COOPERATIVE AGREEMENTFORDENTAL SERVICES

(CommunityDentalProvider)

Thisagreementdatedbyandbetween

(NameofHeadStart/EarlyHeadStartProgram)(AddressofHeadStart/EarlyHeadStartProgram)

(NameofCommunityDentalProvider)(AddressofCommunityDentalProvider)

HereinaftercalledHeadStart/EarlyHeadStartandDentalProvider,agreetothefollowing:

I.DentalProviderResponsibilities:

Thedentalprovider willconduct anoralexaminationof Head Start/EarlyHead Startchildrenwhoare HFS/AllKidsDentalProgram(Medicaideligibleandnon-Medicaid.)Theseexaminationsand servicesaretobeprovidedinthedental officeor clinic,unlesspriorapprovalhasbeenobtainedtoprovidetheseservicesinothersettings.

a.DENTALEXAMINATIONS

Conduct adentalexaminationof each child.Thedental health statusof each child istobe recorded on theState ofIllinois’Proofof School DentalExamination Form.Theexamination willinclude, butnotbelimited to,the following:

  • Aninitialdentalexamination orperiodicdental examination ofthe child,checkingforobviouscavities,bleedingaroundthegumsanddrainage.Theexaminationmustbe conductedusing amountmirror,explorer, andlight (head or flash).
  • Physicalassessmentoforaltissues,includingmucousmembranes-gingivae,periodontaltissues,tongue,palate,andteeth.
  • Assessmentanddocumentationofharmfuloralhabits,whichmayhinderthechild’s development.
  • Physicalassessmentoftheface,lips,andoralcavity.
  • Observationofthethroat.
  • Diagnosticradiographs,wheneverindicated.

b.PREVENTIVESERVICESFORCHILDREN

  • Provideservicesrequired fortherelief ofinfectionandpain.
  • Providedentalprophylaxis.
  • Provideinstruction inself-careoralhygieneprocedures.
  • Provide topical application offluorideutilizingacidfluoridephosphate (AFP).
  • Providedentalsealantstofirstpermanentmolars.

c.DENTALHISTORY

Reviewthedentalandmedicalhistoryfor eachchild.Wherethereisnodentalhistory,theprovider willcompletetheIllinoisProof ofSchool DentalExamination Form.

d.CHILDRENWITHDISABILITIES

Identifythespecialdentalneedsof childrenwith disabilitiesandrecommendhowtheycanbeaddressed,suchas,arrangementorcontinuationofspecial/dental care,useofspecialequipment,specialtrainingforparentsandstafforreferralforadditionalservicesasindicated.

e.REPORTINGOFSUSPECTEDCHILDABUSE/NEGLECT

Whereindicatorsofpossiblechild abuseorneglectare observed,theproviderismandatedtoreportthesuspectedabuse/neglecttotheDCFSHotlineat1-800-252-2873immediately.

f.DENTALTREATMENT

Atthetimeoftheexamination,developawritten planoftreatmentandfollowup,fordentaldefectsdiagnosedproblems,discoveredduringthedentalexaminationand/ordiagnosticradiographs,includingchartingofalldecayand/orrestorationsobserved.

Thepurposeoftheplanistoensurethatappropriatestepsare taken to resolve alldentalproblemsand concerns.Theplanistobedeveloped usingtheIllinois Proof ofSchoolDental ExaminationForm.Thedentalproviderisresponsibleforthetreatmentplan.Itisunderstoodthat:

i)TheDentalProviderwillactivelyencourageparentstoobservetheservicescheduleoutlinedinthetreatmentplan.

ii)TheDentalProviderwillkeeptheparentsinformedregardingtheprogressandtreatmentoftheirchild.

iii)TheDentalProviderwillinvolveparentsintheoverallhealth careoftheirchild.Ongoinginformationsharinganddialogue concerningtheproblemorcondition,treatmentandpreventioneffortsarehighlyrecommended.

iv)TheDentalProviderwillinformHeadStart/EarlyHeadStartstaff,wherechildrenareenrolled,regardingserviceandtreatmentplanandscheduling.Ifchildrenandtheirparentsdonotkeepscheduled appointments,theproviderwillnotifytheHeadStart/EarlyHead Start staff,aswellasassistin reschedulingmissedappointments.

v)TheDentalProvider willreportonaregularbasistothe HeadStart/EarlyHead Startstaffontheprogressof children intreatment.Theprovider willalsonotifytheHeadStart/EarlyHeadStartstaffwhenchildrencompletedentaltreatmentbyprovidinga

writtenrecordofservicesrendered.

vi)TheDentalProvideragreestorefer childrenwhoare difficulttotreatduetoextensivedentalproblemsthatmayexceedthegeneraldentist’sknowledgeandskillstoanotherdentistthatspecializesintreatingchildren.

vii)TheDentalProvideragreestoinform HeadStart/EarlyHead Startstaffofallreferrals.

g.DENTALCONSULTATIONWITHPARENTS

TheDentalproviderwillconductindividualconsultationswithparentsupon completionoftheexaminationandrelated servicesforthechildandwheneverneededduringthecourseoftheprogram.

h.DENTALHEALTHEDUCATIONFORPARENTSANDSTAFF

Uponrequest,nomorethantwo (2)dentalhealtheducation workshopsforgroupsofparentsandstaffwillbeprovided.Theseworkshopsshouldservetoprovidegeneraldental informationobtainedas a resultofthechild’s dental examination, and/orgeneraldentalproblemsseeninthispopulation.Workshoptopicsmayinclude butnotbelimited to:oralhealthstatusandself-esteem,relationshipbetween nutritionanddentalhealth,babybottletoothdecay,howtohandledentalemergenciesanddentalsealantprograms.

The sessionwillbescheduled upontheinitiativeofthe Head Start/EarlyHead Startcenter.The sessionwilllastapproximatelyonehalf hour, withafifteen-minutequestionand answer period.Thedentalprovider willsubmit tothecenterthefollowingdocumentationforeachworkshop:copyoftheagenda,abriefreportontheworkshop/discussionandacopyof theattendance sheet. Thefeeforthe session is

$45.00.When indicated,abilingualSpanish/Englishhealthprofessional willconductthe workshop.Workshopsarenottobe translatedwhile ageneralsession inEnglishisgoingon.

i.PAYMENTSCHEDULE

HeadStart/EarlyHeadStart willreimbursethedentalproviderattheratesestablishedbyIllinois’Departmentof Healthcare and FamilyServicesand administeredby the assigned Managed Care Organization, Dentaquest or the like entity. The fees as follows:

i)CaseManagementFee: $8.00

The case managementfeeisaone-timechargepayableuponthefirst visit andtheprovision ofrequired servicestothe child.Thecase managementfeecoversthosecostsassociated withimplementingtheprogram,which arenotincluded inthefeeforspecificservice, suchasdefined inoverallresponsibilities.

Procedure / Code # / Fee
i. / ComprehensiveOralExamination / D0150 / $21.05
ii. / PeriodicOral Evaluation / D0120 / $28.00
iii. / Prophylaxis-Office / D1120 / $41.00
iv. / Fluoride / D1203orD1206 / $26.00
v. / Sealant (per tooth) / D1351 / $36.00

i)Additionalservicesrenderedto childrenwillbereimbursedasdetailedontheHFS Dental ProgramFeeSchedule.Thefeescheduleisattached.Treatmentcostsexceeding$300.00forasinglechildwillbepriorapprovedbythedesignatedHeadStart /EarlyHeadStartstaffpersonatthecenter.

ii)Thedentalprovideragreestoprepareand submit claimstoDentaQuest or assignedManaged Care OrganizationforallMedicaidenrolledchildren.TheDentalProviderfurtheragreesthatHeadStart/EarlyHeadStart willonlybebilledforservicesrenderedtothenon-Medicaidenrolledchild.

iii)Thedentalprovider willsubmit billstotheHeadStart/EarlyHead Start programbythe10thof eachmonthfor servicesrenderedduringtheprecedingmonth.Thebillwillincludethefollowinginformation:

  • Dateofexaminationorservicesrendered
  • Listofservicesprovidedbychild withcorrespondingADA CDT code(s)
  • Child’slegalname and address

iv)TheHeadStart/EarlyHeadStartfiscalyearisDecember1-November30,thereforeallbillsmustbesubmittedtothe Head Start/EarlyHead Start centernolaterthanDecember10,ofthecurrentfiscalyeartobeconsideredforpayment.Initialrequestsforpaymentreceivedafterthisdatewillbereturnedtotheproviderunpaid.

II. Dental Records and Compliance

i) Dental Provider agrees to utilize the Case Management Form to contact parents or guardians of the HS/EHS child exhausting and documenting three attempts to schedule an examination and follow up dental treatment appointments. Once the Case Management Form is completed, it will be delivered to the HS/EHS site within two weeks of referral.

II) The Dental Follow-up Treatment Form will be filled out by the dental provider and returned to the HS/EHS site. (Following the child’s follow up visit for dental treatment at the contracted dental provider’s office.)

Monthlyclaimsforpaymentwillbemailedordeliveredto:

NameofHeadStart/EarlyHeadStart Center:

Address:ZipCode:

NameandTitleofPersonbillsaretobedirected to:

TheHeadStart/EarlyHeadStartprogramwillsendreimbursementfordentalservicesto:

NameofCommunityDentist:

NameofAgency:

Address:ZipCode:

Phone#:

II.HeadStart/EarlyHeadStartResponsibilities:

a.HeadStart/EarlyHeadStart willrefereligiblenon-MedicaidandMedicaidenrolledchildrentothedesignatedproviderpersonnelinordertoscheduleappointmentsfornecessarypreventiveservicesandexaminations.Parentswillalsobegiven thephonenumber,addressofdentalprovidertoscheduleappointments.

b.HeadStart/EarlyHead Start willprovidethedentalproviderwith the IllinoisProofofSchoolDentalExaminationFormuponrequest.

c.HeadStart/EarlyHeadStart willadvisethedentalproviderofchildren whoarebeingreferredtothedentalprovider,utilizingtheDFSS 3071,areferralform.TheHeadStart/EarlyHeadStartprogramwillprovidethedentalproviderwithinformationaboutchildrenenrolledintheMedicaidprogram.

d.HeadStart/EarlyHeadStartwillreviewallrequestsforreimbursementtoensuretheEarlyHead Start/HeadStart dollaristhedollaroflast resort.The Head Start/EarlyHead Startmoneyistobe used when no otherthirdpartyreimbursementisavailable tothefamily.

Thisagreementbeginson_andwillremainineffect,exceptforannual changesinthefeeschedule, revisionsinthe Head Start/EarlyHead Start performanceStandards,Cityand/orstatelicensingstandardsand/orDFSSrequirements.Eitherpartymayterminatethisagreementbygiving30days’notice.

HeadStart/EarlyHeadStartDirectorDentalProvider

Date:

Date:

Phone:

Phone:

ReviewedbyDFSS:

Date: