Member Handbook
Nevada Medicaid
Dental Program
LIBERTY Dental Plan is committed to being the industry leader in
providing quality, advanced and affordable dental benefits, focusing on
member satisfaction.
Have Questions? Visit us at:
www.libertydentalplan.com/NVMedicaid
Call us at 1-866-609-0418
IMPORTANTE: ¿Puede leer
este aviso? Si no, alguien le
puede ayudar a leerla. Además,
es posible que recital este aviso
por escrito en su propio idioma.
Para obtener ayuda gratuita,
llame ahora mismo al 1-866-
609-0418
LIBERTY Dental Plan of Nevada, Inc.
Making members shine, one smile at a time
TM
www.libertydentalplan.com
Nevada Medicaid Dental Program Member Handbook 01/21
2
Table of Contents
Welcome to LIBERTY Dental Plan ............................................ 4
Notice of Nondiscrimination ....................................................... 6
Notice of Language Assistance ................................................. 8
Contacting LIBERTY ................................................................ 11
Member Rights and Responsibilities ....................................... 13
Notice of Privacy Practice ........................................................ 16
Eligibility and Enrollment .......................................................... 16
Member ID Cards .................................................................... 17
Transportation Services ........................................................... 18
Interpreter/Translation Services ............................................... 19
How to Get Dental Care ........................................................... 21
Continuity of Care .................................................................... 23
Benefits and Services .............................................................. 24
Emergency Services ................................................................ 33
Reporting and Solving Problems ............................................. 35
Appeals .................................................................................... 36
Fair Hearing ............................................................................. 38
Member Participation ............................................................... 40
Provider Participation ............................................................... 40
Important Dental Tips .............................................................. 41
Definitions and Useful Terms ................................................... 43
Frequently Asked Questions .................................................... 46
Forms ....................................................................................... 47
Requesting a Fair Hearing ....................................................... 50
Fair Hearing Request Form ..................................................... 52
Nevada Medicaid Dental Program Member Handbook 01/21
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THIS HANDBOOK IS NOT A
CERTIFICATE OF INSURANCE AND
SHALL NOT BE CONSTRUED OR
INTERPRETED AS EVIDENCE OF
INSURANCE COVERAGE BETWEEN
LIBERTY AND THE RECIPIENT.
Nevada Medicaid Dental Program Member Handbook 01/21
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Welcome to LIBERTY Dental Plan
The LIBERTY Dental Plan Difference
At LIBERTY Dental Plan (“LIBERTY”), our goal
is to provide you with local access to quality
dental care. We use tools to help improve and
maintain your overall dental health.
We are here to help guide you in making the
most of your dental benefits. LIBERTY pledges
to support you through the excellent customer
service you deserve.
You have joined the State of Nevada’s Medicaid
Dental Program. Your dental care is received
through LIBERTY’s network of dentists. As a
member of this dental Plan, we encourage you
to take an active part in the success of your
dental health. LIBERTY advises you to see your
dentist on a regular basis. You may choose a
network dentist from our list of participating
providers to be your Dental Home and will
receive any essential covered dental care
services at that location. LIBERTY and our
participating dentists are here to help arrange
dental care services for you.
We want you to understand your dental program
and its benefits/services.
We are also here to assist you with information
about non-dental services, such as how to
obtain transportation to and from your dental
office if you are unable to get to your
appointments.
This handbook is a summary of the dental
services available to you. Please keep this
handbook for your reference as it contains
Nevada Medicaid Dental Program Member Handbook 01/21
5
important information regarding LIBERTY
and its operations. Any questions you have
regarding coverage on any of the following
specific provisions, or to change your
Dental Home, please call our Member
Services Department at 1-866-609-0418 or
visit us online at
www.libertydentalplan.com/NVMedicaid.
Our pledge to you
LIBERTY is committed to being the industry
leader in providing quality and innovative dental
benefits with the utmost focus on member
satisfaction.
We look forward to serving you!
Nevada Medicaid Dental Program Member Handbook 01/21
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Notice of Nondiscrimination
Discrimination is against the law. LIBERTY Dental Plan
(“LIBERTY”) complies with all applicable Federal civil rights laws and does
not discriminate, exclude people or treat them differently on the basis of
race, color, national origin, age, disability, or sex.
LIBERTY provides free aids and services to people with disabilities, and
free language services to people whose primary language is not English
such as:
• Qualified interpreters, including sign language interpreters
• Written information in other languages and formats, including large
print, audio, accessible electronic formats, etc.
If you need these services, please contact us at 1-866-609-0418.
If you believe LIBERTY has failed to provide these services or has
discriminated on the basis of race, color, national origin, age, disability, or
sex, you can file a grievance with LIBERTY’s Civil Rights Coordinator:
• Phone: 1-888-704-9833
• TTY: 1-800-735-2929
• Fax: 1-888-273-2718
•
Email: compliance@libertydentalplan.com
•
Online:
https://www.libertydentalplan.com/About-LIBERTY-
Dental/Compliance/Contact-Compliance.aspx
If you need help filing a grievance (complaint), LIBERTY’s Civil Rights
Coordinator is available to help you. You can also file a civil rights
complaint with the U.S. Department of Health and Human Services, Office
for Civil Rights:
U.S. Department of Health and Human Services
200 Independence Avenue, SW
Room 509F, HHH Building
Washington, D.C. 20201
1-800-368-1019, 1-800-537-7697 (TDD)
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Or you can contact the Nevada Regional Office at:
Michael Leoz, Regional Manager
Office for Civil Rights
U.S. Department of Health and Human Services
90 7th Street, Suite 4-100
San Francisco, CA 94103
Customer Response Center: 1-800-368-1019
Fax: 1-202-619-3818
TDD: 1-800-537-7697
Email: [email protected]
Online at: https://ocrportal.hhs.gov/ocr/portal/lobby.jsf
Complaint forms are available at:
http://www.hhs.gov/ocr/office/file/index.html
Nevada Medicaid Dental Program Member Handbook 01/21
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Notice of Language Assistance
If you, or someone you support, have questions about LIBERTY Dental Plan,
you have the right to get help and information in your language at no cost.
To speak to an interpreter, call 1-866-609-0418. (English)
ርስዎ፣ ወይም እርስዎ የሚያግዙት ግለሰብ፣ ስለ
LIBERTY Dental Plan
ጥያቄ ካላችሁ፣
ያለምንም ክፍያ በቋንቋዎ እርዳታና መረጃ የማግኘት መብት አላችሁ።
ከአስተርጓሚ
ጋርለመነጋገር፣
1-866-609-0418
ይደውሉ።
. (Amharic)
LIBERTY Dental Plan
.
(Arabic) 1-866-609-0418 ﻢﻗﺮﻟا ﻰﻠﻋ ﻞﺼﺗا ،يرﻮﻓ
如果您，或您正在幫助的人，有關於 LIBERTY Dental Plan
方面的問題，您有權利免費以您的母語得到幫助和訊息. 想要跟一位翻
譯員通話, 請致電 1-866-609-0418. (Chinese)
LIBERTY Dental Plan
.
(Farsi) 1-866-609-0418
de LIBERTY Dental Plan, vous avez le droit d'obtenir de l'aide et
l'information dans votre langue à aucun coût. Pour parler à un interprète,
appelez 1-866-609-0418. (French)
Falls Sie oder jemand, dem Sie helfen, Fragen zum LIBERTY Dental Plan
haben, haben Sie das Recht, kostenlose Hilfe und Informationen in Ihrer
Sprache zu erhalten. Um mit einem Dolmetscher zu sprechen, rufen Sie bitte
die Nummer 1-866-609-0418 an. (German)
No dakayo, wenno maysa a tao a tultulunganyo, ket adda kayatyo a
saludsoden maipanggep iti LIBERTY Dental Plan, adda karbenganyo a
dumawat iti tulong ken impormasion iti bukodyo a pagsasao nga awan ti
bayadanyo. Tapno makipatang iti maysa a mangipatarus iti pagsasao,
tumawag iti numero nga 1-866-609-0418. (Ilocano)
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ご本人様、またはお客様の身の回りの方でもLIBERTY Dental Plan につ
いてご質問がございましたら、ご希望の言語でサポートを受けたり、情報
を入手したりすることができます。料金はかかりません。通訳とお話され
る場合1-866-609-0418までお電話ください (Japanese)
만약 귀하 또는 귀하가 돕고 있는 어떤 사람이 LIBERTY Dental Plan 에
관해서 질문이 있다면 귀하는 그러한 도움과 정보를 귀하의 언어로 비용
부담없이 얻을 수 있는권리가 있습니다. 그렇게 통역사와 얘기하기
위해서는 1-866-609-0418 로전화하십시오.(Korean)
1-866-609-0418 (Russian)
Si usted, o alguien a quien usted está ayudando, tiene preguntas acerca de
LIBERTY Dental Plan, tiene derecho a obtener ayuda e información en su
idioma sin costo alguno. Para hablar con un intérprete, llame al 1- 866-609-
0418. (Spanish)
LIBERTY Dental Plan polokalame, o iai iate oe le aia tatau e maua atu ai i
a talatalanoa i se tagata ua
e lau telefoni 1-866-609-0418. (Samoan)
Kung ikaw, o ang iyong tinutulangan, ay may mga katanungan tungkol sa
LIBERTY Dental Plan may karapatan ka na makakuha ng tulong at
impormasyon sa iyong wika ng walang gastos. Upang makausap
ang isang tagasalin, tumawag sa 1-866-609-0418. (Tagalog)
Nevada Medicaid Dental Program Member Handbook 01/21
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LIBERTY Dental Plan,
1-866-609-0418. (Thai)
1-866-609-0418. (Vietnamese)
Nevada Medicaid Dental Program Member Handbook 01/21
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Contacting LIBERTY
How to reach LIBERTY:
If you have questions regarding your dental benefits, locating a
participating provider, or for help scheduling an appointment, please
contact LIBERTY’s Member Services Department toll-free at 1-866-609-
0418. Business hours are Monday through Friday 5:00 a.m. to 5:00 p.m.
Pacific Standard Time.
➢ Hearing or speech impaired members may call 1-877-855-8039.
➢ Our Address:
LIBERTY Dental Plan of Nevada, Inc.
6385 S. Rainbow Blvd., Suite 200
Las Vegas, NV 89118
Fax: 1-888-401-1129
➢ You can also contact us online at:
www.libertydentalplan.com/NVMedicaid
LIBERTY’s Mobile App and Online Services:
LIBERTY’s Mobile App and Online Services offer a quick and easy way
for you to access your account information. This puts our most popular
online features at your fingertips.
LIBERTY’s Mobile App features include:
• Locate a Network Provider
• View Benefit Plan
• View Covered Benefits
• Electronic ID card
LIBERTY’s Online Services include:
•
Check Utilization
•
Check Eligibility
• Frequently
Asked Questions
(FAQ’s)
• Locate a Network Provider
• View Benefit Plan
• View Covered Benefits
• Print/Request an ID card
• Check Utilization
• View Claim Status
• Dental Health Questionnaire
Nevada Medicaid Dental Program Member Handbook 01/21
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Nevada Medicaid Eligibility:
Phone: 1-800-992-0900
Website: https://www.medicaid.nv.gov
Medical/Dental Emergency:
LIBERTY covers emergency dental care. You can get emergency
dental care 24 hours a day, 7 days a week at any in-network or out-of-
network office. Emergency care can be for pain, bleeding, or swelling.
Call: Your Dental Home for instructions on how to proceed. If you
cannot reach your Dental Home, call LIBERTY at 1-866-609-0418
(TTY 1-877-855-8039). LIBERTY’s 24 hour on call service will help
you.
Medical Emergencies Call: 911
Nevada Medicaid Dental Program Member Handbook 01/21
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Member Rights and Responsibilities
LIBERTY must comply with any applicable Federal and State laws that
pertain to member rights, and ensure that our staff and affiliated providers
take those rights into account when providing services to Medicaid
Members, as required by the Code of Federal Regulations, Enrollee
Rights, 42 CFR § 438.100, which is available online at:
http://www.ecfr.Gov.
Upon enrollment, members are provided the written Member Rights and
Responsibilities included in this handbook.
As a LIBERTY member, you have the right:
• To be treated with courtesy and respect
• Have your dignity and privacy respected at all times
• To maintain confidentiality of your medical and dental information
• To be provided with information about the Plan and its services,
including Covered Services
• To be able to choose your Primary Care Dentist/Dental Home
within the Plan’s network
• To change your Primary Care Dentist/Dental Home upon request
for any reason and as frequently as needed
• To take part in making decisions about your dental care, including
the right to refuse treatment or dental services
• To receive information on available treatment options and
alternatives, presented in a way you can understand
• To voice grievances, either verbally or in writing, about LIBERTY,
dental provider/specialist or the care you received
• To request an appeal of a decision made by LIBERTY to deny,
defer, or limit services or benefits, either verbally or in writing
• To request a Fair Hearing, including information on the
circumstances under which an expedited hearing is possible
• To receive verbal interpretation services in your preferred
language
• To receive written member-information materials in alternative
formats (such as braille, large-size print, and audit format) upon
request and in a timely fashion appropriate for the format being
requested
• To formulate advance directives
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• To have access to your dental records in accordance with
applicable federal and state laws and to request that your dental
records be amended or corrected
• To be free from any form of restraint or seclusion used as a means
of coercion, discipline, convenience, or retaliation
• To be notified of your right to request and obtain a copy of your
member handbook at least once per year, or upon request, at no
cost to you
As a LIBERTY member, you have the responsibility to:
• Present your Nevada Medicaid issued Medicaid ID card and/or
LIBERTY issued ID card when using dental services
• Not permit the use of your ID card(s) by any other person
• Provide the State of Nevada Medicaid office with changes in your
family that might affect eligibility or enrollment, as well as any
name, telephone number, or address changes
• Take an active part in ensuring the success of your dental health
by seeing your dentist on a regular basis and following a mutually
acceptable course of treatment
• Tell your dentist if you have any sudden changes to your physical
and dental health
• Understand your dental program and its benefits, the services you
can receive, the services that are not covered, and any limitations
on covered services
• Treat your Dental Home, dentist and office staff, as well as
LIBERTY staff, with respect and courtesy
• Following all of the dental office’s rules about care and conduct
• Provide dentists with accurate and complete dental information
• Arrive to your dental appointment on time. If you cannot keep your
appointment, contact your dental office at least twenty-four (24)
hours in advance to reschedule your appointment.
• Ask questions of providers to determine the potential risks,
benefits, consequences, and cost of treatment and non-treatment
and all relevant alternatives
• Cooperate with your Dental Home in following a prescribed course
of treatment, or letting the dentist know the reasons the treatment
cannot be followed, as soon as possible
• Call or contact LIBERTY for any questions or information
regarding the Plan
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• Follow LIBERTY’s internal grievances and appeals process to
resolve a disagreement of dissatisfaction with a provider of Plan
decision
• Live a healthy lifestyle and stay clear of behaviors known to be
detrimental to your health
• Notify LIBERTY if you have any other dental insurance or
coverage
• Be aware of and follow the organization’s guidelines in seeking
dental care
• Your own actions if you refuse treatment or do not follow your
dentist’s or specialist’s treatment plan
• Paying any agreed upon fees or monies to your dental office
Nevada Medicaid Dental Program Member Handbook 01/21
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Notice of Privacy Practice
A statement describing LIBERTY’s policies and procedures for
preserving the confidentiality of dental records is available and will be
provided to you upon request.
As required by law, this notice is about your rights, our legal duties, and
privacy practices with respect to the privacy of Personal Health
Information (PHI). This notice also talks about the way we may collect,
use, and disclose your PHI. We must follow the orders of the notice
currently in effect. We keep the right to make changes to this notice from
time to time and to make the changed notice effective for all PHI we keep.
You can find our most current privacy notice on our website at:
https://www.libertydentalplan.com/About-LIBERTY/Compliance/HIPAA-
Privacy-Notice
You may also call our Member Services Department at 1-866-609-0418
(TTY 1-877-855-8039) to request a written copy of this notice at no cost
to you.
Eligibility and Enrollment
LIBERTY is a dental plan for people who qualify for Medicaid in Washoe
and Clark County, Nevada. Payments are sent directly to the dental care
provider for services provided to members.
Who can become a member?
You are eligible for LIBERTY because you qualify for Medicaid and live
in Washoe or Clark County. The Division of Welfare and Supportive
Services determines Medicaid and Nevada Check Up eligibility for
Nevadans. Online applications can be completed using Access Nevada
at www.dwss.nv.gov.
Can I disenroll?
Nevada Medicaid recipients enrolled in a medical managed care
organization (MCO) are automatically enrolled with LIBERTY. You will be
automatically disenrolled if any of the following conditions occur:
Nevada Medicaid Dental Program Member Handbook 01/21
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• You are no longer eligible for Medicaid
• You move to a part of the state that is not covered by a MCO
• You “opt out” of your MCO
If there is not an adequate network provider in your area, LIBERTY will
arrange for services at an out-of-network office. If you experience poor
quality of care, you can change your provider at any time, and you can
exercise your right to the grievance process.
For questions about enrollment or disenrollment, you can call the
Nevada Medicaid District Office at:
• Northern Nevada: 1-775-687-1900 or 1-800-992-0900
• Southern Nevada: 1-702-668-4200 or 1-800-992-0900
Member ID Cards
Each covered member will receive an identification (ID) card issued by
Nevada Medicaid and an identification (ID) card issued by LIBERTY. You
are responsible for bringing your ID card(s) with you to all dental
appointments. If you misplace your ID card or need to correct any
information on the card, you may call LIBERTY at 1-866-609-0418 to ask
for a new ID card.
Sample of what your LIBERTY Insurance ID card will look like:
Your LIBERTY Insurance ID card will include:
• Your Medicaid ID number
• Your first name and last name
• The name, location, and telephone number of your chosen
Dental Home
• Your effective date with LIBERTY
• What to do if you need emergency dental care
• The number to call to speak to LIBERTY’s Member Services
Nevada Medicaid Dental Program Member Handbook 01/21
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Department or to file a grievance (complaint)
• The number to call to report any suspected fraud, waste, or
abuse
LIBERTY will send you a new card when:
• You become eligible
• You request one
• You change or correct the spelling of a name
To request a new ID card, call Member Services at 1-866-609-0418,
request one online at www.libertydentalplan.com/NVMedicaid, or
through the free LIBERTY mobile application on your smart phone. ID
cards are mailed within 5 working days from the date requested.
Transportation Services
Do you need a ride to your appointment?
Non-Emergency Transportation (NET) is provided to Nevada Medicaid
members to get necessary covered services. Nevada Check Up
members are not eligible for NET services.
How do I schedule transportation?
Transportation services are managed through MTM to provide you with
non-emergency transportation to your dental appointments. If you have
questions or need assistance setting up transportation you may call MTM
at 1-844-879-7341, or you may contact LIBERTY’s Member Services
Department at 1-866-609-0418 to help coordinate transportation for you.
When do I have to call?
You must call at least five working days before your non-urgent
appointment to set up transportation. If you have less than five days
before your appointment you should still call MTM at 1-844-879-7341 for
assistance. MTM schedules routine trips Monday through Friday from 7
a.m. to 5 p.m. Pacific Standard Time.
What information do I need to know when I call?
• The street address, including city and zip code of your pick-up
and drop-off locations, and telephone number
• If you have a Nevada Medicaid ID number, please have it ready
for the reservation specialist
Nevada Medicaid Dental Program Member Handbook 01/21
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• Minors under age 18 must travel with an adult 18-years-old or older.
Members 15-17 years of age may travel alone if MTM has an
approved Parental Consent Form on file. Minors under age 18 that
are legally married, emancipated, or obtaining family planning
services are able to travel alone.
• Transportation is only available when you choose to have services
at the nearest appropriate network provider
What if I have a complaint about transportation?
You can file a complaint if you:
• Do not agree with a decision made by MTM
• Are not happy with any services received
• Are not happy about any other part of MTM’s transportation
services
To file a complaint, call MTM’s ‘We Care Line’ at 1-866-436-0457 or you can
go online at: http://www.mtm-inc.net/nevada/.
Interpreter/Translation Services
We want to make sure you fully understand your dental benefits. If English
is not your first language, LIBERTY will provide interpretation and
translation services in your preferred language at no cost to you. To ask
for language services call 1-866-609-0418. If you have a preferred
language, please notify us by calling 1-866-609-0418.
Who do I call for an interpreter?
Call LIBERTY’s Member Services Department at 1-866-609-0418
to request any interpreter services you may need.
The Member Services Department can help if you:
• Have problems hearing, please call TTY 1-877-855-8039
• Have problems seeing or reading
• Need materials in other formats
• Do not speak English
• Do not read English
Nevada Medicaid Dental Program Member Handbook 01/21
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How can I find a dentist who speaks my language?
The provider directory lists all languages spoken at each provider
location and if the office is accepting new members. For help locating a
provider who speaks your language, or if you need a free provider
directory, call Member Services at 1-866-609-0418 and we will mail one
to you. You can also view an up-to-date and searchable provider
directory anytime by visiting us online at
www.libertydentalplan.com/NVMedicaid.
If you are unable to locate or access a provider office that speaks your
language, interpreter services can be provided to you at no cost.
How can I get a face-to-face interpreter for my dental
appointment?
To ensure that you are able to communicate with your dentist during your
appointment, we can arrange for interpreter services during your dental
appointments, at no cost to you.
To arrange face-to-face interpretation, you must:
• Call LIBERTY at 1-866-609-0418
• Call at least 48 hours before the appointment
• Provide the language that you speak
• Provide details on the provider office where you will have
services
• Provide details on your appointment date/time
Nevada Medicaid Dental Program Member Handbook 01/21
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How to Get Dental Care
How can I find a Dentist?
A list of dentists in your area can be found in LIBERTY’s Provider
Directory. This directory will also give you information about each dentist
that is part of the Plan’s network.
The LIBERTY Provider Directory lists dentists and Federally Qualified
Health Centers (FQHCs). The Provider Directory tells you if the provider
is taking new patients and includes, but is not limited to, the following:
• Names
• Addresses
• Phone numbers
• Business hours
• Languages spoken
The Provider Directory is available online at:
www.libertydentalplan.com/NVMedicaid; click on ‘Find & Select a Dentist’
to do a search.
If you need a printed Provider Directory, call 1-866-609-0418 (TTY 1- 877-
855-8039).
How do I change my dentist (Dental Home)?
You may call our Member Services Department at 1-866-609-0418 to
change your Dental Home. A Member Services Representative will assist
you in locating a network provider over the phone. You can also locate
providers online at www.libertydentalplan.com/NVMedicaid; click on ‘Find
& Select a Dentist’ to do a search.
How do I make an appointment?
When you call your Dental Home identify yourself as a LIBERTY member.
Let them know you are calling to make an appointment with the dentist
and see which dates and times are convenient for you.
Write down the date and time of the appointment on your calendar.
Please be sure to be on time to your appointment to avoid having to
reschedule. On the date of your appointment, present your LIBERTY ID
card and/or your Medicaid ID card. The ID numbers on both cards are the
same.
Nevada Medicaid Dental Program Member Handbook 01/21
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What is a Dental Home?
A Dental Home is the Primary Care Dentist or Pediatric Dentist that you
have been assigned to for your dental care needs. A Dental Home
should be established by 12 months of age. A Dental Home is a dentist
you see regularly to provide dental care and will always be available to
you. Your Dental Home will help you care for your teeth by providing
dental guidance and appropriate dental treatment as needed, including
referrals for specialty care when needed.
If you have been to a dental office in the past, please ensure the office
participates in LIBERTY’s network. To locate a Dental Home suitable to
you and your family, call our Member Services Department at 1-866-609-
0418.
Your Dental Home will work with you and your family to stay healthy. It is
important to follow the treatment plan recommended by your dentist.
What if I choose to have services at an office that is not my Dental
Home?
Call our Member Services Department at 1-866-609-0418 to change your
Dental Home prior to having services. Our Member Services Department
will assist you in changing your Dental Home. Members have the freedom
to be assigned to any dentist in the network.
How do I get services from a dental Specialist?
Your Dental Home must submit a referral request to LIBERTY for approval
to see a dental Specialist such as an Endodontist, Oral Surgeon,
Periodontist and/or Prosthodontist. Only services that have been prior
authorized for you by LIBERTY may be performed by a dental Specialist.
Your Specialist will submit a request for prior authorization if you need
more services. Services rendered by a Pediatric Dentist (Pedodontist) do
not require a Specialist referral. If you would like services by a Pediatric
Dentist you can call our Member Services Department to change your
Dental Home to the Pediatric Dentist office.
What are in-network and out-of-network dentists?
In-network dentists have agreed to join LIBERTY’s network of dentists
to treat our members. Out-of-network dentists have not joined our
network. Benefits will not be paid for services performed by an out-of-
network dentist, except for certain emergency situations.
Nevada Medicaid Dental Program Member Handbook 01/21
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What if I choose to have services with a dentist that is out-of-
network?
You will have to pay for any out-of-network services not pre-approved by
LIBERTY, except for covered services needed as an emergency.
Continuity of Care
What if I am already receiving care with a dentist that is out-of-
network?
You may be able to keep seeing your dentist for up to 12 months. If your
dentist does not join our network by the end of the 12 months, you will
need to switch to a dentist in LIBERTY’s network.
How do I know if I can keep receiving care with my dentist that is out-
of-network?
In order to continue your care, you must have seen your dentist at least
once during the last 12 months and your dentist must be willing to work
with your new dental Plan.
What if my dentist stops working with 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 will continue your care 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 will continue your care if the following terms are met:
• The services are covered under your dental Plan
• The services are medically necessary
• The services meet our clinical guidelines
• You do not have access to a LIBERTY dental provider
LIBERTY will not continue your care if the following terms are met:
• The services are not covered under your dental Plan
• The services are not medically necessary
• The services do not meet our clinical guidelines
• You have access to a LIBERTY dental provider
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To learn more about continuity of care, please call our Member
Services Department at 1-866-609-0418.
Benefits and Services
What your dental plan covers
Here, we explain all your covered services as a member of the Plan.
Your covered services are free to you if they are medically necessary
(needed). Care is medically necessary if it is to stop and remove
dental disease, illness, and pain, to return the form and function of
the dentition, and to correct facial disfiguration or dysfunction.
We offer these types of dental services:
Type of Service
Examples
☐
Diagnostic
Exams and x-rays
☐
Preventive
Cleanings, fluoride treatments, sealants
☐
Restorative
Fillings, crowns
☐
Endodontic
Pulpotomies, root canals
☐
Periodontal
Gum surgery
☐
Prosthodontics, Removable
Immediate and complete dentures, relines
☐
Oral and Maxillofacial Surgery
Extractions
☐
Adjunctive
Sedation, general anesthesia
Read the summary of benefits and each of the sections on the following
pages to learn more about the exact services you can get.
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Summary of Benefits:
Summary of Covered Services by Age/Category
Procedure
Newborn –
Age 20
Adults age
21 or older
Pregnant
Adults Age
21 or older
Comprehensive Exam
YES
YES
YES
Focused Exam
YES
YES
YES
Periodic Exam
1
YES
YES
YES
X-rays
YES
YES
YES
Prophylaxis (cleaning)
1
YES
YES
YES
Fluoride
YES
NO
NO
Fluoride Varnish
YES
NO
YES
Restorative Fillings;
2
Amalgams/Composites
YES
YES
YES
Restorative Crowns
2
YES
YES
YES
Scaling and Root Planing
(deep cleaning)
2
YES
NO
YES
Periodontal Maintenance
YES
NO
YES
Root Canals
YES
NO
NO
Partial Dentures
2
YES
YES
YES
Full Dentures
2
YES
YES
YES
Extractions
YES
YES
YES
Emergency Services
YES
YES
YES
1
Non-Pregnant adults age 21 and over receive coverage under
LIBERTY value-added services.
2
Adults age 21 and over receive coverage under special circumstances
and services must be prior authorized by LIBERTY to be covered.
• Comprehensive exams are only a benefit for adults age 21 or
older who have dentures or to determine the need for dentures
• Restorative fillings and crowns are only a benefit for adults ages
21 or older when the tooth is used to support an existing partial
denture or for pregnant adults
• Periodontal scaling and root planing (deep cleaning) is only a
benefit for pregnant adults and members under the age of 21
• Partial dentures are a benefit if four or more teeth in a row are
missing, or four or more teeth are missing that could cause the
person to have difficulty chewing
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• Immediate dentures are covered once per lifetime
Please call LIBERTY at 1-866-609-0418 to find out if you have special
circumstances that would qualify you for coverage.
What does your dental plan cover?
Nevada Medicaid covers the following dental services for members
under age 21 that do not require prior authorization:
• Periodic examinations covered once every 6 consecutive months
• Limited examinations covered up to 2 times every 6 months
• Comprehensive examinations covered once every 12 months
• Full mouth x-ray(s) covered once every 12 consecutive months
• Periapical x-ray(s) covered up to a maximum of 13 every year
• Bite-wing x-ray(s) covered once every 6 consecutive months
• Panoramic x-ray(s) covered once every 3 years
• Teeth cleaning (prophylaxis) covered once every 6 months
• Fluoride is covered once every 6 consecutive months
• Fluoride varnish is covered two times every 12 months
• Dental sealants covered once per tooth per lifetime
• Fillings covered once per tooth every 36 months
• Crowns (tooth cap) covered once per tooth per lifetime
• Pulpotomies covered once per tooth every 36 months
• Root canal procedures for restorable teeth covered once per
tooth per lifetime
• Periodontal scaling/root planing (deep cleaning) covered up to
four units every 12 months
• Osseous surgery (surgery of the gums) covered up to 4 units
every 60 months
• Extractions (tooth removal) covered once per tooth per lifetime
• Alveoloplasty (smoothing of the gums)
• Full and partial dentures (false teeth) once every 60 months
• Denture adjustments once every 6 months
• Denture repair and relines
• Incision & drainage of abscess (draining of infected gums)
• Emergency palliative treatment (relief of immediate pain
or discomfort)
• General anesthesia for covered services and when
medically necessary, covered up to 5 units per day
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As a member of LIBERTY under age 21, you also receive
these additional value-added services:
• One additional fluoride service every 12 months at a Primary
Care Physician or Mobile Unit
• Caries risk assessments covered once per 12 months
• Screenings and assessment at a Primary Care Physician to
facilitate fluoride varnish
Nevada Medicaid covers limited emergency services for adults age
21 and over including the following dental services that do not
require prior authorization:
• Limited examination up to 2 times every 6 months
• Focused oral examination once every 6 months
• Comprehensive oral examination is allowed once every 36
months for adults with dentures or to determine need for dentures
• Full mouth x-ray(s) covered once every 12 consecutive months
• Periapical x-ray(s) covered up to a maximum of 13 every year
• Bite-wing x-ray(s) covered once every 6 consecutive months
• Panoramic x-ray(s) covered once every 3 years
• Full and partial dentures (false teeth) once every 60 months
• Denture adjustments once every 6 months
• Denture repair and relines
• Incision & drainage of abscess (draining of infected gums)
• Alveoloplasty (smoothing of the gums)
• Extractions (tooth removal) covered once per tooth per lifetime
• General anesthesia for covered services and when medically
necessary, covered up to 5 units per day
As a member of LIBERTY age 21 and over, you also receive these
additional value-added services:
• Periodic examinations covered once every 12 months
• Teeth cleaning (prophylaxis) covered once every 12 months
• X-ray
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Nevada Medicaid covers these additional services for adults over
age 21 that are pregnant:
• Comprehensive examinations covered once every 12 months
• Interim caries arresting medication once every 6 months
• Teeth cleaning (prophylaxis) covered once every 6 months
• Topical fluoride covered once every 6 consecutive months
• Gingivectomy or gingivoplasty, up to 4 units every 60 months
• Periodontal scaling/root planing (deep cleaning) covered up to
four units every 12 months
• Periodontal maintenance covered once every 3 months
As a member of LIBERTY age 21 and over and pregnant, you also
receive these additional value-added services:
• Two additional cleanings (prophylaxis) every 12 months
What services does your plan not cover?
There are some services that neither LIBERTY nor Nevada Medicaid will
cover, including:
• Non-dental related services
• Any dental procedure that is not specifically listed as covered
under this dental Plan
• Procedures, appliances, or restorations to treat
temporomandibular joint dysfunction (TMJ)
• Services for cosmetic purposes
• Procedures which are determined not medically necessary by
LIBERTY
• Procedures performed to restore tooth structure lost from
abrasion, erosion, attrition, or abfraction (tooth grinding, clinching,
or wear not from decay)
• Procedures to increase vertical dimension and restore occlusion
• Any services performed outside of your Dental Home, unless
expressly authorized by LIBERTY or covered as an emergency
• Any routine dental service performed by a dentist or dental
Specialist in an inpatient/outpatient hospital setting
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LIBERTY understands there may be other treatment options that can be
offered to you; however, your Dental Home is responsible for providing
covered services as listed by your Plan. If you choose to have any non-
covered service(s) you will be responsible for all the associated costs of
the non-covered service(s). LIBERTY will not pay or cover any non-
covered service.
Do I have to get prior authorization for services?
There are some services that are covered but you must get prior
authorization before you can get them done.
Prior authorization, also called pre-approval, means that LIBERTY has
reviewed the services your Dental Home or Specialist has requested and
agrees that the care is medically necessary (needed). For services that
require prior authorization, your Dental Home will send LIBERTY the
request with the needed information to decide if the services are
medically necessary. The request will be reviewed by LIBERTY and you
and your Dental Home will be notified of the decision in writing to approve
or deny the services. Only a licensed dentist can deny services due to
medical necessity. Standard prior authorizations are processed within 14
calendar days of receipt and urgent prior authorization requests are
processed within 72 hours of receipt. You, your provider, or LIBERTY
may request up to 14 additional calendar days if more time is needed,
and it is in your best interest.
Newborns through age 20 require the following services to be prior
authorized:
• Any service not listed under section ‘What Does Your Dental Plan
Cover?’ must be prior authorized
All services performed by a dental Specialist require a referral and prior
authorization. Services rendered by a Pediatric Dentist (Pedodontist) do
not require a Specialist referral. If you would like services by a Pediatric
Dentist you can call our Member Services Department to change your
Dental Home to the Pediatric Dentist office.
Adults ages 21 and over require the following services to be prior
authorized:
• All services performed by a dental Specialist require a referral and
prior authorization
• Fillings (limitations apply)
• Crowns (limitations apply)
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• Immediate dentures (frequency applies)
• Periodontal Maintenance (for pregnant adults)
• Periodontal scaling/root planing (deep cleaning) (for pregnant
adults)
Treatment Plan and Care
Once your oral examination has been performed at your Dental Home,
you will be provided with a treatment plan. Your dentist will discuss the
benefits and importance of treatment versus non-treatment along with
any alternative treatment options. You have the right to receive
information on available treatment options and alternatives and to
participate in decisions regarding your health care including the right to
refuse treatment.
What if I want a second opinion?
You may request a second opinion if you are unhappy with your dentist,
or disagree with their opinion about your treatment plan. You can get a
second opinion at no cost from another LIBERTY dentist or an out-of-
network dentist for any reason.
To request a second opinion, please call our Member Services
Department at 1-866-609-0418.
Your Dental Home may also request a second opinion on your behalf.
They will submit the appropriate forms with supporting x-rays.
All requests for second opinions are handled by LIBERTY within five (5)
business days of receipt of the request. If you believe there is an
imminent and serious threat to your health, LIBERTY will handle your
case within 72 hours of receipt. LIBERTY will organize the appropriate
steps with your Dental Home about your concerns. Once you have been
advised that your second opinion is approved, you may schedule an
appointment. You may request a copy of LIBERTY's policy description
for a second opinion, at no cost to you.
Do I need to submit claims?
You are not required to file claims directly with LIBERTY. Claims or
encounters are submitted by your Dental Home on your behalf.
Services provided by a dental Specialist are reported to LIBERTY by the
Specialist. If you receive services out-of-network due to an emergency
after-hours or out-of-area situation, please see page 33.
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What if I have other insurance coverage?
As a member, you are responsible for reporting any other health insurance
(third party liability). If you or anyone in your family has other dental
insurance, you must tell LIBERTY and your dentist. Any other insurance
coverage is considered primary to your coverage with LIBERTY and must
pay first.
You may have other dental insurance through your job, or your children
may have other dental insurance through another parent. You must tell
LIBERTY if you have any other coverage, by calling Member Services at
1-866-609-0418 (TTY 1-877-855-8039). When you visit your Dental
Home, you must also let them know about any other insurance coverage.
This will help us make sure all your services get paid for.
How can I report suspected fraud, waste, or abuse?
LIBERTY is committed to conducting its business in an honest and ethical
manner. We seek to operate in strict compliance with all regulatory
requirements that relate to and govern our business and dealings with
employees, members, providers, business associates, suppliers,
competitors, and government agencies.
Health care fraud includes, but is not limited to, the making of intentional
false statements, misrepresentations, or deliberate omissions of material
facts from any record, bill, claim, or any other form for the purpose of
obtaining payment, services, or any type of compensation for health care
services for which you are not entitled.
Health care fraud, waste, and abuse costs taxpayers billions of dollars
each year. You can help stop fraud by reporting it. Some types of health
care fraud are:
• Using someone else’s ID card to get a service or product
• Loaning, selling, or giving your ID card to someone
•
Doctors billing for a service not performed, or billing for a
service
or product that is not needed
• Falsifying eligibility information in order to gain coverage
• Members seeking prescriptions for opioids or controlled
substances which are not medically necessary
• Providers writing prescriptions for opioids or controlled substances
which are not medically necessary
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To report possible unethical business practices or potential illegal
activity regarding our Plan, our providers, vendors, or members, you
may contact LIBERTY:
➢ Compliance Hotline: 1-888-704-9833
➢
E-mail:
➢ Mail: LIBERTY Dental Plan Compliance Department
340 Commerce, Suite 100, Irvine, CA 92602
You may remain anonymous if you prefer. All information received will
be treated as confidential, and the results of investigations will be
discussed only with persons having a legitimate reason to receive the
information.
What kind of quality control or improvement is done by LIBERTY?
We have many quality programs in place to ensure you get the care you
need. Some examples of our quality programs include:
• Member and provider surveys used to measure satisfaction
• Supporting members that have been identified for assistance and
helping with the coordination of their care
• Educating members through newsletters, health fairs, and other
means
• Reviewing the types and quality of services given to members
• Giving members access to various education materials and tools
online
• Measuring various access standards like how long it takes for a
member to get an appointment
• Member Advisory Committee (see page 40)
Phone calls are also monitored to make sure calls are answered timely
and that all information provided is accurate and complete.
All member complaints are reviewed and tracked for any trends or
opportunities for improvement
.
All of LIBERTY’s contracted dentists have gone through strict
credentialing procedures, background checks, and office reviews. Each
dentist must follow strict contractual rules. All dentists are reviewed on a
regular basis. We monitor our providers to assure compliance with state
and federal laws.
For more information about LIBERTY’s quality programs, call our
Member Services Department at 1-866-609-0418.
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Early and Periodic Screening, Diagnosis, and Treatment (EPSDT)
In Nevada, the Early and Periodic Screening, Diagnosis, and Treatment
(EPSDT) program is called Healthy Kids. Children under the age of 21
qualify for EPSDT benefits when covered under Medicaid. EPSDT
services identify health care issues early to prevent the decline of a
child’s health. The EPSDT program recommends that all children have
an established Dental Home by 12 months of age to help with early
intervention. Children that need services that are not part of their benefits
may get them under EPSDT.
LIBERTY will decide medical necessity (need) based on materials your
Dental Home sends us. EPSDT services are provided at no cost to you
and are listed under your ‘Benefits and Services’ on pages 24-30 of this
handbook. Call LIBERTY at 1-866-609-0418 for more information.
Emergency Services
Emergency care is covered anywhere in the world. If you reasonably
believe that not getting immediate care could be dangerous to your life
or to a part of your body, call 911 or go to the nearest hospital.
Emergency care may include care for a bad injury, severe pain, or a
sudden serious dental illness.
All follow-up care should be done at your Dental Home. Do not go back
to the emergency room for follow-up dental care.
You do not need prior authorization to receive emergency/urgent dental
services from any in-network or out-of-network provider. You have the
right to use any provider for emergency/urgent services. You can also
call LIBERTY’s Member Services at 1-866-609-0418; LIBERTY’s 24 hour
on call service will help you.
You may also visit www.libertydentalplan.com/NVMedicaid to find a
dentist and location where emergency/urgent dental care is provided.
Your Dental Home will inform you about their after-hours urgent dental
care policy, including how to contact a dental provider 24 hours a day, 7
days a week for emergency/urgent services.
Directions for what to do in an emergency
If you require emergency dental care, call your Dental Home to schedule
an immediate appointment.
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For urgent or unexpected dental conditions that occur after-hours or on
weekends, contact your Dental Home for instructions on how to proceed.
If your Dental Home is not available, or you are out of the area and cannot
contact LIBERTY to redirect you to another contracted dental office, you
may contact any licensed dentist to receive emergency care. The dentist
may need you to pay in full for the emergency dental care.
LIBERTY will refund you for covered dental emergency services that you
paid for.
If you pay a bill for emergency care, send a copy within 90 days to:
LIBERTY Dental Plan of Nevada
Claims Department
6385 S. Rainbow Blvd., Suite 200
Las Vegas, NV 89118
You should let LIBERTY know as soon as possible after receipt of
emergency dental services.
What services are covered under emergency care?
The Plan will cover emergency dental services only if services are
needed. LIBERTY will also cover these services if you believe that the
condition, if left untreated, may lead to disability, dysfunction, or death. If
you encounter a situation in which there is an imminent and serious threat
to your health, you may wish to call 911. The use of such system should
be done so responsibly.
Emergency dental services covered by LIBERTY include dental
screenings, examination, and evaluation by a dentist or dental Specialist.
The dentist will determine the emergency services necessary to alleviate
any emergency symptoms. Medical emergencies are not covered by
LIBERTY if the services are rendered in a hospital setting which are
covered by a Medical Plan, or if LIBERTY determines the services were
not dental in nature.
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Reporting and Solving Problems
There are two kinds of problems that you may have with LIBERTY:
• A grievance (complaint) is when you have a problem with
LIBERTY, a dental provider, or with the health care or treatment
you got from a provider
• An appeal is when you don’t agree with LIBERTY’s decision not
to cover or to change your services
You can use LIBERTY’s grievances and appeals process to let us know
about your problems. This does not take away any of your legal rights.
We will not discriminate or take any actions against you for filing a
grievance and/or appeal. Letting us know about your problems will help
us improve care for all members.
You should always contact LIBERTY first to let us know about your
problem. Call us Monday through Friday 5:00 a.m. to 5:00 p.m. Pacific
Standard Time at 1-866-609-0418 to tell us about your problem.
How do I submit a grievance (complaint)?
Our Member Service Representatives will help you and take your
grievance over the telephone. You can also send your grievance in the
following ways:
➢ Mail to: LIBERTY Dental Plan of Nevada, Inc.
Grievance and Appeals Department
P.O. Box 26110, Santa Ana, CA 92799
➢ Fax to: 1-833-250-1814, or
➢ Online at: www.libertydentalplan.com/NVMedicaid
Grievance forms are also available on our website,
https://www.libertydentalplan.com/Members/Forms-Literature, by calling
LIBERTY’s Member Services Department, or by asking your provider. A
grievance form is not required to submit a grievance. LIBERTY will review
a grievance submitted in any format.
If someone other than you submits a grievance on your behalf, they must
have your written consent, which is called an authorized representative.
If you need help filing your grievance, we can help you. We can give you
free language services. Please call LIBERTY’s Member Services
Nevada Medicaid Dental Program Member Handbook 01/21
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Department at 1-866-609-0418 (TTY 1-877-855-8039).
When will I get a response to my grievance?
LIBERTY will review your concern and make every effort to get you an
answer within 30 calendar days.
If you need a fast decision because 30 calendar days would put your life,
health, or ability to function in danger, you can ask for an expedited (fast)
review. To ask for an expedited (fast) review, please call 1-866-609-
0418 (TTY 1-877-855-8039). A decision will be made within 72
hours of receipt of the complaint.
Grievances are not eligible for the Fair Hearing process.
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 Action (NOA) letter
telling you that we are denying, delaying, changing, or ending a
service, and you do not agree with the decision, you can file an appeal.
Your dentist can file an appeal on your behalf as well with your written
permission. If you are currently getting treatment and you want to
continue getting treatment, then you must ask for an appeal within 10
calendar days from the date the NOA was delivered to you, or before
the date LIBERTY says services will stop. When you request the
appeal, tell us that you want to continue receiving services.
You must complete LIBERTY’s appeals process before you can
request a Fair Hearing.
How do I submit an appeal?
You or your dentist, on your behalf, may submit an appeal to
LIBERTY. If someone other than you submits an appeal on your
behalf, they must have your written consent, which is called an
authorized representative. All appeals must be submitted within 60
calendar days from the date that you received the NOA. Appeals may
be submitted verbally or in writing.
Our Member Service Representatives will help you and take your appeal
over the telephone. You can also send your appeal in the following ways:
Nevada Medicaid Dental Program Member Handbook 01/21
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➢ Mail to: LIBERTY Dental Plan of Nevada, Inc.
Grievance and Appeals Department
P.O. Box 26110, Santa Ana, CA 92799
➢ Fax to: 1-833-250-1814, or
➢ Online: www.libertydentalplan.com/NVMedicaid
Appeal forms are also available on our website,
https://www.libertydentalplan.com/Members/Forms-Literature, by calling
LIBERTY’s Member Services Department, or by asking your provider.
We will start working on your verbal appeal the first day that it is
received. We will also send you a letter within 5 calendar days to tell
you that we received your appeal. The letter will include a form that you
can complete and return to us if you want to give us more information
about your appeal. If you need help completing the form, please call
our Member Services Department at 1-866-609-0418 (TTY 1-877-
855-8039).
Your appeals must include the following:
• Your Medicaid ID number
• Your date of birth
• Your mailing address
• The number associated with the Notice of Action
• The date of service
• An explanation of why you feel the decision should be reversed
• Any supporting documents or records
When will I get a response to my appeal?
A group that consists of appropriate level staff and dental care
professionals, that were not a part of the first decision, will review your
appeal. You will receive a response within 30 calendar days.
If you feel that the standard time frame for an appeal could cause
serious harm or jeopardy to your dental health, you may request an
expedited (fast) appeal. LIBERTY will not take any actions against you if
you request an expedited (fast) appeal. LIBERTY will also provide you
with the chance to review the case file before and after the processing
of your appeal.
For a fast decision, you will receive a response within 72 hours of
receipt. It is important that you provide LIBERTY with documentation to
support your expedited appeal as soon as possible. You may request
Nevada Medicaid Dental Program Member Handbook 01/21
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an extension of up to 14 calendar days for the expedited review.
LIBERTY may also request an extension of up to 14 calendar days if we
need additional information and it would be in your best interest.
LIBERTY will provide you with a written notice explaining the reasoning
for the delay.
What if I am not satisfied with the response to my appeal?
If you are not satisfied with the resolution to your appeal, you may contact
the Hearings Unit with the Division of Health Care Financing and Policy
at 1-775-684-3604 or 1-800-992-0900, extension 43604 to request a
Fair Hearing. A copy of the Fair Hearing request form is also included
with the Notice of Appeals Resolution letter sent to you.
Can I get a copy of my records from my grievance or appeal?
You can ask for a copy of your records that were used during the review
of your active grievance or appeal at any time. Once we receive your
request, we will provide you with a copy of your records within 5 business
days.
Fair Hearing
You or your dental provider have the right to ask for a Fair Hearing from
the state after you have gone through LIBERTY’s internal appeal
process. If someone other than you asks for a Fair Hearing on your
behalf, they must have your written consent this is called an authorized
representative. If you are not satisfied with the resolution to your appeal,
you may contact the Hearings Unit with the Division of Health Care
Financing and Policy at 1-775-684- 3604 or 1-800-992-0900, extension
43604.
You can request a Fair Hearing by mail by completing and sending the
Fair Hearing request form on page 52 of this member handbook (and
attached to your Notice of Appeals Resolution letter) to:
Nevada Division of Health Care Financing and Policy, Hearings Unit
1100 East William Street, Suite 101 Carson City, NV 89701
You can also go online to access the recipient Fair Hearing request form
at http://dhcfp.nv.gov/resources/PI/Hearings/.
You or your dental provider must ask for a Fair Hearing within 120
calendar days of receiving the Notice of Appeals Resolution letter from
LIBERTY. You may designate a person to act on your behalf and file a
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Fair Hearing in writing.
LIBERTY will continue your dental benefits during the Fair Hearing
process, if the following standards are met:
• Your Fair Hearing Request is received within 10 days after
LIBERTY’s notice of action or the proposed effective date
• Your Fair Hearing Request is about the termination, suspension, or
reduction of previously approved services
• Your Fair Hearing Request is about services ordered by a LIBERTY
dental provider
• You specifically requested to have your benefits extended
Please note that if the outcome of the State Fair Hearing is not in your
favor, you may have to pay the cost of continued benefits received.
If you need information or help, call the State Medicaid Office at:
• Northern Nevada: 1-775-687-1900 or 1-800-992-0900
• Southern Nevada: 1-702-668-4200 or 1-800-992-0900
If you need legal assistance, call the Nevada Legal Services Program:
• Clark County: 1-702-386-0404 or 1-866-432-0404
• Washoe County: 1-775-284-3491 or 1-800-323-8666
If you need information or help, call us at:
• Toll-Free: 1-866-609-0418
• TTY: 1-877-855-8039
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Member Participation
Member Advisory Committee
LIBERTY wants to hear from you. Once a quarter, we meet to discuss
how well we are performing and how we can improve.
The Committee is made up of members, LIBERTY’s Nevada Dental
Director, and other support staff. We are looking for members who would
like to join our Committee. You will take part in:
• Reviewing quality reports, such as grievances (complaints)
• Participation in development of education materials
• Suggesting ways to improve the Plan’s programs and services
• Helping to set policies that affect you
You will be paid for every meeting you attend. If you’re interested in the
chance to participate, please contact LIBERTY by:
➢ Phone: 1-866-609-0418, and ask about taking part in the Member
Advisory Committee, or
➢ Email us at: [email protected]
Provider Participation
Provider Incentive Program
A copy of the provider incentive program is available upon request. If you
would like to request a copy, please call our Member Services
Department at 1-866-609-0418.
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Important Dental Tips
Oral Health is critical to whole body health, especially for children. Dental
visits can provide key diagnostics by identifying diabetes and other
chronic diseases. Taking care of your mouth is one of the best ways to
prevent a wide range of health problems. Here are some ailments that
are linked to poor oral health - so take care of your pearly whites!
• Heart Disease: Those with gum disease are 2X more likely to have
heart disease.
• Stroke and Blood Clots: Gum disease is one of the most common,
preventable diseases in adults that increases susceptibility of
stroke and blood clots.
• Respiratory Disease: Bad bacteria from the mouth can be an
agent for pneumonia and bronchitis.
• Diabetes: Gum disease disrupts the control of blood sugar.
• Kidney Disease: Harmful bacteria from poor oral hygiene can
weaken kidneys.
Thorough daily oral hygiene lays the base for a healthy smile. Regular
brushing, flossing, and dental visits can be enough to help prevent tooth
decay, gum disease, and bad breath.
The importance of flossing
• Cleaning between your teeth is every bit as important as brushing.
Since brushing cannot effectively clean between teeth, it’s
important to use floss to get to those areas.
• Other items also are available to help you clean between your teeth.
Ask your dentist which ones to use.
• Floss between your teeth once a day and brush your teeth at least
twice a day.
Brushing up on technique
Since there are various techniques for brushing your teeth, it’s a good
idea to ask your dentist which one to use. Included below are a few tips
to help you develop a good brushing routine.
Brushing your teeth
• Brush your teeth at least twice a day – once in the morning and
once before bed
• When brushing, use a gentle touch to avoid injuring your gum tissue
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•
Use a toothpaste with fluoride to help prevent tooth decay
• Concentrate on brushing all surfaces
• Use a gentle touch – it doesn’t take much pressure to remove the
plaque from your teeth, and a vigorous scrubbing could irritate your
gums.
Brushing gums
• Hold your toothbrush at a slight angle toward the gums when
brushing along the gum line
Brushing your tongue
• Brushing your tongue gently can help remove bacteria that cause
bad breath
Benefits of a Dental Home
• Having a Dental Home helps you keep a healthy smile
• Families are encouraged to build a relationship with their Dental
Home
• A great Dental Home encourages members to schedule regular
dental checkups
Benefits of establishing a Dental Home
• Patients become familiar with the dentist, their staff, and the office
• Promotes early and regular access to preventive and routine dental
services
• Increases continuity of care, prevention, dental, and overall health
• Decreases duplication of dental services caused by seeking dental
care from multiple dental offices
The American Academy of Pediatrics (AAP), the American Dental
Association (ADA), and the American Academy of Pediatric Dentistry
(AAPD) recommend establishing a “Dental Home” for your child by one
year of age. Children who have a Dental Home are more likely to receive
appropriate preventive and routine care. A well-established Dental Home
also includes appropriate referrals to dental Specialists.
With the rising incidence of tooth decay among young children, having a
Dental Home can be essential in promoting preventive care. In addition
to implementing lifelong oral health at home, establishing and maintaining
an ongoing relationship between the dentist and the patient is imperative.
The Dental Home is an open door to all aspects of oral health care
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delivered in a comprehensive, continuously accessible, coordinated, and
family-centered way.
Definitions and Useful Terms
Action: A decision made by LIBERTY that you have the right to appeal,
including:
• Denial or partial denial of a requested service
• Denial, in whole or in part, of payment for a service
• Failure to provide services in a timely manner
• Failure of LIBERTY to act within specified time frames
Appeal: A request for review of a Notice of Action (see ‘Action’).
Authorization: The notification of authorization by LIBERTY that you
may proceed with treatment requested.
Benefits: The dental health care services available under the Nevada
Medicaid Dental Program.
Benefit Plan: The dental benefit plan provided under your Medicaid
coverage by LIBERTY.
Covered Services: Those dental services that are covered under your
Medicaid benefits.
Dental Home:
A Dental Home is the Primary Care Dentist or Pediatric
Dentist that you have been assigned to for your dental care needs. The
Dental Home is the ongoing relationship between the dentist and you,
inclusive of all aspects of oral health care delivered in a comprehensive,
continuously accessible, coordinated, and family-centered way. The
Dental Home should be established no later than 12 months of age and
includes referral to dental Specialists when appropriate. Also known as
Primary Care Dentist or Primary Care Provider.
Dental Necessity or Dentally Necessary: A covered service that meets
Plan guidelines for appropriateness and reasonableness by virtue of a
clinical review of submitted information.
Covered Services may be reviewed for Dental Necessity prior to a signed
contract to provide services, or after services are rendered. Payment for
services occurs for Covered Services that are deemed Dentally
Necessary by the Plan.
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Dental Records: Refers to diagnostic intraoral and extra-oral
radiographs, written treatment records including, but not limited to,
progress notes, dental and periodontal chartings, treatment plans,
consultation reports, or other written material relating to an individual’s
medical and dental history, diagnosis, condition, treatment, or evaluation.
DHCFP: The abbreviation for the State of Nevada Division of Health Care
Financing and Policy.
Emergency Care/Emergency Dental Service: Emergency dental
service and care include (and are covered by LIBERTY) dental
screening, examination, evaluation by a dentist or dental Specialist to
determine if an emergency dental condition exists, and to provide care
that would be acknowledged as within professionally recognized
standards of care and in order to alleviate any emergency symptoms in
a dental office. Medical emergencies are not covered by LIBERTY if the
services are rendered in a hospital setting which are covered by a
Medical Plan, or if LIBERTY determines the services were not dental in
nature.
Exclusion: A statement describing one or more services or situations
where coverage is not provided for dental services by the Plan.
General Dentist: A licensed dentist who provides general dental
services and who does not identify as a Specialist.
Grievance: Any expression of dissatisfaction with any aspect of care
other than the appeal of actions.
In-Network Benefits: Benefits available to you when you receive
services from a contracted provider.
Non-Participating Provider: A dentist that has no contract to provide
services for LIBERTY.
Out-of-Area Coverage:
Benefits
provided when you are out of the Plan’s
service area, or away from your Dental Home.
Participating Dental Group, Dental Office, or Provider: A dental
facility and its dentists that are under contract to provide services to
LIBERTY members in accordance with LIBERTY’s rules and regulations.
Plan: LIBERTY Dental Plan of Nevada, Inc. (LIBERTY)
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Primary Care Dentist: A dentist affiliated with LIBERTY to provide
services to covered members of the Plan. The Primary Care Dentist is
responsible to provide or arrange for needed dental services. Also known
as a Dental Home.
Prior Authorization: A document submitted on your behalf requesting an
advance determination and approval to render desired treatment services
for you.
Provider: A contracted dentist providing services under contract with the
Plan.
Member: Any presently enrolled Medicaid Member who has completed a
Plan membership application and receives Plan benefits through
LIBERTY, also known as Enrollee/Recipient.
Service Area: The counties in Nevada where LIBERTY provides
coverage.
Specialist: A dentist that has received advanced training in one of the
dental specialties approved by the American Dental Association as a
dental specialty, and practices as a Specialist. Examples are
Endodontists, Oral and Maxillofacial Surgeons, and Periodontists.
Urgent Care: See Emergency Care
Us/We/Our: LIBERTY Dental Plan of Nevada, Inc. (LIBERTY)
You/Your/My/I: Member, recipient, or “you”, are equivalent in this
document.
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Frequently Asked Questions
How can I find a contracted LIBERTY dentist?
Contact LIBERTY at 1-866-609-0418. A Member Service Representative
will assist you in locating a dentist near you or you can locate providers
online at www.libertydentalplan.com/NVMedicaid; click on ‘Find & Select
a Dentist’ to do a search.
I lost my LIBERTY ID card. How can I get another?
Contact LIBERTY at 1-866-609-0418 to request an ID card. See page 17
for details.
Can I change my dentist?
Yes. See page 21 for details.
How do I know what’s covered under my dental plan?
Pages 24-30 of this handbook will provide you with “Benefits and
Services”.
What if I don’t have transportation to my dental appointment?
LIBERTY can arrange transportation to your dental appointment. See
pages 18-19 for details.
Does LIBERTY offer interpreter services?
Yes. See page 19 for details.
What if I want a second opinion?
You may request a second opinion. See page 30 for details.
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Forms
MEMBER GRIEVANCE AND APPEAL FORM – NEVADA
You can use this form to file a grievance or appeal with LIBERTY
Dental Plan ( LIBERTY). You can also use this form to give LIBERTY
more information to help review your case. If you filed an appeal
over the telephone , you can complete this form and mail it back to
LIBERTY. This is optional. We will review your case without a written
appeal.
MEMBER INFORMATION (PLEASE PRINT)
Member last name
Member first name
Today’s date
Member street address
City
State
ZIP code
Member phone number
Member identification number (see identification
card)
Employer or Group
Patient name
Relationship
AUTHORIZED REPRESENTATIVE INFORMATION, IF APPLICABLE (PLEASE PRINT)
I am authorizing LIBERTY Dental Plan to allow the following person to act on my
behalf during the grievance/appeals process
Representative last name
Representative first name
Representative phone
number
Representative Signature
Member Signature
Appeals must be filed within 60 days from the
date on your Notice of Action
(NOA)
Grievances can be filed at any time.
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If you need help completing this form, call our Member Services
Department at ( 866) 609 - 0418 , or TTY: 1 - 877 - 855 - 8039 ,
Monday through Friday 5 :00 a.m. to 5: 00 p. m. ( PST). We can give
you an interpreter at no cost, if you need one. You or someone you
authorize have the right to review your case file at any time. We’ll
give you copies free of charge.
SUMMARY OF GRIEVANCE OR APPEAL
Please share any information you have about your grievance or appeal. Please
give us as many details as you can, if possible please provide the dates, names
and any treatment. If needed, you can attach an additional page.
Please share with us how you would like to see your grievance or appeal resolved.
Member Signature
Date
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PLEASE SEND COMPLETED SIGNED FORM TO:
Mail to:
LIBERTY Dental Plan of
Nevada
Grievances and Appeals
Department
P.O. Box 26110
Santa Ana, CA 92799
• Fax to LIBERTY’s Grievances and Appeals Department at
(833) 250-1814
• Telephone by calling LIBERTY Dental Plan’s Member
Services Department at toll-free number:
(866) 609-0418, or TTY: (877) 855-8039
• Electronically by using our website online grievance filing
process by visiting
www.libertydentalplan.com/NVMedicaid.
You will receive a letter acknowledging receipt of your grievance or appeal within 5
calendar days of receipt by LIBERTY.
You will receive a written resolution to your grievance or appeal within 30 calendar days of
receipt by LIBERTY.
You may request a copy of your records associated with your active grievance or appeal in
writing to LIBERTY at the address listed above.
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Requesting a Fair Hearing
• If you disagree with Medicaid's denial, reduction, suspension, or termination
of service, you may request a Fair Hearing. A Fair Hearing allows you and
Medicaid to give information about your situation to a Hearing Officer. The
Hearing Officer is a neutral party who makes a decision on your appeal. There is
no charge for a Fair Hearing.
• Medicaid must receive your request within 120 calendar days from the Notice
Date.
• You may represent yourself or have the help of another adult. The adult can
be a friend, family member, or lawyer. Medicaid has provided the names of some
agencies that may be able to help you. (See below).
• The request for a Fair Hearing must include: (1) your name, address, telephone
number, (2) Medicaid number; and (3) if someone is helping you, the name,
telephone number and address of the adult who will help you (the "authorized
representative"). You must sign the request unless you are unable to do so because
of your disability. You may use the enclosed form to request a Fair Hearing.
• If you want your services to stay the same during Fair Hearing process, you
must: 1) ask for a hearing not more than 10 calendar days after the Date of
Action (shown on the Notice of Decision); and 2) you must ask that your
services stay the same. (During the Fair Hearing process, your services will be
continued) You may use the enclosed form to do this.
• LIBERTY may ask you to pay back the cost of the continued services if you
lose your appeal.
• After you have requested a Fair Hearing, Medicaid will contact you within 10
days to arrange a Hearing Preparation Meeting (HPM). The meeting will be
by telephone. The goal of this meeting is to try to resolve your appeal. LIBERTY
will explain its decision and give you the chance to provide more information. If
you and LIBERTY cannot agree, you may go to a Fair Hearing. A Hearing
Preparation Meeting (HPM) is optional. You do not have to take part in a HPM.
You can let Medicaid know you want to go directly to a Fair Hearing and have a
Hearing Officer decide your appeal.
To find out more about Medicaid appeals, you may go to the Nevada Department of
Health and Human Services, Division of Health Care Financing and Policy's Medicaid
Service Manual Chapter 3100 Hearings at: http://dhcfp.nv.gov.
If you cannot afford legal counsel, one of the Legal Services programs listed below may
be able to help. Nevada Legal Services, Inc. (Reno) Washoe County: (775) 284-3491
Nevada Legal Services, Inc. (Las Vegas) Clark, Lincoln, Nye, and Esmeralda Counties:
(702) 386-0404 or (866) 432-0404 TDD: (702) 386-1059
Nevada Legal Services, Inc. (Elko) Elko County: (775) 753-5880
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Nevada Legal Services, Inc (Carson City) Carson City and remaining counties:
(775) 883-0404 or (800) 323-8666 Senior Law Project (Las Vegas) Clark County
residents age 60 and older: (702) 229-6596 TDD: (702) 386-9108 Washoe County
Senior Law Project Washoe County residents age 60 and older: (775) 328-2592
Nevada Disability Advocacy and Law Center (South) Disabled Persons and Families with
Disabled Persons: (702) 257-8150 or (888) 349-3843, TTY: (702) 257-8160
Nevada Disability Advocacy and Law Center (North): (775) 333-7878 or (800) 992-5715
or TTY: (775) 788-7824
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Fair Hearing Request Form
I am submitting this form to request a Fair Hearing. (Check all that apply and
complete fields below)
I am requesting my Fair Hearing be expedited because a standard hearing could
jeopardize my life, health or ability to attain, maintain or regain maximum function.
The documentation from my medical provider to support this request is attached. (If
you do not supply this documentation, this request will be processed within the
Standard Fair Hearing timeframe, 90 days)
I am requesting a fair hearing based on the issue of reasonable promptness.
During the Fair Hearing process, I would like my benefits continued. I understand I
may have to pay back the cost of services or items if I do not win the Fair Hearing.
Please send me a free copy of the regulations relevant to my case. Also available at
website: http://dhcfp.nv.gov/.
Recipient name: Phone:
Recipient mailing address:
Recipient ID number:
Recipient signature: Date:
______________
Authorized representative name: Phone:______________
Representative mailing address:
Authorized representative signature: Date:____________
Return this request to: Nevada Medicaid Hearings Unit
1100 East William Street – Suite 101
Carson City, NV 89701
Fax # (775) 684-3610, E-Mail dhcf[email protected]v.gov
Nevada Medicaid Dental Program Member Handbook
© 2021 LIBERTY Dental Plan of Nevada, Inc.
6385 S. Rainbow Blvd. Suite 200
Las Vegas, NV 89118
