SNBC Dental Access Tool

Member Name: Click here to enter text. Member PMI #: Click here to enter text.

Dental Access Outreach: Description of Events

Date(s) of Outreach:	Click here to enter text. Click here to enter text. Click here to enter text.

Description of Events: (Check all that apply)

☐ No Annual Dental Visit Call (member has no previous ADV within the last 12 months)

☐ Annual Dental Visit Reminder Call (member due for ADV soon)

☐ ER (non-traumatic dental concern) Follow-up Call

☐ Unable to reach member through outreach calls - letter and educational materials mailed

Discussion Questions (check yes or no)

☐Y ☐N Does the member have a primary dental provider?

☐Y ☐N Does/did the member have a recent dental exam with his/her primary dental provider? within the last 6 months/next few months?

☐Y ☐N Does the member understand that he/she has access to dental benefits for a dental exam and cleaning every 6 months?

☐Y ☐N Did you offer to assist the member in securing an appointment with a dental provider?

☐Y ☐N Did the member accept your offer to assist in securing an appointment?

☐Y ☐N Did you discuss/offer assistance in arranging transportation (RideConnect)?

☐Y ☐N Did the member accept your offer for transportation assistance?

☐Y ☐N If member used the ER for a non-traumatic dental concern, did they follow-up with a dental provider within 30 days of the visit?

Resolution (check all that apply):

☐ Advised member on the importance of oral health and completing annual preventive care
dental visits.

☐ Educated member on when to see a dental provider for dental concerns and when to go to the hospital emergency room.

☐ Assisted member in scheduling a dental visit with a provider-DOS: Click here to enter text.

☐ Assisted member in arranging transportation to dental appointment.

☐ Member refused assistance with scheduling a dental appointment.
Reason: Click here to enter text.

☐ Member refused transportation assistance-Reason: Click here to enter text.

☐ Member refused phone call – Reason: Click here to enter text.

☐ Completed two attempts to reach member via telephone outreach calls - letter and educational materials mailed.

☐ Care Coordinator signature provides attestation that dental education and outreach support services were attempted and/or provided to the SNBC member.

Care Coordinator Signature: Click here to enter text.	Date: Click here to enter text.