Download Dental-Children-and-Pregnant-Women_dhs16_148002

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Children and Pregnant Women
Revised: 06-14-2016
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Authorization
Covered Services
Orthodontics (Children through age 20)
Legal References
MHCP covers dental services that are medically necessary for children (eligible children through aged 20) and pregnant
women. Refer to the Dental Services Overview for Eligible Providers and Eligible Recipients.
Authorization
Criteria for services that require authorization are located in Authorization. Submit requests electronically using MN–ITS
Authorization (278). Refer to the MN–ITS user guides Dental (PDF) or for consolidated providers Dental with Consolidated
NPI (PDF).
For the Child and Teen Checkup (C&TC) Dental Periodicity Schedule refer to the Dental Services Overview page.
Covered Services
This list of covered services is not all-inclusive.
Diagnostic
Diagnostic services covered include oral evaluations and dental radiographs (x-rays) according to the following criteria:
Oral evaluations
 Periodic oral evaluation: Cannot be performed on same date as a limited or comprehensive evaluation
 Limited oral evaluation
 Cannot be performed on same date as a periodic or comprehensive oral evaluation
 Documentation must include notation of the specific oral health problem or complaint
 Comprehensive oral evaluation: Cannot be performed on same date as a periodic or limited evaluation, or prophylaxis
Dental radiographs (x-rays)
 Pregnant Women
 Bitewings, once in 365 days
 Full Mouth Intraoral – Complete series (including bitewings) or a panoramic x-ray, once in a five-year period
 Intraoral periapicals or intraoral occlusal x-rays, as medically necessary
 Children – The DHS Dental Services Advisory Committee (DSAC) has reviewed existing guidelines on prescribing
dental radiographs by the American Academy of Pediatric Dentistry and the American Dental Association and U.S.
Food and Drug Administration. The guidelines and professional input from DSAC provides the basis for the resulting
Children’s Dental Radiographs policy
 Bitewings, once in 365 days
 Full mouth intraoral – Complete series (including bitewings) or a panoramic x-ray, once in a five-year period
except when medically necessary to evaluate development and to detect anomalies, injuries, and disease
 Intraoral periapicals or intraoral occlusal x-rays, as medically necessary
 Cephalometric films, once in five years
 Cone Beam CT, authorization required using CPT code and must be billed using the 837P claim format
Children should receive only the minimum number of x-rays needed to detect anomalies and diseases, and to evaluate
development. When a child has received recent radiographs in another dental office, make efforts to obtain those
radiographs to avoid re-exposure of the child. MHCP will cover intraoral and extraoral radiographs when necessary to
diagnose a condition.
Exceptions to full-mouth x-rays
Exceptions to Full Mouth X-ray Guidelines
Authorization Documentation Required
Required
When medically necessary for the diagnosis and follow-up of oral No
and maxillofacial pathology and trauma.
Once every two years for children who cannot cooperate for
No
intraoral film due to developmental disability or medical condition
that does not allow for intraoral film placement.
When medically necessary for the diagnosis and treatment of
Yes
symptomatic third molars if root formation has been completed
since the last panoramic x-ray was taken.
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AUC Cover Sheet
Chart documentation
AUC Cover Sheet
Chart documentation
Diagnostic quality copy of the initial
panoramic x-ray with exposure date
indicated.
Preventive
The following preventive services are covered:
 Dental prophylaxis
 Fluoride treatment and varnish application. Note the following criteria:
 Fluoride varnish once per six months
 D1354 Interim Caries Arresting Medicament Application once per six months
 Cannot be performed on the same date as D1206, and D1208
 Cannot be performed on same date as D9910
 Oral hygiene instructions—document the amount of time above and beyond the standard prophylaxis, gross
debridement, scaling and root planing, or other scheduled service that was required for oral hygiene instruction. Oral
hygiene instruction is considered an ongoing integral component of every dental visit. Effective January 1, 2010,
MHCP will reimburse oral hygiene instructions once per lifetime. Minnesota Rules 9505.0270 Subp. 1 E defines oral
hygiene instruction as an organized education program carried out by or under the supervision of a dentist to instruct
a patient about the care of the patient’s teeth. Retain a copy of the organized educational program in the patient chart
and include the following:
 Assessment findings and risk factors for oral disease specific to the patient
 Detailed counseling components presented, based on the assessments and risk factors
 Objectives of the customized care plan
 Educational methodology used and how each educational component was presented
 The amount of time scheduled to complete the organized education program
 For children under age 6, the name of the parent or legal guardian to whom the educational program was
presented
Note: Any additional oral hygiene instruction services must meet the specifications of utilization criteria
 Sealants (children only): Once per tooth per 5 years per permanent molar
 Space maintainers
Restorative
The following restorative services are covered:
 Amalgam and composite fillings, with the following criteria:
 Limited to once in 90 days for the same tooth
 Posterior fillings are all reimbursed at the amalgam rate
Note: MHCP prohibits balance billing posterior composites to the recipient
 Laboratory resin crowns that meet the specifications of utilization review
 Prefabricated stainless steel, or prefabricated resin crowns
 Sedative fillings: Cannot be performed on same date as D9110
Endodontics
Endodontics is covered once per tooth per lifetime.
Periodontics
The following periodontics services are covered:
 Scaling and root planing that meets the specifications of utilization criteria
 Full mouth debridement
Use oral cavity indicators only for periodontal services to designate the quadrants where the service was or will be
provided. Bill using the appropriate numeric oral cavity designation code: 10, 20, 30, or 40.
Prosthodontics
The following prosthodontics services are covered:
 Removable full dentures
 Removable partial dentures that meet the specifications of utilization criteria
 Reline, repair or rebase of a removable complete or partial denture
 Fixed bridges and dental implants that meet the specifications of utilization criteria; porcelain or metal crowns in
conjunction with a medically necessary fixed bridge or implant that meet the specifications of utilization criteria
 CDT codes: D6092 recement implant or abutment supported crown and D6093 recement implant or abutment
supported fixed partial denture do not require authorization, but are subject to utilization review. All other dental
implants codes require authorization. Use the Dental Implants Authorization Form (DHS-3538) (PDF).
Removable Dentures – Complete and Partial
Initial placement or replacement of a removable prosthesis is limited to once every three years per recipient unless one or
more of these conditions apply:
 Replacement of a removable prosthesis in excess of this limit is eligible for payment if the replacement is necessary
because the removable prosthesis was misplaced, stolen, or damaged due to circumstances beyond the recipient’s
control. When applicable, the recipient’s degree of physical and mental impairment must be considered in determining
whether the circumstances were beyond a recipient’s control.
 Replacement of a partial prosthesis is eligible for payment if the existing prosthesis cannot be modified or altered to
meet the recipient’s dental needs.
 Service for a removable prosthesis must include instruction in the use and care of the prosthesis and any adjustment
necessary to achieve a proper fit during the six months immediately following the provision of the prosthesis.
Document the instruction and the necessary adjustments, if any, in the recipient’s dental record.
 Bill denture identification only for dentures previously made without ID markers. Denture identification for new
dentures or partials will deny
 Replacement of missing or broken teeth allows for a maximum number of five teeth
House calls for removable prosthesis
Effective July 1, 2016, house calls (D9410) for fitting removable prosthesis is a covered services limited to for up to five
visits in a calendar year. Bill house calls D9410 with D5992; D9410 will pay at the current rate and D5992 will pay at zero.
Undeliverable Removable Prostheses
MHCP pays a percentage payment of the scheduled allowable for undeliverable removable prostheses. Submit an
attachment for the claim documenting the following:
 Reason for non-delivery noted in the patient chart
 Explanation that includes the incurred lab charges and the percent of work completed
Fax a completed AUC Uniform Cover Sheet for Health Care Claims attachment with the required documentation by the
end of the next business day after submitting the electronic claim. The completed prosthesis must be kept in the
provider’s office, in a deliverable condition, for a period of at least two years.
Payment will be prorated based on the percentage completed and utilization review.
Oral Surgery
Oral surgery services are covered include extractions, and incise and drain.
Extractions
Criteria for extractions coverage includes the following:
 Extractions of impacted teeth must meet the specifications of utilization criteria. Authorization is always required for
the removal of impacted teeth. Requests for authorization for the removal of impacted teeth must be submitted with
the following dental history, case information, and documentation for each tooth to be extracted:
 Documentation that third molar extractions are symptomatic or show evidence of pathology
 Current radiographs with diagnostic value and chart documentation for each tooth being extracted
 For each tooth to be extracted, include objective documentation of at least one of the following symptoms:
 Significant infection which includes at least one of the following:
 Presence of severe pain or swelling
 Documented recurrent episodes of pericoronitis
 An episode of cellulitis
 An episode of abscess formation or untreatable pulpal or periapical pathology
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Active current periodontal disease due to the position of the third molar and its association with the second
molar (periodontal charting required)
External resorption of the third molar or of the second molar where this would appear to be caused by the
third molar
A nonrestorable carious lesion on a partially erupted third molar or a carious lesion on the distal of the second
molar due to the position of the third molar
A pathological condition such as a dentigerous cyst or other related pathology
The primary services or procedures must be covered services under MHCP for ancillary services to be covered. If the
primary procedure is not a covered service, regardless of the complexity or difficulty, coverage of services such as the
administration of anesthesia, diagnostic x-rays, and other related procedures will not be covered.
Dentists and oral surgeons who perform medical procedures must follow the practitioner and general authorization
guidelines for exams, consultation, radiology, surgery, anesthesia, and laboratory services.
Refer to the Dental Services Overview Page for covered dental procedures reported with CPT Codes for the
following:
 Alveoloplasty
 Temporomandibular Joint (TMJ) Disorder
Orthodontics (children through age 20)
MHCP covers orthodontic treatment that meets the specifications of utilization criteria for children through age 20.
Criteria Beginning May 1, 2013
Comprehensive orthodontic treatment is considered medically necessary when adequate corrective treatment is not
achievable with less extensive means, and one of the following criteria is met:
 Dentition affected by significant cleft palate, craniofacial or other congenital or developmental disorder
 Significant skeletal disharmony requiring combination of orthodontic treatment and orthognathic surgery for correction
 Overjet greater than 9mm or reverse overjet greater than 3.5mm
 Anterior openbite greater than 4mm
If one of the criteria immediately above is not met, one of the following criteria must be met and demonstrated functional
impairment must be present:
 Impeded eruption of teeth (with the exception of third molars) due to crowding, displacement, the presence of
supernumerary teeth, retained deciduous teeth or other pathological cause, where conservative removal of the
ectopic tooth would create a significant functional deficit in biting or chewing
 Severe crowding of greater than 7mm in either the maxillary or mandibular arch
 Extensive hypodontia requiring pre-restorative orthodontics or orthodontic space closure to obviate the need for
prosthetic treatment
 Significant posterior openbite (not involving partially erupted teeth or teeth slightly out of occlusion;
 Anterior crossbite involving permanent incisors or canines creating a functional interference and a resulting functional
shift, or gingival stripping
 Posterior transverse discrepancies causing buccal or lingual crossbite involving permanent molar teeth and creating a
functional interference and a resulting functional shift
 Deep anterior overbite of multiple incisors resulting in soft tissue impingement or trauma
 Overjet greater than 6mm or reverse overjet greater than 1mm
 Other conditions as deemed medically necessary
Orthodontic care usually requires lengthy treatment. MHCP recommends that the provider discuss the expected eligibility
period with the family and the county human services agency before initiating treatment. This will clarify the eligibility
policies and help reduce denial of payment due to subsequent ineligibility. A recipient’s eligibility can terminate or may go
from fee-for-service to MCO on a month-to-month basis.
Providers are encouraged to consult with parents or guardians regarding noncompliance and disregard for instructions.
Treatment may be terminated and all appliances removed until a later time when the child is more mature and can follow
instructions. Compliance is critical for a successful orthodontic outcome. Non-compliance with orthodontic treatment can
negatively impact the child by exacerbating oral disease.
Orthodontic Billing
Use D8660 pre-orthodontic treatment visit to report orthodontic full case study.
For comprehensive orthodontic treatment:
 Use D8999 for initial banding and write “initial banding” in the narrative
 Bill adjustments utilizing the appropriate comprehensive code (D8070, D8080, or D8090)
For non-comprehensive orthodontic treatment, MHCP does not reimburse for initial banding. Bill adjustments utilizing:
 the appropriate limited orthodontic treatment code (D8010, D8020, D8030, or D8040); or
 the appropriate interceptive orthodontic treatment code (D8050 or D8060)
Replacement or re-cementing of one or two brackets due to reasonable wear and tear is considered a part of the total
orthodontic treatment. Re-cementing of brackets due to a failure of the patient to comply with provider instructions is a
noncovered service and the provider may bill the member for the cost. Since re-cementation of brackets is not a covered
service, the provider is not required to submit charges to MHCP.
The retention phase of orthodontic treatment is a component of the total orthodontic care for which provider is reimbursed.
The type of retention is a choice made by the provider. Do not bill the recipient.
MHCP FFS recipients with third party liability (TPL) or other insurance
How you bill MHCP will depend on the authorization type you receive.
FFS authorization and TPL or other insurance billing
When MHCP approves an
authorization:
Then bill TPL or other insurance following these
instructions:
Then bill TPL or other insurance following whichever of the these instructions
apply based on whether the TPL or insurance pays an initial down payment or
pays over the entire course of the orthodontic treatment:
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If the MHCP authorization approves an
initial appliance placement and
subsequent monthly adjustments
When TPL or other insurance pays an initial down payment and
subsequent payments over the course of the treatment (monthly, quarterly,
semi-annual or annual payments):
 Bill the approved initial appliance placement code and indicate the TPL
or other insurance initial down payment amount on the claim
 Bill monthly adjustments (one month at a time) indicating the TPL or
other insurance actual monthly payment or the prorated monthly
amount based on the total remaining TPL or other insurance payment
expected, divided by the total months of orthodontic treatment.
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If the MHCP authorization approves
only monthly adjustments
When TPL or other insurance pays over the entire course of the
orthodontic treatment (monthly, quarterly, semi-annual, annual or lump
sum payments):
 Bill the approved initial appliance placement code and monthly
adjustments (one month at a time)
 Indicate the actual TPL or other insurance monthly payment or the
prorated monthly amount based on the total TPL or other insurance
payment expected, divided by the total months of orthodontic
treatment.
Then bill TPL or other insurance according to the following if the TPL or other
insurance makes payments over the course of the treatment:
 Indicate the TPL or other insurance actual monthly payment (one month at
a time)
 Use the calculated prorated monthly amount based on the total TPL or
other insurance payment expected, divided by the total months of
orthodontic treatment
Use one of the following two examples to calculate the prorated payment
amounts:
 TPL or other insurance total payment $1,500 divided by the expected
course of treatment (24 months) equals $62.50 as the monthly prorated
payment
 Your charge for the braces is $4,800 with an expected course of treatment
of 24 months. The TPL or other insurance will pay a total of $2,400 in three
installments ($1,000 at the beginning of the treatment, $1,000 at the
beginning of the second year and $400 at the end of the treatment). TPL or
other insurance is paying is 50% of your total charge; therefore, when
billing MHCP, the TPL or other insurance paid amount should be 50% of
your billed amount.
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Other Services
MHCP covers the following other services:
 Palliative care for the relief of pain
 Anesthesia, which includes the following:
 Deep sedation or general anesthesia – Regardless of the age of the child, the determination of medical necessity
for general anesthesia in conjunction with dental services must consider the information related to general
anesthesia established under the "Guideline on Behavior Guidance for the Pediatric Dental Patient" by the
American Academy of Pediatric Dentistry
 Intravenous conscious sedation or analgesia
 Nitrous oxide analgesia, anxiolysis
 House or extended-care facility call. Extended care facilities are long-term care facilities. These include: nursing
facilities, skilled nursing facilities, boarding care homes, IMDs (Institutions for Mental Disease), ICF/DDs (Intermediate
Care Facilities for Persons with Developmental Disabilities) hospices, and swing beds (a nursing facility bed in a
hospital). A school or Head Start program is not an extended care facility. Criteria for billing house or extended-care
facility includes:
 May not be billed in conjunction with services provided in a Head Start or school setting
 Must be reported along with the addition of the appropriate code(s) for the actual services performed
 Behavior management that is documented as a service necessary to ensure that a covered dental procedure is
correctly and safely performed
 Therapeutic parenteral drugs
 Occlusal adjustment limited according to the following:
 Once per day
 Includes only those services defined by the most current edition of the CDT
 Drugs (D9610, D9612, and D9630): enter additional information in the notes section of the 837D, including:
 Name of drug
 NDC of drug
 Dosage
Community Health Worker – Patient Education
Refer to the Dental Services Overview page for community health worker patient education covered services.
Legal References
Minnesota Statutes 256B.0625, subd. 9 (covered services)
Minnesota Rules 9505.0270 Dental Services
Minnesota Statutes 256B.0625, subd. 49 Community Health Workers
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