Current through Vol. 41, No. 20, July 1, 2024
Payment is made for dental services as set forth in this
Section.
(1)
Adults. The
OHCA Dental Program provides basic medically necessary treatment. The services
listed below are compensable for members twenty-one (21) years of age and over
without prior authorization.
(A)
Comprehensive oral evaluation. The comprehensive oral evaluation
may be performed when a member has not been seen by the same dentist for more
than thirty-six (36) months. The comprehensive oral evaluation must precede any
images, and chart documentation must include image interpretations, six-point
periodontal charting, and both medical and dental health history of the member.
The comprehensive treatment plan should be the final result of this
procedure.
(B)
Periodic oral
evaluation. This procedure may be provided for a member once every six
(6) months. An examination must precede any images, and chart documentation
must include image interpretations, and both medical and dental health history
of member. The comprehensive treatment plan should be the final result of this
procedure.
(C)
Limited oral
evaluation. This procedure is only compensable to the same dentist or
practice for two (2) visits prior to a comprehensive or periodic evaluation
examination being completed.
(D)
Images. To be SoonerCare compensable, images must be of diagnostic
quality and medically necessary. A clinical examination must precede any
images. Documentation must indicate medical necessity and diagnostic findings.
Images must be properly labeled with date and member name. Periapical images
must include at least three (3) millimeters beyond the apex of the tooth being
imaged. Panoramic films are only compensable when chart documentation clearly
indicates reasons for the exposure based on clinical findings. This type of
panoramic film exposure is not to rule out or evaluate caries. Prior
authorization and a narrative detailing medical necessity are required for
additional panoramic films taken within three (3) years of the original
set.
(E)
Dental
prophylaxis. Dental prophylaxis is provided once every six (6) months
along with topical application of fluoride.
(F)
Periodontal Maintenance.
This procedure is provided once every six (6) months for members who have a
history of periodontitis and are no longer eligible for oral
prophylaxis.
(G)
Smoking and
tobacco use cessation counseling. Smoking and tobacco use cessation
counseling is covered per Oklahoma Administrative Code (OAC)
317:30-5-2(DD)
(i) through (iv).
(H)
Medically necessary extractions. Medically necessary extractions,
as defined in OAC
317:30-5-695.
Tooth extraction must have medical need documented.
(I)
Medical and surgical
services. Medical and surgical services performed by a dentist or
physician to the extent such services may be performed under State law when
those services would be covered if performed by a physician.
(J)
Additional services.
Additional covered services, which require a prior authorization, are outlined
in OAC
317:30-5-698.
(2)
Children. The OHCA Dental
Program for children provides medically necessary treatment. For services
rendered to a minor, the minor's parent or legal guardian must provide a
signed, written consent prior to the service being rendered, unless there is an
explicit state or federal exception to this requirement. The services listed
below are compensable for members under twenty-one (21) years of age without
prior authorization. All other dental services must be prior authorized.
Anesthesia services are covered for children in the same manner as adultsper
OAC
317:30-5-696.1. All
providers performing preventive services must be available to perform needed
restorative services for those members receiving any evaluation and preventive
services.
(A)
Comprehensive oral
evaluation. A comprehensive oral evaluation may be performed when a
member has not been seen by the same dentist for more than thirty-six (36)
months. The comprehensive oral evaluation must precede any images, and chart
documentation must include image interpretations, caries risk assessment,
six-point periodontal charting, and both medical and dental health history of
member. The comprehensive treatment plan should be the final result of this
procedure.
(B)
Periodic oral
evaluation. This procedure may be provided for a member once every six
(6) months. An examination must precede any images, and chart documentation
must include image interpretations, and both medical and dental health history
of member. The comprehensive treatment plan should be the final result of this
procedure.
(C)
Limited oral
evaluation. This procedure is only compensable to the same dentist or
practice for two (2) visits prior to a comprehensive or periodic evaluation
examination being completed.
(D)
Images. To be SoonerCare compensable, images must be of diagnostic
quality and medically necessary. A clinical examination must precede any
images, and chart documentation must indicate medical necessity and diagnostic
findings. Images must be properly labeled with date and member name. Periapical
images must include at least three (3) millimeters beyond the apex of the tooth
being imaged. Panoramic films and two (2) bitewings are considered full mouth
images. Full mouth images as noted above or traditional [minimum of twelve (12)
periapical films and two (2) posterior bitewings] are allowable once in a three
(3) year period and must be of diagnostic quality. Individually listed
intraoral images by the same dentist/dental office are considered a complete
series if the number of individual images equals or exceeds the traditional
number for a complete series. Panoramic films are only compensable when chart
documentation clearly indicates reasons for the exposure based on clinical
findings. This type of exposure is not to rule out or evaluate caries. Prior
authorization and a detailed medical need narrative are required for additional
panoramic films taken within three (3) years of the original set.
(E)
Dental sealants. Tooth
numbers 2, 3, 14, 15, 18, 19, 30 and 31 must be caries free on the
interproximal and occlusal surfaces to be eligible for this service. This
service is available through eighteen (18) years of age and is compensable once
every thirty-six (36) months if medical necessity is documented.
(F)
Interim caries arresting medicament
application. This service is available for primary and permanent teeth
once every six (6) months for two (2) occurrences per tooth in a lifetime. The
following criteria must be met for reimbursement:
(i) A member is documented to be unable to
receive restorative services in the typical office environment within a
reasonable amount of time;
(ii) A
tooth that has been treated should not have any non-carious structure
removed;
(iii) A tooth that has
been treated should not receive any other definitive restorative care for three
(3) months following an application;
(iv) Reimbursement for extraction of a tooth
that has been treated will not be allowed for three (3) months following an
application; and
(v) The specific
teeth treated and number and location of lesions must be documented.
(G)
Dental
prophylaxis. This procedure is provided once every six (6) months along
with topical application of fluoride.
(H)
Periodontal Maintenance.
This procedure is provided once every six (6) months for members who have a
history of periodontitis and are no longer eligible for oral
prophylaxis.
(I)
Stainless
steel crowns for primary teeth. The use of any stainless steel crowns is
allowed as follows:
(i) Stainless steel crowns
are allowed if:
(I) The child is five (5)
years of age or under;
(II) Seventy
percent (70%) or more of the root structure remains; or
(III) The procedure is provided more than
twelve (12) months prior to normal exfoliation.
(ii) Stainless steel crowns are treatment of
choice for:
(I) Primary teeth treated with
pulpal therapy, if the above conditions exist;
(II) Primary teeth where three (3) surfaces
of extensive decay exist; or
(III)
Primary teeth where cuspal occlusion is lost due to decay or
accident.
(iii)
Preoperative periapical images and/or written documentation explaining the
extent of decay must be available for review, if requested.
(iv) Placement of a stainless steel crown is
allowed once for a minimum period of twenty-four (24) months. No other
restoration on that tooth is compensable during that period of time. A
stainless steel crown is not a temporizing treatment to be used while a
permanent crown is being fabricated.
(J)
Stainless steel crowns for
permanent teeth. The use of any stainless steel crowns is allowed as
follows:
(i) Stainless steel crowns are the
treatment of choice for:
(I) Posterior
permanent teeth that have completed endodontic therapy if three (3) or more
surfaces of tooth is destroyed;
(II) Posterior permanent teeth that have
three (3) or more surfaces of extensive decay; or
(III) Where cuspal occlusion is lost due to
decay prior to age sixteen (16) years.
(ii) Preoperative periapical images and/or
written documentation explaining the extent of decay must be available for
review, if requested.
(iii)
Placement of a stainless steel crown excludes placement of any other type of
crown for a period of twenty-four (24) months. No other restoration on that
tooth is compensable during that period of time.
(K)
Pulpotomies and
pulpectomies.(i) Therapeutic
pulpotomies and pulpal debridement are allowable once per lifetime. Pre-and
post-operative periapical images must be available for review, if requested.
Therapeutic pulpotomies and pulpal debridement is available for the following:
(I) Primary molars having at least seventy
percent (70%) or more of their root structure remaining or more than twelve
(12) months prior to normal exfoliation;
(II) Tooth numbers O and P before age five
(5) years;
(III) Tooth numbers E
and F before six (6) years;
(IV)
Tooth numbers N and Q before five (5) years;
(V) Tooth numbers D and G before five (5)
years.
(ii) Therapeutic
pulpotomies and pulpal debridement are allowed for primary teeth if exfoliation
of the teeth is not expected to occur for at least one (1) year or if seventy
percent (70%) or more of root structure is remaining.
(L)
Space maintainers. Certain
limitations apply with regard to this procedure. Providers are responsible for
recementation of any maintainer placed by them for six (6) months post
insertion.
(i)
Band and loop type space
maintenance. This procedure must be provided in accordance with the
following guidelines:
(I) This procedure is
compensable for all primary molars where permanent successor is missing or
where succedaneous tooth is more than five (5) millimeters below the crest of
the alveolar ridge.
(II) First
primary molars are not allowed space maintenance if the second primary and
first permanent molars are present and in cuspal interlocking occlusion
regardless of the presence or absence of normal relationship.
(III) If there are missing posterior teeth
bilaterally in the same arch, under the above guidelines, bilateral space
maintainer is the treatment of choice.
(IV) The teeth numbers shown on the claim
must be those of the missing teeth.
(V) Post-operative bitewing images must be
available for review.
(VI)
Bilateral band and loop space maintainer is allowed if member does not have
eruption of the four (4) mandibular anterior teeth in position or if sedation
case that presents limitations to fabricate other space maintenance
appliances.
(ii)
Lingual arch bar. Payment is made for the services provided in
accordance with the following:
(I) Lingual
arch bar is used when permanent incisors are erupted and the second primary
molar (K or T) is missing in the same arch.
(II) The requirements are the same as for
band and loop space maintainer.
(III) Pre and post-operative images must be
available.
(M)
Analgesia. Analgesia services are reimbursable in accordance with
the following:
(i)
Inhalation of
nitrous oxide. Use of nitrous oxide is compensable for four (4)
occurrences per year and is not separately reimbursable, if provided on the
same date as IV sedation, non-intravenous conscious sedation, or general
anesthesia. The medical need for this service must be documented in the
member's record.
(ii)
Non-intravenous conscious sedation. Non-intravenous conscious
sedation is not separately reimbursable, if provided on the same date as
analgesia, anxiolysis, inhalation of nitrous oxide, IV sedation, or general
anesthesia. Non-intravenous conscious sedation is reimbursable when determined
to be medically necessary for documented handicapped members, uncontrollable
members or justifiable medical or dental conditions. The report must detail the
member's condition. No services are reimbursable when provided primarily for
the convenience of the member and/or the dentist, it must be medically
necessary.
(N)
Pulp
caps. Indirect and direct pulp cap must be ADA accepted calcium
hydroxide or mineral trioxide aggregate (MTA) materials, not a cavity liner or
chemical used for dentinal hypersensitivity. Indirect and direct pulp cap codes
require specific narrative support addressing materials used, intent and
reasons for use. Application of chemicals used for dentinal hypersensitivity is
not allowed as indirect pulp cap. Utilization of these codes is verified by
post payment review.
(O)
Protective restorations. This restoration includes removal of
decay, if present, and is reimbursable for the same tooth on the same date of
service with a direct or indirect pulp cap, if needed. Permanent restoration of
the tooth is allowed after sixty (60) days unless the tooth becomes symptomatic
and requires pain relieving treatment.
(P)
Smoking and tobacco use cessation
counseling. Smoking and tobacco use cessation counseling is covered per
OAC
317:30-5-2(DD)
(i) through (iv).
(Q)
Additional services. Additional covered services, which require a
prior authorization, are outlined in OAC
317:30-5-698.
(3)
1915(c) home and community-based
services (HCBS) waivers. Dental services are defined in each waiver and
must be prior authorized.
Added at 12 Ok Reg
751, eff 1-5-95 through 7-14-95 (emergency); Added at 12 Ok Reg 3131, eff
7-27-95; Amended at 14 Ok Reg 2404, eff 4-2-97 (emergency); Amended at 15 Ok
Reg 1528, eff 5-11-98; Amended at 15 Ok Reg 3822, eff 6-24-98 (emergency);
Amended at 16 Ok Reg 692, eff 12-31-98 (emergency); Amended at 16 Ok Reg 1429,
eff 5-27-99; Amended at 19 Ok Reg 2134, eff 6-27-02; Amended at 19 Ok Reg 2922,
eff 7-1-02 (emergency); Amended at 20 Ok Reg 1193, eff 5-27-03; Amended at 20
Ok Reg 1924, eff 6-26-03; Amended at 23 Ok Reg 2489, eff 6-25-06; Amended at 24
Ok Reg 660, eff 2-1-07 (emergency); Amended at 24 Ok Reg 2088, eff 6-25-07;
Amended at 25 Ok Reg 2759, eff 5-1-08 (emergency); Amended at 26 Ok Reg 530,
eff 2-1-09 (emergency); Amended at 26 Ok Reg 2121, eff 6-25-09; Amended at 28
Ok Reg 1419, eff 6-25-11; Amended at 29 Ok Reg 1107, eff
6-25-12