Dental Services

The VCP may pay for treatment of injuries caused by a crime, including but not limited to:

• Repair or replacement of broken or damaged teeth and dentures Temporomandibular
• (TMJ) disorders
• Diagnostic x-rays
• Prescriptions
• Cleaning (if necessary to provide crime-related dental procedures)

Dental Bills

A CMS form is not needed. Most dentists submit bills on a dental claim form such as the ADA-94, or the newer ADA-2000; however any form submitted must contain the following information:

• Patient’s name and address
• Date(s) of service
• Type(s) of service(s) provided (diagnosis and procedure)
• DentiCal or HCPCS (HealthCare Common Procedure Coding System) codes
• Charges for each procedure
• Total charges
• Provider’s name, license number, federal tax identification number (FEIN or SSN), business address, telephone number, signature or signature stamp, and billing date

Reimbursement Rates

The VCP pays 75 percent of the amount billed (subject to review of usual and customary rates).

Preauthorized Approval for Treatment

Dentists may be able to obtain preauthorized approval for treatment. Dentists must submit a pre-treatment estimate on an approved American Dental Association (ADA) Claim Form to the Board for review. The Board will review the estimate to determine if the treatment is necessary and crime-related. The Board may request additional information, such as dental records, from the dentist prior to preauthorization of payment. The Board will only issue a payment for preauthorized treatment after the services have been provided. Call our Customer Service Section at (800) 777-9229 for more information.