PM 21-05-11

Requests for dental services not covered by the MediPlan card, such as partial plates for clients with noticeably missing or malformed teeth or other dental procedures, must be considered on a case by case basis to determine if the condition is a barrier to employment.

  1. (Worker) If the client does not have a dentist who accepts the medical card, give the client Form 2151 referring them to a dentist who does accept the medical card.
    1. revised textIf the Family Community Resource Center is not aware of a dentist who accepts the medical card, call DentaQuest at 1-888-286-2447 for their assistance in locating a Medicaid-enrolled dentist.
  2. (Dentist) Gives the client a written description of the required dental procedure and a cost estimate. The statement must have the dentist's name, address, phone number, license number, Social Security number or FEIN, description of the required dental procedures, fees, and dentist's signature.
  3. (Client) Submits the dentist's statement to the Family Community Resource Center.
  4. revised text(FCRC) If there is a question about a dentist's charge, contact HFS Bureau of Maternal and Child Health Promotion at (217) 557-5438.
  5. (LOA) Makes the decision to approve or deny the request.
  6. (Worker) Notify the client of the decision by sending Notice of Decision on Request for a Financial Assistance Increase/Special Authorization (Form 1934).

    If the services are approved, Form 1934 refers the client back to the dentist. 

  7. (Worker) Send a copy of Form 1934 to the dentist.

    NOTE: Make sure the Family Community Resource Center address appears on the notice. 

  8. (Dentist) When the dental work has been completed, sends the dental bill to the FCRC.
  9. (FCRC) Prepare a Form C-13 and send it with the dentist's bill to:

    DHS Vouchering Unit
    100 South Grand Avenue East, 1st floor
    Springfield, IL 62762 

  10. (Dentist) Receives payment from DHS Vouchering Unit at the maximum allowable Medicaid rate or the actual charge, whichever is less.
  11. (FCRC) Keep copies of the dentist's statement, client notice, and Form C-13 in the case record.