How To Determine If A Dental Provider Is Covered In Delaware

Transcription

1 Dental Provider Specific Policy Revision Table Revision Date Sections Revised Description 7/1/02 All Complete manual revision to reflect changes related to the MMIS and HIPAA compliance. 8/19/ , , CMS prohibits providers from billing Medicaid clients for , 10.0, missed scheduled appointments. Section is being 11.0 and 12.0 removed since DMAP policy cannot allow providers to impose a charge to clients. Local Codes are no longer used by providers when billing DMAP for dental services. Therefore, Appendix A (Section 10.0) is being removed. Also removing reference to 7/1/02 in Sections 11.0 and 12.0 since it is no longer applicable. 9/18/08 Overview Removed obsolete wording. 2/12/ and 12.0 Added required legal wording for use of ADA coding. 4/8/09 Prior to entering the manual Added the required CDT end user licensing agreement as a pop-up dialogue box.

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3 Dental Provider Specific Policy Manual Table of Contents 1.0 Overview 1.1 General Criteria 2.0 Eligibility 2.1 Criteria 3.0 Services 3.1 Covered Services 3.2 General Services 3.3 Emergency Services 3.4 Preventive Services 3.5 Therapeutic Services 3.6 Orthodontic Services 4.0 Billing Information 4.1 General 5.0 Reserved 6.0 Medical Assistance Card 6.1 Eligibility Verification 7.0 Reserved 8.0 Reimbursement 8.1 Payment Conditions 9.0 Reserved 10.0 Reserved 11.0 Appendix B Non-Covered CDT-4 Codes 12.0 Appendix C CDT-4 Codes with Limitations/Restrictions

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5 Dental Provider Specific Policy Manual Dental services are covered and paid directly by the State Medicaid Program, not by the Managed Care Organizations participating in the Diamond State Health Plan (DSHP Medicaid s managed care)*. Dental services are not a covered benefit for children enrolled in the Delaware Healthy Children Program (DHCP), a non-medicaid, health insurance program for uninsured children under age 19 or for Non-Qualified Alien (see Section for exception). *With one exception: MCOs are responsible for covering impacted bony wisdom teeth. 1.0 Overview 1.1 General Criteria Dental services are covered by the Delaware Medical Assistance Program (DMAP) for children through age 20 years through the Early and Periodic Screening & Diagnostic Treatment (EPSDT) program Reserved Reserved An enrolled dental provider may treat any Medicaid eligible child and will be paid directly by the DMAP The EPSDT dental program does impose certain limitations and prior authorization requirements for some services. Refer to Appendix B for Noncovered CDT-4 Codes and Appendix C for Limitations/Restrictions.

7 2.0 Eligibility 2.1 Criteria Children though age 20 years who are currently covered by the DMAP are eligible to receive medically necessary dental services Eligible children need not have been evaluated and referred by the DPH Dental Clinics to be treated by dental providers enrolled in the DMAP (except for orthodontic services) Clients aged 21 and older are not eligible for dental services under Medicaid; billings for clients 21 and older will be denied as non-covered services Criteria for emergency dental services and non-qualified aliens include: Non-qualified aliens are covered for life threatening emergency services and labor and delivery care only. On a case-by-case basis, emergency dental services for a non-qualified alien child under age 21 will be considered for payment when a true documented dental emergency has been substantiated by review by the Public Health Dental Director. Only the initial triage services necessary to treat the emergency condition (pain, infection, bleeding) are covered. Follow-up care is not considered to be emergency in nature.

9 3.0 Services 3.1 Covered Services Medicaid covers medically necessary dental services in appropriate care settings for the relief of pain and infections, restoration of teeth, and maintenance of dental health. 3.2 General Services Examinations Endodontics Prophylactics Oral Surgery Radiographs Extractions Pulpotomies Prosthodontics Sealants In-office Sedation Permanent and temporary fillings Periodontics Fluoride Treatments Adjunctive Services (treatment of dental pain, anesthesia, drug management, etc) Note: Refer to Appendix B and Appendix C for non-covered services and limitations/restrictions of services

10 3.3 Emergency Services Emergency dental services are those necessary to control bleeding, relieve pain, and/or eliminate acute infection including, but not limited to: Operative procedures which are required to prevent pulpal death and the imminent loss of teeth Treatment of injuries to the teeth or supporting structures (e.g. bone or soft tissues contiguous to the teeth), and Palliative therapy for pericoronitis associated with impacted teeth 3.4 Preventive Services Preventive dental services provided either individually or in a group include, but not limited to: Instruction in self-care oral hygiene procedures; Oral prophylaxis (cleaning of teeth), both necessary as a precursor to the application of dental caries preventives where indicated, or independent of the application of caries preventives for patients 1 year of age or older; Professional application of dental sealants when appropriate to prevent pit and fissure caries; Professional application of topical fluoride to prevent caries; Comprehensive and periodic oral examination; and Radiograph/Diagnostic Imaging 3.5 Therapeutic Services Therapeutic dental services include, but are not limited to: Pulp therapy for permanent and primary teeth Restoration of carious (decayed) permanent and primary teeth Scaling and curettage Maintenance of space for posterior teeth lost permanently

11 Provision of removable prosthesis when masticatory function is impaired, or when existing prosthesis is unserviceable, and Orthodontic treatment when medically necessary to correct handicapping malocclusion 3.6 Orthodontic Services Orthodontics is a covered service under Medicaid's EPSDT Dental Program for children through age 20 years who have been diagnosed with a "handicapping" or "crippling" malocclusion All orthodontic care must be referred by and prior approved by the DPH dental clinics Payment of orthodontic services is managed by the DPH through its Special Dental Program.

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13 4.0 Billing Information 4.1 General A CDT-4 procedure code is required for billing dental services provided to Medicaid eligible children. Refer to Appendix B for CDT-4 codes not covered by the DMAP and Appendix C for CDT-4 codes with limitation/restrictions Reserved When billing for EPSDT dental services the appropriate diagnosis must be maintained in the client s file.

15 5.0 Reserved

17 6.0 Medical Assistance Card 6.1 Eligibility Verification The provider is required to check the client s Medicaid card before every service (refer to the Medical Assistance Card section in the General Policy) Dental care is not a covered benefit for all Medicaid clients even if they have a Medicaid card.

19 7.0 Reserved

21 8.0 Reimbursement 8.1 Payment Conditions Medicaid reimbursement is considered payment in full. Therefore, dental providers may not charge clients for balances that are not covered by Medicaid, and may not charge clients for services and reimburse them once Medicaid pays the claim Providers may bill a client when Medicaid denies a claim: If the client is not eligible on the date of service, or When the service is a non-covered benefit (see Appendix B) in the Medicaid Program (example. age 21 or older, cosmetic care, etc.) Reserved Dental services will be reimbursed at a pre-determined rate set by the State.

23 9.0 Reserved

25 10.0 Reserved

27 Non-Covered CDT-4 Codes 11.0 Appendix B Non-Covered CDT-4 Codes The following CDT-4 codes are not covered for dates of services effective on and after 7/1/02. Current Dental Terminology, fourth edition, (CDT) (including procedure codes, definitions (descriptors), and other data) is copyrighted by the American Dental Association American Dental Association. All rights reserved. Applicable FARS/DFARS apply. Service Code Description Comments Diagnostic D0415 Bacteriologic studies for determination of pathologic agents D0425 Caries susceptibility tests Preventive D1310 Nutritional counseling for control of dental disease D1330 Oral hygiene instructions Restorative D2410 D2664 -Gold Foil -Inlay/Onlay -Porcelain/ceramic inlays/onlays -Resin-based composite inlays/onlays D2780 Crown ¾ cast high noble metal D2790 Crown full cast high noble metal D2960 D2962 Labial veneers Endodontics D3331 Treatment of root canal obstruction; non-surgical process D3460 D3920 D3950 Endodontic endosseous implant Hemisection (including any root removal), not including root canal therapy Canal preparation Considered part of oral exam Considered part of oral exam Considered part of root canal procedure

28 Service Code Description Comments and fitting of preformed dowel or post Prosthodontics D5281 Removable unilateral partial denture one piece cast metal (including clasps and teeth) Maxillofacial Prosthetics D5710 D5721 Denture rebase procedures D5860 Overdenture complete, by report D5861 Overdenture partial, by report D5862 D5867 D5875 D5982 D5983 D5984 D5985 Precision attachment, by report Replacement of replaceable part of semi-precision or precision attachment (male or female component) Modification of removable prosthesis following implant surgery Surgical stent Radiation carrier Radiation shield Radiation cone locator Implant Services D6010 D6199 Implant services Partial dentures are covered as an equivalent least costly alternative Fixed Prosthodontics Oral and Maxillofacial Surgery D6200 D6999 D7285 Fixed prosthodontics Biopsy or oral tissue hard (bone, tooth) Partial dentures are covered as an equivalent least costly alternative This procedure is covered as a medical service billable by an oral surgeon only under an appropriate CPT

29 Service Code Description Comments D7286 D7410 D7490 D7610 D7877 D7920 D7955 D7980 D7996 Biopsy of oral tissue soft (all others) Surgical excisions of lesions, tumors, cysts, neoplasms, bone tissue, etc. Treatment of fractures, simple and compound, reduction of dislocations, etc. Other repair procedures Other repair procedures Orthodontics D8010 D8999 Orthodontic services. code This procedure is covered as a medical service billable by an oral surgeon only under an appropriate CPT code These procedures are covered as medical services billable by oral surgeons only under appropriate CPT codes These procedures are covered as medical services billable by oral surgeons only under appropriate CPT codes These procedures are covered as medical services billable by oral surgeons only under appropriate CPT codes These procedures are covered as medical services billable by oral surgeons only under appropriate CPT codes Currently arranged and paid for through the Division of Public Health special dental program. Adjunctive Services D9211 D9215 D9410 D9430 D9941 D9974 Regional, trigeminal, and local anesthesia. Professional Visits Miscellaneous Considered part of procedure.

30 Service Code Description Comments Services (occlusal guard, athletic mouthguard, occlusal analysis, enamel microabrasion, odontoplasty, bleaching, etc.)

31 CDT-4 Codes with Limitations/Restrictions 12.0 Appendix C CDT-4 Codes with Limitations/Restrictions Medicaid dental service CDT limitations have been established to mirror common practice in the commercial insurance environment. Under Medicaid, dental services are only covered for eligible individuals under age 21. Many covered CDT services are open to the full age range from 0 through 20 years of age, but some may have age limitations to reflect normal practice. Also, generally the CDT services are limited to one unit of service per day unless otherwise noted. Only those covered CDT codes with one or more limitations are listed below. Covered dental services may be limited by age range, maximum number of units allowable per day, prior authorization requirements, or attachment requirements. Services that fall outside of these limitations will be subject to review. Current Dental Terminology, fourth edition, (CDT) (including procedure codes, definitions (descriptors), and other data) is copyrighted by the American Dental Association American Dental Association. All rights reserved. Applicable FARS/DFARS apply. Service Code Age Limitation Max Units Per Day Prior Authorization Diagnostic D0210 D years of age D units per day max D units per day max D units per day max D units per day max D0320 D years of age Required. D years of age D0340 D years of age D years of age D years of age D0472 D years of age Preventive D years of age D1120 D years of age D1204 D years of age Attachment Requirements Other Comments

32 Service Code Age Limitation Max Units Per Day Prior Authorization Preventive (Con t) Attachment Requirements Other Comments D years of age Covered for providers who follow the DPH ABC Tobacco Prevention Program; records should document that policy. D years of age Sealants covered for primary and adult dentition except for the following teeth: C,D,E,F,G,H, M,N,O,P,Q,R, 6,7,8,9,10,11, 22,23,23,25,2 6,27. Must identify tooth numbers on claim. D1510 D years of age Identify tooth, quadrant and arch. Restorative D2110 D years of age D2140 D years of age D2330 D years of age D years of age D2380 D years of age

33 Service Code Age Limitation Max Units Per Day Prior Authorization Attachment Requirements Other Comments D2385 D years of age D2710 D years of age D2781 D years of age D2791 D years of age D2799 requires prior authorization. D years of age D2920 D years of age D years of age D years of age Only valid for anterior teeth C, D, E, F, G, H, M, N, O, P, Q, R; 6-12 and D years of age Not billable on same day as a permanent filling for the same tooth. D2950 D years of age D2951 not billable at same time as D2950. D2955 only billable for permanent posterior teeth and requires valid tooth number. D2970 D years of age D2980 and

34 Service Code Age Limitation Max Units Per Day Prior Authorization Attachment Requirements Endodontics D3110 D years of age D years of age D3230 D years of age Documented medical necessity needed for patients over age 13. Attach notes to claim. D3310 D years of age D years of age D3333 D years of age D years of age D3425 D years of age Up to 3 units per day for D3426 only. D3470 D years of age D years of age Required. Periodontics D4210 D years of age Prior authorization required for all procedures except D4355 and D4920. Claim should be submitted with copies of x-rays and report. Other Comments D2999 not valid for primary or permanent teeth and only valid for D4249, D4268, and D4381 require tooth numbers. D4341 not billable in conjunction with D4210,

35 Service Code Age Limitation Max Units Per Day Prior Authorization Prosthodontics D5110 D years of age Prior authorization require for all procedures. D5213 D years of age Prior authorization required for all procedures. Attachment Requirements Claims should be submitted with copies of x-rays and report and missing teeth should be identified. Claims should be submitted with copies of x-rays and report and missing teeth should be identified. Other Comments D4211, or D4220. D5410 D years of age Not billable within 6 months of the provision of full or partial dentures. D5510 D years of age D years of age D years of age D5730 D years of age Not billable within 6 months of D5110, D5120, and D5211 thru D5281. D5810 D years of age Prior Claims should be Approval for

36 Service Code Age Limitation Max Units Per Day Prior Authorization authorization required for all procedures. Attachment Requirements submitted with report and x- rays. Other Comments both immediate dentures and interim dentures should be requested at the same time (D5130, D5140). Prosthodontics D5850 D years of age Not billable within 6 months of a complete or partial denture. Maxillofacial Prosthetics D years of age Prior authorization required. D5911 D years of age Prior authorization required for all procedures. D5986 D years of age Prior authorization required for all procedures. Report required. Report required. Report required. These procedures are generally not covered unless determined to be medically necessary. These procedures are generally not covered unless determined to

37 Service Code Age Limitation Max Units Per Day Prior Authorization Implant Services Fixed Prosthodontics Oral and Maxillofacial Surgery Oral and Maxillofacial Surgery (Con t) Attachment Requirements Other Comments be medically necessary. D6000 D6199 Not covered; see list of noncovered CDT codes. D6200 D6999 Not covered; see list of noncovered CDT codes. D7110 D years of age Indicate tooth number. D years of age Indicate tooth number. D7272 D years of age Prior authorization required for all procedures. Indicate tooth number. D7290 D years of age Prior authorization required for all procedures. D7510 D years of age Prior authorization required for all procedures. D7880 D years of age Prior authorization required for all procedures. D7910 D years of age Indicate tooth number or quadrant where appropriate.

38 Service Code Age Limitation Max Units Per Day Prior Authorization D7960 D years of age Prior authorization required for all procedures. D7997 D years of age. Attachment Requirements Other Comments Orthodontics D8010 D8999 Not currently covered directly through Medicaid. Adjunctive Services D9110 D years of age Not Required. Not Required. D9220 D years of age Not Required. Not Required. D9440 D years of age Not Required. Not Required. D years of age Prior authorization required. Documentation should be submitted explaining the services to be provided and medical need for the services.