Or. Admin. Code § 410-123-1490

Current through Register Vol. 63, No. 11, November 1, 2024

Section 410-123-1490 - Hospital Dentistry

(1) The purpose of hospital dentistry is to provide safe, efficient dental care when providing routine (non-emergency) dental services for (Division) members who present special challenges that require the use of general anesthesia or IV conscious sedation services in an Ambulatory Surgical Center (ASC), inpatient or outpatient hospital setting. Refer to OAR 410-123-1060 for definitions.

(2) Division reimbursement for hospital dentistry is limited to covered services and may be prorated if non-covered dental services are performed during the same hospital visit:

(a) See OAR 410-123-1060 for a definition of Division hospital dentistry services;

(b) Refer to OAR 410-123-1220 for a definition of covered services.

(3) Hospital dentistry is intended for the following Division members:

(a) Children (18 or younger) who:

(A) Through age three (3): Have extensive dental needs;

(B) Four (4) years of age or older: Have unsuccessfully attempted treatment in the office setting with some type of sedation or nitrous oxide;

(C) Have acute situational anxiety, fearfulness, extreme uncooperative behavior, uncommunicative such as a member with developmental or mental disability, a member that is pre-verbal or extreme age where dental needs are deemed sufficiently important that dental care cannot be deferred;

(D) Need the use of general anesthesia (or IV conscious sedation) to protect the developing psyche;

(E) Have sustained extensive orofacial or dental trauma;

(F) Have physical, mental or medically compromising conditions; or

(G) Have a developmental disability or other severe cognitive impairment and one or more of the following characteristics that prevent routine dental care in an office setting:

(i) Acute situational anxiety and extreme uncooperative behavior;

(ii) A physically compromising condition.

(b) Adults (19 or older) who:

(A) Have a developmental disability or other severe cognitive impairment, and one or more of the following characteristics that prevent routine dental care in an office setting:

(i) Acute situational anxiety and extreme uncooperative behavior;

(ii) A physically compromising condition.

(B) Have sustained extensive orofacial or dental trauma; or

(C) Are medically fragile, with a medical or physical condition which requires monitoring during dental procedures (i.e. coronary disease, asthma, or chronic obstructive pulmonary disease (COPD), heart failure, serious blood or bleeding disorder, or unstable diabetes or hypertension), have complex medical needs, contractures or other significant medical conditions potentially making the dental office setting unsafe for the member.

(4) Hospital dentistry is not intended for:

(a) Member convenience. Refer to OAR 410-120-1200;

(b) A healthy, cooperative member with minimal dental needs; or

(c) Medical contraindication to general anesthesia or IV conscious sedation.

(5) Required Documentation: The following information shall be included in the member's dental record:

(a) Informed consent: Member, parental or guardian written consent shall be obtained prior to the use of general anesthesia or IV conscious sedation;

(b) Justification for the use of general anesthesia or IV conscious sedation: The decision to use general anesthesia or IV conscious sedation shall take into consideration:

(A) Alternative behavior management modalities;

(B) Member's dental needs;

(C) Quality of dental care;

(D) Quantity of dental care;

(E) Member's emotional development;

(F) Member's physical considerations.

(c) If treatment in an office setting is not possible, Documentation in the member's dental record shall explain why, in the estimation of the dentist, the member will not be responsive to office treatment;

(d) The Division, or MCE may require additional Documentation when reviewing requests for prior authorization (PA) of hospital dentistry services. See OAR 410-123-1160 and section (6) of this rule for additional information;

(e) If the dentist did not proceed with a previous hospital dentistry plan approved by the Division for the same member, the Division will also require clinical Documentation explaining why the dentist did not complete the previous treatment plan.

(6) Hospital dentistry always requires prior authorization (PA) for the medical services provided by the facility:

(a) If a member is enrolled in an MCE with plan type CCOA:

(A) The dentist is responsible for:

(i) Contacting the MCE for PA requirements and arrangements; and

(ii) Submitting Documentation to the MCE associated with the member record.

(B) The MCE should review the Documentation and discuss any concerns they have, contacting the dentist as needed;

(C) The total response time should not exceed 14 calendar days from the date of submission of all required Documentation for routine dental care and should follow urgent or emergent dental care timelines;

(b) If a member is enrolled in an MCE with plan type CCOB:

(A) The dentist is responsible for:

(i) Contacting the MCE for PA requirements and arrangements; and

(ii) Submitting Documentation to the MCE associated with the member record.

(B) The MCE should review the Documentation and discuss any concerns they have, contacting the dentist as needed. This allows for mutual plan (CCO and FFS) involvement and monitoring;

(D) The MCE is responsible for payment of all facility and anesthesia services. The fee-for-service (FFS) program is responsible for payment of all dental services;

(c) If a member is fee-for-service (FFS) for medical services and enrolled in an MCE with plan type CCOG or CCOF:

(A) The dentist is responsible for faxing Documentation and a completed American Dental Association (ADA) form to the Division. Refer to the Dental Services Provider Guide;

(B) If the member is assigned to a Primary Care Manager (PCM) through FFS medical, the member shall have a referral from the PCM prior to any hospital service being approved by the Division;

(C) The Division is responsible for payment of facility and anesthesia services. The MCE is responsible for payment of all dental services;

(D) The Division will issue a decision on PA requests within 30 days of receipt of the request.

(d) If a member is FFS for both medical and dental or enrolled in MCE plan type CCOE:

(A) The dentist is responsible for faxing Documentation and a completed ADA form to the Division. Refer to the Dental Services Provider Guide;

(B) The Division is responsible for payment of all facility, anesthesia services and dental service.

Or. Admin. Code § 410-123-1490

OMAP 17-2000, f. 9-28-00, cert. ef. 10-1-00; OMAP 48-2002, f. & cert. ef. 10-1-02; OMAP 55-2004, f. 9-10-04, cert. ef. 10-1-04; DMAP 25-2007, f. 12-11-07, cert, ef. 1-1-08; 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 41-2011, 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 50-2021, amend filed 12/24/2021, effective 1/1/2022; DMAP 89-2022, amend filed 12/16/2022, effective 1/1/2023; DMAP 67-2024, minor correction filed 02/21/2024, effective 2/21/2024

Statutory/Other Authority: ORS 413.042, ORS 414.065 & 414.707

Statutes/Other Implemented: ORS 414.065 & 414.707