Current through Vol. 42, No. 1, September 16, 2024
(a)
Utilization parameters.
(1) The Oklahoma Health Care Authority
utilization parameters allow only one (1) permanent restorative service to be
provided per tooth per twenty-four (24) months.
(2) Additional restorations may be authorized
upon approval of OHCA in cases of trauma.
(3) The provider is responsible for follow-up
or any required replacement of a failed restoration, if the member is currently
SoonerCare eligible.
(4) Providers
must document type of isolation used in treatment progress notes.
(5) For members who are under twenty-one (21)
years of age and who are receiving a restoration are eligible within three (3)
months for consideration of a single crown if endodontically treated.
(b)
Coverage for dental
restorations. Restoration of incipient lesions is not considered
medically necessary treatment. Any diagnosis not supported by images requires
documentation of the medical need on which the diagnosis was made. Services for
dental restorations are covered, for adults and children, as follows:
(1) If the mesial occlusal pit and the distal
occlusal pit on an upper molar tooth are restored at the same appointment, this
is a one(1) surface restoration.
(2) If any two (2) separate surfaces on a
posterior tooth are restored at the same appointment, it is a two (2) surface
restoration.
(3) If any three (3)
separate surfaces on a posterior tooth are restored at the same appointment, it
is a three (3) surface restoration.
(4) If the mesial, distal, facial and/or
lingual of an upper anterior tooth is restored at the same appointment, this is
a four (4) surface restoration.
(5)
If any two (2) separate surfaces on an anterior tooth are restored at the same
appointment, it is a two (2) surface restoration.
(6) If any three (3) separate surfaces on an
anterior tooth are restored at the same appointment, it is a three (3) surface
restoration.
(7) An incisal angle
restoration is defined as one (1) of the angles formed by the junction of the
incisal and the mesial or distal surface of an anterior tooth. If any of these
surfaces are restored at the same appointment, even if separate, it is
considered as a single incisal angle restoration.
(8) When four (4) or more separate surfaces
on a posterior tooth are restored at the same appointment it is a four (4)
surface restoration.
(9) Wide
embrasure cavity preparations do not become extra surfaces unless at least one
half of cusp or surface is involved in the restoration. An MODFL restoration
would have to include the mesial-occlusal-distal surfaces as well as either the
buccal groove pit or buccal surface or at least one half the surface of one of
the buccal cusps. The same logic applies for the lingual surface.
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 16 Ok Reg 692,
eff 12-31-98 (emergency); Amended at 16 Ok Reg 1429, eff 5-27-99 ; Amended at
23 Ok Reg 2489, eff 6-25-06 ; 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 30 Ok Reg 1177, eff
7-1-13
