Current through Register Vol. 50, No. 9, March 1, 2024
RELATES TO:
KRS
205.520,
205.622,
205.8451,
313.010,
313.040,
369.102(8),
369.101 to
369.120,
415.152,
42 C.F.R.
400.203,
415.170,
415.172,
415.174,
438.2,
45 C.F.R. Parts 160 and 164,
42 U.S.C.
1320d,
1396a -d
NECESSITY, FUNCTION, AND CONFORMITY: The Cabinet for Health
and Family Services, Department for Medicaid Services, has the responsibility
to administer the Medicaid program.
KRS
205.520(3) authorizes the
cabinet, by administrative regulation, to comply with any requirement that may
be imposed or opportunity presented by federal law to qualify for federal
Medicaid funds. This administrative regulation establishes the Kentucky
Medicaid program provisions and requirements regarding the coverage of dental
services.
Section 1. Definitions.
(1) "Comprehensive orthodontic" means a
medically necessary dental service for treatment of a dentofacial malocclusion
which requires the application of braces for correction.
(2) "Current Dental Terminology" or "CDT"
means a publication by the American Dental Association of codes used to report
dental procedures or services.
(3)
"Debridement" means a preliminary procedure that:
(a) Entails the gross removal of plaque and
calculus that interfere with the ability of a dentist to perform a
comprehensive oral evaluation;
(b)
Does not preclude the need for further procedures; and
(c) Is separate from a regular cleaning and
is usually a preliminary or first treatment when an individual has developed
very heavy plaque or calculus.
(4) "Department" means the Department for
Medicaid Services or its designee.
(5) "Direct practitioner interaction" means
the billing dentist or oral surgeon is physically present with and evaluates,
examines, treats, or diagnoses the recipient, unless the service can be
appropriately performed via telehealth pursuant to
907 KAR 3:170.
(6) "Disabling malocclusion" means a
condition that meets the criteria established in Section 13(7) of this
administrative regulation.
(7)
"Electronic signature" is defined by
KRS
369.102(8).
(8) "Federal financial participation" is
defined by 42 C.F.R.
400.203.
(9) "Implant" means a medical device that is
surgically implanted into the jaw to restore a person's ability to chew or
appearance. An implant provides support for artificial teeth including a crown,
a bridge, or dentures.
(10)
"Incidental" means that a medical procedure:
(a) Is performed at the same time as a
primary procedure; and
(b)
1. Requires little additional practitioner
resources; or
2. Is clinically
integral to the performance of the primary procedure.
(11) "Integral" means that a
medical procedure represents a component of a more complex procedure performed
at the same time.
(12) "Locum
tenens dentist" means a substitute dentist:
(a) Who temporarily assumes responsibility
for the professional practice of a dentist participating in the Kentucky
Medicaid Program; and
(b) Whose
services are paid under the participating dentist's provider number.
(13) "Managed care organization"
means an entity for which the Department for Medicaid Services has contracted
to serve as a managed care organization as defined by
42 C.F.R.
438.2.
(14) "Medically necessary" or "medical
necessity" means that a covered benefit is determined to be needed in
accordance with
907 KAR 3:130.
(15) "Mutually exclusive" means that two (2)
procedures:
(a) Are not reasonably performed
in conjunction with one (1) another during the same patient encounter on the
same date of service;
(b) Represent
two (2) methods of performing the same procedure;
(c) Represent medically impossible or
improbable use of CDT codes; or
(d)
Are described in CDT as inappropriate coding of procedure
combinations.
(16)
"Other licensed medical professional" or "OLMP" means a health care provider
other than a dentist who has been approved to practice a medical specialty by
the appropriate licensure board.
(17) "Prepayment review" or "PPR" means a
departmental review of a claim regarding a recipient who is not enrolled with a
managed care organization to determine if the requirements of this
administrative regulation have been met prior to authorizing payment.
(18) "Prior authorization" or "PA" means
approval that a provider shall obtain from the department before being
reimbursed for a covered service.
(19) "Provider" is defined by
KRS
205.8451(7).
(20) "Public health hygienist" means an
individual who:
(a) Is a dental hygienist as
defined by KRS
313.010(6);
(b) Meets the public health hygienist
requirements established in
KRS
313.040(8);
(c) Meets the requirements for a public
health registered dental hygienist established in
201 KAR 8:562; and
(d) Is employed by or through:
1. The Department for Public Health;
or
2. A governing board of
health.
(21)
"Recipient" is defined by
KRS
205.8451(9).
(22) "Resident" is defined by
42 C.F.R.
415.152.
(23) "Timely filing" means receipt of a claim
by Medicaid:
(a) Within twelve (12) months of
the date the service was provided;
(b) Within twelve (12) months of the date
retroactive eligibility was established; or
(c) Within six (6) months of the Medicare
adjudication date if the service was billed to Medicare.
Section 2. Conditions of
Participation.
(1) A participating provider
shall:
(a) Be licensed as a provider in the
state in which the practice is located;
(b) Comply with the terms and conditions
established in the following administrative regulations:
1.
907 KAR 1:005;
2.
907 KAR 1:671; and
3.
907 KAR 1:672;
(c) Comply with the requirements
to maintain the confidentiality of personal medical records pursuant to
42 U.S.C.
1320d and
45 C.F.R. Parts 160 and
164;
(d) Comply with all applicable
state and federal laws; and
(e)
Meet all applicable medical and dental standards of
practice.
(2)
(a) A participating provider shall:
1. Have the freedom to choose whether to
accept an eligible Medicaid recipient; and
2. Notify the recipient of the decision prior
to the delivery of service.
(b) If the provider accepts the recipient, the provider:
1. Shall bill Medicaid rather than the
recipient for a covered service;
2.
May bill the recipient for a service not covered by Kentucky Medicaid, if the
provider informed the recipient of noncoverage prior to providing the service;
and
3. Shall not bill the recipient
for a service that is denied by the department for:
a. Being:
(i) Incidental;
(ii) Integral; or
(iii) Mutually exclusive;
b. Incorrect billing procedures,
including incorrect bundling of procedures;
c. Failure to obtain prior authorization for
the service; or
d. Failure to meet
timely filing requirements.
(3)
(a) In
accordance with
907 KAR 17:015, Section 3(3), a
provider of a service to an enrollee shall not be required to be currently
participating in the fee-for-service Medicaid program.
(b) A provider of a service to an enrollee
shall be enrolled in the Medicaid program.
(4)
(a) If
a provider receives any duplicate or overpayment from the department or managed
care organization, regardless of reason, the provider shall return the payment
to the department or managed care organization.
(b) Failure to return a payment to the
department or managed care organization in accordance with paragraph (a) of
this subsection may be:
1. Interpreted to be
fraud or abuse; and
2. Prosecuted
in accordance with applicable federal or state law.
(c) Nonduplication of payments and
third-party liability shall be in accordance with
907 KAR 1:005.
(d) A provider shall comply with
KRS
205.622.
Section 3. DMS Activities in Response to
Federal Approval.
(1) The department shall
negotiate the dental program with the federal government consistent with
42 U.S.C.
1396a.
(2) The department shall seek official
federal approval when implementing new covered services. New covered services
may be received via approved state plan amendments with the federal government
or via other reliable methods of receiving federal approval.
Section 4. Record Maintenance.
(1)
(a) A
provider shall maintain comprehensive legible medical records that substantiate
the services billed.
(b) A dental
record shall be considered a medical record.
(2) A medical record shall be signed on the
date of service by the:
(a) Provider;
or
(b) Other practitioner
authorized to provide the service in accordance with:
1.
KRS
313.040; and
2.
201 KAR 8:562.
(3) An X-ray shall be:
(a) Of diagnostic quality; and
(b) Maintained in a manner that identifies
the:
1. Recipient's name;
2. Service date; and
3. Provider's name.
(4) A treatment regimen shall be
documented to include:
(a)
Diagnosis;
(b) Treatment
plan;
(c) Treatment and follow-up;
and
(d) Medical
necessity.
(5) Medical
records, including X-rays, shall be maintained in accordance with
907 KAR 1:672.
Section 5. General and Certain
Service Coverage Requirements.
(1) A covered
service shall be:
(a) Medically necessary;
and
(b) Except as provided in
subsection (2) of this section, furnished to a recipient through direct
practitioner interaction.
(2) A covered service provided by another
licensed medical professional (OLMP) shall be covered if the:
(a) OLMP is employed by the supervising oral
surgeon, dentist, or dental group;
(b) OLMP is licensed in the state of
practice; and
(c) Supervising
provider has direct practitioner interaction with the recipient, except for a
service provided by a dental hygienist if the dental hygienist provides the
service under general supervision of a practitioner in accordance with
KRS
313.040.
(3)
(a) A
medical resident may provide and the department shall cover services if
provided under the direction of a program participating teaching physician in
accordance with 42 C.F.R.
415.170,
415.172, and
415.174.
(b) A dental resident, student, or dental
hygiene student may provide and the department shall cover services under the
direction or supervision of a program participating provider in or affiliated
with an American Dental Association accredited institution.
(4) Services provided by a locum
tenens dentist shall be covered:
(a) If the
locum tenens dentist:
1. Has a national
provider identifier (NPI) and provides the NPI to the department;
2. Does not have a pending criminal or civil
investigation regarding the provision of services;
3. Is not subject to a formal disciplinary
sanction from the Kentucky Board of Dentistry; and
4. Is not subject to any federal or state
sanction or penalty that would bar the dentist from Medicare or Medicaid
participation; and
(b)
For no more than sixty (60) continuous days.
(5) Preventative services provided by a
public health hygienist shall be covered.
(6) The department shall cover the oral
pathology procedures listed on the Kentucky Medicaid Dental Fee Schedule if
provided by an oral pathologist who meets the condition of participation
requirements established in Section 2 of this administrative
regulation.
(7) Coverage shall be
limited to the procedures or services:
(a)
Identified and established on the Kentucky Medicaid Dental Fee Schedule as
available at:
https://www.chfs.ky.gov/agencies/dms/Pages/feesrates.aspx;
or
(b) Established in this
administrative regulation.
(8) The department shall not cover a service
provided by a provider or practitioner that exceeds the scope of services
established for the provider or practitioner in:
(a) Kentucky Revised Statutes;
(b) Kentucky administrative regulations;
or
(c) As established on the
Kentucky Medicaid Dental Fee Schedule as available at:
https://www.chfs.ky.gov/agencies/dms/Pages/feesrates.aspx.
(9) The department
shall not reimburse for services under this administrative regulation that are
only cosmetic in nature.
Section
6. Diagnostic Service Coverage Limitations.
(1)
(a)
Except as provided in paragraph (b) of this subsection, coverage for a
comprehensive oral evaluation shall be limited to one (1) per twelve (12) month
period, per recipient, per provider.
(b) The department shall cover a second
comprehensive oral evaluation if the evaluation is provided in conjunction with
a prophylaxis.
(c) A comprehensive
oral evaluation shall not be covered in conjunction with the following:
1. A limited oral evaluation for trauma
related injuries;
2. A space
maintainer;
3. Denture
relining;
4. A transitional
appliance;
5. A prosthodontic
service;
6. Temporomandibular joint
therapy;
7. An orthodontic
service;
8. Palliative
treatment;
9. An extended care
facility call;
10. A house call;
or
11. A hospital call.
(2)
(a) Coverage for a limited oral evaluation
shall:
1. Be limited to a trauma related
injury or acute infection; and
2.
Be limited to one (1) per date of service, per recipient, per
provider.
(b) A limited
oral evaluation shall not be covered in conjunction with another service except
for:
1. A periapical X-ray;
2. A bitewing X-ray;
3. A panoramic X-ray;
4. Resin, anterior;
5. A simple or surgical extraction;
6. Surgical removal of a residual tooth
root;
7. Removal of a foreign
body;
8. Suture of a recent small
wound;
9. Intravenous sedation;
or
10. Incision and drainage of
infection.
(3)
(a) Except as provided in paragraph (b) of
this subsection, the following limitations shall apply to coverage of a
radiograph service:
1. Bitewing X-rays shall
be limited to four (4) per twelve (12) month period, per recipient, per
provider;
2. Periapical X-rays
shall be limited to fourteen (14) per twelve (12) month period, per recipient,
per provider;
3. An intraoral
complete X-ray series shall be limited to one (1) per twenty-four (24) month
period, per recipient, per provider;
4. Periapical and bitewing X-rays shall not
be covered in the same twelve (12) month period as an intraoral complete X-ray
series per recipient, per provider;
5. A panoramic film shall:
a. Be limited to one (1) per twenty-four (24)
month period, per recipient, per provider; and
b. Require prior authorization in accordance
with Section 15(1), (2), and (3) of this administrative regulation for a
recipient under the age of six (6) years;
6. A cephalometric film shall be limited to
one (1) per twenty-four (24) month period, per recipient, per provider;
or
7. A cephalometric and panoramic
X-ray shall not be covered separately in conjunction with a comprehensive
orthodontic consultation.
(b) The limits established in paragraph (a)
of this subsection shall not apply to:
1. An
X-ray necessary for a root canal or oral surgical procedure; or
2. An X-ray that:
a. Exceeds the established service
limitations; and
b. Is determined by
the department to be medically necessary.
Section 7.
Preventive Service Coverage Limitations.
(1)
(a) Coverage of a prophylaxis shall be
limited to one (1) per six (6) month period, per recipient.
(b) A prophylaxis shall not be covered in
conjunction with periodontal scaling or root planing.
(2)
(a)
Coverage of a sealant shall be limited to:
1.
Each six (6) and twelve (12) year molar once every four (4) years with a
lifetime limit of three (3) sealants per tooth, per recipient; and
2. An occlusal surface that is
noncavitated.
(b) A
sealant shall not be covered in conjunction with a restorative procedure for
the same tooth on the same surface on the same date of service.
(3)
(a) Coverage of a space maintainer shall
require the following:
1.
Fabrication;
2.
Insertion;
3. Follow-up
visits;
4. Adjustments;
and
5. Documentation in the
recipient's medical record to:
a. Substantiate
the use for maintenance of existing interdental space; and
b. Support the diagnosis and a plan of
treatment that includes follow-up visits.
(b) The date of service for a space
maintainer shall be considered to be the date the appliance is placed on the
recipient.
(c) Coverage of a space
maintainer, an appliance therapy specified in the CDT orthodontic category, or
a combination of the two (2) shall not exceed two (2) per twelve (12) month
period, per recipient.
Section 8. Restorative Service Coverage
Limitations.
(1) A four (4) or more surface
resin-based anterior composite procedure shall not be covered if performed for
the purpose of cosmetic bonding or veneering.
(2) Coverage of a prefabricated crown shall
include any procedure performed for restoration of the same tooth.
(3) Coverage of a pin retention procedure
shall be limited to:
(a) A permanent
molar;
(b) One (1) per tooth, per
date of service, per recipient; and
(c) Two (2) per permanent molar, per
recipient.
(4) Coverage
of a restorative procedure performed in conjunction with a pin retention
procedure shall be limited to one (1) of the following:
(a) An appropriate medically necessary
restorative material encompassing three (3) or more surfaces;
(b) A permanent prefabricated resin crown;
or
(c) A prefabricated
stainless-steel crown.
Section 9. Endodontic Service Coverage
Limitations.
(1) A therapeutic pulpotomy
shall not be covered if performed in conjunction with root canal therapy.
(2)
(a) Coverage of root canal therapy shall
require:
1. Treatment of the entire
tooth;
2. Completion of the
therapy; and
3. An X-ray taken
before and after completion of the therapy.
(b) The following root canal therapy shall
not be covered:
1. The Sargenti method of root
canal treatment; or
2. A root canal
that does not treat all root canals on a multi-rooted tooth.
Section 10.
Periodontic Service Coverage Limitations.
(1)
Coverage of a gingivectomy or gingivoplasty procedure shall require prepayment
review and shall be limited to:
(a) A
recipient with gingival overgrowth due to a:
1. Congenital condition;
2. Hereditary condition; or
3. Drug-induced condition; and
(b) One (1) per tooth or per
quadrant, per provider, per recipient per twelve (12) month period.
(2) Coverage of a gingivectomy or
gingivoplasty procedure shall require documentation in the recipient's medical
record that includes:
(a) Pocket-depth
measurements;
(b) A history of
nonsurgical services; and
(c) A
prognosis.
(3) Coverage
for a periodontal scaling and root planing procedure shall:
(a) Not exceed one (1) per quadrant, per
twelve (12) months, per recipient, per provider;
(b) Require prior authorization in accordance
with Section 15(1), (2), and (4) of this administrative regulation;
and
(c) Require documentation to
include:
1. A periapical film or bitewing
X-ray;
2. Periodontal charting of
preoperative pocket depths; and
3.
A photograph, if applicable.
(4) Periodontal scaling and root planing
shall not be covered if performed in conjunction with dental
prophylaxis.
Section 11.
Prosthodontic Service Coverage Limitations.
(1) A denture repair in the following
categories shall not exceed three (3) repairs per twelve (12) month period, per
recipient:
(a) Repair resin denture base;
or
(b) Repair cast
framework.
(2) Coverage
for the following services shall not exceed one (1) per twelve (12) month
period, per recipient:
(a) Replacement of a
broken tooth on a denture;
(b)
Laboratory relining of:
1. Maxillary dentures;
or
2. Mandibular
dentures;
(c) An interim
maxillary partial denture; or
(d)
An interim mandibular partial denture.
(3) An interim maxillary or mandibular
partial denture shall be limited to use:
(a)
During a transition period from a primary dentition to a permanent
dentition;
(b) For space
maintenance or space management; or
(c) As interceptive or preventive
orthodontics.
Section
12. Maxillofacial Prosthetic Service Coverage Limitations. The
following services shall be covered if provided by a board-eligible or
board-certified prosthodontist:
(1) A nasal
prosthesis;
(2) An auricular
prosthesis;
(3) A facial
prosthesis;
(4) A mandibular
resection prosthesis;
(5) A
pediatric speech aid;
(6) An adult
speech aid;
(7) A palatal
augmentation prosthesis;
(8) A
palatal lift prosthesis;
(9) An
oral surgical splint; or
(10) An
unspecified maxillofacial prosthetic.
Section 13. Oral and Maxillofacial Service
Coverage Limitations.
(1) The simple use of a
dental elevator shall not constitute a surgical extraction.
(2) Root removal shall not be covered on the
same date of service as the extraction of the same tooth.
(3) Coverage of surgical access of an
unerupted tooth shall:
(a) Be limited to
exposure of the tooth for orthodontic treatment; and
(b) Require prepayment review.
(4) Coverage of alveoplasty shall:
(a) Be limited to one (1) per quadrant, per
lifetime, per recipient; and
(b)
Require a minimum of a four (4) tooth area within the same quadrant.
(5) An occlusal orthotic device
shall:
(a) Be covered for temporomandibular
joint therapy;
(b) Require prior
authorization in accordance with Section 15(1), (2), and (5) of this
administrative regulation; and
(c)
Be limited to one (1) per lifetime, per recipient.
(6) Frenulectomy shall be limited to two (2)
per date of service.
(7) Coverage
shall be limited to one (1) per lifetime, per recipient, for removal of the
following:
(a) Torus palatinus (maxillary
arch);
(b) Torus mandibularis
(lower left quadrant); or
(c) Torus
mandibularis (lower right quadrant).
Section 14. Orthodontic Service Coverage
Limitations.
(1) Coverage of an orthodontic
service shall require prior authorization except as established in Section
15(1)(b) of this administrative regulation.
(2) The combination of space maintainers and
appliance therapy shall be limited to two (2) per twelve (12) month period, per
recipient.
(3) Space maintainers
and appliance therapy shall not be covered in conjunction with comprehensive
orthodontics.
(4) Orthodontic
braces shall be limited to recipients under the age of twenty-one (21)
years.
(5) Space maintainers shall
be allowed for adults when:
(a) There has been
an extraction or lost tooth;
(b) A
permanent tooth is waiting for a partial;
(c) In preparation for an implant, if an
implant is medically necessary and approved;
(d) A third molar is partially erupted;
or
(e) There is a congenitally
missing tooth.
(6) The
department shall only cover new orthodontic brackets or appliances.
(7) An appliance for minor tooth guidance
shall not be covered for the control of harmful habits.
(8) In addition to the limitations specified
in subsection (1) of this section, a comprehensive orthodontic service shall:
(a) Require a referral by a dentist;
and
(b) Be limited to the
correction of a disabling malocclusion for transitional, full permanent
dentition, or treatment of a cleft palate or severe facial anomaly.
(9) A disabling malocclusion
shall:
(a) Exist if a patient:
1. Exhibits a severe overbite encompassing
one (1) or more teeth in palatal impingement diagnosed by a lingual view of
orthodontic models (stone or digital) showing palatal soft tissue
contact;
2. Exhibits a true
anterior open bite:
a. Either skeletal or
habitual in nature that if left untreated will result in:
(i) The open bite persisting; or
(ii) A medically documented speech
impediment; and
b. That
does not include:
(i) One (1) or two (2) teeth
slightly out of occlusion; or
(ii)
Where the incisors have not fully erupted;
3. Demonstrates a significant
antero-posterior discrepancy (Class II or III malocclusion that is comparable
to at least one (1) full tooth Class II or III):
a. Dental or skeletal; and
b. If skeletal, requires a traced
cephalometric radiograph supporting significant skeletal
malocclusion;
4. Has an
anterior crossbite that involves:
a. More than
two (2) teeth within the same arch; or
b. A single tooth crossbite if there is
evident detrimental changes in supporting tissues including:
(i) Obvious gingival stripping; or
(ii) A functional shift of the mandible or
severe dental attrition for an individual under the age of twelve (12) years;
or
c. An edge-to-edge
crossbite if there is severe dental attrition due to a traumatic
occlusion;
5.
Demonstrates a handicapping posterior transverse discrepancy that:
a. May include several teeth, one (1) of
which shall be a molar; and
b. Is
handicapping in a function fashion as follows:
(i) Functional shift;
(ii) Facial asymmetry; or
(iii) A complete buccal or lingual
crossbite;
6.
Demonstrates a medically documented speech pathology resulting from the
malocclusion;
7. Demonstrates a
significant posterior open bite that does not involve:
a. Partially erupted teeth; or
b. One (1) or two (2) teeth slightly out of
occlusion;
8. Except for
third molars, demonstrates an impacted tooth that:
a. Will not erupt into the arch without
orthodontic or surgical intervention; and
b.
(i) Shows
a documented pathology; or
(ii)
Poses a significant threat to the integrity of the remaining dentition or to
the health of the patient;
9. Has an extreme overjet in excess of eight
(8) millimeters and one (1) of the skeletal conditions specified in
subparagraphs 1 through 8 of this paragraph;
10. Has trauma or injury resulting in severe
misalignment of the teeth or alveolar structures and does not include simple
loss of teeth with no other affects;
11. Has a congenital or developmental
disorder giving rise to a handicapping malocclusion;
12. Has a significant facial discrepancy
requiring a combined orthodontic and orthognathic surgery treatment approach;
or
13. Has developmental anodontia
in which several congenitally missing teeth result in a handicapping
malocclusion or arch deformation; and
(b) Not include:
1. One (1) or two (2) teeth being slightly
out of occlusion;
2. Incisors not
having fully erupted; or
3. A
bimaxillary protrusion.
(10) Coverage of comprehensive orthodontic
treatment shall not include orthognathic surgery.
(11) If comprehensive orthodontic treatment
is discontinued prior to completion, the provider shall submit to the
department:
(a) Documentation of the referral
referenced in subsection (8) of this section; and
(b) A letter detailing:
1. Treatment provided, including dates of
service;
2. Current treatment
status of the patient; and
3.
Charges for the treatment provided.
(12) Remaining portions of comprehensive
orthodontic treatment may be authorized for prorated coverage upon compliance
with the prior authorization requirements specified in Section 15(1), (2), and
(7) of this administrative regulation if treatment:
(a) Is transferred to another provider;
or
(b) Began prior to Medicaid
eligibility.
Section
15. Adjunctive General Service Coverage Limitations.
(1)
(a)
Coverage of palliative treatment for dental pain shall be limited to one (1)
per date of service, per recipient, per provider.
(b) Palliative treatment for dental pain
shall not be covered in conjunction with another service except for a
radiograph.
(2)
(a) Coverage of a hospital or ambulatory
surgical center call or extended care facility call shall be limited to one (1)
per date of service, per recipient, per provider.
(b) A hospital call, ambulatory surgical
center call, or extended care facility call shall not be covered in conjunction
with:
1. Limited oral evaluation; or
2. Comprehensive oral evaluation.
(3) Intravenous
sedation shall not be covered for local anesthesia or nitrous oxide.
Section 16. Implant Policy.
(1) Implants shall meet the medical necessity
criteria and be used to stabilize a retaining prosthetic device.
(2) Implants shall be limited to no more
than:
(a) For an individual who has lost all
of their natural teeth, a total of ten (10) but with a limit of five (5) for
each arch; and
(b) For an
individual who retains some natural teeth, a limit of eight (8) for replacement
of individual teeth of for a larger restorative purpose such as a bridge that
spans three (3) or more teeth.
Section 17. Prior Authorization.
(1)
(a) The
prior authorization requirements established in this administrative regulation
shall apply to services for a recipient who is not enrolled with a managed care
organization.
(b) A managed care
organization shall not be required to apply the prior authorization
requirements established in this administrative regulation for a recipient who
is enrolled with the managed care organization.
(c) Prior authorization shall be required for
the following:
1. A panoramic film for a
recipient under the age of six (6) years;
2. Periodontal scaling and root
planing;
3. An occlusal orthotic
device;
4. A preorthodontic
treatment visit;
5. Removable
appliance therapy;
6. Fixed
appliance therapy;
7. A
comprehensive orthodontic service; or
8. An implant.
(2) Limits may also be exceeded by
prior authorization for children under the age of twenty-one (21) if medically
necessary.
(3) A provider shall
request prior authorization by submitting the following information to the
department:
(a) A MAP 9, Prior Authorization
for Health Services;
(b) Additional
forms or information as specified in subsections (3) through (8) of this
section; and
(c) Additional
information required to establish medical necessity if requested by the
department.
(4) A
request for prior authorization of a panoramic film shall include a letter of
medical necessity.
(5) A request
for prior authorization of periodontal scaling and root planing shall include
periodontal charting of preoperative pocket depths.
(6) A request for prior authorization of an
occlusal orthotic device shall include a MAP 306, Temporomandibular Joint (TMJ)
Assessment Form.
(7) A request for
prior authorization of removable and fixed appliance therapy shall include:
(a) A MAP 396, Kentucky Medicaid Program
Orthodontic Evaluation Form;
(b)
Panoramic film or intraoral complete series; and
(c) Dental models or the digital equivalent
of dental models.
(8) A
request for prior authorization for comprehensive orthodontic services shall
include:
(a) A MAP 396, Kentucky Medicaid
Program Orthodontic Evaluation Form;
(b) A MAP 9A, Kentucky Medicaid Program
Orthodontic Services Agreement;
(c)
A cephalometric X-ray with tracing;
(d) A panoramic X-ray;
(e) Intraoral and extraoral facial frontal
and profile pictures;
(f) An
occluded and trimmed dental model or the digital equivalent of a model;
and
(g) An oral surgeon's
pretreatment work up notes if orthognathic surgery is required.
(9) If prior authorization for
comprehensive orthodontic services is given following a request submitted
pursuant to subsection (8) of this section, additional information shall be
submitted as required in this subsection.
(a)
After six (6) monthly visits are completed, but not later than twelve (12)
months after the banding date of service, the provider shall submit:
1. A MAP 559, Six (6) Month Orthodontic
Progress Report; and
2. An
additional MAP 9, Prior Authorization for Health Services.
(b) Within three (3) months following
completion of the comprehensive orthodontic treatment, the provider shall
submit:
1. Beginning and final records;
and
2. A MAP 700, Kentucky Medicaid
Program Orthodontic Final Case Submission.
(10) Upon receipt and review of the materials
required in subsection (7)(a) through (g) of this section, the department may
request a second opinion from another provider regarding the proposed
comprehensive orthodontic treatment.
(11) If a service that requires prior
authorization is provided before the prior authorization is received, the
provider shall assume the financial risk that the prior authorization may not
be subsequently approved.
(12)
(a) Prior authorization shall not be a
guarantee of recipient eligibility.
(b) Eligibility verification shall be the
responsibility of the provider.
(13) Upon review and determination by the
department that removing a prior authorization requirement shall be in the best
interest of a Medicaid recipient, the prior authorization requirement for a
specific covered benefit shall be discontinued, at which time the covered
benefit shall be available to all recipients without prior authorization, as
necessary, an age limit related prior authorization may continue to be
enforced.
Section 18.
Use of Electronic Signatures.
(1) The
creation, transmission, storage, and other use of electronic signatures and
documents shall comply with the requirements established in
KRS
369.101 to
369.120.
(2) A dental service provider that chooses to
use electronic signatures shall:
(a) Develop
and implement a written security policy that shall:
1. Be adhered to by each of the provider's
employees, officers, agents, or contractors;
2. Identify each electronic signature for
which an individual has access; and
3. Ensure that each electronic signature is
created, transmitted, and stored in a secure fashion;
(b) Develop a consent form that shall:
1. Be completed and executed by each
individual using an electronic signature;
2. Attest to the signature's authenticity;
and
3. Include a statement
indicating that the individual has been notified of his or her responsibility
in allowing the use of the electronic signature; and
(c) Provide the department, immediately upon
request, with:
1. A copy of the provider's
electronic signature policy;
2. The
signed consent form; and
3. The
original filed signature.
Section 19. Auditing Authority.
(1) The department or the managed care
organization in which an enrollee is enrolled shall have the authority to audit
any:
(a) Claim;
(b) Medical record; or
(c) Documentation associated with any claim
or medical record. (2) A dental record shall be considered a medical
record.
Section
20. Federal Approval and Federal Financial Participation. The
coverage provisions and requirements established in this administrative
regulation shall be contingent upon:
(1)
Receipt of federal financial participation for the coverage; and
(2) Centers for Medicare and Medicaid
Services' approval of the coverage.
Section 21. Appeal Rights. An appeal of a
department decision regarding a Medicaid recipient who is:
(1) Enrolled with a managed care organization
shall be in accordance with
907 KAR 17:010; or
(2) Not enrolled with a managed care
organization shall be in accordance with
907 KAR 1:563.
Section 22. Incorporation by
Reference.
(1) The following material is
incorporated by reference:
(a) "MAP 9, Prior
Authorization for Health Services", December 1995;
(b) "MAP 9A, Kentucky Medicaid Program
Orthodontic Services Agreement", December 1995;
(c) "MAP 306, Temporomandibular Joint (TMJ)
Assessment Form", December 1995;
(d) "MAP 396, Kentucky Medicaid Program
Orthodontic Evaluation Form", March 2001;
(e) "MAP 559, Six (6) Month Orthodontic
Progress Report", December 1995;
(f) "MAP 700, Kentucky Medicaid Program
Orthodontic Final Case Submission", December 1995; and
(g) "KY Medicaid Dental Fee Schedule", April
2023.
(2) This material
may be inspected, copied, or obtained, subject to applicable copyright law:
(a) At the Department for Medicaid Services,
275 East Main Street, Frankfort, Kentucky 40621, Monday through Friday, 8 a.m.
to 4:30 p.m.; or
Section 23. This
administrative regulation has been found deficient by the Administrative
Regulation Review Subcommittee on May 9, 2023.
STATUTORY AUTHORITY:
KRS
194A.030(2),
194A.050(1),
205.520(3)