you can file your grievance with, call 877-550-  
3
875(TTY 800-753-2929).  
Complaints  
A complaint (or grievance) can be about care you get from a network provider. A  
complaint can also be about LIBERTY. See below for more about appeals and  
State Hearings. You can file your complaint with your PCD or with LIBERTY.  
You can file a complaint with us by phone or by mail. There is no time limit to file a  
complaint.  
To file a complaint by phone, call your PCD’s office or call 877-550-3875 (TTY 800-  
7
35-2929). Give your dental plan ID number, your name, and the reason for your  
complaint.  
To file a complaint by mail, call 877-550-3875 (TTY 800-735-2929). Ask to have a  
form sent to you. When you get the form, fill it out. Be sure to include your name,  
dental plan ID number, and the reason for your complaint. Tell us what happened  
and how we can help you.  
Mail or Fax the form to:  
LIBERTY Dental Plan  
Quality Management Department  
3
40 Commerce, Suite 100  
Irvine, CA 92602  
Fax: (949) 270-0109  
Call Member Services at 877-550-3875 (TTY 800-735-2929). We’re here  
Monday through Friday 8:00 a.m. to 5:00 p.m. The call is free.  
Visit us online at www.libertydentalplan.com.  
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| Reporting and solving grievances  
If you need help filing your complaint, we can help you. We can give you free language  
services. Call 877-550-3875 (TTY 800-735-2929).  
Within 5 days of getting your complaint, we will send you a letter letting you know we  
received it. Within 30 days, we will tell you how we resolved your problem.  
If you want us to make a fast decision because the time it takes to resolve your complaint would  
put your life, health, or ability to function in danger, you can askfor an expedited (fast) review.  
To ask for an expedited review, call 877-550-3875 (TTY 800-735-2929). We will make a  
decision within 72 hours of receiving your complaint.  
Appeals  
An appeal is different from a complaint. An appeal is a request for LIBERTY to review  
and change a decision we made about coverage for a requested service. If we sent  
you a Notice of Adverse Benefit Determination (NABD) and you do not agree with our  
decision, you can file an appeal, or your PCD can file an appeal for you.  
You can file an appeal by phone or by mail. You must file an appeal within 60 calendar days  
from the date on the notice you received.  
▪
To file an appeal by phone, call 877-550-3875 (TTY 800-735-2929). Give your  
name, health plan ID number, and the service you are appealing.  
▪
To file an appeal by mail, call 877-550-3875 (TTY 800-735-2929). Ask to have a  
form sent to you. When you get the form, fill it out. Be sure to include your name,  
dental plan ID number, and the service you are appealing.  
Mail or fax the form to:  
LIBERTY Dental Plan  
Quality Management Department  
3
40 Commerce, Suite 100  
Irvine, CA 92602  
Fax: (949) 270-0109  
If the notice that we sent tells you services will stop, you can keep receiving services  
during your appeal. To do that, you or your PCD must request an appeal within 10  
days of the date the notice was mailed to you. You should tell us that you want to  
continue receiving services.  
If you need help filing your appeal, we can help you. We can give you free language  
services. Call 877-550-3875 (TTY 800-735-2929).  
Within 5 days of getting your appeal, we will send you a letter letting you know we  
received it. Within 30 days, we will tell you our appeal decision.  
Call Member Services at 877-550-3875 (TTY 800-735-2929). We’re here  
Monday through Friday 8:00 a.m. to 5:00 p.m. The call is free.  
Visit us online at www.libertydentalplan.com.  
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If you or your doctor wants us to make a fast decision because the time it takes to  
resolve your appeal would put your life, health, or ability to function in danger, you can  
ask for an expedited (fast) review. To ask for an expedited review, call 877-550-3875  
(TTY 800-735-2929). We will make a decision within 72 hours of receiving your  
appeal.  
State Hearings  
A State Hearing is a meeting with people from the California Department of Social  
Services (DSS). A judge will help to resolve your problem. You can ask for a State  
Hearing only after you have completed an appeal process within LIBERTY and you are  
still not happy with the decision or if you have not received a decision on your appeal  
after 30 days.  
You can ask for a State Hearing by phone or mail. You must ask for a State Hearing  
within 120 calendar days from the date on the notice telling you of the appeal decision.  
Your PCD can ask for a State Hearing for you if he or she gets approval from DSS.  
Call DSS to ask the state to give approval for your PCD to ask for a State Hearing.  
If the notice that we sent tells you services will stop, you can keep receiving services  
during your State Hearing. To do that, you or your PCD must request a State Hearing  
within 10 days of the date the notice was mailed to you. You should say that you want  
to continue receiving services.  
To ask for a State Hearing by phone, call the California Department of Social Services’  
(DSS) Public Response Unit at 1-800-952-5253. (TTD 1-800-952-8349).  
To ask for a State Hearing by mail, fill out the form provided to you with your appeals  
resolution notice. Send it to:  
California Department of Social Services  
State Hearings Division  
P.O. Box 944243, MS 09-17-37  
Sacramento, CA 94244-2430  
If you need help asking for a State Hearing, we can help you. We can give you free  
language services. Call 877-550-3875 (TTY 800-735-2929).  
At the hearing, you will give your side. We will give our side. It could take up to 90  
days for the judge to decide your case.  
If you want us to make a fast decision because the time it takes to have a State  
Hearing would put your life, health, or ability to function fully in danger, you or your  
Call Member Services at 877-550-3875 (TTY 800-735-2929). We’re here  
Monday through Friday 8:00 a.m. to 5:00 p.m. The call is free.  
Visit us online at www.libertydentalplan.com.  
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| Reporting and solving grievances  
PCD can write to DSS. You can ask for an expedited (fast) State Hearing. DSS  
must make a decision no later than 3 business days after it gets your request.  
If you already had a State Hearing, you cannot ask for an IMR. But, if you ask for an  
IMR first and are not happy with the result, you can still ask for a State Hearing.  
Fraud, waste and abuse  
If you suspect that a provider or a person who gets Medi-Cal has committed fraud,  
waste or abuse, it is your right and responsibility to report it.  
Provider fraud, waste and abuse includes:  
▪
▪
▪
▪
▪
Changing dental records  
Prescribing more medication than is medically necessary  
Giving more dental care services than are medically necessary  
Billing for services that were not given  
Billing for professional services when the professional did not perform the service  
Fraud, waste and abuse by a person who gets benefits includes:  
▪
Lending, selling or giving a dental plan ID card or Medi-Cal Benefits Identification  
Card (BIC) to someone else  
▪
▪
▪
Getting similar or the same treatments or medicines from more than one provider  
Going to an emergency room when it is not an emergency  
Using someone else’s Social Security number or dental plan ID number  
To report fraud, waste and abuse, write down the name, address and ID number of the  
person who committed the fraud, waste or abuse. Give as much information as you can  
about the person, such as the phone number or the specialty if it is a provider. Give the  
dates of the events and a summary of exactly what happened.  
Send your report to:  
LIBERTY Dental Plan  
Special Investigations Unit  
3
40 Commerce, Suite 100  
Irvine, CA 92602  
Or call our 24-Hour Fraud, Waste and abuse Hotline at (888) 704-9833.  
Call Member Services at 877-550-3875 (TTY 800-735-2929). We’re here  
Monday through Friday 8:00 a.m. to 5:00 p.m. The call is free.  
Visit us online at www.libertydentalplan.com.  
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7.  
Important numbers  
and words to know  
Important phone numbers  
▪
▪
▪
▪
▪
▪
▪
▪
▪
LIBERTY Member Services 877-550-3875 (TTY 800-703-2929)  
Denti-Cal Beneficiaries 800-322-6384 (TTY 800-735-2922)  
DMHC Help Center 888-466-2219  
Health Care Options – Medi-Cal Managed Care 800-430-4263  
Health Consumer Alliance 888-804-3536  
Medi-Cal Eligibility 916-552-9200  
Medi-Cal Fair Hearing 800-952-5253 (TTY 800-952-8349)  
Medi-Cal Managed Care 916-449-2000  
Medi-Cal Ombudsman 888-452-8609  
Words to know  
Appeal: A formal request asking LIBERTY to review denied services for treatment provided.  
An appeal may be filed by your dentist.  
Applicable: Applies to, or refers to having an effect on someone or something.  
Authorization: See Prior Authorization.  
Balance Billing: Billing a patient for the difference between the dentist's actual charge and  
the amount paid by LIBERTY. Except for copayments and Share of Cost, balance billing is  
not allowed for covered services.  
Beneficiary: A person who is eligible for Medi-Cal benefits.  
Beneficiary Identification Card (BIC): The identification card provided to beneficiaries by the  
Department of Health Care Services. The BIC includes the beneficiary number and other  
important information.  
Benefits: Medically necessary dental services provided by a LIBERTY dentist that are  
available through the Medi-Cal dental program.  
Call Member Services at 877-550-3875 (TTY 800-735-2929). We’re here  
Monday through Friday 8:00 a.m. to 5:00 p.m. The call is free.  
Visit us online at www.libertydentalplan.com.  
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California Children Services (CCS) Program: A public health program which provides  
specialized diagnostic, treatment, and therapy services to eligible children under the age of 21  
years who have CCS eligible conditions as defined state regulations.  
Caries: Another term for tooth decay or cavities.  
Child Health and Disability Prevention (CHDP) Program Services: Preventive health care  
services for beneficiaries under 21 years of age provided under the state law and regulations.  
Clinical Screening: An examination by a dentist to provide an opinion about the  
appropriateness of treatment proposed or provided by a different DMC dentist. The DMC may  
require a clinical screening under certain circumstances.  
Complaint: A verbal or written expression of dissatisfaction, including any dispute, request for  
reconsideration, or appeal made by you, or a dentist on your behalf. A complaint can also be  
made by your representative.  
Copayment: A small portion of the dentist’s fee that is paid by the beneficiary.  
Covered Services: The set of dental procedures that are benefits of the LIBERTY. The  
LIBERTY will only pay for medically necessary services provided by a LIBERTY dentist that  
are benefits of the Medi-Cal dental program.  
Dental Specialist: A dentist providing specialty care such as endodontics, oral surgery,  
pediatric dentistry, periodontics, and orthodontics (braces).  
Denti-Cal Dentist: A dentist who has been approved to provide covered services to Medi-Cal  
beneficiaries.  
Early and Periodic Screening, Diagnosis and Treatment Program (EPSDT): A federal  
program that provides health care for children through periodic screenings, diagnostic and  
treatment services. Dental care is included in the EPSDT program.  
Eligibility: Refers to meeting the requirements to receive Medi-Cal benefits.  
Emergency Care: A dental examination and/or evaluation by a LIBERTY dentist or dental  
specialist to determine if an emergency dental condition exists, and to provide care to treat  
any emergency symptoms within the capability of the facility within professionally recognized  
standards of care.  
Emergency Dental Condition: A dental condition that the absence of immediate attention  
could reasonably be expected to result in placing the individual’s health in jeopardy, causing  
severe pain or impairing function.  
Endodontist: A dental specialist who limits his or her practice to treating disease and injuries  
of the pulp and root of the tooth.  
Exclusion: Refers to any dental procedure or service not available under the Medi-Cal dental  
program.  
Grievance: See Complaint.  
Identification: Refers to something that proves who a person is, such as a driver’s license.  
Limitations: Refers to the number of services allowed, type of service allowed, and/or the  
most affordable dentally appropriate service.  
Medically Necessary: Covered services which are necessary and appropriate for the  
Call Member Services at 877-550-3875 (TTY 800-735-2929). We’re here  
Monday through Friday 8:00 a.m. to 5:00 p.m. The call is free.  
Visit us online at www.libertydentalplan.com.  
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6
| Reporting and solving grievances  
treatment of the teeth, gums, and supporting structures and that are (a) provided according to  
professionally recognized standards of practice; (b) determined by the treating dentist to be  
consistent with the dental condition; and (c) are the most appropriate type, supply and level of  
service considering the potential risks, benefits, and covered services which are alternatives.  
Non-Covered Service: A dental procedure or service that is not a covered benefit.  
Non-Participating Dentist: A dentist who is not authorized to provide services to Medi-Cal  
eligible beneficiaries.  
Notice of Authorization (NOA): A computer-generated form sent to dentists in response to  
their request for authorization of services. (See Treatment Authorization Request.)  
Other Health Coverage / Other Health Insurance: Coverage for dental related services you  
may have under any private dental plan, any insurance program, any other state or federal  
dental care program, or under other contractual or legal entitlement.  
Oral Surgeon: A dental specialist who limits his or her practice to the diagnosis and surgical  
treatment of diseases, injuries, deformities, defects and appearance of the mouth, jaws and  
face.  
Orthodontist: A dental specialist who limits his or her practice to the prevention and treatment  
of problems in the way the upper and lower teeth fit together in biting or chewing.  
Out-of-Network provider: A provider who is not part of the [DMCP] network.  
Palliative Care: Treatment that relieves pain but does not fix the problem causing the pain, or  
provides only a temporary fix.  
Participating Dental Provider: A provider enrolled in the Medi-Cal Dental program that  
provides dental services to the Plan’s member.  
Pediatric Dentist: A dental specialist who limits his or her practice to treatment of children  
from birth through adolescence, providing primary and a full range of preventive care  
treatment.  
Periodontist: A dental specialist who limits his or her practice to treatment of diseases of the  
gums and tissue around the teeth.  
Premium: The amount of money that a person must pay monthly for dental coverage. Plan  
members do not have to pay a premium.  
Prior Authorization: A request by a LIBERTY dentist to approve services before they  
are performed. Dentists receive a Notice of Authorization (NOA) from LIBERTY for  
approved services.  
Procedure Code: A code number that identifies a specific medical or dental service.  
Prosthodontist: A dental specialist who limits his or her practice to the replacement of  
missing teeth with dentures, bridges or other substitutes.  
Provider: An individual dentist, Registered Dental Hygienist in an Alternative Practice  
(RDHAP), dental group, dental school or dental clinic enrolled in the Medi-Cal dental program  
to provide health care and/or dental services to Medi-Cal beneficiaries.  
Provider Directory: A list of all providers in the LIBERTY network.  
Referral: When your PCP says you can get care from another provider. Some covered care  
Call Member Services at 877-550-3875 (TTY 800-735-2929). We’re here  
Monday through Friday 8:00 a.m. to 5:00 p.m. The call is free.  
Visit us online at www.libertydentalplan.com.  
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| Reporting and solving grievances  
and services require a referral and pre-approval.  
Requirements: Refers to something that you must do, or rules you must follow.  
Responsibility: Refers to something that you should do, or are expected to do.  
Service area: The geographic area LIBERTY serves. This includes the  
counties of Sacramento.  
Share of Cost: The share of health expenses that a beneficiary must pay or promise to pay  
before any Medi-Cal payments can be made for that month.  
Signature: Refers to your name written in your handwriting.  
State Hearing: A State Hearing is a legal process that allows beneficiaries to request a  
reevaluation of any denied or modified Treatment Authorization Request (TAR). It also allows  
a beneficiary or dentist to request a reevaluation of a reimbursement case.  
Treatment Authorization Request (TAR): A request submitted by a LIBERTY dentist for  
approval of certain covered services before treatment can begin. A TAR is required for certain  
services and under special circumstances.  
TAR/Claim Form: The form used by a dentist when requesting authorization to perform a  
service or to receive payment for a completed service.  
Call Member Services at 877-550-3875 (TTY 800-735-2929). We’re here  
Monday through Friday 8:00 a.m. to 5:00 p.m. The call is free.  
Visit us online at www.libertydentalplan.com.  
59