Ala. Admin. Code r. 560-X-15-.03

Current through Register Vol. 43, No. 1, October 31, 2024

Section 560-X-15-.03 - Limitations

(1) Dental care is provided to Medicaid eligible individuals who are under age 21 and are eligible for treatment under the EPSDT Program. Complete details on coverage limitations are contained in Chapter 13 of the Alabama Medicaid Provider Manual. Below are general guidelines.

(2) Dental care under this Program is available either as a result of the EPSDT Referral or as a result of request/need by the recipient. Conditions for each situation are as follows:

(a) EPSDT Referral. If the EPSDT Screening Provider determines a recipient requires dental care or if the recipient is 3 years of age or older and is not currently under the care of a dentist, the recipient must be referred to an enrolled dentist for diagnosis and/or treatment. After the recipient's dental care is initiated, the Consultant's portion of the general referral form must be completed by the dentist and the appropriate copy must be returned to the screening provider.

(b) Recipient Seeking Treatment. If a recipient who has not been screened through the EPSDT Program requests dental care, care may be provided without having an EPSDT Referral. In this situation, after the required care is completed, the dentist should advise the recipient to seek an EPSDT provider to obtain a complete medical assessment.

(3) Dental care is provided to pregnant Medicaid eligbile individuals over 21. Complete details on coverage limitations are contained in Chapter 13 of the Alabama Medicaid Provider Billing Manual.

(4) A periodic oral examination is limited to once every six months for eligible Medicaid recipients under age 21.

(5) Dental sealants are covered by Medicaid, and are limited to one application per tooth in a recipient's lifetime. Refer to Chapter 13 of the Alabama Medicaid Provider Manual for specific limitations.

(6) Orthodontia is covered by Medicaid and is limited to medically necessary orthodontic services for eligible and qualified recipients. The services must be provided as a continuation of treatment initiated through multidisciplinary clinics administered by Alabama Children's Rehabilitation Service or other qualified clinics enrolled in the Medicaid Dental Program as a contract vendor. All medically necessary orthodontic treatment must be prior authorized by Medicaid.

(7) Radiological procedures are limited to those required to make a diagnosis. The radiographs should show all areas where treatment is anticipated. All x-ray films must be properly mounted suitable for interpretation and identification, with the patient's name, date, name of dentist, and marked "left" and "right." Specific limitations are outlined in Chapter 13 of the Alabama Medicaid Provider Manual.

Ala. Admin. Code r. 560-X-15-.03

Rule effective October 1, 1982. Amended effective June 8, 1985. Emergency rule effective December 1, 1986. Amended effective March 12, 1987. Emergency rule effective March 10, 1987. Amended effective June 10, 1987. Emergency rule effective April 1, 1988. Amended effective June 10, 1988. Emergency rule effective February 9, 1989. Amended effective March 14, 1989; July 1, 1989. Emergency rule effective April 1, 1991. Amended effective June 12, 1991; April 14, 1992. Amended: Filed September 6, 2000; effective October 11, 2000. Amended: Filed May 12, 2004; effective June 16, 2004.

Amended by Alabama Administrative Monthly Volume XLI, Issue No. 06, March 31, 2023, eff. 5/15/2023.

Author: Dr. Danny Rush, Dental Program

Statutory Authority: State Plan, Attachment 3.1-A, page 1.2, 4.b(4); Title XIX, Social Security Act; 42 C.F.R. § 441.57.