DENTAL PROGRAM COVERAGE
EARLY AND PERIODIC SCREENING, DIAGNOSIS AND TREATMENT
The Early and Periodic Screening, Diagnosis and Treatment (EPSDT) program is available to all Medicaid beneficiaries under the age of 21. This program was established to detect and correct or ameliorate defects and physical and mental illnesses and conditions discovered in children. Under EPSDT, dental services are to be provided at intervals which meet reasonable standards of dental practice.
Primary Care Physicians (PCPs) should provide an oral health screening and caries risk assessment for beneficiaries under 21 years of age at each well child visit. As an oral health intervention, providers should apply fluoride varnish to high-risk children from birth to 35 months of age up to four times in a 12-month time period.
Providers must complete the online Children’s Oral Health training modules and obtain certification prior to providing oral health screenings and fluoride varnish applications. Providers who complete the certification requirements are allowed to bill Medicaid for these services. Specific certification requirements are available on the MDHHS Oral Health website. (Refer to the Directory Appendix for website information). Refer to the Early and Periodic Screening, Diagnosis and Treatment chapter for additional information.
The Dental Periodicity Schedule follows the American Academy of Pediatric Dentistry (AAPD) Recommendations for Pediatric Oral Health Assessment, Preventive Services, and Anticipatory Guidance/Counseling schedule. (Refer to the Directory Appendix for AAPD website information.)
The AAPD guidelines are designed for the care of children developing normally and without contributing medical conditions. The guidelines include recommendations to modify as needed for children with special health care needs, disease or trauma. The AAPD guidelines emphasize the importance of early professional intervention and continuity of care based on the individualized needs of the child.
The guidelines recommend that a child have a first dental visit when the first tooth erupts or no later than 12 months of age. The examination is to be repeated every six months or as indicated by the child’s risk status and susceptibility to disease. The examination includes assessment of pathology and injuries, growth and development, and caries-risk assessment. Based on clinical findings and susceptibility to disease, the timing and frequency of radiographic imaging, oral prophylaxis, and topical fluoride should be provided as determined necessary. Systemic fluoride supplementation should be considered when fluoride exposure is suboptimal.
Anticipatory guidance/counseling should be an integral part of each dental visit. Counseling on oral hygiene, nutrition/dietary practices, injury prevention, and nonnutritive oral habits should be included. A referral for speech/language development should be made as needed. Determined by growth and developmental assessment, the prevention and treatment of developing malocclusion should be evaluated beginning at 2 years of age. Following current policy, caries-susceptible pits and fissures of teeth should have sealants placed as soon as possible after eruption. Children 6 years of age and older should receive counseling on substance abuse and intraoral and perioral piercing. Children 12 years of age and older need third molar assessment and potential removal as deemed medically necessary.
ADULT DENTAL PROGRAM
Beneficiaries age 21 and older receive dental benefits that are more limited in coverage. Dental benefits are provided for adult Medicaid and Medicaid Health Plan (MHP) beneficiaries through the Medicaid Fee-For-Service (FFS) Program. Healthy Michigan Plan (HMP) beneficiaries will receive their dental benefits through the Medicaid FFS program until they are enrolled in a health plan. The health plan becomes responsible for the beneficiary’s dental services on the enrollment effective date. Upon enrollment in a health plan, beneficiaries must obtain dental services through the health plan’s dental provider network. The Program of All-Inclusive Care for the Elderly (PACE) is responsible for the coverage of dental benefits for PACE enrollees.
HEALTHY MICHIGAN PLAN DENTAL
Beneficiaries enrolled in a health plan will receive their dental coverage through their health plan. Each health plan contracts with a dental provider group or vendor to provide dental services administered according to the contract. The contract is between the health plan and the dental provider group or vendor, and beneficiaries must receive services from a participating provider to be covered. Questions regarding eligibility, prior authorization or the provider network should be directed to the beneficiary’s health plan.
It is important to verify eligibility at every appointment before providing dental services.
Dental services provided to an ineligible beneficiary will not be reimbursed.
For those beneficiaries who are not enrolled in a health plan, dental services will be provided by enrolled dental providers on a FFS basis.
Dentists providing specialty dental services to Children’s Special Health Care Services (CSHCS) Program beneficiaries should refer to the Children’s Special Health Care Services Dental Services Section of this chapter. Refer to the Additional Code/Coverage Resource Materials subsection of the General Information for Providers Chapter for additional information regarding coverage parameters.
Prior authorization (PA) is only required for those services identified in the Dental Chapter and the Medicaid Code and Rate Reference tool. (Refer to the Directory Appendix for website information.)
PRIOR AUTHORIZATION REQUIREMENTS IN CASES OF OVER-UTILIZATION
MDHHS may require a dentist found to be misutilizing services to obtain PA for all or selected dental services separate from those generally requiring authorization. MDHHS is required to explain to the dentist, in writing, the reasons for applying this requirement.
The Dental Prior Approval Authorization Request form (MSA-1680-B) is used to obtain authorization. (Refer to the Forms Appendix for instructions for completing the form.) When requesting authorization for certain procedures, dentists may be required to send specific additional information and materials. Based on the MSA-1680-B and the documentation attached, staff approves or disapproves the request and returns a copy to the dentist. Approved requests are assigned a PA number. For billing purposes, the PA number must be entered in the appropriate field on the claim form. An electronic copy of the MSA-1680-B is available on the MDHHS website.
APPROVED PRIOR AUTHORIZATION REQUESTS
An approved PA request confirms that the beneficiary meets Medicaid’s established medical criteria for the services and that the services are Medicaid-covered benefits. This approval does not guarantee eligibility nor verify a beneficiary’s age. It is also not to be considered an authorization for payment.
The dentist is responsible for verifying the beneficiary’s Medicaid eligibility and age by checking the eligibility response. Eligibility should be verified prior to each appointment. (Refer to the Enrollment Information subsection of this chapter and the Verifying Beneficiary Eligibility section of the Beneficiary Eligibility chapter for additional information.)
PA is granted under the NPI submitted on the PA form. Provided it is the group NPI, it may be transferred or used by any dentist within the same organization without contacting the MDHHS Dental Prior Authorization Unit.
While a beneficiary is eligible, all treatment authorized must be completed within one year from the date of authorization. If treatment is not completed within one year, the PA request must be updated before continuing treatment. The provider has 15 days prior to the end of the prior authorization period to request a one-time 180-day extension. New prior authorization requests must be submitted for existing PA plans over one year old.
Providers may update the PA request by contacting the Dental Prior Authorization Unit by phone or fax if there are no treatment plan changes. (Refer to the Directory Appendix for contact information.) If a change in the treatment plan is necessary, dentists should submit a new MSA-1680-B with appropriate images and information to the Dental Prior Authorization Unit.
If a PA request is denied, the dentist receives a denial notice. The beneficiary also receives a notice of denial for the requested service along with their notice of appeal rights.
LOSS OR CHANGE IN ELIGIBILITY
No service is covered after loss of eligibility except for the following services:
* Endodontic Therapy
* Complete and Partial Dentures
* Laboratory-Processed Crowns
Reimbursement for these services is only allowed under the following circumstances:
* Services were started prior to the loss of eligibility.
* For complete or partial dentures and laboratory-processed crowns, impressions were taken prior to the loss of eligibility.
* Services are completed within 30 days of change and/or loss of eligibility. Conditions not eligible for reimbursement include:
* If a beneficiary’s Medicaid eligibility is terminated after extractions were performed, but prior to the initial impressions. The extractions alone do not qualify the beneficiary for dentures.
* Immediate dentures.
The date of service on the claim is the date the endodontic therapy was started or the date of the initial impressions for complete or partial dentures and laboratory-processed crowns.
A copayment of $3 for each separately reimbursable Medicaid visit may be required for beneficiaries age 21 years and older with the following limitations:
* When more than one reimbursable service is provided during a visit, only one $3 copayment may be charged.
* Where several visits are required to complete a service (such as dentures), only one $3 copayment may be charged.
* Beneficiaries cannot be charged a copayment for procedures that are considered part of normal office operations.
A provider cannot refuse to render service if the beneficiary is unable to pay the required copayment on the date of service.
Some beneficiaries, programs, and places of service are exempt from co-payment requirements. (Refer to the General Information for Providers Chapter for information on exceptions to Medicaid copayment requirements.)
PLACE OF SERVICE
All dental services must be performed in the dental office, public health department dental clinic, dental school, dental hygiene program, or Federally Qualified Health Centers (FQHCs). Special situations may necessitate the provision of services at an alternate site such as a hospital/surgical setting or nursing facility.
INPATIENT OR OUTPATIENT HOSPITAL SETTING
Admission to an inpatient or outpatient hospital setting for any non-emergency dental service is covered for beneficiaries for the following reasons:
* The patient has a high-risk medical condition;
* The type of procedure requires it to be performed in a hospital setting; or
* Other contributing factors could compromise the safety of the patient, such as age, behavioral problems due to mental impairment, etc.
The dentist/physician must document in the beneficiary’s medical record the condition hat required the dental service to be done in the hospital setting. Hospitalization is not a benefit for the convenience of the dentist or beneficiary or because of apprehension on the part of the beneficiary.
For services performed in a surgical setting, the dentist should use the usual and customary (U & C) fee for the service as performed in an office setting. In addition, the CDT procedure code for hospital or ambulatory surgical center call may also be billed if services are provided in a hospital or surgical center. This code may be billed in addition to the appropriate dental procedure code for the actual service performed. This procedure code is not for administrative purposes, such as arranging appointment times, gathering signatures for release forms, etc.
Dental services provided to a beneficiary who resides in a nursing facility are the same benefits as those identified in the Covered Services section of this chapter. All dental services provided to a nursing home beneficiary in a nursing facility, or any other place of service, require the written order of a licensed referring physician (MD, DO). The order must be signed and dated by the physician and a copy of this order must be retained in the beneficiary’s medical record and the beneficiary’s dental record. All dental services provided in a nursing facility must be noted in the beneficiary’s medical record. Documentation must include an updated medical history, the patient’s primary concerns, the current oral health status, and the treatment plan and services rendered.
MOBILE DENTAL FACILITIES
A mobile dental facility is defined as a self-contained, intact facility in which dentistry or dental hygiene is practiced that may be transported from one location to another, or a site used on a temporary basis to provide dental services using portable equipment. A mobile dental permit must be obtained by an operator before providing dental services.
* Completion of the permit application;
* Submission of the required documents;
* Submission of the administrative fee; and
* Memorandum of agreement for follow-up services.
Mobile dental operators can access the Mobile Dental Facility Application and additional information and requirements on the MDHHS website. (Refer to the Directory Appendix for website information.)
To provide dental services and bill Medicaid, a provider must be enrolled in the Community Health Automated Medicaid Processing System (CHAMPS). Instructions for provider enrollment, as well as updating enrollment, can be found on the MDHHS website. (Refer to the Directory Appendix for website information.)
Enrollment as a mobile dental provider is required within 30 days of approval of the Mobile Dental Facility Permit. Groups may select more than one specialty. Dental Hygienists operating in mobile facilities will need to enroll as a mobile provider.
All other sites must be prior approved. In order to receive prior authorization (PA), the dental provider must complete the Dental Prior Approval Authorization Request form (MSA-1680-B) for each individual and submit it to the Prior Authorization Section. (Refer to the Forms Appendix for a copy of the form.) Providers should follow the same instructions for submission of the PA request for site of service as they do requests for procedures.