Referral Guidelines

Regular Specialty Referral

A regular (non-emergency) referral is obtained by completing a referral form and mailing the form to Access. Documentation supporting the reasons for the referral must be included with the referral form. We will respond to a referral request within five (5) business days from the date the request is received in our offices. The form should be mailed to:

Access Dental Plan
Attn: Specialty Referral
8890 Cal Center Drive
Sacramento, CA 95826

Determinations of referrals are based on submitted documentation and the benefit as outlined in Title 22 and Title 10 and the Department of Health Services Medi-Cal Manual of Criteria for Dental Services. A copy of the approved Specialty Referral form is sent to the specialist and the member and the PCD. In addition, the PCD and member receive a letter notifying them of the approval and advising them, when appropriate, that follow-up treatment needs to be performed by the PCD.

Specialty referrals may be denied for any of the following reasons:

Lack of eligibility.
Procedure not a benefit.
Insufficient documentation.
Dental necessity for procedure not evident.
Poor prognosis or longevity questionable.
Procedure requested is within the scope of the PCD.

Decisions resulting in denial, delay or modification of all or part of the requested dental services shall be communicated to the member in writing within two business days and to the member's treating provider within 24 hours of the decision.

Denial notification includes the rationale for the denial as well as the member's right to appeal the decision and the appeal process, including timeframes for submitting an appeal. Members are also advised of their right to seek a second or third opinion at no charge. The Referral/Case Management Coordinator assists the member in obtaining a second or third opinion.

When a referral for a member under the age of 21 is denied based on Medi-Cal benefits, the member's parent or legal guardian will be contacted and advised to seek assistance through the Child Health and Disability Program (CHDP), California Children's Services (CCS) or Early and Periodic Screening, Diagnosis and Treatment (EPSDT) program.

When a referral is denied because the services fall within the scope of the PCD, the member is instructed to return to their PCD for treatment.