Section 7 AAC 110.145 - Dental services for adults(a) Payment for emergent dental services covered under this subsection does not reduce a recipient's annual limit under (b) and (c) of this section. Except as specifically excluded under (g) of this section, the department will pay for the following emergent dental services identified in the Fee Schedule: Emergent Adult Dental Services, adopted by reference in 7 AAC 160.900, for recipients 21 years of age or older, as follows: (1) the following dental services for the immediate relief of pain or acute infection: (A) limited oral evaluation not more than two times per fiscal year; (B) extractions; under this subparagraph, (i) a claim submitted for up to two extractions in a single day must be accompanied by medical justification; and (ii) a provider must obtain prior authorization from the department for three or more extractions in a single day or four or more extractions in a 12-month period; (C) one intraoral periapical radiograph to determine if an extraction is necessary; (D) anesthesia or sedation in accordance with 7 AAC 110.155 and necessary for dental services covered under this section; a claim submitted to the department for payment of costs for general anesthesia must be accompanied by written medical justification for the service; (2) a dental service that exceeds a limit established in (b) and (c) of this section if the department determines, based on medical justification submitted with a prior authorization request, that a delay in the provision of the service will endanger the life of the recipient. (b) Subject to appropriation under AS 47.07.067 and except as specifically excluded under (g) of this section, the department will pay up to $ 1,150 per state fiscal year for the dental services identified in the Fee Schedule: Enhanced Adult Dental Services, adopted by reference in 7 AAC 160.900 and provided to a recipient 21 years of age or older, as follows: (1) periodic or comprehensive oral evaluation not more than one time per fiscal year, panoramic radiographs not more than one time per fiscal year and other dental radiographs necessary for dental care; (2) preventive care, including (A) prophylaxis, including necessary scaling, polishing, and instructions on oral hygiene and diet, not more than two times per fiscal year; and (B) topical application of fluoride not more than four times per fiscal year, or topical fluoride varnish not more than four times per fiscal year, or a combination of topical application of fluoride and fluoride varnish not more than four times per fiscal year; (3) restorative care for the treatment of decayed or fractured teeth, including amalgams and resins, and crowns if the tooth cannot be restored with amalgams or resin; under this paragraph, (A) a claim submitted for up to two crowns in a single day must be accompanied by medical justification; (B) a provider must obtain prior authorization from the department for three or more crowns in a single day or four or more crowns in a 12 -month period; (C) all surfaces restored on a single tooth on the same day are considered connected; therefore, payment is limited to one single or multi-surface restoration code per tooth per day; (D) final restorations are limited to not more than five surfaces per tooth; tooth preparation, temporary restorations, sedative and cement bases, and local anesthesia are considered components of a complete restorative procedure and may not be billed separately; and (E) the department will provide payment for a crown only upon seatment of the permanent crown, and for a partial or denture only upon seatment of the appliance; the department will not provide partial payment for incomplete or in-progress dental services; (4) endodontics, with the following limitations: (A) palliative and sedative treatments may not exceed two times per tooth before a definitive treatment; (B) with respect to root canal therapy, tooth preparation, temporary filling of the root canal, and follow-up care are considered components of a complete root canal and may not be billed separately; (C) a separate claim in addition to a root canal claim may be made for pin retention and restoration, and may not exceed five surfaces per tooth; (5) periodontics, including treatment of pain or acute infection of supporting tissues of the teeth, including gingivitis, periodontitis, and periodontal abscess;(6) oral surgery; under this paragraph, (A) prior authorization from the department is required for extractions; and (B) local anesthesia, materials, and routine postoperative care are considered components of a complete surgical procedure and may not be billed separately; (7) professional consultation, if medically necessary or if requested by the department. (c) Prior authorization from the department is required for prosthodontic services. Except as specifically excluded under (g) of this section, the department will pay up to $1,150 per state fiscal year for prosthodontic services provided to a recipient 21 years of age or older, and up to twice the annual limit if one annual limit is not adequate to cover the cost of the provision of upper and lower dentures at the same time. If the department authorizes use of up to twice the annual limit for dentures, the maximum amount authorized is the remaining amount from the current fiscal year and the entire amount allotted for the succeeding fiscal year limit. In the succeeding fiscal year, the department will not authorize a new or additional annual limit. The department will pay for prosthodontic services identified in Fee Schedule: Prosthodontic Adult Dental Services, adopted by reference in 7 AAC 160.900, as follows: (1) a complete denture, maxillary; (2) a complete denture, mandibular;(3) a partial denture, maxillary; (4) a partial denture; mandibular; (5) replacement of a complete or partial denture only if the existing denture is unusable and only once per five years, unless the department determines, based on medical justification submitted with the prior authorization request, that a delay will endanger the life of the recipient; (6) replacement of a partial denture with a complete denture not earlier than five years after payment for the partial denture, unless the department determines, based on medical justification submitted with the prior authorization request, that a delay will endanger the life of the recipient; (7) a denture within the same dental arch no more than three times per lifetime, unless the department determines, based on medical justification submitted with the prior authorization request, that a delay will endanger the life of the recipient; (8) adjustments to a complete or partial denture not earlier than six months following the seatment date of the denture and not more than four times per fiscal year; (9) rebase and reline procedures of a complete or partial denture not earlier than six months following the seatment date of the denture and not more than once per three fiscal years. (d) The cost of anesthesia or sedation in accordance with 7 AAC 110.155 and necessary for dental services covered under this section does not reduce the recipient's annual limit described in (b) and (c) of this section. (e) A dental service provided after a recipient's annual limit under (b) and (c) of this section has been exhausted is considered a noncovered service and the department will not provide payment. Notwithstanding 7 AAC 145.015, a provider may bill a recipient for the difference under (c) of this section if the unused portion of a recipient's annual limit is less than the allowable Medicaid payment rate, or under (b) and (c) of this section if the unused portion of the recipient's combined annual limit is less than the allowable Medicaid payment rate. A provider shall inform a recipient in advance of the recipient's obligation to pay for the difference. The provider shall document in the recipient's records that the recipient was informed of and agreed to pay for any balance above the annual limit for the service provided. (f) The department will assist a provider and recipient to the extent possible in monitoring the recipient's annual limit. However, the department will not assume financial responsibility for dental services provided that exceed the recipient's annual limit. (g) The department will not pay for the following dental services provided to a recipient 21 years of age or older: (1) dental services not identified in the Fee Schedule: Emergent Adult Dental Services, the Fee Schedule: Enhanced Adult Dental Services, and the Fee Schedule: Prosthodontic Adult Dental Services, adopted by reference in 7 AAC 160.900; (3) indirect pulp capping; (4) endodontic apical surgery and retrograde fillings; (5) immediate, interim, and temporary dentures; (6) dental implant and implant-related dental services; (7) inlays, overlays, and three-fourth crowns; (8) restoration of etched enamel or deep grooves without obvious dentin involvement; (10) tobacco counseling; tobacco counseling is considered a component of periodic and comprehensive evaluations and may not be billed separately; (11) denture characterization and personalization, and precision attachments; (12) experimental dental procedures; (13) local anesthesia; local anesthesia is considered a component of covered dental procedures and may not be billed separately; (14) anesthesia or sedation in conjunction with a noncovered service or a service for which service limits have been exhausted; (16) orthodontic services.Eff. 2/1/2010, Register 193; am 8/25/2010, Register 195; am 11/1/2010, Register 196; am 5/1/2016, Register 218, July 2016; am 12/1/2022, Register 244, January 2023Authority:AS 47.05.010
AS 47.07.030
AS 47.07.040
AS 47.07.067