Current through Reg. 49, No. 38; September 20, 2024
(a) Emergency dental services. The Texas
Department of Human Services (DHS) will reimburse nursing facilities the cost
of emergency dental services provided to eligible Medicaid residents residing
in Medicaid-contracted facilities or distinct parts.
(1) Recipients must be 21 years of age or
older.
(2) Dental care for
recipients under the age of 21 is covered under the Early and Periodic
Screening, Diagnosis, and Treatment (EPSDT) program.
(3) Services reimbursed are subject to the
limitations specified in § 554.1401(b) of Title 40 (relating to Dental
Services).
(4) Emergency dental
services may be provided only if the attending physician orders a dental
consultation. See § 554.1201 of Title 40 (relating to Physician
Services).
(b) Dental
providers. Emergency dental services must be provided by a dentist licensed by
the Texas State Board of Dental Examiners who, if not employed by the facility,
contracts with the facility according to the specifications outlined in §
554.1906 of Title 40 (relating to Use of Outside Resources).
(c) Reimbursement for Emergency Dental
Services. The cost of emergency dental services provided to eligible Medicaid
residents residing in nursing facilities will be reimbursed to facilities,
provided that the services are not reimbursable by the Medicaid claims
processor or the EPSDT program.
(d)
Payment of Claims.
(1) The facility must
accept payment by DHS as payment in full for services. Neither the dentist nor
the facility may charge an additional fee to the recipient, his family, or his
trust fund, except that the dentist may charge the recipient for services that:
(A) the recipient requests; and
(B) are not reimbursable by the Texas Medical
Assistance Program.
(2)
Payments for emergency dental services are the lower of the:
(A) dentist's usual fee; or
(B) maximum fee as determined by the Texas
Health and Human Services Commission (HHSC).
(3) DHS reimburses facilities for services
properly rendered in accordance with applicable laws, regulations, and
operational instructions. DHS may withhold or suspend payment for services that
are not properly rendered.
(4)
Nursing Facility Emergency Dental Services makes no payment for services that
are available under any other Texas Medical Assistance Program.
(5) Complete and accurate claims for services
must be received within 12 months from the date of service.
(6) Claims for services delivered before the
effective date of this section must be submitted within 12 months of the
effective date of this section.
(7)
Adjustments to claims must be received by DHS's claims processor during the
applicable 12-month period. Claims and adjustments rejected or denied during
the 12-month period through no fault of the dentist may be paid upon approval
by DHS.
