Arkansas Administrative Code
Agency 016 - DEPARTMENT OF HUMAN SERVICES
Division 06 - Medical Services
Rule 016.06.06-074 - State Plan Amendment #2006-001 and Dental Update #85
Current through Register Vol. 49, No. 9, September, 2024
ATTACHMENT 3.1-A
AMOUNT, DURATION AND SCOPE OF SERVICES PROVIDED
CATEGORICALLY NEEDY
4.b. Early and Periodic Screening and Diagnosis of Individuals Under 21 Years of Age, and Treatment of Conditions Found.
Refer to Attachment 3.1-A, Item 4. b. (16) for information regarding dental services for EPSDT eligible children under age 21
Dental services are available for Medicaid beneficiaries age 21 and over only when provided as a result of a life-threatening medical necessity. All adult dental services must be prior authorized..
All other procedures require prior authorization from the Medical Assistance Section. A full mouth radiograph is limited to once every five years. Periodic oral exam, prophylaxis, fluoride treatment, and bite-wing X-rays are limited to once per every 6 (six) months plus 1 (one) day. Scaling is limited to one per state fiscal year (July 1 through June 30). Periapical X-rays are limited to four (4) per recall visit. Any limits will be exceeded based on medical necessity.
Refer to Attachment 3.1-B, Item 4. b. (16) for information regarding dental services for EPSDT eligible children under age 21 Dental services are available for Medicaid beneficiaries age 21 and over only when provided as a result of a life-threatening medical necessity. All adult dental services must be prior authorized..
Medicaid dental rates will be adjusted as follows. The Division of Medical Services and the Arkansas State Dental Association shall meet on two year cycles beginning January 1, 2007, to evaluate the dental rates considering the factors set out in 42 U.S.C. Section 1396a(a)(30)(A) and shall review Delta Dental's then current Premier rates, identify rate adjustment to be made, and agree on the implementation methodology and date.
Procedure code D0350 (oral/facial photographic images) is not covered by the 2006 Delta Dental Premier Plan. For dates of service beginning February 1, 2006, the Medicaid maximum rate for procedure code D0350 is $33.25. The rate is based on 47.5% of the $70.00 2006 Delta Dental Plan of Arkansas Inc.'s Premier rate for procedure code D0340 as of January 16, 2006.
Procedure code D9248 (non-intravenous conscious sedation) is not covered by the 2006 Delta Dental Premier Plan. For dates of service beginning February 1, 2006, the maximum rate for procedure code D9248 is $96.74. The rate is based on 75% of the $128.99 physician reimbursement maximum rate for procedure code 99143 (conscious sedation). See Attachment 4.19-B, Page 2 for Physician Services reimbursement methodology.
Procedure code D9310 (consultation, second opinion examination) is not covered by the 2006 Delta Dental Premier Plan. For dates of service beginning February 1, 2006, the maximum rate for procedure code D9310 is $40.13. The rate is based on 75% of the $53.50 physician reimbursement maximum rate for procedure code 99241 (office visit, consultation). See Attachment 4.19-B, Page 2 for Physician Services reimbursement methodology.
Procedure code D1320 (tobacco counseling) is not covered by the 2006 Delta Dental Premier Plan. For dates of service beginning February 1, 2006, the maximum rate for procedure code D1320 is $25.00. The rate is based on 100% of the $25.00 physician reimbursement maximum rate for procedure code 99212 (office or other outpatient visit). See Attachment 4.19-B, Page 2 for Physician Services reimbursement methodology.
Procedure code D9920 (behavior management tobacco) is not covered by the 2006 Delta Dental Premier Plan. For dates of service beginning February 1, 2006, the maximum rate for procedure code D9920 is $20.00. The rate is based on 80% of the $25.00 physician reimbursement maximum rate for procedure code 99212 (office or other outpatient visit). See Attachment 4.19-B, Page 2 for Physician Services reimbursement methodology.
Reimbursement is based on the lesser of the amount billed or the maximum Title XIX (Medicaid) charge allowed. Reimbursement rates (payments) shall be as ordered by the United States District Court for the Eastern District of Arkansas in the case of Arkansas Medical Society v. Reynolds.
For dates of service on and after February 1, 2006, oral surgeon rates for procedure codes that also may be billed by dentists shall be set in accordance with sub paragraph (a) above. Rates for other procedure codes are set as follows.
For dates of service occurring April 1, 2004 and after:
Reimbursement is made at the lower of:
The Medicaid maximum is based on the 50th percentile of the Arkansas Medicare facility rates in effect March 1, 1988. Rates will be reviewed annually.
After discussion with CMS, it was determined that the Arkansas Medicare 75th percentile is considered the norm for Arkansas Medicare reimbursement. Since the State reimburses at Arkansas Medicare's 50th percentile, the reimbursement rates will not exceed Arkansas Medicare on the aggregate.
Effective for claims with dates of service on or after July 1, 1992, the Title XIX maximum rates were decreased by 20%.
Effective for dates of service on and after October 1, 2004, the Arkansas Medicaid Program covers training in peritoneal self-dialysis for beneficiaries with end-stage renal disease.
Reimbursement for peritoneal self-dialysis and training has been established as follows.
The Arkansas Medicaid maximum allowable daily fee for training in continuous ambulatory peritoneal dialysis (CAPD) equals the maximum allowable daily fee ($130) for a hemodialysis treatment plus $12.00 per day. This is the same methodology used by Medicare to calculate their CAPD training reimbursement rate.
The Arkansas Medicaid maximum allowable daily fee for training in continuous cycling peritoneal dialysis (CCPD) equals the maximum allowable daily fee ($130) for a hemodialysis treatment plus $20.00 per day. This is the same methodology used by Medicare to calculate their CCPD training reimbursement rate.
Refer to Attachment 4.19-B, Item 4.b.(18).
Reimbursement rate maximums are calculated at 95% of the 2006 Delta Dental Plan of Arkansas Inc.'s Premier rates as of January 16, 2006. Upon CMS approval, the reimbursement rates calculated under this method will be submitted to the United States District Court for the Eastern District of Arkansas (case of Arkansas Medical Society v. Reynolds) for its approval.
Medicaid dental rates will be adjusted as follows. The Division of Medical Services and the Arkansas State Dental Association shall meet on two year cycles beginning January 1, 2007, to evaluate the dental rates considering the factors set out in 42 U.S.C. Section 1396a(a)(30)(A) and shall review Delta Dental's then current Premier rates, identify rate adjustment to be made, and agree on the implementation methodology and date.
Section II
Dental
The Child Health Services (EPSDT) periodic and interperiodic dental screening exams consist of an inspection of the oral cavity by a licensed dentist. The purpose of the dental screening exams is to check for obvious dental abnormalities and to assure access to needed dental care. Regular screening exams should be performed in accordance with the recommendations of the Child Health Service (EPSDT) periodicity schedule.
The Child Health Services (EPSDT) periodic dental screening exam is limited to two screening exams per every six (6) months plus one (1) day for individuals under age 21. These benefits may be extended if documentation is provided that verifies medical necessity. See Section 262.100 to view the procedure code for periodic dental screening exams.
Individuals under age 21 enrolled in the EPSDT Program may receive an interperiodic dental screening exam as often as is medically necessary. Prior authorization from the Division of Medical Services Dental Care Unit is required for this service and must be requested on the ADA Claim Form. View or print form ADA-J510. See Section 262.100 for the interperiodic dental screening exam procedure code.
Infant oral health care examinations must be based on the recommendations of the American Academy of Pediatric Dentistry. Essential elements of an infant oral health care visit are a thorough medical and dental history, oral examination, parental counseling, preventive health education and determination of appropriate periodic re-evaluation. See Section 201.500 for information regarding the dentist's role in the EPSDT Program.
The EPSDT periodic screening exam must include two bitewing films that cover the distal of the cuspids to the distal of the most posterior tooth.
The EPSDT periodic screening exam must include only two bitewings and is allowed every six (6) months plus one (1) day for individuals under age 21. See Section 262.100 for the appropriate procedure code.
Dental prophylaxis and a fluoride treatment for patients under age 21 are preventive treatments covered by Medicaid. Prophylaxis and/or fluoride treatments may be performed on patients under age 21 every six (6) months plus one (1) day. If more frequent treatment is needed due to severe periodontal problems, the provider should request prior authorization with a brief narrative.
Medicaid does not reimburse for nitrous oxide for examinations, fluorides, oral prophylaxis and sealants unless other procedures are performed at the same time.
A provider may generally perform the following procedures without prior authorization:
Arkansas Medicaid reimbursement is based on the lesser of the amount billed or the Title XIX (Medicaid) maximum charge allowed.
The following ADA procedure codes are covered by the Arkansas Medicaid Program. These codes are payable for beneficiaries under the age of 21.
Beside each code is a reference chart that indicates whether X-rays are required and when prior authorization (PA) is required for the covered procedure code. If a concise report is required, this information is included in the PA column.
* Revenue code
***(...) This symbol, along with text in parentheses, indicates the Arkansas Medicaid description of the covered service.
** Prior authorization is required for panoramic x-rays performed on children under six years of age. (See section 216.100)
|
ADA Code |
Description |
PA Yes/No |
Submit X-Ray with Treatment Plan Yes/No |
|
Child Health Services (EPSDT) Dental Screening (See section 215.000) |
|||
|
D0120 |
CHS/EPSDT Dental Screening Exam |
No |
No |
|
D0140 |
CHS/EPSDT Interperiodic Dental Screening Exam |
Yes, and requires report |
No |
|
Radiographs (See sections 216.000 - 216.300) |
|||
|
D0210 |
Intraoral - complete series (including bitewings) |
No |
No |
|
D0220 |
Intraoral - periapical - first film |
No |
No |
|
D0230 |
Intraoral - periapical - each additional film |
No |
No |
|
D0240 |
Intraoral - occlusal film |
No |
No |
|
D0250 |
Extraoral - first film |
No |
No |
|
D0260 |
Extraoral - each additional film |
No |
No |
|
D0272 |
Bitewings - two films |
No |
No |
|
D0330 |
Panoramic film |
No** |
No |
|
D0340 |
Cephalometric film |
Yes |
No |
|
Tests and Laboratory |
|||
|
D0470 |
Diagnostic casts |
Yes |
No |
|
D0350 |
Diagnostic photographs |
Yes |
No |
|
Preventive |
|||
|
Dental Prophylaxis (See section 217.100) |
|||
|
D1120 |
Prophylaxis - child (ages 0-9) |
No |
No |
|
D1110 |
Prophylaxis - adult (ages 10-20) |
No |
No |
|
Topical Fluoride Treatment (Office Procedure) (See Section 217.100) |
|||
|
D1201 |
Topical application of fluoride (including prophylaxis) |
No |
No |
|
Dental Sealants (See section 217.200) |
|||
|
D1351 |
Sealant per tooth (1st and 2nd permanent molars only) |
No |
No |
|
Space Maintainers (See section 218.000) |
|||
|
D1510 |
Space maintainer - fixed - unilateral |
Yes |
Yes |
|
D1515 |
Space maintainer - fixed - bilateral |
Yes |
Yes |
|
D1525 |
Space maintainer - removable-bilateral |
Yes |
Yes |
|
Restorations (See sections 219.000 - 219.200) |
|||
|
Amalgam Restorations (including polishing) (See section 219.100) |
|||
|
D2140 |
Amalgam - one surface |
No |
No |
|
D2150 |
Amalgam - two surfaces |
No |
No |
|
D2160 |
Amalgam - three surfaces |
No |
No |
|
D2161 |
Amalgam - four or more surfaces |
No |
No |
|
Composite Resin Restorations (See section 219.200) |
|||
|
D2330 |
Resin - one surface, anterior, permanent |
No |
No |
|
D2331 |
Resin - two surfaces, anterior, permanent |
No |
No |
|
D2332 |
Resin - three surfaces, anterior, permanent |
No |
No |
|
D2335 |
Resin - four or more surfaces or involving incisal angle, permanent |
Yes |
Yes |
|
Crowns - Single Restoration Only (See section 220.000) |
|||
|
D2710 |
Crown - resin (laboratory) |
Yes |
Yes |
|
D2752 |
Crown - porcelain-ceramic substrate |
Yes |
Yes |
|
D2920 |
Re-cement crown |
No |
Yes |
|
D2930 |
Prefabricated stainless steel crown - primary |
No |
No |
|
D2931 |
Prefabricated stainless steel crown - permanent |
Yes |
Yes |
|
Endodontia (See section 221.000) |
|||
|
Pulpotomy |
|||
|
D3220 |
Therapeutic pulpotomy (excluding final restoration) |
No |
No |
|
D3221 |
Gross pulpal debridement, primary and permanent teeth |
Yes |
No |
|
Root canal therapy (including treatment plan, clinical procedures and follow-up care) |
|||
|
D3310 |
One canal (excluding final restoration) |
Yes |
Yes |
|
D3320 |
Two canals (excluding final restoration) |
Yes |
Yes |
|
D3330 |
Three canals (excluding final restoration) |
Yes |
Yes |
|
Periapic |
al Services |
||
|
D3410 |
Apicoectomy (per tooth) - first root |
Yes |
Yes |
|
Periodontal Procedures (See section 222.000) |
|||
|
Surgical Services (including usual postoperative services) |
|||
|
D4341 |
Periodontal scaling and root planing |
Yes |
Yes |
|
D4910 |
Periodontal maintenance procedures (following active therapy) |
Yes |
Yes |
|
Complete dentures (Removable Prosthetics Services) (See section 223.000) |
|||
|
D5110 |
Complete denture - maxillary |
Yes |
Yes |
|
D5120 |
Complete denture - mandibular |
Yes |
Yes |
|
Partial Dentures (Removable Prosthetic Services) (See section 223.000) |
|||
|
D5211 |
Upper partial - acrylic base (including any conventional clasps and rests) |
Yes |
Yes |
|
D5212 |
Lower partial - acrylic base (including any conventional clasps and rests) |
Yes |
Yes |
|
Repairs to Partial Denture (See section 223.000) |
|||
|
D5610 |
Repair acrylic saddle or base |
Yes |
No |
|
D5620 |
Repair cast framework |
Yes |
No |
|
D5640 |
Replace broken teeth - per tooth |
Yes |
No |
|
D5650 |
Add tooth to existing partial denture |
Yes |
No |
|
Fixed Prosthodontic Services (See section 224.000) |
|||
|
D6930 |
Re-cement bridge |
Yes |
No |
|
Oral Surgery (See section 225.000) |
|||
|
Simple Extractions (includes local anesthesia and routine postoperative care) (See section 225.100) |
|||
|
D7111 |
Extraction, coronal remnants-deciduous tooth |
No |
No |
|
D7140 |
Extraction, erupted tooth or exposed root (elevation and/or forceps removal) |
No |
No |
|
Surgical Extractions (includes local anesthesia and routine postoperative care) (See section 225.200) |
|||
|
D7210 |
Surgical removal of erupted tooth requiring elevation of mucoperiosteal flap and removal of bone and/or section of tooth |
Yes |
Yes |
|
D7220 |
Removal of impacted tooth - soft tissue |
Yes |
Yes |
|
D7230 |
Removal of impacted tooth - partially bony |
Yes |
Yes |
|
D7240 |
Removal of impacted tooth - completely bony |
Yes |
Yes |
|
D7241 |
Removal of impacted tooth - completely bony, with unusual surgical complications |
Yes |
Yes |
|
D7250 |
Surgical removal of residual tooth roots (cutting procedure) |
Yes |
Yes |
|
Other Surgical Procedures |
|||
|
D7270 |
Tooth reimplantation and/or stabilization of accidentally evulsed or displaced tooth and/or alveolus |
Yes |
Yes |
|
D7280 |
Surgical exposure of impacted or unerupted tooth for orthodontic reasons (including orthodontic attachments) |
Yes |
Yes |
|
D7285 |
Biopsy of oral tissue - hard |
Yes |
Yes |
|
D7286 |
Biopsy of oral tissue - soft |
Yes |
Yes |
|
Osteoplasty for Prognathism, Micrognathism or Apertognathism |
|||
|
D7510 |
Incision and drainage of abscess, intraoral soft tissue |
Yes |
No |
|
Frenulectomy |
|||
|
D7960 |
Frenulectomy (Frenectomy or Frenotomy) Separate procedure |
Yes |
Yes |
|
Orthodontics (See section 226.000) |
|||
|
Minor Treatment of Control Harmful Habits |
|||
|
D8210 |
Removable appliance therapy |
Yes |
Yes |
|
D8220 |
Fixed appliance therapy |
Yes |
Yes |
|
Comprehensive Orthodontic Treatment - Permanent Dentition |
|||
|
D8070 |
Class I Malocclusion |
Yes |
Yes |
|
D8080 |
Class II Malocclusion |
Yes |
Yes |
|
D8090 |
Class III Malocclusion |
Yes |
Yes |
|
Other Orthodontic Devices |
|||
|
D8999 |
Unspecified orthodontic procedure, by report |
Yes |
Yes |
|
Anesthesia |
|||
|
D9220 |
General Anesthesia - first 30 minutes |
Yes |
Yes |
|
D9221 |
General Anesthesia - each 15 minutes |
Yes |
No |
|
D9230 |
Analgesia N20 |
No, but requires report for request for more than 1 unit per day |
No |
|
D9248 |
Non-I.V. Conscious Sedation |
Yes and requires report |
No |
|
Consultations (See section 214.000) |
|||
|
D9310 |
***(Second opinion examination) Consultation, diagnostic service provided by dentist or physician other than practitioner providing treatment |
Yes |
No |
|
Outpatient Hospital Services (See section 228.200) |
|||
|
0361* |
Outpatient hospitalization - for hospital only |
Yes |
No |
|
0360* |
Outpatient hospitalization - for hospital only |
Yes |
No |
|
0369* |
Outpatient hospitalization - for hospital only |
Yes |
No |
|
0509* |
Outpatient hospitalization - for hospital only |
Yes |
No |
|
Smoking Cessation |
|||
|
D1320 |
Tobacco counseling for the control and prevention of oral disease |
No |
No |
|
D9220 |
Behavior management, by report (tobacco counseling) |
No |
No |
|
Unclassified Treatment |
|||
|
D9110 |
Palliative treatment with dental pain |
Yes |
No |
