(a) Payment for
emergent dental services covered under this subsection does not reduce a
recipient's annual limit under (b) and (c) of this section. Except as
specifically excluded under (g) of this section, the department will pay for
the following emergent dental services identified in the Fee Schedule:
Emergent Adult Dental Services, adopted by reference in
7
AAC 160.900, for recipients 21 years of age or older,
as follows:
(1) the following dental services
for the immediate relief of pain or acute infection:
(A) limited oral evaluation not more than two times per fiscal
year;
(B) extractions; under this
subparagraph,
(i) a claim submitted for up
to two extractions in a single day must be accompanied by medical
justification; and
(ii) a provider
must obtain prior authorization from the department for three or more
extractions in a single day or four or more extractions in a 12-month
period;
(C) one
intraoral periapical radiograph to determine if an extraction is
necessary;
(D) anesthesia or
sedation in accordance with
7
AAC 110.155 and necessary for dental services covered
under this section; a claim submitted to the department for payment of costs
for general anesthesia must be accompanied by written medical justification for
the service;
(2) a
dental service that exceeds a limit established in (b) and (c) of this section
if the department determines, based on medical justification submitted with a
prior authorization request, that a delay in the provision of the service will
endanger the life of the recipient.
(b) Subject to appropriation under
AS
47.07.067 and except as specifically excluded
under (g) of this section, the department will pay up to $ 1,150 per state
fiscal year for the dental services identified in the Fee Schedule:
Enhanced Adult Dental Services, adopted by reference in
7
AAC 160.900 and provided to a recipient 21 years of
age or older, as follows:
(1) periodic or
comprehensive oral evaluation not more than one time per fiscal year, panoramic
radiographs not more than one time per fiscal year and other dental radiographs
necessary for dental care;
(2)
preventive care, including
(A) prophylaxis,
including necessary scaling, polishing, and instructions on oral hygiene and
diet, not more than two times per fiscal year; and
(B) topical application of fluoride not more
than four times per fiscal year, or topical fluoride varnish not more than four
times per fiscal year, or a combination of topical application of fluoride and
fluoride varnish not more than four times per fiscal year;
(3) restorative care for the treatment of
decayed or fractured teeth, including amalgams and resins, and crowns if the
tooth cannot be restored with amalgams or resin; under this paragraph,
(A) a claim submitted for up to two crowns
in a single day must be accompanied by medical justification;
(B) a provider must obtain prior
authorization from the department for three or more crowns in a single day or
four or more crowns in a 12 -month period;
(C) all surfaces restored on a single tooth on the same day are
considered connected; therefore, payment is limited to one single or
multi-surface restoration code per tooth per day;
(D) final restorations are limited to not
more than five surfaces per tooth; tooth preparation, temporary restorations,
sedative and cement bases, and local anesthesia are considered components of a
complete restorative procedure and may not be billed separately; and
(E) the department will provide payment for
a crown only upon seatment of the permanent crown, and for a partial or denture
only upon seatment of the appliance; the department will not provide partial
payment for incomplete or in-progress dental services;
(4) endodontics, with the following
limitations:
(A) palliative and sedative
treatments may not exceed two times per tooth before a definitive
treatment;
(B) with respect to
root canal therapy, tooth preparation, temporary filling of the root canal, and
follow-up care are considered components of a complete root canal and may not
be billed separately;
(C) a
separate claim in addition to a root canal claim may be made for pin retention
and restoration, and may not exceed five surfaces per
tooth;
(5) periodontics,
including treatment of pain or acute infection of supporting tissues of the
teeth, including gingivitis, periodontitis, and periodontal abscess;
(6) oral surgery; under this paragraph,
(A) prior authorization from the department
is required for extractions; and
(B) local anesthesia, materials, and routine postoperative care
are considered components of a complete surgical procedure and may not be
billed separately;
(7)
professional consultation, if medically necessary or if requested by the
department.
(c) Prior
authorization from the department is required for prosthodontic services.
Except as specifically excluded under (g) of this section, the department will
pay up to $1,150 per state fiscal year for prosthodontic services provided to a
recipient 21 years of age or older, and up to twice the annual limit if one
annual limit is not adequate to cover the cost of the provision of upper and
lower dentures at the same time. If the department authorizes use of up to
twice the annual limit for dentures, the maximum amount authorized is the
remaining amount from the current fiscal year and the entire amount allotted
for the succeeding fiscal year limit. In the succeeding fiscal year, the
department will not authorize a new or additional annual limit. The department
will pay for prosthodontic services identified in Fee Schedule:
Prosthodontic Adult Dental Services, adopted by reference in
7
AAC 160.900, as follows:
(1) a complete denture, maxillary;
(2) a complete denture, mandibular;
(3) a partial denture, maxillary;
(4) a partial denture; mandibular;
(5) replacement of a complete or partial
denture only if the existing denture is unusable and only once per five years,
unless the department determines, based on medical justification submitted with
the prior authorization request, that a delay will endanger the life of the
recipient;
(6) replacement of a
partial denture with a complete denture not earlier than five years after
payment for the partial denture, unless the department determines, based on
medical justification submitted with the prior authorization request, that a
delay will endanger the life of the recipient;
(7) a denture within the same dental arch no more than three times
per lifetime, unless the department determines, based on medical justification
submitted with the prior authorization request, that a delay will endanger the
life of the recipient;
(8)
adjustments to a complete or partial denture not earlier than six months
following the seatment date of the denture and not more than four times per
fiscal year;
(9) rebase and reline
procedures of a complete or partial denture not earlier than six months
following the seatment date of the denture and not more than once per three
fiscal years.
(d) The
cost of anesthesia or sedation in accordance with
7
AAC 110.155 and necessary for dental services covered
under this section does not reduce the recipient's annual limit described in
(b) and (c) of this section.
(e) A
dental service provided after a recipient's annual limit under (b) and (c) of
this section has been exhausted is considered a noncovered service and the
department will not provide payment. Notwithstanding
7
AAC 145.015, a provider may bill a recipient for the
difference under (c) of this section if the unused portion of a recipient's
annual limit is less than the allowable Medicaid payment rate, or under (b) and
(c) of this section if the unused portion of the recipient's combined annual
limit is less than the allowable Medicaid payment rate. A provider shall inform
a recipient in advance of the recipient's obligation to pay for the difference.
The provider shall document in the recipient's records that the recipient was
informed of and agreed to pay for any balance above the annual limit for the
service provided.
(f) The
department will assist a provider and recipient to the extent possible in
monitoring the recipient's annual limit. However, the department will not
assume financial responsibility for dental services provided that exceed the
recipient's annual limit.
(g) The
department will not pay for the following dental services provided to a
recipient 21 years of age or older:
(1)
dental services not identified in the
Fee Schedule: Emergent Adult
Dental Services, the Fee Schedule: Enhanced Adult Dental Services, and
the
Fee Schedule: Prosthodontic Adult Dental Services, adopted
by reference in
7
AAC 160.900;
(3) indirect pulp capping;
(4) endodontic apical surgery and retrograde fillings;
(5) immediate, interim, and temporary
dentures;
(6) dental implant and
implant-related dental services;
(7) inlays, overlays, and three-fourth crowns;
(8) restoration of etched enamel or deep
grooves without obvious dentin involvement;
(10) tobacco counseling; tobacco counseling is considered a
component of periodic and comprehensive evaluations and may not be billed
separately;
(11) denture
characterization and personalization, and precision attachments;
(12) experimental dental
procedures;
(13) local anesthesia;
local anesthesia is considered a component of covered dental procedures and may
not be billed separately;
(14)
anesthesia or sedation in conjunction with a noncovered service or a service
for which service limits have been exhausted;
(16) orthodontic services.
