Section 471-6-005 - BILLING AND PAYMENT FOR DENTAL SERVICES005.01BILLING.005.01(A)GENERAL BILLING REQUIREMENTS. Providers must comply with all applicable billing requirements codified in 471 NAC 3. In the event that billing requirements in 471 NAC 3 conflict with billing requirements outlined in this chapter, the billing requirements in this chapter will govern.005.01(B)SPECIFIC BILLING REQUIREMENTS.005.01(B)(i)BILLING INSTRUCTIONS. The provider must bill Medicaid using the procedure codes outlined in the Nebraska Medicaid Dental Fee Schedule and in accordance with the billing instructions. The fees listed on the dental claim must be the dentist's usual and customary charge for each procedure code.005.02PAYMENT.005.02(A)GENERAL PAYMENT REQUIREMENTS. Medicaid will reimburse the provider for services rendered in accordance with the applicable payment regulations codified in 471 NAC 3. In the event that individual payment regulations in 471 NAC 3 conflict with payment regulations outlined in this chapter, the individual payment regulations in this chapter will govern.005.02(B) SPECIFIC PAYMENTS REQUIREMENTS.005.02(B)(i) REIMBURSEMENT. Medicaid pays for covered dental services at the lower of:(1) The provider's submitted charge; or(2) The allowable amount for that procedure code in the Nebraska Medicaid Practitioner Fee Schedule in effect for that date of service.005.02(B)(ii)RESTORATIVE SERVICES RATES. Operative dentistry fee includes local anesthetic, bases, or insulation and other procedures necessary to complete the case. Pins are billed separately.005.02(B)(iii)PAYMENT FOR INTERCEPTIVE AND COMPREHENSIVE ORTHODONTIC TREATMENT. Payment for authorized orthodontic treatment is made upon approval of the treatment plan and submittal of a dental claim. 005.02(B)(iii)(1)TRANSFER OF INTERCEPTIVE AND COMPREHENSIVE ORTHODONTIC CASES. If the client transfers to another dentist, the dentist who obtained the original authorization and initiated orthodontic treatment, must refund to Medicaid the portion of the amount paid by Medicaid that applies to the treatment not completed. The transfer request must be submitted and reviewed by the Department to determine the amount to be refunded. Transfers are only allowed under hardship circumstances.005.02(B)(iii)(2)INTERCEPTIVE AND COMPREHENSIVE ORTHODONTIC TREATMENT NOT COMPLETED. If prior authorized orthodontic treatment is not completed, the dentist who obtained the original authorization and initiated the treatment must refund to Medicaid the portion of the amount paid by Medicaid that applies to the treatment not completed. The request to discontinue treatment must be submitted and reviewed by the Department to determine the amount to be refunded.005.02(B)(iv)AUDIT RECORDS. Medicaid may request end of treatment diagnostic models and x-rays in accordance with this chapter. Payment for the end of treatment records is included in the dollar amount prior authorized.471 Neb. Admin. Code, ch. 6, § 005
Adopted effective 6/26/2021