Cda Peer Review Manual

Peer Review Manual
© 2016 by
The California Dental Association
All Rights Reserved
Printed in the United States of America
This document must be considered in its entirety and no summary or

abridgement of this report shall be permitted unless first reviewed and
approved by the California Dental Association.
California Dental Association

Post Box 13749
Sacramento, CA 95853-4749
Version: 14
Table of Contents
Page
I. General Information....................................................................................................................... 1-1

Ethical Basis of the Peer Review System............................................................................................... 1-1
CDA Code of Ethics............................................................................................................................ 1-1
Lines of Responsibility ......................................................................................................................... 1-2
Legal Protection of and Constraints Upon Peer Review Committees and
Peer Review Records..................................................................................................................... 1-5
Parameters of Peer Review ................................................................................................................... 1-6
Confidentiality..................................................................................................................................... 1-7
Definitions........................................................................................................................................... 1-8
II. Responsibilities of the Peer Review Staff .......................................................................................... 2-1

Receipt of Inquiry From Initiating Party .............................................................................................. 2-1
Receipt of Completed Forms ............................................................................................................... 2-2
Notification of Review to Involved Parties ........................................................................................... 2-6
Preparation and Contents of Case File ................................................................................................ 2-9
Appropriate for Review...................................................................................................................... 2-11
Non-Routine...................................................................................................................................... 2-13
III. Responsibilities of the Component and Specialty Peer Review Committee ......................................... 3-1
Clinical Examination ........................................................................................................................... 3-2
Dentist Interview ................................................................................................................................. 3-3
Peer Review Committee Meeting ......................................................................................................... 3-4
Use of the Clinical Examination Worksheet........................................................................................ 3-5
Purpose of the Resolution Addendum................................................................................................. 3-5
Preparation of Resolution Letter.......................................................................................................... 3-6
Counseling the Dentist........................................................................................................................ 3-8
IV. Appeals………………………………………………………………………………………………………………………………4-1
General Overview ................................................................................................................................ 4-1
Resolution Letter ................................................................................................................................. 4-1
Corrective Treatment Plan and Cost Estimate Approval Letter ........................................................... 4-3
V. Over-Utilization Review Procedures................................................................................................. 5-1

Receipt of Request for Over-Utilization Review from Carrier.............................................................. 5-1
CDA .................................................................................................................................................... 5-1
Appeals ................................................................................................................................................ 5-2
VI. Referrals to the Judicial Council ...................................................................................................... 6-1

Dentist Non-Compliance with the Final Decision ............................................................................... 6-1
Patterns of Practice .............................................................................................................................. 6-1
Grossly Inadequate/Inappropriate Treatment ..................................................................................... 6-1
False or Fraudulent Insurance/Health Care Benefit Claims/Alleged Fraud or
Billing Irregularities .......................................................................................................................... 6-2
Alleged Fraud or Billing Irregularities .................................................................................................. 6-3
Dentist Drops Membership During Review ......................................................................................... 6-4
VII. Forms/Form Letters ....................................................................................................................... 7-1
i
I. General Information
In keeping with its obligation of service to the public, the California Dental Association (CDA) has established a
statewide peer review system. The purpose of the peer review system is to resolve disputes that may arise in the delivery
of dental services to the public by CDA member dentists, including, in particular, disputes regarding the quality of
dental treatment, the appropriateness of dental treatment, utilization, and/or potential billing when the complaint
involves quality and/or appropriateness of dental treatment..
The CDA Peer Review Manual has been developed by CDA for its 32 component dental societies and the recognized
specialty organizations, and all parties involved in the CDA peer review process, to describe the procedures and
policies for the management of disputes between dentists, patients, and carriers. These procedures are designed to be
consistent to assure that all parties concerned with a review are treated fairly.
The geographical jurisdiction of the CDA review system is the State of California and all its component dental
societies. All peer review cases referred for consideration by a peer review committee shall be adjudicated within the
jurisdiction of the component society where the treatment was rendered unless the dentist or patient has a valid
conflict of interest. The review of a dentist or patient with a valid conflict of interest is conducted in the closest
neighboring component which can handle the review if one or both parties has requested an interview with the
committee. When a case can be evaluated on the basis of records alone, and the patient and the dentist both indicate
that they do not wish to be interviewed by the committee, the CDA Council on Peer Review chair may select the
component to which the case will be transferred without regard to geographic location. When a case requiring transfer
originates in a component that uses separate geographic panels, the component may retain the case and transfer the
case to another geographic panel. In the case of a specialist, matters will be adjudicated by the appropriate specialty
organization within the jurisdiction of the component in which the treatment was rendered, unless they are unable to
function within the guidelines for appointing a specialty peer review committee. If they are unable to do so, the
component peer review committee, utilizing a consultant, will conduct the review within the jurisdiction of the
component in which the treatment was rendered.
Ethical Basis of the Peer Review System

In 1976, the CDA peer review system was established with the passage by the CDA House of Delegates of
HR15-1976-H. This resolution mandated the formation of a uniform statewide CDA system for resolving disputes
regarding dental care.
Membership in CDA requires agreement by the dentist to abide by the association’s Code of Ethics. This agreement to
abide is the basis for each CDA member's cooperation with the peer review process. The Code of Ethics requires that
each member provide appropriate and timely service within the bounds of the clinical circumstances presented by the
patient. The peer review system functions to assist member-dentists and the public at large in the resolution of
problems and disputes which may arise from the provision of such services. The Code of Ethics requires a member to
“comply with the reasonable requests of a duly constituted committee, council or other body of the component society
or of this association . . . and to abide by the decisions of such body.”
CDA Code of Ethics

Section 1. Service to the Public
Service to the public is the primary obligation of the dentist as a professional person. Service to the public includes the
delivery of quality, competent and timely care within the bounds of the clinical circumstances presented by the
patient.
Section 1A. Professional Esteem

While serving the public, a dentist has the obligation to act in a manner that maintains or elevates the esteem of the
profession.
1-1 Rev: 11/18/13

CDA Peer Review Manual General Information
Section 1B. Accepting Patient Into the Dental Practice

In serving the public, a dentist may exercise reasonable discretion in accepting patients into the dental practice.
However, in keeping with the core value of justice, it is unethical for a dentist to refuse to accept a patient into the
practice, deny dental service to a patient, or otherwise discriminate against a patient because of the patient's gender,
sexual, racial, religious or ethnic characteristics.
Section 1C. Standards of Care

Wherever “standards of care” or “quality services” are undefined by law, such standards or services shall be defined by
the CDA or such agency as designated by the association. It is unethical for a dentist to render, or cause to be
rendered, substandard care.
Section 1D. Informed Consent

Fully informed consent is essential to the ethical practice of dentistry and reflects the patient’s right of self-decision.
Except as exempted by state law, a dentist has the obligation to obtain the fully informed consent of the patient or the
patient’s legal guardian prior to treatment, or the use of any identifiable artifacts (such as photographs, radiographs,
study models, etc.) for any purpose other than treatment. Informed consent is also required when using a human
subject for research.
Section 3. Cooperation With Duly Constituted Committees

A dentist has the obligation to comply with the reasonable requests of a duly constituted committee, council or other
body of the component society or of this association necessary or convenient to enable such a body to perform its
functions and to abide by the decisions of such body.
As a CDA member-dentist involved in the peer review process, membership in CDA requires compliance with
provisions of the association’s Code of Ethics. In becoming a member, the dentist agrees to abide by the Code of
Ethics and in doing so gives assurance that he or she will cooperate with and abide by the procedures and findings of a
peer review committee.
Since a dentist is required to comply with the committee decisions, patients are also asked to comply with all decisions
rendered by a peer review committee. Consequently, prior to any review, written assurance that the patient will comply
with peer review decisions is also obtained. Additionally, the patient must sign a Release of All Claims form prior to
receipt of any money that might be awarded.
Section 6A. False and Misleading Advertising and Solicitations

It is unethical for a dentist to mislead a patient or misrepresent in any material respect either directly or indirectly the
dentist’s identity, training, competence, services, or fees.
Section 7. Billing Practices

A dentist has the obligation to submit any billing for services rendered or to be rendered in a manner which is not
fraudulent, deceitful, or misleading.
Lines of Responsibility
As a statewide system, certain reporting chains and lines of responsibility have been established to provide for
continuity and uniformity in the system.
Board of Trustees
The CDA Board of Trustees is the managing body of CDA. According to the CDA Bylaws, it has the power:
"To establish interim policies when the house is not in session and when such policies are essential
to the management of the association; provided, however, that all such policies must be presented
for approval at the next session of the house." [CDA Bylaws, Chapter V, Section 60.C.]
1-2 Rev: 11/18/13

In this context, policy changes for the peer review system are submitted to the Board of Trustees by the Council on
Peer Review prior to implementation. Recommendations approved by the Board of Trustees are then submitted to the
CDA House of Delegates.
Council on Peer Review

The Council on Peer Review is charged with the responsibility of monitoring and guiding the peer review system.
The peer review system was organized by the CDA Council on Dental Care in the early 1970s. In 1976, the House of
Delegates adopted a resolution establishing the Council on Dental Care as the entity responsible for the development
and implementation of the statewide CDA peer review system. In 1994, CDA House of Delegates approved a
resolution which established the Council on Peer Review and officially separated the functions of peer review from the
Council on Dental Care.
The CDA Policy Manual outlines the objectives, functions and membership of entities of the CDA and describes the
objectives of the Council on Peer Review as “to ensure that the public and profession have access to an objective,
professional review of disputes concerning quality and/or appropriateness of dental care, via the statewide peer review
system.”
The Council on Peer Review performs all professional and administrative functions necessary to ensure that the peer
review system is implemented uniformly throughout the state. The functions of the council regarding peer review are
to:
1. Oversee the peer review system to ensure that component/specialty committees, component staff and CDA
staff consistently follow the policies and procedures outlined in the CDA Peer Review Manual.
2. Monitor the conduct of the component/specialty peer review committees to assure that reviews are
conducted without procedural defects and that sufficient investigation has been made in order that
component peer review committees may avail themselves of the qualified immunity set forth in Section 43.7
of the California Civil Code.
If circumstances exist wherein a component general peer review committee or specialty peer review
committee refuses to follow CDA peer review guidelines, or submits a resolution that is not supported by the
resolution addendum or other evidence, the Council on Peer Review is empowered to remand the resolution
letter back to the component or specialty committee for correction and subsequent approval and finalization
by CDA.
If a component general peer review committee or specialty peer review committee fails or refuses to make the
appropriate and necessary corrections after remand, following a seven (7) out of nine (9) council members
vote, the Council on Peer Review is authorized to correct the discrepancies in the resolution letter and
resolution addendum. The corrected resolution letter will be mailed on CDA letterhead. As a follow up, a
member of the Council on Peer Review will hold a meeting or telephone conference with case captain of that
component/specialty peer review committee to discuss the reasons for the Council on Peer Review’s decision.
If members of the component general peer review committee or specialty committee cannot or will not
perform their duties according to CDA procedures, CDA Council on Peer Review may request that they be
replaced. In the event a component or specialty organization has no review committee operating under the
established peer review guidelines, the CDA Council on Peer Review may request a neighboring component
general peer review committee or specialty peer review committee to act in this capacity.
3. Serve as the official appeal committee for the association in matters of peer review. Manage and oversee the
appeals process to ensure that all appeals of peer review resolutions are objective and fair to all parties
involved.
4. Develop and codify statistical data relative to the peer review system.
1-3 Rev: 11/18/13

5. Provide reports and case listings to components and specialty chairs to ensure that cases are processed in a
timely manner.
6. Conduct peer review conference(s) for general membership to promote a better understanding of the CDA
peer review process.
7. Provide policy, procedural and clinical evaluation guidance and training to component and specialty peer
review committee members and staff to ensure uniformity, consistency, timeliness and effectiveness. Provide
training materials for orientation of new committee members.
8. Review and approve procedural changes in the peer review system prior to implementation. Changes in the
review system will be distributed to the component/specialty peer review committees by memorandum, with
correction pages for the manual, as necessary.
9. Review, finalize, and distribute final resolution letters for all peer review cases.
10. Facilitate and maintain communication between component and specialty peer review committees.
11. Review and update the CDA Peer Review Manual and the Guidelines for the Assessment of Clinical Quality
and Professional Performance (Quality Evaluation Manual) as needed.
CDA Central Office

The CDA central office peer review staff assists the Council on Peer Review in monitoring and guiding the
component and specialty peer review committees in carrying out the peer review system uniformly throughout the
state. The CDA central office peer review staff is also responsible for the following aspects of the peer review system:
1. Performing all administrative duties required in processing a peer review case.

2. Maintaining peer review cases for a 36-month period unless a subsequent case is initiated on the same dentist
within the next 24-month period. Should a new case arise within the 24-month period, all cases initiated on
the same dentist are maintained for another 36-month period.
3. Screening all peer review cases to ensure compliance with established peer review procedures and standards.
4. Distributing all resolution letters to parties involved in the dispute.
5. Developing statistical data on the overall peer review system and serves as an information clearinghouse for
components.
Component Dental Societies and Specialty Organizations

The component dental societies and specialty organizations are encouraged to contact the Council on Peer Review
with recommendations for changes in the peer review system. Suggestions submitted by components and specialty
organizations will be considered by the Council on Peer Review; change or modification in the system will be
implemented in accordance with the above guidelines if a change is deemed appropriate.
Structure of the Component and Specialty Peer Review Committee

The peer review committee is appointed by the component dental society and/or specialty organization, and is under
the jurisdiction of the CDA Council on Peer Review of the California Dental Association.
The purpose of the component general peer review committee and specialty peer review committee is to review matters
related to the quality of treatment, appropriateness of care, utilization, and billing disputes in conjunction with quality
of dental treatment rendered by a member dentist to a patient. The peer review committee can act at the request of a
patient, a dentist, or a carrier. It is the obligation of the peer review committee to conduct unbiased and objective
investigations.
The committee shall determine the professional acceptability of completed treatment(s), including appropriateness
and consistency with diagnosis, and treatment plan.
The committee shall evaluate the skill with which treatment is provided in light of the standards which generally
prevail within the profession by those who routinely perform the treatment in question.
A component or specialty organization must choose one committee, which consists of an uneven number of dentists
(minimum of three) to conduct the entire review, i.e., review case material, conduct a clinical exam (if appropriate),
1-4 Rev: 11/18/13

interview the dentist (if appropriate), deliberate their findings and ultimately draft the resolution letter and
addendum.
Appointing the Component and Specialty Peer Review Committee

The following conditions are essential and should be met when appointing a component general and specialty peer
review committee.
1. All committee members, both general and specialty committees must be CDA members, attend CDA
training workshops as required by the council, and are actively practicing dentistry.
2. The number of members serving on review committees should reflect the caseload and geographical
considerations faced by the committee. The committee or subcommittee must consist of an uneven number
of dentists (minimum of three).
3. Members of the committee should serve staggered terms of three to five years to insure continuity of
experience. Members of the committee that continue actively practicing dentistry may be reappointed.
4. Members of the committee shall be selected for their ability to maintain objectivity, discretion, and
understanding, and should be comprised of practitioners held in high esteem by their peers.
5. General Committees: Members of the general committees shall be general practitioners. If reviewing services
provided by a dentist in an ADA recognized specialty area, the general committee (minimum of three) must
use a specialty dentist consultant (minimum of one) who limits his or her practice to the same ADA
recognized specialty area as the dentist under review. If reviewing services provided by a dentist in an area of
dentistry not recognized as an ADA specialty, the general committee must use a minimum of one consultant
who is a general dentist with knowledge of the procedures under review and/or a dentist who limits his or
her practice to an ADA recognized specialty which requires knowledge of the procedures under review.
When using a consultant, the committee must still consist of an uneven number of dentists: either three
general practitioners and two consultants, or four general practitioners and one consultant. The committee
cannot consist of two general practitioners and one consultant.
6. Specialty Committees: The members of specialty committees must be dentists practicing in the same ADA
recognized specialty area as the dentist under review, and the committee must consist of an uneven number
of dentists (minimum of three).
7. Each general and specialty peer review committee member must have practiced for a minimum of five years.
(Specialists must have practiced in their specialty areas for a minimum of five years.) Since experience is
essential for review committees, if one member has only five years experience in practice, another member
should have experience exceeding five years.
8. The peer review committee should reflect the quality of dentistry provided in the component area as set forth
by the CDA Quality Evaluation Manual.
9. As volunteers, members of component and specialty review committees shall not be paid for their services.
Any dentist volunteering to conduct an examination on behalf of a review committee, because of a particular
treatment modality, shall not receive a fee.
10. It is recommended that a committee chair serve a minimum three-year term as a committee member and a
minimum three-year term as a chair for continuity.
11. All general and specialty peer review committee members, as well as CDA peer review staff, are expected to
fulfill the Council on Peer Review training requirements in order to participate in the peer review system.
12. Component and specialty chairs and committee members are required to participate in an initial and
biennial peer review training conducted by the Council on Peer Review.
Legal Protection of and Constraints upon Peer Review Committees and

Peer Review Records
A component dental society peer review committee or specialty committee may not implement changes in the peer
review system prior to approval from the Council on Peer Review and/or CDA Board of Trustees. To do so may
jeopardize the legal position of the peer review committee and its members.
1-5 Rev: 11/18/13

Section 43.7(b) of the California Civil Code provides, in pertinent part, that “[t]here shall be no monetary liability on
the part of, and no cause of action for damages shall arise against . . . any member of any peer review committee whose
purpose is to review the quality of . . . dental . . . services rendered by . . . dentists, . . . which committee is composed
chiefly of . . . dentists, . . . for any act or proceeding undertaken or performed in reviewing the quality of . . . dental
services. . . rendered by . . . dentists . . . if the . . . member acts without malice, has made a reasonable effort to obtain
the facts of the matter as to which he, she, or it acts, and acts in the reasonable belief that the action taken by him,
her, or it is warranted by the facts known to him, her, or it after the reasonable effort to obtain facts.”
Section 43.8(a) of the California Civil Code provides, in pertinent part, that “ . . . there shall be no monetary liability
on the part of, and no cause of action for damages shall arise against, any person on account of the communication of
information in the possession of that person to any . . . professional society . . . professional licensing board . . . peer
review committee . . . when the communication is intended to aid in the evaluation of the qualifications . . . of a
practitioner of the healing . . . arts.”
These sections are clear in their intent to protect those involved in peer review, but they do require, in essence, that
the information communicated must represent the fruit of reasonable efforts to uncover the facts and that the
conclusions drawn there from not be arbitrary or unsupported by facts. Hence, the final written resolutions to disputes
should demonstrate the procedural steps taken to reasonably discover all pertinent facts.
Section 1157 of the California Evidence Code provides, in pertinent part, that “[n]either the proceedings nor the
records of . . . a peer review body, as defined in Section 805 of the Business and Professions Code, . . . having the
responsibility of evaluation and improvement of the quality of care, shall be subject to discovery.” Moreover, except as
otherwise provided in this section, “no person in attendance at a meeting of any of those committees shall be required
to testify as to what transpired at that meeting.” This section of the Evidence Code protects peer review records from
discovery in a civil action but does not preclude committee members from testifying voluntarily about proceedings of
the committee. Therefore, CDA has taken steps to close this loophole by requiring peer review committee members
and staff to hold such information in confidence. Thus, it is CDA policy that neither records nor testimony may be
provided in a civil action, unless ordered by a court after a hearing has been held concerning the protection afforded
by this section.
These ethical principles and legal implications and constraints have been embodied in the CDA Peer Review Manual
as the operational guidelines, procedures, and policies and as such have been approved by the CDA Board of Trustees.
Parameters of Peer Review

The peer review system is considered by the CDA to be an equitable alternative to legal proceedings. Cases are
reviewed at no cost to the patient or member dentist except for any unusual costs sustained by the peer review
committee, for example, those for duplicating radiographs or study models shall be borne by the party referring the
case to review. A fee of $500.00 is charged for each carrier-initiated review.
Who Can Initiate Cases

Peer review cases are generally initiated by one of the following parties:
1. Patient
2. Dentist (utilization case to obtain patient benefits)
A dentist cannot initiate a peer review concerning the quality of his/her own treatment except to appeal a
carrier decision or obtain benefits for a patient (utilization review). A dentist cannot initiate a case against
another dentist.
3. Carriers (insurance companies, service corporations, or administrative agencies)
1-6 Rev: 11/18/13

Types of Cases Accepted for Review

1. Quality of Dental Treatment
2. Appropriateness of Dental Treatment
3. Utilization
4. Billing disputes when the complaint involves quality and/or appropriateness of dental treatment
Cases that are accepted for peer review must fall within at least one of the following areas:
Quality
Cases submitted for a review of the quality of care will be concerned with the functional and/or aesthetic character of
dental treatment. The Quality Evaluation Manual has been developed by CDA as an aid for the peer review committee
in evaluating the technical quality of dental procedures performed.
Appropriateness
Cases submitted for an appropriateness review will be concerned with whether the treatment is (or was) suitable for
the patient, the condition or occasion, i.e. whether the treatment is (or was) proper or fitting. Reviews for
appropriateness are by necessity subjective evaluations to determine whether treatment is (or was) necessary.
Treatment is defined as including examination, diagnosis, and treatment planning in addition to clinical services.
However, it is not within the purview of peer review to provide second opinions with regard to a diagnosis and
recommended treatment plan.
Utilization
Cases submitted for utilization review will be concerned with whether treatment can be (could have been) alternatively
performed with acceptable results, and/or whether the type of treatment is "customary" for the geographic area.
Utilization cases also include those submitted for a review to determine whether a carrier has properly interpreted its
contract, and has failed to provide proper benefits. Quality review on a utilization case will only be performed at the
discretion of the committee chair.
Utilization cases can be submitted by a member dentist, carrier or patient.
A peer review committee can also be asked to determine whether or not a given service involves special consideration
because of its extraordinary difficulty. The committee may be asked to affirm the unusual and special nature and
circumstances of the treatment in question.
In that peer review can sometimes be over-utilized (over three cases in any rolling twelve month period), component
peer review committees may charge a reasonable fee to the initiator (dentist or patient) to cover the dental society's
handling and administrative expenses for each additional peer review case. Any over-utilization fees and policies
MUST be established in advance by the component board of directors and must be uniformly applied by the
component.
Confidentiality
Any communication or information relating to peer review committee investigations or proceedings and the records of
the peer review committee related thereto, shall be held in confidence by committee members and component or
CDA staff. If ordered to appear at a deposition, the individual shall refuse to divulge confidential information. If
compelled to testify at a trial, arbitration or other proceeding, the individual shall assert Evidence Code Section 1157
as authority for the right to maintain the confidentiality of such information and then abide by the ruling of the
tribunal.
1-7 Rev: 11/18/13

Definitions
Since a dentist is responsible for all examination, diagnoses, and treatment provided in the dental office, any questions
regarding these types of dental services are considered appropriate for a review by a dentist’s peers. The following are
definitions of terms to be used throughout this manual. When a term is henceforth cited, the meaning is that which is
provided herein.
Applicant: A dentist who has made application for membership in a local dental society and the CDA, but has not
yet been elected to membership. If there are any questions regarding peer review benefits, contact a representative in
the CDA Membership Records Department for the status.
Billing Disputes: Billing disputes when the complaint involves quality and/or appropriateness of dental treatment.
Billing Irregularities: Billing practices in violation of state law and applicable ethical codes. Billing Irregularities
exclude quality review. See Chapter VI. Referrals to the Judicial Council.
Carrier: An insurer, employer health care service plan, employee benefit plan or other entity responsible for paying
for or reimbursing for any part of the cost for health care services rendered to the patient.
Dentist Practicing in a Mobile Clinic: Peer review cases involving dentists practicing full-time in mobile
clinics should be processed by the component where the treatment was rendered.
Grossly Inadequate Treatment: Dentistry provided for a patient which does not correct the pathological
condition it was intended to correct, or fails prematurely under normal conditions of use, or fails to meet acceptable
esthetic standards, or facilitates and/or contributes to the worsening of the patient’s dental health, and/or leaves a
disease entirely untreated or undiagnosed. However, for the purpose of referral to the CDA Judicial Council, the
above definition should not be so narrowly enforced as to base a referral on only one tooth but rather on the overall
evaluation of the work performed or unperformed by the treating dentist.
Grossly Inappropriate Treatment: Dentistry performed that is unnecessary and/or unwarranted. The quality
of the treatment need not be in question. This type of treatment can include, but is not limited to: dentistry
performed solely for profit, dentistry performed for which the treating dentist is inadequately trained, dentistry
performed that leads to a pathological condition that did not exist prior to treatment, and dentistry performed when a
prognosis is so poor that immediate failure is readily apparent or treatment which endangers the patient’s general
health.
Indefinite Practice Address: Dentists who currently do not have a definite practice address but are in the
process of seeking a permanent practice location, i.e. recent graduates, dentists who are unemployed. Peer review is
conducted by the component where the treatment was rendered.
Itinerant Dentists: Dentists that do not have a permanent practice address, i.e. traveling specialists, or working as
a “temp.” Peer review is conducted by the component where the treatment was rendered.
Independent Contractor: An independent contractor, unlike an employee, is an independent businessperson

engaged to provide services, and he or she is not subject to the control or direction of another as to the means and
methods of accomplishing a particular work objective.
Over-Utilization Review: A review requested by a carrier to show a pattern of over-utilization by a dentist.
1-8 Rev: 11/18/13

Peer: An individual who is licensed to practice dentistry in the State of California.
 A dentist who graduated from a Commission on Dental Accreditation (CODA) accredited specialty program
and is limiting his or her practice to that ADA recognized specialty area will be reviewed by a CDA-calibrated
specialty committee (minimum three), unless the specialty committee is unable to review the case, then the
case shall be reviewed by the general committee utilizing a minimum of one calibrated specialty consultant.
 A dentist who graduated from a CODA accredited specialty program but is not limiting his or her practice to
that ADA recognized specialty area will be reviewed by the general committee. However, if the treatment in
question involves specialty treatment in an area in which the dentist holds qualified specialty training, the
treatment will be reviewed by a CDA calibrated specialty peer review committee (minimum three), unless the
specialty committee is unable to review the case, then the case shall be reviewed by the general committee
utilizing a minimum of one calibrated specialty consultant.
Peer Review Committee: A body composed of licensed CDA member-dentists who practice dentistry in a
specific geographic (component) area and are duly appointed by their component dental society according to specific
Council on Peer Review guidelines. For specialists, a peer review committee is defined as a body composed of CDA
member-dentists who are duly-appointed according to specific Council on Peer Review guidelines.
Quality Evaluation Manual: Quality Evaluation Manual is also known as “Guidelines for the Assessment of
Clinical Quality and Professional Performance.”
Records: All pertinent data which will enable a complete review, such as study models, treatment records, financial
records, images, radiographs, and relevant insurance forms.
Treatment: Is defined as including examination, diagnosis and treatment planning in addition to clinical services.
Utilization: See Page 1-7.
1-9 Rev: 11/18/13

II. Responsibilities of the Peer Review Staff
The role of peer review staff is to oversee the opening of the case and to monitor the review to assure that it is
completed in a timely fashion. This section of the manual provides the appropriate steps to be taken in processing a
peer review case. Within the given parameters, a component and specialty organization must use one committee,
which consists of an uneven number of dentists (minimum of three) to conduct the entire review (review the case
material, conduct a clinical examination, complete the clinical worksheets, interview the dentist if appropriate,
deliberate their findings, and draft the Resolution Addendum (Form #63), and the Resolution Letter (Form #59).
It is essential to the peer review system that all aspects of a case be documented and the procedures followed in order
to best serve the patient, carrier, and dentist. The procedures must be consistent for all cases, thus assuring that all
parties concerned with a review are treated fairly.
Receipt of Inquiry from Initiating Party

No case will be accepted until all the proper forms have been completed by the party initiating the review and received
by the California Dental Association (CDA). All forms must be unaltered, legible, and capable of being reproduced
clearly.
Patient-Initiated Requests
All patient-initiated requests for peer review must be made on a “Request for Review Form”. Patients utilizing the
system must sign an “Authorization for Use and Disclosure of Health Information” and a “Patient Agreement Form”
before peer review may be initiated. Additionally, a patient must sign a Release of All Claims Form prior to any
distributions of refund. A sample of a Release of All Claims must be mailed to the patient with the initial forms.
Cases that do not include these completed forms are not acceptable for peer review and will not be processed. The
following steps must be taken when a patient initiates a request for review:
1. Telephone Requests
When any inquiry regarding peer review is received over the telephone, staff must explain the peer review
system, policies, procedures, and parameters. If requested, send the following forms to the patient, which
must be dated and mailed the same day the telephone inquiry was received:
a. Initial Patient Response Letter (Form #1)

b. Request for Review Form (Form #3)
c. Patient Agreement Form (Form #4)
d. Authorization for Use and Disclosure of Health Information (Form #5)
e. (Sample) Release of All Claims (Form #72)
f. Patient Request for Interview Form (Form #90). Note: If the patient resides in another state send
Patient Will/Will Not Attend Clinical Examination (Form #85)
2. Written Requests
Upon receipt of a written request for review, determine if all items listed in item number 1 are included. If
they are not, forward the appropriate forms to the patient.
If all forms are received but are incomplete in some manner, or not all forms are returned, or the forms have
been altered, or the forms are illegible, the case cannot be processed. The following steps must be taken:
a. Copies of the documents submitted by the patient must be returned to the patient with the Patient
Notification of Incomplete Forms (Form #6).
b. Recall the file in fourteen (14) calendar days. If no response is received, close the case file.
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CDA Peer Review Manual Responsibilities of the
Peer Review Staff
Dentist-Initiated Requests
Dentist-initiated requests for peer review will involve the benefits predetermined or paid by a carrier for dental services
rendered. Per this line of reasoning, a dentist may submit a request for review on behalf of a patient. A dentist cannot
initiate a review concerning the quality of his or her own treatment or that of another dentist. Those cases must
ultimately be patient initiated. There is one exception to this policy. A dentist may initiate a quality review if the
purpose of the review is to appeal a carrier decision against his or her treatment.
The following procedures must be undertaken when a dentist initiates a request for review:
1. Telephone Request
When a dentist contacts peer review staff for information about the peer review system, he or she must be
advised of the system's policies, procedures, and parameters. If the dentist wishes to pursue a peer review
request, send the following forms to the dentist:
Dentist’s Forms
a. Initial Response To Dentist Letter (Form #7)
b. Dentist Request for Review Information (Form #8)
c. Dentist Will/Will Not Attend Meeting Form (Form #16)
Upon receipt of the completed forms from the dentist, send the patient the following forms:
Patient’s Forms
a. Patient Notification Letter (Form #20) or Carrier Appeal by Dentist (Form #74)
b. Patient Agreement Form (Form #4)
c. Authorization for Use and Disclosure of Health Information (Form #5)
d. Patient Request for Interview Form (Form #90). Note: If the patient resides in another state send
Patient Will/Will Not Attend Clinical Examination (Form #85)
2. Written Request
Upon receipt of a written request for review, send all items listed in item number 1 above.
3. Receipt of Incomplete and/or Altered Forms

If all forms are received but are incomplete in some manner, or not all forms are returned, or the forms have
been altered, or the forms are illegible, the case cannot be processed. The following steps must be taken:
a. Copies of the documents submitted by the dentist must be returned to the dentist with the Dentist
Notification of Incomplete Forms (Form #9).
b. Incomplete forms from the patient must be returned to the patient for completion (Form #6).
c. Recall the file in 14 calendar days. If no response is received, close the case file.
Carrier-Initiated Over-Utilization Cases. Refer to Section V.
Receipt of Completed Forms

The Notification of New Case (Form #10) must be completed for each request for review whether or not the
request is deemed appropriate. Upon receipt of the completed Request for Review Form (Form #3), Patient
Agreement Form (Form #4), Authorization for Use and Disclosure of Health Information (Form #5), and the
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Patient Request for Interview Form (Form #90) the case information must be entered in the computer system. The
open date is the date that all the completed forms are received from the initiating party. A copy of the Notification of
New Case (Form #10) must also be sent to the component and/or specialty peer review committee chair notifying him
or her that a case is forthcoming.
Screening Procedures
The purpose of screening a peer review inquiry, including inquiries involving specialists, is to determine whether a
case is appropriate or inappropriate for the peer review system. Once all materials have been received from the
initiating party and the Notification of New Case (Form #10) has been forwarded to the component and/or specialty
chair, the request must be screened before initiating any action. The Peer Review Checklist (Form #12) must be
completed and attached to each case file.
It is also important to note that, even if the case meets all initial screening criteria, a case may become
inappropriate at a later time in the review process, due to the discovery of new information, etc.
If more than one “no” answer appears to the following questions, determine appropriate handling. If any “no” answer
renders the case inappropriate for review, follow the guidelines for that item before proceeding with the screening.
Questions to consider when opening a case.

1. Does this case fall within at least one of these types of complaints?
1. Quality of treatment
2. Utilization
3. Appropriateness of treatment
4. Billing disputes when the complaint involves quality and/or appropriateness of dental treatment.
YES. If the complaint fits at least one type or one area as defined in the manual, continue with the
screening.
NO. If the complaint does not fall within one of the case types defined in this manual, check no and
after completing the Peer Review Checklist (Form #12), these steps must be followed:
a. Determine what the request for review does involve.

b. Refer to the Peer Review Manual Index and/or Table of Contents to determine the
appropriate section and page for handling the complaint in question.
c. If the complaint in question is not dealt with in this manual, send the complaint and all
background material to the Council on Peer Review, along with a Non-Routine Case
Memo (Form #39) indicating the problem.
2. Is the dentist a CDA member?
YES. If the dentist is a member with privileges of peer review as specified in the CDA Bylaws and the
CDA Membership Desk Reference Manual, proceed with the screening.
NO. If the dentist is not a member of CDA or is a member who does not have privileges of peer review
as specified in the CDA Bylaws and the CDA Membership Desk Reference Manual:
send the patient the Notification of Non-Member Dentist (Form #34). Copy the dentist on the
letter and include a copy of the complaint with the dentist copy. Close the case file.
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Peer Review Staff
3. Is the dentist a general dentist?
YES. If the dentist involved does not limit his or her practice to one of the ADA-recognized specialties, he
or she is considered a general dentist, check yes and proceed with the screening.
NO. If the dentist is a specialist, check no, specify ADA-recognized specialty in the Peer Review Checklist
(Form #12).
4. Are there any subsequent or consulting treating dentist(s) involved? If yes, list all the names of the
subsequent/consulting treating dentist(s) and indicate if he or she is a member of CDA.
5. Verify that the dentist under review and subsequent/consulting dentist(s) are not peer review committee
members. If a case involves a member of the peer review committee as the treating dentist or subsequent treating
dentist, forward the case to the CDA Council on Peer Review chair for direction (see Section III).
6. Was there a carrier involved? If so, include the carrier’s information.
7. Was treatment completed within three years of the date the complaint was received?
a. Enter the date the Request for Review (Form #4) is received in the Peer Review Checklist (Form #12).
b. What was the date the treatment in question was completed?
c. Was the treatment in question completed within the last 3 years?
YES. If less than three years has passed since the treatment was completed, proceed with the screening.
NO. If treatment was completed more than three years prior to the date the complaint is received, check
no and conduct the following:
1. Forward to the Council on Peer Review the following information:

i. Copy of the complaint and all case background information including
the Treating Dentist Reply Form (Form #15) with patient records and
consulting dentist(s) reply, if applicable.
ii. Draft of the Notification of Time Limitations (Form #38).
2. The Council on Peer Review will confirm that the case is outside the time
limitation.
3. Send copies of the letter (Form #38) to the parties involved.
4. Close the case file.
8. Does it appear that the complainant became aware of the problem within the past year?
YES. A complainant must file the complaint within one year from the date he or she became aware of
the problem. An exception in this instance would be if, upon recognition of the problem, the
complainant returned to the dentist against whom the complaint is filed for correction of the
problem. Then the longest amount of time that could transpire would be one year between the last
date of treatment and receipt of the complaint at CDA.
NO. If a greater amount of time has transpired, check no and conduct the following:
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Peer Review Staff
a. Forward to the Council on Peer Review the following information:

1. Copy of the complaint and all case background information including the
Treating Dentist Reply Form (Form #15) with patient records and consulting
dentist(s) reply, if applicable.
2. Draft of the Notification of CDA’s Time Limitations (Form #38).
b. The Council on Peer Review will confirm that the case is outside the time limitation.
c. Send copies of the letter (Form #38) to the parties involved.
d. Close the case file.
9. Does it appear that this case has not been or is not in litigation/arbitration?
YES. If no mention is made of any litigation/arbitration, i.e., small claims court, notice of intent to sue,
or if any malpractice suit or arbitration has been filed, continue with the review.
NO. It must be noted that the mention of contact with an attorney does not render a case
inappropriate for review; however, if litigation or arbitration has been initiated, peer review staff
must verify that the litigation/arbitration is proceeding by contacting the respective party and
requesting written verification.
If it is verified that litigation/arbitration is in process, these steps must be followed:
a. Forward to the Council on Peer Review the following information:

1. Copy of the complaint and all case background information.
2. Notification of Litigation/Arbitration (Form #45).
b. The Council on Peer Review will confirm that the case is in litigation/arbitration.
c. Send copies of the Notification of Litigation/Arbitration (Form #45) to the parties
involved.
d. Close the case file.
10. Is the case “routine”, exhibiting nothing out of the ordinary?
YES. If, in the judgment of peer review staff screening the case, the inquiry is “routine”, forward the
Notification of Complaint Being Processed (Form #65) to the initiating party.
NO. Some “non-routine” features may be evident and some may be less obvious. Therefore, it is
important that this question be considered very carefully. If there is some feature of the complaint
that deviates from the routine, indicate the reason on the line provided, and follow these steps:
a. Determine what the request for review does involve.

b. Refer to the Peer Review Manual Index and/or Table of Contents to determine the
appropriate section and page for handling the complaint in question.
c. If the complaint in question is not dealt with in this manual, send the complaint and all
the background material to the Council on Peer Review, along with a Notification of
Non-Routine Case Memo (Form #39) indicating what the problem is.
11. Does the carrier-initiated request include all necessary information?
Answer only if the request is initiated by a carrier.
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Peer Review Staff
YES. In order for a carrier-initiated case to be appropriate for peer review, it must include the following
information listed in questions 1, 2, 3, and 4 of the Peer Review Checklist (Form #12) and the
$500.00 fee. If all information is included, continue to Notification of Review to Involved Parties.
NO. If the answer to any or all of 1, 2, 3, or 4 is no, and if the $500.00 was not received, these steps must
be followed:
a. Determine what information is necessary to proceed with the review.

b. Check the appropriate box and send the carrier the Initial Carrier Response Letter (Form
#23).
c. Recall the file in fourteen (14) calendar days.
d. If the requested response is received by the date specified, the case is appropriate for
review, continue to Notification of Review to Involved Parties.
e. If the carrier fails to respond by the specified date, send a copy of the complaint along with
all the case background information and a copy of the Initial Carrier Response Letter
(Form #23) to the Council on Peer Review.
f. Close the case file.
The screening phase of peer review has now been completed and a determination has been made whether a case is
appropriate for peer review.
Notification of Review to Involved Parties

Involved parties are notified at this time that a peer review has been initiated.
Patient - Initiated Requests

All parties mentioned in the patient's request for review are notified at the same time. Send the patient Notification of
Complaint Being Processed (Form #65).
1. Contact the Treating Dentist: In order to obtain the required information, the following forms must be sent
to the dentist named in a patient-initiated case:
 Dentist Notification and Response Request Letter (Patient Initiated) (Form #13) (Use Form #14 for
utilization cases).
 Treating Dentist Reply Form (Form #15).
 Dentist Will/Will Not Attend Meeting Form (Form #16).
 Copy of the signed Request for Review Form (Form #3).
 Copy of signed Authorization for Use and Disclosure of Health Information (Form #5).
 Copy of signed Patient Agreement Form (Form #4).
2. Treating Dentist Failure to Respond: If a member fails to provide the information requested, these steps
must be followed:
a. Send the dentist, by certified mail, return receipt requested, the Dentist Non-Compliance during
Review Letter (Form #51).
b. Recall file in fourteen (14) calendar days.
c. If the dentist complies as requested, proceed with the review.
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Peer Review Staff
d. If the dentist responds within the specified time, but cannot produce the records as requested for
circumstances beyond his or her control, the case must be referred to the Council on Peer Review
for direction.
e. If the dentist fails to comply within the specific time, staff must contact the dentist by telephone to
confirm that the dentist has received the request for records.
f. If the dentist fails to respond within the specified time, send the Council on Peer Review a copy of
the case file for direction on how to proceed with the case.
g. CDA will send the Dentist Non-Compliance with Records (Form #91) giving the dentist fourteen
(14) calendar days to comply with the request for records. If the dentist fails to respond within the
specified time, the Council on Peer Review will refer the dentist to the Judicial Council with Dentist
Referral to Judicial Council (Form #93) and the case will be closed. Patient must be notified of the
referral with the Notification to Patient of Dentist Referral to Judicial Council (Form #88A).
h. If the dentist complies within the specified time, proceed with the review.
3. Contact Any Carrier Involved: If a carrier is mentioned in the request for review, whether or not the
request pertains to benefits, send the following forms:
 Carrier Notification Letter (Form #17).

 Copy of signed Authorization for Use and Disclosure of Health Information (Form #5).
 If the carrier does not respond within the fourteen (14) calendar days, re-send the Carrier
Notification Letter (Form #17) and a copy of the signed Authorization for Use and Disclosure of
Health Information (Form #5) indicating “Second Request”.
4. Carrier Does Not Cooperate with Peer Review: If after two written requests for information a carrier does
not cooperate with the request for information, these steps must be followed:
a. If the case can be reviewed without input from the carrier, continue with the review.
b. If the case cannot be reviewed without input from the carrier, send a copy of the case file and a
Non-Routine Case Memo (Form #39) to the Council on Peer Review. Suspend the peer review until
direction is received from the Council on Peer Review.
c. In cases involving a refund in which the carrier failed to provide the committee with requested
information and/or confirm their willingness to reestablish patient's eligibility without affecting
patient's current yearly benefit, the refund will go to the patient even if they are still covered by that
carrier. In this instance, the carrier will no longer be considered a part of the peer review case and
WILL NOT be copied on the final letter of resolution.
5. Consulting or Subsequent Treating Dentist: Send the following forms to all dentists mentioned as
consultants or subsequent treating dentists:
 Consulting/Subsequent Dentist Notification Letter (Form #18).

 Copy of Signed Authorization for Use and Disclosure of Health Information (Form #5).
 Consulting/Subsequent Dentist Reply Form (Form #19).
6. Consulting or Subsequent Treating Dentist's Failure to Respond: If a consulting or subsequent treating

member dentist fails to comply with the request for radiographs, records, etc. and the requested information
is necessary for completion of review, the following procedures must be followed:
a. Send the consulting/subsequent treating dentist, by certified mail, return receipt requested,
Dentist Non-Compliance During Review Letter (Form #51).
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Peer Review Staff
b. Recall the file in fourteen (14) calendar days.

c. If the consulting/subsequent treating dentist complies as requested, proceed with the review.
d. If the consulting/subsequent treating dentist fails to comply within the specified time, staff must
contact the dentist by telephone to confirm that the dentist has received the request for records.
e. If a consulting/subsequent treating dentist is a member of CDA, and fails to respond by the
specified date, send the second notice Non-Compliance of Consulting/Subsequent Dentist Letter
(Form #56).
f. Recall the file in fourteen (14) calendar days.
g. If the consulting/subsequent treating dentist complies as requested, proceed with the review.
h. If a consulting/subsequent treating dentist is a member of CDA, and fails to comply within the
specified time, CDA Council on Peer Review will refer the consulting/subsequent treating dentist
to Judicial Council (Notification to Dentist Referral to Judicial Council Form #53A). If possible,
simultaneously proceed with peer review based on the information available.
i. If the consulting/subsequent treating dentist is uncooperative, instruct the patient to obtain copies
of records (see Form #71).
7. Records and Information Requested from Treating and Consulting or Subsequent Treating Dentists:
Pursuant to the CDA Code of Ethics, Section 3, Cooperation with Duly Constituted Committees, treating
and consulting/subsequent member dentists are requested to provide records and pertinent information in a
timely manner and as outlined in request documents. Records and information requested so the case may be
fairly evaluated based on evidence includes:
a. Treating/Consulting Dentist Reply and Records Checklist

b. Original Treatment Records
c. Typed Verbatim Transcript of treatment records
d. Single Patient Account Ledger
e. Any additional information that will assist the committee with its review
f. Study Models (of diagnostic quality and identifiable by date)
g. Radiographs and Photographs (of diagnostic quality and identifiable by date)
Dentist - Initiated Requests

A dentist may initiate a quality review of his or her treatment if the purpose of the review is to appeal a carrier decision
against his or her treatment.
1. Contact with Patient: Since a dentist initiates a case concerning benefits on behalf of a patient, the following
forms must be sent to the patient:
 Patient Notification Letter (Dentist-Initiated) (Form #20) for Utilization review or Patient
Notification Letter (Dentist’s Appeal to a Carrier’s Decision) (Form #74).
 Patient Agreement Form (Form #4).
 Authorization for Use and Disclosure of Health Information (Form #5).
 Release of All Claims Sample Form (Form #72).
 Patient Request for Interview Form (Form #90).
2. Receipt of Incomplete Forms from Patient: If forms are received but are not signed, or if they have been
altered, the case cannot proceed in peer review. Copies of incomplete forms submitted by the patient must be
returned with the Patient Notification of Incomplete Forms (Form #6).
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Peer Review Staff
3. Contact with Any Carrier Involved: The carrier must be contacted for its input. Send the following forms:
a. Carrier Notification Letter (Form #17).

b. Copy of Dentist Request for Review Information Form (Form #8).
c. Authorization for Use and Disclosure of Health Information (Form #5).
d. If the carrier does not respond within the specified time, re-send the Carrier Notification Letter
(Form #17), a copy of the Dentist Request for Review Information Form (Form #8) and a copy of
the signed Authorization for Use and Disclosure of Health Information (Form #5) indicating
“Second Request”.
4. Carrier Does Not Cooperate with Peer Review: If after two requests for information a carrier does not
cooperate with the request for information, suspend the peer review until direction is received from the
Council on Peer Review.
5. Receipt of all Completed Forms and Requested Responses: When the case file is complete with all
information necessary to properly conduct the review, the case is ready to be reviewed by the peer review
committee. Proceed to Preparation and Contents of Case File.
Preparation and Contents of Case File

A file folder must be prepared for each case. It is suggested that the file label include the following information.
 Treating dentist's last name, first name.

 Patient's last name, first name.
 Carrier involved (if any).
 Case number.
Cases involving more than one dentist must be cross-referenced. The review of each dentist must be handled as a
separate case. A Notification of New Case Form (Form #10) and the Peer Review Checklist (Form #12) for each
dentist must be completed.
It is recommended that open cases be separated from closed cases.
Contents of the Case File

All information (originals and/or copies of letters) pertaining to a case must be stored in the case file. It is essential to
the peer review system that all aspects of a case be documented and the procedures followed in order to best serve
the patient, carrier, and dentist. The procedures must be consistent for all cases, thus assuring that all parties
concerned with a review are treated fairly.
Items that must be included are listed below:
Notification of New Case Clinical Examination Worksheets

Peer Review Checklist Resolution Addendum (Form #63)*
Initial Patient Response Letter (Patient Initiated) Resolution Letter (Form #59)*
Request for Review Form Refund Distribution Worksheet*
Patient Agreement Form Inappropriate for Review Closing Letter*
Authorization for Use and Disclosure of Health Release of All Claims Form*
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Information
Patient Request for Interview Form Release of All Claims Letter*
Sample of Release of all Claims Copy of Check(s) Submitted by the Dentist*
Patient Notification of Incomplete Forms Initial Response to Dentist Letter (Utilization)*
Dentist Notification and Response Request Letter Dentist Request for Review Information Form
(Utilization)*
Treating Dentist Reply Form and Patient Records Dentist Notification Utilization Letter (Patient Initiated)*
Dentist Will/Will Not Attend Meeting Form Patient Notification Letter (Dentist Initiated)*
Dentist Notification of Incomplete Forms* Patient Notification Letter (Carrier Initiated)*
Consulting/Subsequent Dentist Notification Letter Dentist Notification Letter (Carrier Initiated)*
Consulting/Subsequent Treating Dentist Reply Forms Initial Carrier Response Letter*
and Patient Records
Carrier Notification Letter* Carrier Initiated Review Fee Request*
Initial Patient Examination Letter* Carrier Notification of Incomplete Forms
Dentist Invitation Letter to Attend Review Committee Please Note : * If Applicable
Meeting*
Following is a list of items that may also be found in a case file:
 Examining Panel Notification Memo

 Appeal Criteria
 Appeal Criteria Statement (Over-Utilization Case Review)
 Other Supporting Records or Information Provided by the Patient
 Notification to Specialty Organization
 Notification of Review Committee For Specialty Case
 Notification of Non-Member Dentist
 Final Notification To Patient of Dentist Expulsion/Dropped Membership/No Further Action
 Dentist Practicing In Another Component Area Memo
 Notification of Deceased Dentist
 Notification of CDA’s Time Limitation
 Non-Routine Case Memo
 Notification of CDA Policy Regarding Fee Review
 Notification of Benefit Exclusion
 Notification of Communication Problem
 Notification of Completed/Altered Treatment
 Notification of Litigation
 Notification of Settlement
 Notification To Patient of Dentist Dropping Membership
 Acknowledgement of Dropping Membership
 Patient Notification of Failure to Appear
 Non-Compliance During Review Letter
 Dentist Non-Compliance with Resolution Letter (Form #59)
 Dentist Non-Compliance with Resolution Letter (Form #59) (second notice)
 Non-Compliance Referral to CDA Memo
 Non-Compliance Referral to CDA Memo Pattern of Practice
 Non-Compliance of Consulting/Subsequent Dentist Letter
 Notification of Compliance Memo
 Notification To Committee of Additional Information Received
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 Any other notes or correspondence related to the case
Each case is different; this list is not all-inclusive. For a list of all forms, refer to Section VII of this manual. Not for
use as step-by-step administrative processing instructions detailed throughout this section.
Appropriate For Review
The following section of the manual outlines all steps that are to be followed by peer review staff after an inquiry as
been screened and found to be appropriate, and a Notification of New Case (Form #10) has been completed.
Completion of Peer Review Checklist

The Peer Review Checklist (Form #12) must be completed for each case reviewed. It is designed to assure that all
steps required in the peer review process are completed and recorded. It must be placed in the case file at the time the
case is initiated, and updated as the case proceeds. It is extremely important to record actual dates of peer review
procedures on the Peer Review Checklist (Form #12).
Assignment to Component/Specialty Peer Review Committee and Set-Up of Clinical

Examination
When a case has been accepted as appropriate for review and all information has been received from involved parties:
1. Send the Notification of New Case to Component/Specialty Chair (Form #32) to the component/specialty
peer review committee chair or committee member and component staff as designated by the peer review
committee chair to establish a date, time, and location to hold the review meeting. If the case involves
specialty review, the state specialty peer review chair must be notified.
2. When an examination of the patient is necessary to gain sufficient information for the peer review committee
to reach a conclusion, or if the patient has indicated in the Patient Request for Interview Form (Form #90)
that he or she wishes to be interviewed by the committee, a location convenient to the patient (such as a
dental office of one of the members of the peer review committee, or the component society office) must be
used for the peer review meeting.
Note: If a utilization review is being conducted, and the treatment is complete, no examination will be
conducted unless further clarification is required by the committee chair.
3. If the dental condition demands immediate treatment that could affect the committee’s determination for
review, the peer review committee must make every effort to immediately conduct a patient examination
prior to treatment.
4. Once the meeting date has been established, prepare the Examining Panel Notification Memo (Form #26) for
each committee member.
5. Forward the Examining Panel Notification Memo (Form #26) to the component/specialty committee
members and component peer review staff. Component staff will provide copies of the case file to the peer
review committee members as requested. Maintain original case file at CDA. Provide a copy of the
Resolution Letter Worksheet (Form #59), Resolution Addendum Form (Form #63), and appropriate
examination worksheets.
6. Forward to the patient the Initial Patient Examination Letter (Form #27) and enter the date the letter was
sent on the Peer Review Checklist. Invitation by telephone is NOT acceptable.
7. If the dentist under review has indicated on the Dentist Will/Will Not Attend Meeting Form (Form #16)
that he or she wishes to attend the meeting, it is mandatory that the dentist be offered the opportunity in
writing. Forward to the dentist by certified mail, return receipt requested the Dentist Invitation Letter to
Attend the Review Committee Meeting (Form #28). Invitation by telephone is NOT acceptable. If the
dentist stated, “possibly”, “maybe”, or “if the committee feels it is helpful,” or “necessary”, etc., on the Dentist
Will/Will Not Attend Meeting Form (Form #16), the dentist must be invited in writing to attend the
meeting. A treating dentist will be given no more than two (2) opportunities to meet with the committee.
8. The patient will receive no more than two (2) opportunities to be examined. If the patient fails to appear for
an examination, these steps must be followed.
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a. Send the Patient Notification of Failure to Appear (Form #50).

b. Send the Council on Peer Review a copy of the inquiry and a copy of the Patient Notification of
Failure to Appear letter.
c. Close the case file.
9. Should there not be a minimum of three (3) calibrated specialists to serve as the review committee, or if a
drafted resolution is not submitted by the specialty committee within sixty (60) calendar days (without
explanation concerning the delay), then CDA has the right and authority to intervene and request that a
component general committee conduct the review using specialty representation (a consultant) to examine
the patient and render a resolution.
Distribution of Resolution Letter (Form #59)

1. Upon receipt of the draft Resolution Letter (Form #59), the Resolution Addendum (Form #63) and
examination worksheets (minimum three) from the component or specialty peer review chair, CDA
staff will make every effort to contact the component or specialty chair within thirty (30) calendar
days should further clarifications or revisions be necessary. Neither the component/specialty chairs
nor the component staff must forward a resolution to the parties involved.
2. When the Council on Peer Review has approved and finalized the letter of resolution, CDA will
notify all parties involved in the review.
3. Resolution Letter (Form #59) must be sent certified mail, return receipt requested.
The letters to the parties are all mailed on the same date and are distributed as follows:
Dentist - Copy of Resolution Letter (Form #59)

Copy of Resolution Addendum (Form #63)
Copy of Appeal Criteria
Patient - Copy of Resolution Letter (Form #59)

Carrier - Copy of Resolution Letter (Form #59)

(Only if carrier has cooperated with peer review committee.)
4. CDA will forward a copy of the final dated copy (called an FDC) of the Resolution Letter (Form
#59) and Resolution Addendum (Form #63), marked as such in the upper right corner to the
component.
5. If an error is discovered in the Resolution Letter (Form #59) after it has been mailed to the parties
involved (i.e., incorrect refund, patient no longer covered by insurance, insurance refund was
erroneously omitted, etc.) CDA will draft an amended letter and will forward to the parties
involved. The amended letter is not to be mailed prior to the expiration of the original 30-day
appeal period and prior to approval by the Council on Peer Review.
Distribution of Refund Check(s)

Within fourteen (14) calendar days after the expiration of the appeal period or the determination of an appeal
decision, the dentist is to have forwarded his or her refund check(s) to CDA. Upon receipt of the check, the following
procedures must be followed:
1. If the carrier has cooperated with the committee, the check to the carrier is mailed immediately after
the expiration of the appeal period or the determination of any appeal of the decision and upon
receipt of the signed Release of All Claims Form (Form #72). A carrier’s refund check cannot be
held by the CDA for any reason. The check must be recorded prior to mailing.
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Peer Review Staff
2. If the patient has submitted a signed Release of All Claims (Form #72), the patient’s check may also
be released immediately following the appeal period or the determination of any appeal.
3. If the patient fails to comply with signing the Release of All Claims (Form #72), the check is
recorded and returned to the dentist.
Non-Routine
This section of the manual deals with non-routine situations that may or may not be appropriate for review.
Non-routine situations are as follows:
 Amicable Resolution
 Communication from Attorney
 Communication Problem
 Complaint Regarding Treatment Rendered by Dental Student in a University Setting
 Conflict of Interest
 Dentist against Whom Inquiry is Filed is No Longer Practicing
 Dentist Dies after Review is Initiated
 Dentist Drops CDA Membership During Review
 Dentist is Deceased at Time Request for Review is Received
 Dentist-to-Dentist Initiated Requests
 Dispute between Patient or Dentist and Peer Review Committee
 Financial Responsibility Statement
 Incomplete Treatment
 Inquiries Beyond the Expertise of Component
 Litigation and Arbitration
 Litigation and Arbitration is Initiated after Peer Review Has been Initiated
 Miscellaneous Non-Routine Inquiries
 Outside Agency Initiated Requests
 Patient Dies after Review is Initiated
 Patient in Pain
 Patient Residing in Different State
 Provisional/Temporary Treatment
 Request for Case to be Transferred to Neighboring Component
 Request for Review of Completed/Altered Treatment
 Request for Review when a Prosthesis or Crown has been Fabricated but not Delivered
 Review of Dentist’s Fees
 Time Limitation Criteria
 Unclear Inquiry
Amicable Resolution
If settlement of a case occurs before review is completed, these steps must be followed:
1. Discontinue action on the case review. However, if the patient has been clinically examined, a
Resolution Letter (Form #59) and Resolution Addendum (Form #63) must be written and held in
the case file.
2. Send the involved parties the Notification of Settlement Letter (Form #47).
3. Recall the file in ten (10) calendar days.
4. If no response is received, close the case file.
5. If a response is received indicating the matter has not been settled, notify the parties involved that
the case is still open, and proceed with the review. Proceed to Notification of Review to Involved
Parties section of this manual.
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Peer Review Staff
Communication from Attorney

When communication is received from an attorney, these steps must be followed:
1. Requests from attorneys for information concerning the peer review system must be forwarded to
the Council on Peer Review with a Non-Routine Case Memo (Form #39) for response.
2. If litigation has not been initiated and an attorney wishes to initiate peer review on behalf of a
patient, send a copy of the complaint to the Council on Peer Review with a Non-Routine Case
Memo (Form #39). Proceed with the case as though it is a patient-initiated case. The forms may be
sent to the lawyer if requested.
3. If there is an indication that a previous out-of-court settlement has been made, the case must be
referred to the Council on Peer Review with a Non-Routine Case Memo (Form #39) for the
appropriate response.
4. Unless litigation is initiated, proceed with peer review.
5. If litigation is initiated, refer to the Litigation section.
6. If a party to the review simply indicates that an attorney is involved, no action is necessary.
7. If a party to the review requests that an attorney be present for the review, the peer review
committee and CDA must deny the request, since the peer review system is evaluative rather than
judicial.
Communication Problem
If the complaint pertains to a communication problem between the dentist and the patient, these procedures must be
followed:
1. Draft a response following the format of the Notification of Communication Problem (Form #43),
that appropriately fits the situation.
2. Send a copy of the inquiry, all the background material and the draft response to the Council on
Peer Review.
3. If no response is received from the Council on Peer Review, contact the appropriate council
member to confirm receipt of the case.
4. CDA will send the Notification of Communication Problem to involved parties and close the case
file.
Complaint Regarding Treatment Rendered by Dental Student in a University Setting

If a complaint is received concerning a dental student, these steps must be followed:
1. Refer the patient directly to the dental school.

2. Send a copy of the complaint along with the Non-Routine Case Memo (Form #39) and all
background material to the Council on Peer Review.
3. Close the case file.
Conflict of Interest
Members must avoid placing themselves in a position where personal or professional interests may conflict with their
duty to the component/specialty peer review committee. Members must also avoid using information learned through
committee membership for personal gain or advantage. To that end, CDA staff must be notified if either of the
following circumstances exist: 1) if any committee member has been engaged at any time by the patient, dentist or
carrier who is a party to the dispute, or 2) if any committee member has served, or is serving, as an expert witness for
the Dental Board of California on a case involving the patient or dentist who is a party to the peer review dispute. If
this occurs, the review of the case should not proceed until direction is received by the council chair (see Section III.
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Peer Review Staff
Responsibilities of Component/Specialty Peer Review Committee). In addition, a committee member shall not accept
a patient in his or her practice for a minimum period of one year subsequent to final case closure (if applicable, this
includes the termination of the appeals process.)
Additionally, a member of the general/specialty peer review committee shall be automatically disqualified from
evaluation or decision making when a request for peer review involves (i) that member, as either the treating dentist or
subsequent treating dentist; or (ii) a close friend, family member, or close business associate of that member.
To avoid any appearance of conflict of interest, no person serving on any of the following capacities may serve on a
peer review committee:
1. CDA officers, trustees or members of the Judicial Council or Council on Peer Review.
2. Dental Board of California board members.
Component officers and component board members may concurrently serve as peer review committee
members if (i) in the event the component board must vote on an issue related to peer review, members
who serve concurrently on the peer review committee and the component board must recuse themselves
from the vote; and (ii) in the event peer review committee members recuse themselves, the component
board must be able to maintain a quorum.
To avoid an actual conflict of interest, a member of a peer review committee must recuse themselves from
any case in the following situations:
1. Consultants, employed dentists, fiduciaries or members or any review committee of any insurance
carrier or Knox-Keene plan must recuse themselves from any case that involves that company.
2. Ethics committee members must recuse themselves from any peer review case in which he or she has
already participated in an ethics review based on similar facts between the same parties.
3. Dental Board of California consultants must recuse themselves from any peer review case or dental
board case in which he or she has already participated in a review involving the same parties.
Components may, at their discretion, create stricter requirements to avoid any actual or perceived conflicts
of interest. Each component is urged to be consistent in its own application of such policies.
Dentist Against Whom Inquiry is Filed is No Longer Practicing

If a complaint is filed against a dentist who is no longer practicing, these steps must be followed:
1. Determine the dentist's membership status.

2. If the dentist is a member, the case is appropriate for review.
3. If the dentist is no longer a member, or never was a member, forward a Notification Non-Member
Letter Form (Form #34) and close case.
Dentist Dies after Review is Initiated

If a dentist dies after review is initiated, these steps must be followed:
1. If the dentist had an opportunity to present input to the committee, proceed with peer review.
2. If the dentist did not present input, and the estate does not wish to abide by the decision, send the
involved parties the Notification of Deceased Dentist Letter (Form #37).
3. Send a copy of the file and a copy of the Notification of Deceased Dentist Letter to the Council on
Peer Review and close the case file.
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Peer Review Staff
Dentist Drops CDA Membership During Review

If, during the peer review process, staff becomes aware that the dentist has dropped membership, these steps must be
followed:
1. Contact the dentist to verify that he or she has dropped membership.

2. If it is verified that a dentist has dropped his or her membership, staff should promptly follow the
procedures in Section VI – Dentist Drops Membership During Review.
3. If the dentist has dropped his or her membership but states in writing that he or she is still willing
to cooperate, the peer review committee should proceed with the review.
4. If the dentist indicates an unwillingness to cooperate but all the necessary forms have been
completed, the peer review committee should proceed with the review.
5. If and when the peer review is completed, advise the patient in the Resolution Letter (Form #59)
that the dentist is no longer a member.
6. If the dentist fails to comply with the committee's decision within the delineated time period, advise
the patient that the dentist is not a member and has not cooperated with the peer review
determination by following the procedures in Section VI – Dentist Non-Compliance with the Final
Decision. Please note that it is imperative that the non-compliance referral be made in a timely
manner. Should the dentist ever wish to re-instate his or her membership, CDA would be aware of
his or her previous non-compliance with the peer review committee.
Dentist is Deceased at Time Request for Review is Received

Attempt to contact the estate of the deceased. Proceed with review if the estate is willing to abide by the decision. If
the estate does not agree to the review, these steps must be followed:
1. Send the party initiating the review the Notification of Deceased Dentist Letter (Form #37).
2. Send a copy of the complaint and a copy of the notification letter to the Council on Peer Review.
Close the case file.
Dentist-to-Dentist Initiated Requests

A dentist cannot initiate a case against another dentist. If a second treating dentist initiates a case against a prior
treating or another dentist, it must ultimately be opened as a patient initiated request.
Dispute Between Patient or Dentist and Peer Review Committee

During the review of a peer review complaint, if a dispute arises between the patient or dentist and the peer review
committee or the Council on Peer Review regarding the processing, handling or disposition of the complaint, CDA
legal counsel should review all further correspondence, including e-mail(s), before it is sent to the parties involved.
Financial Responsibility Statement

The treating dentist shall be financially responsible for any adverse peer review decisions regarding the quality and/or
appropriateness of treatment rendered regardless of his or her employment status.
Incomplete Treatment
If a request for review is received involving incomplete treatment, for example:
1. Undelivered crowns or prosthesis

2. Delivered crowns or prosthesis which have not had completed adjustments (i.e. occlusion or sore
spots, extensions, roughness, etc.)
3. Incomplete orthodontic treatment
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Peer Review Staff
The committee must evaluate available records, radiographs, images, models, etc., to determine if a conclusive
determination regarding the quality and/or appropriateness of the incomplete treatment can be reached up to the
point when the treatment was halted.
If a determination is possible, then the case is appropriate for review. Continue to Notification of Complaint Being
Processed (Form #65).
1. If the committee determines that the incomplete treatment does not meet the guidelines in the
CDA Quality Evaluation Manual, a full refund is in order. If additional harm has been caused, then
the treating dentist is financially responsible for corrective treatment.
2. If the committee determines that the incomplete treatment meets the guidelines in the CDA
Quality Evaluation Manual, the following steps must be followed:
a. The patient is financially responsible for the portion of the treatment that has been
completed. This may include the cost of temporary/provisional restorations, appliances,
prosthesis, radiographs and other diagnostic procedures.
b. The dentist is not financially responsible for the completion of treatment when:
i. The treatment has reached a particular phase as in Phase I of orthodontic

treatment when Phase II will follow or in distinct phases pertaining to restorative
treatment.
ii. The patient does not return for adjustments as in cases pertaining to fixed and
removable appliances or in ortho cases, after banding of dentition or placement
of retainers.
iii. The patient had erroneously determined that the treatment was unacceptable
and refused to have treatment completed.
iv. After fabrication of prosthesis or appliance and the patient has elected not to
return for placement or insertion.
v. The dentist is entitled to receive a reasonable fee in proportion to the degree in
which the treatment has been completed as determined by the committee.
3. If a determination is not possible, a letter must be sent to the initiating party stating that a
determination of the incomplete treatment cannot be made.
4. Other cases that do not fall under these guidelines shall be submitted to the Council on Peer
Review, along with a Non-Routine Case Memo (Form #39) indicating the problem.
5. The Council on Peer Review will refer the case back to the component with suggested guidelines.
Inquiries Beyond the Expertise of Component Peer Review Committee

If a case is determined by the committee to fall outside its area of expertise, the case must be referred to the Council
on Peer Review. Examples of cases which might fall in this category are: acupuncture, and any other
new/controversial treatment modalities.
1. If the committee determines that a request requires knowledge beyond the expertise of the
committee, refer the case to the Council on Peer Review using the Non-Routine Case Memo (Form
#39).
2. The component will be notified of any action taken if the case is handled by the Council on Peer
Review. Otherwise, the council will refer the case back to the component with suggested guidelines.
Litigation and Arbitration

The peer review system is a service to the public designed to be an alternative to civil litigation which might otherwise
arise between the parties. Consequently, no inquiry will be accepted for peer review if either party has initiated
litigation (including small claims court), and/or has initiated or has gone through an arbitration process concerning
any aspects of the dental services which might otherwise be reviewed.
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Peer Review Staff
In addition, should legal action or arbitration be initiated by any party involved after the peer review process begins,
including the appeal process, the peer review action will cease immediately. A 90-day notice of intent to file suit is to
be construed as litigation. No matter that is or has been the subject of litigation or arbitration will be accepted into the
peer review system. Additionally, any case that has been litigated to judgment regarding any aspect of the dental
services in question is not eligible for peer review. Involvement of an attorney, i.e., correspondence from an attorney
or initiation of peer review on behalf of a patient, does not necessarily mean litigation has been initiated.
Litigation or Arbitration is Initiated after Peer Review Has Been Initiated

If litigation or arbitration is initiated by either the patient or the dentist after the case has been initiated, these steps
must be followed:
1. If the patient initiates litigation or arbitration after review process has been initiated:
a. Obtain a copy of the summons, letter of intent, or notification that arbitration will be or has
commenced from the dentist.
b. Send the Council on Peer Review a copy of the inquiry, a copy of the summons, letter of intent, or
notification that arbitration will be or has commenced; a copy of a draft response using the
Notification of Litigation (Form #45) as a guideline.
c. Mail the notification to involved parties and close the case file.
2. If the dentist initiates litigation or arbitration after review has been initiated:
a. Obtain a copy of the summons, or notification that arbitration will be or has commenced if
possible.
b. Send the dentist a Request for Withdrawal of Litigation/Arbitration (Form #46).
c. Recall the file after 21 calendar days.
d. If the dentist complies with the request, proceed with peer review.
e. If the dentist fails to comply with the request by the specified date, discontinue review procedures,
and
i. Send the Council on Peer Review a copy of the case file and a Non-Compliance Referral
Memo (Form #54).
ii. No further action is required until requested by the Council on Peer Review.
Miscellaneous Non-Routine Inquiries

Should a non-routine situation occur that is not included in this listing, send a copy of the case and a Non-Routine
Case Memo (Form #39) to the Council on Peer Review.
Outside Agency Initiated Requests

If an inquiry is received from someone other than a dentist, patient, or carrier, these steps must be followed:
1. Determine who initiated the inquiry, i.e., the Dental Board of California, a consumer group,
legislator, etc.
2. Refer the case to the Council on Peer Review for determination if special handling and/or response
is necessary. Include the Non-Routine Case Memo (Form #39).
3. The component peer review committee or specialty chair will be notified of any action taken if the
case is handled by the Council on Peer Review. Otherwise, the Council will refer the case to the
component peer review committee or specialty chair with instructions to review as a routine case.
Patient Dies After Review Is Initiated

If a patient dies after review is initiated, these steps must be followed:
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Peer Review Staff
1. If the patient has been examined, or a determination can be made without an examination, proceed
with peer review.
2. If the review cannot be completed without a patient examination, send involved parties a letter
modeled after the Notification of Deceased Dentist Letter (Form #37).
3. Send a copy of the closing letter to the Council on Peer Review for approval. Close the case.
Patient in Pain
If the inquiry indicates that the patient is in pain, these steps must be followed:
1. If the dental condition demands immediate treatment which could affect the committee's
determination for review, the component or specialty peer review committee must make every effort
to immediately conduct a patient examination prior to treatment.
2. If no written complaint has been received (telephone request) by the patient or all the necessary
forms have not been completed, CDA, at its discretion, may request that a component or specialty
peer review committee conduct a patient examination and then proceed with review once the
written request forms are received.
Patient Residing in Different State

If the patient resides in another state, these steps must be followed:
Request that the patient travel back to the “home component” where the treatment was rendered for the patient
examination. If it is impossible for the patient to travel to the “home component” for either medical reasons,
financial hardship, etc., determine if a decision can be rendered based on the records, if not, close the case. If a
decision can be made based on the records, proceed with the review.
Provisional/Temporary Treatment
Treatment involving temporary or provisional restorations may be evaluated. The entire treatment will be evaluated as
it relates to records, diagnosis, and treatment planning. The temporary or provisional restorations will be clinically
evaluated.
Since there are no written standards of care for temporary or provisional restorations, the consensus of the
examination panel will determine if the temporary or provisional restoration is adequate given the nature and
expected service life of the temporary/provisional restoration.
The provisional/temporary restoration shall maintain the dentition and shall not allow further harm.
If the provisional/temporary restoration is adequate and/or treatment plan meets the standards of care, then no
refund is in order for the provisional/temporary treatment.
If the provisional/temporary restoration is inadequate and/or the treatment plan did not meet the standard of care,
then a refund is in order.
If the provisional/temporary restorations are inadequate and/or the treatment plan did not meet the standard of care
and there has been additional harm caused, then corrective treatment is in order.
Request for Case to be Transferred to Neighboring Component
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Peer Review Staff
A dentist or patient may request that the peer review case be transferred to a neighboring component if there is a valid
conflict of interest or a perceived conflict of interest with one or more member(s) of the peer review committee. These
steps must be followed:
1. Request that the dentist or patient forward to the Council on Peer Review a written description of
the conflict of interest situation, as well as copies of all relevant documentation that will support his
or her claim.
2. Once received, staff must discuss the dentist’s or patient’s claim(s) with the appropriate member(s)
of the Council on Peer Review. If the dentist or patient demonstrates an actual or potential conflict
of interest, send the complaint directly to the closest neighboring component dental society with the
Transfer to Neighboring Component Memo (Form #97). Please note that, in any questionable case,
the CDA Council on Peer Review must rule in favor of finding that a valid conflict of interest exists
and proceed accordingly.
3. If the dentist or patient does not demonstrate an actual or potential conflict of interest, send the
Notification to Dentist/Patient that Case Will Remain at Component (Form #98), and continue
the review at the original component.
Request for Review of Completed but Altered Treatment

When a patient questions the quality of treatment that has been replaced or altered, these steps must be followed:
1. The Council on Peer Review must evaluate available records, compare pre-operative and post-
operative radiographs/images, models, etc., to see if an objective conclusive determination regarding
treatment can be made.
2. The determination on an altered treatment case must be based on hard evidence specific to the
nature of the patient’s complaint. If the subsequent treating dentist’s records indicate that the
treatment in question is unacceptable, it must be supported by hard evidence, i.e.,
radiographs/images, models, etc.
3. If an objective conclusive determination is possible, then the case is appropriate for review and must
be assigned to the component/specialty peer review committee for review.
4. If an objective conclusive determination is not possible, a letter must be sent to the initiating party
advising that although the questions posed are valid, no determination can be made since it is not
possible to evaluate treatment that has been redone or altered. Draft the Notification of
Complete/Altered Treatment letter (Form #44). Then:
a. Send a copy of the inquiry and the draft response to the Council on Peer Review for review
and approval.
b. If no response is received from the Council on Peer Review that the case was received, call
the Council on Peer Review to confirm receipt of the case.
c. CDA will approve and send the Notification of Completed/Altered Treatment to the
involved parties and close the case file.
Request for Review when a Prosthesis or Crown has been Fabricated but not Delivered
If a request for review is received involving an undelivered prosthesis or crown, these steps must be followed:
1. Send the inquiry and all background material to the Council on Peer Review, along with a
Non-Routine Case Memo (Form #39) indicating the problem.
2. Postpone the review until direction is received from Council on Peer Review.
Review of Dentist's Fees

If the complaint involves fees, these steps must be followed:
1. Draft a response following the format of the Notification of CDA Policy Regarding Fee Review
(Form #41).
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Peer Review Staff
2. Send a copy of the inquiry along with all the background material, and the draft response to the
Council on Peer Review.
3. Following approval by the Council on Peer Review, send the Notification of CDA Policy Regarding
Fee Review (Form #41) to involved parties. Close the case file.
Time Limitation Criteria

The time limitation for considering a case in the peer review system is as follows:
“The inquiry must be received within three (3) years from the date of completion, or within one year from the date the
initiator of review became aware of the alleged problem, whichever occurs first.”
Since passage of time alters clinical conditions and makes recollection of details and procedures difficult, the following
time limitations must be met in order for a case to be considered in the peer review system:
1. The inquiry must be received within three (3) years from the date of completion, or within one (1)
year from the date the initiator of review became aware of the alleged problem, whichever occurs
first.
An exception in this instance would be if, upon recognition of the problem, the complainant
returned for correction of the problem to the dentist against whom the complaint is filed. Then the
longest amount of time that could transpire would be one year between the last date of treatment
and receipt of the complaint by CDA.
Unclear Inquiry
On occasion inquiries received do not clearly explain the patient's/dentist's concern. It is important, however, to
assure that all persons have equal access to the peer review system.
These steps must be followed:
1. Send a letter along with the complaint to the initiator of the case explaining to them that the
complaint is not specific enough and/or that their concern(s) is not clearly stated. Allow the
initiator fourteen (14) calendar days to respond.
2. If the initiator does not respond within the time limit allowed send a copy of the drafted letter along
with the complaint and background material to the Council on Peer Review. Close the case file.
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III. Responsibilities of the Component and Specialty Peer Review
Committee
When all the necessary background information has been gathered by CDA peer review staff, the entire case file is
forwarded to the component and/or specialty peer review committee chair and component staff to screen for
completeness and appropriateness.
The component peer review chair is responsible for overseeing all cases originating in his or her component, including
specialty cases. The responsibilities of the chair include, but are not limited to, the format and content of all
resolution letters and resolution addenda, including all specialty cases. The chair is also responsible for assuring that
the composition, grammar, and accuracy of all resolution letters and addenda have been completed appropriately.
Additionally, the chair must assure that all sections of the resolution addendum have been thoroughly documented
prior to the case being forwarded to CDA peer review staff.
Resolution letters must not be sent to CDA before the component chair has reviewed the format, content, refund
figures, etc., as this is the responsibility of the chair and committee. The resolution letter and resolution addendum
must be forwarded to CDA only after being reviewed and approved by the chair.
All resolution letters will be finalized on CDA letterhead. Due to confidentiality issues, component and specialty
committee members must utilize component peer review staff for administrative purposes (typing resolutions, copying,
etc.) rather than their own personal office staff.
Thorough documentation of the activities of the reviewing committee is required and essential to protect against
future allegations of prejudice, failure to consider pertinent material, or improper procedures.
If a case involves a member of the peer review committee as the treating dentist or if there is an actual conflict of
interest, the case will be forwarded to a neighboring component peer review committee for review, at the direction of
the CDA Council on Peer Review chair. If a case involves a member of the peer review committee as a subsequent
treating dentist, the CDA Council on Peer Review chair will consult with the peer review committee chair to
determine whether the potential conflict requires the case to be transferred. If the CDA Council on Peer Review chair
determines that case will remain with the component, the subsequent treating dentist must be recused from the review
panel and must not be permitted to receive the case file or participate in any discussion of the case.
Additionally, a dentist or patient may request that the peer review case be transferred to a neighboring component if
there is a valid or perceived conflict of interest with one or more members of the peer review committee. The transfer
request will be granted or denied at the direction of the CDA Council on Peer Review chair.
Component and specialty peer review committee chairs will receive periodic reports from CDA of all cases in review.
Specialty cases will also be listed on the component report. These reports will enable each committee to track cases and
will provide statistical data regarding the number of cases, the length of time a case has been open, and the type and
disposition of the case.
If at any time during the review a committee member has a question on procedures, refunds, corrective treatment, etc.,
contact either CDA peer review staff or Council on Peer Review Liaison for direction on how to proceed prior to
completing the resolution letter and/or addendum.
The following procedures are to be followed by the component and specialty peer review committees in conducting a
peer review:
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CDA Peer Review Manual Responsibilities of the Component/
Specialty Peer Review Committee
Clinical Examination
Note: If a utilization review is being conducted, and the treatment is complete, no examination will be conducted
unless further clarification is required by the committee chair.
Prior to conducting the clinical examination, these procedures must be followed:
1. Notify CDA peer review staff in writing of the date, time, and location of the patient examination.
2. Provide the names of the examiners to CDA staff for confirmation that all CDA requirements have been
met.
3. Upon receipt of the Examining Panel Notification Memo (Form #26) and the case file, each peer review
committee member must study the case content thoroughly and acquaint themselves with the exact nature of
the inquiry under review. The committee must collectively review the case content to determine that all
needed information is included, and that the case qualifies for review, i.e., time limitation, altered treatment,
litigation, conflict of interest, etc.
Note: The case chair must contact the patient when a positive response is noted on the Request for
Review Form (Form #3) (Do you require antibiotics for dental treatment?) to advise the patient to
contact his or her physician regarding pre-medication.
4. Make notes of the initiator's inquiry and be prepared to discuss the case with the co-committee members and
to clinically examine the patient.
5. If the dental condition demands immediate treatment that could affect the committee’s determination for
review, the committee must make every effort to immediately conduct a patient examination prior to
treatment.
6. An uneven number of dentists (minimum of three) must be in attendance at the patient examination. In all
cases of review, thorough documentation of the reviewing committee’s activities are required and essential to
protect against future allegations of prejudice, failure to consider pertinent material, or improper procedure.
Conducting the Clinical Examination

The examiners must exhibit a professional demeanor and represent the dental profession at its highest level when
performing the examination. At the time of the patient examination, advise the patient that the examination by your
committee does not constitute a full dental examination, only the treatment in question.
1. The criteria used for the examination will be the CDA Guidelines for the Assessment of Clinical Quality and
Professional Performance (Quality Evaluation for Dental Care).
2. A thorough examination of the treatment in question must be performed, and the findings must be legibly
documented on each examiner’s Clinical Examination Worksheet. The clinical examination must address all
the issues relevant to the complaint, and must exclude treatment planning, observations, or implications
without a demonstrable basis of fact.
3. Queries from the patient during the examination must be handled diplomatically without implying any
wrong-doing on the part of the dentist under review.
4. Findings are not to be discussed in the presence of the patient, nor should the peer review committee discuss
any evidence or conclusions of the case with the patient.
5. The appropriate clinical examination worksheet must be completed thoroughly by each examiner when
recording the clinical findings. The findings must be recorded in such a way that notes are legible and will
provide sufficient detailed information for the peer review committee to make a rational decision in the case.
6. Verbal or written information furnished by the patient during the examination must be entered on the
clinical examination worksheet and must be identified as a comment from the patient. If the patient raises
additional questions concerning treatment that was not included in the Request for Review Form (Form #3)
or expands upon the original inquiry, the committee must make a note of it in the clinical examination
worksheet. The dentist under review must be given the opportunity to address these additional questions
and/or concerns in writing and must be afforded another interview prior to the committee making a
determination.
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7. If the committee recognized substandard care or an area of an emergency nature that is not included in the
patient’s initial complaint, these steps must be followed:
a. Verbally inform the patient at the time of the examination that there are conditions that require the
attention of a dentist.
b. Note the problem areas on the clinical examination worksheet and record that the patient was
verbally informed about the need to seek the attention of a dentist.
c. In the resolution letter draft, indicate that the committee noted areas in the patient’s mouth that
require further dental treatment.
8. In order to make a more definite decision, radiographs may be taken if the committee deems it necessary,
with the patient's consent, during the examination.
9. The committee must perform periodontal probings, when appropriate.
10. The findings from the Clinical Examination Worksheets must be incorporated into the typed Resolution
Addendum (Form #63) that is attached to the dentist's copy of the resolution letter. These findings must
support the determination made by the committee.
When CDA reviews the resolution addendum for approval, the following are some points, which are
addressed:
a. Does the resolution addendum address all of the patient’s complaints?

b. Does the resolution addendum state the results of the clinical examination as it relates to the
patient's inquiries?
c. Does the resolution addendum offer advice, give reprimands, or otherwise contain information
unrelated to the actual "findings" of the committee? If so, delete.
d. Does the resolution addendum include treatment planning by the committee? If so, delete.
e. If radiographs were reviewed, are the type(s), date, and findings included in the resolution
addendum? Likewise, if radiographs were reviewed but no clinical examination was conducted, has a
resolution addendum been prepared from the radiographic evidence?
f. If periodontal probings were performed, are the committee’s findings noted in the resolution
addendum?
g. Does the resolution addendum support the recommendation of the peer review committee in the
resolution letter?
h. Do the clinical examination worksheets support the recommendations of the committee in the
resolution addendum and resolution letter?
11. Once a patient has been clinically examined, under no circumstances should the committee (or a
committee member) contact the dentist under review, or the patient, in an attempt to resolve the case
amicably. The case must, at this point, be resolved through a formal letter of resolution with the
determination being based on pertinent information reviewed and the clinical examination. Should the
dentist and patient reach a settlement after the clinical examination, the resolution letter and addendum
must be drafted and held in the case file. The case must be closed with Notification of Settlement (Form
#47).
12. Legal counsel for any party involved in the review is not permitted to be present during any portion of the
meeting.
13. No recording or eves-dropping devices are permitted during any peer review meeting.
Dentist Interview
The dentist interview must be conducted in a professional and diplomatic manner following the patient examination.
Interview Guidelines
 It is not an interrogation
 It must not be hostile
 DO NOT make accusations
3-3 Rev: 3/5/16

 DO NOT answer questions regarding the case or examination

 It is the treating dentist’s opportunity to present his or her side of the story
1. The dentist interview, if applicable, follows the patient's interview and examination. Patient and dentist must
never be interviewed together. The dentist interview must be conducted by a minimum of three peer review
committee members.
2. If the dentist attends the meeting, he or she shall be excused after being given an opportunity to present his
or her position. No deliberations shall take place while the dentist under review is present and the dentist
must not be advised of any interim or tentative decisions of the committee.
3. The chair must explain how the interview will be conducted to the treating dentist prior to the interview.
Give the dentist ample time to state his or her case and ask at the conclusion if he or she has anything further
to contribute.
4. The committee must not address questions raised by the treating dentist regarding any aspect of the case.
The dentist interview is an opportunity for the treating dentist to elaborate on the patient complaint and/or
treatment records. If you have questions concerning his or her treatment records, ask for clarification or
interpretation. If further complaints have been presented by the patient at the clinical examination, the
dentist must be given an opportunity to respond in writing.
5. Do not discuss any evidence, findings, or conclusions of the case with the dentist during the interview.
6. Staff members of the dentist under review are not permitted to be present during any portion of the meeting.
Such staff members, however, may submit written information to the committee.
7. Legal counsel for any party involved in the review is not permitted to be present during any portion of the
meeting.
8. No recording or eves-dropping devices are permitted during any peer review meeting.
Peer Review Committee Meeting

Following the patient examination and the dentist interview, the examining committee must discuss all the evidence
reviewed, discuss results of the clinical examination, and decide each case by majority vote of those members present
(an uneven number of dentists, a minimum of three). The following procedures are pertinent to all review committee
meetings:
1. Thoroughly review the case material again. Each examiner must discuss with the committee his or her clinical
examination findings as they were recorded on the clinical examination worksheet. Then address the
following questions:
a. According to the Quality Evaluation Manual, do the findings deem the treatment to meet the
guidelines of dental care as set forth by the California Dental Association?
b. Is it possible that a portion of the treatment meets the guidelines while another portion does not?
c. Has the treatment possibly caused the patient further damage that will necessitate corrective
treatment?
d. Does the patient have a periodontal problem that was possibly untreated and/or undiagnosed?
e. Always evaluate the diagnosis and treatment plan.
2. After discussion of the above, the committee must make an unbiased and unprejudiced determination of the
case. The decision of the committee must be by majority vote. It must be noted that once a patient has been
clinically examined, under no circumstances should any member of the committee contact the dentist
under review or make suggestions to the patient on how the case could be amicably resolved. The case
must, at this point, be resolved through a formal letter of resolution with the determination being based on
the committee's findings.
3. Using the notes from the clinical examination worksheets, write a Resolution Addendum (Form #63) that
addresses exactly what was seen during the examination and that addresses all treatment in question. The
resolution addendum must support the committee's determination as stated in the resolution letter. This
written clinical description is attached to the dentist's copy of the resolution letter.
3-4 Rev: 3/5/16

4. Draft a resolution letter using the Resolution Letter Worksheet (Form #59) and Resolution Letter Guidelines
(Form #60) from your Peer Review Manual. If you consider each one of the questions asked in the guidelines,
your letter should cover everything needed to make it procedurally correct.
5. Forward the drafted resolution letter, resolution addendum, and clinical examination worksheets to CDA.
Additionally, the draft resolution letter and resolution addendum must also be forwarded to peer review staff
via e-mail.
6. Once the committee concludes the review, the case must be discussed with no one. The case must only be
discussed by the committee members again if there is a question to be answered for CDA. Resolutions
returned for clarification must be rewritten by the committee, making necessary corrections or amendments
according to the comments provided by the CDA Council on Peer Review. A new letter of resolution must
be written and the procedures previously outlined must be followed, unless otherwise notified. Forward the
revised resolution letter and addendum to CDA peer review staff via e-mail.
In situations where resolutions are remanded by either the Advisory Panel Subcommittee or a member of the
CDA Council on Peer Review or the Appeals Panel to the component or specialty peer review committee,
which requires review of new evidence provided by the patient, the dentist under review must be given the
opportunity to respond.
Use of the Clinical Examination Worksheet

All peer review component and/or specialty committee members must carefully review the complaint (Patient’s
Request for Review Form (Form #3)) prior to the clinical examination and prepare the clinical examination
worksheets.
List your findings for each portion of the complaint and then indicate the appropriate code from the Quality
Evaluation Manual, i.e., Romeo, Sierra, Tango or Victor. Detailed notes of the peer review committee’s findings must
be included in all the clinical examination worksheets.
If a case is appealed, it may be necessary to refer to the clinical examination worksheets several months after the
patient examination. If the clinical examination worksheets are incomplete or illegible, they will not be a reliable
source of reference.
Send copies of the Clinical Examination Worksheets (minimum three), and the typed Resolution Addendum (Form
#63), Resolution Letter (Form #59), to the CDA peer review staff.
If a clinical examination of the patient was not performed, the Clinical Examination Worksheets must still be
completed to document radiographic and record findings.
Purpose of the Resolution Addendum (Form #63)

The purpose of the Resolution Addendum is to support the committee’s decision and to inform the dentist of the
actual clinical condition of the treatment in question, as noted during a clinical examination of the patient and/or
records, and to explain to the dentist how the committee arrived at its decision regarding the patient's chief
complaints.
Clinical Examination Worksheets have been provided in the manual for use when examining the patient. A clinical
examination worksheet must be completed by each examining dentist and must address each of the patient's
complaints, indicating exactly what is being examined, and the clinical condition at time of the examination. A clinical
examination worksheet must be completed even if the patient was not examined. These clinical examination
worksheets are used to write the final Resolution Addendum (Form #63) that will be mailed to the treating dentist
with the Resolution Letter (Form #59). Fact and accuracy are imperative. The Resolution Addendum (Form #63) must
support the final determination made by the committee in the Resolution Letter (Form #59).
3-5 Rev: 3/5/16

The Resolution Addendum (Form #63) is a separate part of the dentist's copy of the Resolution Letter. A Resolution
Addendum is included regardless of whether the treatment is acceptable or unacceptable. THE PATIENT IS NOT
COPIED ON THIS ADDENDUM.
If a determination cannot be made after a case proceeds through the entire review process, an addendum may be
included with the resolution letter to the dentist under review to convey that a thorough review of the evidence was
conducted. Otherwise, an addendum will not be provided in non-determination cases.
The resolution addendum MUST include:

1. Treatment in question.
2. Clinical evaluation. Actual evidence from the examination including teeth numbers, types and description of
restorations, periodontal findings, prosthesis descriptions, committees’ clinical findings, etc.
3. Radiographic evaluation, types(s) and date(s) of radiographs. What is seen and where.
4. Treatment notes. Evidence from patient records, i.e., images, study models, materials, diagnosis, treatment
plan, carrier information, contracts, consent forms, pertinent evidence contributing to the conclusion.
5. Conclusion. Determination of the committee.
The resolution addendum may NOT contain:

1. Information unrelated to the treatment in question, such as results of a full mouth comprehensive clinical
examination.
2. Reprimands, advice, treatment planning, refund information, consulting/subsequent treating dentist’s
names, or information unrelated to the patient's complaint or the clinical findings.
Preparation of Resolution Letter

When any case is resolved within the peer review system, regardless of its source or type, a resolution letter with an
attached resolution addendum and clinical examination worksheets (minimum three) must be forwarded to the
CDA Council on Peer Review for evaluation, approval, and finalization prior to distribution. The basis for this
directive is that if any concerns arise on the council's part with regard to the wording of the resolution on a legal,
procedural, or policy ground, it is preferable for the council to communicate with the component on a confidential
basis, rather than involving all parties.
In order to be consistent, the format and guidelines for writing letters of resolution are listed on the following pages.
Letters of resolution that are not consistent with the format and guidelines will be returned to the component
dental society for corrections.
Resolution Format
 Final resolutions must be typed in a neat draft form and forwarded via e-mail copy to CDA for review and
finalization.
 If the review was conducted by a specialty committee, this must be addressed in the resolution.
 The resolution is to be addressed to the party that initiated the review.
 Parties directly involved in the review are to be copied on the letter of resolution. (This does not include
consulting dentists, nor would it include the carrier if carrier failed to cooperate with the review committee.)
Guidelines for the Resolution Letter (Form #60), Refund (Form #61), and Corrective Treatment Guidelines (Form
#62) can be found in the Forms/Form Letters section of this manual.
Requirements of a Resolution Letter

The Resolution Letter Worksheet (Form #59) in the Forms/Form Letters section of this manual was developed as a
guide in preparing the resolution letter. A resolution letter must contain the following items:
1. A statement specifying who requested the review, the type of inquiry (i.e., quality of care, appropriateness,
etc.), and the parties involved.
3-6 Rev: 3/5/16

2. The committee must provide a complete description of the initiator's concerns, using the verbiage of the
initiator.
3. List the procedures followed by the committee and the evidence considered in conducting a review:
a. A review of the inquiry.

b. Clinical examination.
c. Information from the carrier, if appropriate.
d. Information from the consulting/subsequent treating dentist.
e. Information from the treating dentist.
f. If radiographs and study models were reviewed, note in the resolution letter.
4. Summarize the committee's recommendation for final action:
 The treatment in question meets the guidelines for dental care as set forth by the CDA; therefore,
no recommendation is made for a refund or retreatment. In a non-clinical manner, explain to the
patient why the dental treatment is acceptable.
 Partial refunds/adjustments may be considered when a patient has paid in advance or has been
billed for a treatment plan and a review is initiated prior to completion of the treatment. If the
treatment in question meets CDA guidelines but is incomplete, a refund/adjustment may be
awarded for the portion of the treatment that was not completed. (See Incomplete Treatment
section of this manual.) A thorough explanation of the reason for the partial refund and/or
adjustment must accompany the ruling. NOTE: No refunds/adjustments for incomplete treatment
must be considered when there is a written contract or other written agreement that states that the
payment is made in advance and there will be no refunds.
 The patient’s complaint is valid (the treatment in question is unacceptable and does not meet the
guidelines for dental care as set forth by the CDA):
(1) A refund not to exceed the original fee collected must be proposed in the resolution.
(2) If further damage was caused and corrective dental treatment is necessary, refer to the
Corrective Treatment Guidelines (Form #62) for proper procedures.
5. A resolution containing a recommendation for a refund must include an additional paragraph that outlines
the procedures to be followed for carrying out the refund.
These procedures are:
a. The dentist is to make out a draft, check, or money order in the specified amount to the patient
and/or carrier and forward it to the CDA within fourteen (14) calendar days following expiration of
the appeal period if there is no appeal. NOTE: If a carrier fails to provide information and/or does
not confirm their willingness to reestablish patient's eligibility for the amount of the refund without
affecting current remaining yearly benefits, the carrier's portion of the refund will go directly to the
patient.
b. Upon receipt of the dentist's refund check(s) and the signed Release of All Claims form, peer review
staff will record and forward the check(s), to the patient and/or carrier. The carrier's check will be
forwarded to reestablish eligibility.
c. In the event a committee recommends corrective treatment, the resolution letter must include
language specifying the limitations of the corrective treatment. The patient must be advised to
submit a written corrective treatment plan and cost estimate to CDA for review and approval within
thirty (30) calendar days from the expiration of the appeal period or the determination of any appeal
of the decision. The component or specialty peer review committee and the CDA Council on Peer
Review must review and approve all corrective treatment plans and cost estimates prior to informing
the parties involved. The approved corrective treatment amount is to be paid in full by the dentist
at fault. The resolution letter must also state that if a corrective treatment plan and cost estimate is
3-7 Rev: 3/5/16

not postmarked from the patient within the thirty (30) calendar day specified time period, and/or if
reasonable reason for failing to do so is not provided in writing, the cost of the corrective treatment
will be the responsibility of the patient. At the discretion of CDA, an extension for submitting a
corrective treatment plan and cost estimate may be granted if deemed appropriate and necessary.
(For further instructions, please see Form #62 – Corrective Treatment Guidelines.)
6. If the committee recommends a partial refund, the resolution will be screened by the CDA Advisory Panel
Subcommittee before authorization for release will be given by the CDA Council on Peer Review staff. The
committee’s decision for a partial refund and the rationale in figuring the dollar amount must be thoroughly
explained in all cases.
While it is possible that a single denture of a pair can be judged unacceptable on the basis of esthetics or
extension, when the problem is one of occlusion, stability, or retention, it is difficult to conceive of a
situation where the opposing denture is not a contributing factor. Therefore, a partial refund for a peer
review case involving dentures will only be approved by the Advisory Panel Subcommittee when the
component or specialty peer review committee has specifically outlined the clinical findings and relationships
of the dentures in a manner which would clearly demonstrate that the acceptable denture does not in any
way contribute to the unacceptability of the opposing denture.
7. All final resolution letters must be sent by CDA peer review staff to the parties involved with a copy of the
Appeal Criteria Statement (Form #29). There must also be a statement in the resolution letter indicating the
decision is not final until the expiration of thirty (30) calendar days without an appeal filed by either party or
the determination of any appeal of this decision.
8. The Resolution Addendum (Form #63) supporting the decision of the committee is to be submitted to CDA
in addition to the resolution letter. This attachment is to be sent only to the dentist with his or her copy of
the final resolution letter from CDA peer review staff. A Resolution Addendum (Form #63) is required for
all cases that result in a “meets” or “fails to meet” the guidelines determination.
9. The signature line of the resolution letter must be listed as: Council on Peer Review.
Counseling the Dentist

Occasionally, the committee may feel that the dentist involved in a particular peer review needs some “one-on-one”
attention. This may be true for various reasons. The dentist may lack an understanding of the appropriate standard of
care, or lack an understanding of the peer review system and how it functions. If a dentist is in danger of becoming a
“pattern of practice” dentist, i.e., three adverse peer review decisions in a 24-month period, or one case of absolute
grossly inappropriate or grossly inadequate treatment, it may be wise to talk with the dentist. A dentist that is
developing a track record of problems may benefit and appreciate some advice or counseling from the peer review
committee. A contact such as this, if performed in an appropriate manner, will show the committee as a
compassionate entity, interested in the well-being of the dentist as well as his or her patients. However, counseling
should not become a part of any peer review records. Neither should the dentist be contacted and/or counseled prior
to the resolution of the peer review case. Once the appeal period is closed or after the determination of an appeal, the
committee could either arrange a private meeting with the dentist, or a completely separate letter could be mailed.
Remember that counseling of a dentist is not a part of the peer review system. It would be an action taken solely at the
discretion of the committee.
3-8 Rev: 3/5/16

IV. Appeals
General Overview
The appeal process has been established to ensure that the CDA peer review process has been administered correctly
by the general and specialty peer review committees. The Appeals Panel will only review and address issues raised by
the appellant(s) that meet one or more of the applicable appeal criteria. Should the panel determine that none of the
issues raised by the appellant meet the applicable appeal criteria, the appeal request will be denied and the matter will
be considered closed.
I. Resolution Letter
Any party to a peer review, has the right to submit a request for an appeal to the CDA Council on Peer Review
Appeals Panel within thirty (30) calendar days from the date of the resolution letter (weekends and holidays are
included). All parties to the review must be apprised, at the time of resolution, of this right and the time limitation in
which to submit an appeal. An Appeal Criteria Statement (Form #29) is included with all resolution letters.
The Appeals Panel will not examine specific evidence such as radiographs, study models, etc., or re-interview a
dentist/re-examine a patient. However, if the Appeals Panel deems it necessary, they may request that the peer review
committee re-interview the dentist or re-examine the patient and consider additional information/evidence.
If an error is discovered in the letter of resolution after it has been mailed to the parties involved (e.g., incorrect
refund, patient no longer covered by insurance, insurance refund was erroneously omitted, etc.) an amended letter
must be drafted by the Appeals Panel. The amended letter is not to be mailed prior to the expiration of the original
thirty (30) calendar day appeal period or determination of an appeal prior to approval by CDA Council on Peer
Review.
Non-Appealable Issues
1. Cases that are inappropriate for review, or which result in a "non-resolution" letter are not appealable and
therefore, do not receive a thirty (30) calendar day appeal period.
2. Issues related to incorrect refunds, insurance refunds erroneously omitted, or the patient is no longer covered
by their insurance carrier, are not appealable. These types of matters will be dealt with by CDA peer review
staff.
3. Partial refunds involving dentures are not an issue subject to appeal.
Appeal Review Procedures

The following are procedures in processing an appeal request:
1. Appeal requests received by the Appeals Panel with a postmarked date within thirty (30) calendar days from
the date of the peer review resolution letter will be screened by CDA peer review staff to determine the
appropriateness based upon fulfillment of the criteria necessary for an appeal review. Facsmile transmission
of appeals will not be accepted.
2. Upon receipt of the appeal request, the Appeals Panel will inform the component, dentist, patient, and
carrier(s) (when applicable) that the appeal request has been received.
3. CDA peer review staff screens the request for appeal to determine its appropriateness, using the screening
criteria detailed below:
a. Was the appeal postmarked within thirty (30) calendar days from the date of the resolution letter?
b. Does the appeal request factually demonstrate that either one or more appeal criteria have been
met?
4-1 Rev: 11/18/13

CDA Peer Review Manual Appeals
4. Appeal requests will be denied if they are not postmarked within thirty (30) calendar days from the date of
the resolution letter (weekends and holidays are included), or do not meet one or more appeal criteria.
Procedures for denial are as follows:
a. Requests which are considered to be inappropriate for appeal after the initial screening by CDA
peer review staff will be forwarded to the Appeals Panel for their review and comment. The
rationale for the determination will be included.
b. If the Appeals Panel agrees with the preliminary screening/recommendation, the appeal request will
be denied, the case closed and the component peer review decision will become final and binding
for all parties. All parties will subsequently be notified in writing of the Appeals Panel decision and
no further review of the case will be entertained by the CDA peer review system.
c. If, however, the Appeals Panel disagrees with the preliminary screening/ recommendation, the
appeal request will proceed through the regular appeal review process.
5. Appeal requests will be accepted if they are determined to meet the established criteria for acceptance. Such
requests are processed as follows:
a. The Appeals Panel will mail a letter to the component/specialty peer review chair requesting a
written response to the appealed issue(s). The component/specialty chair will be requested to mail
the written response to the Appeals Panel within fourteen (14) calendar days from the date of the
panel's request. The purpose of the written response is to specifically address the issue(s) raised in
the appeal request.
b. When the written response to the appeal statement and all other pertinent information is received
by CDA peer review staff, the entire case file will be forwarded to the Appeals Panel.
c. The Appeals Panel will thoroughly and objectively examine and review the entire case file and
render its decision accordingly. The decision made by the Appeals Panel shall be one of the
following:
 Uphold - If the peer review committee is able to demonstrate that the appellant’s
allegations are unfounded, the decision of the peer review committee will be upheld.
The Appeals Panel’s final decision will be drafted by CDA peer review staff, under the
direction of the Appeals Panel. All parties will subsequently receive the final decision in
writing. The decision will be final and binding and the case will be closed. Consequently,
no further review of the case will be entertained by the CDA peer review system.
 Remand - If the Appeals Panel believes that additional information and/or further
clarification of the issues is required from the peer review committee in order to render a
decision, the case will be remanded to the component/specialty chair to specifically address
those issues. The chair must respond to the Appeals Panel within fourteen (14) calendar
days of receipt of the remanded letter.
In situations where resolutions are remanded by the Appeals Panel to the component
which require the component committee to review new evidence, the dentist must be
given the opportunity to respond (if applicable).
Upon CDA's receipt of this information, the entire case file will be forwarded to the
Appeals Panel for re-examination. If the Appeals Panel, upon its re-examination of the
case, concludes that the component has inadequately addressed the Appeals Panel’s
concerns, the case may be remanded a second time. Subsequently, a final decision will be
rendered and all parties involved will be notified of the Appeals Panel’s decision.
4-2 Rev: 11/18/13

 Overrule/Re-Review - If the component refuses to make the appropriate, necessary

corrections after remand, the Appeals Panel is authorized to correct the discrepancies in
the resolution and/or resolution addendum, and mail it to all parties involved on CDA
letterhead.
Should there be an appearance of a conflict of interest alleged by either party to the

dispute, the case will be referred to another component at the discretion of the Appeals
Panel, for re-review.
6. If the factual conclusions of the peer review committee's original decision are changed by either the
committee or panel, the Appeals Panel will draft an Amended Resolution (Form #66) and/or amended
resolution addendum (Form #75). The resolution should always offer another thirty (30) calendar day appeal
period UNLESS the resolution merely corrects an erroneously calculated refund amount, clarifies a
refund/corrective treatment amount, corrects a typographical error, or makes any other clarification that does
not change the decision of the peer review committee.
II. Corrective Treatment Plan and Cost Estimate Approval Letter

Any party to a peer review has the right to submit a request for an appeal to the Appeals Panel within fifteen (15)
calendar days from the date of the corrective treatment plan and cost estimate approval letter (Form #94) (weekends
and holidays are included). All parties to the review must be apprised at the time of the approval letter of this right
and the time limitation in which to submit an appeal. An appeal criteria statement (Form #29A) is included with all
approval letters.
The Appeals Panel will not examine specific evidence such as x-rays, study models, etc., or re-interview a dentist/re-
examine a patient. However, if the Appeals Panel deems it necessary, they may request that the peer review committee
consider additional information/evidence.
If an error is discovered in the corrective treatment plan and cost estimate approval letter after it has been mailed to
the parties involved (e.g., approved corrective treatment is misidentified, incorrect cost estimate, etc.), an amended
approval letter must be drafted and forwarded to CDA for approval. The amended approval letter is not to be mailed
prior to the expiration of the original fifteen (15) calendar day appeal period or prior to approval by the Appeals Panel.
Corrective Treatment Plan and Cost Estimate Appeal Review Procedures

The following are procedures in processing an appeal request:
1. Appeal requests received by the Appeals Panel with a postmarked date within fifteen (15) calendar days from
the date of the corrective treatment plan and cost estimate approval letter will be screened by CDA staff to
determine their appropriateness based upon fulfillment of the criteria necessary for an appeal review.
Facsmile transmission of appeals will not be accepted.
2. Upon receipt of the appeal request, the Appeals Panel will inform the component, dentist, and patient that
the appeal request has been received.
3. Initially, CDA staff screens the request for appeal by determining its appropriateness using the screening
criteria detailed below:
a. Was the appeal postmarked within fifteen (15) calendar days from the date of the corrective
treatment plan and cost estimate approval letter?
b. Does the appeal request factually demonstrate that either one or more appeal criteria have been
met?
4. Appeal requests will be denied if they are not postmarked with a postmarked date within fifteen (15) calendar
days from the date of the corrective treatment plan and cost approval letter (weekends and holidays are
included), or do not meet one or more appeal criteria.
Procedures for denial are as follows:
4-3 Rev: 11/18/13

a. Requests which are considered to be inappropriate for appeal after the initial screening by CDA
peer review staff will be forwarded to the Appeals Panel for their review and comment. The
rationale for the determination will be included.
b. If the Appeals Panel agrees with the preliminary screening/recommendation, the appeal request will
be denied and the corrective treatment plan and cost estimate approval will become final for all
parties. All parties will subsequently be notified in writing of the Appeals Panel decision and no
further review of the corrective treatment plan and/or cost estimate will be entertained by the CDA
peer review system.
c. However, the Appeals Panel disagrees with the peer review staff’s preliminary screening/
recommendation, the appeal request will proceed through the regular appeal review process.
5. Appeal requests will be accepted if they are determined to meet the established criteria for acceptance. Such
requests are processed as follows:
a. The Appeals Panel will mail a letter to the component/specialty peer review chair requesting a
written response to the appealed issue(s). The chair will be requested to mail the written response to
the Appeals Panel within ten (10) calendar days from the date of the panel's request. The purpose
of the written response is to specifically address the issue(s) raised in the appeal request.
b. When the Appeals Panel has received the component's/specialty committee’s written response to
the appeal statement and all other pertinent information, the entire case file will be forwarded to
the Appeals Panel.
c. The Appeals Panel will thoroughly and objectively examine and review the entire file and render its
decision accordingly. The decision made by the Appeals Panel shall be one of the following:
 Uphold - If the peer review committee is able to demonstrate that the appellant’s
allegations are unfounded, the decision of the component/specialty peer review committee
regarding the approved corrective treatment plan and cost estimate will be upheld.
The Appeals Panel’s final decision will be drafted by CDA peer review staff, under the
direction of the Appeals Panel. All parties will receive the final decision in writing. The
decision will be final for all parties. Consequently, no further review of the corrective
treatment plan and cost estimate will be entertained by the CDA peer review system.
 Remand - If the Appeals Panel believes that additional information and/or further
clarification of the issues is required from the peer review committee in order to render a
decision, the corrective treatment plan and cost estimate will be remanded to the
component/specialty chair to specifically address those issues. The component/specialty
chair must respond to the Appeals Panel within ten (10) calendar days of receipt of the
remanded approval letter.
In situations where approval letters are remanded by the Appeals Panel to the
component/specialty peer review committee, which requires the component/specialty peer
review committee to review new evidence, the dentist must be given the opportunity to
respond.
Upon CDA's receipt of this information, the entire case file will be forwarded to the
Appeals Panel for its re-examination. If the Appeals Panel, upon its re-examination of the
file, concludes that the component/specialty committee has inadequately addressed the
Appeals Panel’s concerns, the corrective treatment plan and cost estimate may be
remanded for a second time. Subsequently, a final decision will be rendered and all parties
involved will be notified of the Appeals Panel’s decision.
4-4 Rev: 11/18/13

 Overrule/Re-Review - If the component refuses to make the appropriate, necessary

corrections after remand, the Appeals Panel is authorized to correct the discrepancies in
the corrective treatment plan and cost estimate approval letter, and send them out on
CDA letterhead.
Should there be an appearance of a conflict of interest alleged by either party to the

dispute, the case will be referred to another component at the discretion of the Appeals
Panel, for re-review.
6. If the factual conclusions of the peer review committee’s original corrective treatment plan and cost estimate
approval letter are changed by either the committee or the Appeals Panel, the Appeals Panel will draft an
Amended Corrective Treatment Plan and Cost Estimate Approval Letter (Form #94). The approval letter
must always offer another fifteen (15) calendar day appeal period UNLESS the approval letter merely clarifies
a corrective treatment amount, corrects a typographical error, or makes any other clarification that does not
change the decision of the peer review committee.
4-5 Rev: 11/18/13

V. Over-Utilization Review Procedures
The over-utilization review system was approved by the Board of Trustees in March 1984. The following procedures
are to be followed by the component peer review committee when conducting carrier-initiated over-utilization reviews.
The purpose of an over-utilization review being requested by a carrier is to show a pattern of over-utilization by the
dentist. The findings in an over-utilization review could result in a refund to the carrier by the dentist and the dentist
being referred to the CDA Judicial Council for investigation.
All over-utilization reviews requested by a carrier involving a specialist should be handled by the component peer
review committee where the treatment was rendered using the expertise of a dentist from the particular specialty
involved. This must be done in the interest of time as it would be impossible to send the case to the specialty
committee and stay within the suggested working time frame.
If, during a review and patient examination, the component peer review committee determines that the dentistry
proposed or already performed is grossly inadequate or grossly inappropriate, the component peer review committee
should forward a separate cover letter along with the letter of resolution to the CDA Council on Peer Review
requesting that the case be referred to the CDA Judicial Council for possible referral to the Dental Board of
California.
Receipt of Request for Over-Utilization Review from Carrier

When an over-utilization review is requested by a third party carrier, the following steps should be taken:
1. Screen the written request to make sure it includes the following:
a. Description of the problem.

b. Specific questions the review is to address.
c. Copy of carrier's consultant evaluation.
d. Copies of claim forms, preauthorization form if available, radiographs and any other
correspondence pertinent to the case.
e. A signed Carrier Agreement Form (Form #68) (or a statement in the initial letter of request for
review) stating that the carrier will abide by the decision of the committee on all cases not pertaining
to issues concerning services covered under dental contracts.
f. A check payable to CDA for the proper amount to cover the review. This amount will be $500.00
per case and is non-refundable.
2. A Notification of New Case (Form #10) must be completed and a copy forwarded to the component chair
and component staff.
3. Complete the Peer Review Checklist (Form #12). (Refer to Screening Procedures Section II –
Responsibilities of the Peer Review Staff.)
90-Calendar Day Time Limitation for Review
CDA
The letter to the dentist requesting information must be mailed by certified mail return receipt requested, and will
allow a maximum of seven (7) calendar days from date of receipt to respond with requested information. The letter to
the dentist will state that failure to do so will result in the review continuing without benefit of dentist information, as
well as a probable referral to the Judicial Council for non-compliance.
If these time limitations cannot be met by any party involved for any reason, contact the Council on Peer Review.
a. When a request from a carrier is received, CDA will have seven (7) calendar days to complete the
screening, gather additional information needed, and assign the case to the component peer review
5-1 Rev: 11/18/13

CDA Peer Review Manual Over-Utilization Review Procedures
committee for a clinical examination. NOTE: No Record Release or Patient Agreement forms
will be necessary.
b. The component peer review committee will have thirty (30) calendar days to perform a clinical
examination if necessary and submit a resolution letter to the CDA Council on Peer Review.
c. If additional information is necessary from the carrier, CDA’s request letter will be sent by certified
mail return receipt requested, and will allow the carrier a maximum of seven (7) calendar days from
date of receipt to respond. The letter will state that failure to do so will result in the review being
terminated.
d. Upon receipt of the Resolution Letter (Form #59) CDA will have seven (7) calendar days to review
the resolution letter and either approve as written or contact the component for additional
information. The component peer review committee will then have seven (7) additional calendar
days to supply the requested information and/or submit a redrafted resolution.
e. CDA will approve and finalize the resolution. CDA will mail the resolution to the involved parties
by certified mail return receipt requested, and will forward a copy to the component peer review
committee chair.
f. Carrier and dentist will have ten (10) calendar days from date of the resolution letter to initiate an
appeal.
Appeals
a. The carrier or the dentist must forward a written statement to the Council on Peer Review’s Appeals
Panel outlining the reason for an appeal within ten (10) calendar days from the date of the
resolution letter.
b. CDA will have thirty (30) calendar days to conduct an appeal. The appeal process begins the date
the appeal request is received by CDA.
c. Final decision will be mailed to the carrier and dentist by the end of the thirty (30) calendar days.
5-2 Rev: 11/18/13

VI. Referrals to the Judicial Council
Dentist Non-Compliance with the Final Decision

In the event a member elects not to comply with the final decision, the CDA Council on Peer Review will refer the
matter to the CDA Judicial Council for violation of Section 3 of the CDA Code of Ethics.
1. Procedures to be followed by CDA peer review staff:
a. Send the dentist, by certified mail return receipt mail, the Dentist Non-Compliance with
Resolution Decision Letter (Form #52 - first notice).
b. Recall file in fourteen (14) calendar days.
c. If the dentist complies within the specified time frame, proceed with the case review.
d. If the dentist fails to comply by the specific date, staff must contact the dentist by telephone to
confirm that the dentist has received the request for the refund.
e. If the dentist fails to respond by the specified date, send the dentist, by certified return receipt
mail, the Dentist Non-Compliance with Resolution Letter (Form #53) – second notice).
f. Recall the file in fourteen (14) calendar days.
g. If the dentist fails to respond by the recall date, send the Council on Peer Review the “Memo
Requesting Approval for Referral to Judicial Council.” If the Council on Peer Review approves the
referral, send the dentist the CDA Notification to Dentist Referral to CDA Judicial Council (Form
#53A).
h. If the Council on Peer Review does not approve the referral to the Judicial Council, the case will be
returned to staff with instructions about procedures to be followed.
i. If the dentist complies with the request at any time prior to the referral to the Judicial Council, the
file will be closed and no further action will be taken.
j. No further action will be taken by the Council on Peer Review unless otherwise requested by the
Judicial Council.
Patterns Of Practice
To identify and process pattern of practice cases, the following procedures will be utilized:
1. When a potential pattern of practice becomes apparent, the Council on Peer Review will consider the case
files for only the following:
 appropriateness for review
 procedural integrity
 decision "not arbitrary"
2. As a general guideline, if there are at least three adverse decisions for cases initiated within a twenty-four (24)
month period, the pattern is appropriate for referral and the Council on Peer Review will forward the CDA
Judicial Council copies of the complaints, resolution letters and resolution addenda.
3. The CDA Council on Peer Review will advise the dentist and the component of the action taken.
4. The CDA Judicial Council may refer the case to the Dental Board of California for its investigation.
5. This process does not apply to utilization cases.
Grossly Inadequate/Inappropriate Treatment

Grossly Inadequate Treatment: Dentistry provided to a patient which does not correct the pathological condition it
was intended to correct, or fails prematurely under normal conditions of use, or fails to meet acceptable esthetic
standards, or facilitates and/or contributes to the worsening of the patient’s dental health, and/or leaves a disease
entirely untreated or undiagnosed. However, for the purpose of referral to the CDA Judicial Council, the above
definition should not be so narrowly enforced as to base a referral on only one tooth but rather on the overall
evaluation of the work performed or unperformed by the treating dentist.
6-1 Rev: 04/05/16

CDA Peer Review Manual Referrals to the Judicial Council
Grossly Inappropriate Treatment: Dentistry performed that is unnecessary and/or unwarranted. The quality of the
treatment need not be in question. This type of treatment can include, but is not limited to; dentistry performed solely
for profit; dentistry performed for which the treating dentist is inadequately trained; dentistry performed that leads to
a pathological condition that did not exist prior to treatment; and dentistry performed when a prognosis is so poor
that immediate failure is readily apparent; or treatment which endangers the patient’s general health.
In a situation involving a single case of grossly inadequate or inappropriate treatment, the following procedural steps
are as follows:
1. When a peer review committee determines that a single peer review case demonstrates "grossly inadequate or
grossly inappropriate treatment," a separate letter regarding possible endorcement of the CDA Code of Ethics
should be directed from the peer review committee to the CDA Council on Peer Review at the time the
proposed letter of resolution is drafted. A copy of the case file must be forwarded, with the draft resolution
letter and resolution addendum, to the CDA Council on Peer Review outlining the basis of the committee's
request for referral.
2. Following the expiration of the appeal period or the determination of any appeal of the decision, the CDA
Council on Peer Review will review the file. If the CDA Council on Peer Review concurs, the council will
forward the CDA Judicial Council a copy of the complaint, resolution letter and resolution addendum.
3. If the component/specialty committee fails to identify and advise the Council on Peer Review of the “grossly
inadequate or grossly inappropriate treatment,” the Council on Peer Review may refer the case directly to the
Judicial Council for possible enforcement of the CDA Code of Ethics, following the expiration of the appeal
period or the determination of any appeal of the decision.
4. The Council on Peer Review will inform the dentist and the component of the action taken.
False or Fraudulent Insurance/Health Care Benefit Claims/Alleged Fraud

or Billing Irregularities
False or Fraudulent Insurance/Health Care Benefit Claims: In Section 1871(a) of the California Insurance Code,
the legislature has declared:
“(a) The business of insurance involves many transactions that have the potential for abuse and illegal activities.
There are numerous law enforcement agencies on the state and local levels charged with the responsibility for
investigating and prosecuting fraudulent activity. This chapter is intended to permit the full utilization of the
expertise of the commissioner and the department so that they may more effectively investigate and discover
insurance frauds, halt fraudulent activities, and assist and receive assistance from federal, state, local and
administrative law enforcement agencies in the prosecution of persons who are parties in insurance frauds.
….
(h) Health insurance fraud is a particular problem for health insurance policyholders. Although there are no
precise figures, it is believed that fraudulent activities account for billions of dollars annually in added health
care costs nationally. Health care fraud causes losses in premium dollars and increases health care costs
unnecessarily.”
To deal with the health care fraud, the Legislature has added a section to the Penal Code, making it a crime to engage
in health care fraud. Under Section 550 of the Penal Code, it is a felony to knowingly present false or fraudulent
claims to an insurer, including a health care insurer; to knowingly make multiple claims for the same loss or injury; to
knowingly make or prepare an oral or written statement with intent to use the same in support of any false or
fraudulent claim; or to conceal or knowingly fail to disclose the occurrence of an event that affects any person’s initial
or continued right to any insurance benefit.
Every person who violates Section 550 may be punished by imprisonment for two to five years and by a fine of up to
$50,000, except a public offense involving a claim of $400 or less, is only punishable by imprisonment in the county
jail not to exceed six months and by a fine not to exceed $1,000 or both.
6-2 Rev: 04/05/16

Section 810 of the California Business and Professions Code provides:
“(a) It shall constitute unprofessional conduct and grounds for disciplinary action, including suspension or
revocation of a license or certificate, for a health care professional to do any of the following in connection
with his or her professional activities:
(1) Knowingly present or cause to be presented any false or fraudulent claim for the payment of a loss
under a contract of insurance.
(2) Knowingly prepare, make, or subscribe any writing, with intent to present or use the same, or to
allow it to be presented or used in support of any such claim.
(b) It shall constitute cause for revocation or suspension of a license or certificate for a health care professional to
engage in any conduct prohibited under Section 1871.4 of the Insurance Code or Section 549 or 550 of the
Penal Code.
(d) As used in this section, health care professional means any person licensed or certified pursuant to this
division, or licensed pursuant to the Osteopathic Initiative Act, or the Chiropractic Initiative Act.”
If the exact language of these sections of the code is required, it may be obtained from the CDA Legal Department.
Alleged Fraud Or Billing Irregularities

Irregular billing includes billing for services in a manner which is fraudulent, deceitful, or misleading according to
state law and applicable codes [Section 1871.1 of the California Insurance Code and the ADA Principles of Ethics and
Code of Professional Conduct (Section 5.B. Advisory Opinions; 5.B.1. Waiver of co-payment; 5.B.2. Overbilling;
5.B.4. Treatment Dates; 5.B.5. Dental Procedures; and 5.B.6. Unnecessary Services.)].
No case will be accepted as a peer review case until all the proper forms have been completed by the party initiating
review and delivered to CDA. All forms must be legible and capable of being reproduced clearly.
Examples of irregular billing include submitting a claim to a carrier for treatment not yet completed or for procedures
not provided or billing a patient for procedures not provided.
In such instances where alleged fraud or billing irregularities, or false or fraudulent insurance/health care benefit
claims are suspected,, these procedures should be followed:
1. When a peer review committee determines that a peer review case demonstrates possible fraud or a billing
irregularity, or false or fraudulent insurance/health care benefit claims, a letter should be directed from the
peer review committee to the CDA Council on Peer Review at the time the letter of resolution is drafted.
The letter should outline the basis of the peer review committee's request for referral for possible
enforcement of the CDA Code of Ethics. A copy of the case file should be forwarded to the CDA Council
on Peer Review.
2. Following the expiration of the appeal period or the determination of any appeal of the decision, the CDA
Council on Peer Review will review the file. If the CDA Council on Peer Review concurs with the peer
review committee’s recomendations, the council will forward to CDA Judicial Council a copy of the
complaint, resolution letter and resolution addendum.
3. If the component/specialty committee fails to identify and advise the Council on Peer Review of the alleged
fraud or billing irregularities or false or fraudulent insurance/health care benefit claims, the Council on Peer
Review may refer the case directly to the CDA Judicial Council for possible enforcement of the CDA Code
of Ethics, following the expiration of the appeal period or the determination of any appeal of the decision.
4. The Council on Peer Review will advise the dentist and the component of the action taken (Form #53A).
6-3 Rev: 04/05/16

Dentist Drops Membership During Review

In the event a member drops membership during the peer review process, the Council on Peer Review will refer the
matter to CDA Judicial Council for compliance with possible reporting requirements to the Dental Board of
California. In these instances, the following procedures should be followed:
1. Procedures to be followed by the CDA peer review staff:
a. Upon discovering that the dentist under review has dropped his or her membership, CDA peer
review staff must notify the patient immediately that the dentist has dropped membership with
Notification to Patient of Dentist Dropping Membership (Form #48).
2. Procedures to be followed by the Council on Peer Review:
a. The Council on Peer Review will promptly refer the case to the CDA Judicial Council.
b. No further action will be taken by the CDA Council on Peer Review unless otherwise requested by
the CDA Judicial Council.
6-4 Rev: 04/05/16

CDA Peer Review Manual Forms/Form Letters
VII. Forms/Form Letters
Number Forms/Form Letter Title
49 Acknowledgment of Dropped Membership

66 Amended Resolution Letter Worksheet
75 Amended Resolution Addendum Format
29 Appeal Criteria Statement
29A Appeal Criteria Statement for Corrective Treatment Plan and Cost Estimate
30 Appeal Criteria Statement (Over–Utilization Case Review)
05 Authorization for Use and Disclosure of Health Information Form
68 Carrier Agreement Form (Over–Utilization Case Review)
24 Carrier Initiated Review Fee Request
25 Carrier Notification of Incomplete Information
17 Carrier Notification Letter
78 Clinical Worksheet – Complete Dentures Prosthodontics
77 Clinical Worksheet – Crowns & Fixed Partial Prosthodontics
76 Clinical Worksheet – Endodontics
99 Clinical Worksheet – Implants and Implant Prosthodontics
80 Clinical Worksheet – Operative Dentistry
83 Clinical Worksheet – Oral Surgery
82 Clinical Worksheet – Orthodontics
81 Clinical Worksheet – Periodontics
79 Clinical Worksheet – Removable Partial Prosthodontics
18 Consulting/Subsequent Dentist Notification Letter
19 Consulting/Subsequent Treating Dentist Reply Form
62 Corrective Treatment Guidelines
94 Corrective Treatment Plan and Cost Estimate Approval Letter
28 Dentist Invitation Letter to Attend Review Committee
08 Dentist Request for Review Information Form
51 Dentist Non–Compliance During Review Letter (first notice)
91 Dentist Non–Compliance with Records
92 Dentist Non–Compliance with Resolution
52 Dentist Non–Compliance with Resolution Letter (first notice)
53 Dentist Non–Compliance with Resolution Letter (second notice)
13 Dentist Notification and Response Request Letter
22 Dentist Notification Letter (Carrier Initiated)
70 Dentist Notification Letter (Over–Utilization)
09 Dentist Notification of Incomplete Forms (Utilization Review)
14 Dentist Notification Utilization Letter (Patient Initiated)
16 Dentist Will/Will Not Attend Meeting Form
96 Dropped Membership Referral to CDA Memo
26 Examination Panel Notification Memo
86 Explanation of Clinical Examination
35 Final Notification to Patient of Dentist Expulsion/Dropped Membership Further Action
23 Initial Carrier Response Letter
27 Initial Patient Examination Letter
01 Initial Patient Response Letter
02 Initial Patient Response Letter (Utilization Case)
07 Initial Response to Dentist Letter (Utilization Case)
56 Non–Compliance of Consulting/Subsequent Dentist Letter (second notice)
55 Non–Compliance Referral (Pattern of Practice)
7-1 Rev: 3/8/14

40 Non–Member Dentist Requesting Review Letter

39 Non–Routine Case Memo
42 Notification of Benefit Exclusion
41 Notification of CDA Policy Regarding Fee Review
38 Notification of CDA’s Time Limitations
43 Notification of Communication Problem
65 Notification of Complaint Being Processed
44 Notification of Completed/Altered Treatment
57 Notification of Compliance Memo
37 Notification of Deceased Dentist
45 Notification of Litigation or Arbitration
10 Notification of New Case
32 Notification of New Case to Component/Specialty Chair
34 Notification of Non–Member Dentist
47 Notification of Settlement
58 Notification to Committee of Additional Information Received
98 Notification to Dentist/Patient that Case Will Remain at Component
53A Notification to Dentist Referral to Judicial Council
93 Notification to Dentist Referral to Judicial Council (records and resolution)
48 Notification to Patient of Dentist Dropping Membership
88A Notification to Patient of Dentist Referral to Judicial Council (records)
88B Notification to Patient of Dentist Referral to Judicial Council (resolution)
04 Patient Agreement Form
21 Patient Notification Letter (Carrier Initiated)
74 Patient Notification Letter (Dentist’s Appeal to a Carrier’s Decision)
20 Patient Notification Letter (Dentist Initiated)
50 Patient Notification of Failure to Appear
06 Patient Notification of Incomplete Forms
71 Patient Request for Copy of Records/Radiographs Letter (Patient Initiated)
90 Patient Request for Interview
84 Patient Residing in another State Regarding Status of Case Letter
85 Patient Will/Will Not Attend Clinical Form
12 Peer Review Checklist
87 Refund Distribution Worksheet
61 Refund Guidelines
72 Release of All Claims Form
73 Release of All Claims Transmittal Letter
69 Request for Additional Information from Carrier (Over–Utilization Case)
03 Request for Review Form
46 Request for Withdrawal of Litigation/Arbitration
63 Resolution Addendum Format
60 Resolution Letter Guidelines
59 Resolution Letter Worksheet
97 Transfer to Neighboring Component Memo
15 Treating Dentist Reply Form
7-2 Rev: 3/8/14

Form #1
Initial Patient Response Letter
Date
Patient
Address
City, ST Zip Code
Subject: (Dentist) / (Patient)
Dear (Patient):
Thank you for contacting the California Dental Association (CDA) about the dental treatment you received
from the above-named dentist. Before we begin the peer review process, we would like to explain how our
system works.
CDA has developed the peer review system to help resolve disputes regarding dental treatment that the
dentist and patient have not been able to settle themselves. A special committee of dentists, known as a
“peer review committee,” volunteers their time to consider questions about the quality and appropriateness
of dental care. Cases may also be submitted for review when there is a question regarding an insurance
claim. These are the only types of questions that the peer review committee can answer. It is not within the
scope of peer review to provide second opinions regarding treatment recommendations by a treating
dentist.
There is no charge for this service; however, any unusual costs sustained by the peer review committee in
conducting the review, including but not limited to duplicating radiographs, study models or treatment
records, shall be borne by the party initiating the review.
There is a time limitation for accepting a complaint in the peer review system. A complaint must be
received within three years from the date the dental treatment was completed or one year from the date
you recognized there was a problem, whichever occurs first.
The peer review system is an alternative to formal legal proceedings and cannot be used if such proceedings
have begun, or if the case has already been decided by a court of law. We have no authority to supersede the
decisions of a court of law or an arbitrator. If you file a lawsuit against the dentist after the peer review
process begins, the peer review action will cease immediately. If you signed an arbitration agreement with
the dentist, and the dentist elects to invoke the arbitration agreement upon notice of the peer review action,
the peer review action will cease immediately.
Once CDA has your completed paperwork, we will request your records from your dentist(s). After we have
gathered all of the required evidence, your case will be assigned to a peer review committee located as
closely as possible to you.
The peer review committee will review your dental records and, if the committee members determine that it
is necessary, invite you to meet with them so that they may examine the treatment in question. You will be
notified by certified mail of the date, time and location of the examination. If an examination is not
necessary because a decision can be made using only your treatment records, you may request an interview
7-3 Rev: 3/8/14

with the peer review committee by completing the enclosed Patient Request for Interview (Form #90). The
committee may also interview your dentist separately.
The peer review committee will then evaluate all available evidence to make a determination. The decision
will be issued by CDA in the form of a letter of resolution. The letter will be sent to you via certified mail.
The peer review committee may decide the treatment was acceptable and/or appropriate. However, if the
peer review committee determines the treatment was not acceptable or was not appropriate for you, it may
make a recommendation to the dentist, such as:
1) The dentist is requested to refund all or part of your money so that you may go to the dentist
of your choice to have the treatment done again, or,
2) The dentist is requested to pay for corrective treatment if it is determined by the peer review
committee that additional harm has been done.
The only monetary award the peer review system can recommend is a refund for the dental treatment in
question, or the cost of corrective dental treatment. It is not within the scope of the peer review system to
handle complaints for time lost from work or pain suffered as a result of your treatment, and the decision
of the peer review system cannot compensate for any damages of this nature. Additionally, it is not within
the scope of the peer review system to evaluate the need for medical treatment or recommend
compensation for the cost of corrective medical treatment.
It is possible that peer review may be unable to come to a conclusion regarding all or a portion of your
complaint based on the available evidence. If only a portion of your complaint is appropriate for review, the
committee will consider only that portion of the complaint which is reviewable.
All parties to the peer review process are expected to abide by the decision of the peer review committee. As
a patient, you agree to allow the committee to review your case and make a final decision. Because CDA is a
membership organization, it does not accept requests for review of non-member dentists. The dentist, by
virtue of his or her membership in the association, has agreed to abide by the decision rendered by the peer
review committee. However, the peer review committee has no authority to compel the dentist to comply
with the decision beyond their membership agreement. Should the dentist choose not to abide by the
decision, CDA can take action against the dentist’s membership status, subjecting them to expulsion from
CDA and loss of access to all member benefits.
Should the peer review committee determine a refund is in order, you will be required to sign a Release of
All Claims form prior to receipt of any refund. Attached is a sample copy of the form for your review.
Upon receipt of the committee’s decision, you or the dentist may appeal the decision to the CDA Council
on Peer Review Appeals Panel. Appeal criteria will be enclosed with your resolution letter. If an appeal
review is deemed appropriate, it will only review the procedures followed to determine if they were
appropriate and whether the decision was supported by the evidence considered. It will not entail a new
review of the evidence. Once a decision is made on an appeal, it is final and binding, and you may no
longer use the peer review system on this matter.
Please be aware that the utilization of peer review does not stop, interrupt or suspend the running of the
time period for filing a civil suit against the dentist in question. The filing of such actions is governed by
7-4 Rev: 3/8/14

California Code of Civil Procedure Section 340.5. This law may preclude you from filing a suit against the
dentist after peer review is concluded.
If you decide you want to use our services, please carefully read and complete the enclosed four forms:
Request for Review Form, Patient Agreement Form, Authorization for Use and Disclosure of Health
Information Form and Patient Request for Interview Form. The purpose of these forms is explained at the
top of each one. The committee urges you to be concise and limit your written comments to the specific
complaints that you want reviewed. Do not give personal opinions that cannot be used in making a
determination in your case. The completed forms must be mailed to:

P.O. Box 13749
All forms must be completed and returned to CDA as soon as possible before review can begin. Please
note that all forms must be originals; CDA cannot accept photocopies. A notification will be mailed
confirming receipt of your Request for Review within twenty-one (21) calendar days from the date of
receipt. Should you not receive a confirmation, please contact the California Dental Association.
The CDA Peer Review Manual contains the policies and procedures that govern how a Peer Review claim is
conducted. You may view a copy of the manual at www.cda.org or it may be purchased by contacting the
California Dental Association.
Most patients using our system find it fair, less costly, and less time consuming than going to court. We are
happy to help you and look forward to hearing from you. If you have any questions regarding completion of
the forms, please call CDA at 800.232.7645.
Sincerely,
Enclosures: Request for Review Form (Form #3)

Patient Agreement Form (Form #4)
Authorization for Use and Disclosure of Health Information Form (Form #5)
Patient Request for Interview (Form #90)
Release of All Claims Form (Sample)
7-5 Rev: 3/8/14

Form #2
Initial Patient Response Letter
(Utilization Case)
Date
Name
Address
City, ST Zip Code
Subject: (Dentist)/(Patient)
Dear (Patient):
Thank you for contacting the California Dental Association (CDA) requesting the assistance of the peer review
committee in obtaining benefits for your treatment performed by the above-named dentist. Before we begin the peer
review process, we would like to explain how our system works.
CDA has developed the peer review system to help solve problems about dental treatment that the dentist and patient
have not been able to settle themselves or about disputes regarding an insurance carrier providing benefits on
treatment performed by a dentist. A special committee of dentists, known as the “review committee”, volunteer their
time to consider questions about the quality and appropriateness of dental care. Cases may also be submitted for
review when there is a question regarding an insurance claim. These are the only types of questions which the
committee can answer. If the committee determines that the initial request involves a specific benefit exclusion of the
insurance policy, the committee has no power to ask a carrier to allow benefits. There is a time limitation for
accepting a complaint in the peer review system. A complaint must be filed within three years from the date the
work was completed or one year from the date you became aware that there was a problem, whichever occurs first.
There is no charge for this service; however, any unusual costs sustained by the peer review committee in conducting
the review, including but not limited to duplicating radiographs, study models or treatment records, shall be borne by
the party initiating the review. The peer review system is also an alternative to formal legal proceedings, and cannot be
used if such proceedings have begun, or if the case has already been decided by a court of law. We have no authority to
supersede the decisions of a court of law. Should legal action or arbitration be initiated by any party involved after the
peer review process begins, the peer review action will cease immediately.
The review committee will examine your dental records, and if the committee determines that it is necessary, talk to
you and your dentist separately, and examine the treatment in question before making its decision. Please be advised
that in some cases, an examination of the dental treatment may not be necessary since records, radiographs,
photographs, etc. may be sufficient to render a decision. If an examination is not necessary, you may request an
interview with the peer review committee by completing the enclosed Form #90, Patient Request for Interview.
Upon receipt of the committee’s decision, you or the dentist may submit a request for reconsideration, known as an
“appeal”. Once a decision is made on an appeal, it is final and binding, and you may no longer use the peer review
system on this matter.
If you decide to use our services, please carefully read and complete the enclosed four forms: Request for Review
Form, Patient Agreement Form, Authorization for Use and Disclosure of Health Information Form and Patient
Request for Interview Form. The purpose of these forms is explained at the top of each one. All forms must be
completed and returned to CDA Council on Peer Review, P.O. Box 13749, Sacramento, CA 95853-4749 before
the review can begin.
The committee urges you to be concise and limit your written comments to the specific complaints that you wish
reviewed. Do not give personal opinions that cannot be used in making a determination in your case.
7-6 Rev: 3/8/14

Please be aware that the initiation of peer review does not stop, interrupt or suspend the running of the time period
for filing a civil suit against the dentist in question. The filing of such actions are governed by California Code of Civil
Procedure Section 340.5. This law may preclude you from filing a suit against the dentist after peer review is
concluded.
A notification will be mailed confirming receipt of your Request for Review within twenty-one (21) calendar days from
the date of receipt. Should you not receive a confirmation, please contact the California Dental Association.
Most patients using our system find it fair, less costly, and less time consuming than going to court. We are happy to
help you and look forward to hearing from you. If you have any questions regarding completion of the forms, please
call CDA at 800.232.7645.
Sincerely,
Enclosures: Request for Review Form

Patient Agreement Form
Authorization for Use and Disclosure of Health Information Form
Patient Request for Interview
7-7 Rev: 3/8/14

Form #3
Request for Review Form
This form will give the review committee some of the necessary important background information.
Without it the review cannot be conducted. Please clearly type or print in ink the information asked. Your
case will not be considered filed until all of the required forms are complete. This form will be returned to
you if it is incomplete or if the committee cannot read it, and you will have to fill it out again. This will
delay the opening of your case, and may affect your eligibility to file a peer review case due to the time
limitations on filing. Finally, the more clearly you can describe the situation or problem, the more effective
the review committee can be.
Please list the name of the dentist who provided the specific dental treatment in question. If you wish to
file a complaint against more than one dentist, separate forms are needed for each dentist.
_____________________________________________________________________________________
Patient’s First and Last Name:

Mailing Address:
City: Zip Code:
Preferred Phone Number: ( ) □ Home □ Work □ Cell
Alternate Phone Number: ( ) □ Home □ Work □ Cell
Email Address:
Date of Birth: / /
Name of Patient’s Parent or Guardian (if patient is less than 18 years old):
Mailing Address:
City: Zip Code:
Home Phone: ( ) Work Phone: ( )
Treating Dentist’s First and Last Name:

Name of Dental Practice:
Address:
City: Zip Code:
Phone Number: ( )
Date treatment was started: Date treatment was completed:
Date you were last seen by this dentist:
Date you became aware there was a problem regarding the treatment you are asking us to evaluate:
7-8 Rev: 3/8/14

1. Is this dentist a specialist? □ Yes □ No □ Not Sure

If yes, what specialty?
2. Have you tried to settle this matter with the dentist? □ Yes □ No
Dates:
Did the dentist respond? □ Yes □ No
If yes, what action was taken?
3. Have you been examined or treated by any other dentist(s) about this problem? □ Yes □ No
If yes, please give name, address and phone number of the other dentist(s) on the
enclosed Authorization for Use or Disclosure of Health Information form (Form #5).
4. Have you altered the treatment in question? □ Yes □ No
5. Has any person/dentist altered the dental work in question? □ Yes □ No
6. Is the dental work in question still in your mouth? □ Yes □ No
7. Have you asked for help from any person, organization or agency (ex: Dental Board □ Yes □ No
of California, Better Business Bureau)?
If yes, give names, dates, and what action is being taken:
8. Are you aware of any litigation concerning this complaint, including small claims court, notice of
intent to sue, notification that arbitration will be or has commenced, or if a malpractice suit has
been filed? □ Yes □ No
If yes, what type of action?
9. Did your dental insurance pay for any portion of the treatment in question? □ Yes □ No
If yes, please provide amount: $
Primary Insurance Company:
Address:
7-9 Rev: 3/8/14

Subscriber’s Name:
Subscriber’s ID: Group ID Number:
Subscriber’s Employer:
Has the insurance company been notified of this matter? □ Yes □ No
Are you still covered by this insurance plan? □ Yes □ No
Secondary Insurance Company:

Address:
Subscriber’s ID: Group ID Number:
Has the insurance company been notified of this matter? □ Yes □ No
Are you still covered by this insurance plan? □ Yes □ No
10. Your employer:
11. How did you become aware of California Dental Association’s peer review system?
12. Could you suggest a fair solution to your problem? □ Yes □ No

If yes, explain:
Probing of the tissue surrounding the teeth may be necessary in order to render a decision in your peer
review case. Patients with certain medical conditons may require antibiotic premedication prior to a dental
examination. If you answer “yes” or are unsure about your answers to any of the following seven questions,
please contact your physician and notify the California Dental Association peer review staff prior to your
peer review examination appointment.
1. Do you require antibiotics for dental treatment? □ Yes □ No

If yes, please indicate:
2. Have you ever been diagnosed with endocarditis? □ Yes □ No
3. Have you had a heart transplant? □ Yes □ No
7-10 Rev: 3/8/14

4. Have you had a heart valve replacement? □ Yes □ No

5. Have you ever been diagnosed with a congenital heart defect? □ Yes □ No
6. Have you ever had a hip or joint replacement? □ Yes □ No
7. Are you allergic to latex? □ Yes □ No
I understand that peer review handles only matters relating to appropriateness and/or quality of dental
care. Problems about prices charged or getting money for time lost from work or pain suffered cannot be
handled by the peer review committee.
I further understand that the initiation of peer review does not stop, interrupt or suspend the running
of the time period for filing a civil suit against the dentist in question. The filing of such actions is
governed by California Code of Civil Procedure Section 340.5. This law may preclude me from filing a suit
against the dentist after peer review is concluded.
I affirm and certify that the foregoing information is true and correct to the best of my knowledge and if
called as a witness, I would so testify.
Signature of Patient or Patient’s Parent/Guardian Date
7-11 Rev: 3/8/14

Description of Complaints
Please briefly describe your complaints below. Indicate the type of treatment you are asking us to evaluate
(ex: crowns, bridges, fillings, etc.), including tooth numbers or the specific location in your mouth of the
treatment in question, and treatment dates.
The committee urges you to limit your written comments to the specific complaints you want reviewed. Do
not give personal opinions that cannot be used in making a determination in your case. Please note that it
is not within the scope of peer review to evaluate complaints regarding fees, communication issues, office
procedures, etc.
Include the names of all dentists seen for treatment or consultation and the dates you visited them. All
dentists listed on this page must be listed on your Authorization for Use or Disclosure of Health
Information (Form #5).
If you need more space, use additional sheets and attach them to this form when you return it to CDA.
Attach a copy of the dentist’s bill, if available. Please type or print clearly and legibly in ink.
7-12 Rev: 3/8/14

Summary of Specific Complaints
In order of importance, please list your specific complaints below, summarized in one or two sentences.
Please include tooth number(s) if you know them, or describe the specific areas of your mouth where you
are experiencing problems (ex: Is it an upper tooth or a lower tooth? Is it a tooth on the right or left or in
the middle?).
1.
2.
3.
4.
5.
7-13 Rev: 3/8/14

Form #4
Patient Agreement Form
This form is required as it indicates your agreement to abide by the decision of the Peer Review Committee
and the California Dental Association. This form must be signed without any alterations or modifications.
The [Component Dental Society] Dental Society (or any dental society to which the case may be
transferred) (hereinafter “dental society”) and the California Dental Association (CDA) have been
requested to review the dental services provided to you by Dr. (First and Last
Name of Dentist) on or about (Treatment Date). Both you and the dentist must consent
to the review by the dental society and CDA according to the CDA’s policies and procedures.
Because your dentist is a member of CDA, he or she has already agreed to abide by the decision reached by
the dental society’s peer review committee and the CDA. Therefore, his or her signature is not needed.
However, the peer review committee has no authority to compel your dentist to comply with the decision.
It is definitely understood and agreed by you that:
1. The dental society and CDA, and any of their members and employees, are released from any and all
liability resulting from or arising in any manner from the review of the dental services you received.
Therefore, you agree that you will not sue any of these organizations or individuals with respect to this
review.
2. By virtue of the California Evidence Code Section 1157, neither the records nor any proceedings
relating to this matter of the dental society’s peer review committee or of the CDA’s Council on Peer
Review can be provided or used to reveal information in any manner.
3. The only monetary award the dental society’s peer review committee can recommend is a refund for
the dental treatment in question or the cost of corrective dental treatment. No recovery for pain
and/or suffering or time away from work exists in the peer review system, and the decision by the peer
review committee cannot compensate for any damages of this nature suffered by you.
4. The peer review committee cannot evaluate the need for medical treatment or recommend
compensation for the cost of corrective medical treatment.
5. The decision reached by the dental society’s peer review committee or a decision reached by the CDA’s
Council on Peer Review on an appeal shall be determinative of any issues involved in connection with
the dental treatment described above.
6. It is possible that peer review may be unable to come to a conclusion regarding all or a portion of your
complaint.
7. I declare that I am now making any and all complaints or claims against the dentist which I believe
exist of any nature whatsoever.
7-14 Rev: 3/8/14

8. I understand that there is a time limitation for accepting a complaint in the peer review system. A
complaint must be received within three years from the date the dental treatment was completed or
one year from the date you recognized there was a problem, whichever comes first.
9. The initiation of peer review does not stop, interrupt or suspend the running of the time period for
filing a civil suit against the dentist in question. The filing of such actions are governed by California
Code of Civil Procedure Section 340.5. This law may preclude you from filing a suit against the
dentist after peer review is concluded.
10. I agree to sign the Release of All Claims Form should peer review determine that a refund is in order
(a sample Release of All Claims Form #72 is enclosed).
11. Should the peer review committee find in favor of the dentist, I agree to pay the dentist under review
any outstanding balance for the treatment in question after either the expiration of thirty (30) calendar
days following the date of the resolution letter without an appeal being filed or the decision of an
appeal.
12. The policies and procedures which govern how this peer review claim will be conducted are
established in the CDA Peer Review Manual. I understand that a copy of the manual is available for
review on the Internet at www.cda.org or may be purchased by contacting the CDA.
13. I understand and agree that peer review is an evaluative rather than judicial process and that the
parties are not entitled to the following procedural rights that might otherwise be available in an
arbitration or civil action: (a) representation by legal counsel and/or an attorney; (b) the ability to
conduct discovery or take depositions (i.e., the ability to obtain the evidence the opposing party
intends to submit and the ability to question the opposing party with regard to such evidence); and (c)
the ability to cross-examine the opposing party and/or present opposing evidence. By signing this
form, I understand that I am agreeing to have this proceeding conducted in accordance with the
procedures contained in the Peer Review Manual.
Your signature below shows your acceptance of and agreement to all items listed above. Any alterations
made in this form will prevent its acceptance into the peer review system.
ACCEPTED AND AGREED:
Name of Patient (print)
7-15 Rev: 3/8/14

Form #5
Authorization for Use or Disclosure of Health Information
This authorization allows the California Dental Association to request your dental records, which are
necessary to review your peer review complaint. You must list ALL dentists seen for treatment or
consultation regarding this matter.
Your case will not be considered filed until all of the required forms are complete. This form will be
returned to you if it is incomplete or if the committee cannot read it, and you will have to fill it out again.
This will delay the opening of your case, and may affect your eligibility to file a peer review case due to the
time limitations on filing.
Print the Patient’s First and Last Name
I hereby authorize the following persons and/or entities (please list the full name – first and last – and
address of the treating dentist; and other dentists you have seen regarding this matter, and your insurance
carrier, if any)
Treating Dentist (Dentist you are complaining about): First Name, Last Name and Address
Other/Consulting Dentist: First Name, Last Name and Address
Insurance Carrier: Name and Address
to disclose to the [Component Dental Society] (or any dental society to which the case may be transferred),
the California Dental Association, the American Dental Association, and/or any state or federal
governmental agency responsible for licensing, accrediting, or maintaining or releasing reports on health
care practitioners, such as the Dental Board of California, the California Department of Health Services,
and the U.S. Department of Health and Human Services, any and all health information, including
protected health information, concerning the above-named patient with respect to any dental care and
treatment, medical care and treatment, illness or injury, dental history, medical history, consultation,
prescriptions, x-rays, plates and copies of all dental records, medical and/or hospital records to be used in
connection with a request for peer review, and in connection with any subsequent investigations,
disciplinary proceedings, reporting obligations, and litigation arising from said peer review complaint, and
as otherwise specifically required or permitted by law.
7-16 Rev: 3/8/14

I understand that I have the right to revoke this authorization at any time by giving each of the foregoing
persons and/or entities written notice of my revocation. I understand that revocation of this authorization
will not affect any action that any of the foregoing persons and/or entities took in reliance on this
authorization before the person and/or entity received my revocation, and that my peer review complaint
may not be reviewed or to continue being reviewed if I revoke this authorization. I understand that
although federal law does not protect health information that is disclosed to someone other than another
health care provider, health plan, or health care clearinghouse, under California law all recipients of health
care information are prohibited from re-disclosing it except as specifically required or permitted by law.
I also give my permission to the above-named dental society to examine, as appropriate, the patient named
above. A photocopy of this release form will be as effective and valid as the original.
This authorization is effective now and will remain in effect until three (3) years from the date entered
below.
If not signed by the patient, please indicate relationship:
[ ] parent or guardian of minor patient (to the extent minor could not have consented to the care)
[ ] guardian or conservator of an incompetent patient
7-17 Rev: 3/8/14

Form #6
Patient Notification of Incomplete Forms
Date
Name
Address
City, ST Zip Code
Dear (Patient):
In order for the California Dental Association (CDA) to proceed with your request for a review of the dental
treatment provided by the above mentioned dentist, the following forms must be completed and returned to CDA:
(Check appropriate boxes)
____Request for Review Form
____Authorization for Use and Disclosure of Health Information Form
____Patient Agreement Form
____The Patient Agreement Form may not be altered.

A new copy is included with this letter
____Patient Request for Interview Form
Should the requested forms not be returned to CDA, Council on Peer Review, P.O. Box 13749, Sacramento, CA
95853-4749 within fourteen (14) calendar days from the date of this letter, the matter will be considered closed.
Sincerely,
7-18 Rev: 3/8/14

Form #7
Initial Response to Dentist Letter (Utilization Case)
Date
Name
Address
City, ST Zip Code
Subject: (Patient)/(Carrier)
Dear (Dentist):
Thank you for contacting the California Dental Association (CDA) requesting the assistance of the peer review
committee in obtaining benefits for your patient. Before we can begin the peer review process, further information is
necessary.
To assist the review committee in resolving this problem it is necessary for you to complete and return the enclosed
Dentist Request for Review Information Form. Also, please provide all pertinent data which will enable a complete
review, such as duplicate study models, a legible copy of the treatment record, a copy of all radiographs, copies of
relevant insurance forms, and any other materials which may be helpful to the committee. Your treatment records
must be typed and transcribed verbatim.
You are invited to attend a portion of the peer review committee’s meeting to present your side of the story. Please
notify the committee by filling out the attached form indicating whether or not you wish to attend the meeting. If you
desire to attend, you will be informed of the time and place of the meeting. Your interview will not be in the presence
of the patient.
It is our intent to review this matter as soon as possible. Therefore, please complete and return the enclosed form(s),
including all pertinent information to CDA, Council on Peer Review, P.O. Box 13749, Sacramento, CA 95853-4749
as soon as possible. Should you have questions please contact CDA at 800.232.7645.
Sincerely,
Enclosure: Dentist Request for Review Information Form

Dentist Will/Will Not Attend Meeting Form
7-19 Rev: 3/8/14

Form #8
Dentist Request for Review Information Form
IMPORTANT - This must be typewritten or legibly printed in ink. Without this form a review cannot be conducted.
Patient’s Name: Dentist’s Name:

Address: Address:
City: Zip: City: Zip:
Home Phone: Wk: Home: Office:
Parent/Guardian if patient is less than 18 years old: Type of Practice:
General Specialty
Address:
Type of Specialty:
City: Zip:
Do you limit your practice? Yes No
Home Phone: Wk:
Is treatment complete? Yes ____ No
If yes, date:
Patient’s Employer:
Insurance Company:
Address:
Insured Person:
Insured Date of Birth: Group I.D. Number:
Did you contact the carrier regarding this problem? Yes _____ No _____
If yes, what was the carrier’s response?
What was the total fee for the services in question?
Important: The committee must have an accurate breakdown of the fee charged for each individual procedure in
question. Please provide an itemized statement.
Tooth No. or Fee for Patient Ins. Balance

Procedure Description Service Payment Payment Owing
If insurance coverage is provided by an additional source, please include the same information as above on another
sheet of paper.
Check data submitted:

Radiographs ______________ (date) ______________
______________ (date) ______________
______________ (date) ______________
Study models
Treatment Record
Insurance Forms
7-20 Rev: 3/8/14

Other ______
Has any of the treatment in question been completed without receiving prior authorization of the carrier?
__________________________________________________________________________________
Are you aware of any litigation involving this complaint, including small claims court, notice of intent to sue, or if a
malpractice suit has been filed? Yes _____ No _____
If yes, what type of action?
Briefly describe the problem. If you need more space, use additional sheets and attach them to this form when you
return it to California Dental Association.
Dentist’s Signature Date
7-21 Rev: 3/8/14

Form #9
Dentist Notification of Incomplete Forms (Utilization Review)
Date
Name
Address
City, ST Zip Code
Dear (Dentist):
In order for the California Dental Association (CDA) to proceed with your request for review regarding the dental
treatment provided to the above-mentioned patient, the Dentist Request for Review Information must be completed
and returned to CDA, Council on Peer Review, P.O. Box 13749, Sacramento, CA 95853-4749 within fourteen (14)
calendar days from the date of this letter. Should the requested forms not be returned within fourteen (14) calendar
days from the date of this letter, the matter will be considered closed.
Sincerely,
7-22 Rev: 3/8/14

Form #10
Notification Of New Case
PLEASE TYPE CDA Case #
Component Name:
Open Date:
Dentist (Last name first) and mailing address:
ADA Number: Specialty: _______________________________

Reviewing Entity: _____________________
Patient (Last name first) and mailing address:
Carrier (Primary) and mailing address:
Initiated by (circle one): P D C

Case Type (circle one): Q U A O
Complaint Code (circle one): PD EN PR OD SU
(Please refer to code guide on reverse) FD FB RA CR IM
TM DX OR OT
Inappropriate Code: Appeal Date:

Decision Code: Appeal Initiator:
Close Date: Appeal Decision:
Refund: Appeal Close Date:
Patient:
Carrier:
Adjusted:
Additional/Corrective Treatment: $
COMMENTS:
C: Dental Society
7-23 Rev: 3/8/14

DEFINITION OF CODES
Initiated By Case Type

C - Carrier A - Appropriateness
D - Dentist Q - Quality
P - Patient U - Utilization
O - Other
Complaint Code
PD - Pediatric Dentistry RA - Removable Appliance (partial denture)
EN - Endodontics CR - Crown
PR - Periodontics IM - Implants
OD - Orthodontics TM - Temporomandibular Joint Dysfunction
SU - Surgery DX - Diagnosis
FD - Full Dentures OR - Other Restoration
FB - Fixed Bridge OT - Other Treatment
Inappropriateness Codes Appeals Closing Codes

01 Too old 01 Upheld
02 Fees 02 Denied
03 Resolved prior to PR 03 Remanded, upheld
04 Communications/attitude 04 Remanded, upheld w/amended
05 Office procedures resolution or letter of clarification
06 Litigation 05 Denied, w/amended resolution or letter of
07 Non-member clarification
08 Benefit exclusion 06 Remanded, overturned by committee
09 Patient uncooperative 07 Remanded, overturned by CPR
10 Treatment redone 08 Withdrawn
11 Dentist referred to JC for 09 Vacated/No response to 15-day letter
non-compliance 10 Litigation
12 Carrier uncooperative - Forms 11 Other/Received appeal after 30 days
incomplete/not returned
14 Other ________________
7-24 Rev: 3/8/14

Form #12
Peer Review Checklist
Initiating Party:________________________________________________________________
Type of Inquiry: Quality: Utilization: Appropriateness: Other:

Patient:
Name:
Date Initial Written or Telephone Inquiry Received:
Dentist Named in Dispute:
1. Member: Yes: No:
Is the dentist a general dentist? Yes: No: If no, type of speciality:___________________
Component: __________________
Consulting or Other Treating Dentist(s):
1. Member: Yes: No:
2. Member: Yes: No:
3. Member: Yes: No:
4. Member: Yes: No:
*Verify dentist under review and subsquent treating dentist(s) are not peer review committee members.
Carrier Information:
Primary Carrier: Contact Person:
Secondary Carrier: Contact Person:
******************************************************************************
Does the carrier-initiated request include all necessary information?
1. Is there a description of the problem? Yes: No:
2. Are the specific questions to be addressed by committee delineated? Yes: No:
3. Is a copy of the dental consultant’s evaluation of the situation included? Yes: No:
4. Are copies of necessary correspondence, claim forms, radiographs (if available to the carrier), and all other
pertinent information related to the request included? Yes: No:
******************************************************************************
Communication to Patient: Date Sent Response Received
Initial Response Letter (Form # 01):
Request for Review (Form # 03):
Patient Agreement (Form # 04):
Authorization (Form # 05):
“Sample” Release of All Claims (Form # 72)
Patient Request for Interview (Form # 90)
Coordinator’s Screening of Patients Complaint: Initials: Date:

Date Request for Review (Form #3) is received: (This is the open date of case)
7-25 Rev: 7/27/15

Date treatment was completed:

Was treatment completed within the last 3 years? Yes: No:
Date the patient became aware of the problem:
Is the case within the time limitation? Yes: No:
Does the patient’s complaint delineate the specific complaints? Yes: No:
*If not, return the complaint to the patient with instructions for specific details of the issues.
Does it appear that the case is or has been in litigation? Yes: No:
Notification of Complaint Being Processed (Form #65) sent to patient: Date:
Notification To Dentist Against Whom Complaint Is Filed:
Dentist Notification & Response Request (Forms # 3,4,5,13,15,16):
Date Sent: Due Date (14 calendar days after notification): Response Received:
Form #15 Received Form #16 Received
First Notice for Non-Compliance with Records (Form#51):
Contact dentist by telephone to confirm that the dentist has received the request for records.
Second Notice for Non-Compliance with Records (Form #91):
*If no response, begin JC Referral process.
Notification to the dentist of referral to JC: Date:
Information Received From Treating Dentist:
Copy of Treatment Record: Date Received:

Transcribed Treatment Records:
Radiographs: Date Received:
Dated:
Dated:
Study Models:
Dated:
Other:
Dated:
Consulting/Subsequent Treating Dentists:
Consulting/Subsequent Treating Dentist Reply (Form #’s 18, 19, 5):
1) Name:
7-26 Rev: 7/27/15

2) Name:
3) Name:
4) Name:
First Notice (Form #51):
1) Name:
2) Name:
Second Notice (Form #56):
1) Name:
2) Name:
*If no response, begin JC Referral process.
If study models or radiographs are provided, list items below.

Date: Submitted by:
Notification to Carrier(s): Date Sent Due Date (14 calendar days) Response Received
Carrier Notification Letter (Form #’s 17, 5):
Carrier 2nd Notification Letter: Sent: Due: Response Received:
Coordinator Preliminary Screening of Case File:

Initials: Date:
Sent Case to Council to Confirm Appropriateness of Review:
Initials: Date: Sent to:
Response from Council Member:
7-27 Rev: 7/27/15

Initials: Date:
Case Assigned and Mailed to (along with Form #26): Date:
Draft Resolution/Addendum/Clinical Worksheets Due to CDA (within 60 calendar days): Date:
Copy of the case sent to Component: Name: Phone:
Copy of the case sent to Component/Specialty Chair: Name: Phone:
Copy of the case sent to Case Captain: Name: Phone:
1) Exam Panel Member: Name: Phone: E-mail:
4) Consultant: Name: Phone: E-mail:
Peer Review Committee Meeting:
Date of Meeting:
Dentist Wishes to Attend (see Form #16)? Yes: No:
Dentist Notified of Meeting (Form #28):
Date Sent: Date Response Received:
Patient Wishes to Attend (see Form #90)? Yes: No:
Patient Notified of Meeting (Form #27):
Date Sent: Date Response Received:
******************************************************************************
Clinical Exam Conducted: Yes: No:
Date Examined: If not, reason:
Dentist Attended Meeting? Yes: No: Date:
Draft Resolution/Addendum/Clinical Worksheets/Refund Worksheet (due within 60 calendar days after form #26 is
mailed):
Date Received:
Case assigned to Administrator: Date: Administrator:
Forward case to Council on Peer Review for review and approval: Date:
Forward case to Advisory Panel for Review:
Date of Conference Call:
Advisory Panel I
Advisory Panel II
7-28 Rev: 7/27/15

Advisory Panel III
Remand CDA’s Revisions to Component/Specialty: Date:
Received Approval from Component/Specialty: Date:
Final Dated Copy: Date:
******************************************************************************
Appeals:
Appeals Due Date: Date:
Received request for an extension: Date:
Extension granted: Yes: No: Appeal Due Date:
Appeals received (Postmarked Date): Date:

Appeal Criteria:
1 2  3 4 5
Send Notification of Receipt of Appeal Acknowledgement Letter to:
Patient: Date:
Dentist: Date:
Component: Date:
Forward appeal to the Appeals Panel for review: Date:
Received Appeals Panel Response:
Panel Member:______________ Date:

Remand Appeal to Component/Specialty Peer Review Committee: Date:
Conference Call: Date:
Appeal Decision: Date:
Appeal Decision:
01 02 03 04 05 06 07 08 09 10
Second Appeals:
Appeals Due Date: Date:
Received request for an extension: Date:
Extension granted: Yes: No: Appeal Due Date:
Appeals received (Postmarked Date): Date:

Appeal Criteria: 1 2  3 4 5
Send Notification of Receipt of Appeal Acknowledgement Letter to:
Patient: Date:
7-29 Rev: 7/27/15

Dentist: Date:
Component: Date:
Forward appeal to the Appeals Panel for review: Date:

Remand Appeal to Component/Specialty Peer Review Committee: Date:
Conference Call: Date:
Appeal Decision: Date:
Appeal Decision:
01 02 03 04 05 06 07 08 09 10
******************************************************************************
Refunds:
Was refund awarded: Yes: No:
Patient Amount: Carrier Amount: Ledger Adjustment:
Check(s) Due Date (14 calendar days after expiration of appeal period):
Date Received: Amount:
Release of All Claims Form forwarded to Patient for Signature (Form #’s 72 & 73):
Initial: Date:
Received Release of All Claims Form with Patient Signature:
Initial: Date:
Check forwarded to Patient and Carrier: Initial: Date:
Copy of release sent to Dentist: Initial: Date:
Radiographs, Models, Etc., Returned to Treating & Subsequent Treating Dentist(s):
Date:
CORRECTIVE TREATMENT:
Was Corrective Awarded: Yes: No:
Limitations of the Corrective Treatment:
7-30 Rev: 7/27/15

Date Corrective Treatment Plan and Cost Estimate is due: Date:
Date Corrective Treatment Plan and Cost Estimate was received: Date:
Forwarded the Corrective Treatment Plan and Cost Estimate to Component/Specialty Peer Review Committee and
Council on Peer Review for review and approval: Date:
Received the Approval from Component/Specialty Peer Review Committee and Council for the Peer Review for the
Corrective Treatment Plan and Cost Estimate: Date:
Approved Corrective Treatment Plan and Cost Estimate:
Corrective Treatment Plan and Cost Estimate Approval Letter to all parties: Date:
******************************************************************************
Corrective Treatment Plan and Cost Estimate Appeals:
Corrective Appeals Due Date (15 calendar days): Date:
Appeals received: Date:

Appeal Criteria:
1 2 
Forward Corrective Treatment Plan and Cost Estimate Appeal to the Appeals Panel for review:
Date:

Appeals Determinations: Date:
******************************************************************************
Request Refund Check for the Approved Corrective Treatment Plan and Cost Estimate: Date:
Check Due Date:
Date Check Received: Amount:
Release of All Claims Form forwarded to Patient for Signature (Form #’s 72 & 73):
Initial: Date:
Received Release of All Claims Form with Patient Signature:
Initial: Date:
Check Forwarded to Patient: Initial: Date:
Copy of Release Sent to Dentist: Initial: Date:
7-31 Rev: 7/27/15

Form #13
Dentist Notification and Response Request Letter
Date
Name
Address
City, ST Zip Code
Dear Dr. :
The California Dental Association (CDA) peer review program recently received an inquiry from your
patient named above. Upon receipt of this information, the patient was requested to complete the
following:
1. Request for Review Form: This form includes a summary of the data pertinent to the inquiry.
2. Patient Agreement Form: This form states that CDA member-dentists have an obligation, by virtue
of their membership, to abide by decisions of duly constituted committees and requires the patient
to sign a statement agreeing to abide by the committee’s decision in this matter.
3. Authorization for Use and Disclosure of Health Information Form: By signing this form, the
patient has authorized you to release the records to the review committee.
Copies of these forms, signed by your patient, are enclosed for your records.
The peer review system is a CDA member benefit, as it is an alternative to litigation designed to resolve
disputes that may arise in the delivery of dental services to the public. Peer Review follows specific
procedures to make a fair and impartial determination about the quality and/or appropriateness of the
treatment in question. Because of the time and effort involved in providing this service without charge, Peer
Review is a benefit available only to CDA member dentists.
To assist the peer review committee in resolving this inquiry and determining its validity, you are requested
to provide your side to this matter by completing the enclosed Treating Dentist Reply and Records
Checklist and submitting requested records. The records requested are listed in the Records Checklist
portion of the form. The committee urges you to be concise and limit your written comments to the
specific information that is requested. Do not give personal opinions that cannot be used in making a
determination in this case.
The committee wishes to emphatically point out that the request for all relevant records and data made
herein, as well as notification of your opportunity to appear before the committee, comprises your only
chance to present your “side of the story.” The peer review process is evaluative, not adversarial. It is not a
court-like proceeding. You will not have an opportunity to cross-examine the patient, nor will you have the
option of being represented by an attorney. You will, however, be given a fair opportunity to present your
position in this matter. No deliberations will occur in your presence, nor will the committee discuss results
of the clinical examination with you.
If this case has an outstanding balance or has been turned over for collection, please hold in abeyance any
collection procedures until the peer review committee has completed its review.
7-32 Rev: 7/27/15

Please notify the committee on the enclosed Dentist Will/Will Not Attend Meeting Form (Form #16)
whether or not you wish to attend the peer review meeting. If you indicate that you wish to attend, you will
be informed regarding the time and place of the meeting. Your presentation should be as concise as
possible, since the committee has a limited amount of time available to hear the cases before it.
The peer review committee will evaluate all the available evidence, including your patient’s dental records,
and, if necessary, will examine your patient before making a decision. This decision, after approval and
finalization by CDA, will be set forth in a letter of resolution that will include its rationale for the decision.
The resolution letter will be addressed to your patient and copied to you on the date of release. All
resolution letters are sent to CDA for approval; therefore, no interim or tentative decision may be given to
you before such approval.
If a party to a review can factually demonstrate that a procedural error may have occurred, or the decision
was not based on facts, an appeal may be requested of the CDA Council on Peer Review. This appeal must
be mailed within thirty (30) calendar days of the date the letter of resolution and should be sent via certified
mail. Any decision of an appeal panel is final and binding. If an appeal review is deemed appropriate, it will
only review the procedures followed to determine if they were fair and whether the decision was supported
by the evidence considered. It will not entail a new review of the evidence.
Should the committee find in favor of the patient and should you be requested to refund, you have the
option of submitting the claim to your professional liability carrier. However, should a payment be made to
the patient as a result of an adverse peer review decision by anyone other than you (i.e. your professional
liability carrier or another business entity), the paying entity may be required to report the payment
information to the Dental Board of California and/or the National Practitioner Data Bank. If you have any
questions about these reporting obligations, you should contact your professional liability carrier and/or
personal attorney for legal advice.
As a CDA member, you have agreed to abide by the decisions of a duly constituted committee. In the event
you are an employee of, independent contractor for, or co-owner with another dentist or entity engaged in
the practice of dentistry, it remains your personal obligation to comply with the requests of the peer review
committee. As the treating dentist, you will be responsible for the quality and appropriateness of the
treatment rendered, and you will be financially responsible for any adverse peer review decisions, regardless
of your employment status.
Should you fail to comply with a request or recommendation of the peer review committee, you may be in
violation of Section 3 of the CDA Code of Ethics, Cooperation with Duly Constituted Committees, and
shall be referred to the CDA Judicial Council for investigation. The Judicial Council will review the records
to assure your rights have been protected, proper procedures were followed, and the committee’s decision
was supported by evidence. Should the matter go to hearing, no further evidence regarding the peer review
issue will be heard. The Judicial Council hearing will focus on why you have failed to comply with the peer
review resolution.
Further, if you receive three (3) or more adverse peer review decisions in cases initiated in a 24-month
period, or a finding of grossly inadequate or grossly inappropriate treatment, or fraud or billing
irregularities, you could be referred to the CDA Judicial Council for investigation of possible ethical
violations.
To reiterate your rights, your opportunities to supply all evidence are at the initiation of the peer review
process and at the meeting with the component peer review committee. Neither the appeal mechanism
nor Judicial Council proceedings provide a mechanism to rehear or reexamine the evidence presented
during the initial review process.
7-33 Rev: 7/27/15

It has been our experience that many inquiries can be resolved between the dentist and patient if even a
small attempt is made to rectify the problem. Therefore, if you are able to settle this problem with your
patient without the intervention of the peer review committee, please advise CDA in writing of your
resolution within fourteen (14) calendar days from the date of this letter. If you have the patient sign a
release form, please also provide CDA with a copy of the signed release.
Please note: It is imperative that you notify CDA staff immediately should you receive a 90-day notice of
intent to sue, or any other legal correspondence that would initiate legal proceedings while this review is in
progress, or notification that arbitration will be or has commenced. With the initiation of legal action or
arbitration by the patient, our review immediately ceases. If you intend to assert your rights to arbitrate
this case pursuant to an arbitration agreement with the patient, you must notify CDA of this fact in
writing within fourteen (14) calendar days from the date of this letter. If you fail to notify CDA of your
right to arbitration, you waive the right to challenge the peer review process or any decision of the peer
review committee on the basis of the arbitration agreement.
The CDA Peer Review Manual contains the policies and procedures that govern how a Peer Review claim is
conducted. You may view a copy of the manual at www.cda.org or it may be purchased by contacting CDA
at 800.232.7645.
It is our intent to review this matter as soon as possible. Therefore, your prompt attention to this request
will certainly be appreciated. Please complete and return the requested information and enclosed forms
within fourteen (14) calendar days from the date of this letter to:

P.O. Box 13749
Sacramento, CA 95853-4749.
Should you have any questions, please contact the CDA Council on Peer Review at 800.232.7645.
Sincerely,
Enclosures: Treating Dentist Reply Form (Form #15)

Dentist Will/Will Not Attend Meeting Form (Form #16)
(Copy) Request for Review Form (executed)
(Copy) Patient Agreement Form (executed)
(Copy) Authorization for Use and Disclosure of Health Information Form (executed)
7-34 Rev: 7/27/15

Form #14
Dentist Notification Utilization Letter (Patient Initiated)
Date
Name
Address
City, ST Zip Code

Carrier (if any)
Dear (Dentist):
The California Dental Association (CDA) was recently contacted for assistance from the above-mentioned patient.
Upon receipt of this information, the patient was requested to complete the following:
1. Request for Review Form: This form includes a summary of the data pertinent to the complaint.
2. Patient Agreement Form: This form states that CDA member-dentists have an obligation, by virtue of their
membership, to abide by decisions of duly constituted committees, and, requests that the patient sign a
statement agreeing to abide by the committee’s decision in this matter.
3. Authorization for Use and Disclosure of Health Information Form: By signing this form, the patient has
authorized you to release the records to the review committee.
To assist the peer review committee in resolving this problem, you are requested to provide, on the enclosed Treating
Dentist Reply Form, your side to this dispute. Also, please provide all pertinent data which will enable a complete
review; including (if applicable), study models, a copy of the original treatment record, financial records, a single
patient ledger, all radiographs, copies of relevant insurance forms, and other information which you think will assist
the committee. Your treatment records must be typed and transcribed verbatim. Please complete and return the
enclosed forms, including all pertinent information to California Dental Association, Council on Peer Review, P.O.
Box 13749, Sacramento, CA 95853-4749 within fourteen (14) calendar days from the date of this letter.
The review committee will evaluate all the available evidence and make a final determination. The decision will be
approved and finalized by CDA, and will be issued by CDA in the form of a letter of resolution which will include the
rationale for the decision. If the committee determines that the initial request involves a specific benefit exclusion of
the insurance policy and/or a contract limitation, the committee and CDA have no power to ask a carrier to allow
benefits. If a party to a review can factually demonstrate that a procedural error may have occurred, or that the
decision was not based on facts, an appeal may be requested of the CDA Council on Peer Review Appeals Panel. This
appeal must be mailed within thirty (30) calendar days of the date the letter of resolution and should be certified.
Any decision of an appeal panel is final and binding. If an appeal review is deemed appropriate, it will only review the
procedures followed to determine if they were appropriate and whether the decision was supported by the evidence
considered. It will not entail a new review of the evidence.
The peer review committee wishes to emphatically point out that the request for all relevant records and data made
herein as well as notification of your opportunity to appear before the committee comprises your only chance to
present your "side of the story". The committee can base its decision only on the information made available to it. The
information provided is confidential and by virtue of the California Evidence Code Section 1157, neither the records
nor any proceedings related to this matter can be provided or used to reveal information in any matter whatever in any
type of future action.
As a CDA member, you have agreed to abide by the decisions of a duly constituted committee. Should you fail to
comply with a request or recommendation of the peer review committee, you may be in violation of Section 3 of the
CDA Code of Ethics, Cooperation with Duly Constituted Committees, and shall be referred to the CDA Judicial
7-35 Rev: 7/27/15

Council for investigation. The Judicial Council will review the records to assure your rights have been protected, that
proper procedures were followed, and that the committees decision was supported by evidence. Should the matter go
to trial, no further evidence regarding the peer review issue will be heard.
To reiterate your rights, your opportunity to supply all evidence is at the initiation of the peer review process and at
the meeting with your component society peer review committee. Neither the appeal mechanism nor Judicial Council
proceedings provide a mechanism to rehear or re-examine the evidence presented during the initial review process.
Consequently, you are invited to attend a portion of the peer review committee’s meeting to discuss this matter. Please
notify the committee on the enclosed Dentist Will/Will Not Attend Meeting Form whether or not you wish to attend
the meeting. If you indicate that you wish to attend, you will be informed regarding the time and place of the meeting.
Your presentation should be as concise as possible, since the committee has a limited amount of time available.
The peer review committee will examine your patient’s dental records and, if necessary, will examine your patient
before making a decision. This decision, after approval and finalization by CDA, will be set forth in a letter of
resolution which will be addressed to the patient and copied to you and the carrier on the date of release. All
resolution letters must be approved by CDA. Therefore, no interim or tentative decision may be given to you before
such approval.
If you intend to assert your rights to arbitrate this case pursuant to an arbitration agreement with the patient, you must
notify CDA of this fact in writing within fourteen (14) calendar days from the date of this letter. If you fail to notify
CDA of your right to arbitration, you waive the right to challenge the peer review process or any decision of the peer
review committee on the basis of the arbitration agreement.
It is our intent to review this matter as soon as possible. Therefore, your prompt attention to this request will certainly
be appreciated.
Sincerely,
Enclosures: Treating Dentist Reply Form

Request for Review
Patient Agreement Form (executed)
Authorization for Use and Disclosure of Health Information Form (executed)
C: Insurance Carrier
7-36 Rev: 7/27/15

Form #15
Treating Dentist Reply Form and Records Checklist
IMPORTANT -- This must be typewritten or legibly printed in ink.
Dentist Name:
Mailing Address:
City: Zip Code:
Phone #: Fax #:
Email Address:
Type of Practice? □ General □ Specialty (Type of Specialty: )
Do you limit your practice? □ Yes □ No
1. Name of patient:
2. Last known address:
3. Occupation: Employer:
4. Age: Sex: Phone Number:
5. Insurance Company:
Address:
Subscriber’s ID: Group I.D. Number:
If insurance coverage is provided by an additional source, please include same information on
another sheet of paper.
6. How long have you treated patient: (years or months)
7. Date initial dental service rendered:
8. Date of last visit to your office:
9. Describe type of service(s) rendered:
10. Are you aware of a subsequent treating dentist? □ Yes □ No

If yes, dentist’s name
11. Were you aware of the patient’s dissatisfaction? □ Yes □ No
If yes, what measures, if any, did you take to satisfy the patient?
7-37 Rev: 7/27/15

12. Has this case previously been litigated or is it currently in litigation? □ Yes □ No
It is imperative that you notify CDA staff immediately should you receive a 90-day notice of intent
to sue, or any other legal correspondence that would initiate legal proceedings while this review is
in progress, or notification that arbitration will be or has commenced.
13. Has arbitration been initiated? □ Yes □ No
If you intend to assert your rights to arbitrate this case pursuant to an arbitration agreement with
the patient, you must notify CDA of this fact in writing within fourteen (14) calendar days from
the date of CDA’s notification and response request letter that accompanied this form. If you fail
to notify CDA of your right to arbitration, you waive the right to challenge the peer review process
or any decision of the peer review committee on the basis of the arbitration agreement.
14. Please add other pertinent comments: (If necessary, continue on another sheet of paper)
15. What do you feel would be a satisfactory solution to this problem?
16. Are you the owner of your practice? □ Yes □ No
Records Checklist
The following documentation must be provided with your submission to the Council on Peer
Review within 14 calendar days from the date of the cover letter accompanying this packet.
Please note the importance of providing all requested items, as failure to do so will result in
additional correspondence from the Council on Peer Review, up to referral to the Judicial
Council.
Included?
A. Typed or legibly printed Treating Dentist Reply Form □Yes □No
B. Completed Form 16, Dentist Wishes to Attend Meeting □Yes □No
C. Photocopy of the patient’s original treatment records □Yes □No
D. Typed transcript of the patient’s treatment records □Yes □No

 Records must be typed and transcribed verbatim so the Peer Review Committee can
read your handwriting and understand your abbreviations.
 If more than one provider documented in the treatment record, each record entry must
be identified by provider name.
7-38 Rev: 7/27/15

E. Single Patient Account Ledger □Yes □No
What was the total amount charged for the services in question? _________________
Was any insurance company billed for the services □Yes □No
If yes, what amount was paid by the carrier? _________________________________
What is the current status of the patient’s account? ___________________________
Has the account been turned over for collection? □Yes □No
The committee must have an accurate breakdown of the fee charged for each individual procedure in
question. Please provide an itemized statement.
Tooth No. or Fee for Patient Ins. Balance

Procedure Description Service Payment Payment Owing
F. Additional information that will assist the committee with its review □Yes □No
(i.e. health history form, referrals, consent forms, financial records, relevant insurance forms)
G. Study Models
Did you take study models? □Yes □No
Do you have study models taken by another provider? □Yes □No
Models must be labeled by date taken, patient name, and provider. □Yes □No □N/A
H. Radiographs and photographs

Did you take x-rays? □Yes □No
Do you have x-rays taken by another provider? □Yes □No
Providing digital images and photographs via disk or email □Yes □No □N/A
Digital images or photographs should be supplied on a disk or emailed to

pr.coordinator@cda.org. Patient records sent via email must be encrypted. If you do not
have the ability to encrypt messages and would like to email records, please send an email
to have an encrypted email initiated.
o All images must be dated. Please note that when attaching some images, the dates
are lost when the images are emailed.
o As email systems cannot always handle large files in one email, you may need to
send multiple emails with a smaller number of images.
PAs, BWs, panographs, orthodontic composites, or photographs □Yes □No □N/A

o Images should be submitted as JPG files in the highest resolution possible. Please
do not reduce the file size of the images.
o Create a separate folder for each date the images were taken using the following
format: YYYY-MM-DD, or individually date each image.
7-39 Rev: 7/27/15

CT, CBCT, or RAW file images □Yes □No □N/A

o In addition to the image files, the image viewer must be included on the disk.
Providing traditional film radiographs □Yes □No □N/A

o Place the radiographs in mounts and include the patient’s name, your name, and
the date(s) the films were taken.
If you require any of your radiographs or study models to be returned to you, please make your
request in writing; otherwise, the radiographs and study models will be treated as duplicates. At
the conclusion of the case, the radiographs and study models will be kept for three years and
then they will be discarded.
As the treating dentist, you will be responsible for the quality and appropriateness of treatment rendered,
and you will be financially responsible for any adverse peer review decisions regardless of your employment
status.
I certify that the foregoing information is true and correct to the best of my knowledge and if called as a
witness I would so testify. I also certify that the information requested has been provided as requested.
If possible, please send copies of treatment records and x-rays rather than your originals. Also, please
include a copy of the patient’s health history form.
Notice:
If you receive three (3) or more adverse peer review decisions in cases initiated in a 24-month period, or a
finding of grossly inadequate or grossly inappropriate treatment, or fraud or irregular billing, you could
be referred to the CDA Judicial Council for investigation of possible ethical violations.
7-40 Rev: 7/27/15

Form #16
Dentist Will/Will Not Attend Meeting
I, Dr.
NO I do not wish to have a personal interview with the peer review committee. I understand
that my written response will be fully considered although I will not be present.
YES I wish to have a personal interview with the peer review committee. “Maybe” will be taken
as a “yes” response.
Patient’s name
Please note: This will be your only opportunity to personally present the facts you feel are important in
support of your case. We encourage you to attend this meeting. No deliberations will occur in your
presence, nor will the committee discuss results of the clinical examination with you.
The peer review process is not adversarial. It is not a court-like proceeding. You will not have an
opportunity to cross examine the patient nor will you have the option of being represented by an attorney.
You will, however, be given a fair opportunity to present your position in this matter.
7-41 Rev: 7/27/15

Form #17
Carrier Notification Letter
Date
Name (Carrier)
Address
City, ST Zip Code
Subject: Patient’s Name:

Subscriber’s ID:
Group ID No.:
Dentist:
Dear (Insuring Entity):
The California Dental Association has received a request for peer review of dental services provided by the
above-named dentist and requires the following information:
1. Is patient currently eligible for benefits? □ Yes □ No
2. Payment(s) on the following dental treatment (including an itemized explanation of

benefit determination):
Treatment Amount Paid by Carrier Patient’s Portion
3. If a refund is recommended for the treatment under review, will the carrier re-establish patient’s
eligibility for any refund amount without affecting current remaining yearly benefits for the above
mentioned patient in order for the patient to have the treatment redone? □ Yes □ No
4. The type of plan (e.g., HMO, PPO, DMO, Capitation, fee-for-service, etc.)
We look forward to receiving your response within fourteen (14) calendar days from the date of this letter.
Your cooperation is greatly appreciated. Should you have any questions, please contact the CDA Council
on Peer Review at 800.232.7645.
Sincerely,
Enclosure: Authorization for Use and Disclosure of Health Information Form
7-42 Rev: 7/27/15

Form #18
Consulting/Subsequent Dentist Notification Letter
Date
Name
Address
City, ST Zip Code
Subject: (Patient)
Dear Dr. :
The California Dental Association (CDA) has received a request from the above-named patient for peer
review of the dental services proposed or rendered by a member of our organization. Your name is listed as
one of the dentists visited by the patient. As you may know, the function of the peer review system is to be
of service to the dentist, the patient, and the carrier by bringing about a resolution of this matter. Your
information is necessary to enable a complete and fair review of your colleague’s treatment.
Please complete and return the enclosed Consulting/Subsequent Treating Dentist Reply and Records
Checklist within fourteen (14) calendar days from the date of this letter.
Should you fail to comply with a request or recommendation of the peer review committee, you may be in
violation of Section 3 of the CDA Code of Ethics, Cooperation with Duly Constituted Committees, and
shall be referred to the CDA Judicial Council for investigation.
Please return the requested information and enclosed forms, within fourteen (14) calendar days from the
date of this letter to:
P.O. Box 13749
Should you have any questions, please contact the CDA Council on Peer Review at 800.232.7645.
Thank you for your assistance.
Sincerely,
Enclosures: (Copy) Authorization for Use and Disclosure of Health Information Form (executed)
Consulting/Subsequent Treating Dentist Reply Form
7-43 Rev: 7/27/15

Form #19
Consulting/Subsequent Dentist Reply Form and Records Checklist
IMPORTANT -- This must be typewritten or legibly printed in ink.
Dentist Name:
Mailing Address:
City: Zip Code:
Phone #: Fax #:
Email Address:
Type of Practice? □ General □ Specialty (Type of Specialty: )
1. Name of patient:
2. Last known address:
3. Occupation: __________________________Employer:
4. Age: Sex: Phone Number:
5. Insurance Company:
Address:
Subscriber’s ID: Group I.D. Number:
If insurance coverage is provided by an additional source, please include same information on
another sheet of paper.
6. Date initial dental service rendered:

7. Date of last visit to your office:
8. Describe type of service(s) rendered:
9. Were you aware of the patient’s dissatisfaction with his or her previous dentist? □ Yes □
No
If yes, what were the patient’s complaints? (Please explain in the patient’s own words.)
10. What measures, if any, did you take to satisfy the patient?
7-44 Rev: 7/27/15

11. What do you feel would be a satisfactory solution to this problem?
12. Please add other pertinent comments: (If necessary, continue on another sheet of paper)
Records Checklist
The following documentation must be provided with your submission to the Council on
Peer Review within 14 calendar days from the date of the cover letter accompanying this
packet.
Please note the importance of providing all requested items, as failure to do so will result
in additional correspondence from the Council on Peer Review, up to referral to the
Judicial Council.
Included?
A. Typed or legibly printed Consulting/ Subsequent Treating Dentist Reply Form □Yes □No
B. Photocopy of the patient’s original treatment records □Yes □No
C. Typed transcript of the patient’s treatment records □Yes □No

 Records must be typed and transcribed verbatim so the Peer Review Committee can
read your handwriting and understand your abbreviations.
 If more than one provider documented in the treatment record, each record entry
must be identified by provider name.
 Information obtained regarding matters of this nature are held in strict confidence within the
committee.
D. Single Patient Account Ledger □Yes □No
E. Additional information that will assist the committee with its review □Yes □No
(i.e. health history form, referrals, consent forms, financial records, relevant insurance forms)
F. Study Models
Did you take study models? □Yes □No
Do you have study models taken by another provider? □Yes □No
Models must be labeled by date taken, patient name, and provider. □Yes □No □N/A
G. Radiographs and photographs

Did you take x-rays?□Yes □No
7-45 Rev: 7/27/15

Do you have x-rays taken by another provider? □Yes □No
Providing digital images and photographs via disk or email □Yes □No □N/A
Digital images or photographs should be supplied on a disk or emailed to
pr.coordinator@cda.org. Patient records sent via email must be encrypted. If you do
not have the ability to encrypt messages and would like to email records, please send
an email to have an encrypted email initiated.
o All images must be dated. Please note that when attaching some images, the dates
are lost when the images are emailed.
o As email systems cannot always handle large files in one email, you may need to
send multiple emails with a smaller number of images.
PAs, BWs, panographs, orthodontic composites, or photographs □Yes □No □N/A

o Images should be submitted as JPG files in the highest resolution possible. Please
do not reduce the file size of the images.
o Create a separate folder for each date the images were taken using the following
format: YYYY-MM-DD, or individually date each image.
CT, CBCT, or RAW file images □Yes □No □N/A

o In addition to the image files, the image viewer must be included on the disk.
Providing traditional film radiographs □Yes □No □N/A

o Place the radiographs in mounts and include the patient’s name, your name, and
the date(s) the films were taken.
I certify that the foregoing information is true and correct to the best of my knowledge and if called as a
witness I would so testify. I also certify that the information requested has been provided as requested.
7-46 Rev: 7/27/15

Form #20
Patient Notification Letter (Dentist Initiated)
Date
Name
Address
City, ST Zip Code

Carrier (if any)
Dear (Patient):
Recently, the above-named dentist contacted the California Dental Association (CDA) on your behalf requesting the
assistance of the peer review committee in obtaining benefits for you from your insurance company. Before we can
begin the peer review process, further assistance from you is necessary.
A special committee of dentists, known as the “review committee”, will examine your dental records and may wish to
talk to you and your dentist, and, if necessary, examine you before making a decision. The committee may decide that
the treatment is appropriate and request that your insurance company allow the benefits in question. However, a
committee cannot direct an insurance company to pay for benefits that are specifically excluded in your policy.
If any party involved in this review does not feel the committee’s decision is fair and can factually demonstrate that a
procedural error occurred, or feels that the decision is arbitrary (not based on facts), they may submit a request for
reconsideration, known as an “appeal”. Once a decision is made on an appeal, it is final and binding, and you may no
longer use the peer review system on this matter.
If you decide to use our services, please carefully read, complete and return the enclosed two forms to the California
Dental Association, Council on Peer Review, P.O. Box 13749, Sacramento, CA 95853-4749 within fifteen (15)
calendar days from the date of this letter. The purpose of these forms is explained at the top of each one. All forms
must be completed and received by CDA before we can begin the review process.
Sincerely,
Enclosures: Patient Agreement Form

C: Dentist
Insurance Carrier
7-47 Rev: 7/27/15

Form #21
Patient Notification Letter (Carrier Initiated)
Date
Name
Address
City, ST Zip Code

(Carrier)
Dear (Patient):
Recently, your insurance carrier named above contacted the California Dental Association on your behalf requesting
the assistance of our peer review committee in determining benefits for treatment rendered to you. Before we can
begin the peer review process, your assistance is necessary.
A special committee of dentists, known as the "review committee", will examine your dental records and may wish to
talk to you and your dentist, and, if necessary, examine you before making a decision. The committee may decide that
the treatment is appropriate and request that your insurance company allow the benefits in question. However, a
committee cannot direct an insurance company to pay for benefits that are specifically excluded in your policy.
If any party involved in this review do not feel the committee’s decision is fair and can factually demonstrate that a
procedural error occurred, or feel that the decision is arbitrary (not based on facts), they may submit a request for
reconsideration, known as an "appeal”. Once a decision is made on an appeal, it is final and binding, and the peer
review system can no longer be used on this matter.
If you decide to use our services, please carefully read and complete the enclosed two forms and return them to the
California Dental Association, Council on Peer Review, P.O. Box 13749, Sacramento, CA 95853-4749 within fifteen
(15) calendar days from the date of this letter. The purpose of these forms is explained at the top of each one. All
forms must be completed and received by CDA before we can begin the review process.
Sincerely,

C: Dentist
Insurance Carrier
7-48 Rev: 7/27/15

Form #22
Dentist Notification Letter (Carrier Initiated)
Date
Name
Address
City, ST Zip Code

(Carrier)
Dear (Dentist):
The California Dental Association (CDA) has recently received the enclosed request for assistance from the
above-mentioned carrier. Upon receipt of this information, the patient was requested to complete the following:
1. Patient Agreement Form: This form states that CDA member-dentists have an obligation, by virtue
of their membership, to abide by decisions of duly constituted committees, and, requests that the
patient sign a statement agreeing to be bound by the committee’s decision in this matter.
2. Authorization for Use and Disclosure of Health Information Form: By signing this form, the
patient has authorized you to release the records to the review committee.
Based on the information provided in the insurance company’s letter, this request has been determined to be
appropriate for the peer review system. To assist the peer review committee in resolving this problem, you are
requested to complete and return the enclosed Treating Dentist Reply Form (Form #15). Also, please provide all
pertinent data which will enable a complete review; such as, study models, a copy of the treatment record, all
radiographs, copies of relevant insurance forms, and other information which you think will assist the committee.
Your treatment records must be typed and transcribed verbatim. Please return the completed form, including all
pertinent information to the California Dental Association, Council on Peer Review, P.O. Box 13749, Sacramento,
CA 95853-4749 within fourteen (14) calendar days from the date of this letter.
The peer review committee will evaluate all the available evidence and make a final determination. The decision must
be approved and finalized by CDA’s Council on Peer Review, and will be issued in the form of a letter of resolution
which will include the rationale for the decision. If a party to a review can factually demonstrate that a procedural
error may have occurred, or that the decision was not based on facts, an appeal may be requested of the CDA Council
on Peer Review Appeals Panel. This appeal must be mailed within thirty (30) calendar days of the date the letter of
resolution and should be certified. Any decision of an appeal panel is final and binding. If an appeal review is
deemed appropriate, it will only review the procedures followed to determine if they were fair and whether the
decision was supported by the evidence considered. It will not entail a new review of the evidence.
The peer review committee wishes to emphatically point out that the request for all relevant records and data made
herein as well as notification of your opportunity to appear before the committee comprises your only chance to
present your “side of the story”. The committee can base its decision only on the information made available to it.
The information provided is confidential and by virtue of the California Evidence Code Section 1157, neither the
records nor any proceedings related to this matter can be provided or used to reveal information in any matter
whatsoever in any type of future action.
CDA Code of Ethics, Cooperation with Duly Constituted Committees, and shall be referred to the CDA Judicial
Council for investigation. The Judicial Council will review the records to assure your rights have been protected: that
proper procedures were followed, and that the committee’s decision was supported by the evidence. Should the matter
go to trial, no further evidence regarding the peer review issue will be heard. If you intend to assert your rights to
7-49 Rev: 7/27/15

arbitrate this case pursuant to an arbitration agreement with the patient, you must notify CDA of this fact in writing
within fourteen (14) calendar days from the date of this letter. If you fail to notify CDA of your right to arbitration,
you waive the right to challenge the peer review process or any decision of the peer review committee on the basis of
the arbitration agreement.
the meeting with your component society peer review committee. Neither the appeal mechanism nor Judicial
Council proceedings provide a mechanism to rehear or reexamine the evidence presented during the initial review
process.
notify the committee on the attached form whether or not you wish to attend the meeting. If you indicate that you
wish to attend, you will be informed regarding the time and place of the meeting. Your presentation should be as
concise as possible, since the committee has a limited amount of time available.
The peer review committee will examine your patient’s dental records and, if necessary, will examine your patient
before making a decision. This decision, after approval and finalization by the CDA Council on Peer Review, will be
set forth in a letter of resolution which will be copied to you and your patient on the date of release. All resolution
letters must be approved by the CDA. Therefore, no interim or tentative decision may be given to you before such
approval.
It is our intent to review this matter as soon as possible. Please complete and return the enclosed form(s) including all
pertinent information to the California Dental Association, Council on Peer Review, P.O. Box 13749, Sacramento,
CA 95853-4749 within fourteen (14) calendar days from the date of this letter.
Sincerely,
Enclosures: Treating Dentist Reply Form

Request for Review From Carrier
Patient Agreement Form (executed)
Authorization for Use and Disclosure of Health Information Form (executed)
C: Patient
Insurance Carrier
7-50 Rev: 7/27/15

Form #23
Initial Carrier Response Letter
Date
Name (Carrier)
Address
City, ST Zip Code

(Insured)
(Insured’s Date of Birth and group I.D. number)
Dear (Carrier):
Thank you for contacting the California Dental Association (CDA) concerning a peer review of treatment provided, or
about to be provided, by the above-mentioned dentist. It is imperative that you first attempt to resolve the question
directly with the dentist before referring the matter to peer review. If the dentist involved is not a CDA member, peer
review cannot accept the case. There is a $500 non-refundable filing fee per case charged to carriers to offset the cost of
peer review that is carrier initiated.
In that the peer review system affords an opportunity for personal testimony, should a representative wish to be
present at the time the committee meets to review this case, please state in your response letter and you will be notified
of the meeting details. Prior to initiating a review of this matter, further information is necessary. Please respond to the
items checked below and return this information to CDA.
________ A description of the problem
________ Delineate the specific questions the review committee

is to address
________ Provide a copy of the dental consultant’s evaluation

of the situation
________ Provide copies of all correspondence, claim forms, and

radiographs (if available)
________ $500 filing fee per case
The review committee would appreciate your response within fourteen (14) calendar days in order that we may
proceed with a review of this matter. If the requested information is not received within the specified time frame, this
case will be considered closed.
Sincerely,
7-51 Rev: 7/27/15

Form #24
Carrier Initiated Review Fee Request
Date
Name (Carrier)
Address
City, ST Zip Code
Dear (Carrier):
We are in receipt of your letter dated _____________.
A review fee of $500 per case is charged to carriers to offset the cost of peer review that is carrier initiated. A check in
the amount of $500 per case should accompany each request for review, made payable to the California Dental
Association (CDA).
Please send the filing fee, payable to CDA and the review will begin. Should we not receive your check within
fourteen (14) calendar days from the date of this letter, we will consider your request withdrawn and close our file.
Thank you for your cooperation in this matter.
Sincerely,
C: Dental Society
Dentist
Patient
7-52 Rev: 7/27/15

Form #25
Carrier Notification of Incomplete Information
Date
Name (Insurance Carrier)

Address
City, ST Zip Code
Dear (Insurance Carrier):
In order for the California Dental Association (CDA) to proceed with your request for review regarding the dental
treatment provided by the above-mentioned dentist, the following information must be submitted to CDA:
(Check appropriate boxes)
____ Description of the problem
____ Delineation of the specific questions the carrier wants the review committee to address
____ Copy of the consultant’s evaluation of the situation
____ Copies of all correspondence, claim forms, radiographs (if available) and any other
pertinent information related to the request
____ Copy of patient’s benefit contract
Unless the requested information is returned within fourteen (14) calendar days from the date of this letter, the matter
will be considered closed.
Sincerely,
(copy for tickler file)
7-53 Rev: 7/27/15

Form #26
Examination Panel Notification Memo
Date
To: , DDS
, DDS
, DDS
From:
Peer Review Coordinator
Subject: Peer Review Examining Panel
This is to confirm the meeting of the examining panel for_______________, at _____, at ____________‘s office,
__________________________. If appropriate, the case should be discussed prior to the patient examination.
Please review the case and confirm that the complaint has been filed within the time limitation and that the treatment
in question has not been altered. If the treatment in question has been altered, review the records to determine if the
committee has sufficient conclusive objective evidence to render a decision.
If you personally know any of the parties involved in this case, including the patient, treating dentist, or subsequent
treating dentist(s), you must notify CDA prior to the patient examination. If you are the dentist or a subsequent
treating dentist on the case, you must also notify CDA prior to the patient examination.
As peer review loses its impact and significance with time, please review the case and submit a draft Resolution Letter
(Form #59), a draft Resolution Addendum (Form #63), a Refund Distribution Worksheet (Form #87) and the
appropriate clinical examination worksheets (minimum 3) to CDA within twenty-one (21) calendar days following the
patient examination.
The following patients and dentist are scheduled to be examined/interviewed:
Case #1 DDS/Patient
Captain:
Team Members:
Patient Exam:
Dentist Interview:
Case #2 DDS/Patient
Captain:
Team Members:
Patient Exam:
Dentist Interview:
Should you have any questions, please contact me at 800.232.7645 (extension) or at (email)
C: (component/specialty peer review chair)
7-54 Rev: 7/27/15

Form #27
Initial Patient Examination Letter
Date
Name (Patient)
Address
City, ST Zip Code

Carrier (if any)
Dear (Patient):
A panel of dentists has been formed for the purpose of conducting an examination of your dental condition to aid our
committee in evaluating the above mentioned peer review case. Although no charge is made to you, the formation of
this panel represents a considerable donation of valuable time on the part of the members. It is, therefore, of the
utmost importance that you appear as scheduled before the panel.
To give you an understanding of the examination process, we are including important information about your dental
examination.
You will be examined by three or more dentists who will make an independent and impartial evaluation of your dental
treatment which you have brought to the attention of the peer review committee.
The prime objective of the peer review system is to offer a fair hearing to all parties concerned, and we want to thank
you in advance for your cooperation and consideration.
The examining dentists may ask you any questions they feel are pertinent to your problem. Their written evaluation
will be submitted to the full peer review committee for consideration.
The examining dentists do not make decisions on the resolution of your request for review, and they cannot advise
you of the peer review committee’s final decision since the examination is only one aspect of the review process. We
ask that you refrain from questioning the examining dentists regarding the results of their examination. If you have
additional comments pertinent to your complaint, you should present them during the examination.
We have made every effort to protect your confidentiality as well as that of the dentist involved. We expect your
cooperation in this regard.
The results of this examination and the decision of the peer review committee will be communicated to you in writing.
Every effort will be made to bring this matter to a fair conclusion.
Your examination is scheduled for (date, time and location).
Probing of the tissue surrounding the teeth may be necessary in order to render a decision in your peer review case. If
you indicate in the Request for Review Form that you have a medical condition that requires antibiotic premedication,
please contact your physician and notify the California Dental Association peer review staff prior to your examination
appointment. It is your responsibility to acquire and take the appropriate medication prior to your scheduled
examination. Failure to do so may require rescheduling of your examination and will result in a significant delay in the
resolution of your case.
Your failure to appear, without notice, will require us to consider your request for review closed. Should you then wish
to pursue this matter further, you will be required to file a new request for review.
7-55 Rev: 7/27/15

Please call the California Dental Association at 800.232.7645 to confirm the appointment by
.
Sincerely,
C: Dental Society
7-56 Rev: 7/27/15

Form #28
Dentist Invitation Letter to Attend Review Committee Meeting
CERTIFIED RETURN RECEIPT MAIL
Date
To: Dentist
From: Council on Peer Review
Subject: Peer Review Committee Meeting
The peer review committee meeting at which the Request for Review of the above-mentioned peer review case will be
discussed is scheduled as follows:
Location:__________________________________________________
Date: __________________________________________________
Time: __________________________________________________
In preparation for the discussion, you may wish to review your records and bring with you any (originals) radiographs,
models or charts you may have. This is your opportunity to provide additional information to the committee that will
help them in their deliberations. Unless we are advised in writing that you do not wish to attend (see attached Dentist
Will/Will Not Attend Meeting Form), we will expect you at the above noted time.
Your cooperation is appreciated.
Enclosure: Dentist Will/Will Not Attend Meeting Form #16
C: Dental Society
7-57 Rev: 7/27/15

Form #29
Appeal Criteria Statement
If you wish to appeal the decision reached by the Peer Review Committee, please review and follow these instructions:
Submitting an Appeal/Appeal Process:

 Appeals must be postmarked within thirty (30) calendar days from the date of the resolution letter.
 The Appeals Panel will only accept further information or evidence within the appeal period of thirty (30)
calendar days following the date of the resolution letter. This evidence must be submitted with the appeal request.
The Appeals Panel will not contact the patient or any dentist to obtain additional information or evidence.
 The appeal mechanism does not provide a new review of existing records or a new interview.
 The Appeals Panel will only review and address requests that meet one or more of the appeal criteria.
 Should the Appeals Panel determine that none of the issues raised meet the criteria, the appeal will be denied.
 The appeal letter must not be a restatement of the original inquiry, but an explanation of how the criteria have
been met.
 The appeal request will not be accepted if written by an attorney or any other party on behalf of the appellant. An
appeal request will be accepted if written by the legal guardian on behalf of a minor child.
 It is suggested the request be sent by certified mail. When an appeal request is received at CDA, a letter
acknowledging its receipt will be sent to the parties involved.
Appeal Criteria:
The appellant(s) must factually demonstrate in writing one or more of the following appeal criteria:
1. You were not provided with an opportunity to meet with the Peer Review Committee (i.e., you requested to
meet with the committee but were not given an opportunity).
2. The peer review committee did not perform a clinical evaluation. A clinical evaluation encompasses written
statements, patient records and clinical evidence (such as radiographs, clinical examination, if applicable,
etc.).
3. Relevant information or evidence exists which, in the exercise of reasonable diligence, was not considered or
could not have been presented to the Peer Review Committee prior to the clinical examination and/or
dentist interview. Evidence must be submitted with the appeal request.
4. The resolution of the case appears contrary to the information presented. Describe how the decision is
contrary to the information presented.
5. The peer review committee made a procedural error in evaluating your case. The Peer Review Manual is
available at www.cda.org.
All appeal requests MUST be mailed to: OR Sent by overnight service to:
California Dental Association California Dental Association

Council on Peer Review-Appeals Panel Council on Peer Review-Appeals Panel
Post Office Box 13749 1201 K Street, 16 th Floor
Sacramento, CA 95853-4749 Sacramento, CA 95814
Facsimile or emailed appeals to the Appeals Panel will not be accepted.
Issues that Cannot be Appealed:

 Cases that are inappropriate for review or which result in a “non-resolution” letter cannot be appealed and,
therefore, do not receive a thirty (30)-day appeal period.
 For treatment that was determined to be acceptable but incomplete, no appeal shall be granted that solely
disputes the amount of the refund.
If you have a question about an incorrect refund, an insurance refund erroneously omitted, or a patient no longer
covered by an insurance carrier, contact the California Dental Association office at 800-232-7645 for clarification or
correction of these matters.
Final Decision:
7-58 Rev: 7/27/15

The peer review decision becomes final when:

 No appeal is filed by either party within thirty (30) calendar days following the date of the resolution letter.
 The Appeals Panel renders a determination regarding an appeal request that meets one or more of the appeal
criteria (some Appeals Panel decisions may provide a new appeal period).
 The parties to the peer review may expressly agree to waive any appeal and if so waived, this decision becomes
final and binding immediately upon written waiver by all parties.
7-59 Rev: 7/27/15

Form #29A
Appeal Criteria Statement for Corrective Treatment Plan and Cost Estimate
If you wish to appeal the decision reached by the Peer Review Committee regarding your corrective treatment plan
and cost estimate, please review and follow these instructions:
Submitting an Appeal/Appeal Process:

 Appeals must be postmarked within fifteen (15) calendar days from the date of the corrective treatment plan and
cost estimate approval letter.
 The Appeals Panel will only accept further information or evidence within the appeal period of fifteen (15)
calendar days following the date of the corrective treatment plan and cost estimate approval letter. This evidence
must be submitted with the appeal request. The Appeals Panel will not contact the patient or any dentist to
obtain additional information or evidence.
 The corrective treatment plan and cost estimate appeal mechanism does not provide a new review of the original
case or an interview.
 The Appeals Panel will only review and address requests that meet one or more of the appeal criteria.
 Should the Appeals Panel determine that none of the issues raised meet the criteria, the appeal will be denied.
 The appeal letter must not be a restatement of the original inquiry, but an explanation of how the criteria have
been met with regard to the corrective treatment plan and cost estimate.
 The appeal request will not be accepted if written by an attorney or any other party on behalf of the appellant. An
appeal request will be accepted if written by the legal guardian on behalf of a minor child.
 It is suggested the request be sent by certified mail. When an appeal request is received at CDA, a letter
acknowledging its receipt will be sent to the parties involved.
Appeal Criteria:
The appellant(s) must factually demonstrate in writing one or more of the following appeal criteria:
1. Relevant information or evidence exists which, in the exercise of reasonable diligence, was not considered or
could not have been presented to the Peer Review Committee prior to the submission of your original corrective
treatment plan and cost estimate to the committee. Evidence must be submitted with the appeal request.
2. The corrective treatment plan and/or cost estimate approved by the peer review committee appear to be
inconsistent with the corrective procedures as listed in the final resolution.
All appeal requests MUST be mailed to: OR Sent by overnight service to:

Facsimile or emailed appeals to the Appeals Panel will not be accepted.
Final Decision:
The peer review decision regarding the corrective treatment plan and cost estimate becomes final when:
 No appeal is filed by either party within fifteen (15) calendar days following the date of the corrective treatment
plan and cost estimate approval letter.
 The Appeals Panel renders a determination regarding an appeal request that meets one or more of the appeal
criteria (some Appeals Panel decisions may provide a new appeal period).
 The parties to the peer review may expressly agree to waive any appeal and if so waived, this decision becomes
7-60 Rev: 7/27/15

Form #30
Appeal Criteria Statement (Over-Utilization Case Review)
The peer review decision is not final until the latest to occur of the following:
1. Expiration of the tenth (10th) calendar day following the date of the resolution letter, without an appeal
being filed by either party; or
2. The determination of any appeal of this decision, which was filed within ten (10) calendar days from the date
of the resolution letter.
However, the parties to the peer review may expressly agree to waive any appeal and if so waived, this decision becomes
In order to be granted an appeal review of this case, the appellant(s) must factually demonstrate in a request for an
appeal review at least one of the following criteria:
1. The peer review committee did not provide you with an opportunity to meet with the committee (this
criteria is applicable to the dentist only).
2. The peer review committee did not perform a clinical evaluation. A clinical evaluation encompasses written
statements, patient records, clinical evidence (such as radiographs), clinical examination (if applicable), etc.
3. Relevant information exists which, in the exercise of reasonable diligence, could not have been presented to
the peer review committee, prior to the clinical examination and/or dentist interview.
4. The resolution of this case appears contrary to the information presented.
5. The peer review committee made a procedural error in evaluating your case. Peer review manuals are
available online at www.cda.org, or a manual may be purchased by contacting the California Dental
Association.
Therefore, in fairness to all parties, if the appeal does not include or is not based on the above criteria, the request
will be denied.
Your appeal statement must either be typed or printed legibly. The appeal statement will not be accepted if written
by an attorney on behalf of the appellant. Appeal statements faxed to the Council on Peer Review’s Appeals Panel
will not be accepted. The appeal letter must not be a restatement of the original inquiry but a list explaining how the
above criteria have been met. The appeal mechanism does not provide a new review or interview.
NON-APPEALABLE ISSUES
1. Cases that are inappropriate for review, or which result in a "non-resolution" letter are not appealable and,
therefore, do not receive a thirty (30)-day appeal period.
2. Denture cases involving a partial refund will not be an issue subject to appeal.
3. Issues related to incorrect refunds, insurance refunds erroneously omitted, or a patient is no longer covered
by their insurance carrier, are not appealable. Contact the California Dental Association.
If you wish to request an appeal review of the decision reached by the peer review committee, you must, within ten
(10) calendar days from the date of the resolution letter, demonstrate in writing one or more of the aforementioned
criteria. The Appeals Panel will not accept any further information or evidence pertaining to the appeal after the
expiration of the tenth (10th) calendar day following the date of the resolution letter. It is suggested this request be sent
by certified mail. When an appeal request is received at California Dental Association, a letter acknowledging its
receipt will be sent to the parties involved.
All appeal requests MUST be mailed to (FAXES WILL NOT BE ACCEPTED):

Council on Peer Review-Appeals Panel
Post Office Box 13749
7-61 Rev: 7/27/15

APPEAL REQUESTS SENT TO THE DENTAL SOCIETY OFFICE WILL BE RETURNED.
7-62 Rev: 7/27/15

Form #32
Notification of New Case to Component/Specialty Chair
Date
To: _______________, Chair

Component/Specialty Peer Review Committee
From:
CDA Peer Review Coordinator
We are requesting your assistance in resolving the above named peer review case. Attached is a copy of the case for
your review. While CDA staff has pre-screened the case, as the peer review chair, you are also responsible for
confirming that the case is appropriate for review. The following forms for processing the case are also attached:
Appropriate Clinical Worksheet(s)

Form #59 - Resolution Letter Worksheet
Form #60 - Resolution Letter Guidelines
Form #63 - Resolution Addendum Format
Form #87 – Refund Distribution Worksheet
The case materials and forms have also been forwarded to the dental society office, should you or your committee
members require additional printed copies.
As a reminder, your peer review committee has a total of sixty (60) calendar days from the date of this letter (date) in
which to conduct the patient examination; interview the dentist; and complete the appropriate clinical examination
clinical worksheets (minimum 3), resolution letter worksheet, resolution addendum format and refund distribution
worksheet. (Please note: completed clinical worksheets (minimum 3), resolution letter worksheet, resolution
addendum and refund distribution worksheet are due to CDA within twenty-one (21) calendar days from the date of
the clinical examination and dentist interview.)
In order to meet the required timeline, please provide the following information within twenty-one (21) calendar days
from the date of this letter:
 Peer Review Meeting Date, Time and Location

 Chair/Case Captain
 Names of Exam Panel Members
Upon receipt of this information, CDA staff will forward a confirmation notice regarding the date, time and location
of the meeting to the patient, dentist under review and each peer review examination panel member.
Should you need assistance in obtaining additional information, scheduling patient examinations, or other aspects of
the review process, please contact me at 800.232.7645 ext. ________, or (email address).
Attachments: Case Materials

Clinical Worksheet(s)
Form #s 59, 60, 63, 87
C: ___________________Dental Society
Notice: Prior to case assignment, please confirm that exam panel members have met the calibration requirements.
Additionally, should any of the peer review committee members have a conflict of interest or should there be a
perceived conflict of interest, please notify CDA before proceeding with the case review.
7-63 Rev: 7/27/15

Form #34
Notification of Non-Member Dentist
Date
Name (Patient)
Address
City, ST Zip Code
Dear (Patient):
This letter is in response to your request for review of the above-mentioned dentist. Since he/she is not a member of
the California Dental Association (CDA), we are unable to act on this matter.
Because CDA is a membership organization, it does not accept requests for review of non-member dentists, as this
would be giving a benefit of membership to those who have not assumed the obligations of such membership.
Therefore, we regret that we are unable to be of service to you.
As an alternative, you may wish to forward your questions to the Dental Board of California which reviews complaints
involving all licensed California dentists. Should you wish to pursue this matter, you may contact the board by
addressing your correspondence to:
Dental Board of California

2005 Evergreen Street, Suite 1550
Sacramento, CA 95815
(916) 263-2300
www.dbc.ca.gov
Sincerely,
C: Dentist
Dental Society
7-64 Rev: 7/27/15

Form #35
Final Notification to Patient of Dentist Expulsion/Dropped
Membership/No Further Action
(This form is to be sent ONLY following instruction from CDA’s Council on Peer Review)
Date
Name (Patient)
Address
City, ST Zip Code

(Carrier, if any)
Dear (Patient):
The California Dental Association (CDA) wishes to bring you up to date on the above referenced matter.
At the time peer review began in this case, you signed the patient agreement form and agreed to abide by the decision
reached in connection with the dental treatment rendered by Dr. . In addition, Dr. , by virtue of
his or her membership in CDA, agreed to abide by the peer review decision. However, because Dr. is no
longer a member of CDA, we are unable to act further on this matter.
You may wish to refer your complaint to the Dental Board of California, which reviews complaints involving all
California licensed dentists. Should you wish to do so, you may contact the board by addressing your correspondence
as follows:
Dental Board of California

2005 Evergreen Street, Suite 1550
Sacramento, CA 95815
(916) 263-2300
www.dbc.ca.gov
We regret that we are unable to be of further service to you.
Sincerely,
C: Dentist
Dental Society
7-65 Rev: 7/27/15

Form #37
Notification of Deceased Dentist
Date
Name (Patient)
Address
City, ST Zip Code
Dear (Patient):
The California Dental Association is in receipt of your request for a review of the services provided by the
above-mentioned dentist. In reviewing the matter, our records indicate that Dr. __________ is deceased. Therefore,
due to the nature of the peer review system, we are unable to be of assistance to you.
Thank you for contacting us regarding your concerns.
Sincerely,
C: Dental Society
7-66 Rev: 7/27/15

Form #38
Notification of CDA’s Time Limitations
Date
Name (Patient)
Address
City, ST Zip Code
Dear (Patient):
The California Dental Association (CDA) is in receipt of your recent letter regarding dental treatment provided by the
above dentist. We must inform you that the time limitation for accepting a request in the peer review system is three
years from the date of completion of the service or one year from recognition of the alleged problem, whichever occurs
first. Because the passage of time can alter clinical conditions, we trust you understand the difficulty we might have in
fairly assessing a situation long after the fact.
Since the complaint was received after the time limitation has expired, the California Dental Association is unable to
assist you in this matter.
By copy of this letter, we are notifying Dr. _____________ of your concerns.
Sincerely,
C: Dental Society
Dentist
7-67 Rev: 7/27/15

Form #39
Non-Routine Case Memo
Date
To: Council Member (Name)

From: (Name)
(CDA Council on Peer Review staff)

(Insurance Carrier, if any)
The California Dental Association is in receipt of the enclosed request for review which appears to be non-routine as
follows:
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
We request notification of how this matter will be handled. Thank you for your assistance.
Attachment
Enclosure: Case File
7-68 Rev: 7/27/15

Form #40
Non-Member Dentist Requesting Review Letter
Date
Name (Dentist)
Address
City, ST Zip Code

Dear (Dentist):
The California Dental Association (CDA) is in receipt of your request for a review regarding the above-mentioned
party(ies). However, our records indicate that you are not a member of CDA.
Because CDA is a membership organization, it does not accept requests for review from non-member dentists, as this
would be giving a benefit of membership to those who have not assumed the obligations of such membership.
Therefore, we regret that we cannot be of assistance to you in this matter.
Sincerely,
C: Dental Society
7-69 Rev: 7/27/15

Form #41
Notification of CDA Policy Regarding Fee Review
Date
Name (Patient)
Address
City, ST Zip Code
Dear (Patient):
The California Dental Association is in receipt of your request for a review of fees charged by Dr. __________. We
wish to advise you of the policy and limitations of the peer review system.
The purpose of the peer review system is to investigate complaints concerning the quality and/or appropriateness of
dental treatment. A review committee will not comment on a dentist’s fees. However, by copy of this letter we are
advising Dr. __________ of your dissatisfaction and suggest that you contact him directly to discuss your concerns.
We regret that we cannot be of further assistance to you in this matter.
Sincerely,
C: Dental Society
Dentist (include inquiry)
7-70 Rev: 7/27/15

Form #42
Notification of Benefit Exclusion
Date
Name (Patient or Dentist)

Address
City, ST Zip Code
Subject: (Dentist or Patient) / (Patient or Dentist)

(Insured)
(Insurance Carrier)
Dear (Patient or Dentist):
The California Dental Association has received your request for a peer review of dental treatment provided, or about
to be provided, by the above-mentioned dentist. However, it appears that this request concerns a specific benefit
exclusion or contract limitation of the policy.
A review committee is unable to request that a carrier allow benefits which are specifically excluded in a patient’s
policy, and, therefore, we would be unable to assist you in this matter. (For patient initiated case add, "We suggest that any
questions you have concerning your policy benefits should be discussed with your employer, the purchaser of the contract.")
Thank you for contacting the California Dental Association.
Sincerely,
C: Dental Society
Dentist or Patient
Insurance Carrier
7-71 Rev: 7/27/15

Form #43
Notification of Communication Problem
Date
Name (Patient)
Address
City, ST Zip Code
Dear (Patient):
The California Dental Association is in receipt of your letter concerning the above mentioned dentist. We wish to
advise you of the limitations of the peer review system.
The purpose of the peer review system is to investigate inquiries concerning the quality and/or appropriateness of
dental treatment. The peer review system cannot review complaints concerning (fill in the basis of complaint, i.e., a
dentist’s attitude, collection procedures, office conditions, appointment scheduling). However, by copy of this letter we
are advising Dr. __________ of your dissatisfaction and suggest that you contact him/her directly to discuss your
concerns.
Sincerely,
C: Dental Society
Dentist (include inquiry)
7-72 Rev: 7/27/15

Form #44
Notification of Completed/Altered Treatment
Date
Name (Patient)
Address
City, ST Zip Code

Dear (Patient):
The California Dental Association Peer review committee has completed a review regarding your request to determine
if the quality of care rendered to you by Dr. ___________ was acceptable.
The review committee evaluated the records and radiographs submitted by Dr. ___________ and by your subsequent
treating dentist. The review committee was unable to make a determination on the basis of the records since the work
has been altered or redone, and since it was not possible to evaluate the treatment in question, no recommendation
can be made.
We regret that we are unable to be of assistance to you in this matter.
Sincerely,
C: Dental Society
Dentist
Carrier, if any
7-73 Rev: 7/27/15

Form #45
Notification of Litigation or Arbitration
Date
Name (Patient)
Address
City, ST Zip Code
Dear (Patient):
Thank you for your recent letter regarding treatment rendered by the dentist named above.
It appears that this matter is presently in or has previously been through [litigation] [arbitration]. A 90-day notice of
intent to file suit is to be construed as litigation and no case in litigation will be accepted into the peer review system.
The peer review system is an alternative to legal proceedings, and cannot be used if [legal proceedings have]
[arbitration has] begun. We have no authority to supersede the decisions of a court of law. This case would not be
appropriate for review in accordance with California Dental Association’s peer review policy.
We appreciate your contacting the California Dental Association and regret that we are unable to be of assistance in
this case.
Sincerely,
C: Dental Society
Dentist
7-74 Rev: 7/27/15

Form #46
Request for Withdrawal of Litigation/Arbitration
Date
Dentist
Address
City, ST Zip Code

Dear (Dentist):
The California Dental Association (CDA) has been informed that, subsequent to a complaint filed by your patient
with the peer review committee, you have initiated [legal action] [arbitration] regarding this matter.
As outlined in Section 3 of the California Dental Association Code of Ethics, Cooperation with Duly Constituted
Committees:
"It is the duty of the member to comply with the reasonable requests of a duly constituted committee".
According to the CDA Judicial Council, a member-dentist who [files a lawsuit] [initiates arbitration] after a peer review
is initiated is in violation of the Code of Ethics, and failure to withdraw such a [lawsuit without prejudice] [an
arbitration] pending resolution of the peer review may compel the Council on Peer Review to forward this matter to
the Judicial Council.
The Council on Peer Review respectfully requests that you withdraw this [lawsuit] [arbitration] within twenty-one (21)
calendar days of the date of this letter and that you provide CDA a [copy of the court's action which you have taken to
withdraw this case] [copy of the action which you have taken to withdraw arbitration]. If, however, our information is
incorrect, please notify CDA within twenty-one (21) calendar days of the date of this letter.
The Council on Peer Review would also like to inform you that the utilization of peer review does not stop, interrupt
or suspend the running of the time period for a dentist to file a civil suit against a patient for payment of services.
The filing of such actions are governed by the California Code of Civil Procedures Sections 337 and 339.
Sincerely,
C: Dental Society
(Patient)
7-75 Rev: 7/27/15

Form #47
Notification of Settlement
Date
Name (Dentist or Patient)

Address
City, ST Zip Code

Dear (Dentist or Patient):
The California Dental Association has been notified by ___________ that an agreement has been reached concerning
the above-mentioned peer review case. We are pleased that this matter has been amicably resolved.
If this information is incorrect, please contact the California Dental Association, Council on Peer Review, P.O. Box
13749, Sacramento, CA 95853-4749 within ten (10) calendar days from the date of this letter. Otherwise, we will
consider the case closed.
Sincerely,
C: Dental Society
Dentist or Patient
7-76 Rev: 7/27/15

Form #48
Notification to Patient of Dentist Dropping Membership
Date
Name (Patient)
Address
City, ST Zip Code

Dear (Patient):
reached in connection with the dental treatment rendered by Dr. _____________. In addition, Dr. ______________,
by virtue of his or her membership in CDA, agreed to abide by the peer review decision.
However, it has come to our attention that Dr. ___________________ has withdrawn his or her membership in
CDA. Since he or she was a member at the time peer review was initiated we believe Dr. _______________ may agree
to abide by the decision. Therefore, we will proceed with the resolution of this matter and upon completion of review,
CDA will forward its decision to you. Please be advised, should Dr. __________ choose not to cooperate with the
peer review decision, you may not be able to collect on any money that the peer review committee may award. If Dr.
_____________ is unwilling to cooperate, then the actions that the peer review committee can take against him or her
will not include compelling him or her to pay the amount awarded through any formal legal process.
It is our hope that by providing you with this information, you will be in a better position to evaluate the need to
pursue other options in resolving this matter.
Thank you for your cooperation and understanding in this matter.
Sincerely,
C: Dental Society
Dentist
Insurance Carrier, if any
7-77 Rev: 7/27/15

Form #49
Acknowledgment of Dropped Membership
Date
Name
Address
City, ST Zip Code

Dear (Dentist):
In light of your relinquished membership in California Dental Association (CDA) and ______________ Dental
Society, we are writing to discuss your membership status as it relates to your pending peer review case(s).
We wish to remind you that you are still bound to abide by the decisions pursuant to the CDA Code of Ethics and
Bylaws in that you were a CDA member when peer review was initiated in this case. Upon completion of the
review, CDA will forward the approved decision to you.
Thank you for your cooperation in this matter.
Sincerely,
C: Dental Society
7-78 Rev: 7/27/15

Form #50
Patient Notification of Failure to Appear
Date
Name (Patient)
Address
City, ST Zip Code

Dear (Patient):
On (date) and (date), a panel of dentists were brought together for the purpose of conducting an examination of your
dental work.
Your failure to appear on both occasions, with no notice, requires us to close the case.
Sincerely,
C: Dental Society
Dentist
7-79 Rev: 7/27/15

Form #51
Dentist Non-Compliance During Review Letter (First Notice)
Date
Name
Address
City, ST Zip Code
Dear (Dentist):
Our records indicate that you have not sent:

( ) the completed Treating Dentist Reply Form (Form #15)
( ) the completed Consulting/Subsequent Treating Dentist Reply Form (Form #19)
( ) typed, verbatim transcription of treatment notes
( ) copy of original progress records
( ) radiographs
( ) models
( ) billing information (including a single patient ledger)
which was requested for review of the above mentioned case. Lack of cooperation by any member reduces the
effectiveness of your review committee.
According to the Code of Ethics of the California Dental Association (CDA), Section 3, Cooperation with Duly
Constituted Committees:
"A dentist has the obligation to comply with the reasonable requests of a duly constituted
committee, council or other body of the component society or of this association necessary or
convenient to enable such a body to perform its functions and to abide by the decisions of such
body"
If, for any reason, the committee has been in error in processing this request or if you have been able to resolve this
matter in the interim, please notify the California Dental Association, Council on Peer Review, P.O. Box 13749,
Sacramento, CA 95833-4749 in writing within fourteen (14) calendar days from the date of this letter.
Should you not comply within fourteen (14) calendar days from the date of this letter, you may be referred to the
Judicial Council.
Sincerely,
C: Dental Society
7-80 Rev: 7/27/15

Form #52
Dentist Non-Compliance with Resolution Letter (First Notice)
Date
Name
Address
City, ST Zip Code
Dear (Dentist):
The California Dental Association (CDA) requested that you refund $__________ to the patient to resolve this
complaint. The appeal period has closed; therefore, the decision has become final.
Please forward your check in the amount of $__________, made payable to _____________, to the California Dental
Association, Council on Peer Review, PO Box 13749, Sacramento, CA 95853-4749 within fourteen (14) calendar
days from the date of this letter. Failure to do so may be a violation of Section 3 of the CDA Code of Ethics,
"Cooperation with Duly Constituted Committees”, and may be referred to the CDA Judicial Council for possible
disciplinary action.
Your cooperation is appreciated.
Sincerely,
C: Dental Society
Patient
7-81 Rev: 7/27/15

Form #53
Dentist Non-Compliance with Resolution Letter (Second Notice)
CERTIFIED MAIL RETURN RECEIPT MAIL
Date
Name
Address
City, ST Zip Code
Dear (Dentist):
The nature of this correspondence is the relationship of your membership status to your pending peer review case(s)
involving the above-mentioned party(ies).
The California Dental Association (CDA) Council on Peer Review (council) wishes to inform you that you agreed to
abide by the peer review committee’s decisions pursuant to CDA’s Code of Ethics and Bylaws.
Your compliance with the enclosed case resolution is requested and will close the case file on this matter. Should you
fail to comply, you may be in violation of Section 3 of the CDA Code of Ethics, “Cooperation with Duly Constituted
Committees”, and our committee will have no alternative but to refer you to the CDA Judicial Council for
consideration of possible disciplinary action.
Pursuant to this final decision and the previous discussion, we respectfully request your compliance within fourteen
(14) calendar days from the date of this letter, to prevent any further referrals on our part. Thank you for your
cooperation in this matter.
Sincerely,
Enclosure: Resolution Letter
C: Dental Society
Patient
7-82 Rev: 7/27/15

Form #53A
Notification to Dentist Referral to Judicial Council
Date
Name
Address
City, ST Zip Code
Dear Dr.________:
With regard to the referenced matter, the Council on Peer Review wishes to inform you that this matter has been
referred to the Judicial Council of the California Dental Association (CDA) citing a potential violation of Section 3 of
the CDA Code of Ethics.
Any future questions or correspondence should be directed to the CDA Judicial Council at the California Dental
Association, Judicial Council, Post Office Box 13749, Sacramento, CA 95853-4749.
Thank you for your attention.
Sincerely,
C: Dental Society
CDA Judicial Council
7-83 Rev: 7/27/15

Form #55
Non-Compliance Referral Memo (Pattern of Practice)
Date
To: , DDS
Chair, Peer Review Committee
From: , DDS
Chair, Council on Peer Review
Subject: , DDS
The following cases were determined to be adverse and were initiated within a 24-month period. The dates following
the case names reflect the initiation dates.
, DDS/ , Patient __________________

(insert date)
, DDS/ , Patient __________________

(insert date)
, DDS/ , Patient __________________

(insert date)
If the Council on Peer Review determines that there is cause to investigate, the treating member dentist shall be
referred to Judicial Council for further investigation.
(Should there be anything unusual about the dentist’s membership status at the time the cases were initiated and/or
during the review, please make notation of it here, i.e. Please note that Dr. was a pending applicant at the time these
cases were opened, however, he or she was denied membership on .)
Date
Enclosure:
7-84 Rev: 7/27/15

Form #56
Non-Compliance of Consulting/Subsequent Dentist Letter
Date
Name
Address
City, ST Zip Code

(Insurance Carrier)
Dear (Dentist):
Our records indicate that you have not responded to the California Dental Association’s (CDA’s) request for your
input regarding the above-mentioned peer review case. Lack of cooperation by any member reduces the effectiveness of
your review committee.
According to the Code of Ethics of the California Dental Association, Section 3, Cooperation with the Duly
Constituted Committees:
"A dentist has the obligation to comply with the reasonable requests of a duly constituted
committee, council or other body of the component society or of this association necessary or
convenient to enable such a body to perform its functions and to abide by the decisions of such
body"
If for any reason the committee has been in error in processing this request, please notify the California Dental
Association in writing within fourteen (14) calendar days from the date of this letter. Should you not comply within
fourteen (14) calendar days from the date of this letter, you may be referred to Judicial Council for further
investigation.
Sincerely,
C: Dental Society
7-85 Rev: 7/27/15

Form #57
Notification of Compliance Memo
Date
To: Dental Society

Recently, the California Dental Association (CDA) staff contacted Dr. ____________ concerning non-compliance
with the committee’s recommendation of a refund. The refund has been received at CDA and we are therefore closing
this case.
C: Dentist
Patient
7-86 Rev: 7/27/15

Form #58
Notification to Committee of Additional Information Received
Date
(Name)
Chair, Peer Review Committee
Specialty Review Organization
Address
City, ST Zip Code

Dear (Dentist):
Additional information is enclosed for your committee’s consideration in the above referenced peer review matter.
We look forward to receiving the committee’s final determination. Thank you for your assistance.
Sincerely,
Enclosure:
C: Dentist
Patient
7-87 Rev: 7/27/15

Form #59
Resolution Letter Worksheet
Date
For further instructions or clarification, please refer to the Peer Review Manual, Section III, Responsibilities of
Component and Specialty Peer review committee, Preparation of Resolution Letter.
(Address letter to person initiating complaint)

_____________________________________________
_____________________________________________
_____________________________________________
Subject: __________________, DDS /________________, Patient

Insuring Entity: _________________ (if applicable)
Name of Insured: _________________ Group No: __________
Social Security No.: _____________________
Dear ________________:
This resolution is written regarding a problem that occurred between the above-mentioned parties wherein you asked
the ______________Dental Society and the California Dental Association (CDA) to determine if the (specify
treatment) __________ rendered to you by Dr. ____________ was acceptable (and/or appropriate).
(If the dentist involved is a specialist and the review was conducted by a specialty organization, include in the first
paragraph) Since Dr. _________ is a specialist, the review was conducted by the _______________________(name
of organization). (If the dentist involved is a specialist and the review was conducted by the local component using a
consultant as an expert, include in the first paragraph) Since Dr. _________ is a specialist, the review was conducted
using the expertise of a consultant.
(If the case involves an itinerant dentist, include in the first paragraph) Although Dr. _________ is a member of the
_________ Dental Society, this review was conducted by the _________ Dental Society which serves the area in which
the treatment in question was rendered. (Copy the "home component" on the final letter of resolution, along with
pertinent background material, so that they can maintain accurate peer review records on their own members.)
(Inquiry)
In your request for review you stated that: (List/summarize all concerns/complaints of initiating party.)
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
(Procedures followed and evidence considered)
The committee has reviewed: your written inquiry; results of the clinical examination, which was performed using
CDA’s Guidelines for the Assessment of Clinical Quality and Professional Performance; information from your
insurance carrier (if applicable); information from your consulting/subsequent treating dentist(s) (if applicable); and
the response from Dr.________. The clinical examination performed on ______________(date) was a thorough
evaluation of the dental treatment in question. Peer Review does not provide for a comprehensive full mouth dental
examination. (If a clinical examination was not performed, explain why. Expand on above and list any additional
evidence as necessary.)
(Address concerns that fall outside the parameter of peer review.)

______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
7-88 Rev: 7/27/15

(Conclusion(s))
It has been determined that the treatment in question meets the guidelines for dental care as set forth by the
California Dental Association. Therefore, the ruling of the committee is that a refund is not in order. (The committee
must address the patient’s complaint and in a non-clinical manner explain why the treatment is acceptable.)
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
-or-
It has been determined that your complaint regarding ____________________________ is valid.

(specify treatment)
Therefore, the ruling of the committee is that Dr. __________ refund for the treatment rendered in the amount of
$ ______________. Any additional costs that may be incurred as a result of re-treatment will be your responsibility.
Per the Patient Agreement Form signed by you on ______ (date), you agreed to sign a Release of All Claims Form
should the committee determine that a refund is in order. Therefore, prior to receiving a refund, you will be required
to sign a Release of All Claims.
-or-
It has been determined that the treatment in question meets the guidelines for dental care as set forth by the
California Dental Association. However, the treatment is incomplete. Therefore, the ruling of the committee is that
Dr. ______________ refund for the portion of the treatment which was not completed in the amount of
$______________ (if applicable). (The committee must address the patient’s complaint and provide an explanation
as to why the treatment is acceptable but incomplete.)
______________________________________________________________________________
______________________________________________________________________________
(Refund Information)
Dr. ______________ is instructed to forward his or her check in the amount of $_________ made payable to
______________ (patient’s name) and a check in the amount of $_________ made payable to
______________________ (insurance carrier name, if applicable) to the California Dental Association, Council on
Peer Review, P.O. Box 13749, Sacramento, CA 95853-4749, within fourteen (14) calendar days following the
expiration of the appeal period or the determination of any appeal of this decision. Within fourteen (14) calendar days
of receiving the check from Dr. _____________, CDA will forward a Release of All Claims Form for your signature.
The check made payable to you and the check made payable to the insurance carrier (if applicable) will be mailed
within fourteen (14) calendar days of CDA receiving the signed Release of All Claims Form. The check to the carrier
will be mailed to re-establish your eligibility. (In instances where a refund is to be deducted from the patient’s
outstanding balance, or the balance reduced to zero, request that an adjusted statement be sent to CDA reflecting
that fact.)
If corrective treatment is recommended, include the following paragraph: Dr. ______________ is responsible for
your corrective treatment limited to_______________ (periodontal, prosthodontic, endodontic). You will have thirty
(30) calendar days from the expiration of the appeal period or the determination of any appeal of this decision to
submit a written corrective treatment plan and cost estimate from the dentist of your choice to the California Dental
Association, Council on Peer Review, P.O. Box 13749, Sacramento, CA 95853-4749, for review and approval.
Once the corrective treatment plan and cost estimate have been approved, any additional treatment or fee that is not
further approved by the Peer Review Committee will be your responsibility. (Note: Must include corrective
treatment criteria. See Corrective Treatment Plan and Cost Estimate Approval Letter Form #94 and Appeal
Criteria Statement for Corrective Treatment Plan and Cost Estimate Form #29A). Upon written approval of the
corrective treatment plan and cost estimate, Dr. ____________ will be requested to forward his or her check for the
approved amount to the California Dental Association, Council on Peer Review, P.O. Box 13749, Sacramento, CA
95853-4749 within fourteen (14) calendar days. Within fourteen (14) calendar days of receiving the check from Dr.
___________, CDA will forward a Release of All Claims Form for your signature. Upon receipt of the signed Release
of All Claims, CDA will record and forward the check to you and the case will be considered closed. If a written
corrective treatment plan and cost estimate are not received within the thirty (30) calendar day time period and
7-89 Rev: 7/27/15

reasonable reason for failing to do so is not provided in writing to CDA the corrective treatment will be your
responsibility.
Enclosed are the appeal criteria that are also enclosed with Dr. ____________’s copy of this letter. The appellant(s) must
within the thirty (30) calendar days from the date of this resolution letter, factually demonstrate in writing (typed or
printed legibly) one or more of the appeal criteria on the enclosed appeal criteria statement.
All appeal requests MUST be MAILED to: OR Overnighted to:

Council on Peer Review - Appeals Panel Council on Peer Review - Appeals Panel
Facsimile transmissions of appeals will not be accepted. If you choose to appeal the decision of this committee, the
appeal must be postmarked no later than DATE. The decision is not final until the expiration of thirty (30) calendar
days from the date of this letter without an appeal filed, or the determination of any appeal of this decision.
Thank you for allowing the ______________ Dental Society and the California Dental Association to be of assistance
to you.
Sincerely,
Enclosure: Appeal Criteria
C: Dental Society
Specialty Committee’s Name (if applicable)
Treating Dentist’s Name
Insurance Carrier
7-90 Rev: 7/27/15

Form #60
Resolution Letter Guidelines
The following points are to be used in reviewing the resolution letter. These points are intended to be guidelines.
• Does the resolution letter identify whether or not the review was conducted by a specialty organization?
• Does the resolution letter identify all the inquiries contained in the patient’s request for review?
• Does the resolution letter include a statement of evidence considered by the peer review committee including
x-rays, consulting dentist information, periodontal probings, etc?
• Does the resolution letter make reference to the performance and date of a clinical examination? If not, does
it explain why a clinical examination was not performed?
• If the treatment has been found to be acceptable, does the resolution letter address -- in a non-clinical manner
-- each of the patient’s complaints as to why the treatment is acceptable?
• If quality of care does not meet the guidelines of care, has the dentist under review caused further harm to
the patient which will result in corrective treatment? Has this been addressed in the resolution letter?
• Has refund been adequately explained so all parties will understand how the figures have been arrived?
• If applicable, has the carrier been reimbursed?
• If corrective treatment is involved, has an allowance been made for submission of estimates and payment by
the dentist under review?
• Make sure no "clinical" findings are included in the letter, with the exception of utilization reviews.
• Is appeal criteria statement included?
• Have all parties been copied on letter?
7-91 Rev: 7/27/15

Form #61
Refund Guidelines
The following questions and statements will assist in computing refunds in peer review cases.
1. a. Was the patient covered by insurance at the time of the treatment?

b. Did the insurance company pay on the treatment in question?
c. Is the patient still covered by insurance?
2. a. Was all the treatment in question found to be unacceptable? If not, spell out which treatment was
acceptable and which was not.
b. What was the total amount charged for all the treatment?
c. What was the total amount charged for the unacceptable treatment?
d. What was the total amount charged for the acceptable treatment?
3. Determine:
a. Did the insurance carrier pay on the unacceptable treatment? How much?
b. Did the insurance carrier pay on the acceptable treatment? How much?
4. Determine:
a. What is the patient’s financial responsibility for unacceptable treatment?

b. What is the patient’s financial responsibility for acceptable treatment?
5. a. Did the patient make any payments? How much?

b. Is there an outstanding balance on the account? How much?
6. Compute the refund using the following assumptions:
a. If the patient is still covered by the carrier, and the carrier has indicated that benefits will be
reestablished, the carrier will receive a full refund for all benefits paid toward unacceptable
treatment.
b. If the patient is no longer covered by the carrier, the patient will receive a full refund for all benefits
paid by the carrier toward the unacceptable treatment, however, if the patient has an outstanding
balance for acceptable treatment, a full credit for the benefits paid for the unacceptable treatment by
the carrier will be applied towards the patient’s outstanding balance.
c. Any payments paid by patient will be applied first to charges for acceptable treatment, then to any
outstanding balance for acceptable treatment, and, finally, to a cash refund to the patient and/or
adjusted account balance.
7. For capitation plan refunds:
a. If the patient is still covered by the capitation plan:

i. Insert the following statement into the resolution letter: "By copy of this resolution letter,
[capitation plan name] is instructed to debit Dr. _________’s account according to their
own internal accounting procedures in order to re-establish [patient’s] eligibility to have the
treatment redone by another participating dentist."
ii. If the patient paid a co-payment for any treatment that is deemed unacceptable, the co-
payment will be refunded to the patient.
b. If the patient is no longer covered by the capitation plan, the patient will receive a refund for the co-
payment paid toward the unacceptable treatment. Proof of completion of treatment is not required
for refund.
7-92 Rev: 7/27/15

Other things to consider when figuring refunds:
1. The check to the carrier is always mailed immediately following the expiration of the thirty (30) calendar day
appeal period or the determination of any appeal of the decision and upon receipt of the sign Release of All
Claims Form in order reestablish the patient’s eligibility for that treatment which was found to be
unacceptable.
2. Anytime an outstanding balance is to be forgiven and/or reduced, an adjusted ledger card reflecting the
adjustment must be requested from the dentist.
1. Refunds may include the cost of services directly related to the provision of the treatment in question.
2. If the treatment in question meets the California Dental Association guidelines but is incomplete, a
refund/adjustment may be awarded for the portion of the treatment which was not complete.
3. It is important to note the distinction between retreatment and corrective treatment. If the treatment was
determined to be unacceptable, and the remedy to the problem involves replacing or redoing the treatment, a
refund may be awarded. If additional harm resulted from the treatment, corrective treatment may be awarded
for expenses necessary to correct the problem.
7-93 Rev: 7/27/15

Form #62
Corrective Treatment Guidelines
Should the peer review committee determine that the treatment under review has caused further harm (see the rating
system in the Quality Evaluation Manual) the following steps should be followed:
1. The resolution addendum must include documented evidence, including but not limited to, the clinical
examination, radiographs, photographs, models (when indicated), diagnostic casts and any other pertinent
information to support that further harm was caused by the dentist under review.
2. The resolution letter must include instructions to the patient regarding the corrective treatment plan and cost
estimate, including that the patient may go to the dentist of their choice. When possible, the resolution
letter should also include language specifying the limitations of the corrective treatment to be approved by
the committee. (See Resolution Letter Format Form #59.)
a. The patient must be notified in the resolution letter that he or she has thirty (30) calendar days from
the date of the expiration of the appeal period or the determination of any appeal to submit a
corrective treatment plan and cost estimate to the California Dental Association (CDA) for review
and approval. Should the patient notify CDA in writing that he or she is unable to submit the
corrective treatment plan and cost estimate within the thirty (30) calendar day period, CDA may, at
their discretion, extend the time frame if deemed appropriate and necessary. Additionally, the
patient and the dentist under review must be notified in writing should an extension be granted.
3. The peer review committee must review the corrective treatment plan and cost estimate and make a
determination of award within ten (10) calendar days of its receipt by the committee. The following points
should be considered when reviewing a corrective treatment plan and cost estimate:
 The peer review committee and CDA are permitted discretionary authority to allow only a portion
of the corrective treatment estimate if it exceeds the usual and customary fee for dentists of similar
training in their specific geographic area.
 The peer review committee and CDA may not independently establish a fee for the corrective
treatment.
 The peer review committee and CDA have the discretion to request a second treatment plan and
cost estimate if the treatment plan and cost estimate are not appropriate, according to generally
accepted professional standards.
 The peer review committee and CDA have the authority to confirm that the corrective treatment
plan is consistent and the cost estimate is within the scope of what is listed in the final resolution.
Once approved by the peer review committee and CDA, all parties must be notified in writing of the
approved corrective treatment plan and cost estimate. Any treatment or fee that is not approved by the peer
review committee and CDA will be the responsibility of the patient.
4. Once the corrective treatment plan and cost estimate have been approved, and following the expiration of
the appeal period or the determination of any appeal of the corrective treatment and cost estimate approval
the dentist under review must be instructed to forward a check(s) made payable to the patient for the
approved corrective treatment amount to CDA. (See Form #94 Corrective Treatment Plan and Cost Estimate
Decision Letter and Form #29A Appeal Criteria Statement for Corrective Treatment.)
a. The dentist under review is responsible for all costs incurred for the approved corrective treatment.
Fees for corrective treatment may not be written off of an outstanding balance or deducted from a
refund for unacceptable treatment. However, outstanding fees for acceptable treatment should be
deducted from the approved corrective cost estimate.
b. The patient and the dentist under review must be notified in writing that either party has the right
to submit a request for an appeal to the CDA Council on Peer Review’s Appeals Panel within
fifteen (15) calendar days from the date of the Corrective Treatment Plan and Cost Estimate
7-94 Rev: 7/27/15

Approval Letter (Form #94). An Appeal Criteria Statement for Corrective Treatment Plan and Cost
Estimate (Form #29A) must be included with the letter.
7-95 Rev: 7/27/15

Form #63
Resolution Addendum Format
Doctor:
Patient:
The records in the above case indicate that the patient was examined and/or records were reviewed by (#)
members of the ________________ Dental Society Peer review committee on (date) . These records
were also reviewed by the California Dental Association Council on Peer Review.
The Treatment in Question:
Clinical Evaluation:
Radiographic/Photographic Evaluation:
Additional Evaluation (i.e., Stone Cast Models):
Treatment Notes:
Conclusion:
Peer Review Committee certifies that the above information is contained in the records of this case.
Peer Review Committee
Notice:
Finally, if you receive three (3) or more adverse peer review decisions in cases initiated in a 24-month period, a
finding of grossly inadequate or grossly inappropriate treatment, or fraud or billing irregularities, you could be
referred to the CDA Judicial Council for investigation of possible ethical violations.
7-96 Rev: 7/27/15

Form #65
Notification of Complaint Being Processed
Date
Name (Patient)
Address
City, ST Zip Code
Dear (Patient):
Thank you for completing and returning the Request for Review Form (if sent), Patient Agreement Form (Form #4),
and Authorization for Use and Disclosure of Health Information (Form #5). We wish to update you on the status of
the above-referenced peer review case.
We are presently in the process of performing an initial screening of the case and contacting all involved parties for
records and input. Once the committee receives all of the information, we will, if necessary, be contacting you to
schedule a patient examination. If an examination is not deemed necessary, we will proceed with the review process to
reach a final determination.
The peer review committee wishes to remind you that utilization of peer review does not stop, interrupt or suspend
the running of the time period for filing for a civil suit against the dentist in question. The filing of such actions is
governed by California Code of Civil Procedure Section 340.5. This law may preclude you from filing a suit against
the dentist after peer review is concluded.
The Peer review committee requests your patience and cooperation as we proceed. In the meantime, if you have any
questions, please feel free to contact the California Dental Association.
Sincerely,
C: Dental Society
7-97 Rev: 7/27/15

Form #66
Amended Resolution Letter Worksheet
Date
Name (Address letter to person initiating complaint)

Address
City, ST Zip Code
Insuring Entity:
Name of Insured: Group No.:
Insured Date of Birth:
Dear (Dentist)/Mr./Ms.:
This amended resolution letter is written as a result of the (date) appeal request you submitted to the California
Dental Association (CDA) Council on Peer Review Appeals Panel (if applicable, insert the reason for the amended
resolution, such as "to correct the calculated refund amount."). All other aspects of the (date) resolution letter remain
the same, unless otherwise stated in this amended resolution letter.
Conclusion(s):
Restate the conclusion(s) as indicated in the original resolution letter, unless the decision was overturned. If the
decision was overturned, type in the new conclusion(s).
Refund Information:
Restate the refund information as indicated in the original resolution letter, unless the refund has been corrected or a
refund is no longer appropriate. Additionally, refund checks should be forwarded to CDA within fourteen (14)
calendar days from the date of the amended resolution letter.
If corrective treatment is recommended, the corrective treatment plan and cost estimate must be submitted to CDA
within thirty (30) calendar days from the date of the amended resolution letter.
Appeal Criteria Statement:
The amended resolution letter should afford another thirty (30) calendar day appeal period, unless the amended
resolution merely corrects an erroneously calculated refund amount, clarifies a refund/corrective treatment amount,
corrects a typographical error, or any other clarification that does not change the decision of the peer review
committee.
Thank you for allowing the California Dental Association to be of assistance to you.
Sincerely,
Enclosure: Appeal Criteria (if applicable)
C: Dental Society
Dentist
Insurance Carrier
Patient, as appropriate
7-98 Rev: 7/27/15

Form # 68
Carrier Agreement Form
This form is required as it indicates your agreement to be bound by the decision of the peer review committee.
The California Dental Association (CDA) has been requested to review the dental services provided or proposed by
Dr. _____________________ for your insured, ___________________________________. All parties concerned
must consent to the review by the dental society peer review committee and CDA according to CDA’s policies and
procedures.
The CDA will only review over-utilization cases involving member dentists. A dentist, by membership in CDA,
automatically agrees to be bound by the decision reached by the peer review committee and the CDA. Therefore, his
or her signature is not needed.
It is definitely understood and agreed by you that:
1. The dental society and CDA, and any of their members and employees are released from any and all liability
resulting from or arising in any manner from the review of the dental services rendered or proposed.
2. By virtue of the California Evidence Code Section 1157, neither the records nor any proceedings relating to
this matter of the dental society’s peer review committee, or CDA’s Council on Peer Review can be provided
or used to reveal information in any manner.
3. The decision reached by the dental society’s peer review committee and CDA or a decision reached by
CDA’s Council on Peer Review’s Appeals Panel on an appeal shall be determinative of any issues involved in
connection with the dental treatment rendered or proposed as described.
4. _______________________________________ (carrier) agrees to abide by the decision of the Peer review

committee in allowing benefits as deemed appropriate by the peer review committee within the boundaries of
the contractual agreement with the patient.
Your signature below on behalf of the carrier shows your acceptance of and agreement to all items listed above. Any
alterations made in this form shall render it null and void and will prevent its acceptance into the peer review system.
Approved and accepted this _______ day of _________________, ________.
Signed: _______________________________________
Authorized Representative of Carrier
for _______________________________________
Name of Carrier
7-99 Rev: 7/27/15

Form # 69
Request for Additional Information from Carrier
Date
Name(Carrier)
Address
City, ST Zip Code
Dear (Insurance Carrier):
We are in receipt of your request for review of the above referenced case(s). Before we can initiate this review, our
committee needs the following additional information:
1.
2.
3.
Upon receipt of the requested information, the review will commence.
In an effort to complete this review within ninety (90) calendar days, it is requested that you respond to this letter
within seven (7) calendar days from date of receipt. Failure to do so will result in the review being terminated. Thank
you very much for your cooperation.
Sincerely,
7-100 Rev: 7/27/15

Form #70
Dentist Notification Letter (Over-Utilization)
Date
Name
Address
City, ST Zip Code

(Insurance Carrier)
Dear (Dentist) ______________:
The California Dental Association (CDA) has recently received the enclosed request for assistance from the
above-mentioned insurance company. Based on information provided in the carrier’s letter, this request has been
determined to be appropriate for the peer review system. To assist the peer review committee in resolving this
problem, you are requested to provide, on the enclosed Treating Dentist Reply Form (Form #15), your side of this
dispute. Also, please provide all pertinent data which will enable a complete review; i.e., study models, a copy of the
treatment record, radiographs, copies of relevant insurance forms, and any other information pertinent to the case.
Your treatment notes must be typed and transcribed verbatim.
Pursuant to a resolution passed by the trustees at their March 1984 meeting, these over-utilization reviews must be
completed within ninety (90) calendar days. Our committee is allowed thirty (30) calendar days to gather information
from parties involved and submit a letter of resolution. Therefore, it is necessary that you respond to this letter within
seven (7) calendar days. If you are unable to do so, please contact CDA immediately. Failure to do so will result in the
review continuing without benefit of dentist information, as well as a possible referral to the CDA Judicial Council for
noncompliance.
The review committee will evaluate all the available evidence and make a final determination in the form of a letter of
resolution which will include its rationale for the decision. If a party to a review can factually demonstrate that a
procedural error may have occurred, or that the decision was not based on facts, an appeal may be requested of the
CDA’s Council on Peer Review Appeals Panel. This appeal must be mailed certified within ten (10) calendar days
from the date of the resolution letter. Any decision of an appeal panel is final and binding. If an appeal review is
deemed appropriate, it will only review the procedures followed to determine if they were fair and whether the
decision was supported by the evidence considered. It will not entail a new review of the evidence.
The committee wishes to emphatically point out that the request for all relevant records and data made herein as well
as notification of your opportunity to appear before the committee comprises your only chance to present your “side
of the story”. The committee can base its decision only on the information made available to it. The information
provided is confidential and by virtue of the California Evidence Code Section 1157, neither the records nor any
proceedings related to this matter can be provided or used to reveal information in any manner whatever in any type
of future action.
CDA Code of Ethics, Cooperation with Duly Constituted Committees, and shall be referred to CDA’s Judicial
Council for investigation. The Judicial Council will review the records to assure your rights have been protected: that
proper procedures were followed, and that the committees decision was supported by evidence. Should the matter go
to trial, no further evidence regarding the peer review issue will be heard. If you intend to assert your rights to arbitrate
this case pursuant to an arbitration agreement with the patient, you must notify CDA of this fact in writing within
fourteen (14) calendar days from the date of this letter. If you fail to notify CDA of your right to arbitration, you waive
the right to challenge the peer review process or any decision of the peer review committee on the basis of the
arbitration agreement.
7-101 Rev: 7/27/15

the meeting with your component society peer review committee. Neither the appeal mechanism nor Judicial
Council proceedings provide a mechanism to rehear or reexamine the evidence presented during the initial review
process.
notify the committee on the attached form whether or not you wish to attend the meeting. If you indicate that you
wish to attend, you will be informed regarding the time and place of the meeting. Your presentation should be as
concise as possible, since the committee has a limited amount of time available.
The review committee will examine your patient’s dental records and, if the committee determines that it is necessary,
will examine your patient before making a decision. This decision will be set forth in a letter of resolution which will
be forwarded to you on the date of release. All resolution letters are sent to the CDA for approval and finalization;
therefore, no interim or tentative decision may be given to you before such approval.
It is our intent to complete this review as soon as possible; therefore, your reply to this request within the allotted
seven (7) calendar days will certainly be appreciated.
Sincerely,
Enclosure
C: Insurance Carrier
7-102 Rev: 7/27/15

Form #71
Patient Request for Copy of Records/Radiographs Letter
Date
Name
Address
City, ST Zip Code
Subject: Patient Records for (name)
Dear (Dentist):
In accordance with Section 1684.1(a)(1) and (2) of the Dental Practice Act, Health and Safety Code, please accept this
as my written request for the following:
Patient records
Radiographs
The aforementioned section of the Dental Practice Act further states that you must provide me with the requested
copies within fifteen (15) calendar days after receipt of this written request.
Please send the requested information to:
Name
Address
City, ST Zip Code
If you have any questions regarding any of the above, please do not hesitate to contact me at (phone number).
Sincerely,
(Patient Name)
C: California Dental Association

Dental Society
7-103 Rev: 7/27/15

Form #72
Release of All Claims
(This form must be properly executed in order for the document(s) to be released to the patient.)
[Refund to Patient: Within fourteen (14) calendar days of the California Dental Association (CDA)
receiving this executed release, I understand and agree that CDA will deliver the sum of $
to me as a refund for treatment provided to me by Dr. . Such payment shall be made by
check number .]
[Refund to Insurance Carrier: Within fourteen (14) calendar days of the California Dental Association
(CDA) receiving this executed release, I understand and agree that CDA will deliver the sum of $
to my insurance carrier as a refund for treatment provided to me by Dr. . Such payment
shall be made by check number .]
[Adjusted Balance: Within fourteen (14) calendar days of the California Dental Association (CDA)
receiving this executed release, CDA will deliver to me a copy of an adjusted ledger, reflecting an
adjustment of $ from my outstanding balance for treatment rendered by Dr. .]
[Corrective Treatment: Within fourteen (14) calendar days of CDA receiving this executed release, I
understand and agree that CDA will deliver the sum of $ to me as payment for my
approved corrective treatment. Such payment shall be made by check number .]
Closing Statement: In consideration of the above-referenced [check(s), adjusted balance, and/or carrier
refund], I hereby release and forever discharge Dr. of and from any and all claims,
damages, costs, expenses and compensation whatsoever, which now exist or which may hereafter accrue on
account of or in any way growing out of the treatment rendered to from the
( ) day of , to the ( ) day of , , which
treatment has been reviewed by the peer review committee.
I further understand and agree that all rights under Section 1542 of the Civil Code of California are hereby
expressly waived. Section 1542 provides as follows:
“A general release does not extend to claims which the creditor does not know or suspect to exist in
his or her favor at the time of executing the release, which if known by him or her must have
materially affected his or her settlement with the debtor.”
Thus, I am forever waiving any right to pursue a claim for unknown or unsuspected injuries that may exist.
In doing so, I rely on my own judgment, belief and knowledge of the claim without relying on any
statement or representation of the parties hereby released.
It is understood and agreed that by accepting the above-referenced [checks, adjusted balance, and/or carrier
refund] I am forever giving up any right to pursue a claim in arbitration or court regarding the treatment in
question. I have voluntarily chosen to pursue this claim through the CDA peer review system knowing that
the system does not provide for recovery for pain or suffering or other damages. I also understand that I
have agreed to hold the dental society and CDA, and any of their members and employees harmless for any
and all liability resulting from or arising in any manner from the review of the dental services received.
I understand and agree to treat this release, its terms, and all information that I obtained during the peer
review case involving the above-named dentist as being confidential and not to voluntarily, at any time,
disclose, provide, or describe such information to any third parties. However, without notifying the above-
7-104 Rev: 7/27/15

named dentist, I may disclose the terms of this release: (1) to my attorneys, accountants, and financial
advisers to the extent necessary to receive professional advice, (2) to my health care providers to the extent
necessary to receive medical or dental care, and (3) to the extent necessary to enforce its terms or as
otherwise required by law.
I further understand and agree to refrain from making any negative or derogatory statement, oral or
written, or other publication (including, but not limited to, Internet review sites or other social media)
concerning the above-named dentist on account of any event or circumstance relating to the peer review
case occurring prior to the date of this release.
This release shall be construed in accordance with, and all disputes hereunder shall be governed by, the
laws of the State of California.
I HAVE READ THE FOREGOING RELEASE AND FULLY UNDERSTAND IT.
C: Treating Dentist
Dental Society
7-105 Rev: 7/27/15

Form #73
Release of All Claims Transmittal Letter
Date
Patient
Address
City, ST Zip Code
Dear Patient:
Refund to Patient:
Per the resolution letter, dated _______________ , (and the decision of the Appeals Panel on _______________, [if
appropriate]), Dr. _______________ was instructed to refund in the amount of $__________. The California Dental
Association (CDA) is in receipt of his or her check made payable to you.
Enclosed is the Release of All Claims Form for you to sign and date and forward to the California Dental Association,
Council on Peer Review, P.O. Box 13749, Sacramento, CA 95853-4749, within twenty-one (21) calendar days from
the date of this letter. Within fourteen (14) calendar days of receiving the executed document, the check will be
forwarded to you.
If we do not receive the signed Release of All Claims Form within the twenty-one (21) calendar day period, the check
will be returned to Dr. _______________ and this case will be considered closed.
Should you have any questions, please contact CDA at 800.232.7645.
Corrective Treatment:
Per the resolution letter, dated _______________, (and the decision of the Appeals Panel on _______________ [if
appropriate]), Dr. _______________ was instructed to pay for corrective treatment. CDA is in receipt of his or her
check made payable to you in the amount of $_________.
Enclosed is the Release of All Claims Form for you to sign and date and forward to the California Dental Association,
Council on Peer Review, P.O. Box 13749, Sacramento, CA 95853-4749, within twenty-one (21) calendar days.
Within fourteen (14) calendar days of receiving the executed document, the check will be forwarded to you. If we do
not receive the signed Release of All Claims Form within the twenty-one (21) calendar day period, the check will be
returned to Dr. _______________ and this case will be considered closed.
Should you have any questions, please contact CDA at 800.232.7645.
Sincerely,
Enclosure
C: Dental Society
Dentist
7-106 Rev: 7/27/15

Form #74
Patient Notification Letter (Dentist’s Appeal to a Carrier’s Decision)
Date
Name
Address
City, ST Zip
(Insurance Carrier)
Dear (Patient):
Dr. has contacted us about the dental treatment you received in his or her office. Per the (Carrier)’s
letter, dated , Dr. has requested an appeal of the decision through the California Dental
Association (CDA). Before we begin the peer review process, we would like to explain how our system works.
The California Dental Association has developed a peer review system to help solve problems about dental treatment
that the dentist and patient have not been able to settle themselves. A special committee of dentists, known as the Peer
review committee, volunteers their time to consider questions about the quality and/or appropriateness of dental care.
Cases may also be submitted for review when there is a question regarding an insurance claim. There is a time
limitation for accepting a complaint in the peer review system. A complaint must be filed within three years from the
date the work was completed or one year from the date you recognized that there was a problem, whichever occurs
first.
There is no charge for this service; however, any unusual costs sustained by the committee in conducting the review,
such as, duplicating radiographs or study models, shall be borne by the party initiating the review. It is not within the
scope of the peer review system to handle questions about getting money back for time lost from work or pain suffered
as a result of your treatment. In addition, the peer review system is an alternative to litigation, and cannot be used if
such proceedings have begun, or if the case has already been decided by a court of law. Should any party involved
initiate litigation after the peer review process begins, the peer review action will cease immediately.
The review committee will examine your dental records, and if the committee determines that it is necessary, talk to
you and your dentist separately, and examine you before making its decision. The committee may decide that the
treatment was acceptable; however, if the committee decides the treatment was not acceptable or was not appropriate,
it will make a recommendation to the dentist, such as:
1. The dentist must refund all or part of monies paid by you and/or your insurance carrier so that you may go
to the dentist of your choice and have the treatment redone.
2. If the committee finds that further harm was caused by the treatment rendered, the dentist may be
responsible for the corrective treatment.
Additionally, you must sign a Release of All Claims form prior to receipt of any refund and/or corrective treatment
that may be awarded.
Upon receipt of the peer review’s decision, you, the dentist or the carrier may submit a request for reconsideration,
known as an “appeal”. Once a decision is made on an appeal, it is final and binding, and you may no longer use the
peer review system on this matter.
Please carefully read and complete the enclosed three forms: Patient Agreement Form (Form #4), Authorization for
Use and Disclosure of Health Information Form (Form #5) and Patient Request for Interview Form (Form #90). The
purpose of these forms is explained at the top of each one. All forms must be completed and returned to the
California Dental Association, Council on Peer Review, P.O. Box 13749, Sacramento, CA 95853-4749 within
fifteen (15) calendar days from the date of this letter before review process can begin.
7-107 Rev: 7/27/15

Please be aware that the utilization of peer review does not stop, interrupt or suspend the running of the time period
for filing a civil suit against the dentist in question. The filing of such actions are governed by California Code of Civil
Procedure Section 340.5. This law may preclude you from filing a suit against the dentist after peer review is
concluded.
Most patients using our system find it fair, less costly, and less time consuming than going to court. We are happy to
help you and look forward to hearing from you. If you have any questions regarding completion of the forms, please
contact CDA at 800.232.7645.
Sincerely,

Patient Request for Interview Form
C: Dentist
Insurance Carrier
7-108 Rev: 7/27/15

Form #75
Amended Resolution Addendum Format
Doctor:
Patient:
This amended resolution addendum is written as a result of the (date) appeal request (name of appellant) submitted to
the California Dental Association Council on Peer Review Appeals Panel.
The records in the above case indicate that the patient was examination and/or records reviewed by #
members of the Peer review committee on (date) .
(If applicable -- In response to the appeal request, the above patient was re-examination and/or records re-reviewed by
member(s) of the Peer review committee on (date) .)
Treatment in Question:
Clinical Examination:
Radiographic/Photographic Evaluation:
Additional Evaluation (i.e., Stone Cast Models):
Treatment Notes:
Conclusion:
Peer Review Committee certifies that the above information is contained in the records of this case.
Notice:
Finally, if you receive three (3) or more adverse peer review decisions in cases initiated in a 24-month period, a
finding of grossly inadequate or grossly inappropriate treatment, or fraud or irregular billing you could be referred
to the CDA Judicial Council for investigation of possible ethical violations.
7-109 Rev: 7/27/15

Form #76
Endodontics
Patient: Dentist: _______________________________
Date of Examination: __________________________Examiner: _________________________________
Treatment in Question: ___________________________________________________________________
Radiographs taken at examination? Yes ___ No____ Date & Type radiograph(s) reviewed: _______________
Describe radiographic findings: _______________________________________________________________
______________________________________________________________________________________
Describe periodontal health of tooth/teeth being treated: __________________________________________
Patient’s contribution: _______________________________________________________________________
Remarks: (wishes and attitudes)________________________________________________________________
General health:__________ Additional Complaints: _____________________________________________
Remarks to Patient: _________________________________Patient told to seek treatment. Yes ___ No____
1. Additional ________________ 2. Immediate _________________ 3. Emergency____________________
CLINICAL SUMMARY: Satisfactory/Unsatisfactory (circle one)
State reason for above summary: _______________________________________________________________
__________________________________________________________________________________________
Circle and describe where appropriate:
Operational Explanation: Comments/Observations:
R - Range of excellence
S - Satisfactory
T - Unsatisfactory, future damage is likely to occur
V - Unsatisfactory, damage to patient has now occurred
Root Canal Treatment: ______________________ Vital/Pulp Treatment: ________________________
Tooth protection: Restored ____________________ Temporized: _______________________
Evaluation:
Asymptomatic _________________________ Pain (describe)__________________________
Percussion, Palpation_____________________________________________________________
Electric ________________________________________________________________________
Thermal _______________________________________________________________________
Mobility _______________________________________________________________________
Canal Instrumentation:
Instrumented to radiographic apex  Perforated canal 
Instrumental short of the radiographic apex  Under-instrumented 
Instrumented past the radiographic apex  Over-instrumented 
Transported canal  Canal not Negotiated 
Canal Obturation:
Material used: Gutta percha ____ Paste ____ Silver point ___ Other/Unknown ____ R S T V (circle one)
Density R S T V (circle one) Single Point Fill R S T V (circle one)
Surplus/Overfill R S T V (circle one) Short Fill R S T V (circle one)
Swelling Y es ______ No______ Comments/Observations:
Sinus Tract Y es ______ No______
7-110 Rev: 7/27/15

Form #77
Crowns And Fixed Partial Prosthodontics
Patient: ___________________________________ Dentist:__________________________________________
Date of Examination: ___________________________ Examiner: _____________________________________
Treatment in Question: __________________________________________________________________________
Radiographs taken at examination? Yes ______ No ______ Date & Type radiograph(s) reviewed: ______________
____________________________________________________________________________________________
Describe radiographic findings: ___________________________________________________________________
_________________________________________________________________________________________
Describe general periodontal health: ________________________________________________________________
Patient’s Contribution:__________________________________________________________________________
General health: ________________________________________________________________________________
Remarks: (wishes and attitudes) ___________________________________________________________________
Additional Complaints: _________________________________________________________________________
Remarks to Patient: ____________________________________Patient told to seek treatment. Yes ____ No _____
1. Additional _________________ 2. Immediate _________________ 3. Emergency _____________________

State reason for above summary: _________________________________________________________________
____________________________________________________________________________________________
____________________________________________________________________________________________
Circle and describe where appropriate:
Operational Explanation Comments/Observations
S - Satisfactory
V - Unsatisfactory, damage to patient is now occurring
Tooth & Treatment Comments/Observations

Perio Pockets
Mobility & Furca
Comments/Observations
Shade R S T V (circle one)
Surface Texture R S T V (circle one)
Contours R S T V (circle one)
Occlusion R S T V (circle one)
Contacts R S T V (circle one)
Margins R S T V (circle one)
7-111 Rev: 7/27/15

Tooth & Treatment
Perio Pockets
Mobility & Furca
Tooth & Treatment
Perio Pockets
Mobility & Furca
7-112 Rev: 3/8/14

Form #78
Complete Denture Prosthodontics
Patient: ____________________________________ Dentist: ______________________________________
Date of Examination: _________________________ Examiner: _____________________________________
Treatment in Question: Upper (Maxillary) / Lower (Mandibular) Denture
Patient’s Contribution:
General health
Remarks: (wishes and attitudes)
Additional Complaints:
Remarks to Patient: ____________________________________Patient told to seek treatment. Yes _____ No
1. Additional _________________ 2. Immediate ___________________ 3. Emergency ____________________

State reason for above summary: _____________________________________________________________
________________________________________________________________________________________
S - Satisfactory
Esthetics: (circle one) Comments/Observations

Facial Harmony R S T V
Shade R S T V
Teeth R S T V
Extensions: (circle one) Comments/Observations
Overextended R S T V
Underextended R S T V
Peripheral Seal R S T V
Occlusion: (circle one) Comments/Observations
Centric R S T V
Vertical R S T V
Lateral R S T V
Protrusive R S T V
Teeth Surfaces R S T V
Stability & Retention: (circle one) Comments/Observations
Stability R S T V
Retention R S T V
7-113 Rev: 7/27/15

Form #79
Removable Partial Prosthodontics
Patient: ______________________________ Dentist: ______________________________________________________
Date of Examination: ______________________ Examiner: _______________________________________________
Treatment in Question: ________________________________________________________________________________
Radiographs: Taken at Examination? Yes_____ No ______ Date & Type radiographs reviewed: ___________________
Describe radiographic findings: _______________________________________________________________________
________________________________________________________________________________________________
Describe general periodontal health: ______________________________________________________________________
Patient’s Contribution: ______________________________________________________________________________
General health: _______________________________________________________________________________________
Remarks: (wishes and attitudes) __________________________________________________________________________
Additional Complaints: ________________________________________________________________________________
Remarks to Patient: ____________________________________________Patient told to seek treatment. Yes____No___
1. Additional_____________________ 2. Immediate______________________ 3. Emergency__________________
State reason for above summary: _____________________________________________________________________
_______________________________________________________________________________________________
Operational Explanation (circle one)

S - Satisfactory
Maxillary Partial Comments/Observations
Mandibular Partial
Periodontal Status of Abutments
Clasps
Tooth #s
Replacing
Tooth #s
(circle one)
Design R S T V
Saddles R S T V
Stability R S T V
Retention R S T V
Occlusion R S T V
7-114 Rev: 3/8/14

Form #80
Operative Dentistry
Patient: _____________________________ Dentist: _________________________________________________
Date of Examination: ______________________________ Examiner: _________________________________
Treatment in Question: ________________________________________________________________________
Radiographs taken at examination? Yes____ No____ Date & Type radiographs reviewed: __________________
Describe radiographic findings: ________________________________________________________________
_________________________________________________________________________________________
Describe general periodontal health: ______________________________________________________________
Patient’s Contribution: _______________________________________________________________________
General health: ______________________________________________________________________________
Remarks: (wishes and attitudes) ________________________________________________________________
Additional Complaints: ________________________________________________________________________
Remarks to Patient: _______________________________ Patient told to seek treatment. Yes ____No _____
1. Additional __________________ 2. Immediate __________________ 3. Emergency __________________
State reason for above summary: _______________________________________________________________
_________________________________________________________________________________________
S - Satisfactory
Tooth / Treatment Comments/Observations

Perio Pockets
Mobility & Furca
(circle one) Comments/Observations

Shade R S T V
Surface Texture R S T V
Contours R S T V
Marginal Ridge R S T V
Occlusion R S T V
Contacts R S T V
Margins R S T V
7-115 Rev: 3/8/14


Perio Pockets
Mobility & Furca

Shade R S T V

Contours R S T V
Occlusion R S T V
Contacts R S T V

Margins R S T V

Perio Pockets
Mobility & Furca

Shade R S T V

Contours R S T V
Occlusion R S T V
Contacts R S T V

Margins R S T V

Perio Pockets
Mobility & Furca

Shade R S T V

Contours R S T V
Occlusion R S T V
Contacts R S T V
Margins R S T V
7-116 Rev: 3/8/14

Form #81
Periodontics
Patient: _______________________________ Dentist: __________________________________
Date of Examination: __________________________ Examiner: ________________________________________
Treatment in Question: __________________________________________________________________________
Radiographs taken at examination? Yes ____ No ____ Date & Type radiographs reviewed:____________________
Describe radiographic findings:
_________________________________________________________________________________________
Describe general periodontal health:

Patient’s Contribution: _______________________________________________________________________
General health: _______________________________________________________________________________ _
Remarks: (wishes and attitudes) _________________________________________________________________
Additional Complaints: ________________________________________________________________________
Remarks to Patient: ______________________________________Patient told to seek treatment. Yes ____No ___
1. Additional _____________________ 2. Immediate ___________________ 3. Emergency _________________
Informed Consent(prior to treatment): Yes _____ No _____ Not Applicable _____
State reason for above summary: _________________________________________________________________
___________________________________________________________________________________________
Operational Explanation (circle one) Comments/Observations

S - Satisfactory
Root Planning & Sealing
Treatment Plan acceptable / non-acceptable (circle one)
Treatment R S T V (circle one)
Gingival Curettage
Treatment Plan acceptable / non-acceptable (circle one)
Periodontal Surgery Type: gingivectomy flap osseus muco-gingival other_____________

Treatment Plan acceptable / non-acceptable
7-117 Rev: 3/8/14

7-118 Rev: 3/8/14

Form #82
Orthodontics
Patient: Dentist:
Date of Examination: Examiner:
Treatment in Question:
Radiographs taken at examination? Yes No Date & Type radiographs reviewed: ___________________________
Describe radiographic findings:
Describe general periodontal health:
Patient’s Contribution: __________________________________________________________________________________

General health:
Remarks: (wishes and attitudes)
Remarks to Patient: _____________________________________________ Patient told to seek treatment. Yes No ____

1. Additional ___________________ 2. Immediate ___________________ 3. Emergency ____________________
State reason for above summary:

S - Satisfactory
T – Unsatisfactory, future damage is likely to occur
V – Unsatisfactory, damage to patient has now occurred
Diagnosis Comments/Observations
(circle one)
R S T V
Treatment Plan Comments/Observations
(circle one)
R S T V
Examination Findings (clinical or records) Comments/Observations

(circle one)
R S T V
Patient Cooperation Comments/Observations
(circle one)
R S T V
Myofunctional Problems Comments/Observations
Retention Phase Comments/Observations

(circle one)
R S T V
7-119 Rev: 3/8/14

PRETREATMENT CONDITION
Angle Right Side Left Side

Classification Molar Molar Dental Condition
Cuspid Cuspid
Class I
Class II Div I
Class II Div
II
Class III
Arch Length Maxillary Excess Adequate Deficient Amount _____mm
Mandibular Excess Adequate Deficient Amount______mm
Crossbite Right Side Left Side Anterior
Overbite Normal Open Bite____mm Closed bite___mm
Overjet Normal Edge to Edge Excessive____mm
Curve of Spee Normal Reversed Flat Deep
Dentition Primary Mixed Permanent
Midline Maxillary Midline to Midsagital ___________/__________

Mandibular Midline At Rest___________/__________
Occlusion_________/________
Path of Closure Normal Right Lateral Slide Left Lateral Slide Anterior Slide
TMJ Normal Click right/left Restricted opening Closed Lock

Pain Deviation right/left
Lip Posture Normal Together Strained Apart
Lip Tonus Normal Hypotonus Hypertonus
Frenum Normal Heavy Upper/Lower
Tonsils Normal Enlarged Enlarged & Pitted Problem
Eruption Normal Early Late
Profile Normal Retrusive Flat Protrusive
Myofunctional None Tongue Thrust Lip Wedging Mentalis
Habits None Thumb sucking Mouth breathing Fingernail
Hygiene Excellent Good Fair Poor
7-120 Rev: 3/8/14

EXAMINATION FINDINGS
Angle Right Side Left Side Dental Condition

Classification Molar Molar
Cuspid Cuspid
Class I
Class II Div I
Class II Div
II
Class III
Arch Length Maxillary Excess Adequate Deficient Amount _____mm
Mandibular Excess Adequate Deficient Amount______mm
Crossbite Right Side Left Side Anterior
Overbite Normal Open Bite____mm Closed bite___mm
Overjet Normal Edge to Edge Excessive____mm
Curve of Spee Normal Reversed Flat Deep
Dentition Primary Mixed Permanent
Midline Maxillary Midline to Midsagital ___________/__________

Mandibular Midline At Rest___________/__________
Occlusion_________/________
Path of Closure Normal Right Lateral Slide Left Lateral Slide Anterior Slide
Lip Posture Normal Together Strained Apart
Lip Tonus Normal Hypotonus Hypertonus
Frenum Normal Heavy Upper/Lower
Tonsils Normal Enlarged Enlarged & Pitted Problem
Eruption Normal Early Late
Profile Normal Retrusive Flat Protrusive
Myofunctional None Tongue Thrust Lip Wedging Mentalis
Habits None Thumb sucking Mouth breathing Fingernail
Hygiene Excellent Good Fair Poor
7-121 Rev: 3/8/14

Form #83
Oral Surgery
Patient: _____________________________ Dentist: _________________________________________
Date of Examination: ________________________ Examiner: _________________________________________
Treatment in Question: _________________________________________________________________________
Radiographs taken at examination? Yes_____ No ______ Date & Type radiographs reviewed:_________________
Describe radiographic findings: ___________________________________________________________________
_____________________________________________________________________________________________
Describe general periodontal health: _______________________________________________________________
Patient’s Contribution: __________________________________________________________________________
General health: ________________________________________________________________________________
Remarks: (wishes and attitudes) ___________________________________________________________________
Additional Complaints: __________________________________________________________________________
Remarks to Patient: Patient told to seek treatment. Yes ____ No _____
1. Additional _________________ 2. Immediate __________________ 3. Emergency _____________________
State reason for above summary: __________________________________________________________________
_________________________________________________________________________________________
S - Satisfactory
EXTRACTIONS: (circle one) Comments/Observations
Appropriateness of treatment R S T V
Completeness of Extraction R S T V
Tissue Management R S T V
PATHOLOGY: (circle one) Comments/Observations

Diagnosis R S T V
Surgical Techique R S T V
Referrals and Supportive Care R S T V
TMJ: (circle one) Comments/Observations

Appropriateness of treatment R S T V
Surgical R S T V
Non Surgical R S T V
Appliances R S T V
TRAUMA: (circle one) Comments/Observations

Appropriateness of Treatment R S T V
Diagnosis R S T V
Supportive Care R S T V
7-122 Rev: 3/8/14

Form #84
Letter to Patient Residing in Another State Regarding Status of Case
Date
Patient
Address
City, ST Zip Code
Dear (Patient):
Thank you for completing and returning the Request for Review Form (Form #3), Patient Agreement Form (Form #4),
Authorization for Use and Disclosure of Health Information Form (Form #5) and Patient Request for Interview Form
(Form #90). We wish to update you on the status of the above-referenced peer review case.
We are presently in the process of performing an initial screening of the case and contacting all involved parties for records
and input. Once the committee receives all of the information, we will, if necessary, be contacting you to schedule a patient
examination.
If an examination is necessary, you will need to return to California sometime within one hundred twenty (120) calendar days
of this letter. Please use the enclosed form to acknowledge your ability to return for the clinical examination and return it to
the California Dental Association (CDA) within twenty-one (21) calendar days.
If an examination is not deemed necessary, we will proceed with the review process to reach a final determination.
The peer review committee requests your patience and cooperation as we proceed. In the meantime, if you have any
questions, please feel free to contact CDA.
Sincerely,
7-123 Rev: 3/8/14

Form # 85
Patient Will/Will Not Attend Clinical Form
(Patient Residing in Another State)
I, , Patient
YES ___ I AM ABLE TO RETURN TO CALIFORNIA, IF NECESSARY, FOR A CLINICAL EXAMINATION OF

MY DENTAL TREATMENT.
NO ___ I WILL NOT BE ABLE TO RETURN TO CALIFORNIA FOR A CLINICAL EXAMINATION OF MY

DENTAL TREATMENT.
Patient:
(Sign) (Date)
Please note: If you are unable to return to California for the clinical examination, and it is necessary to conduct one
in order to review the case, the case will be considered closed.
Return within twenty-one (21) calendar days to:

P.O. Box 13749
7-124 Rev: 3/8/14

Form # 86
Explanation of Clinical Examination
Thank you for attending the clinical examination. Before we begin, we would like you to read the following:
1. The clinical exam is only one aspect of the peer review system considerations.
2. The committee is here to exam your dental work and listen to your concerns. The committee may not comment on
whether or not your treatment meets the standard of care and cannot agree or disagree with your statements
regarding your treatment.
3. The committee examining you today will prepare a report and send it to the dental society office. If you wish to find
out how the case is progressing, please call the dental society and not a member of the panel that is examining you.
This is an examining panel and is not involved in the routine matters of following the case to closure.
4. You will be notified by certified mail of the decision of the committee. Prior to the mailing of the resolution letter,
no one involved in this process is able to comment on the possible outcome.
5. After the clinical examination, if you feel you need to obtain treatment prior to the final resolution of your case, you
may seek treatment from the dentist of your choice. Please note, however, that the financial responsibility for this
treatment is yours, but there may be a reimbursement for the treatment if the final decision is in your favor.
Please sign here, indicating you have read and understood the above.
____________________________ __________________________
Signature Date
7-125 Rev: 3/8/14

Form #87
Refund Distribution Worksheet
Dates of treatment rendered: From: ____________ To: _____________
Insurance
Treatment Fee Charged Pt. Payment Payment Refund
1) __________ __________ __________ __________ _________

2) __________ __________ __________ __________ _________
3) __________ __________ __________ __________ _________
4) __________ __________ __________ __________ _________
5) __________ __________ __________ __________ _________
6) __________ __________ __________ __________ _________
7) __________ __________ __________ __________ _________
8) __________ __________ __________ __________ _________
9) __________ __________ __________ __________ _________
10) __________ __________ __________ __________ _________
Total: __________ __________ __________ __________ $________
Is treatment in question incomplete? Yes _______ No _______
Is treatment in question ACCEPTABLE up to the point of incompletion? Yes _______ No _______
What portion (%) of the full treatment does this incomplete portion represent? _________ (33%, 50%, 66%, other)
1/3 of Fees ___________

1/2 of Fees ___________
2/3 of Fees ___________
If other, please explain:
Are there any discounts given or charge reversals on unacceptable treatment? $_________
Yes______ No ______
Refund amount to patient: $____________

Refund amount to carrier: $____________
Outstanding balance of patient: $____________
Refund credited balance: $____________
7-126 Rev: 3/8/14

Form #88A
Notification to Patient of Dentist Referral to Judicial Council
(Non-Compliance with Records)
Date
Name (Patient)
Address
City, State, Zip Code

Dear (Patient):
reached in connection with the dental treatment rendered by Dr. ________. In addition, Dr. ____________, by virtue
of his or her membership in the CDA, agreed to abide by the peer review decision. The peer review committee had every
confidence that Dr. ________ would assist the peer review committee by providing all pertinent data which would
enable a complete review of your case.
However, Dr. ________has failed to comply with our request to provide copies of relevant records and data in this
matter. Dr. _________’s failure to comply has resulted in a referral to the CDA’s Judicial Council for potential
disciplinary action. Please be advised, however, that the peer review committee, in referring this matter to the Judicial
Council, has exhausted all available options for resolving this matter. As such, it is with regret that we must inform you
that we are unable to review your complaint against Dr. _________ since he has not complied with the committee’s
request. Therefore, this case is now considered closed.
It is our hope that by providing you with this information, you will be in a better position to evaluate the need to pursue
other options in resolving this matter.
Thank you for your cooperation and understanding.
Sincerely,
C: Dental Society
Dentist
7-127 Rev: 3/8/14

Form #88B
Notification to Patient of Dentist Referral to Judicial Council

(Non-Compliance with Resolution)
Date
Name (Patient)
Address
City, ST, Zip Code

Dear (Patient):
reached in connection with the dental treatment rendered by Dr. _____________. In addition, Dr. ______________,
by virtue of his or her membership in the CDA, agreed to abide by the peer review decision. The peer review committee
had every confidence that both parties would abide by the decision reached.
However, Dr. ___________________ has failed to comply with the resolution of this matter as indicated in the
resolution letter (DATE). Dr. _______________’s failure to comply has resulted in a referral to the CDA’s Judicial
Council for potential disciplinary action. Please be advised, however, that the peer review committee, in referring this
matter to CDA’s Judicial Council, has exhausted all available options for resolving this matter. As such, it is with regret
that we must inform you that we will not be able to enforce the final resolution should the dentist continue to choose
not to comply.
It is our hope that by providing you with this information, you will be in a better position to evaluate the need to pursue
other options in resolving this matter.
Thank you for your cooperation and understanding.
Sincerely,
C: Dental Society
Dentist
7-128 Rev: 3/8/14

Form #90
Patient Request for Interview Form
If a clinical examination is not necessary because a decision can be made using only your treatment records,
please indicate below if you would still like to meet with the Peer Review Committee.
YES I wish to be interviewed by members of the Peer Review Committee.
NO I do not wish to be interviewed by members of the Peer Review Committee. I

understand that my dental treatment records, radiographs and photographs will be
fully considered by the Peer Review Committee.
Name of Patient (print)
Please note: If you are currently residing in another state and unable to return to California for the
clinical examination, and it is necessary to conduct one in order to review the case, the case will be closed.
7-129 Rev: 3/8/14

Form #91
Dentist Non-Compliance with Records
Date
Name (Dentist)
Address
City, ST, Zip Code
Dear Dr.__________:
Our records indicate that you have failed to comply with the committee's request for records concerning the above
mentioned peer review case.
The Council on Peer Review wishes to remind you that by virtue of your membership in the California Dental
Association (CDA), you agreed to comply with the reasonable requests of a duly constituted committee, council or other
body of the component society or of this association necessary or convenient to enable such a body to perform its
functions. Failure to do so may be in violation of Section 3 of the CDA Code of Ethics, “Cooperation with Duly
Constituted Committees,” and shall be referred to the CDA Judicial Council for investigation. Please comply with the
committee’s request within fourteen (14) calendar days from the date of this letter (DATE). Your expedient cooperation
is appreciated.
Sincerely,
C: Dental Society
7-130 Rev: 3/8/14

Form #92
Dentist Non-Compliance with Resolution
Date
Name (Dentist)
Address
City, ST, Zip Code
Dear Dr. _________:
Our records indicate that you have failed to comply with the committee's recommendation concerning the above-
mentioned matter. A copy of its resolution is enclosed for your reference.
The Council on Peer Review wishes to remind you that by virtue of your membership in the California Dental
Association, you agreed to abide by the decision of the peer review committee. Failure to do so may be in violation of
Section 3 of the CDA Code of Ethics, “Cooperation with Duly Constituted Committees”, and shall be referred to the
CDA Judicial Council for investigation. Please comply with the request within fourteen (14) calendar days from the date
of this letter (DATE). Your expedient cooperation is appreciated.
Sincerely,
Enclosure
C: Dental Society
7-131 Rev: 3/8/14

Form #93
Notification to Dentist Referral to Judicial Council
(Non-Compliance with Resolution and Records)
Date
Name (Dentist)
Address
City, ST, Zip Code
Dear Dr. __________:
With regard to the referenced matter, the Council on Peer Review wishes to inform you that this matter has been
referred to the Judicial Council of the California Dental Association citing a potential violation of Section 3 of the
California Dental Association’s Code of Ethics.
Any future questions or correspondence should be directed to the Judicial Council.
Sincerely,
C: Dental Society
Judicial Council
7-132 Rev: 3/8/14

Form #94
Corrective Treatment Plan and Cost Estimate Approval Letter
Date
Patient Name
Address
City, ST, Zip

Approval of Corrective Treatment Plan and Cost Estimate
Dear (Patient):
This letter is to confirm receipt and approval of the written corrective treatment plan and cost estimate submitted for
your corrective treatment as defined in the resolution letter dated .
The ___________________Dental Society Peer Review Committee (committee) and the California Dental Association
(CDA) have approved the following corrective treatment plan and cost estimate from your subsequent treating dentist:
(Specify Corrective Treatment Approved) (Specify Cost Estimate Approved)

_______________________________ ______________________________
_______________________________ ______________________________
_______________________________ ______________________________
Total:
The committee and CDA would like to remind you that, as indicated in the resolution letter, once an estimate has been
approved, any additional treatment or fee that is not further approved by the peer review committee will be your
responsibility.
Enclosed are the appeal criteria which are also enclosed with Dr. ’s copy of this letter. In order to be
granted an appeal review of the decision reached by the committee regarding your corrective treatment plan and cost
estimate, the appellant(s) must, within fifteen (15) calendar days from the date of this letter, factually demonstrate in
writing (typed or legibly printed) how one or more of the appeal criteria on the attached appeal criteria statement have
been met.
All appeal requests must be MAILED to: OR Sent by OVERNIGHT SERVICE to:
Facsimile transmission of appeals will not be accepted. All appeal requests must be postmarked no later than (Date).
The decision reached by the committee regarding your corrective treatment plan and cost estimate is not final until the
expiration of fifteen (15) calendar days from the date of this letter without an appeal filed or the determination of any
appeal of this decision.
Within fourteen (14) calendar days following expiration of the appeal period or the determination of any appeal of this
decision, Dr. _______________ is hereby requested to forward a check for the approved corrective treatment in the
amount of $ ________made payable to __________to the California Dental Association, Council on Peer Review,
P.O. Box 13749, Sacramento, CA 95853-4749.
Per the patient agreement form signed by you on ___________, you agreed to sign a Release of All Claims Form should
the committee determine that a refund is in order. Therefore, prior to receiving the refund check for your corrective
treatment, you will be required to sign a Release of All Claims Form. Within fourteen (14) calendar days of CDA’s
receipt of Dr. _____________’s check for the corrective treatment, CDA will forward a Release of All Claims Form for
7-133 Rev: 3/8/14
your signature. Within fourteen (14) calendar days of CDA’s receipt of your signed Release of All Claims, CDA will
forward Dr. ______________’s check for the corrective treatment to you.
If you have any questions, please contact the California Dental Association at 800.232.7645.
Sincerely,
Enclosure: Appeal Criteria Statement for Corrective Treatment Plan and Cost Estimate
C: Dentist
Dental Society
7-134 Rev: 3/8/14

Form #96
Dropped Membership Referral To CDA Memo
Date
To: (Name), Chair

From: (Name)
Component

Our dental society has learned that the above-referenced dentist has dropped [his or her] membership.
The peer review committee is referring this matter to you for further handling, including possible referral to the CDA
Judicial Council for compliance with any applicable reporting requirements.
Enclosure: File to Date
7-135 Rev: 3/8/14

Form #97
Transfer to Neighboring Component Memo
Date
To: (Name)
Chair, Peer review committee
_______________ Dental Society


We recently received a peer review case filed by the above mentioned patient regarding treatment rendered by
Dr.__________.
Since it has been determined that it would be a conflict of interest for our component peer review committee to review
this matter, we are forwarding the case to you for handling.
Thank you for your assistance.
C: Dentist
Patient
7-136 Rev: 3/8/14

Form #98
Notification to Dentist/Patient that Case Will Remain at Component
Date
Name (Dentist)
Address
City, ST Zip Code

Dear (Dentist):
Thank you for forwarding information regarding your perceived conflict of interest with ____________, a member of
our peer review committee.
We have thoroughly reviewed the information that you provided to us, and have interviewed __________ about the
issues you raised. Based on our review of the information and discussion with __________, we have determined that
there is no actual or perceived conflict of interest in this situation.
[Give specific details that support the decision here.]
Accordingly, we will proceed with processing the above complaint at the ________ Dental Society. The peer review
committee requests your patience and cooperation as we proceed. In the meantime, if you have any questions, please feel
free to contact the California Dental Association.
Sincerely,
7-137 Rev: 3/8/14

Form #99
IMPLANTS AND IMPLANT PROSTHODONTICS
Patient: Dentist:
Date of Examination: Examiner:
Treatment in Question: _______________________________________________________________________

(# of Implants, Tooth/Arch Position of Implants, Type of Implant Restoration) Removable Restoration (Attach
Complete Denture Prosthodontics Form) Fixed Restoration (Complete Page 2 Restorative Evaluation Section):
Patient’s Contribution:
Remarks to Patient: Patient told to seek treatment. Yes No
1. Additional___________________ 2. Immediate_____________________ 3. Emergency _______________
General Health/Medical Risks:
State reason for above summary:
S - Satisfactory
Pre-Treatment Evaluation
Surgical Placement of Implant by Doctor under Review: Yes______ No______
Restoration of Implant by Doctor under Review: Yes______ No______
Informed Consent Prior to Treatment: Yes______ No______
Diagnostic Models Yes______ No ______
Surgical Stent Yes______ No ______
3-D Imaging Yes______ No ______ Type and Date ____________________
Radiographs Yes______ No ______ Type and Date ____________________
7-138 Rev: 3/8/14

Radiographic Evaluation
Radiographs: Pre - Op __________________________________Date and Type ____________________________
Radiographic Findings:__________________________________________________________________________
Radiographs: Post - Op __________________________________Date and Type____________________________
Radiographic Findings:__________________________________________________________________________
Radiographs Taken at time of Examination: Yes _____ No ______ Date and Type _______________________
Radiographic Findings: __________________________________________________________________________
Surgical Evaluation
Date of Implant Placement: ____________________________ Type of Implant Placed :______________________
Tooth/Arch Position of Implant Placed: __________________________ Esthetic Zone Yes____ No ___
Treatment Plan: Acceptable / Not Acceptable _______________________________________________________
Surgical Protocol: Acceptable / Not Acceptable _____________________________________________________
Fixture Placement (Position/Alignment): Acceptable / Not Acceptable ____________________________________
Appropriateness of Implant Selected: Acceptable / Not Acceptable_______________________________________
Integration of Implant to Bone: Explanation)_________________________________________________________
Bone Augmentation Procedures:_____________________________ Date and Type _________________________
Description:
Clinical Summary: Satisfactory/Unsatisfactory
State Reason for Above Summary: _________________________________________________________________
Repeat Above Criteria For Each Individual Implant Evaluated
7-139 Rev: 3/8/14

Restorative Evaluation
Date of Restoration Placement ______________ Type of Restoration ________________________________
Note: For Removable Prosthesis – Attach Form #78 Complete Denture Prosthodontics
Restoration in Esthetic Zone: Yes ____ No _____ Observations:___________________________________
Peri-Implant Health / Tissue Contours _______________________________________________________
Implant/Abutment Selection: Acceptable/Not Acceptable Comments/Observations
Prosthetic Design: Acceptable/Not Acceptable
(circle one)
Shade R S T V
Contours R S T V
Occlusion R S T V
Contacts R S T V
Implant/Restoration Interface R S T V
Repeat Above Criteria for Each Unit of Restoration Evaluated
7-140 Rev: 3/8/14

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Peer Review Manual

This document must be considered in its entirety and no summary or

California Dental Association

I. General Information....................................................................................................................... 1-1

II. Responsibilities of the Peer Review Staff .......................................................................................... 2-1

V. Over-Utilization Review Procedures................................................................................................. 5-1

VI. Referrals to the Judicial Council ...................................................................................................... 6-1

VII. Forms/Form Letters ....................................................................................................................... 7-1

Ethical Basis of the Peer Review System

CDA Code of Ethics

Section 1A. Professional Esteem

1-1 Rev: 11/18/13

Section 1B. Accepting Patient Into the Dental Practice

Section 1C. Standards of Care

Section 1D. Informed Consent

Section 3. Cooperation With Duly Constituted Committees

Section 6A. False and Misleading Advertising and Solicitations

Section 7. Billing Practices

1-2 Rev: 11/18/13

Council on Peer Review

1-3 Rev: 11/18/13

CDA Central Office

1. Performing all administrative duties required in processing a peer review case.

Component Dental Societies and Specialty Organizations

Structure of the Component and Specialty Peer Review Committee

1-4 Rev: 11/18/13

Appointing the Component and Specialty Peer Review Committee

Legal Protection of and Constraints upon Peer Review Committees and

1-5 Rev: 11/18/13

Parameters of Peer Review

Who Can Initiate Cases

1-6 Rev: 11/18/13

Types of Cases Accepted for Review

Utilization cases can be submitted by a member dentist, carrier or patient.

1-7 Rev: 11/18/13

Independent Contractor: An independent contractor, unlike an employee, is an independent businessperson

Over-Utilization Review: A review requested by a carrier to show a pattern of over-utilization by a dentist.

1-8 Rev: 11/18/13

Peer: An individual who is licensed to practice dentistry in the State of California.

Utilization: See Page 1-7.

1-9 Rev: 11/18/13

Receipt of Inquiry from Initiating Party

a. Initial Patient Response Letter (Form #1)

2-1 Rev: 7/27/15

3. Receipt of Incomplete and/or Altered Forms

Carrier-Initiated Over-Utilization Cases. Refer to Section V.

Receipt of Completed Forms

2-2 Rev: 7/27/15

Questions to consider when opening a case.

a. Determine what the request for review does involve.

2. Is the dentist a CDA member?

2-3 Rev: 7/27/15

3. Is the dentist a general dentist?

6. Was there a carrier involved? If so, include the carrier’s information.

1. Forward to the Council on Peer Review the following information:

2-4 Rev: 7/27/15

a. Forward to the Council on Peer Review the following information:

If it is verified that litigation/arbitration is in process, these steps must be followed:

a. Forward to the Council on Peer Review the following information:

10. Is the case “routine”, exhibiting nothing out of the ordinary?

a. Determine what the request for review does involve.

11. Does the carrier-initiated request include all necessary information?

Answer only if the request is initiated by a carrier.

2-5 Rev: 7/27/15