CCHP Senior Program (HMO)

Transcription

1 DeltaCare USA CCHP Senior Program (HMO) 2017 Dental Provider Directory Optional Supplemental Dental Plan H0571_2018_31 Accepted We keep you smiling deltadentalins.com/enrollees _HL_DCU_76609_ _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 Chinese Community Health Plan complies with applicable Federal civil rights laws and does not discriminate on the basis of race, color, national origin, age, disability, or sex. H0571_2018_31

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: ). Copyright 2016 Delta Dental. All rights reserved. HL_DCU_ #99493 (rev. 8/16)

6 DeltaCare USA Participating DeltaCare USA Dental Offices A Registered Mark of Delta Dental Plans Open Offices Belmont #DC Maria Lourdes Yeo DDS 2130 Ralston Ave Ste I D, (650) #DC Belmont Plaza Dental Care 390 El Camino Real Ste D, (650) Burlingame #DC Masha Mekhteys DDS 1860 El Camino Real Ste 315, (650) Daly City #DC Bella Lim DDS 7455 El Camino Real Ste C, (650) #DC Maria Lourdes Yeo DDS 2055 Gellert Blvd Ste 4, (650) #DC Mouhannad Al Majdalani DDS 320 Washington St Apt 105, (650) #DC Rodolfo Villasin DMD 341 Westlake Ctr Ste 237, (650) East Palo Alto #DC Ravenswood Family Dentistry 1807 Bay Rd, (650) Foster City #DC Jing Jing Qian DDS 1289 E Hillsdale Blvd Ste 3, (650) Menlo Park #DC Joseph K Sarkosh DDS 888 Oak Grove Ave Ste 6, (650) Millbrae #DC Cecilia Ju DDS 140 El Camino Real, (650) #DC Pedro Caturay DDS 1301 Broadway Ste 7, (650) #DC Dental Ease 1070 Broadway, (650) Redwood City #DC Eugene Espiritu 705 Veterans Blvd Ste 1, (650) #DC United Dental 647 Veterans Blvd, (650) #DC Birch Dental Group 155 Birch St Ste 5, (650) #DC Western Dental Services 975 Veterans Blvd, (650) #DC Siva Cherukuri DDS 193 Arch St Ste B & C, (650) #DC Randhawa Dental Practice 570 El Camino Real Ste 130, (650) S San Fran #DC Noel S Miranda DMD 1486 Huntington Ave Ste 302, (650) San Bruno #DC San Bruno Smile 797 Jenevein Ave, (650) #DC Maria Luisa B Santos 1001 San Bruno Ave W, (650) #DC Eugene Espiritu 1230 El Camino Real Ste K, (650) San Francisco #DC Ocean Dental Office 758 La Playa St, (415) August /01/2017 DR_DCU_CCHP_76609_AUG2017_ PLCCHP

7 #DC Center Of Cosmetic Dentistry 1550 Lombard St, (415) #DC Kayvan Kafayi DDS 450 Sutter St Rm 1433, (415) #DC Roberto Calabio DMD Inc nd St, (415) #DC Michael Cole DDS 2595 Mission St Ste 308, (415) #DC Western Dental Services 2776 Mission St, (415) #DC Mission Dental 2482 Mission St, (415) #DC Alexander Kogan DDS Inc 255 King St Ste A, (415) #DC Cosmo Dental 490 Post St Ste 1022, (415) #DC Gentle Dental 2494 Mission St, (415) #DC Dental Arts Practice Dr Albina Batchaeva 450 Sutter St Rm 1925, (415) #DC Bernardo Gonzalez DDS th St, (415) #DC J T Dental 2415 Noriega St, (415) #DC Grand Mission Dental Group 4749 Mission St, (415) #DC Richmond Dental Care 4312 Geary Blvd, (415) #DC San Bruno Ave Dental Clinic 2817 San Bruno Ave, (415) #DC Noriega Dental 3749 Noriega St, (415) #DC Van Ness Dental Group 2243 Van Ness Ave Ste 201, (415) #DC South Van Ness Dental Group 240 Shotwell St Ste 230, (415) San Mateo #DC Deepak Sachdev DDS 1415 S El Camino Real, (650) #DC Deccan Dental 1528 S El Camino Real #408, (650) #DC A + Dental Center 400 N San Mateo Dr Ste 2, (650) #DC Western Dental Services 4100 S El Camino Real, (650) #DC Blue Rock Dental 70 N El Camino Real, (650) #DC Derek Wong DDS 255 N San Mateo Dr Ste 2, (650) #DC2C0001 Peninsula Dental 401A N San Mateo Dr, (650) South San Francisco #DC Winston Manor Dental Office 101 Hickey Blvd Ste C, (650) #DC Trinity Dental Care 1124 Mission Rd, (650) #DC Jeanette Estipona DDS 2400 Westborough Blvd Ste 103, (650) #DC Epitacio N Sison Jr DDS 100 Arroyo Dr Ste C, (650) #DC Cecilia R H Avenido DMD Inc 2400 Westborough Blvd Ste 200, (650)

8 #DC Union Dental 215 Miller Ave, (650) #DC Grand Mission Dental Group 125 Northwood Dr Ste A, (650) 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: ) 3

9 Discrimination is Against the Law Chinese Community Health Plan (CCHP) complies with applicable Federal civil rights laws and does not discriminate on the basis of race, color, national origin, age, disability, or sex. CCHP does not exclude people or treat them differently because of race, color, national origin, age, disability, or sex. Chinese Community Health Plan: Provides free aids and services to people with disabilities to communicate effectively with us, such as: o Qualified sign language interpreters o Written information in other formats (large print, audio, accessible electronic formats, other formats) Provides free language services to people whose primary language is not English, such as: o Qualified interpreters o Information written in other languages If you need these services, contact CCHP Member Services. If you believe that CCHP has failed to provide these services or discriminated in another way on the basis of race, color, national origin, age, disability, or sex, you can file a grievance with us in person, by phone, by mail, or by fax at: CCHP Member Services 445 Grant Ave, Suite 700, San Francisco, CA , TTY Fax You can also file a civil rights complaint with the U.S. Department of Health and Human Services, Office for Civil Rights electronically through the Office for Civil Rights Complaint Portal, available at or by mail or phone at: U.S. Department of Health and Human Services 200 Independence Avenue SW. Room 509F, HHH Building Washington, DC 20201, , (TDD) Complaint forms are available at 華人保健計劃 (CCHP 遵守適用的聯邦民權法律規定, 不因種族 膚色 民族血統 年齡 殘障或性別而歧視任何人 華人保健計劃 (CCHP) 不因種族 膚色 民族血統 年齡 殘障或性別而排斥任何人或以不同的方式對待他們 華人保健計劃 (CCHP): 向殘障人士免費提供各種援助和服務, 以幫助他們與我們進行有效溝通, 如 : o 合格的手語翻譯員 o 以其他格式提供的書面資訊 ( 大號字體 音訊 無障礙電子格式 其他格式 ) 向母語非英語的人員免費提供各種語言服務, 如 : o 合格的翻譯員 o 以其他語言書寫的資訊如果您需要此類服務, 請聯絡華人保健計劃 (CCHP) 如果您認為華人保健計劃 (CCHP) 未能提供此類服務或者因種族 膚色 民族血統 年齡 殘障或性別而透過其他方式歧視您, 您可以親自提交投訴, 或者以郵寄 傳真或電郵的方式向我們提交投訴 :

10 CCHP Member Services 445 Grant Ave, Suite 700, San Francisco, CA , 聽力殘障人仕電話 傳真 您還可以向 U.S. Department of Health and Human Services( 美國衛生及公共服務部 ) 的 Office for Civil Rights( 民權辦公室 ) 提交民權投訴, 透過 Office for Civil Rights Complaint Portal 以電子方式投訴 : 或者透過郵寄或電話的方式投訴 : U.S. Department of Health and Human Services 200 Independence Avenue, SW Room 509F, HHH Building Washington, D.C , (TDD)( 聾人用電信設備 ) 登入 可獲得投訴表格 Chinese Community Health Plan (CCHP) cumple con las leyes federales de derechos civiles aplicables y no discrimina por motivos de raza, color, nacionalidad, edad, discapacidad o sexo. Chinese Community Health Plan no excluye a las personas ni las trata de forma diferente debido a su origen étnico, color, nacionalidad, edad, discapacidad o sexo. Chinese Community Health Plan: Proporciona asistencia y servicios gratuitos a las personas con discapacidades para que se comuniquen de manera eficaz con nosotros, como los siguientes: o Intérpretes de lenguaje de señas capacitados. o Información escrita en otros formatos (letra grande, audio, formatos electrónicos accesibles, otros formatos). Proporciona servicios lingüísticos gratuitos a personas cuya lengua materna no es el inglés, como los siguientes: o Intérpretes capacitados. o Información escrita en otros idiomas. Si necesita recibir estos servicios, comuníquese con CCHP Member Services. Si considera que CCHP no le proporcionó estos servicios o lo discriminó de otra manera por motivos de origen étnico, color, nacionalidad, edad, discapacidad o sexo, puede presentar un reclamo a la siguiente persona: CCHP Member Services 445 Grant Ave, Suite 700, San Francisco, CA , TTY Fax También puede presentar un reclamo de derechos civiles ante la Office for Civil Rights (Oficina de Derechos Civiles) del Department of Health and Human Services (Departamento de Salud y Servicios Humanos) de EE. UU. de manera electrónica a través de Office for Civil Rights Complaint Portal, disponible en o bien, por correo postal a la siguiente dirección o por teléfono a los números que figuran a continuación: U.S. Department of Health and Human Services 200 Independence Avenue, SW Room 509F, HHH Building Washington, D.C , (TDD) Puede obtener los formularios de reclamo en el sitio web

11 English: ATTENTION: If you speak another language, language assistance services, free of charge, are available to you. Call (TTY: ). Spanish: ATENCIÓN: si habla español, tiene a su disposición servicios gratuitos de asistencia lingüística. Llame al (TTY: ). Chinese: 注意 : 如果您使用繁體中文, 您可以免費獲得語言援助服務 請致電 (TTY: ) Tagalog: PAUNAWA: Kung nagsasalita ka ng Tagalog, maaari kang gumamit ng mga serbisyo ng tulong sa wika nang walang bayad. Tumawag sa (TTY: ). Vietnamese: CHÚ Ý: Nếu bạn nói Tiếng Việt, có các dịch vụ hỗ trợ ngôn ngữ miễn phí dành cho bạn. Gọi số (TTY: ). Korean: 주의 : 한국어를사용하시는경우, 언어지원서비스를무료로이용하실수있습니다 (TTY: ) 번으로전화해주십시오. Russian: ВНИМАНИЕ: Если вы говорите на русском языке, то вам доступны бесплатные услуги перевода. Звоните (телетайп: ) Arabic: ملحوظة: إذا كنت تتحدث اذكر اللغة فا ن خدمات المساعدة اللغویة تتوافر لك بالمجان. اتصل برقم (رقم ھاتف الصم والبكم: ). Hindi: ध य न द: यद आप हद ब लत ह त आपक लए म फ त म भ ष सह यत स व ए उपलब ध ह (TTY: ) पर क ल कर Japanese: 注意事項 : 日本語を話される場合 無料の言語支援をご利用いただけます (TTY: ) まで お電話にてご連絡ください Armenian: ՈՒՇԱԴՐՈՒԹՅՈՒՆ Եթե խոսում եք հայերեն, ապա ձեզ անվճար կարող են տրամադրվել լեզվական աջակցության ծառայություններ: Զանգահարեք (TTY (հեռատիպ) ): Punjabi: ਧਆਨ ਦਓ: ਜ ਤ ਸ ਪ ਜ ਬ ਬ ਲਦ ਹ, ਤ ਭ ਸ਼ ਵ ਚ ਸਹ ਇਤ ਸ ਵ ਤ ਹ ਡ ਲਈ ਮ ਫਤ ਉਪਲਬਧ ਹ (TTY: ) 'ਤ ਕ ਲ ਕਰ Cambodian: របយ ត ប ស ន អ កន យ ខ រ, ស ជ ន យ ផ ក យម នគ តឈ ល គ ច នស ប ប រ អ ក ច រ ទ រស ព (TTY: ) Hmong: LUS CEEV: Yog tias koj hais lus Hmoob, cov kev pab txog lus, muaj kev pab dawb rau koj. rau (TTY: ). Thai: เร ยน: ถ าค ณพ ดภาษาไทยค ณสามารถใช บร การช วยเหล อทางภาษาได ฟร โทร (TTY: ). Persian (Farsi): Multi-language Interpreter Services توجھ: اگر بھ زبان فارسی گفتگو می کنید تسھیلات زبانی بصورت رایگان برای شما فراھم می باشد. با -1 (TTY: ( تماس بگیرید. Hu