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Dental/denturist Services


Published: 2015

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The Oregon Administrative Rules contain OARs filed through November 15, 2015

 
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OREGON HEALTH AUTHORITY, DIVISION OF MEDICAL ASSISTANCE PROGRAMS




 

DIVISION 123
DENTAL/DENTURIST SERVICES

410-123-1000
Eligibility, Providing Services and Billing
(1) Eligibility:
(a) Providers are responsible to verify client eligibility
and must do so before providing any service or billing the Division of Medical Assistance
Programs (Division) or any Oregon Health Plan (OHP) Prepaid Health Plan (PHP);
(b) The Division may not pay for services
provided to an ineligible client even if services were authorized. Refer to General
Rules OAR 410-120-1140 (Verification of Eligibility) for details.
(2) Co-payments for OHP clients
may be required for certain services. See General Rules OAR 410-120-1230 for specific
information on co-pays.
(3) Billing:
(a) Providers must follow the
Division rules in effect on the date of service. All Division rules are intended
to be used in conjunction with the Division’s General Rules Program (chapter
410, division 120), the OHP Administrative Rules (chapter 410, division 141), Pharmaceutical
Services Rules (chapter 410, division 121) and other relevant Division OARs applicable
to the service provided, where the service is delivered, and the qualifications
of the person providing the service including the requirement for a signed provider
enrollment agreement;
(b) Third Party Resources: A
third party resource (TPR) is an alternate insurance resource, other than the Division,
available to pay for medical/dental services and items on behalf of OHP clients.
Any alternate insurance resource must be billed before the Division or any OHP PHP
can be billed. Indian Health Services or Tribal facilities are not considered to
be a TPR pursuant to the Division’s General Rules Program rule (OAR 410-120-1280);
(c) Fabricated Prosthetics:
(A) If a dentist or denturist
provides an eligible client with fabricated prosthetics that require the use of
a dental laboratory, the date of the final impressions must have occurred:
(i) Prior to the client’s
loss of eligibility; and
(ii) For dentures for adults
age 21 and older, no later than six months from the date of the last extraction
from the jaw for which the denture is being provided;
(B) The dentist/denturist should
use the date of final impression as the date of service only when criteria in (A)
is met and the fabrication extends beyond:
(i) The client’s OHP eligibility;
or
(ii) Six months after the extractions
(for dentures for adults);
(C) The date of delivery must
be within 45 days of the date of the final impression and the date of delivery must
also be indicated on the claim. These are the only exceptions to the Division’s
General Rules Program rule (OAR 410-120-1280). All other services must be billed
using the date the service was provided;
(d) Refer to OAR 410-123-1160
for information regarding dental services requiring prior authorization (PA). Refer
to OAR 410-123-1100 for information regarding dental services that require providers
to submit reports for review (“by report” - BR) prior to reimbursement;
(e) The client's records must
include documentation to support the appropriateness of the service and level of
care rendered;
(f) The Division shall only
reimburse for dental services that are dentally appropriate as defined in OAR 410-123-1060;
(g) Refer to OAR chapter 410,
division 147 for information about reimbursement for dental services provided through
a Federally Qualified Health Center (FQHC) or Rural Health Center (RHC);
(4) Treatment Plans: Being consistent
with established dental office protocol and the standard of care within the community,
scheduling of appointments is at the discretion of the dentist. The agreed upon
treatment plan established by the dentist and patient shall establish appointment
sequencing. Eligibility for medical assistance programs does not entitle a client
to any services or consideration not provided to all clients.
Stat. Auth.: ORS 413.042 &
414.065

Stats. Implemented: ORS 414.065

Hist.: HR 3-1994, f. & cert.
ef. 2-1-94; HR 20-1995, f. 9-29-95, cert. ef. 10-1-95; OMAP 13-1998(Temp), f. &
cert. ef. 5-1-98 thru 9-1-98; OMAP 28-1998, f. & cert. ef. 9-1-98; OMAP 23-1999,
f. & cert. ef. 4-30-99; OMAP 17-2000, f. 9-28-00, cert. ef. 10-1-00; OMAP 48-2002,
f. & cert. ef. 10-1-02; OMAP 65-2003, f. 9-10-03 cert. ef. 10-1-03; DMAP 25-2007,
f. 12-11-07, cert, ef. 1-1-08; DMAP 18-2008, f. 6-13-08, cert. ef. 7-1-08; DMAP
41-2009, f. 12-15-09, cert. ef. 1-1-10; DMAP 14-2010, f. 6-10-10, cert. ef. 7-1-10;
DMAP 31-2010, f. 12-15-10, cert. ef. 1-1-11; DMAP 45-2011, f. 12-21-11, cert. ef.
12-23-11; DMAP 46-2011, f. 12-23-11, cert. ef. 1-1-12
410-123-1060
Definition of Terms
(1) Anesthesia — The following
depicts the Division of Medical Assistance Programs’ (Division) usage of certain
anesthesia terms; however, for further details refer also to the Oregon Board of
Dentistry administrative rules (OAR chapter 818, division 026):
(a) Conscious Sedation:
(A) Deep Sedation —
A drug-induced depression of consciousness during which patients cannot be easily
aroused but respond purposefully following repeated or painful stimulation. The
ability to independently maintain ventilatory function may be impaired. Patients
may require assistance maintaining a patient airway, and spontaneous ventilation
may be inadequate. Cardiovascular function is usually maintained;
(B) Minimal Sedation —
A minimally depressed level of consciousness produced by non-intravenous pharmacological
methods that retains the patient’s ability to independently and continuously
maintain an airway and respond normally to tactile stimulation and verbal command.
When the intent is minimal sedation for adults, the appropriate initial dosing of
a single non-intravenous pharmacological method is no more than the maximum recommended
dose (MRD) of a drug that can be prescribed for unmonitored home use. Nitrous oxide/oxygen
may be used in combination with a single non-intravenous pharmacological method
in minimal sedation;
(C) Moderate Sedation —
A drug-induced depression of consciousness during which the patient responds purposefully
to verbal commands, either alone or accompanied by light tactile stimulation. No
interventions are required to maintain a patient airway, and spontaneous ventilation
is adequate. Cardiovascular function is usually maintained;
(b) General Anesthesia —
A drug-induced loss of consciousness during which the patient is not arousable even
by painful stimulation. The ability to independently maintain ventilatory function
is often impaired. Patients often require assistance in maintaining a patient airway,
and positive pressure ventilation may be required because of depressed spontaneous
ventilation or drug-induced depression of neuromuscular function. Cardiovascular
function may be impaired;
(c) Local Anesthesia —
The elimination of sensation, especially pain, in one part of the body by the topical
application or regional injection of a drug;
(d) Nitrous Oxide Sedation
— An induced controlled state of minimal sedation produced solely by the inhalation
of a combination of nitrous oxide and oxygen in which the patient retains the ability
to independently and continuously maintain an airway and to respond purposefully
to physical stimulation and to verbal command;
(2) Citizen/Alien-Waived
Emergency Medical (CAWEM) — Refer to OAR 410-120-0000 for definition of clients
who are eligible for limited emergency services under the CAWEM benefit package.
The definition of emergency services does not apply to CAWEM clients. OAR 410-120-1210
provides a complete description of limited emergency coverage pertaining to the
CAWEM benefit package.
(3) Covered Services —
Services on the Health Evidence Review Commission's (HERC) Prioritized List of Health
Services (Prioritized List) that have been funded by the legislature and identified
in specific program rules. Services are limited as directed by General Rules —
Excluded Services and Limitations (OAR 410-120-1200), the Division’s Dental
Services Program rules (chapter 410, division 123), and the Prioritized List. Services
that are not considered emergency dental services as defined by 410-123-1060(12)
are considered routine services.
(4) Dental Hygienist —
A person licensed to practice dental hygiene pursuant to state law.
(5) Dental Hygienist with
Expanded Practice Dental Hygiene Permit (EPDH) — A person licensed to practice
dental hygiene with an EPDH permit issued by the Board of Dentistry and within the
scope of an EPDH permit pursuant to state law.
(6) Dental Practitioner —
A person licensed pursuant to state law to engage in the provision of dental services
within the scope of the practitioner's license and/or certification.
(7) Dental Services —
Services provided within the scope of practice as defined under state law by or
under the supervision of a dentist or dental hygienist or denture services provided
within the scope of practice as defined under state law by a denturist.
(8) Dental Services Documentation
— Shall meet the requirements of the Oregon Dental Practice Act statutes;
administrative rules for client records and requirements of OAR 410-120-1360, "Requirements
for Financial, Clinical and Other Records;" and any other documentation requirements
as outlined in the Dental rules.
(9) Dentally Appropriate
— In accordance with OAR 410-141-0000, services that are required for prevention,
diagnosis, or treatment of a dental condition and that are:
(a) Consistent with the symptoms
of a dental condition or treatment of a dental condition;
(b) Appropriate with regard
to standards of good dental practice and generally recognized by the relevant scientific
community, evidence-based medicine, and professional standards of care as effective;
(c) Not solely for the convenience
of an OHP member or a provider of the service; and
(d) The most cost effective
of the alternative levels of dental services that can be safely provided to a member.
(10) Dentist — A person
licensed to practice dentistry pursuant to state law.
(11) Denturist — A
person licensed to practice denture technology pursuant to state law.
(12) Direct Pulp Cap —
The procedure in which the exposed pulp is covered with a dressing or cement that
protects the pulp and promotes healing and repair.
(13) Emergency Services:
(a) Refer to OAR 410-120-0000
for the complete definition of emergency services. (This definition of emergency
services does not apply to CAWEM clients. 410-120-1210 provides a complete description
of limited emergency coverage pertaining to the CAWEM benefit package);
(b) Covered services for
an emergency dental condition manifesting itself by acute symptoms of sufficient
severity requiring immediate treatment. This includes services to treat the following
conditions:
(A) Acute infection;
(B) Acute abscesses;
(C) Severe tooth pain;
(D) Unusual swelling of the
face or gums; or
(E) A tooth that has been
avulsed (knocked out);
(c) The treatment of an emergency
dental condition is limited only to covered services. The Division recognizes that
some non-covered services may meet the criteria of treatment for the emergency condition;
however, this rule does not extend to those non-covered services. Routine dental
treatment or treatment of incipient decay does not constitute emergency care;
(14) Hospital Dentistry —
Dental services normally done in a dental office setting but due to specific client
need (as detailed in OAR 410-123-1490) are provided in an ambulatory surgical center,
inpatient, or outpatient hospital setting under general anesthesia (or IV conscious
sedation, if appropriate).
(15) Medical Practitioner
— A person licensed pursuant to state law to engage in the provision of medical
services within the scope of the practitioner's license and certification.
(16) Procedure Codes —
The procedure codes in the Dental Services rulebook (OAR chapter 410, division 123)
refer to Current Dental Terminology (CDT), unless otherwise noted. Codes listed
in this rulebook and other documents incorporated in rule by reference are subject
to change by the American Dental Association (ADA) without notification.
(17) Standard of Care —
What reasonable and prudent practitioners would do in the same or similar circumstances.
Stat. Auth.: ORS 413.042, 414.065
Stats. Implemented: ORS 414.065
Hist.: HR 3-1994, f. &
cert. ef. 2-1-94; OMAP 13-1998(Temp), f. & cert. ef. 5-1-98 thru 9-1-98; OMAP
28-1998, f. & cert. ef. 9-1-98; OMAP 23-1999, f. & cert. ef. 4-30-99; OMAP
17-2000, f. 9-28-00, cert. ef. 10-1-00; OMAP 48-2002, f. & cert. ef. 10-1-02;
OMAP 49-2004, f. 7-28-04 cert. ef. 8-1-04; DMAP 25-2007, f. 12-11-07, cert, ef.
1-1-08; DMAP 16-2009 f. 6-12-09, cert. ef. 7-1-09; DMAP 41-2011, f. 12-21-11, cert.
ef. 1-1-12; DMAP 46-2011, f. 12-23-11, cert. ef. 1-1-12; DMAP 13-2013, f. 3-27-13,
cert. ef. 4-1-13; DMAP 75-2013(Temp), f. 12-31-13, cert. ef. 1-1-14 thru 6-30-14;
DMAP 36-2014, f. & cert. ef. 6-27-14
410-123-1100
Services Reviewed by the Division of Medical Assistance Programs (Division)
(1) Services requiring prior authorization (PA): See OAR 410-123-1160 for information about services that require PA and how to request PA.
(2) By Report Procedures:
(a) Request for payment for dental services listed as “by report” (BR), or services not included in the procedure code listing must be submitted with a full description of the procedure, including relevant operative or clinical history reports and/or radiographs. Payment for BR procedures will be approved in consultation with a Division of Medical Assistance Program (Division) dental consultant;
(b) Refer to the “Covered and Non-Covered Dental Services” document for a list of procedures noted as BR. See OAR 410-123-1220.
(3) Treatment Justification: The Division may request the treating dentist to submit appropriate radiographs or other clinical information that justifies the treatment:
(a) Before issuing PA;
(b) In the process of utilization/post payment review; or
(c) In determining responsibility for payment of dental services.
Stat. Auth.: ORS 413.042 & 414.065

Stats. Implemented: ORS 414.065

Hist.: HR 3-1994, f. & cert. ef. 2-1-94; HR 32-1994, f. & cert. ef. 11-1-94; OMAP 48-2002, f. & cert. ef. 10-1-02; DMAP 25-2007, f. 12-11-07, cert, ef. 1-1-08; DMAP 16-2009 f. 6-12-09, cert. ef. 7-1-09
410-123-1160
Prior Authorization
(1) Division of Medical Assistance Programs
(Division) prior authorization (PA) requirements:
(a) For fee-for-service (FFS)
dental clients, the following services require PA:
(A) Crowns (porcelain fused
to metal);
(B) Crown repair;
(C) Retreatment of previous
root canal therapy — anterior;
(D) Complete dentures;
(E) Immediate dentures;
(F) Partial dentures;
(G) Prefabricated post and
core in addition to fixed partial denture retainer;
(H) Fixed partial denture
repairs;
(I) Skin graft; and
(J) Orthodontics (when covered
pursuant to OAR 410-123-1260);
(b) Hospital dentistry always
requires PA, regardless of the client’s enrollment status. Refer to OAR 410-123-1490
for more information;
(c) Oral surgical services
require PA when performed in an ambulatory surgical center (ASC) or an outpatient
or inpatient hospital setting and related anesthesia. Refer to OAR 410-123-1260
(Oral Surgery Services), and the current Medical Surgical Services administrative
rule 410-130-0200 for information;
(d) Maxillofacial surgeries
may require PA in some instances. Refer to the current Medical Surgical Services
administrative rule 410-130-0200, for information.
(2) The Division does not
require PA for outpatient or inpatient services related to life-threatening emergencies.
The client's clinical record must document any appropriate clinical information
that supports the need for the hospitalization.
(3) How to request PA:
(a) Submit the request to
the Division in writing. Refer to the Dental Services Provider Guide for specific
instructions and forms to use. Telephone calls requesting PA will not be accepted;
(b) Treatment justification:
The Division may request the treating dentist to submit appropriate radiographs
or other clinical information that justifies the treatment:
(A) When radiographs are
required they must be:
(i) Readable copies;
(ii) Mounted or loose;
(iii) In an envelope, stapled
to the PA form;
(iv) Clearly labeled with
the dentist's name and address and the client's name; and
(v) If digital x-ray, they
must be of photo quality;
(B) Do not submit radiographs
unless it is required by the Dental Services administrative rules or they are requested
during the PA process.
(4) The Division will issue
a decision on PA requests within 30 days of receipt of the request. The Division
will provide PA for services when:
(a) The prognosis is favorable;
(b) The treatment is practical;
(c) The services are dentally
appropriate; and
(d) A lesser-cost procedure
would not achieve the same ultimate results.
(5) PA does not guarantee
eligibility or reimbursement. It is the responsibility of the provider to check
the client's eligibility on the date of service.
(6) For certain services
and billings, the Division will seek a general practice consultant or an oral surgery
consultant for professional review to determine if a PA will be approved. The Division
will deny PA if the consultant decides that the clinical information furnished does
not support the treatment of services.
(7) For managed care PA requirements:
(a) For services other than
hospital dentistry, contact the client’s Dental Care Organization (DCO) for
PA requirements for individual services and/or supplies listed in the Dental Services
administrative rules. DCOs may not have the same PA requirements for dental services
as listed in this administrative rule;
(b) For hospital dentistry,
refer to OAR 410-123-1490 for details regarding PA requirements.
Stat. Auth.: ORS 413.042, 414.065
Stats. Implemented: ORS 414.065
Hist.: HR 3-1994, f. &
cert. ef. 2-1-94; HR 32-1994, f. & cert. ef. 11-1-94; OMAP 23-1999, f. &
cert. ef. 4-30-99; OMAP 17-2000, f. 9-28-00, cert. ef. 10-1-00; OMAP 48-2002, f.
& cert. ef. 10-1-02; DMAP 25-2007, f. 12-11-07, cert, ef. 1-1-08; DMAP 38-2008,
f. 12-11-08, cert. ef. 1-1-09; DMAP 16-2009 f. 6-12-09, cert. ef. 7-1-09; DMAP 41-2009,
f. 12-15-09, cert. ef. 1-1-10; DMAP 14-2010, f. 6-10-10, cert. ef. 7-1-10; DMAP
13-2013, f. 3-27-13, cert. ef. 4-1-13; DMAP 28-2013(Temp), f. 6-26-13, cert. ef.
7-1-13 thru 12-28-13; Administrative correction, 2-5-14
410-123-1200
Services Not To Be Billed Separately
(1) Services that are not to be billed
separately may be included in the Current Dental Terminology (CDT) codebook and
may not be listed as combined with another procedure; however, they are considered
to be either minimal, included in the examination, part of another service, or included
in routine post-op or follow-up care.
(2) The following services
do not warrant an additional fee:
(a) Alveolectomy/Alveoloplasty
in conjunction with extractions;
(b) Cardiac and other monitoring;
(c) Caries risk assessment
and documentation;
(d) Curettage and root planing
— per tooth;
(e) Diagnostic casts;
(f) Dietary counseling;
(g) Direct pulp cap;
(h) Discing;
(i) Dressing change;
(j) Electrosurgery;
(k) Equilibration;
(l) Gingival curettage —
per tooth;
(m) Gingival irrigation;
(n) Gingivectomy or gingivoplasty
to allow for access for restorative procedure, per tooth;
(o) Indirect pulp cap;
(p) Local anesthesia;
(q) Medicated pulp chambers;
(r) Occlusal adjustments;
(s) Occlusal analysis;
(t) Odontoplasty;
(u) Oral hygiene instruction;
(v) Periodontal charting,
probing;
(w) Post removal;
(x) Polishing fillings;
(y) Post extraction treatment
for alveolaritis (dry socket treatment) if done by the provider of the extraction;
(z) Pulp vitality tests;
(aa) Smooth broken tooth;
(bb) Special infection control
procedures;
(cc) Surgical procedure for
isolation of tooth with rubber dam;
(dd) Surgical splint;
(ee) Surgical stent; and
(ff) Suture removal.
Stat. Auth.: ORS 413.042, 414.065
Stats. Implemented: ORS 414.065
Hist.: HR 3-1994, f. &
cert. ef. 2-1-94; HR 32-1994, f. & cert. ef. 11-1-94; OMAP 48-2002, f. &
cert. ef. 10-1-02; DMAP 25-2007, f. 12-11-07, cert, ef. 1-1-08; DMAP 13-2013, f.
3-27-13, cert. ef. 4-1-13; DMAP 75-2013(Temp), f. 12-31-13, cert. ef. 1-1-14 thru
6-30-14; DMAP 19-2014(Temp), f. 3-28-14, cert. ef. 4-1-14 thru 6-30-14; DMAP 36-2014,
f. & cert. ef. 6-27-14
410-123-1220
Coverage According to the Prioritized List
of Health Services
(1) This rule incorporates by reference
the “Covered and Non-Covered Dental Services” document, dated October
1, 2015, and located on the Division of Medical Assistance Programs’ (Division)
website at: http://www.oregon.gov/oha/healthplan/Pages/dental.aspx.
(a) The “Covered and
Non-Covered Dental Services” document lists coverage of Current Dental Terminology
(CDT) procedure codes according to the Oregon Health Evidence Review Commission
(HERC) Prioritized List of Health Services (Prioritized List) and the client’s
specific Oregon Health Plan benefit package;
(b) This document is subject
to change if there are funding changes to the Prioritized List.
(2) Changes to services funded
on the Prioritized List are effective on the date of the Prioritized List change:
(a) The Division administrative
rules (chapter 410, division 123) will not reflect the most current Prioritized
List changes until they have gone through the Division rule filing process;
(b) For the most current
Prioritized List, refer to the HERC website at www.oregon.gov/oha/herc/Pages/PrioritizedList.aspx;
(c) In the event of an alleged
variation between a Division-listed code and a national code, the Division shall
apply the national code in effect on the date of request or date of service.
(3) Refer to OAR 410-123-1260
for information about limitations on procedures funded according to the Prioritized
List. Examples of limitations include frequency and client’s age.
(4) The Prioritized List
does not include or fund the following general categories of dental services, and
the Division does not cover them for any client. Several of these services are considered
elective or “cosmetic” in nature (i.e., done for the sake of appearance):
(a) Desensitization;
(b) Implant and implant services;
(c) Mastique or veneer procedure;
(d) Orthodontia (except when
it is treatment for cleft palate);
(e) Overhang removal;
(f) Procedures, appliances,
or restorations solely for aesthetic or cosmetic purposes;
(g) Temporomandibular joint
dysfunction treatment; and
(h) Tooth bleaching.
Stat. Auth.: ORS 413.042 & 414.065
Stats. Implemented: ORS 414.065
Hist.: HR 3-1994, f. &
cert. ef. 2-1-94; HR 21-1994(Temp), f. 4-29-94, cert. ef. 5-1-94; HR 32-1994, f.
& cert. ef. 11-1-94; HR 20-1995, f. 9-29-95, cert. ef. 10-1-95; HR 9-1996, f.
5-31-96, cert. ef. 6-1-96; OMAP 13-1998(Temp), f. & cert. ef. 5-1-98 thru 9-1-98;
OMAP 28-1998, f. & cert. ef. 9-1-98; OMAP 23-1999, f. & cert. ef. 4-30-99;
OMAP 8-2000, f. 3-31-00, cert. ef. 4-1-00; OMAP 17-2000, f. 9-28-00, cert. ef. 10-1-00;
OMAP 48-2002, f. & cert. ef. 10-1-02; OMAP 3-2003, f. 1-31-03, cert. ef. 2-1-03;
OMAP 65-2003, f. 9-10-03 cert. ef. 10-1-03; DMAP 25-2007, f. 12-11-07, cert, ef.
1-1-08; DMAP 38-2008, f. 12-11-08, cert. ef. 1-1-09; DMAP 16-2009 f. 6-12-09, cert.
ef. 7-1-09; DMAP 41-2009, f. 12-15-09, cert. ef. 1-1-10; DMAP 14-2010, f. 6-10-10,
cert. ef. 7-1-10; DMAP 31-2010, f. 12-15-10, cert. ef. 1-1-11; DMAP 17-2011, f.
& cert. ef. 7-12-11; DMAP 41-2011, f. 12-21-11, cert. ef. 1-1-12; DMAP 46-2011,
f. 12-23-11, cert. ef. 1-1-12; DMAP 13-2013, f. 3-27-13, cert. ef. 4-1-13; DMAP
7-2015(Temp), f. & cert. ef. 2-17-15 thru 8-15-15; DMAP 28-2015, f. & cert.
ef. 5-1-15; DMAP 46-2015(Temp), f. 8-26-15, cert. ef. 10-1-15 thru 3-28-16; DMAP
65-2015, f. 11-3-15, cert. ef. 12-1-15
410-123-1230
Buying-Up
(1) Buying-up as defined in OAR 410-120-0000 is prohibited.
(2) Providers are not permitted to bill and accept payment from the Division of Medical Assistance Programs (Division) or a managed care plan for a covered service when:
(a) A non-covered service has been provided; and
(b) Additional payment is sought or accepted from the client.
(3) If a client wants to purchase a non-covered service or item, the client must be responsible for full payment. A payment from the Division or the managed care plan for a covered service cannot be credited toward the non-covered service and then an additional client payment sought to obtain, for example, a gold crown (not covered) instead of the stainless steel crown (covered).
Stat. Auth.: ORS 413.042 & 414.065

Stats. Implemented: ORS 414.065

Hist.: OMAP 14-1999(T), f. & cert. ef. 4-1-99 thru 9-1-99; OMAP 29-1999, f. 6-9-99, cert. ef. 6-10-99; OMAP 48-2002, f. & cert. ef. 10-1-02; DMAP 38-2008, f. 12-11-08, cert. ef. 1-1-09
410-123-1240
The Dental Claim Invoice
(1) Providers: Refer to the Dental Services
Provider Guide for information regarding claims submissions and billing information.
(2) Providers billing dental
services on paper must use the 2012 version of the American Dental Association (ADA)
claim form.
(3) Submission of electronic
claims directly or through an agent must comply with the Electronic Data Interchange
(EDI) rules. OAR 943-120-0100 et seq.
(4) Specific information
regarding Health Insurance Portability and Accountability Act (HIPAA) requirements
can be found on the Division Web site.
(5) Providers will not include
any client co-payments on the claim when billing for dental services.
Stat. Auth.: ORS 413.042, 414.065
Stats. Implemented: ORS 414.065
Hist.: HR 3-1994, f. &
cert. ef. 2-1-94; OMAP 28-1998, f. & cert. ef. 9-1-98; OMAP 23-1999, f. &
cert. ef. 4-30-99; OMAP 8-2000, f. 3-31-00, cert. ef. 4-1-00; OMAP 17-2000, f. 9-28-00,
cert. ef. 10-1-00; OMAP 48-2002, f. & cert. ef. 10-1-02; OMAP 76-2002, f. 12-24-02,
cert. ef. 1-1-03; OMAP 65-2003, f. 9-10-03 cert. ef. 10-1-03; OMAP 55-2004, f. 9-10-04,
cert. ef. 10-1-04; OMAP 36-2005, f. & cert. ef. 8-1-05; DMAP 25-2007, f. 12-11-07,
cert, ef. 1-1-08; DMAP 38-2008, f. 12-11-08, cert. ef. 1-1-09; DMAP 13-2013, f.
3-27-13, cert. ef. 4-1-13; DMAP 47-2015(Temp), f. 8-26-15, cert. ef. 10-1-15 thru
3-28-16
410-123-1260
OHP Plus Dental Benefits
(1) GENERAL:
(a) Early and Periodic Screening,
Diagnosis and Treatment (EPSDT):
(A) Refer to Code of Federal
Regulations (42 CFR 441, Subpart B) and OAR chapter 410, division 120 for definitions
of the EPSDT program, eligible clients, and related services. EPSDT dental services
include, but are not limited to:
(i) Dental screening services
for eligible EPSDT individuals; and
(ii) Dental diagnosis and
treatment that is indicated by screening at as early an age as necessary, needed
for relief of pain and infections, restoration of teeth, and maintenance of dental
health;
(B) Providers shall provide
EPSDT services for eligible Division of Medical Assistance Programs (Division) clients
according to the following documents:
(i) The Dental Services Program
administrative rules (OAR chapter 410, division 123), for dentally appropriate services
funded on the Oregon Health Evidence Review Commission’s Prioritized List
of Health Services (Prioritized List); and
(ii) The “Oregon Health
Plan (OHP) — Recommended Dental Periodicity Schedule,” dated January
1, 2010, incorporated in rule by reference and posted on the Division website in
the Dental Services Provider Guide document at www.oregon.gov/oha/healthplan/Pages/dental.aspx;
(b) Restorative, periodontal,
and prosthetic treatments:
(A) Documentation shall be
included in the client’s charts to support the treatment. Treatments shall
be consistent with the prevailing standard of care and may be limited as follows:
(i) When prognosis is unfavorable;
(ii) When treatment is impractical;
(iii) A lesser-cost procedure
would achieve the same ultimate result; or
(iv) The treatment has specific
limitations outlined in this rule;
(B) Prosthetic treatment,
including porcelain fused to metal crowns, are limited until rampant progression
of caries is arrested and a period of adequate oral hygiene and periodontal stability
is demonstrated; periodontal health needs to be stable and supportive of a prosthetic.
(2) ENHANCED ORAL HEALTH
SERVICES IN PRIMARY CARE SETTINGS:
(a) Topical fluoride treatment:
(A) For children under 19
years of age, topical fluoride varnish may be applied by a licensed medical practitioner
during a medical visit. Providers must bill:
(i) The Division directly
when the client is fee-for-service (FFS), is enrolled in a Coordinated Care Organization
(CCO) that does not include integrated medical and dental services, or is enrolled
in a PHP that does not include integrated medical and dental services;
(ii) The client’s CCO
if the client is enrolled in a CCO that includes integrated medical and dental services;
(iii) Using a professional
claim format with either the appropriate Current Dental Terminology (CDT) code (D1206-Topical
Fluoride Varnish) or the appropriate Current Procedural Terminology (CPT) code (99188
- Application of topical fluoride varnish by a physician or other qualified health
care professional);
(B) Topical fluoride treatment
from a medical practitioner counts toward the overall maximum number of fluoride
treatments, as described in subsection (4) of this rule;
(b) Assessment of a patient:
(A) For children under six
years of age, CDT code D0191-Assessment of a Patient is covered as an enhanced oral
health service in medical settings;
(B) For reimbursement in
a medical setting, D0191-Assessment of a patient must include all of the following
components:
(i) Caries risk assessment
using a standardized tool endorsed by Oregon Oral Health Coalition, the American
Dental Association, the American Academy of Pediatric Dentistry, or the American
Academy of Pediatrics;
(ii) Anticipatory guidance
and counseling with the client’s caregiver on good oral hygiene practices
and nutrition;
(iii) Referral to a dentist
in order to establish a dental home;
(iv) Documentation in medical
chart of risk assessment findings and service components provided;
(C) For reimbursement, the
performing provider must meet all of the following criteria:
(i) Be a physician (MD or
DO), an advance practice nurse, or a licensed physician assistant; and
(ii) Hold a certificate of
completion from one of the following approved training programs within the previous
three years:
(I) Smiles for Life; or
(II) First Tooth through
the Oregon Oral Health Coalition;
(D) For reimbursement, the
medical practitioners must bill:
(i) The Division directly
when the client is fee-for-service (FFS), is enrolled in a Coordinated Care Organization
(CCO) that does not include integrated medical and dental services, or is enrolled
in a PHP that does not include integrated medical and dental services;
(ii) The client’s CCO
if the client is enrolled in a CCO that includes integrated medical and dental services;
(iii) Using a professional
claim format with the appropriate CDT code (D0191-Assessment of a Patient);
(E) D0191 Assessment of a
Patient may be reimbursed under this subsection up to a maximum of once every 12
months;
(F) D0191 Assessment of a
Patient from a medical practitioner does not count toward the maximum number of
CDT code D0191-Assessment of a Patient services performed by a dental practitioner
described in subsection three (3) of this rule;
(c) For tobacco cessation
services provided during a medical visit, follow criteria outlined in OAR 410-130-0190;
(3) DIAGNOSTIC SERVICES:
(a) Exams:
(A) For children under 19
years of age:
(i) The Division shall reimburse
exams (billed as CDT codes D0120, D0145, D0150, or D0180) a maximum of twice every
12 months with the following limitations:
(I) D0150: once every 12
months when performed by the same practitioner;
(II) D0150: twice every 12
months only when performed by different practitioners;
(III) D0180: once every 12
months;
(ii) The Division shall reimburse
D0160 only once every 12 months when performed by the same practitioner;
(B) For adults 19 years of
age and older, the Division shall reimburse exams (billed as CDT codes D0120, D0150,
D0160, or D0180) once every 12 months;
(C) For problem focused exams
(urgent or emergent problems), the Division shall reimburse D0140 for the initial
exam. The Division shall reimburse D0170 for related problem-focused follow-up exams.
Providers must not bill D0140 and D0170 for routine dental visits;
(D) The Division only covers
oral exams performed by medical practitioners when the medical practitioner is an
oral surgeon;
(E) As the American Dental
Association’s Current Dental Terminology (CDT) codebook specifies, the evaluation,
diagnosis, and treatment planning components of the exam are the responsibility
of the dentist. The Division may not reimburse dental exams when performed by a
dental hygienist (with or without an expanded practice permit);
(b) Assessment of a patient
(D0191):
(A) When performed by a dental
practitioner, the Division shall reimburse:
(i) If performed by a dentist
outside of a dental office;
(ii) If performed by a dental
hygienist with an expanded practice dental hygiene permit;
(iii) Only if an exam (D0120-D0180)
is not performed on the same date of service. Assessment of a patient (D0191) is
included as part of an exam (D0120-D0180);
(iv) For children under 19
years of age, a maximum of twice every 12 months; and
(v) For adults age 19 and
older, a maximum of once every 12 months;
(B) An assessment does not
take the place of the need for oral evaluations/exams;
(c) Radiographs:
(A) The Division shall reimburse
for routine radiographs once every 12 months;
(B) The Division shall reimburse
bitewing radiographs for routine screening once every 12 months;
(C) The Division shall reimburse
a maximum of six radiographs for any one emergency;
(D) For clients under age
six, radiographs may be billed separately every 12 months as follows:
(i) D0220 — once;
(ii) D0230 — a maximum
of five times;
(iii) D0270 — a maximum
of twice, or D0272 once;
(E) The Division shall reimburse
for panoramic (D0330) or intra-oral complete series (D0210) once every five years,
but both cannot be done within the five-year period;
(F) Clients shall be a minimum
of six years old for billing intra-oral complete series (D0210). The minimum standards
for reimbursement of intra-oral complete series are:
(i) For clients age six through
11- a minimum of ten periapicals and two bitewings for a total of 12 films;
(ii) For clients ages 12
and older - a minimum of ten periapicals and four bitewings for a total of 14 films;
(G) If fees for multiple
single radiographs exceed the allowable reimbursement for a full mouth complete
series (D0210), the Division shall reimburse for the complete series;
(H) Additional films may
be covered if dentally or medically appropriate, e.g., fractures (Refer to OAR 410-123-1060
and 410-120-0000);
(I) If the Division determines
the number of radiographs to be excessive, payment for some or all radiographs of
the same tooth or area may be denied;
(J) The exception to these
limitations is if the client is new to the office or clinic and the office or clinic
is unsuccessful in obtaining radiographs from the previous dental office or clinic.
Supporting documentation outlining the provider's attempts to receive previous records
shall be included in the client's records;
(K) Digital radiographs,
if printed, shall be on photo paper to assure sufficient quality of images.
(4) PREVENTIVE SERVICES:
(a) Prophylaxis:
(A) For children under 19
years of age — Limited to twice per 12 months;
(B) For adults 19 years of
age and older — Limited to once per 12 months;
(C) Additional prophylaxis
benefit provisions may be available for persons with high risk oral conditions due
to disease process, pregnancy, medications, or other medical treatments or conditions,
severe periodontal disease, rampant caries and for persons with disabilities who
cannot perform adequate daily oral health care;
(D) Are coded using the appropriate
Current Dental Terminology (CDT) coding:
(i) D1110 (Prophylaxis —
Adult) — Use for clients 14 years of age and older; and
(ii) D1120 (Prophylaxis —
Child) — Use for clients under 14 years of age;
(b) Topical fluoride treatment:
(A) For adults 19 years of
age and older — Limited to once every 12 months;
(B) For children under 19
years of age — Limited to twice every 12 months;
(C) Additional topical fluoride
treatments may be available, up to a total of four treatments per client within
a 12-month period, when high-risk conditions or oral health factors are clearly
documented in chart notes for clients who:
(i) Have high-risk oral conditions
due to disease process, medications, other medical treatments or conditions, or
rampant caries;
(ii) Are pregnant;
(iii) Have physical disabilities
and cannot perform adequate, daily oral health care;
(iv) Have a developmental
disability or other severe cognitive impairment that cannot perform adequate, daily
oral health care; or
(v) Are under seven years
old with high-risk oral health factors, such as poor oral hygiene, deep pits and
fissures (grooves) in teeth, severely crowded teeth, poor diet, etc.;
(D) Fluoride limits include
any combination of fluoride varnish (D1206) or other topical fluoride (D1208);
(c) Sealants (D1351):
(A) Are covered only for
children under 16 years of age;
(B) The Division limits coverage
to:
(i) Permanent molars; and
(ii) Only one sealant treatment
per molar every five years, except for visible evidence of clinical failure;
(d) Tobacco cessation:
(A) For services provided
during a dental visit, bill as a dental service using CDT code D1320 when the following
brief counseling is provided:
(i) Ask patients about their
tobacco-use status at each visit and record information in the chart;
(ii) Advise patients on their
oral health conditions related to tobacco use and give direct advice to quit using
tobacco and a strong personalized message to seek help; and
(iii) Refer patients who
are ready to quit, utilizing internal and external resources, to complete the remaining
three A’s (assess, assist, arrange) of the standard intervention protocol
for tobacco;
(B) The Division allows a
maximum of ten services within a three-month period;
(e) Space management:
(A) The Division shall cover
fixed and removable space maintainers (D1510, D1515, D1520, and D1525) only for
clients under 19 years of age;
(B) The Division may not
reimburse for replacement of lost or damaged removable space maintainers.
(5) RESTORATIVE SERVICES:
(a) Amalgam and resin-based
composite restorations, direct:
(A) Resin-based composite
crowns on anterior teeth (D2390) are only covered for clients under 21 years of
age or who are pregnant;
(B) The Division reimburses
posterior composite restorations at the same rate as amalgam restorations;
(C) The Division limits payment
for replacement of posterior composite restorations to once every five years;
(D) The Division limits payment
of covered restorations to the maximum restoration fee of four surfaces per tooth.
Refer to the American Dental Association (ADA) CDT codebook for definitions of restorative
procedures;
(E) Providers shall combine
and bill multiple surface restorations as one line per tooth using the appropriate
code. Providers may not bill multiple surface restorations performed on a single
tooth on the same day on separate lines. For example, if tooth #30 has a buccal
amalgam and a mesial-occlusal-distal (MOD) amalgam, then bill MOD, B, using code
D2161 (four or more surfaces);
(F) The Division may not
reimburse for an amalgam or composite restoration and a crown on the same tooth;
(G) Interim therapeutic restoration
on primary dentition (D2941) is covered to restore and prevent progression of dental
caries. Interim therapeutic restoration is not a definitive restoration.
(H) Reattachment of tooth
fragment (D2921) is covered once in the lifetime of a tooth when there is no pulp
exposure and no need for endodontic treatment.
(I) The Division reimburses
for a surface not more than once in each treatment episode regardless of the number
or combination of restorations;
(J) The restoration fee includes
payment for occlusal adjustment and polishing of the restoration;
(b) Indirect crowns and related
services:
(A) General payment policies:
(i) The fee for the crown
includes payment for preparation of the gingival tissue;
(ii) The Division shall cover
crowns only when:
(I) There is significant
loss of clinical crown and no other restoration will restore function; and
(II) The crown-to-root ratio
is 50:50 or better, and the tooth is restorable without other surgical procedures;
(iii) The Division shall
cover core buildup (D2950) only when necessary to retain a cast restoration due
to extensive loss of tooth structure from caries or a fracture and only when done
in conjunction with a crown. Less than 50 percent of the tooth structure must be
remaining for coverage of the core buildup.
(iv) Reimbursement of retention
pins (D2951) is per tooth, not per pin;
(B) The Division shall not
cover the following services:
(i) Endodontic therapy alone
(with or without a post);
(ii) Aesthetics (cosmetics);
(iii) Crowns in cases of
advanced periodontal disease or when a poor crown/root ratio exists for any reason;
(C) The Division shall cover
acrylic heat or light cured crowns (D2970 temporary crown, fractured tooth) —
allowed only for anterior permanent teeth;
(D) The Division shall cover
the following only for clients under 21 years of age or who are pregnant:
(i) Prefabricated plastic
crowns (D2932) are allowed only for anterior teeth, permanent or primary;
(ii) Stainless steel crowns
(D2930/D2931) are allowed only for anterior primary teeth and posterior permanent
or primary teeth;
(iii) Prefabricated stainless
steel crowns with resin window (D2933) are allowed only for anterior teeth, permanent
or primary;
(iv) Prefabricated post and
core in addition to crowns (D2954/D2957);
(v) Permanent crowns (resin-based
composite — D2710 and D2712, and porcelain fused to metal (PFM) — D2751
and D2752) as follows:
(I) Limited to teeth numbers
6–11, 22 and 27 only, if dentally appropriate;
(II) Limited to four in a
seven-year period. This limitation includes any replacement crowns allowed according
to (E)(i) of this rule;
(III) Only for clients at
least 16 years of age; and
(IV) Rampant caries are arrested,
and the client demonstrates a period of oral hygiene before prosthetics are proposed;
(vi) PFM crowns (D2751 and
D2752) shall also meet the following additional criteria:
(I) The dental practitioner
has attempted all other dentally appropriate restoration options and documented
failure of those options;
(II) Written documentation
in the client’s chart indicates that PFM is the only restoration option that
will restore function;
(III) The dental practitioner
submits radiographs to the Division for review; history, diagnosis, and treatment
plan may be requested. (See OAR 410-123-1100 Services Reviewed by the Division);
(IV) The client has documented
stable periodontal status with pocket depths within 1–3 millimeters. If PFM
crowns are placed with pocket depths of 4 millimeters and over, documentation shall
be maintained in the client’s chart of the dentist’s findings supporting
stability and why the increased pocket depths will not adversely affect expected
long-term prognosis;
(V) The crown has a favorable
long-term prognosis; and
(VI) If the tooth to be crowned
is a clasp/abutment tooth in partial denture, both prognosis for the crown itself
and the tooth’s contribution to partial denture shall have favorable expected
long-term prognosis;
(E) Crown replacement:
(i) Permanent crown replacement
limited to once every seven years;
(ii) All other crown replacement
limited to once every five years; and
(iii) The Division may make
exceptions to crown replacement limitations due to acute trauma, based on the following
factors:
(I) Extent of crown damage;
(II) Extent of damage to
other teeth or crowns;
(III) Extent of impaired
mastication;
(IV) Tooth is restorable
without other surgical procedures; and
(V) If loss of tooth would
result in coverage of removable prosthetic;
(F) Crown repair (D2980)
is limited to only anterior teeth.
(6) ENDODONTIC SERVICES:
(a) Endodontic therapy:
(A) Pulpal therapy on primary
teeth (D3230 and D3240) is covered only for clients under 21 years of age;
(B) For permanent teeth:
(i) Anterior and bicuspid
endodontic therapy (D3310 and D3320) is covered for all OHP Plus clients; and
(ii) Molar endodontic therapy
(D3330):
(I) For clients through age
20, is covered only for first and second molars; and
(II) For clients age 21 and
older who are pregnant, is covered only for first molars;
(C) The Division covers endodontics
only if the crown-to-root ratio is 50:50 or better and the tooth is restorable without
other surgical procedures;
(b) Endodontic retreatment
and apicoectomy:
(A) The Division does not
cover retreatment of a previous root canal or apicoectomy for bicuspid or molars;
(B) The Division limits either
a retreatment or an apicoectomy (but not both procedures for the same tooth) to
symptomatic anterior teeth when:
(i) Crown-to-root ratio is
50:50 or better;
(ii) The tooth is restorable
without other surgical procedures; or
(iii) If loss of tooth would
result in the need for removable prosthodontics;
(C) Retrograde filling (D3430)
is covered only when done in conjunction with a covered apicoectomy of an anterior
tooth;
(c) The Division does not
allow separate reimbursement for open-and-drain as a palliative procedure when the
root canal is completed on the same date of service or if the same practitioner
or dental practitioner in the same group practice completed the procedure;
(d) The Division covers endodontics
if the tooth is restorable within the OHP benefit coverage package;
(e) Apexification/recalcification
procedures:
(A) The Division limits payment
for apexification to a maximum of five treatments on permanent teeth only;
(B) Apexification/recalcification
procedures are covered only for clients under 21 years of age or who are pregnant.
(7) PERIODONTIC SERVICES:
(a) Surgical periodontal
services:
(A) Gingivectomy/Gingivoplasty
(D4210 and D4211) — limited to coverage for severe gingival hyperplasia where
enlargement of gum tissue occurs that prevents access to oral hygiene procedures,
e.g., Dilantin hyperplasia; and
(B) Includes six months routine
postoperative care;
(C) The Division shall consider
gingivectomy or gingivoplasty to allow for access for restorative procedure, per
tooth (D4212) as part of the restoration and will not provide a separate reimbursement
for this procedure;
(b) Non-surgical periodontal
services:
(A) Periodontal scaling and
root planing (D4341 and D4342):
(i) For clients through age
20, allowed once every two years;
(ii) For clients age 21 and
over, allowed once every three years;
(iii) A maximum of two quadrants
on one date of service is payable, except in extraordinary circumstances;
(iv) Quadrants are not limited
to physical area, but are further defined by the number of teeth with pockets 5
mm or greater:
(I) D4341 is allowed for
quadrants with at least four or more teeth with pockets 5 mm or greater;
(II) D4342 is allowed for
quadrants with at least two teeth with pocket depths of 5 mm or greater;
(v) Prior authorization for
more frequent scaling and root planing may be requested when:
(I) Medically/dentally necessary
due to periodontal disease as defined above is found during pregnancy; and
(II) Client’s medical
record is submitted that supports the need for increased scaling and root planing;
(B) Full mouth debridement
(D4355):
(i) For clients through age
20, allowed only once every two years;
(ii) For clients age 21 and
older, allowed once every three years;
(c) Periodontal maintenance
(D4910):
(A) For clients through age
20, allowed once every six months;
(B) For clients age 21 and
older:
(i) Limited to following
periodontal therapy (surgical or non-surgical) that is documented to have occurred
within the past three years;
(ii) Allowed once every twelve
months;
(iii) Prior authorization
for more frequent periodontal maintenance may be requested when:
(I) Medically/dentally necessary,
such as due to presence of periodontal disease during pregnancy; and
(II) Client’s medical
record is submitted that supports the need for increased periodontal maintenance
(chart notes, pocket depths and radiographs);
(d) Records shall clearly
document the clinical indications for all periodontal procedures, including current
pocket depth charting and/or radiographs;
(e) The Division may not
reimburse for procedures identified by the following codes if performed on the same
date of service:
(A) D1110 (Prophylaxis —
adult);
(B) D1120 (Prophylaxis —
child);
(C) D4210 (Gingivectomy or
gingivoplasty — four or more contiguous teeth or bounded teeth spaces per
quadrant);
(D) D4211 (Gingivectomy or
gingivoplasty — one to three contiguous teeth or bounded teeth spaces per
quadrant);
(E) D4341 (Periodontal scaling
and root planning — four or more teeth per quadrant);
(F) D4342 (Periodontal scaling
and root planning — one to three teeth per quadrant);
(G) D4355 (Full mouth debridement
to enable comprehensive evaluation and diagnosis); and
(H) D4910 (Periodontal maintenance).
(8) REMOVABLE PROSTHODONTIC
SERVICES:
(a) Clients age 16 years
and older are eligible for removable resin base partial dentures (D5211-D5212) and
full dentures (complete or immediate, D5110-D5140);
(b) The Division limits full
dentures for clients age 21 and older to only those clients who are recently edentulous:
(A) For the purposes of this
rule:
(i) "Edentulous" means all
teeth removed from the jaw for which the denture is being provided; and
(ii) "Recently edentulous"
means the most recent extractions from that jaw occurred within six months of the
delivery of the final denture (or, for fabricated prosthetics, the final impression)
for that jaw;
(B) See OAR 410-123-1000
for detail regarding billing fabricated prosthetics;
(c) The fee for the partial
and full dentures includes payment for adjustments during the six-month period following
delivery to clients;
(d) Resin partial dentures
(D5211-D5212):
(A) The Division may not
approve resin partial dentures if stainless steel crowns are used as abutments;
(B) For clients through age
20, the client shall have one or more anterior teeth missing or four or more missing
posterior teeth per arch with resulting space equivalent to that loss demonstrating
inability to masticate. Third molars are not a consideration when counting missing
teeth;
(C) For clients age 21 and
older, the client shall have one or more missing anterior teeth or six or more missing
posterior teeth per arch with documentation by the provider of resulting space causing
serious impairment to mastication. Third molars are not a consideration when counting
missing teeth;
(D) The dental practitioner
shall note the teeth to be replaced and teeth to be clasped when requesting prior
authorization (PA);
(e) Replacement of removable
partial or full dentures, when it cannot be made clinically serviceable by a less
costly procedure (e.g., reline, rebase, repair, tooth replacement), is limited to
the following:
(A) For clients at least
16 years and under 21 years of age, the Division shall replace full or partial dentures
once every ten years, only if dentally appropriate. This does not imply that replacement
of dentures or partials shall be done once every ten years, but only when dentally
appropriate;
(B) For clients 21 years
of age and older, the Division may not cover replacement of full dentures but shall
cover replacement of partial dentures once every ten (10) years only if dentally
appropriate;
(C) The ten year limitations
apply to the client regardless of the client’s OHP or Dental Care Organization
(DCO)/Coordinated Care Organization (CCO) enrollment status at the time the client’s
last denture or partial was received. For example: A client receives a partial on
February 1, 2002, and becomes a FFS OHP client in 2005. The client is not eligible
for a replacement partial until February 1, 2012. The client gets a replacement
partial on February 3, 2012 while FFS and a year later enrolls in a DCO or CCO.
The client would not be eligible for another partial until February 3, 2022, regardless
of DCO, CCO, or FFS enrollment;
(D) Replacement of partial
dentures with full dentures is payable ten years after the partial denture placement.
Exceptions to this limitation may be made in cases of acute trauma or catastrophic
illness that directly or indirectly affects the oral condition and results in additional
tooth loss. This pertains to, but is not limited to, cancer and periodontal disease
resulting from pharmacological, surgical, and medical treatment for aforementioned
conditions. Severe periodontal disease due to neglect of daily oral hygiene may
not warrant replacement;
(f) The Division limits reimbursement
of adjustments and repairs of dentures that are needed beyond six months after delivery
of the denture as follows for clients 21 years of age and older:
(A) A maximum of four times
per year for:
(i) Adjusting complete and
partial dentures, per arch (D5410-D5422);
(ii) Replacing missing or
broken teeth on a complete denture, each tooth (D5520);
(iii) Replacing broken tooth
on a partial denture, each tooth (D5640);
(iv) Adding tooth to existing
partial denture (D5650);
(B) A maximum of two times
per year for:
(i) Repairing broken complete
denture base (D5510);
(ii) Repairing partial resin
denture base (D5610);
(iii) Repairing partial cast
framework (D5620);
(iv) Repairing or replacing
broken clasp (D5630);
(v) Adding clasp to existing
partial denture (D5660);
(g) Replacement of all teeth
and acrylic on cast metal framework (D5670, D5671):
(A) Is covered for clients
age 16 and older a maximum of once every ten (10) years, per arch;
(B) Ten years or more shall
have passed since the original partial denture was delivered;
(C) Is considered replacement
of the partial so a new partial denture may not be reimbursed for another ten years;
and
(D) Requires prior authorization
as it is considered a replacement partial denture;
(h) Denture rebase procedures:
(A) The Division shall cover
rebases only if a reline may not adequately solve the problem;
(B) For clients through age
20, the Division limits payment for rebase to once every three years;
(C) For clients age 21 and
older:
(i) There shall be documentation
of a current reline that has been done and failed; and
(ii) The Division limits
payment for rebase to once every five years;
(D) The Division may make
exceptions to this limitation in cases of acute trauma or catastrophic illness that
directly or indirectly affects the oral condition and results in additional tooth
loss. This pertains to, but is not limited to, cancer and periodontal disease resulting
from pharmacological, surgical, and medical treatment for aforementioned conditions.
Severe periodontal disease due to neglect of daily oral hygiene may not warrant
rebasing;
(i) Denture reline procedures:
(A) For clients through age
20, the Division limits payment for reline of complete or partial dentures to once
every three years;
(B) For clients age 21 and
older, the Division limits payment for reline of complete or partial dentures to
once every five years;
(C) The Division may make
exceptions to this limitation under the same conditions warranting replacement;
(D) Laboratory relines:
(i) Are not payable prior
to six months after placement of an immediate denture; and
(ii) For clients through
age 20, are limited to once every three years;
(iii) For clients age 21
and older, are limited to once every five years;
(j) Interim partial dentures
(D5820-D5821, also referred to as “flippers”):
(A) Are allowed if the client
has one or more anterior teeth missing; and
(B) The Division shall reimburse
for replacement of interim partial dentures once every five years but only when
dentally appropriate;
(k) Tissue conditioning:
(A) Is allowed once per denture
unit in conjunction with immediate dentures; and
(B) Is allowed once prior
to new prosthetic placement;
(9) MAXILLOFACIAL PROSTHETIC
SERVICES:
(a) Fluoride gel carrier
(D5986) is limited to those patients whose severity of oral disease causes the increased
cleaning and fluoride treatments allowed in rule to be insufficient. The dental
practitioner shall document failure of those options prior to use of the fluoride
gel carrier;
(b) All other maxillofacial
prosthetics (D5900-D5999) are medical services. Refer to the “Covered and
Non-Covered Dental Services” document and OAR 410-123-1220:
(A) Bill for medical maxillofacial
prosthetics using the professional (CMS1500, DMAP 505 or 837P) claim format:
(B) For clients receiving
services through a CCO or PHP, bill medical maxillofacial prosthetics to the CCO
or PHP;
(C) For clients receiving
medical services through FFS, bill the Division.
(10) ORAL SURGERY SERVICES:
(a) Bill the following procedures
in an accepted dental claim format using CDT codes:
(A) Procedures that are directly
related to the teeth and supporting structures that are not due to a medical condition
or diagnosis, including such procedures performed in an ambulatory surgical center
(ASC) or an inpatient or outpatient hospital setting;
(B) Services performed in
a dental office setting or an oral surgeon’s office:
(i) Such services include,
but are not limited to, all dental procedures, local anesthesia, surgical postoperative
care, radiographs, and follow-up visits;
(ii) Refer to OAR 410-123-1160
for any PA requirements for specific procedures;
(b) Bill the following procedures
using the professional claim format and the appropriate American Medical Association
(AMA) CPT procedure and ICD-10 diagnosis codes:
(A) Procedures that are a
result of a medical condition (i.e., fractures, cancer);
(B) Services requiring hospital
dentistry that are the result of a medical condition/diagnosis (i.e., fracture,
cancer);
(c) Refer to the “Covered
and Non-Covered Dental Services” document to see a list of CDT procedure codes
on the Prioritized List that may also have CPT medical codes. See OAR 410-123-1220.
The procedures listed as “medical” on the table may be covered as medical
procedures, and the table may not be all-inclusive of every dental code that has
a corresponding medical code;
(d) For clients enrolled
in a DCO or CCO responsible for dental services, the DCO or CCO shall pay for those
services in the dental plan package;
(e) Oral surgical services
performed in an ASC or an inpatient or outpatient hospital setting:
(A) Require PA;
(B) For clients enrolled
in a CCO or FCHP, the CCO or FCHP shall pay for the facility charge and anesthesia
services. For clients enrolled in a Physician Care Organization (PCO), the PCO shall
pay for the outpatient facility charge (including ASCs) and anesthesia. Refer to
the current Medical Surgical Services administrative rules in OAR chapter 410, division
130 for more information;
(C) If a client is enrolled
in a CCO or PHP, the provider shall contact the CCO or PHP for any required authorization
before the service is rendered;
(f) All codes listed as “by
report” require an operative report;
(g) The Division covers payment
for tooth re-implantation only in cases of traumatic avulsion where there are good
indications of success;
(h) Biopsies collected are
reimbursed as a dental service. Laboratory services of biopsies are reimbursed as
a medical service;
(i) The Division does not
cover surgical excisions of soft tissue lesions (D7410-D7415);
(j) Extractions — Includes
local anesthesia and routine postoperative care, including treatment of a dry socket
if done by the provider of the extraction. Dry socket is not considered a separate
service;
(k) Surgical extractions:
(A) Include local anesthesia
and routine post-operative care;
(B) The Division limits payment
for surgical removal of impacted teeth or removal of residual tooth roots to treatment
for only those teeth that have acute infection or abscess, severe tooth pain, or
unusual swelling of the face or gums;
(C) The Division does not
cover alveoloplasty in conjunction with extractions (D7310 and D7311) separately
from the extraction;
(D) The Division covers alveoplasty
not in conjunction with extractions (D7320-D7321) only for clients under 21 years
of age or who are pregnant;
(l) Frenulectomy/frenulotomy
(D7960) and frenuloplasty (D7963):
(A) The Division covers either
frenulectomy or frenuloplasty once per lifetime per arch only for clients under
age 21;
(B) The Division covers maxillary
labial frenulectomy only for clients age 12 through 20;
(C) The Division shall cover
frenulectomy/frenuloplasty in the following situations:
(i) When the client has ankyloglossia;
(ii) When the condition is
deemed to cause gingival recession; or
(iii) When the condition
is deemed to cause movement of the gingival margin when the frenum is placed under
tension;
(m) The Division covers excision
of pericoronal gingival (D7971) only for clients under age 21 or who are pregnant.
(11) ORTHODONTIA SERVICES:
(a) The Division limits orthodontia
services and extractions to eligible clients:
(A) With the ICD-10-CM diagnosis
of:
(i) Cleft palate; or
(ii) Cleft palate with cleft
lip; and
(B) Whose orthodontia treatment
began prior to 21 years of age; or
(C) Whose surgical corrections
of cleft palate or cleft lip were not completed prior to age 21;
(b) PA is required for orthodontia
exams and records. A referral letter from a physician or dentist indicating diagnosis
of cleft palate or cleft lip shall be included in the client's record and a copy
sent with the PA request;
(c) Documentation in the
client's record shall include diagnosis, length, and type of treatment;
(d) Payment for appliance
therapy includes the appliance and all follow-up visits;
(e) Orthodontists evaluate
orthodontia treatment for cleft palate/cleft lip as two phases. Stage one is generally
the use of an activator (palatal expander), and stage two is generally the placement
of fixed appliances (banding). The Division shall reimburse each phase separately;
(f) The Division shall pay
for orthodontia in one lump sum at the beginning of each phase of treatment. Payment
for each phase is for all orthodontia-related services. If the client transfers
to another orthodontist during treatment, or treatment is terminated for any reason,
the orthodontist shall refund to the Division any unused amount of payment after
applying the following formula: Total payment minus $300.00 (for banding) multiplied
by the percentage of treatment remaining;
(g) The Division shall use
the length of the treatment plan from the original request for authorization to
determine the number of treatment months remaining;
(h) As long as the orthodontist
continues treatment, the Division may not require a refund even though the client
may become ineligible for medical assistance sometime during the treatment period;
(i) Code:
(A) D8660 — PA required
(reimbursement for required orthodontia records is included);
(B) Codes D8010-D8690 —
PA required.
(12) ADJUNCTIVE GENERAL AND
OTHER SERVICES:
(a) Fixed partial denture
sectioning (D9120) is covered only when extracting a tooth connected to a fixed
prosthesis and a portion of the fixed prosthesis is to remain intact and serviceable,
preventing the need for more costly treatment;
(b) Anesthesia:
(A) Only use general anesthesia
or IV sedation for those clients with concurrent needs: age; physical, medical or
mental status; or degree of difficulty of the procedure (D9220, D9221, D9241 and
D9242);
(B) The Division reimburses
providers for general anesthesia or IV sedation as follows:
(i) D9220 or D9241: For the
first 30 minutes;
(ii) D9221 or D9242: For
each additional 15-minute period, up to three hours on the same day of service.
Each 15-minute period represents a quantity of one. Enter this number in the quantity
column;
(C) The Division reimburses
administration of Nitrous Oxide (D9230) per date of service, not by time;
(D) Oral pre-medication anesthesia
for conscious sedation (D9248):
(i) Limited to clients under
13 years of age;
(ii) Limited to four times
per year;
(iii) Includes payment for
monitoring and Nitrous Oxide; and
(iv) Requires use of multiple
agents to receive payment;
(E) Upon request, providers
shall submit a copy of their permit to administer anesthesia, analgesia, and sedation
to the Division;
(F) For the purpose of Title
XIX and Title XXI, the Division limits payment for code D9630 to those oral medications
used during a procedure and is not intended for "take home" medication;
(c) The Division limits reimbursement
of house/extended care facility call (D9410) only for urgent or emergent dental
visits that occur outside of a dental office. This code is not reimbursable for
provision of preventive services or for services provided outside of the office
for the provider or facilities’ convenience;
(d) Oral devices/appliances
(E0485, E0486):
(A) These may be placed or
fabricated by a dentist or oral surgeon but are considered a medical service;
(B) Bill the Division, CCO,
or the PHP for these codes using the professional claim format.
Stat. Auth.: ORS 413.042 & 414.065
Stats. Implemented: ORS 414.065
Hist.: HR 3-1994, f. &
cert. ef. 2-1-94; HR 20-1995, f. 9-29-95, cert. ef. 10-1-95; OMAP 13-1998(Temp),
f. & cert. ef. 5-1-98 thru 9-1-98; OMAP 28-1998, f. & cert. ef. 9-1-98;
OMAP 23-1999, f. & cert. ef. 4-30-99; OMAP 8-2000, f. 3-31-00, cert. ef. 4-1-00;
OMAP 17-2000, f. 9-28-00, cert. ef. 10-1-00; OMAP 48-2002, f. & cert. ef. 10-1-02;
OMAP 3-2003, f. 1-31-03, cert. ef. 2-1-03; OMAP 65-2003, f. 9-10-03 cert. ef. 10-1-03;
OMAP 55-2004, f. 9-10-04, cert. ef. 10-1-04; OMAP 12-2005, f. 3-11-05, cert. ef.
4-1-05; DMAP 25-2007, f. 12-11-07, cert, ef. 1-1-08; DMAP 18-2008, f. 6-13-08, cert.
ef. 7-1-08; DMAP 38-2008, f. 12-11-08, cert. ef. 1-1-09; DMAP 16-2009 f. 6-12-09,
cert. ef. 7-1-09; DMAP 41-2009, f. 12-15-09, cert. ef. 1-1-10; DMAP 14-2010, f.
6-10-10, cert. ef. 7-1-10; DMAP 31-2010, f. 12-15-10, cert. ef. 1-1-11; DMAP 17-2011,
f. & cert. ef. 7-12-11; DMAP 41-2011, f. 12-21-11, cert. ef. 1-1-12; DMAP 46-2011,
f. 12-23-11, cert. ef. 1-1-12; DMAP 13-2013, f. 3-27-13, cert. ef. 4-1-13; DMAP
28-2013(Temp), f. 6-26-13, cert. ef. 7-1-13 thru 12-28-13; DMAP 68-2013, f. 12-5-13,
cert. ef. 12-23-13; DMAP 75-2013(Temp), f. 12-31-13, cert. ef. 1-1-14 thru 6-30-14;
DMAP 10-2014(Temp), f. & cert. ef. 2-28-14 thru 8-27-14; DMAP 19-2014(Temp),
f. 3-28-14, cert. ef. 4-1-14 thru 6-30-14; DMAP 36-2014, f. & cert. ef. 6-27-14;
DMAP 56-2014, f. 9-26-14, cert. ef. 10-1-14; DMAP 7-2015(Temp), f. & cert. ef.
2-17-15 thru 8-15-15; DMAP 28-2015, f. & cert. ef. 5-1-15; DMAP 46-2015(Temp),
f. 8-26-15, cert. ef. 10-1-15 thru 3-28-16; DMAP 51-2015, f. 9-22-15, cert. ef.
10-1-15; DMAP 65-2015, f. 11-3-15, cert. ef. 12-1-15
410-123-1490
Hospital Dentistry
(1) The purpose of hospital dentistry
is to provide safe, efficient dental care when providing routine (non-emergency)
dental services for Division of Medical Assistance Programs (Division) clients who
present special challenges that require the use of general anesthesia or IV conscious
sedation services in an Ambulatory Surgical Center (ASC), inpatient or outpatient
hospital setting. Refer to OAR 410-1231060 for definitions.
(2) Division reimbursement
for hospital dentistry is limited to covered services and may be prorated if non-covered
dental services are performed during the same hospital visit:
(a) See OAR 410-123-1060
for a definition of Division hospital dentistry services;
(b) Refer to OAR 410-123-1220
and the “Covered and Non-Covered Dental Services” document.
(3) Hospital dentistry is
intended for the following Division clients:
(a) Children (18 or younger)
who:
(A) Through age 3 —
Have extensive dental needs;
(B) 4 years of age or older
— Have unsuccessfully attempted treatment in the office setting with some
type of sedation or nitrous oxide;
(C) Have acute situational
anxiety, fearfulness, extreme uncooperative behavior, uncommunicative such as a
client with developmental or mental disability, a client that is pre-verbal or extreme
age where dental needs are deemed sufficiently important that dental care cannot
be deferred;
(D) Need the use of general
anesthesia (or IV conscious sedation) to protect the developing psyche;
(E) Have sustained extensive
orofacial or dental trauma;
(F) Have physical, mental
or medically compromising conditions; or
(G) Have a developmental
disability or other severe cognitive impairment and one or more of the following
characteristics that prevent routine dental care in an office setting:
(i) Acute situational anxiety
and extreme uncooperative behavior;
(ii) A physically compromising
condition;
(b) Adults (19 or older)
who:
(A) Have a developmental
disability or other severe cognitive impairment, and one or more of the following
characteristics that prevent routine dental care in an office setting:
(i) Acute situational anxiety
and extreme uncooperative behavior;
(ii) A physically compromising
condition;
(B) Have sustained extensive
orofacial or dental trauma; or
(C) Are medically fragile,
have complex medical needs, contractures or other significant medical conditions
potentially making the dental office setting unsafe for the client.
(4) Hospital dentistry is
not intended for:
(a) Client convenience. Refer
to OAR 410-120-1200;
(b) A healthy, cooperative
client with minimal dental needs; or
(c) Medical contraindication
to general anesthesia or IV conscious sedation.
(5) Required documentation:
The following information must be included in the client's dental record:
(a) Informed consent: client,
parental or guardian written consent must be obtained prior to the use of general
anesthesia or IV conscious sedation;
(b) Justification for the
use of general anesthesia or IV conscious sedation. The decision to use general
anesthesia or IV conscious sedation must take into consideration:
(A) Alternative behavior
management modalities;
(B) Client’s dental
needs;
(C) Quality of dental care;
(D) Quantity of dental care;
(E) Client’s emotional
development;
(F) Client’s physical
considerations;
(c) If treatment in an office
setting is not possible, documentation in the client's dental record must explain
why, in the estimation of the dentist, the client will not be responsive to office
treatment;
(d) The Division, Coordinated
Care Organization (CCO) or Prepaid Health Plan (PHP) may require additional documentation
when reviewing requests for prior authorization (PA) of hospital dentistry services.
See OAR 410-123-1160 and section (6) of this rule for additional information;
(e) If the dentist did not
proceed with a previous hospital dentistry plan approved by the Division for the
same client, the Division will also require clinical documentation explaining why
the dentist did not complete the previous treatment plan.
(6) Hospital dentistry always
requires prior authorization (PA) for the medical services provided by the facility:
(a) If a client is enrolled
in a CCO or PHP and a Dental Care Organization (DCO):
(A) The dentist is responsible
for:
(i) Contacting the CCO or
PHP for PA requirements and arrangements; and
(ii) Submitting documentation
to both the CCO or PHP and DCO;
(B) The CCO or PHP and DCO
should review the documentation and discuss any concerns they have, contacting the
dentist as needed. This allows for mutual plan involvement and monitoring;
(C) The total response time
should not exceed 14 calendar days from the date of submission of all required documentation
for routine dental care and should follow urgent/emergent dental care timelines;
(D) The CCO or PHP is responsible
for payment of all facility and anesthesia services. The DCO is responsible for
payment of all dental professional services;
(b) If a client is enrolled
in a Physician Care Organization (PCO) and a Dental Care Organization (DCO):
(A) The PCO is responsible
for payment of all facility and anesthesia services provided in an outpatient hospital
setting or an ASC. The Division is responsible for payment of all facility and anesthesia
services provided in an inpatient hospital setting. The DCO is responsible for payment
of all dental professional services;
(B) The dentist is responsible
for:
(i) Contacting the PCO, if
services are to be provided in an outpatient setting or an ASC, for PA requirements
and arrangements; or
(ii) Contacting the Division,
if services are to be provided in an inpatient setting; and
(iii) Submitting documentation
to both the PCO (or the Division) and the DCO;
(C) The PCO or the Division
and the DCO should review the documentation and discuss any concerns they have,
contacting the dentist as needed. This allows for mutual plan involvement and monitoring;
(D) The total response time
should not exceed 14 calendar days from the date of submission of all required documentation
for routine dental care and should follow urgent/emergent dental care timelines;
(c) If a client is fee-for-service
(FFS) for medical services and enrolled in a DCO:
(A) The dentist is responsible
for faxing documentation and a completed American Dental Association (ADA) form
to the Division. Refer to the Dental Services Provider Guide;
(B) If the client is assigned
to a Primary Care Manager (PCM) through FFS medical, the client must have a referral
from the PCM prior to any hospital service being approved by the Division;
(C) The Division is responsible
for payment of facility and anesthesia services. The DCO is responsible for payment
of all dental professional services;
(D) The Division will issue
a decision on PA requests within 30 days of receipt of the request;
(d) If a client is enrolled
in an CCO or PHP and is FFS dental:
(A) The dentist is responsible
for contacting the CCO or PHP to obtain the PA and arrange for the hospital dentistry;
(B) The dentist is responsible
for submitting required documentation to the CCO or PHP;
(C) The CCO or PHP is responsible
for all facility and anesthesia services. The Division is responsible for payment
of all dental professional services;
(e) If a client is FFS for
both medical and dental:
(A) The dentist is responsible
for faxing documentation and a completed ADA form to the Division. Refer to the
Dental Services Provider Guide;
(B) The Division is responsible
for payment of all facility, anesthesia services and dental professional charges.
Stat. Auth.: ORS 413.042, 414.065
Stats. Implemented: ORS 414.065
Hist.: OMAP 17-2000, f. 9-28-00,
cert. ef. 10-1-00; OMAP 48-2002, f. & cert. ef. 10-1-02; OMAP 55-2004, f. 9-10-04,
cert. ef. 10-1-04; DMAP 25-2007, f. 12-11-07, cert, ef. 1-1-08; DMAP 38-2008, f.
12-11-08, cert. ef. 1-1-09; DMAP 16-2009 f. 6-12-09, cert. ef. 7-1-09; DMAP 41-2011,
f. 12-21-11, cert. ef. 1-1-12; DMAP 46-2011, f. 12-23-11, cert. ef. 1-1-12; DMAP
13-2013, f. 3-27-13, cert. ef. 4-1-13; DMAP 28-2013(Temp), f. 6-26-13, cert. ef.
7-1-13 thru 12-28-13; Administrative correction, 2-5-14
410-123-1540
Citizen/Alien-Waived Emergency Medical
(CAWEM)
(1) CAWEM clients who are not pregnant
(benefit package identifier CWM) have a limited benefit package. Dental coverage
is limited to dental services provided in an emergency department hospital setting.
Refer to OAR 410-120-1210(4)(e).
(2) CAWEM clients who are
pregnant (benefit package identifier CWX) receive the OHP Plus dental benefit package
as described in OAR 410-123-1260.
(3) All CAWEM clients are
exempt from enrollment in a Dental Care Organization (DCO) or Coordinated Care Organization
(CCO). Providers must bill the Division directly for any allowable services provided.
Stat. Auth.: ORS 413.042 & 414.065
Stats. Implemented: ORS 414.065
Hist.: OMAP 17-2000, f. 9-28-00,
cert. ef. 10-1-00; OMAP 48-2002, f. & cert. ef. 10-1-02; DMAP 18-2008, f. 6-13-08,
cert. ef. 7-1-08; DMAP 31-2010, f. 12-15-10, cert. ef. 1-1-11; DMAP 75-2013(Temp),
f. 12-31-13, cert. ef. 1-1-14 thru 6-30-14; DMAP 36-2014, f. & cert. ef. 6-27-14
410-123-1600
Managed Care Organizations
(1) The Division contracts with Managed
Care Organizations (MCO) and Primary Care Managers (PCM) to provide medical services
for clients under the Division (Title XIX and Title XXI services):
(a) MCOs for dental services
are called Dental Care Organizations (DCO). See General Rules OAR 410-120-0250 —
Managed Care Organizations for definitions and responsibilities of MCOs;
(b) See General Rules OAR
410-120-1210(4) — Medical Assistance Programs and Delivery Systems for a description
of how clients receive services through MCOs and PCMs.
(2) The Division prepays
DCOs to cover dental services, including the professional component of any services
provided in an Ambulatory Surgical Center (ASC) or an outpatient or inpatient hospital
setting for hospital dentistry. See OAR 410-123-1490 for more information about
hospital dentistry.
(3) The Division will not
pay for services covered by a MCO; reimbursement is a matter between the MCO and
the provider.
(4) For clients enrolled
in a DCO, it is the responsibility of the dental provider to coordinate all dental
services with the client’s DCO prior to providing services.
Stat. Auth.: ORS 413.042, 414.065 &
414.651
Stats. Implemented: ORS 414.651
Hist.: OMAP 23-1999, f. &
cert. ef. 4-30-99; OMAP 17-2000, f. 9-28-00, cert. ef. 10-1-00; OMAP 48-2002, f.
& cert. ef. 10-1-02; DMAP 16-2009 f. 6-12-09, cert. ef. 7-1-09; DMAP 28-2013(Temp),
f. 6-26-13, cert. ef. 7-1-13 thru 12-28-13; Administrative correction, 2-5-14
410-123-1620
Procedure and Diagnosis Codes
(1) The Division requires providers
to use the standardized code sets adopted by the Health Insurance Portability and
Accountability Act (HIPAA) and the Centers for Medicare and Medicaid Services (CMS).
Unless otherwise directed in rule, providers must accurately code claims according
to the national standards in effect for the date the service(s) was provided.
(2) Procedure codes:
(a) For dental services,
use Current Dental Terminology (CDT) codes as maintained and distributed by the
American Dental Association. Contact the American Dental Association (ADA) to obtain
a current copy of the CDT reference manual. Current Dental Terminology (including
procedure codes, definitions (descriptors) and other data) is copyrighted by the
ADA. © 2012 American Dental Association. All rights reserved. Applicable Federal
Acquisition Regulation Clauses/Department of Defense Federal Acquisition Regulation
Supplement (FARS/DFARS) apply;
(b) For physician services
and other health care services, use Health Care Common Procedure Coding System (HCPCS)
and Current Procedural Terminology (CPT) codes.
(3) Diagnosis codes:
(a) International Classification
of Diseases 10th Clinical Modification (ICD-10-CM) diagnosis codes are not required
for dental services submitted on an ADA claim form;
(b) When Oregon Administrative
Rule (OAR) 410-123-1260 requires services to be billed on a professional claim form,
ICD-10-CM diagnosis codes are required. Refer to the Medical-Surgical administrative
rules for additional information, OAR 410 division 130.
Stat. Auth.: ORS 413.042, 414.065
Stats. Implemented: ORS 414.065
Hist.: OMAP 23-1999, f. &
cert. ef. 4-30-99; OMAP 17-2000, f. 9-28-00, cert. ef. 10-1-00; OMAP 48-2002, f.
& cert. ef. 10-1-02; OMAP 65-2003, f. 9-10-03 cert. ef. 10-1-03; DMAP 25-2007,
f. 12-11-07, cert, ef. 1-1-08; DMAP 38-2008, f. 12-11-08, cert. ef. 1-1-09; DMAP
16-2009 f. 6-12-09, cert. ef. 7-1-09; DMAP 13-2013, f. 3-27-13, cert. ef. 4-1-13;
DMAP 51-2015, f. 9-22-15, cert. ef. 10-1-15
410-123-1640
Prescriptions
(1) Follow criteria outlined in OAR 410-121-0144.
(2) Practitioner-Managed Prescription Drug Plan (PMPDP) -- Follow criteria outlined in PMPDP -- OAR 410-121-0030.
Stat. Auth.: ORS 413.042, 414.065

Stats. Implemented: ORS 414.065

Hist.: OMAP 39-2002, f. 9-13-02, cert. ef. 9-15-02; OMAP 65-2003, f. 9-10-03 cert. ef. 10-1-03

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