Arkansas Administrative Code
Agency 016 - DEPARTMENT OF HUMAN SERVICES
Division 06 - Medical Services
Rule 016.06.13-008 - Provider Manual Update Transmittal DENTAL-2-13
Current through Register Vol. 49, No. 9, September, 2024
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 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 twice per SFY. Extension of benefits is available in cases of medical necessity. .View or print form ADA-J400. See Section 262.100 for the interperiodic dental screening examprocedure code.
NOTE: ARKids First-B beneficiaries may also receive an interperiodic dental
screening exam twice per SFY. There is no extension of benefits for ARKids First-B beneficiaries.
Extension of benefits requests, in addition to a narrative and any supporting documentation, should be submitted to the Division of Medical Services Dental Care Unit - ATTN Dental
Extension of Benefits. .View or print the Division of Medical Services Dental Care Unit_______
contact information.
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.
Bitewing radiographs are covered for beneficiaries of all ages. There are different limitations of coverage for beneficiaries under age 21 and for those beneficiaries age 21 and older.
The EPSDT periodic screening exam may include only two bitewings and is allowed every six (6) months plus one (1) day for beneficiaries under age 21. See Section 262.100 for the appropriate procedure code.
Two bitewing films are allowed once per state fiscal year (July 1 through June 30) for beneficiaries age 21 and over. See Section 262.200 for appropriate procedure codes.
Root canal treatment should attempt to achieve the following:
Pulpotomy for deciduous teeth may be performed without prior authorization for beneficiaries under age 21. Pulpotomies are not covered for beneficiaries age 21 and over.
Current indications require carious exposure of the pulp. Payment for pulp caps is included in the fee for restorations and is not payable separately.
Endodontic therapy is not covered for beneficiaries age 21 and over.
The fee for endodontic therapy does not include restoration to close a root canal access, but does include films for measurement control and post-op.
Medicaid does not cover endodontic retreatment, apexification, retrograde fillings or root amputation. See Section 262.100 for applicable procedure codes.
Providers administering general anesthesia services must possess the appropriate permit as required by Arkansas law. Services performed in the dental office must be documented in the patient's record to include specific information on intubation, pharmacologic agents and amounts used, monitoring of vital signs and total anesthesia time. Prior authorization is required for deep sedation and general anesthesia procedures. General anesthesia and intravenous sedation will not be reimbursed for periods of time in excess of two (2) hours. D9220 and D9248 are not allowed on the same day. These codes are subject to post payment review; therefore, providers should be prepared to justify utilization of these procedures and the amount of time patients were kept under deep sedation and general anesthesia.
All inpatient and outpatient hospitalization for dental treatment requires prior authorization. The dental consultant may request a second opinion when reviewing requests for dental prior authorization.
To request prior authorization, the dental treatment plan must be submitted on the ADA claim form with the appropriate X-rays. A copy of the Additional Information form (DMS-32-A) should be attached indicating the reason(s) hospitalization is necessary and the name of the hospital. .View or print form DMS-32-A ._________________________________________________________
In unusual cases, for beneficiaries under age 21, when it is impossible to determine the treatment plan before the patient is anesthetized, indicate the information on the DMS-32-A. Beneficiaries age 21 and over are not covered for general anesthesia, nitrous oxide and non-intravenous conscious sedation.
The provider must complete the first portion of the ADA claim form (the ID of the patient and doctor) and submit both forms together. After the treatment is performed, any procedure(s) requiring prior authorization must be submitted to the dental consultant for authorization.
Hospitalization for dental treatment may be approved when the patient's age, medical or mental problems and/or the extensiveness of treatment necessitates hospitalization. Consideration is given in cases of traumatic accidents and extenuating circumstances.
Because of the cost of a hospital stay, providers are encouraged to use outpatient hospital care whenever feasible. The length of hospitalization should be kept to a minimum.
Request for hospitalization should be made only when other methods such as premedication, delay of treatment, limited in office treatment, sedation, etc., have been evaluated.
When a primary procedure to be performed in outpatient surgery is medical in nature, Arkansas Medicaid will not cover a dental procedure that is incidental to the primary procedure (e.g., the removal of a wisdom tooth when a tonsillectomy is being performed). When the primary procedure is medical, and it is cancelled, the provider may request a prior authorization for the dental procedure to be performed as outpatient surgery.
Information that should be included in the request for prior authorization for outpatient surgery includes the following.
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) |
No, but limited to two (2) per SFY |
No |
|
Radiographs (See Sections 216.000 - 216.300) |
|||
|
D0210 |
Intraoral - complete series (including bitewings) |
No |
No |
|
D0220 |
Intraoral - periapical - first film |
No, but limited to five (5) per SFY |
No |
|
D0230 |
Intraoral - periapical - each additional film |
No, but limited to five (5) per SFY |
No |
|
D0240 |
Intraoral - occlusal film |
No, but limited to five (5) per SFY |
No |
|
D0250 |
Extraoral - first film |
No |
No |
|
D0260 |
Extraoral - each additional film |
No, but limited to five (5) per SFY |
No |
|
D0272 |
Bitewings - two films |
No |
No |
|
D0330 |
Panoramic film |
No** |
No |
|
D0340 |
Cephalometric film |
Yes |
No |
|
Tests and Laboratory |
|||
|
D0350 |
Oral/facial photographic images |
Yes |
No |
|
D0470 |
Diagnostic casts |
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) |
|||
|
D1203 |
Topical application of fluoride (prophylaxis not included) - child ***(ages 0-20) |
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, but no PA required when billed for tooth numbers 3, 14, 19 and 30. |
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 |
|
Endodontic (Root Canal) therapy (including treatment plan, clinical procedures and follow-up care) |
|||
|
D3310 |
Anterior tooth (excluding final restoration) |
No |
No |
|
D3320 |
Bicuspid tooth (excluding final restoration) |
No |
No |
|
D3330 |
Molar (excluding final restoration) |
No |
No |
|
Periapical 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 un-erupted 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 |
|
Smoking Cessation |
|||
|
D1320 |
Tobacco counseling for the control and prevention of oral disease - Counseling and referral by a provider to a tobacco cessation program |
No |
No |
|
D9920 |
Behavior Management by Report - Tobacco counseling received from the provider for the control and prevention of oral disease |
No |
No |
|
Unclassified Treatment |
|||
|
D9110 |
Palliative treatment with dental pain |
Yes |
No |
Age 21 and Older
The following list shows the procedure code, procedure code description, whether or not prior authorization is required, whether an X-ray should be submitted with a treatment plan and if there is a benefit limit on a procedure.
The column titled Benefit Limit indicates the benefit limit, if any, and how the limit is to be applied. When the column indicates "Yes, $500.00", then that item, when used in combination with other items listed, cannot exceed the $500.00 Medicaid maximum allowable reimbursement limit for the state fiscal year (July 1 through June 30). Other limitations are also shown in the column (i.e.: 1 per lifetime). If "No" is shown, the item is not benefit limited.
NOTE: The use of the symbol, #*, along with text in parentheses, indicates the Arkansas Medicaid description of the product.
|
ADA Code |
Description |
PA Yes/No |
Submit X-Ray with Treatment Plan Yes/No |
Benefit Limit Yes/No |
|
Dental Screening (See Section 215.000) |
||||
|
D0120 |
Periodic oral evaluation |
No |
No |
Yes-$500 Yes-1 per year |
|
D0140 |
Limited oral evaluation-problem focused |
No |
No |
Yes-$500 Yes-12 per year |
|
Radiographs (See Sections 216.000 - 216.300) |
||||
|
D0210 |
Intraoral - complete series (including bitewings) |
No |
No |
Yes-$500 Yes-1 per 5 years |
|
D0220 |
Intraoral - periapical - first film |
No |
No |
Yes-$500 Yes-5 per year |
|
D0230 |
Intraoral - periapical - each additional film |
No |
No |
Yes-$500 Yes-5 per year |
|
D0272 |
Bitewings - two films |
No |
No |
Yes-$500 Yes-1 per year |
|
D0330 |
Panoramic film |
No |
No |
Yes-$500 Yes-1 per 5 years |
|
Tests and Laboratory |
||||
|
D0470 |
Diagnostic Casts (full denture) Diagnostic Casts (partial denture) |
No Yes |
No Yes |
Yes-$500 Yes-4 per lifetime |
|
Dental Prophylaxis (See Section 217.100) |
||||
|
D1110 |
Prophylaxis - adult |
No |
No |
Yes-$500 Yes-1 per year |
|
Topical Fluoride Treatment (Office Procedure) (See Section 217.100) |
||||
|
D1204 |
Topical application of fluoride (prophylaxis not included) - adult |
No |
No |
Yes-$500 Yes-1 per year |
|
Restorations (See Sections 219.000 - 219.200) |
||||
|
Amalgam Restorations (including polishing) (See Section 219.100) |
||||
|
D2140 |
Amalgam - one surface, primary or permanent |
No |
No |
Yes-$500 |
|
D2150 |
Amalgam - two surfaces, primary or permanent |
No |
No |
Yes-$500 |
|
D2160 |
Amalgam - three surfaces, primary or permanent |
No |
No |
Yes-$500 |
|
D2161 |
Amalgam - four or more surfaces, primary or permanent |
No |
No |
Yes-$500 |
|
Composite Resin Restorations (See Section 219.200) |
||||
|
D2330 |
Resin - one surface, anterior, permanent |
No |
No |
Yes-$500 |
|
D2331 |
Resin - two surfaces, anterior, permanent |
No |
No |
Yes-$500 |
|
D2332 |
Resin - three surfaces, anterior, permanent |
No |
No |
Yes-$500 |
|
D2335 |
Resin - four or more surfaces or involving incisal angle, permanent |
Yes |
Yes |
Yes-$500 |
|
Crowns - Single Restoration Only (See Section 220.000) |
||||
|
D2920 D2931 |
Re-cement crown Prefabricated stainless steel crown - permanent |
No Yes, but no PA required when billed for tooth numbers 3, 14, 19 and 30. |
Yes Yes |
Yes-$500 Yes-$500 |
|
Surgical Services (including usual postoperative services) |
||||
|
D4341 |
Periodontal scaling and root planing-four or more contiguous |
Yes |
Yes |
Yes-$500 |
|
D4355 |
Full mouth debridement to enable comprehensive evaluation and diagnosis |
Yes |
Yes |
Yes-$500 |
|
D4910 |
Periodontal maintenance procedures (following active therapy) |
Yes |
Yes |
Yes-$500 |
|
Repairs to Complete and Partial Dentures (See Section 223.000) |
||||
|
D5410 |
Adjust complete denture-maxillary |
No |
No |
Yes-$500 Yes-3 per lifetime |
|
D5411 |
Adjust complete denture-mandibular |
No |
No |
Yes-$500 Yes-3 per lifetime |
|
D5610 D5640 D5650 D5730 |
Repair acrylic saddle or base Replace broken teeth - per tooth Add tooth to existing partial denture Reline complete maxillary denture (chairside) |
Yes Yes Yes No |
No No No No |
Yes-$500 Yes-$500 Yes-$500 Yes-$500 Yes-1 every 3 years |
|
D5731 |
Reline lower complete mandibular denture (chairside) |
No |
No |
Yes-$500 Yes-1 every 3 years |
|
Fixed Prosthodontic Services (See Section 224.000) |
||||
|
D6930 |
Re-cement bridge |
Yes |
No |
Yes-$500 |
|
Oral Surgery (See Section 225.000) |
||||
|
Simple Extractions (includes local anesthesia and routine postoperative care) (See Section 225.100) |
||||
|
D7140 |
Single tooth |
No |
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 |
No |
|
D7220 |
Removal of impacted tooth - soft tissue |
Yes |
Yes |
No |
|
D7230 |
Removal of impacted tooth - partially bony |
Yes |
Yes |
No |
|
D7240 |
Removal of impacted tooth - completely bony |
Yes |
Yes |
No |
|
D7241 |
Removal of impacted tooth - completely bony, with unusual surgical complications |
Yes |
Yes |
No |
|
D7250 |
Surgical removal of residual tooth roots (cutting procedure) |
Yes |
Yes |
Yes-$500 |
|
Other Surgical Procedures |
||||
|
D7285 |
Biopsy of oral tissue - hard |
Yes |
Yes |
Yes-$500 |
|
D7286 |
Biopsy of oral tissue - soft |
Yes |
Yes |
Yes-$500 |
|
D7310 |
Alveoplasty in conjunction with extractions-four or more teeth |
Yes |
No |
Yes-$500 |
|
D7472 |
Removal of torus palatinus |
Yes |
No |
Yes-$500 1 per lifetime |
|
D7473 |
Removal of torus mandibularis |
Yes |
No |
Yes-$500 1 per lifetime |
|
Osteoplasty for Prognathism, Micrognathism or Apertognathism |
||||
|
D7510 |
Incision and drainage of abscess, intraoral soft tissue |
Yes |
No |
Yes-$500 |
|
Unclassified Treatment |
||||
|
D9110 |
Palliative treatment with dental pain |
Yes |
No |
Yes-$500 |
|
Smoking Cessation |
||||
|
D1320 |
Tobacco counseling for the control and prevention of oral disease - Counseling and referral by a provider to a tobacco cessation program |
No |
No |
Yes-$500 2 counseling sessions per SFY |
|
D9920 |
Behavior Management by Report - Tobacco counseling received from the provider for the control and prevention of oral disease |
No |
No |
Yes-$500 2 counseling sessions per SFY |
