016.06.14 Ark. Code R. 014
Arkansas Medicaid covers fluoride varnish application, ADA code D1206, performed by physicians who have completed the online training program approved by the Arkansas Department of Health, Office of Oral Health. Eligible physicians may delegate the application to a nurse or other licensed health care professional under his or her supervision that has also completed the online training. The online training course can be accessed at http://ar.train.org. Each provider must maintain documentation to establish his or her successful completion of the training and submit a copy of the certificate of completion to HP Provider Enrollment.
The American Dental Association (ADA) procedure code D1206 is covered by the Arkansas Medicaid Program. This code is payable for beneficiaries under the age of 21. Topical fluoride varnish application benefit is two (2) per SFY for beneficiaries under age 21.
A new specialty code, FC-Fluoride Certification will be tied to provider types 01, 03, 58 and 69. These providers must send proof of their fluoride varnish certification to HP Provider Enrollment before the specialty code will be added to their file in the MMIS. After the specialty code, FC-Fluoride Certification, is added to the provider's file, the provider will be able to bill for procedure code D1206, Topical Application of Fluoride Varnish.
Providers must check the Supplemental Eligibility Screen to verify that topical fluoride varnish benefit of two (2) per State Fiscal Year (SFY) has not been exhausted. If further treatment is needed due to severe periodontal disease, then the beneficiary must be referred to a Medicaid dental provider.
NOTE: This service is billed on form CMS-1500 with ADA procedure code D1206 (Topical application of fluoride varnish (prophylaxis not included) - child (ages 0-20). View a form CMS-1500 sample form.
Dental prophylaxis and a fluoride treatment are preventive treatments covered by Medicaid. Prophylaxis, in addition to application of topical fluoride and/or fluoride varnish, is covered every six (6) months plus one (1) day for beneficiaries under age 21. Arkansas Medicaid covers fluoride varnish application, ADA code D1206, performed by physicians who have completed the online training program approved by the Arkansas Department of Health, Office of Oral Health. Eligible physicians may delegate the application to a nurse or other licensed health care professional under his or her supervision that has also completed the online training. Physicians and nurse practitioners must complete training on dental caries risk and have an approved fluoride varnish certification from the Arkansas Department of Health, Office of Oral Health. Each provider must maintain documentation to establish his or her successful completion of the training and submit a copy of the certificate to HP Provider Enrollment. The course that meets the requirements outlined by the ACT can be accessed at http://ar.train.org. If further treatment is needed due to severe periodontal problems, the provider must request prior authorization with a brief narrative.
Prophylaxis and fluoride treatments are each covered once per state fiscal year (July 1 through June 30) for beneficiaries age 21 and over. Topical fluoride treatment or fluoride varnish is covered every six (6) months plus one (1) day for beneficiaries under age 21.
A new specialty code, FC-Fluoride Certification will be tied to provider types 01, 03, 58 and 69. These providers must send proof of their fluoride varnish certification to HP Provider Enrollment before the specialty code will be added to their file in the MMIS. After the specialty code, FC-Fluoride Certification, is added to the provider's file, the provider will be able to bill for procedure code D1206, Topical Application of Fluoride Varnish.
Medicaid does not reimburse for nitrous oxide for examinations, fluorides, oral prophylaxis and sealants unless other procedures are performed at the same time.
A provider may generally perform the following procedures without prior authorization:
See Sections 262.100 and 262.200 for applicable codes.
The following ADA procedure codes are covered by the Arkansas Medicaid Program. These codes are payable for beneficiaries under the age of 21.
NOTE: Only physicians who have completed the training on dental caries and have an approved fluoride varnish certification on file with HP provider enrollment can bill for the fluoride varnish treatment. Eligible physicians may delegate the application to a nurse or other licensed health care professional under his or her supervision that has also completed the online training. Providers must check the Supplemental Eligibility Screen to verify that topical fluoride treatment or fluoride varnish was not applied by another Medicaid dental provider.
Beside each code is a reference chart that indicates whether X-rays are required and when prior authorization (PA) is required for the covered procedure code. If a concise report is required, this information is included in the PA column.
Revenue code
A(...) This symbol, along with text in parentheses, indicates the Arkansas Medicaid description of the covered service.
Prior authorization is required for panoramic X-rays performed on children under six years of age (See Section 216.100).
ADA Code | Description | PA Yes/No | Submit X-Ray with Treatment Plan Yes/No |
Child He | alth Services (EPSDT) Dental Screening (See Se | ction 215.000) | |
D0120 | A(CHS/EPSDT Dental Screening Exam) | No | No |
D0140 | A(CHS/EPSDT Interperiodic Dental Screening Exam) | No, but limited to two (2) per SFY | No |
Radiogr | aphs(See Sections 216.000 - 216.300) | ||
D0210 | Intraoral - complete series (including bitewings) | No | No |
D0220 | Intraoral - periapical - first film | No, but limited to five (5) per SFY | No |
D0230 | Intraoral - periapical - each additional film | No, but limited to five (5) per SFY | No |
D0240 | Intraoral - occlusal film | No, but limited to five (5) per SFY | No |
D0250 | Extraoral - first film | No | No |
D0260 | Extraoral - each additional film | No, but limited to five (5) per SFY | No |
D0272 | Bitewings - two films | No | No |
D0330 | Panoramic film | No** | No |
D0340 | Cephalometric film | Yes | No |
Tests an | d Laboratory | ||
D0350 | Oral/facial photographic images | Yes | No |
D0470 | Diagnostic casts | Yes | No |
Preventive | ||
Dental Prophylaxis(See Section 217.100) | ||
D1120 Prophylaxis - child A(ages 0-9) | No | No |
D1110 Prophylaxis - adult A(ages 10-20) | No | No |
Topical Fluoride Treatment (Office Procedure) (See Section 217.100) | ||
D1206 Topical application of fluoride varnish (prophylaxis not included) - child A(ages 0-20) | No | No |
D1208 Topical application of fluoride (prophylaxis not included) - child A(ages 0-20) | No | No |
Dental Sealants(See Section 217.200) | ||
D1351 Sealant per tooth A(1st and 2nd permanent molars only) | No | No |
Space Maintainers(See Section 218.000) | ||
D1510 Space maintainer - fixed - unilateral | Yes | Yes |
D1515 Space maintainer - fixed - bilateral | Yes | Yes |
D1525 Space maintainer - removable-bilateral | Yes | Yes |
Restorations(See Sections 219.000 - 219.200) | ||
Amalgam Restorations (including polishing) (See Section 219.100) | ||
D2140 Amalgam - one surface | No | No |
D2150 Amalgam - two surfaces | No | No |
D2160 Amalgam - three surfaces | No | No |
D2161 Amalgam - four or more surfaces | No | No |
Composite Resin Restorations(See Section 219.200) | ||
D2330 Resin - one surface, anterior, permanent | No | No |
D2331 Resin - two surfaces, anterior, permanent | No | No |
D2332 Resin - three surfaces, anterior, permanent | No | No |
D2335 Resin - four or more surfaces or involving incisal angle, permanent | Yes | Yes |
Crowns - Single Restoration Only(See Section 220.000) | ||
D2710 Crown - resin (laboratory) | Yes | Yes |
D2752 Crown - porcelain -ceramic substrate | Yes | Yes |
D2920 Re-cement crown | No | Yes |
D2930 Prefabricated stainless steel crown - primary | No | No |
D2931 Prefabricated stainless steel crown - permanent | Yes, but no PA required when billed for tooth numbers 3, 14, 19 and 30. | Yes |
Endodontia(See Section 221.000) | ||
Pulpotomy | ||
D3220 Therapeutic pulpotomy (excluding final restoration) | No | No |
D3221 Gross pulpal debridement, primary and permanent teeth | Yes | No |
Endodontic (Root Canal) therapy (including treatment plan, clinical procedures and follow-up care) | ||
D3310 Anterior tooth (excluding final restoration) | No | No |
D3320 Bicuspid tooth (excluding final restoration) | No | No |
D3330 Molar (excluding final restoration) | No | No |
Periapical Services | ||
D3410 Apicoectomy (per tooth) - first root | Yes | Yes |
Periodontal Procedures(See Section 222.000) | ||
Surgical Services (including usual postoperative services) | ||
D4341 Periodontal scaling and root planing | Yes | Yes |
D4910 Periodontal maintenance procedures (following active therapy) | Yes | Yes |
Complete dentures (Removable Prosthetics Services) (See Section 223.000) | ||
D5110 Complete denture - maxillary | Yes | Yes |
D5120 Complete denture - mandibular | Yes | Yes |
Partial Dentures (Removable Prosthetic Services) (See Section 223.000) | ||
D5211 Upper partial - acrylic base (including any conventional clasps and rests) | Yes | Yes |
D5212 Lower partial - acrylic base (including any conventional clasps and rests) | Yes | Yes |
Repairs to Partial Denture(See Section 223.000) | ||
D5610 Repair acrylic saddle or base | Yes | No |
D5620 Repair cast framework | Yes | No |
D5640 Replace broken teeth - per tooth | Yes | No |
D5650 Add tooth to existing partial denture | Yes | No |
Fixed Prosthodontic Services(See Section 224.000) | ||
D6930 Re-cement bridge | Yes | No |
Oral Surgery(See Section 225.000) | ||
Simple Extractions (includes local anesthesia and routine postoperative care)(See Section 225.100) | ||
D7111 Extraction, coronal remnants-deciduous tooth | No | No |
D7140 Extraction, erupted tooth or exposed root (elevation and/or forceps removal) | No | No |
Surgical Extractions (includes local anesthesia and routine postoperative care)(See Section 225.200) | ||
D7210 Surgical removal of erupted tooth requiring elevation of mucoperiosteal flap and removal of bone and/or section of tooth | Yes | Yes |
D7220 Removal of impacted tooth - soft tissue | Yes | Yes |
D7230 Removal of impacted tooth - partially bony | Yes | Yes |
D7240 Removal of impacted tooth - completely bony | Yes | Yes |
D7241 Removal of impacted tooth - completely bony, with unusual surgical complications | Yes | Yes |
D7250 Surgical removal of residual tooth roots (cutting procedure) | Yes | Yes |
Other Surgical Procedures | ||
D7270 Tooth reimplantation and/or stabilization of accidentally evulsed or displaced tooth and/or alveolus | Yes | Yes |
D7280 Surgical exposure of impacted or un-erupted tooth for orthodontic reasons (including orthodontic attachments) | Yes | Yes |
D7285 Biopsy of oral tissue - hard | Yes | Yes |
D7286 Biopsy of oral tissue - soft | Yes | Yes |
Osteoplasty for Prognathism, Micrognathism or Apertognathism | ||
D7510 Incision and drainage of abscess, intraoral soft tissue | Yes | No |
Frenulectomy | ||
D7960 Frenulectomy (Frenectomy or Frenotomy) Separate procedure | Yes | Yes |
Orthodontics(See Section 226.000) | ||
Minor Treatment of Control Harmful Habits | ||
D8210 Removable appliance therapy | Yes | Yes |
D8220 Fixed appliance therapy | Yes | Yes |
Comprehensive Orthodontic Treatment - Permanent Dentition | ||
D8070 Class I Malocclusion | Yes | Yes |
D8080 Class II Malocclusion | Yes | Yes |
D8090 Class III Malocclusion | Yes | Yes |
Other Orthodontic Devices | ||
D8999 Unspecified orthodontic procedure, by report | Yes | Yes |
Anesthesia | ||
D9220 General Anesthesia - first 30 minutes | Yes | Yes |
D9221 General Anesthesia - each 15 minutes | Yes | No |
D9230 Analgesia N20 | No, but requires report for request for more than 1 unit per day | No |
D9248 Non-I.V. Conscious Sedation | Yes and requires report | No |
Consultations(See Section 214.000) | ||
D9310 A(Second opinion examination) Consultation, diagnostic service provided by dentist or physician other than practitioner providing treatment | Yes | No |
Smoking Cessation | ||
D1320 Tobacco counseling for the control and prevention of oral disease - Counseling and referral by a provider to a tobacco cessation program | No | No |
D9920 Behavior Management by Report - Tobacco counseling received from the provider for the control and prevention of oral disease | No | No |
Unclassified Treatment | ||
D9110 Palliative treatment with dental pain | Yes | No |
Arkansas Medicaid will expand coverage for fluoride varnish application, ADA code D1206, to physicians and nurse practitioners who have completed the online training program approved by the Arkansas Department of Health, Office of Oral Health. The online training course can be accessed at http://ar.train.org. The provider will need to maintain a copy of the certificate of completion in their files and submit a copy to the Arkansas Medicaid provider enrollment unit.
The American Dental Association (ADA) procedure code D1206 is covered by the Arkansas Medicaid Program. This code is payable for beneficiaries under the age of 21. Topical fluoride varnish is covered every six (6) months for beneficiaries under age 21.
A new specialty code, FC-Fluoride Certification will be tied to provider types 01, 03, 58 and 69. These providers must send proof of their fluoride varnish certification to Provider Enrollment before the specialty code will be added to their file in the MMIS. After the specialty code, FC-Fluoride Certification, is added to the provider's file, the provider will be able to bill for procedure code D1206, Topical Application of Fluoride Varnish.
Providers must check the Supplemental Eligibility Screen to verify that topical fluoride varnish benefit of two (2) per State Fiscal Year (SFY) has not been exhausted. If further treatment is needed due to severe periodontal disease, then the beneficiary must be referred to a Medicaid dental provider.
NOTE: This service is billed on form CMS-1500 with ADA procedure code D1206 (Topical application of fluoride varnish (prophylaxis not included) - child (ages 0-20). View a form CMS-150 sample form.
All other procedures require prior authorization from the Medical Assistance Section. A full mouth radiograph is limited to once every five years. Periodic oral exam, prophylaxis, fluoride treatment, fluoride varnish and bite-wing X-rays are limited to once per 6 (six) months plus 1 (one) day. Scaling is limited to one per state fiscal year (July 1 through June 30). Periapical X-rays are limited to four (4) per recall visit. Any limits will be exceeded based on medical necessity.
All other procedures require prior authorization from the Medical Assistance Section. A full mouth radiograph is limited to once every five years. Periodic oral exam, prophylaxis, fluoride treatment, fluoride varnishand bite-wing X-rays are limited to once per 6 (six) months plus 1 (one) day. Scaling is limited to one per state fiscal year (July 1 through June 30). Periapical X-rays are limited to four (4) per recall visit. Any limits will be exceeded based on medical necessity.
016.06.14 Ark. Code R. 014