PURPOSE: This rule describes the dental services for which the MO HealthNet Division shall pay when the service is provided to an eligible assistance participant; the service is provided by a licensed dentist, licensed dental hygienist, or licensed and certified dental specialist who has entered into an agreement for that purpose with the division; and the service is listed as a covered item in the MO HealthNet Dental Manual sponsored by the division. The MO HealthNet Dental Manual describes the dental services which shall be paid under limitations and those which shall not be paid under present conditions.

PUBLISHER’S NOTE: The secretary of state has determined that the publication of the entire text of the material which is incorporated by reference as a portion of this rule would be unduly cumbersome or expensive. This material as incorporated by reference in this rule shall be maintained by the agency at its headquarters and shall be made available to the public for inspection and copying at no more than the actual cost of reproduction. This note applies only to the reference material. The entire text of the rule is printed here.

1. (1) Administration. The MO HealthNet dental program shall be administered by the MO HealthNet Division, 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 MO HealthNet Division and shall be included in the MO HealthNet Dental Provider Manual, which is incorporated by reference and made part of this rule as published by the Department of Social Services, MO HealthNet Division, 615 Howerton Court, Jefferson City, MO 65109, at its website at www.dss.mo.gov/mhd, September 15, 2009. This rule does not incorporate any subsequent amendments or additions. Dental services covered by the MO HealthNet 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 MO HealthNet 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 services under the MO HealthNet program. 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 MO HealthNet program. A dental hygienist shall be licensed by the dental board of the state for at least three
3. (3) consecutive years and practicing in a public health setting to provide fluoride treatments, teeth cleaning, and sealants to MO HealthNet/MO HealthNet for Kids eligible children ages zero (0) to twenty (20).

4. (3) Participant Eligibility. The MO HealthNet dental provider shall ascertain the patient’s MO HealthNet status before any service is performed. The participant’s MO Health- Net/MO HealthNet for Kids eligibility is determined by the Family Support Division. The participant’s eligibility shall be verified from a current MO HealthNet/MO HealthNet for Kids identification card or a letter of new approval in the participant’s possession. The patient must be a MO HealthNet eligible participant under the MO HealthNet/MO HealthNet for Kids program on the date the service is performed. The MO HealthNet Division is not allowed to pay for any service to a patient who is not eligible under the MO HealthNet/MO HealthNet for Kids program.

   1. (A) MO HealthNet reimbursement of dental services shall be limited to MO HealthNet eligible children or persons receiving MO HealthNet under a category of assistance for pregnant women or the blind.
   2. (B) MO HealthNet participants living in a nursing facility will not experience dental service reductions. Nursing facility level of care must be indicated on the MO HealthNet eligibility file. When providing dental services to a participant who is living in a nursing facility providers should continue to submit claims to MO HealthNet. MO HealthNet eligible nursing facility residents will have payments for dental care adjudicated through the MO HealthNet claims payment system.
   3. (C) For all other eligibility categories of MO HealthNet assistance dental services will only be reimbursed if the dental care is related to trauma of the mouth, jaw, teeth, or other contiguous sites as a result of injury or 13 CSR 70-35

as related to a medical condition when a written referral from the participant’s physician states the absence of dental treatment would adversely affect the stated pre-existing medical condition.

1. 1. Reimbursement for dental care shall be

limited to those procedure codes identified in section (19) of the MO HealthNet Dental Provider Manual which may be referenced at www.dss.mo.gov/mhd; and

1. 2. Participants must have a written refer-

ral from their physician stating the absence of dental treatment would adversely affect the stated pre-existing medical condition. This referral must be maintained in the patient’s record and made available to the MO Health- Net Division or its agent upon request.

1. (4) Prior Authorization. When prior authorization is required, the form provided by the MO HealthNet Division 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 MO HealthNet eligible participant on the date the service is performed. The division reserves the right to request documentation regarding any specific request for prior authorization.
2. (5) Services, Covered and Noncovered. The MO HealthNet Dental Manual shall provide the detailed listing of procedure codes for services covered by the MO HealthNet Dental Program. Pricing information can be obtained from the fee schedule posted at www.dss.mo.gov/mhd/providers/pages/cptagree.htm.
3. (6) General Regulations. General regulations of the MO HealthNet program apply to the dental program.
4. (7) Records Retention. Sanctions may be imposed by the MO HealthNet agency against a provider for failing to make available, and disclosing to the MO HealthNet agency or its authorized agents, all records relating to services provided to MO HealthNet participants or records related to MO HealthNet payments, whether or not the records are comingled with non-MO HealthNet records in compliance with 13 CSR 70-3.030. These records must be retained for five (5) years from the date of service. Fiscal and medical records coincide with and fully document services billed to the MO HealthNet agency. Providers must furnish or make the records available for inspection or audit by the Department of Social Services or its representative upon request. Failure to furnish, reveal, or retain adequate documentation for services billed to the MO HealthNet program, as specified above, is a violation of this regulation.

AUTHORITY: sections 208.152, 208.153, and 208.201, RSMo Supp. 2008.* This rule was previously filed as 13 CSR 40-81.040. Original rule filed Jan. 21, 1964, effective Jan. 31, 1964. Amended: Filed March 30, 1964, effective April 9, 1964. Amended: Filed April 27, 1965, effective May 7, 1965. Amended: Filed Dec. 7, 1966, effective Dec. 17, 1966. Amended: Filed Oct. 13, 1967, effective Oct. 23, 1967. Amended: Filed Jan. 22, 1968, effective Feb. 1, 1968. Amended: Filed Aug. 24, 1968, effective Sept. 3, 1968. Amended: Filed April 16, 1970, effective April 26, 1970. Amended: Filed Feb. 16, 1971, effective Feb. 26, 1971. Amended: Filed Jan. 3, 1973, effective Jan. 13, 1973. Amended: Filed Feb. 6, 1975, effective Feb. 16, 1975. Amended: Filed July 9, 1976, effective Oct. 11, 1976. Amended: Filed Feb. 7, 1977, effective May 11, 1977. Amended: Filed Nov. 14, 1977, effective Feb. 11, 1978. Emergency rescission filed June 14, 1979, effective 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, effective Sept. 14, 1979. Emergency amendment filed April 10, 1981, effective April 20, 1981, expired July 10, 1981. Amended: Filed April 10, 1981, effective July 11, 1981. Emergency amendment filed Sept. 18, 1981, effective Oct. 1, 1981, expired Jan. 13, 1982. Amended: Filed Sept. 18, 1981, effective Jan. 14, 1982. Amended: Filed July 15, 1991, effective Nov. 30, 1991. Amended: Filed Aug. 14, 1992, effective Feb. 26, 1993. Emergency amendment filed June 27, 2002, effective July 7, 2002, terminated Dec. 17, 2002. Emergency amendment filed Aug. 19, 2005, effective Sept. 1, 2005, expired Feb. 27, 2006. Amended: Filed June 15, 2005, effective Jan. 30, 2006. Amended: Filed Aug. 17, 2009, effective Feb. 28, 2010. *Original authority: 208.152, RSMo 1967, amended 1969, 1971, 1972, 1973, 1975, 1977, 1978, 1978, 1981, 1986, 1988, 1990, 1992, 1993, 2004, 2005, 2007; 208.153, RSMo 1967, amended 1973, 1989, 1990, 1991, 2007; and 208.201, RSMo 1987, amended 2007.