Change in Adult Dental Benefits
||All HFS-Enrolled Dental Providers, FQHCs and Certified Local Health Departments|
||June 13, 2012|
||Change in Adult Dental Benefits|
The recently passed Save Medicaid Access and Resources Together (SMART) Act requires changes to the Healthcare and Family Services (HFS) Dental Program. Senate Bill 2840, Section 5-5f (b)(v) (elimination and limitations of medical assistance services), states that the Department shall limit adult dental services to emergencies. This provider notice provides details about how emergency is defined, how DentaQuest will handle prior authorizations and the benefits that will be covered services for adults age 21 and older, after July 1, 2012.
Additional information and details will be published in the Dental Office Reference Manual to be distributed later this summer. If you have questions regarding the changes to adult dental benefits please contact your DentaQuest provider representative or the DentaQuest Provider Relations Hotline at 1-888-281-2076.
Definition of Emergency (ies)
An emergency is defined as a situation deemed medically necessary to treat pain, infection, swelling, uncontrolled bleeding, or traumatic injury that can be treated by extraction only.
Adult Dental Benefit Coverage after July 1, 2012
Adult dental benefits are limited to the following procedure codes.
||Limited oral evaluation-problem focused
||Intraoral-periapical first film
||Intraoral-periapical each additional film
||Extraction, erupted tooth or exposed root
||Surgical removal of erupted tooth requiring removal of bone and/or sectioning of tooth, and including elevation of mucoperiosteal flap if indicated
||Inhalation of Nitrous Oxide/Anxiolysis, Analgesia
||Non-Intravenous Conscious Sedation
Limited emergency exam (D0140), X-rays (D0220, D0230 or D0330) and sedation (D9230 or D9248) will only be covered when performed in conjunction with an extraction (D7140 or D7210). Claims for exams (D0140), X-rays (D0220, D0230 or D0330) and/or sedation (D9230 or D9248) will deny unless they are done on the same date of service as an extraction (D7140 or D7210).
This is an emergency dental benefit to treat pain, infection, swelling, or uncontrolled bleeding; therefore, it is not anticipated that multiple extractions would be done on the same date of service. Multiple extractions should not be done. If multiple extractions are done on the same date of service, the claim will be subject to utilization review to determine medical necessity.
Fractured teeth, fractured jaws, and other traumatic injuries due to external trauma will be considered medical injuries/or conditions. The only dental treatment covered (under the dental benefit package) for traumatic injury is extraction. All other traumatic oral cases are considered medical and should be billed as medical services. If a dentist holds a specialty license in Oral and Maxillofacial Surgery, he or she may enroll with HFS as a medical provider and bill HFS for appropriate medical services. Check for enrollment information on the Medical Programs General Provider Enrollment Requirements Web page
Emergent Medical Conditions Requiring Dental Care
Medically necessary dental services requested by the patient’s physician prior to receiving medical treatment such as, but not limited to, cancer treatment, joint replacement, organ transplants or other emergent medical conditions requiring good oral health to continue medical treatment will be considered after prior authorization. Documentation of the condition and referral from a physician are required to be considered for approval by DentaQuest.
Handling of Open Authorizations
All open authorizations for services requiring a single appointment will expire on June 30, 2012.
All open authorizations for services requiring multi-step procedures (multiple appointments) will expire on August 31, 2012. Examples of multi-step procedures are as follows:
||D5110, D5120, D5130, D5140|
||D2740, D2750, D2751, D2752, D2790, D2791, D2792|
|Root Canal Therapy
Services authorized prior to June 30, 2012 for multi-step procedures must be completed by August 31, 2012, in order for the service to be paid.