Current through Register No. 40, October 3, 2024
(a) Payment for dental services shall be made
in accordance with rates established by the department in accordance with
RSA 161:4,
VI(a).
(b) Dental providers shall submit claims for
payment to the department's fiscal agent.
(c) Pursuant to
He-W
566.07(b)(2), for extractions that
warrant immediate action, both the prior authorization request and the claim
for payment shall be submitted to the address in
He-W
566.07(b)(4).
(d) Dental providers shall maintain
supporting records, in accordance with He-W 520 and this part.
(e) Payments for endodontic treatments,
including root canal treatment, shall be made only when the provider submits a
radiograph that demonstrates that the endodontic therapy was successful,
effective, and complete when completely filled to the apex of the root(s) of
the tooth.
(f) Payment for
palliative treatments shall be made only when the provider submits
documentation by report that demonstrates that the treatment was completed and
the services provided were consistent with palliative treatment as defined in
He-W
566.01(n).
(g) Payment for comprehensive orthodontic
treatment shall be inclusive of, but not limited to:
(1) All examinations associated with the
orthodontic treatment including periodic and emergency examinations;
(2) All periodic adjustments associated with
the orthodontic treatment;
(3) All
radiographs, diagnostic models, images, and other records associated with the
orthodontic treatment;
(4) Space
maintenance, when performed by the orthodontic provider within 2 years of the
banding;
(5) Appliances as
applied;
(6) Application and
removal of appliances;
(7)
Replacement and repair of brackets, bands, and arch wires;
(8) Retainers and follow-up examinations;
(9) Treatment ancillary to the
orthodontia, including, but not limited to, separators and
radiographs;
(10) Orthodontically
related palliative treatment; and
(11) Closing records.
(h) Payment for interceptive orthodontic
treatment shall be inclusive of, but not limited to:
(1) All examinations associated with the
orthodontic treatment including periodic and emergency examinations;
(2) All periodic adjustments associated with
the orthodontic treatment;
(3) All
radiographs, diagnostic models, images, and other records associated with the
orthodontic treatment;
(4) Space
maintenance, if applicable;
(5)
Appliances as applied;
(6)
Application and removal of appliances;
(7) Replacement and repair of brackets,
bands, and arch wires;
(8)
Retainers and follow-up examinations, if applicable;
(9) Treatment ancillary to the orthodontia,
including but not limited to separators and radiographs;
(10) Orthodontically related palliative
treatment; and
(11) Closing
records.
(i) Payments
for comprehensive orthodontic treatment for services prior authorized shall be
made to the provider in 3 equal installments upon the department's receipt of
an orthodontic claim and as follows:
(1) A
payment shall be made following the application of appliances;
(2) A payment shall be made following the
completion of the 12th month of treatment and the submission of a progress
report as described in
He-W
566.05(l)(1); and
(3) A payment shall be made following case
completion and the submission of the final treatment report and photographs as
described in
He-W
566.05(l)(2).
(j) In the event of termination, provider
payment for comprehensive treatment shall be prorated as follows:
(1) If the appliances have been applied and
the recipient is terminated or transferred before completing 12 months of
treatment, the provider shall receive payment in accordance with (i)(1) above
plus a payment equal to the reimbursement rate for each periodic adjustment the
recipient received; and
(2) If the
recipient has completed 12 months of treatment and is terminated prior to case
completion, the provider shall receive payment in accordance with (i)(1)-(2)
above plus a payment equal to the reimbursement rate for each periodic
adjustment the recipient received following the 12th month of treatment, up to
10 adjustments.
(k) If
treatment of the recipient is transferred to another provider, the new provider
shall:
(1) Request prior authorization for
treatment in accordance with
He-W 566.07;
and
(2) Receive payment based on
the terms of the treatment plan that has been approved through prior
authorization by the department in accordance with
He-W
566.07.
(l) Prior to terminating orthodontic
treatment of a recipient, the provider shall remove the appliances and provide
retention.
#7012, eff 6-15-99; ss by #7912, eff 7-1-03; ss by #9902,
eff 6-1-11
