Nebraska Administrative Code
Topic - HEALTH AND HUMAN SERVICES SYSTEM
Title 471 - NEBRASKA MEDICAL ASSISTANCE PROGRAM SERVICES
Chapter 6 - DENTAL SERVICES
Section 471-6-005 - BILLING AND PAYMENT FOR DENTAL SERVICES
Universal Citation: 471 NE Admin Rules and Regs ch 6 ยง 005
Current through September 17, 2024
005.01 BILLING.
005.01(A)
GENERAL BILLING REQUIREMENTS. Providers must comply
with all applicable billing requirements codified in 471 NAC 3. In the event
that billing requirements in 471 NAC 3 conflict with billing requirements
outlined in this chapter, the billing requirements in this chapter will
govern.
005.01(B)
SPECIFIC BILLING REQUIREMENTS.
005.01(B)(i)
BILLING
INSTRUCTIONS. The provider must bill Medicaid using the procedure
codes outlined in the Nebraska Medicaid Dental Fee Schedule and in accordance
with the billing instructions. The fees listed on the dental claim must be the
dentist's usual and customary charge for each procedure code.
005.02 PAYMENT.
005.02(A)
GENERAL PAYMENT REQUIREMENTS. Medicaid will reimburse
the provider for services rendered in accordance with the applicable payment
regulations codified in 471 NAC 3. In the event that individual payment
regulations in 471 NAC 3 conflict with payment regulations outlined in this
chapter, the individual payment regulations in this chapter will
govern.
005.02(B)
SPECIFIC PAYMENTS REQUIREMENTS.
005.02(B)(i)
REIMBURSEMENT. Medicaid pays for covered dental services at the
lower of:
(1) The provider's submitted charge;
or
(2) The allowable amount for
that procedure code in the Nebraska Medicaid Practitioner Fee Schedule in
effect for that date of service.
005.02(B)(ii)
RESTORATIVE
SERVICES RATES. Operative dentistry fee includes local anesthetic,
bases, or insulation and other procedures necessary to complete the case. Pins
are billed separately.
005.02(B)(iii)
PAYMENT FOR
INTERCEPTIVE AND COMPREHENSIVE ORTHODONTIC TREATMENT. Payment for
authorized orthodontic treatment is made upon approval of the treatment plan
and submittal of a dental claim.
005.02(B)(iii)(1)
TRANSFER OF
INTERCEPTIVE AND COMPREHENSIVE ORTHODONTIC CASES. If the client
transfers to another dentist, the dentist who obtained the original
authorization and initiated orthodontic treatment, must refund to Medicaid the
portion of the amount paid by Medicaid that applies to the treatment not
completed. The transfer request must be submitted and reviewed by the
Department to determine the amount to be refunded. Transfers are only allowed
under hardship circumstances.
005.02(B)(iii)(2)
INTERCEPTIVE
AND COMPREHENSIVE ORTHODONTIC TREATMENT NOT COMPLETED. If prior
authorized orthodontic treatment is not completed, the dentist who obtained the
original authorization and initiated the treatment must refund to Medicaid the
portion of the amount paid by Medicaid that applies to the treatment not
completed. The request to discontinue treatment must be submitted and reviewed
by the Department to determine the amount to be refunded.
005.02(B)(iv)
AUDIT RECORDS.
Medicaid may request end of treatment diagnostic models and
x-rays in accordance with this chapter. Payment for the end of treatment
records is included in the dollar amount prior authorized.
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