Or. Admin. Code § 410-123-1060

Current through Register Vol. 64, No. 1, January 1, 2025

Section 410-123-1060 - Definition and Acronyms

(1) "Alveoplasty" is a dental procedure often performed following a tooth extraction, to help recreate the natural contour of the gums and jaw that may have been lost due to bone loss from tooth extraction, or for another reason.

(2) "Ancillary codes" are procedure codes for treatments or services that are not provided alone, but along with other treatments or services.

(3) "Anesthesia Services" has the same meaning as provided in OAR 410-120-0000 and means administration of anesthetic agents to cause loss of sensation to the body or body part. These services must be provided in accordance with Chapter 818, Division 26.

(4) "Anterior teeth" are referred to as the front teeth. Permanent (adult) teeth are also referred to by numbers and differentiated by upper and lower:

(a) The upper anterior teeth are indicated by the numbers 6, 7, 8, 9, 10, 11; and

(b) The lower anterior teeth are indicated by the numbers 22, 23, 24, 25, 26, 27.

(5) "Apexification" is a dental treatment provided on permanent teeth when the roots of the teeth are incompletely formed, to encourage development and formation of the root.

(6) "Apicoectomy" involves the removal of a tooth's root tip and surrounding tissue.

(7) "Bicuspid teeth" are permanent teeth, they have two points or cusps on the crown (chewing surface) and two points or cusps on the root:

(a) Upper bicuspid teeth are indicated by the numbers 4, 5, 12, 13; and

(b) Lower bicuspid teeth are indicated by the numbers 20, 21, 28, 29.

(8) "Billing" definition is provided in OAR 410-120-1280.

(9) "By Report" (BR) has the meaning as provided in OAR 410-120-0000.

(10) "Canine teeth" are anterior teeth that are pointed. In addition to numbered permanent (adult) teeth, primary (baby) teeth are also referred to by letters and differentiated between upper and lower.

(a) Primary upper canine teeth are indicated by the letters C, H;

(b) Primary lower canine teeth are indicated by the letters M, R;

(c) Permanent upper canine teeth are indicated by the numbers 6, 11; and

(d) Permanent lower canine teeth are indicated by the numbers 22, 27.

(11) "Composite restorations" are white/tooth colored fillings.

(12) "Current Dental Terminology (CDT)" codes are the alphanumeric codes that identify a specific dental procedure, as designated by the federal government, and used by the American Dental Association.

(13) "Dental" means teeth and supporting structures.

(14) "Dental Care Organization (DCO)" as provided for in ORS 414.025 who provide the following:

(a) Dental services to the coordinated care organization's members, on a pre-paid capitated basis;

(b) Administrative services on behalf of the coordinated care organization as they relate to the delivery of dental services, including, without limitation: provider credentialing, prior authorization or denial of services, or encounter claims processing; or

(c) Both of the foregoing.

(15) "Dental Emergency Condition" means any incident involving the teeth and gums which may require immediate treatment to stop ongoing tissue bleeding, alleviate severe and sudden pain or infection, treat unusual swelling of the face or gums, or to preserve an avulsed tooth:

(a) Emergency conditions are based on the presenting symptoms (not the final diagnosis) as perceived by a prudent layperson (rather than a Health Care Professional) and includes cases in which over-the-counter medications in the absence of immediate medical attention may not in fact have had the adverse results; and

(b) The treatment of an emergency dental condition is limited only to Covered Services. The Authority 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.

(16) "Dental Emergency Services" has the meaning as provided in OAR 410-120-0000. For the purpose of the Authority's rules, Dental Emergency Services is synonymous with emergency dental care and emergency oral health care.

(17) "Dental Hygienist" has the meaning as provided in OAR 410-120-0000.

(18) "Dental Hygienist with "Expanded Practice Dental Hygiene (EPDH) Permit " has the meaning as provided in OAR 410-120-0000.

(19) "Dental Practitioner" (practitioner) means an individual licensed pursuant to state law to engage in the provision of dental services within the scope of the practitioner's license and certification.

(20) "Dental Services" has the meaning as provided in OAR 410-120-0000, and means 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 or dental hygienist with an Expanded Practice Permit (EPP).

(21) "Dental Services Documentation" means meeting the requirements of the Oregon Dental Practice Act statutes, administrative rules for member records and requirements of OAR 410-120 1360 Requirements for Financial, Clinical and Other Records, and any other documentation requirements as outlined in OAR chapter 410 division 123 (Dental rules).

(22) "Dental Therapist" has the meaning provided in ORS 679.010.

(23) "Dentally Appropriate" has the meaning as provided in OAR 410-120-0000.

(24) "Dentist" has the meaning as provided in OAR 410-120-0000.

(25) "Denturist" has the meaning as provided in OAR 410-120-0000.

(26) "Distant Site" means the site where the dentist is being contacted for consultation by the originating site.

(27) "Documentation" means dental services documentation which meets the requirements of the Oregon Dental Practice Act statutes, administrative rules for member records and requirements of OAR 410-120 1360 Requirements for Financial, Clinical and Other Records, and any other documentation requirements as outlined in OAR chapter 410, division 123 (Dental/Denturist rules).

(28) "Early and Periodic Screening, Diagnostic, and Treatment (EPSDT)" means the program requiring specific coverage for children and young adults, as described in OAR chapter 410, division 151.

(29) "EPSDT Beneficiary" means an individual under age 21 who is covered by the Oregon Health Plan. Young Adults with Special Health Care Needs (YSHCN) are included in EPSDT program benefits.

(30) "Electronic Data Interchange (EDI)" has the meaning as provided in OAR 943-120-0100.

(31) "Eligibility" has the meaning as provided in OAR chapter 410, division 200.

(32) "Emergency Dental Condition" means any incident involving the teeth and gums which may require immediate treatment to stop ongoing tissue bleeding, alleviate severe and sudden pain or infection, treat unusual swelling of the face or gums, or to preserve an avulsed (knocked out) tooth:

(a) Emergency conditions are based on the presenting symptoms (not the final diagnosis) as perceived by a prudent layperson (rather than a Health Care Professional) and includes cases in which the absence of immediate medical attention may not in fact have had the adverse results; and

(b) The treatments of emergency dental conditions are limited only to covered services. The Authority 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.

(33) "Endodontic" means relating to the inner tissues of teeth, otherwise known as the pulp or nerve. Endodontic treatments include pulpal therapy and root canal therapy.

(34) "Fillings" are provided when an area of decay on a tooth is removed by a dental provider, leaving a hole or space that is then filled with a material.

(35) "Fraud" has the meaning as provided in OAR 410-120-0000.

(36) "Gingivectomy" is the surgical removal of diseased gum tissue, to prevent damage to the bone.

(37) "Gingivoplasty" is the surgical reshaping of gum tissue around the teeth.

(38) "Health Care Interpreter (HCI)" means an individual who has been approved and certified by the Authority under ORS 413.558 to accurately interpret oral statements and documents to a person with limited English proficiency or in sign language. Qualified Health Care Interpreter has the same meaning.

(39) "Hemoglobin A1c (HbA1c)" is a measure of the amount of glucose attached to red blood cells and directly relates to average blood glucose levels.

(40) "Incisors" are anterior (front) teeth that have single, narrow edges. They are the four front, upper teeth, and the four front lower teeth.

(a) Primary upper incisors are indicated by the letters D, E, F, G;

(b) Primary lower incisors are indicated by the letters N, O, P, Q;

(c) Permanent upper incisors are indicated by the numbers 7, 8, 9, 10; and;

(d) Permanent lower incisors are indicated by the numbers 23, 24, 25, 26.

(41) "Interpreter Services" means services available to those with Limited English Proficiency (LEP) as described in Title VI of the Civil Rights Act of 1964; Section 1557 of the Affordable Care Act; and ORS 413.550 Meaningful Language Access Interpreter services may also be accessed for deaf or hard of hearing members to ensure effective communication, as required by the Americans with Disabilities Act. The interpreter must be a certified or qualified health care interpreter (HCI) (refer to chapter 950, division 50).

(42) "Malocclusion" is a misalignment or incorrect relation of the upper and lower teeth when the jaw is closed.

(43) "Mandibular" refers to the lower jaw and the lower teeth.

(44) "Maxillary" refers to the upper jaw and the upper teeth.

(45) "Managed Care Entity (MCE)" is a general term that means an entity that enters into one or more contracts with the Authority to provide services in a managed care delivery system, including but not limited to the following types of entities defined in and subject to 42 CFR Part 438 : managed care organizations (MCOs), primary care case managers (PCCMs), prepaid ambulatory health plans (PAHPs), and prepaid inpatient health plans (PIHPs). A CCO is an MCE for its managed care contract(s) with the Authority, without regard to whether the contract(s) involves federal funds or state funds or both.

(46) "Maxillofacial" means relating to the face, head, neck or jaw. Treatments may be necessary due to congenital defects or caused by trauma or disease.

(47) "Medical Practitioner" means an individual licensed pursuant to state law to engage in the provision of medical services within the scope of the practitioner's license and certification.

(48) "Medically Necessary" has the meaning as provided in OAR 410-120-0000.

(49) "Medicament" means a substance or combination of substances intended to be pharmacologically active, specially prepared to be prescribed, dispensed, or administered to prevent or treat disease.

(50) "Oral Health" refers to the health of teeth, gums, lips, tongue, inner cheeks, and the entire oral-facial system that allows us to smile, speak, and chew. Some of the most common diseases that impact our oral health include cavities (tooth decay), gum disease (periodontitis), and oral cancer.

(51) "Oral Health Services" refers to services offered to members for their improved oral health. The workforce involved in the services offered includes (but is not limited to) delivery systems staff, educational programs staff, licensed dental providers, dental assistants, and primary care providers such as doctors, nurses, and medical assistants.

(52) "Oregon Health Authority (Authority)" means the organization that administers Medicaid (Oregon Health Plan or OHP).

(53) "Originating Site" means the site where the member is located, and dental care providers are working and performing services in conjunction with a dentist who is not at that site, all while using telehealth technology.

(54) "Periapical X-rays" capture an image of an entire tooth, from the crown to the root tip.

(55) "Periodontal scaling" and "root planing" refer to non-surgical treatments to remove plaque and tartar from teeth roots and gums.

(56) "Periodontal" refers to the soft tissues supporting and surrounding teeth.

(57) "Permanent teeth", often referred to as adult teeth, are the second set of teeth people get. There are 32 permanent teeth which include incisors, canines, and premolars, and molars. They are identified by the numbers 1 through 32.

(58) "Posterior teeth" are referred to as the back teeth:

(a) Permanent upper posterior teeth are indicated by the numbers 1, 2, 3, 4, 5, 12, 13, 14, 15, 16;

(b) Permanent lower posterior teeth are indicated by the numbers 17, 18, 19, 20, 21, 28, 29, 30, 31, 32;

(c) Primary upper posterior teeth are indicated by the letters A, B, I, J; and

(d) Primary lower posterior teeth are indicated by the letters S, T, K, L.

(59) "Practitioner-Managed Prescription Drug Plan" (PMPDP) has the meaning provided in OAR 410-121-0030.

(60) "Premolars" are permanent teeth and also called bicuspid teeth. They are positioned between the canines and molars:

(a) The upper premolar teeth are indicated by the numbers 4, 5, 12, 13; and

(b) The lower premolar teeth are indicated by the numbers 20, 21, 28, 29.

(61) "Prepaid Ambulatory Health Plans (PAHP)" has the meaning provided in 42 CFR § 438.2.

(62) "Prescriptions" means services as outlined in OAR 410-121-0144.

(63) "Primary Teeth" are also known as baby teeth. These are the first set of teeth that people get. There are 20 primary teeth that shall exfoliate (fall out) as the permanent teeth grow in. Primary teeth are indicated by the letters A, B, C, D, E, F, G, H, I, J, K, L, M, N, O, P, Q, R, S, T.

(64) "Prior Authorization (PA) has the meaning as provided in OAR 410-120-0000.

(65) "Prioritized List of Health Services (Prioritized List)" has the meaning as provided in OAR 410-120-0000.

(66) "Procedure Codes" means Current Dental Terminology (CDT), unless otherwise noted. Codes listed in this rule and other documents incorporated in rule by reference are subject to change by the American Dental Association (ADA) without notification.

(67) "Program Integrity" has the meaning as provided in OAR 410-120-1360 through 410-120-1580.

(68) "Prophylaxis" is a dental service to thoroughly clean the teeth.

(69) "Prosthodontics" refers to the replacement of missing or damaged teeth with artificial devices, most commonly dentures.

(70) "Provider Audits" has the meaning as provided in OAR 410-120-1396.

(71) "Provider Responsibility" means to maintain clinical, financial, and other records consistent with OAR 410-120-1360.

(72) "Pulpal regeneration" is a dental treatment used to restore the pulp of a diseased or damaged tooth.

(73) "Pulpal therapy" involves removing pulp from the crown of a primary tooth and treating it with medicament.

(74) "Record retention" means the schedule whereby FFS providers must keep clinical information on file for seven (7) years, and financial records five (5) years. Providers contracted with MCE must refer to OAR 410-141-3520.

(75) "Scaling" is a deep-cleaning procedure for removing hardened tarter from teeth and roots.

(76) "Standard of Practice" means what reasonable and prudent practitioners may do in the same or similar circumstances.

(77) "Teledentistry" means using electronic and telecommunications technologies, for the distance delivery of dental care services and clinical information designed to improve a member's health status and to enhance delivery of the health care services and clinical information (Refer to modes specified in OAR 410-123-1265).

(78) "Telehealth" has the meaning as provided in OAR 410-120-0000.

(79) "Third Party Resources (TPR)" has the meaning as provided in OAR 410-120-1280.

(80) "Urgent Dental Care" means the management of conditions that require prompt attention to relieve pain and/or risk of infection and to alleviate the burden on hospital emergency departments. These conditions must be treated as minimally invasively as possible. Urgent dental care is distinguished from emergency dental care in that urgent dental care requires prompt but not immediate treatment. Examples include dull toothache, mildly swollen gums, or small chips or cracks in teeth.

Or. Admin. Code § 410-123-1060

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; DMAP 34-2016, f. 6-30-16, cert. ef. 7/1/2016; DMAP 61-2020, amend filed 12/11/2020, effective 1/1/2021; DMAP 50-2021, amend filed 12/24/2021, effective 1/1/2022; DMAP 24-2022, minor correction filed 02/16/2022, effective 2/16/2022; DMAP 89-2022, amend filed 12/16/2022, effective 1/1/2023; DMAP 79-2023, amend filed 09/26/2023, effective 10/1/2023; DMAP 59-2024, minor correction filed 02/21/2024, effective 2/21/2024; DMAP 139-2024, amend filed 12/06/2024, effective 1/1/2025

Statutory/Other Authority: ORS 413.042 & ORS 414.065

Statutes/Other Implemented: ORS 414.065