PURPOSE: This rule describes the dental seruices for which the Division of Family Seruices shall pay when the seruice is provided to an eligible assistance recipient, the seruice is provided by a licensed dentist OT licensed and certi. fied dental specialist who has entered into an agreement for that purpose with the division and the seruice is listed as a cowed item either in the new rule or the MedicaidDentalManual sponsored by the diuision. This rule or the Medicaid Dental Manual also describes the dentalservices whichshall bepaid mder limitations and those which shall not be paid underpresent conditions.

Editor’s Note: The secretary of state has determined that the publication of this rule in its entirety would be unduly cumbersome or expensive. The entire text of the material referenced has been filed with the secretary of state. This material may be found at the Office of the Secretary of State mat the headquarters of the agency and is available to any interested persoia at a cost established by state law.

1. (I) Administration. The Missouri Medicaid dental program shall be administered by the Division of Medical Services, Department of Social Services. The dental services covered and not covered, the limitations under which services are covered and the maximum allowable fees for all covered services shall be determined by the Division of Medical Services. Dental services covered by the Missouri Medicaid program shall include only those which are clearly shown to be medically necessary. The division reserves the right to effect changes in services, limitations and fees with proper notification to Medicaid dental providers.
2. (2) Provider Participation. A dentist shall be licensed by the dental board of the state in which s/he is practicing and shall have signed a participation agreement to provide dental servicesundertheMissouriMedicaidprogram. An oral surgeon or other dentist specialist shall be licensed in his/her specialty area by the dental board of the state in which s/he is practicing. In those states not having a specialty licensure requirement, the dentist specialist shall be a graduate of and hold a certificate from a graduate training program in that specialty in an accredited dental school. In either case, the dental specialist shall have signed a participation agreement to provide dental services under the Missouri Medicaid program.
3. (3) Recipient Eligibility. The Medicaid dental provider shall ascertain the patient’s Medicaid status before any service is performed. The recipient’s Medicaid eh~bd~ty is determined by the Division of Family Services. The recipient’s ehg.lblhty shall be verified from a current Medicaid identification card or a letter of new approval in the recipient’s possession. The patient must be a Medicaid.eligible recipient under the Missouri program on the date the service is performed. The Division of Medical Services is not allowed to pay for any service to apatientwhoisnot eligibleunderthe Missouri Medicaid program.
4. (4) Prior Authorization. Prior authorization shall be required in the following two (2) eases: a) initial placement or replacement of all full dentures (upper, lower or both) and b) placement or replacement of all partial dentures. When prior authorization is required, the form provided by the Division ofMedical Services or its contracted agent shall be used. The dental service shall not be started until written approval has been received. Telephone approval shall not be given. Prior authorization shall be effective for a period of one hundred twenty (120) days from the date of written approval. Prior authorization approves the medical necessity of the requested dental service. It shall not guarantee payment for that service as the patient must be a Medicaideligible recipient on the date the service is performed. The division reserves the right to request documentation regarding any specific request for prior authorization.

5. (5) Claims.TheMedicaiddentalprovidershall submit his/her usual charge to the general public on the claim form provided by the Division of Medical Services or its contracted agent. Medicaid reimbursement for dental servicesis basedonanestablishedfeeschedule as published in Section 19 of the Dental Manua:. When a claim is reimbursed by Medicaid (or Medicare-Medicaid), no amount in addition to copayment or coinsurance amounts as specified in Section 19 of the Dental Manual shall be collected from the recipient, his/her immediate family or anyone else. The reimbursement provided by Medicaid (orMedicare-Medicaid)shallbeacceptedinf~ll settlement of the dental claim. The recipient shall be responsible for any noncovered service (no reimbursement). The division reserves the

   CODE OFSTATE REGULATIONS 13 CSR 70-35 ,

   m

right to request documentation regarding any specific dental claim.

1. (6) Other Source Payment. The Medicaid payment for dental services cannot duplicate or replace benefits available to the recipient from any other source, public or private. A settlement received from private insurance or litigation as the result of an accident must be used toward payment of the dental care. Medicaidshallbethelast sourceofpayment on any claim. Any payment received from a private insurance carrier or other acceptable source shall be listed on the claim form. If the settlement received is equal to or exceeds the fee which could be allowed by Medicaid, no payment shall be made by Medicaid.
2. (7) Dental Certification. A dental certification form as provided by the Division of Medical Services or its contracted agent shall be completed in the case of any denture, partial or full, except for those flipper-type partials identified in the Dental Services Provider Manual. This completed form shall be attached to the claim and the request for prior authorization.
3. (8) Dental Manual. A Medicaid Dental Manual shall be produced by the Division of Medical Services and shall be distributed to all dental providers participating in the Missouri Medicaid program. It shall contain a list of covered and noncovered services, the limitations under which services are covered and other pertinent data to supplement this rule. The Health Care Financing Administration’s Common Procedure Coding System (HCPCS) Level 1,2 or 3 procedure codes, which includes a modification of the American Dental Am. ciation’s (ADA) Code on Dental Procedures andNomenclatureshallbeusedinthemanua1. Maximum allowable fees by the Missouri Medicaid Dental Program shall be published in provider manuals and bulletins.

4. (9) Servicesi Covered and Noncovered. Thelist shown in this se&n represents the groupings of medically necessary services covered by the Missouri Medicaid program. The Medicaid Dental Manual shall provide the detailed listing ofprocedure codes and pricing informa. tion.

   1. (A) Anesthesia. General anesthesia administered in the office is a covered service. General anesthesia administered in the hospital for dental care is payable to the hospital. Local anesthesia is not paid under a separate procedure code and is included in the treatment fee. Nitrous oxide is not covered;
   2. (B) Crowns, Bridges, Inlays. A cnxvn of chrom.e or stainless steel is a covered item. A crown of polycarbonate material is a covered item for an anterior tooth. Crowns of other 13 CSR 70-35-SOCIALSERVICES

materials are not covered. Cast restorations indicated by an early periodic screening diagnosis and treatment (EPSDT) screen are covered;

1. (C) Full Dentures. One (I) upper full denture, one (1) lower full denture, or one (1) complete set (upperandlower) offull denturesiscovered. A full denture must be constructed of acrylic material and must meet the following criteria: full arch impression, bite registration, each tooth set individually in wax, tryin of teeth set individually in wax before denture processing, insertion of the processed denture and six (6). month follow-up adjustments, to be a covered item. Service in the ease of any full denture is not completed and shall not be claimed until the denture is placed. Noncovered items include temporary full dentures, full overden. tures and immediate placement full dentures;
2. (D) Partial Dentures. Apartialdenture shall replace permanent teeth and must be constructed of acrylic material to be a covered item. Service in the case of any partial denture is not completed and shall not be claimed until the denture is placed. Noncovered items include temporary partial dentures and partial overdentures. Immediate placement partial dentures are noncovered except for those flipper-type partials identified in the Dental Services Provider Manual under orocedure codes D5820, D5820W5, D5820W6, D5820W9, D5821. D5821W5. D5821W6. D5821W9:
3. (E) Denture Adjustment ‘and Repair. Den. ture adjustment is a covered service but not to the originating dentist of a new denture until six (6) months after the denture is placed. Repair of a broken denture ma,y be accom~ ulished on the same date of service as denture huplication or reline;
4. (F) Denture Duplication and Reline. Duo& catIon of a partiai or full denture is a co&d service. Reline of a partial or full denture, either chair-side or laboratory, is covered. Duplications and relines are not covered within twelve (12) months of initial placement of an original denture. Additional denture relines or duplications are limited to once within three (3) years from the date of the last preceding reline or duplication. Denture duplication or reline may be accomplished on the same date of wvice as repair of a broken denture;
5. (G) Emergency Treatment. Emergency dental care does not require prior authorization andiscovered whetherperformed byalicensed dentist or a licensed dentist specialist. Emergency care is provided after the sudden onset of a medical condition manifestingitseifby acute symptoms of sufficient severity (including severe pain) that the absence of immediate medical attention resonably could be expected to result in-placing the patient’s health in serious jeopardy or serious impairment of bodily functions or serious dysfunction of any bodily organ or part. Emergencycarenotlisted in the Medicaid Dental Manual shall be explained on the claim. An emergency oral examination is not paid under a separate procedure code and is included in the treatment fee. Palliative treatment on the same date of service as other dental care on the same tooth is not covered. Denture dental services are not subject to emergency treatment consideration;
6. (H) Examinations, Visits, Consultations. An initial oral examination in the office is covered. Subsequent office medical services are covered. A professional visit to a nursing homeis covered and shallinclude thefeeforan oral examination. A professional visit to a hospital is covered and shall include the fee for an oral examination. A consultation by a dentist is a covered service and shall include the fee for an oral examination;
7. (I) Extractions. Extraction fees for permanent and deciduous teeth, as listed in the Medicaid Dental Manual, apply whether the service is performed in the office, hospital or ambulatory surgical center. Preoperative X rays involving extractions may be covered but postoperative X rays are not covered;
8. (J) Preventive Treatment. Fluonde treatment may be covered but is limited to the applieat,ion of stannous fluoride or acid phosphate fluoride. Sodium flnoride treatments are not covered. Fluoride treatment shall include both the upper and lower arch and shall be a separate service from prophylaxis. Fluoride treatment for recipients under age twenty-one (21) is covered. Fluoride treatment for recipients age twenty-one (21) and over is limited to individuals with rampant caries, or those who are undergoing radiation therapy to head and neck, or those with diminished salivary flow, or individuals who are mentally retarded or have cemental or roof surface caries secondary to gingival recession. For recipients ages five through twenty (5&O), topical application of sealants as outlined in Section 19 of the Medicaid Dental Manual is covered. Dietary planning, oral hygiene instruction and training in preventive dental care are not covered;
9. (K) Hospital Dental Care. Dental services provided in an inpatient hospital or an outpatient hospital place of service are subject to the same general benefits and limitations applicable to all dental services and all are not selectively restricted based on place of service;

10. (L) Injections. Procedure codes for the injections which are covered shall be shown in Section 19 of the Dental Manual; !Mj Oral Surgery (or Other Qualified Dentist Specialist). Oral surgery is limited to medi,cally necessary care. Cosmetic oral surgeries shall not be paid. Procedures as covered for a certified oral surgeon ior other

    -

qualified dentist specialist) shall be indicated in the Medicaid Dental Manual. A medically necessary oral surgery procedure not specifically listed in the Medicaid Dental Manual may be billed using the procedure code identified in the dental manual as Unspecified. The Unspecified procedure must be explained on the claim form.

1. (N) Orthodontic Treatment/Space Management Therapy. Medically necessary minor orthodontic appliances for interceptive and oral development as listed in the Medicaid Dental Manual are covered. Fixed space maintainers are covered for the premature loss of deciduous teeth. Medically necessary orthodontic treatment and space maintainers for recipients under age twentyone (21) is covered when indicated by an EPSDT screen and prior authorized;
2. (0) Periodontie Treatment. A gingivectomy or gingivolplasty is allowed for epileptic patients on Dilantin therapy, or medically necessary drug-induced hyperplasia. Limited occlusaI adjustment is covered when it is necessary as emergency treatment. Other periodontiz procedures are not covered;
3. (P) Prophylaxis (Preventive). Prophylaxis may beacoveredservicefor theupperarch, the lower arch or both arches. Prophylaxis shall be a separate service from fluoride treatment and shall include scaling and polishing of the teeth;
4. (Q) Pulp Treatment (Endodontic). A pulpotomy on deciduous teeth is covered and shall include complete amputation of the vital coronal nerve, with placement of a suitable drug over the remaining exposed tissue. The fee excludes final restoration. Pulp vitality tests and pulp caps are not covered;

5. (R) Restorations (Fillings). Fees for any restorative care listed in the Medicaid Dental Manual apply whether the service is performed in the office, hospital, ambulatory surgical center or nursing facility. Amalgam fillings are covered for Class I, Class II and Class V restorations on posterior teeth. A maximum fee shall apply for any one (1) posterior tooth and shall include polishing, local anesthesia and treatment base. Silicate cement, acrylic or composite fillings are not covered for Class I and Class II restorations but are covered for Class III, Class IV and Class V restorations on anterior teeth. A maximum fee shall apply for any one (1) anterior tooth and shall include polishing, local anesthesia and treatment base. Fillings of other materials are not covered, except when a sedative filling is necessary as emergency treatment. x rays may be covered; iSi Root Canal Theranv (Endodontic). Root c&l therapy is a co&d’service for ~&manent teeth. The fee excludes final restoration but includes all in treatment X rays.

   Ray 0. Blunt

   (l/5/93) secretary Of Sib

Pre-operative and postoperative X rays may be reimbursed. An apicoectomy is a covered service for permanent teeth but not on the same day as a root canal. Excluding a pulpotomy, other endodontic procedures are not covered; and

1. (T) X rays. X rays shall not be submitted routinely with a request for prior authorization or with a claim, unless the practitioner shall have been specifically requested to submit X rays. X my8 shall be taken at the discretion of the dental practitioner. Films which are not of diagnosticvalue shallnotbe cleimed. Xrays to be covered shall be ofthe intraoral type, except when a panoramic-type film is required. A preoperative full-mouth X-ray survey of permanent or deciduous teeth, or mixed dentition, is covered as described in the MedicaidDentalManual. Medically necessary X rays of an edentulous mouth are covered.

1. (10) General Regulations. General regulations ofthe Missouri Medicaid program apply to the dental program.

   Auth: sections 208.152, RSMo (Cum SUPP. 19901,208.153, RSMo (Cum. Supp. 1991) and 208.201, RSMo (Supp. 19871.’ This rule was previously filed as 13 CSR 40-81.040. ‘&.&al rule filed Jan. 21, 1964, effective Jan. 31, 1964. Amended: Filed March 30, 1964, ejjectiue April 9, 1964. Amended: Filed April 27, 1965, ejjectiue May 7, 1965. Amended: Filed Dec. 7, 1966, effective Dec. 17, 1966. Amended: Filed Oct. 13, 1967, ejjectectiue Oct. 23, 1967. Amended: Filed Jan. 22, 1968, ejfectiue Feb. 1, 1968. Amended: Filed Aug. 24, 1968, ejjectiue Sept. 3, 1968. Amended: Filed April 16, 1970, effective April 26, 1970. Amended: Filed Feb. 16, 1971, ejjectiue Feb. 26, 1971. Amended: Filed Jan. 3, 1973, efjective Jan. 13, 1973. Amended: Filed Feb. 6, 1975, ejjectiue Feb. 16, 1975. Amended: Piled July 9,1976, ejjective Oct. 11,1976. Amended: Filed Feb. 7, 1977, effective May 11, 1977. Amended: Filed Nou. 14, 1977, efjecteetiue Feb. 11, 1978. Emergency re~cx~~on jiled June 14, 1979, ejfeetiue July 31, 1979, expired Sept. 13, 1979. Emergency rule filed June 14, 1979, effective Aug. 1, 1979, expired Sept. 13, 1979. Rescinded and readopted: Filed June 14, 1979, ejjectiue Sept. 14, 1979. Emergency amendment jiled April 10, 1981, ejjectectiue April 20, 1981, expired July 10, 1981. Amended: Filed April 10, 1981, ejjectiue July 11,1981. Emergency amendment jiled Sept. l&1981, ejjectiue 13, Oct. 1, 1981, expired Jan. 1982. Amended: Filed Sept. 18, 1981, ejfectiue Jan. 14, 1982. Amended: Filed July 15,

   Roy D. Blunt (l/5/93) seentaiy Of state 13 CSR 70-35 , ‘Es

1991, effective Nov. 30, 1991. Amended: Filed Aug. 14, 1992, effective Feb. 26, 1993. “Original authority: 208.152, RSMo (19671, amended 1969, 1971, 1972, 1973, 1975, 1977, 1978, 1981, 1986, 1988, 1990; 208.153, RSMo 119671, amended 1973, 1989, 1990, 1991; and 208.201, RSMo (1987).

._

COOEOF STATE REGULATIONS 13CSR70-35-SOCIALSERVICES

GTE COPY

Ray 0. Blunt

(l/5/93) seclbtaly Of state

1. 1. Inpatient Hospital
2. 2. Outpatient Hospital
3. 3. Office
4. 4. Home
5. 7. Nursing Home

Roy D. Blunt (l/5/93) Type of Service Code

1. 7. Dental Services

Place of Service Codes 13 CSR 70-35 ,

m

1. 8. Skilled Nursing Facility
2. 9. Ambulance
3. 0. Other Locations
4. A. Independent Laboratory
5. C. Emergency 13 CSR70-35-SOCIALSERVICES Division 704livision

MISSOURI DEPARTMENT OF SOCIAL SERVICES DIVISION OF MEDICAL SERVICES PRIOR AUTHORIZATION REQUEST

8 CODE OF STATE REGULATIONS (l/5/93) of Medical Services

RETURN TO: GTE DATA SERVICES P. 0. BOX 5700 JEFFERSON CITY. MO 65107

Roy D. Blunt Lcreflry 01 state 13 CSR 70-35

THIS FORM IS TO BE USED FOR EPSDT (HCY) RELATED SERVICES ONLY

FlELD NUMBER AND NAME - ,NSTR”CTfONS FOR COMPLETION 1. 1. 2. 3. 4. 5. 6. 7. 8. 9. II. 10. 11. 12. 13. 14, 15. Of. 16. 17. 18. 19, 20. 2,. 22. 23. 24.

I”. 25. 26. 27. 28,

V.

Roy !I. Blunt (l/5/93) CODE OF STATE REGULATIONS *ecratary Of state 13 CSR70-35-SOCIALSERVICES

This form must be completed provided to any eligible Missouri zation Form. Please be sure

Recipient’s Name

Recipient’s Medicaid

Recipient’s Address

Dentist’s Name __

Dentist’s Medicaid Provider Number

I certify that the recipient will be in the bes: ability or impairment

I further certify that

TO SE COMPLETED ONLY

1 certify that the dentist

I certify that / initiated

*If the recipient is unable was unable to sign. TITLE XIX MISSOURI

DENTAL CERTIFICATION

in conjunction recipient.

this form

Identification Number

initiated the

interest of the recipient which will prevent

full absorption has

IF SERVICES ARE PROVIDED

named above.

the request for

to sign the with all dentures Attach

is comoieted in full.

request for and that the normal use and benefit

taken place.

has obtained my approval

this service.

form, detailed MEDICAID PROGRAM

FORM

either partial or full: initial or replacement,

the completed form to the Request for Prior Authori-

Recipient’s Birthdate ~

the described seTvice( that providing the service(s) the recipient does not have any physical or mental disthereof.

IN A NURSING HOME

to provide services in this nursing home.

information must be included as to why the recipient

(l/5/93) Roy 0. Blunt SEI.INY Of state