Arkansas Administrative Code
Agency 016 - DEPARTMENT OF HUMAN SERVICES
Division 06 - Medical Services
Rule 016.06.14-014 - Revision to Dental 5-13; Nurse Practitioner 4-13; Physician 7-13 and SPA #2014-004

Arkansas Medicaid covers fluoride varnish application, ADA code D1206, performed by physicians who have completed the online training program approved by the Arkansas Department of Health, Office of Oral Health. Eligible physicians may delegate the application to a nurse or other licensed health care professional under his or her supervision that has also completed the online training. The online training course can be accessed at http://ar.train.org. Each provider must maintain documentation to establish his or her successful completion of the training and submit a copy of the certificate of completion to HP Provider Enrollment.

The American Dental Association (ADA) procedure code D1206 is covered by the Arkansas Medicaid Program. This code is payable for beneficiaries under the age of 21. Topical fluoride varnish application benefit is two (2) per SFY for beneficiaries under age 21.

A new specialty code, FC-Fluoride Certification will be tied to provider types 01, 03, 58 and 69. These providers must send proof of their fluoride varnish certification to HP Provider Enrollment before the specialty code will be added to their file in the MMIS. After the specialty code, FC-Fluoride Certification, is added to the provider's file, the provider will be able to bill for procedure code D1206, Topical Application of Fluoride Varnish.

Providers must check the Supplemental Eligibility Screen to verify that topical fluoride varnish benefit of two (2) per State Fiscal Year (SFY) has not been exhausted. If further treatment is needed due to severe periodontal disease, then the beneficiary must be referred to a Medicaid dental provider.

NOTE: This service is billed on form CMS-1500 with ADA procedure code D1206 (Topical application of fluoride varnish (prophylaxis not included) - child (ages 0-20). View a form CMS-1500 sample form.

Dental prophylaxis and a fluoride treatment are preventive treatments covered by Medicaid. Prophylaxis, in addition to application of topical fluoride and/or fluoride varnish, is covered every six (6) months plus one (1) day for beneficiaries under age 21. Arkansas Medicaid covers fluoride varnish application, ADA code D1206, performed by physicians who have completed the online training program approved by the Arkansas Department of Health, Office of Oral Health. Eligible physicians may delegate the application to a nurse or other licensed health care professional under his or her supervision that has also completed the online training. Physicians and nurse practitioners must complete training on dental caries risk and have an approved fluoride varnish certification from the Arkansas Department of Health, Office of Oral Health. Each provider must maintain documentation to establish his or her successful completion of the training and submit a copy of the certificate to HP Provider Enrollment. The course that meets the requirements outlined by the ACT can be accessed at http://ar.train.org. If further treatment is needed due to severe periodontal problems, the provider must request prior authorization with a brief narrative.

Prophylaxis and fluoride treatments are each covered once per state fiscal year (July 1 through June 30) for beneficiaries age 21 and over. Topical fluoride treatment or fluoride varnish is covered every six (6) months plus one (1) day for beneficiaries under age 21.

A new specialty code, FC-Fluoride Certification will be tied to provider types 01, 03, 58 and 69. These providers must send proof of their fluoride varnish certification to HP Provider Enrollment before the specialty code will be added to their file in the MMIS. After the specialty code, FC-Fluoride Certification, is added to the provider's file, the provider will be able to bill for procedure code D1206, Topical Application of Fluoride Varnish.

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:

The following ADA procedure codes are covered by the Arkansas Medicaid Program. These codes are payable for beneficiaries under the age of 21.

NOTE: Only physicians who have completed the training on dental caries and have an approved fluoride varnish certification on file with HP provider enrollment can bill for the fluoride varnish treatment. Eligible physicians may delegate the application to a nurse or other licensed health care professional under his or her supervision that has also completed the online training. Providers must check the Supplemental Eligibility Screen to verify that topical fluoride treatment or fluoride varnish was not applied by another Medicaid dental provider.

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

A(...) 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).

Arkansas Medicaid will expand coverage for fluoride varnish application, ADA code D1206, to physicians and nurse practitioners who have completed the online training program approved by the Arkansas Department of Health, Office of Oral Health. The online training course can be accessed at http://ar.train.org. The provider will need to maintain a copy of the certificate of completion in their files and submit a copy to the Arkansas Medicaid provider enrollment unit.

The American Dental Association (ADA) procedure code D1206 is covered by the Arkansas Medicaid Program. This code is payable for beneficiaries under the age of 21. Topical fluoride varnish is covered every six (6) months for beneficiaries under age 21.

A new specialty code, FC-Fluoride Certification will be tied to provider types 01, 03, 58 and 69. These providers must send proof of their fluoride varnish certification to Provider Enrollment before the specialty code will be added to their file in the MMIS. After the specialty code, FC-Fluoride Certification, is added to the provider's file, the provider will be able to bill for procedure code D1206, Topical Application of Fluoride Varnish.

Providers must check the Supplemental Eligibility Screen to verify that topical fluoride varnish benefit of two (2) per State Fiscal Year (SFY) has not been exhausted. If further treatment is needed due to severe periodontal disease, then the beneficiary must be referred to a Medicaid dental provider.

NOTE: This service is billed on form CMS-1500 with ADA procedure code D1206 (Topical application of fluoride varnish (prophylaxis not included) - child (ages 0-20). View a form CMS-150 sample form.