2015 Dental Provider Directory CCHP Senior Program (HMO) Optional Supplemental Dental Plan

Transcription

1 2015 Dental Provider Directory CCHP Senior Program (HMO) Optional Supplemental Dental Plan H0571_2015_31 Accepted HL_DCU_6609_ _CCHP

2 CCHP Senior Program (HMO) Optional Supplemental Dental Plan Dental Provider Directory This directory provides a list of DeltaCare USA providers available to the CCHP Senior Program (HMO) Optional Supplemental Dental Plan. This directory is for San Francisco and Northern San Mateo Counties. This directory is current as of August Some plan providers may have been added or removed from the list after this directory was printed. We do not guarantee that each provider is still accepting new members. To get the most up-to-date information about DeltaCare USA s providers in your area, you can call DeltaCare USA s Customer Service at (TTY/TDD: ), Monday through Friday between 5:00 a.m. and 6:00 p.m. (excluding holidays) Pacific time, or access the website at or call CCHP Member Services at , 8:00 a.m. to 8:00 p.m. 7 days a week, (TTY/TDD: ) CCHP Senior Program (HMO) is an HMO plan with a Medicare contract. Enrollment in CCHP Senior Program (HMO) depends on contract renewal. CCHP Senior Program (HMO) es un plan de atención coordinada que tiene un contrato con Medicare. La inscripción en CCHP Senior Program (HMO) depende de la renovación del contrato. 東 華 耆 英 (HMO) 計 劃 是 一 個 HMO 與 聯 邦 保 健 簽 有 合 約, 而 東 華 耆 英 (HMO) 計 劃 能 否 接 收 會 員 取 決 於 這 合 約 是 否 獲 得 續 約 This information is available for free in other languages. Please contact our customer service number at (TTY ) from 8:00 a.m. to 8:00 p.m., seven days a week. Esta información está disponible gratuitamente en otros idiomas. Por favor póngase en contacto con nuestro número de servicio al cliente al (TTY ) de 8:00 a.m. a 8:00 p.m., siete días a la semana. 此 文 件 有 其 它 的 語 言 版 本 免 費 提 供 了 解 詳 情 請 致 電 與 會 員 服 務 中 心 聯 絡 ( 聽 力 殘 障 人 仕 請 電 TTY ), 每 週 7 天, 上 午 8 時 至 晚 上 8 時 This document may be available in other formats, such as Braille, large print, or other alternate formats. You may call CCHP Senior Program (HMO) Member Services at for more information. TTY users should call H0571_2015_31 Accepted

3 Section 1 Introduction This directory provides a list of DeltaCare USA providers available to the CCHP Senior Program (HMO) Optional Supplemental Dental Plan. To get detailed information about your dental coverage, please see your CCHP Senior Program (HMO) Evidence of Coverage, as well as your DeltaCare USA Dental HMO Program Benefit Booklet ( Evidence of Coverage ), which will be mailed along with your DeltaCare USA ID card. Contract Dentists When you enroll in the CCHP Senior Program (HMO) Optional Supplemental Dental Plan, you must select a Contract Dentist from the DeltaCare USA network. A Contract Dentist is a dentist who provides services in general dentistry and has agreed to provide benefits to enrollees under this program. Please refer to the list of Participating DeltaCare USA Providers for Contract Dentists that are available in the service area. Or, you may access the website at to view DeltaCare USA Contract Dentists near your home or work. You must indicate the provider name and number of your selected Contract Dentist on your dental enrollment form. The network providers listed in this directory have agreed to provide you with your dental coverage. You may choose one of the network providers listed in the directory to be your Contract Dentist; however, some services may require a referral. If you have been going to one Contract Dentist, you are not required to continue going to that same Contract Dentist. You may change your Contract Dentist by contacting Delta Dental Customer Service prior to the 21st of the month, and the change will take effect the first day of the following month. Your selected Contract Dentist will design a treatment plan to meet your individual needs. Prior to beginning treatment, it is best to discuss your treatment plan and financial responsibilities with your Contract Dentist. Dental services that are not performed by your Contract Dentist, or are not covered under emergency care, must be pre-authorized by Delta Dental to be covered by DeltaCare USA. In some cases, you may get covered services from non-network providers. You must use DeltaCare USA providers except in emergency or urgent care situations. If you obtain routine care from out-of-network providers neither Medicare nor CCHP/DeltaCare USA will be responsible for the costs. You are covered for out-of-network dental emergencies, up to $100 of dental expenses per emergency. When you receive a bill for emergency care or other services that have been pre-authorized by Delta Dental, but not performed by your Contract Dentist, you should submit the bill to Delta Dental for processing and determination of liability. The bill should be submitted within 90 days of the end of treatment to Delta Dental. Referrals to DeltaCare USA Contract Specialists During the course of treatment, your selected Contract Dentist may recommend the services of a Contract Specialist. Your selected Contract Dentist is responsible for coordinating your dental care and if necessary, referring you to a DeltaCare USA Contract Specialist, and will submit all required documentation for any necessary referral.

4 Emergency Dental Services If emergency services are needed, you should contact your Contract Dentist whenever possible. If you are a new enrollee needing emergency services, but do not have an assigned Contract Dentist yet, contact Delta Dental s Customer Service Department at , Monday through Friday from 5:00 a.m. to 6:00 p.m. Pacific time (TTY/TDD: ) for help in locating a Contract Dentist. Benefits for emergency services by an out-of-network dentist are limited to necessary care to stabilize your condition and/or provide palliative relief when you: 1) Have made a reasonable attempt to contact the Contract Dentist and the Contract Dentist is unavailable or you cannot be seen within 24 hours of making contact; or 2) Have made a reasonable attempt to contact Delta Dental prior to receiving emergency services, or it is reasonable for you to access emergency services without prior contact with Delta Dental; or 3) Reasonably believe that your condition makes it dentally/medically inappropriate to travel to the Contract Dentist to receive emergency services. Benefits for emergency services not provided by the Contract Dentist are limited to a maximum of $ per emergency, per enrollee, less the applicable copayment. If the maximum is exceeded, or the above conditions are not met, you are responsible for any charges for services by a provider other than your Contract Dentist. You must use plan providers except in emergency situations. If you obtain routine care from out-of-network providers neither Medicare nor CCHP/DeltaCare USA will be responsible for the costs. During non-business hours or if you are 35 miles or more from your assigned Contract Dentist, you do not need a referral and may seek treatment from any dentist other than your assigned Contract Dentist. If you do not require emergency dental services and a delay in receiving treatment would not be detrimental to your health, please contact your Contract Dentist or DeltaCare USA Customer Service Department at , Monday through Friday between 5:00 a.m. to 6:00 p.m. (excluding holidays) (TTY/TDD: ) to make reasonable arrangements for your care. What is the service area for the CCHP Senior Program (HMO) Optional Supplemental Dental Plan? The counties in our service area are listed below. San Francisco County San Mateo County, the following zip codes only: 94005, 94010, 94011, 94014, 94015, 94016, 94017, 94019, 94030, 94037, 94038, 94044, 94066, 94080, 94083, 94128, 94401, 94402, 94403, 94404, 94407, 94497

5 How to find a DeltaCare USA provider in your area? The DeltaCare USA providers in this directory are listed alphabetically by City, Provider Number, and Provider Name. To find a DeltaCare USA provider in your area, first look for your city, then look for your zip code. Listing in this directory does not guarantee that the dentist is still in the network or accepting new patients. Once you become effective with the dental plan, simply call the Contract Dentist you selected and schedule an appointment. Most dental facilities are open during regular business hours. If you have questions about when the dental facility of your selected Contract Dentist is open, simply call the dental facility directly. The address and telephone number of your selected Contract Dentist is listed in this Dental Provider Directory. You may also call DeltaCare USA s Customer Service at (TTY/TDD: ), Monday through Friday between 5:00 a.m. and 6:00 p.m. (excluding holidays) for information regarding the Contract Dentist you selected or call CCHP Member Services at , 8:00 a.m. to 8:00 p.m., 7 days a week (TTY: ).

6 Participating DeltaCare USA Dental Offices A Registered Mark of Delta Dental Plans Open Offices August 2014 BELMONT # BELMONT PLAZA DENTAL CARE 390 EL CAMINO REAL STE D, (650) F/T 2 (RU) # MARIA LOURDES Y YEO DDS 2130 RALSTON AVE STE I D, (650) F/T 3 BURLINGAME # MASHA MEKHTEYS, DDS 1860 EL CAMINO REAL STE 315, (650) (RU) DALY CITY # BELLA LIM, DDS 7455 EL CAMINO REAL STE C, (650) # CAMPUS HEIGHTS DENTAL 901 CAMPUS DR STE 304, (650) # MARIA LOURDES Y YEO DDS 2055 GELLERT BLVD #4, (650) F/T 3 # MARIVIC AGONCILLO DDS INC 343 GELLERT BLVD STE G, (650) # MOUHANNAD AL MAJDALANI, DDS 320 WASHINGTON ST APT 105, (650) (CH, AR, TA, SP) # RODOLFO VILLASIN, DMD 341 WESTLAKE CTR STE 237, (650) (TA) # SERRAMONTE SMILE CENTER 347 GELLERT BLVD STE K, (650) FOSTER CITY # JING JING QIAN, DDS 1289 E HILLSDALE BLVD STE 3, (650) (CH) MENLO PARK # JOSEPH K SARKOSH, DDS 888 OAK GROVE AVE STE 6, (650) (SP) 1 MILLBRAE # CECILIA JU, DDS 140 EL CAMINO, (650) (CH) # DENTAL EASE 1070 BROADWAY, (650) # PEDRO CATURAY, DDS 1301 BROADWAY STE 7, (650) (TA, SP) REDWOOD CITY # BIRCH DENTAL GROUP 155 BIRCH ST STE 5, (650) # EUGENE ESPIRITU 705 VETERANS BLVD STE SUITE1, (650) (CA, CH, SP, TA) # UNITED DENTAL 647 VETERANS BLVD, (650) # WESTERN DENTAL SERVICES 975 VETERANS BLVD, (650) F/T 4 P/T 29 07/29/2014 DR_DCU_CCHP_6609_AUG2014_ PLCCHP

7 SAN BRUNO # EUGENE ESPIRITU 1230 EL CAMINO REAL STE K, (650) # SAN BRUNO DENTAL CARE 211 EL CAMINO REAL, (650) F/T 2 (SP, TA, GE) SAN FRANCISCO # ALEXANDER KOGAN DDS INC 255 KING ST STE A, (415) # BERNARDO GONZALEZ, DDS TH ST, (415) (SP) # CENTER OF COSMETIC DENTISTRY 1550 LOMBARD ST, (415) #NONE00 DeltaCare USA Null Facility 100 FIRST STREET 9TH FLOOR, # GENTLE DENTAL 2494 MISSION ST, (415) F/T 2 P/T 4 (SP, RU) # GENTLE DENTAL SAN FRANCISCO 2364 GEARY BLVD, (415) P/T 2 (CA, SP, CH) # GRAND MISSION DENTAL GROUP 4749 MISSION ST, (415) (TA, SP) # HIPOLITO BARONIA, DDS 2480 MISSION ST STE 214, (415) (TA, SP) # J T DENTAL 2415 NORIEGA ST, (415) (CA, 12, SP) # KAYVAN KAFAYI, DDS 450 SUTTER ST RM 1433, (415) # MAT KIISK, DDS TH AVE, (415) F/T 2 # MICHAEL COLE, DDS 2595 MISSION ST STE 308, (415) (SP) # MIKHAIL BERDICHEVSKY, DDS 4444 GEARY BLVD STE 303, (415) (RU) # MISSION DENTAL 2482 MISSION ST, (415) F/T 2 (SP) # NORIEGA DENTAL 3749 NORIEGA ST, (415) (CA, CH) # OCEAN DENTAL OFFICE 760 LA PLAYA ST, (415) (12, RU, CH, TA, SP, CA) # RICHMOND DENTAL CARE 4312 GEARY BLVD, (415) F/T 2 (CH, SP, RU) # ROBERTO CALABIO DMD INC ND ST, (415) # RONALD YOUNG, DDS 1637 LOMBARD ST, (415) (SP, 12, CA) # SAN BRUNO AVE DENTAL CLINIC 2817 SAN BRUNO AVE, (415) (12, SP, CH) # SOUTH VAN NESS DENTAL GROUP 240 SHOTWELL ST STE 230, (415) (SP) # VAN NESS DENTAL GROUP 2243 VAN NESS AVE STE 101, (415) F/T 4 (VI, 12, SP, CH, CA) 2

8 # WESTERN DENTAL SERVICES 1282 MARKET ST, (415) F/T 3 6 (SP) # WESTERN DENTAL SERVICES 2813 MISSION ST, (415) (SP) SAN MATEO # A + DENTAL CENTER 400 N SAN MATEO DR 2, (650) (CA, SP, TA) # DECCAN DENTAL 1528 S EL CAMINO REAL #408, (650) F/T 2 (HI, CA, CH) # GEORGE WOLFF, DDS 255 N SAN MATEO DR, (650) #2C0001 PENINSULA DENTAL 401 A N SAN MATEO DR, (650) P/T 2 # TAOS DENTAL CARE 1927 S EL CAMINO REAL, (650) F/T 2 # WESTERN DENTAL SERVICES 4100 S EL CAMINO REAL, (650) F/T 2 P/T 9 (SP) SOUTH SAN FRANCISCO # CECILIA R H AVENIDO DMD INC 2400 WESTBOROUGH BLVD STE200, (650) (TA, SP) # GRAND MISSION DENTAL GROUP 125 NORTHWOOD DR STE A, (650) (SP, TA) # JEANETTE ESTIPONA, DDS 2400 WESTBOROUGH BLVD # 103, (650) (TA) #2C2301 NORTHWOOD DENTAL CARE 125 NORTHWOOD DR STE A, (650) # PURE SMILE DENTAL GROUP 1133 EL CAMINO REAL STE# 5, (650) (TA, CH) # TRINITY DENTAL CARE 1124 MISSION RD, (650) (TA) 3

9 Visit us at our website: deltadentalins.com F/T Full Time Dentist P/T Part Time Dentist AF Afrikaans AR Arabic AM Armenian CA Cantonese CH Chinese CL Creole CS Czech EI East Indian FR French GE German GR Greek HE Hebrew HI Hindi HR Croatian Foreign languages spoken in the dental office are listed by code in ( ). Below is a key to the foreign language codes. HU Hungarian IN Indonesian IT Italian JA Japanese KO Korean PE Persian PL Polish RO Romanian RU Russian SP Spanish/ Español TA Tagalog TH Thai TR Turkish VI Vietnamese LANGUAGE ASSISTANCE: Language capabilities are self reported by the individual dental facilities and not independently verified by Delta Dental. If an enrollee requires language assistance to enable communication in a dental setting, Delta Dental will arrange for professional services through a certified interpretation vendor at no cost to the enrollee. Additional Dental Offices will be added as required. You may call our Customer Service department at Monday through Friday between 5 a.m. and 6 p.m. (excluding holidays) (TDD/TTY: ) for updates to the provider list. If any office is closed to further enrollment, Delta Dental reserves the right to assign you another dental office as close to your home as possible. In California, DeltaCare USA is underwritten by Delta Dental of California and administered by Delta Dental Insurance Company. NOTE: Contact the provider before making your choice if you have scheduling problems or small children. This document may be available in other formats, such as Braille, large print, or other alternate formats. You may call CCHP Senior Program (HMO) Member Services at for more information. TTY users should call The wheelchair symbol indicates functional accessibility for individuals with limited mobility. Information regarding dental office accessibility for patients with mobility impairments is available by calling Delta Dental s Customer Service department at Monday through Friday between 5 a.m. and 6 p.m. (excluding holidays) (TDD/TTY: ) 4