Or. Admin. Code § 410-123-1260

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

Section 410-123-1260 - Coverage, Limitations, Exclusions

(1) The Oregon Health Authority (Authority) offers Medicaid dental/denturist benefits on a Fee-For-Service (FFS) basis. chapter 410, division 123 rules are intended to give FFS providers direction in the delivery of dental services and in the preparation of dental care claims. (For Managed Care Entities (MCE) direction in the delivery of dental services and in the preparation of dental care claims refer to OAR 410-141-3835.)

(2) This rule incorporates the Oregon Health Evidence Review Commission (HERC) Prioritized List of Health Services (Prioritized List), funded through the stated covered line and including all line items, diagnostic and treatment codes, guideline notes, statements of intent, coding specifications and annotations (refer to OAR 410-141-3830).

(3) Dental services covered by Oregon Health Plan (OHP) can be found by referencing the:

(a) OHA FFS Fee Schedule (https://www.oregon.gov/oha/hsd/ohp/pages/fee-schedule.aspx);

(b) Funded lines on the Prioritized List as defined in OAR 410-141-3830. (https://www.oregon.gov/oha/hpa/dsi-herc/pages/prioritized-list.aspx);

(c) Oregon.Gov Covered Dental Codes list;

(d) Approved ancillary codes, listed in OAR 410-123-1620; and

(e) Oregon Administrative Rules (OAR), Medicaid covered services, are found throughout chapter 410;

(4) All coverage limitations and exclusions are subject to Early and Periodic Screening, Diagnostic, and Treatment (EPSDT) (refer to chapter 410, division 151.

(5) Diagnostic services (CDT codes D0100 - D0999):

(a) Dental screenings (D0190) including state or federally mandated screenings, are limited observations performed as mass screenings or EPSDT well-child and preventative care visits, to identify individuals who have suspected oral health needs and who must be seen by a dentist for diagnosis. Reimbursement is for providers who hold a certificate of completion from Smiles for Life or First Tooth;

(b) Dental assessments (D0191) are limited clinical inspections performed to identify possible signs of oral systemic disease, malformation, or injury, and the potential need for referral diagnosis and treatment. Reimbursement is for licensed or certified dental professionals whose scope of practice includes assessing oral health or Physicians (MD or DO), advance practice nurses, or licensed physician assistants who hold a certificate of completion from Smiles for Life or First Tooth.

(c) The assessment tool used for D0190 and D0191 must be endorsed by the American Dental Association, the American Academy of Pediatric Dentistry, the Association of State and Territorial Dental Directors, or the American Academy of Pediatrics.

(A) Referrals for identified dental needs or for the establishment of a dental home are to be made to the member's primary care dentist for FFS members, or to the member's CCO;

(B) Anticipatory guidance and counseling on good dental hygiene practices and nutrition is to be provided to the member's caregiver;

(C) Risk assessment findings and service components provided are to be documented in the medical chart;

(D) Reimbursable only if an exam (D0120-D0180) is not performed on the same date of service. Assessment of a Patient (D0191) is included as part of an exam (D0120-D0180);

(E) For EPSDT beneficiaries, a maximum of twice (2) every twelve (12) months (refer to chapter 410, division 151); and

(F) For non-EPSDT beneficiaries, a maximum of once (1) every twelve (12) months.

(G) An assessment does not take the place of the need for dental evaluations/exams.

(d) Referrals:

(A) If, during the screening process (periodic or inter-periodic), a dental, medical, substance abuse, or medical condition is discovered, the member must be referred to an appropriate provider for further diagnosis and/or treatment;

(B) The screening provider must explain the need for the referral to the member, member's parent, or guardian;

(C) If the member, member's parent, or guardian agrees to the referral, assistance in finding an appropriate provider and making an appointment shall be offered;

(D) The member's FFS provider or the MCE program shall make available care coordination as needed.

(e) Clinical Dental evaluations (Exams) for:

(A) EPSDT beneficiaries (refer to OAR 410-200-0455):

(i) The Authority covers exams (D0120, D0145, D0150, or D0180) a maximum of twice (2) every twelve (12) months with the following limitations:

(I) D0150: once (1) every twelve (12) months when performed by the same practitioner;

(II) D0180: once (1) every twelve (12) months.

(ii) The Authority must reimburse D0160 only once (1) every twelve (12) months when performed by the same practitioner.

(B) For non-EPSDT beneficiaries, the Authority must reimburse exams (billed as CDT codes D0120, D0150, D0160, or D0180) once (1) every twelve (12) months;

(C) For problem focused exams (urgent or emergent problems), the Authority must reimburse D0140 for the initial exam. The Authority must reimburse D0170 for related problem-focused follow-up exams. Providers must not bill D0140 and D0170 for routine dental visits;

(D) The Authority only covers dental exams performed by medical practitioners when the medical practitioner is an oral surgeon. The surgeon may hold a dual degree, but must bill as an oral surgeon;

(E) As the American Dental Association's (ADA's) Current Dental Terminology (CDT) codebook specifies, the evaluation, diagnosis, and treatment planning components of the exam are the responsibility of the licensed provider. The Authority may not reimburse dental exams when performed by a dental hygienist (with or without an expanded practice permit).

(f) Diagnostic imaging:

(A) The Authority covers routine imaging once (1) every twelve (12) months;

(B) The Authority covers bitewing radiographs for routine screening once (1) every twelve (12) months;

(i) D0240, D0250, D0251, D0273, D0274, D0277, D0321, D0322, D0701 - D0709 are reimbursed once (1) every twelve (12) months for all members;

(ii) D0210, D0330 are reimbursed once (1) every five (5) years, unless D0210 has been billed within the five (5) year period.

(C) The Authority covers a maximum of six (6) images for any one (1) emergency;

(D) For members under age six (6), images may be billed separately every twelve (12) months as follows:

(i) D0220 - once (1);

(ii) D0230 - a maximum of five (5) times;

(iii) D0270 - a maximum of twice (2), or D0272 once (1).

(E) The Authority covers panoramic radiographic image or intra-dental complete series once (1) every five (5) years, but both cannot be done within the five (5) year period;

(F) Members must be a minimum of six (6) years old for billing intra-dental complete series. The minimum standards for reimbursement of intra-dental complete series are:

(i) For members age six (6) through eleven (11) a minimum of ten (10) periapical and two (2) bitewings for a total of twelve (12) films;

(ii) For members ages twelve (12) and older a minimum of ten (10) periapical and four (4) bitewings for a total of fourteen (14) films.

(G) If fees for multiple single radiographs exceed the allowable reimbursement for an intraoral-complete series (full mouth), the Authority must reimburse for the complete series;

(H) Additional films are covered if dentally necessary and medically appropriate, e.g., fractures);

(I) If the Authority determines the number of radiographs to be excessive, payment for some or all radiographs of the same tooth or area shall be denied;

(J) The exception to these limitations is if the member is new to the office or clinic and the office or clinic is unsuccessful in obtaining radiographs from the previous dental office or clinic. Supporting documentation outlining the provider's attempts to receive previous records must be included in the member's records;

(K) Digital radiographs, if printed, must be on photo paper to assure sufficient quality of images.

(6) Preventative Services (CDT codes D1000-D1999):

(a) Topical fluoride treatment:

(A) For EPSDT beneficiaries, limited to twice (2) every twelve (12) months;

(B) For non-EPSDT beneficiaries, limited to once (1) every twelve (12) months;

(C) Additional topical fluoride treatments are available, up to a total of four (4) treatments per member within a twelve (12) month period, when high-risk conditions or dental health factors are clearly documented in chart notes for members who:

(i) Have high-risk dental conditions due to disease process, medications, other medical treatments or conditions, or rampant caries;

(ii) Are pregnant;

(iii) Have physical disabilities and cannot perform adequate, daily dental health care;

(iv) Have a developmental disability or other severe cognitive impairment that cannot perform adequate, daily dental health care; or

(v) Are under seven (7) years old with high-risk dental health factors, such as poor dental hygiene, deep pits, and fissures (grooves) in teeth, severely crowded teeth, poor diet, etc.

(D) Fluoride limits include any combination of fluoride varnish or other topical fluoride.

(b) Sealants:

(A) Are covered only for children under sixteen (16) years of age;

(B) The Authority limits coverage to:

(i) Permanent molars; and

(ii) Only one (1) sealant treatment per molar every five (5) years, except for visible evidence of clinical failure.

(c) Dental prophylaxis:

(A) EPSDT beneficiaries, limited to twice (2) per twelve (12) months;

(B) Non-EPSDT beneficiaries, limited to once (1) per twelve (12) months; and

(C) Additional prophylaxis benefit provisions are available for persons with high-risk dental conditions due to disease process, pregnancy, medications, or other medical treatments or conditions, severe periodontal disease, rampant caries and for persons with disabilities who cannot perform adequate daily dental health care.

(d) Interim caries arresting medicament application (D1354, D1355): When used to represent silver diamine fluoride (SDF) applications for the treatment (rather than prevention) of caries, is limited to:

(A) Two (2) applications per year;

(B) Requires that the tooth or teeth numbers be included on the claim;

(C) Must be covered with topical application of fluoride when performed on the same date of service when treating a carious lesion;

(D) Must be covered with an interim therapeutic restoration (D2941) or a permanent restoration and (D1354, D1355) on the same tooth, when medically necessary and dentally appropriate.

(e) Interim caries arresting medicament application (D1354) is also included on the Prioritized List to arrest or reverse non-cavitated carious lesions. See Prioritized List Guideline Note 91 for more detail.

(f) Tobacco cessation:

(A) For services provided during a dental visit, bill as a dental service using D1320 when the following 5 step counseling is provided:

(i) ASK: Identify the member's tobacco-use status at each visit and record information in the chart;

(ii) ADVISE: Using a strong personalized message, advise members on their dental health conditions related to tobacco use and give direct advice to quit using tobacco and seek help;

(iii) ASSESS: Refer member to external resources or internal counseling and intervention protocol if the tobacco user is willing to make a quit attempt;

(iv) ASSIST: Provide counseling and pharmacotherapy to help member quit tobacco, if dental provider chooses to assist; and

(v) ARRANGE: Schedule follow-up contact, in person or by telephone, preferably within the first week after the quit date if dental provider chooses to arrange.

(B) The Authority covers a maximum of ten (10) services within a three (3) month period.

(e) Space maintenance (passive appliances) are:

(A) Covered for EPSDT beneficiaries;

(B) Not replaceable when lost or damaged.

(7) Restorative Services (CDT codes D2000-D2999):

(a) Amalgam and resin-based composite restorations, direct:

(A) Resin-based composite crowns on anterior teeth (D2390) are only covered for EPSDT beneficiaries, and members who are pregnant;

(B) The Authority reimburses posterior composite restorations at the same rate as amalgam restorations;

(C) The Authority limits payment of posterior composite restorations to once (1) every five (5) years, per tooth;

(D) The Authority limits payment of covered restorations to the maximum restoration fee of four (4) surfaces per tooth. Refer to the ADA CDT codebook for definitions of restorative procedures;

(E) Providers must combine and bill multiple surface restorations as one line per tooth using the appropriate code. Providers may not bill multiple surface restorations performed on a single tooth on the same day on separate lines. For example, if tooth #30 has a buccal amalgam and a mesial-occlusal-distal (MOD) amalgam, then bill MOD, B, using code D2161 (four or more surfaces);

(F) The Authority shall not reimburse for an amalgam or composite restoration and a crown on the same tooth;

(G) Interim therapeutic restoration on primary dentition is covered to restore and prevent progression of dental caries. Interim therapeutic restoration is not a definitive restoration;

(H) Reattachment of tooth fragment is covered once in the lifetime of a tooth when there is no pulp exposure and no need for endodontic treatment;

(I) The Authority reimburses for a surface not more than once (1) in each treatment episode regardless of the number or combination of restorations;

(J) The restoration fee includes payment for occlusal adjustment and polishing of the restoration.

(b) Indirect crowns and related services:

(A) General payment policies:

(i) The fee for the crown includes payment for preparation of the gingival tissue;

(ii) The Authority covers crowns only when:

(I) There is significant loss of clinical crown, and no other restorations restore function; and

(II) The crown-to-root ratio is 50:50 or better, and the tooth is restorable without other surgical procedures.

(iii) The Authority covers core buildup only when necessary to retain a cast restoration due to extensive loss of tooth structure from caries or a fracture and only when done in conjunction with a crown. Less than 50 percent of the tooth structure must be remaining for coverage of the core buildup;

(iv) Reimbursement of retention pins is per tooth, not per pin.

(B) The Authority does not cover the following services:

(i) Endodontic therapy alone (with or without a post);

(ii) Aesthetics (cosmetics);

(iii) Crowns in cases of advanced periodontal disease or when a poor crown/root ratio exists for any reason.

(C) Prefabricated stainless steel crowns are allowed only for anterior primary teeth and posterior permanent or primary teeth;

(D) The Authority covers the following only for EPSDT beneficiaries, and for members who are pregnant:

(i) Prefabricated resin crowns for anterior teeth, permanent or primary;

(ii) Prefabricated resin crowns for posterior teeth, permanent or primary, once (1) per tooth in a five (5) year period;

(iii) Prefabricated stainless-steel crowns with resin window are allowed only for anterior teeth, permanent or primary;

(iv) Prefabricated post and core in addition to crowns;

(v) Crowns (resin-based composite - D2710 and D2712, porcelain fused to metal (PFM) - D2751 and D2752), and porcelain ceramic - D2740 as follows:

(I) Limited to teeth numbers 6-11, 22, and 27 only, if dentally appropriate;

(II) Limited to four (4) in a seven (7) year period. This limitation includes any replacement crowns allowed; and

(Ill) Rampant caries are arrested, and the member demonstrates a period of dental hygiene before prosthetics are proposed.

(vi) Porcelain fused to metal crowns (D2751, D2752), and porcelain ceramic crowns (D2740) must meet the following additional criteria:

(I) The Dental Practitioner has attempted all other dentally appropriate restoration options and documented failure of those options;

(II) Written documentation in the member's chart indicates that PFM is the only restoration option that restores function;

(III) The Dental Practitioner submits radiographs to the Authority for review. History, diagnosis, and treatment plan may be requested;

(IV) The member has documented stable periodontal status with pocket depths within 1-3 millimeters. If PFM crowns are placed with pocket depths of 4 millimeters and over, documentation must be maintained in the member's chart of the dentist's findings supporting stability and why the increased pocket depths shall not adversely affect expected long-term prognosis;

(V) The crown has a favorable long-term prognosis; and

(VI) If the tooth to be crowned is a clasp/abutment tooth in partial denture, both prognosis for the crown itself and the tooth's contribution to partial denture must have favorable expected long-term prognosis.

(E) Crown replacement coverage is as follows:

(i) D2710, D2712, D2740, D2751, D2752 are limited to once (1) every seven (7) years;

(ii) All other covered crowns are limited to once (1) every five (5) years; and

(iii) Exceptions to the above limitations due to acute trauma are based on the following factors:

(I) Extent of crown damage;

(II) Extent of damage to other teeth or crowns;

(III) Extent of impaired mastication;

(IV) Tooth is restorable without other surgical procedures; and

(V) If loss of tooth may result in coverage of removable prosthetic.

(F) Crown repair is limited to only anterior teeth.

(8) Endodontic Services (CDT codes D3000-D3999):

(a) Endodontic therapy:

(A) All primary teeth are covered for EPSDT beneficiaries;

(B) Permanent teeth:

(i) Anterior and bicuspid teeth are covered for all members; and

(ii) Molars are covered as follows:

(I) EPSDT beneficiaries, first and second molars; and

(II) Members who are pregnant, only first molars.

(C) The Authority covers endodontics only if the crown-to-root ratio is 50:50 or better and the tooth is restorable without other surgical procedures.

(b) Endodontic retreatment and apicoectomy:

(A) The Authority does not cover retreatment of a previous root canal or apicoectomy for bicuspid teeth or molars;

(B) The Authority limits either a retreatment or an apicoectomy (but not both procedures for the same tooth) to symptomatic anterior teeth when:

(i) Crown-to-root ratio is 50:50 or better;

(ii) The tooth is restorable without other surgical procedures; or

(iii) If loss of tooth shall result in the need for removable prosthodontics.

(C) Retrograde filling is covered only when done in conjunction with a covered apicoectomy of an anterior tooth.

(c) The Authority does not allow separate reimbursement for open-and-drain as a palliative procedure when the root canal is completed on the same date of service or if the same practitioner or Dental Practitioner in the same group practice completed the procedure;

(d) The Authority covers endodontics if the tooth is restorable.

(e) Apexification/recalcification procedures:

(A) The Authority limits payment for apexification to a maximum of five (5) treatments on permanent teeth only;

(B) Covered only for EPSDT beneficiaries, or members who are pregnant.

(9) Periodontic Services (CDT codes D4000-D4999):

(a) Surgical periodontal services:

(A) Gingivectomy/Gingivoplasty limited to coverage for severe gingival hyperplasia where enlargement of gum tissue occurs that prevents access to dental hygiene procedures, e.g., Dilantin hyperplasia;

(B) Includes six (6) months routine postoperative care; and

(C) The Authority considers gingivectomy or gingivoplasty to allow for access for restorative procedure, per tooth (D4212) as part of the restoration and does not provide a separate reimbursement for this procedure.

(b) Non-surgical periodontal services:

(A) Periodontal scaling and root planing:

(i) Allowed once (1) every two (2) years;

(ii) A maximum of two (2) quadrants on one date of service is payable, except in extraordinary circumstances supported by documentation;

(iii) Quadrants are not limited to physical area, but are further defined by the number of teeth with pockets of 5 mm or greater:

(I) D4341 is allowed for quadrants with at least four (4) or more teeth with pockets of 5 mm or greater. Single implants may now be covered by counting the implant as an additional tooth when billing D4341. The maximum number per quadrant and pocket depth requirements still apply; or

(II) D4342 is allowed for quadrants with at least two (2) teeth with pocket depths of 5 mm or greater. Single implants may now be covered by counting the implant as an additional tooth when billing D4342. The maximum number per quadrant and pocket depth requirements still apply.

(B) Full mouth debridement allowed only once (1) every two (2) years;

(C) Scaling in the presence of generalized moderate or severe gingival inflammation, full mouth, after dental evaluation, allowed only once (1) every two (2) years.

(c) Periodontal maintenance allowed once (1) every six (6) months:

(A) Limited to following periodontal therapy (surgical or non-surgical) that is documented to have occurred within the past three (3) years;

(B) Additional periodontal maintenance requires PA and may be requested when:

(i) Medically necessary and dentally appropriate, such as due to presence of periodontal disease during pregnancy; and

(ii) Member's medical record is submitted that supports the need for increased periodontal maintenance (chart notes, pocket depths and radiographs).

(d) Records must clearly document the clinical indications for all periodontal procedures, including current pocket depth charting and radiographs;

(e) The Authority does not reimburse for procedures identified by the following codes if performed on the same date of service:

(A) D1110 (Prophylaxis - adult);

(B) D1120 (Prophylaxis - child);

(C) D4210 (Gingivectomy or gingivoplasty - four (4) or more contiguous teeth or bounded teeth spaces per quadrant);

(D) D4211 (Gingivectomy or gingivoplasty, one (1) to three (3) contiguous teeth or bounded teeth spaces per quadrant);

(E) D4341 (Periodontal scaling and root planing, four (4) or more teeth per quadrant);

(F) D4342 (Periodontal scaling and root planing, one (1) to three (3) teeth per quadrant);

(G) D4346 (Scaling in presence of generalized moderate to severe inflammation, full mouth after dental evaluation);

(H) D4355 (Full mouth debridement to enable comprehensive evaluation and diagnosis); and

(I) D4910 (Periodontal maintenance).

(10) Prosthodontics, Removable (CDT codes D5000-D5899):

(a) If a dentist or denturist provides an eligible member with fabricated prosthetics that require the use of a dental laboratory, the date of the final impressions must have occurred prior to the member's loss of coverage;

(b) The dentist or denturist shall use the date of final impression as the date of service only when criteria in (a) is met and the fabrication extends beyond the member's OHP coverage;

(c) The date of delivery must be within 45 days of the date of the final impression and the date of delivery must also be indicated on the claim. All other services must be billed using the date the service was provided.

(d) The fee for the partial and complete dentures includes payment for adjustments during the six (6) month period following delivery to members;

(e) Resin partial dentures:

(A) The Authority does not approve resin partial dentures if stainless steel crowns are used as abutments;

(B) For EPSDT beneficiaries, the member must have one (1) or more anterior teeth missing or four (4) or more missing posterior teeth per arch with resulting space equivalent to that loss demonstrating inability to masticate. Third molars are not a consideration when counting missing teeth;

(C) For non-EPSDT beneficiaries, the member must have one (1) or more missing anterior teeth or six (6) or more missing posterior teeth per arch with documentation by the provider of resulting space causing serious impairment to mastication. Third molars are not a consideration when counting missing teeth;

(D) The Practitioner must note the teeth to be replaced and teeth to be clasped when requesting Prior Authorization (PA).

(f) Replacement of removable partial or complete dentures, when it cannot be made clinically serviceable by a less costly procedure (e.g., reline, rebase, repair, tooth replacement), is limited to the following:

(A) Complete dentures once (1) every ten (10) years, only if medically necessary and dentally appropriate;

(B) Partial dentures once (1) every five (5) years, only if medically necessary and dentally appropriate.

(C) The five (5) and ten (10) year limitations apply to the member regardless of the member's OHP or MCE enrollment status at the time the member's last denture or partial was received.;

(D) Replacement of partial dentures with complete dentures is payable five (5) years after the partial denture placement. Exceptions to this limitation may be made in cases of acute trauma, natural disaster, or catastrophic illness that directly or indirectly affects the dental condition and results in additional tooth loss. This pertains to, but is not limited to, cancer and periodontal disease resulting from pharmacological, surgical, and medical treatment for the conditions mentioned earlier. Severe periodontal disease due to neglect of daily dental hygiene may not warrant replacement.

(g) The Authority limits reimbursement of adjustments and repairs of dentures that are needed beyond six (6) months after delivery of the denture as follows:

(A) A maximum of four (4) times per year for:

(i) Adjustments to dentures, per arch - complete and partial (D5410 - D5422);

(ii) Replace missing or broken teeth - complete denture, each tooth (D5520);

(iii) Replace broken tooth on a partial denture - each tooth (D5640);

(iv) Add tooth to existing partial denture (D5650).

(B) A maximum of two (2) times per year for:

(i) Repair broken complete denture base (D5511, D5512);

(ii) Repair resin partial denture base (D5611, D5612);

(iii) Repair cast partial framework (D5621, D5622);

(iv) Repair or replace broken retentive/clasping materials - per tooth (D5630);

(v) Add clasp to existing partial denture - per tooth (D5660).

(h) Replacement of all teeth and acrylic on cast metal framework (D5670, D5671) is covered with a PA:

(A) A maximum of once (1) every ten (10) years, per arch;

(B) When ten (10) or more years have passed since the original partial denture was delivered; and

(C) And is considered replacement of the partial so a new partial denture shall not be reimbursed for another ten (10) years.

(i) Denture rebase procedures:

(A) The Authority covers rebases only if a reline does not adequately solve the problem;

(B) For EPSDT members, the Authority covers rebase once (1) every three (3) years;

(C) For non-EPSDT members:

(i) There must be documentation of a current reline that has been done and failed; and

(ii) The Authority limits payment for rebase to once (1) every five (5) years.

(D) The Authority may make exceptions to this limitation in cases of acute trauma or catastrophic illness that directly or indirectly affects the dental condition and results in additional tooth loss. This pertains to, but is not limited to, cancer and periodontal disease resulting from pharmacological, surgical, and medical treatment of these conditions. Severe periodontal disease due to neglect of daily dental hygiene may not warrant rebasing;

(j) Denture reline procedures:

(A) For EPSDT members, the Authority covers reline of complete or partial dentures once (1) every three (3) years;

(B) For non-EPSDT members, the Authority limits payment for reline of complete or partial dentures to once (1) every five (5) years;

(C) The Authority may make exceptions to this limitation under the same conditions warranting replacement;

(D) Laboratory relines:

(i) Are not payable prior to six (6) months after placement of an immediate denture;

(ii) For EPSDT members, the Authority limits payment to once (1) every three (3) years;

(iii) For non-EPSDT members, the Authority limits payment to once (1) every five (5) years.

(k) Interim partial dentures (also referred to as "flippers"):

(A) Are allowed if the member has one (1) or more anterior teeth missing; and

(B) The Authority must reimburse for replacement of interim partial dentures once (1) every five (5) years but only when medically necessary and dentally appropriate.

(l) Tissue conditioning:

(A) Is allowed once per denture unit in conjunction with immediate dentures; and

(B) Is allowed once prior to new prosthetic placement.

(11) Maxillofacial Prosthetic Services (CDT codes D5900-D5999):

(a) Fluoride gel carrier is limited to those members whose severity of dental disease causes the increased cleaning and fluoride treatments allowed in rule to be insufficient. The Dental Practitioner must document failure of those options prior to use of the fluoride gel carrier; and

(b) All other maxillofacial prosthetics are medical services;

(A) Bill for medical maxillofacial prosthetics using the professional (CMS1500, DMAP 505, 837D or 837P) claim format;

(B) For members receiving services through an MCE bill medical maxillofacial prosthetics to the MCE; and

(C) For members receiving medical services through FFS, bill the Authority.

(12) Prosthodontics, fixed (CDT codes D6200-D6999) - D6100 and D6105 are only covered when there is advanced peri-implantitis with bone loss and mobility, abscess or implant fracture.

(13) Oral & Maxillofacial Surgery (D7000-D7999): Billing Procedures:

(a) Bill on a dental claim form using CDT codes for procedures that are directly related to the teeth and the structures directly supporting teeth;

(b) The Medical/Surgical Program is responsible for all dental health procedures performed due to an underlying medical condition (i.e., procedures on or in preparation for treatment of the jaw, tongue, roof of mouth). Such procedures must be billed using ICD-10, HCPCS and CPT billing codes using the professional (CMS1500, DMAP 505 or 837P) claim format;

(c) The following services are covered based on severity and included situations deemed to cause gingival recession or movement of the gingival margin when frenum is placed under tension:

(A) Buccal/labial frenectomy (frenulectomy) (D7961)

(B) Lingual frenectomy (frenulectomy) (D7962)

(C) Frenuloplasty (D7963)

(d) Emergency tracheotomy (D7990) is an ancillary code reimbursable for all members;

(e) All ancillary and diagnosis codes must be used for services that are medically necessary and dentally appropriate.

(f) Alveoloplasty not in conjunction with extractions are reimbursable for EPSDT beneficiaries, and for members who are pregnant. (D7320, D7321).

(14) Orthodontics (CDT Codes D8000-D8999):

(a) The Authority covers orthodontia services to treat cleft palate with airway obstruction, cleft palate and/or cleft lip, or deformities of the head, and handicapping malocclusions (HM), not for cosmetic purposes, when:

(A) The member has a craniofacial anomaly health condition that is included on a covered line of the Prioritized List of Health Services; and

(B) The Authority approves the PA request for orthodontic treatment.

(b) Pre-orthodontic treatment examinations (D8660) must be provided by a licensed dentist.

(c) Pre-orthodontic treatment examinations (D8660) are covered only for members whose clinical presentation and preliminary findings strongly suggest that they may qualify for orthodontic treatment under HM criteria, as established by the Authority. Reimbursement does not require PA, and is allowable:

(A) Once (1) per member, per provider, in a twelve (12) month period (not on the same day as another routine or general dental evaluation or examination); and

(B) When submitted alongside the following documentation to justify the need for treatment:

(i) The Authority-approved Handicapping Labiolingual Deviation (HLD) Index California Modified Scoring Form (completed, scored, and signed);

(ii) Intra-oral and extra-oral photographs of diagnostic quality, adhering to American Association of Orthodontists (AAO) standards, capturing key aspects of the malocclusion;

(iii) Panoramic radiographs and cephalometric images including tracings that document skeletal and dental relationships crucial for evaluating the severity of malocclusion; and

(iv) A comprehensive narrative of medical necessity, explicitly stating how the malocclusion significantly impacts the member's oral health, airway, or overall functional capacity.

(d) PA approval for comprehensive orthodontic treatment (D8070, D8080, D8090), must meet the criteria in Guideline Note 169 of the Prioritized List of Health Service.

(e) Comprehensive orthodontic treatment must be completed by a licensed dentist who has:

(A) Completed a Commission of Dental Accreditation (CODA) orthodontic fellowship or residency program;

(B) Certified additional orthodontic training, a minimum of thirty (30) hours of orthodontic continuing education (CE) in the past three (3) years that was approved by the American Dental Association Continuing Education Recognition Program (ADA CERP); or

(C) Completed five (5) comprehensive orthodontic treatment cases in the past three (3) years, verified by case logs and patient outcomes.

(f) Orthodontic treatment must begin while the member is an EPSDT beneficiary, or immediately after, if surgical corrections that were started during the member's EPSDT beneficiary period for covered conditions were not completed during that period.

(g) For auditing purposes, refer to OAR 410-120-1396.

(h) Payment for comprehensive orthodontic treatment includes all appliances and all follow-up visits.

(i) The Authority pays for orthodontia in one lump sum upon beginning of treatment;

(A) If the member transfers to another orthodontist during treatment, or treatment is terminated, the Authority shall recover the overpayment (refer to OAR 410-120-1397) based on the length of the treatment plan from the first date of service (DOS); and

(B) Providers may discontinue orthodontic treatment of a member in cases including poor dental hygiene, continued missed appointments, or if treatment is a detriment to the member.

(j) Licensed dentists providing orthodontic treatment may:

(A) Submit PA requests for the extractions and/or bond surgeries that are documented as needed in the member's orthodontic treatment plan; and

(B) Refer members to enrolled specialists for extractions and/or bond surgeries when such services are beyond the scope of the member's primary care dentist.

(k) As long as the orthodontist continues treatment, the Authority may not require a refund even though the member may become ineligible for medical assistance sometime during the treatment period.

(l) Care navigation assistance for members must be made available during transfer of care in situations such as provider changes.

(15) Adjunctive General and Other Services (CDT codes D9000-D9999):

(a) Fixed partial denture sectioning is covered only when extracting a tooth connected to a fixed prosthesis and a portion of the fixed prosthesis is to remain intact and serviceable, preventing the need for more costly treatment;

(b) Anesthesia:

(A) The Authority reimburses administration of general anesthesia or IV sedation only for those members with concurrent needs: age; physical, medical, or mental status; or degree of difficulty of the procedure; and

(B) The Authority reimburses providers with a current permit to administer General Anesthesia or IV Sedation as follows:

(i) For each 15-minute period, up to two and a half hours on the same day of service in a dental office setting, and up to three and a half hours on the same day of service in a hospital setting;

(ii) Each 15-minute period represents a quantity of one. Enter this number in the quantity column.

(C) The Authority reimburses administration of Nitrous Oxide per date of service, not by time;

(D) Non-intravenous conscious sedation:

(i) Limited to members under 13 years of age;

(ii) Limited to four (4) times per year;

(iii) Includes payment for monitoring and Nitrous Oxide; and

(iv) Requires use of multiple agents to receive payment.

(E) Upon request, providers must submit a copy of their permit to administer Anesthesia, Analgesia, and Sedation to the Authority; and

(F) For the purpose of Title XIX and Title XXI, the Authority limits payment for code D9630 to those dental medications used during a procedure and is not intended for "take home" medication.

(c) The Authority limits reimbursement of house/extended care facility calls only for urgent or emergent dental visits that occur outside of a dental office. This code is not reimbursable for provision of preventive services or for services provided outside of the office for the provider or facilities' convenience.

(16) Sleep Apnea Services:

(a) These devices and appliances may be placed or fabricated by a dentist or oral surgeon but are considered a medical service;

(b) Bill the Authority or MCE for these codes using the professional claim format;

(c) Custom sleep apnea appliance fabrication and placement (D9947) must be billed on a dental claim form (See HERC Guideline Notes 27 and 36 for limitations), and is replaceable at the end of the five (5) year reasonable useful lifetime;

(d) Adjustments for dental sleep apnea appliances (D9948) are considered normal follow-up care within the first ninety (90) days after provision of the device, and is included as a bundled rate with D9947; and

(e) Dental sleep apnea repairs (D9949) are covered when necessary and appropriate to make item serviceable. If the expense for repairs exceeds the estimated expense of purchasing another item, no payment must be made for the excess.

(17) Restorative, Periodontal, and Prosthetic Treatment Limitations:

(a) Documentation must be included in the member's charts to support the treatment;

(b) Treatments must be consistent with the prevailing standard of care and may be limited as follows, when:

(A) Prognosis is unfavorable;

(B) Treatment is impractical;

(C) A lesser cost procedure achieves the same ultimate result; or

(D) The treatment has specific limitations outlined in this rule.

(c) Prosthetic treatment, including porcelain fused to metal crowns and porcelain/ceramic crowns are limited until rampant caries is arrested and a period of adequate dental hygiene and periodontal stability is demonstrated. Periodontal health needs to be stable and supportive of a prosthetic;

(d) Complete and/or partial denture replacement. For indications and limitations of coverage and dental appropriateness, the Authority may cover reasonable and necessary replacement of medically necessary and dentally appropriate, covered complete and/or partial dentures, including those items purchased or in use before the member enrolled with the OHP:

(A) Replacement of complete and/or partial dentures because of loss due to circumstances beyond the member's control, accident or natural disaster/ situations involving the provision of medically necessary and dentally appropriate items when:

(i) There is a change in the member's condition that warrants a new device;

(ii) The item is not repairable;

(iii) There is coverage for the specific item as identified in chapter 410, division 123;

(iv) Complete and partial dentures that the member owns may be replaced in cases of loss due to circumstances beyond the member's control or irreparable damage. Irreparable damage refers to a specific accident or to a natural disaster.

(B) Cases suggesting malicious damage, culpable neglect, or wrongful disposition of complete or partial dentures may not be covered.

(18) Dental care access standards for pregnant members with FFS:

(a) Pregnant members must be seen, treated in person or via teledentistry for the following OHP-covered services and within the time frames as followed:

(A) Emergency dental care: within 24 hours (seen or treated);

(B) Urgent dental care: within one (1) week.

(C) Routine dental care: within four (4) weeks, unless there is a documented special clinical reason that may make it appropriate to see the member beyond this timeframe;

(D) Initial dental screening or examination: four (4) weeks.

(b) Additional Dental Services are available to pregnant members if authorized as medically necessary and dentally appropriate, and include:

(A) Additional prophylaxis, fluoride, and periodontal services;

(B) Permanent crowns and resin-based composite crowns for anterior teeth;

(C) Prefabricated post and core;

(D) Root canals on first molars;

(E) Apexification/recalcification, pulpal regeneration; and

(F) Alveoplasty not in conjunction with extractions.

(c) Nothing obligates a pregnant FFS member to accept an offered appointment; and

(d) Dental care benefits for pregnant members shall continue for twelve (12) months following the end of pregnancy.

(19) Services considered incidental, integral to the primary service rendered, part of another service, or included in routine post-op or follow-up care are not eligible for separate reimbursement.

(a) Participating providers may not balance bill members for these services;

(b) Services that are not to be billed separately may be included in the Current Dental Terminology (CDT) codebook;

(c) May not be listed as combined with another procedure; and

(d) For CMS Medicare Dental Coverage information https://www.cms.gov/medicare/coverage/dental.

(20) The following services are not eligible for separate reimbursement:

(a) Alveolectomy/Alveoloplasty in conjunction with extractions;

(b) Cardiac and other monitoring;

(c) Caries risk assessment and documentation;

(d) Curettage and root planing - per tooth is not eligible for separate reimbursement unless the service is significant and separately identifiable;

(e) Diagnostic casts;

(f) Dietary counseling;

(g) Direct pulp cap;

(h) Discing;

(i) Dressing change;

(j) Electrosurgery;

(k) Equilibration;

(l) Gingival curettage - per tooth;

(m) Gingival irrigation;

(n) Gingivectomy or gingivoplasty to allow for access for restorative procedure, per tooth;

(o) Indirect pulp cap;

(p) Local anesthesia;

(q) Medicated pulp chambers;

(r) Occlusal adjustments;

(s) Occlusal analysis;

(t) Odontoplasty;

(u) Oral hygiene instruction;

(v) Periodontal charting, probing;

(w) Post removal;

(x) Polishing fillings;

(y) Post extraction treatment for alveolaritis (dry socket treatment) if done by the provider of the extraction;

(z) Pulp vitality tests;

(aa) Smooth broken tooth;

(bb) Special infection control procedures;

(cc) Surgical procedure for isolation of tooth with rubber dam;

(dd) Surgical splint;

(ee) Surgical stent; and

(ff) Suture removal.

(21) The following general categories of dental services are not covered for any member, unless coverage is specified or member is an EPSDT beneficiary and meets requirements of OAR chapter 410, division 151, as several of these services are considered elective or "cosmetic" in nature (i.e., done for the sake of appearance):

(a) Desensitization;

(b) Implant and implant services (See Prioritized List Guideline Notes 123 and 169);

(c) Mastique or veneer procedure;

(d) Orthodontic treatment (except for cleft palate with airway obstruction, cleft palate and/or cleft lip, or deformities of head and handicapping malocclusion meeting criteria and PA requirements);

(e) Overhang removal;

(f) Procedures, appliances, or restorations solely for aesthetic or cosmetic purposes;

(g) Temporomandibular joint (TMJ) dysfunction treatment; and

(h) Tooth bleaching.

Or. Admin. Code § 410-123-1260

HR 3-1994, f. & cert. ef. 2-1-94; HR 20-1995, f. 9-29-95, cert. ef. 10-1-95; 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 8-2000, f. 3-31-00, cert. ef. 4-1-00; OMAP 17-2000, f. 9-28-00, cert. ef. 10-1-00; OMAP 48-2002, f. & cert. ef. 10-1-02; OMAP 3-2003, f. 1-31-03, cert. ef. 2-1-03; OMAP 65-2003, f. 9-10-03 cert. ef. 10-1-03; OMAP 55-2004, f. 9-10-04, cert. ef. 10-1-04; OMAP 12-2005, f. 3-11-05, cert. ef. 4-1-05; DMAP 25-2007, f. 12-11-07, cert, ef. 1-1-08; DMAP 18-2008, f. 6-13-08, cert. ef. 7-1-08; DMAP 38-2008, f. 12-11-08, cert. ef. 1-1-09; DMAP 16-2009 f. 6-12-09, cert. ef. 7-1-09; DMAP 41-2009, f. 12-15-09, cert. ef. 1-1-10; DMAP 14-2010, f. 6-10-10, cert. ef. 7-1-10; DMAP 31-2010, f. 12-15-10, cert. ef. 1-1-11; DMAP 17-2011, f. & cert. ef. 7-12-11; 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 28-2013(Temp), f. 6-26-13, cert. ef. 7-1-13 thru 12-28-13; DMAP 68-2013, f. 12-5-13, cert. ef. 12-23-13; DMAP 75-2013(Temp), f. 12-31-13, cert. ef. 1-1-14 thru 6-30-14; DMAP 10-2014(Temp), f. & cert. ef. 2-28-14 thru 8-27-14; DMAP 19-2014(Temp), f. 3-28-14, cert. ef. 4-1-14 thru 6-30-14; DMAP 36-2014, f. & cert. ef. 6-27-14; DMAP 56-2014, f. 9-26-14, cert. ef. 10-1-14; DMAP 7-2015(Temp), f. & cert. ef. 2-17-15 thru 8-15-15; DMAP 28-2015, f. & cert. ef. 5/1/2015; DMAP 46-2015(Temp), f. 8-26-15, cert. ef. 10-1-15 thru 3-28-16; DMAP 51-2015, f. 9-22-15, cert. ef. 10/1/2015; DMAP 65-2015, f. 11-3-15, cert. ef. 12/1/2015; DMAP 74-2015(Temp), f. 12-18-15, cert. ef. 1-1-16 thru 6-28-16; DMAP 5-2016(Temp), f. & cert. ef. 2-9-16 thru 6-28-16; DMAP 36-2016, f. 6-30-16, cert. ef. 7/1/2016; DMAP 45-2016, f. & cert. ef. 7/13/2016; DMAP 71-2016(Temp), f. 12-28-16, cert. ef. 1-1-17 thru 6-29-17; DMAP 25-2017, f. & cert. ef. 6/29/2017; DMAP 42-2018, minor correction filed 05/25/2018, effective 5/25/2018; DMAP 98-2018, temporary amend filed 10/26/2018, effective 11/01/2018 through 04/29/2019; DMAP 120-2018, amend filed 12/26/2018, effective 01/01/2019; 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 10-2022, minor correction filed 02/04/2022, effective 2/4/2022; DMAP 13-2022, amend filed 02/09/2022, effective 2/9/2022; 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 64-2024, 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