13-006 Code Vt. R. 13-140-006-X

Current through August, 2024

Section 13 140 006 - CHILDREN'S COMPREHENSIVE DENTAL HEALTH PROGRAM

Pursuant to the authority conferred upon the Secretary of the Agency of Human Services by Title 33, V.S.A., Section 3302, the following regulations necessary to administer the Children's Comprehensive Dental Health program are hereby established.

Section 1.0 DEFINITIONS

1.1 DIVISION - means the Division of Dental Health in the Department of Health, Agency of Human Services.

1.2 SECRETARY - means the Secretary of the Agency of Human Services.

1.3 COMMISSIONER - means the Commissioner of the State Department of Health.

1.4 PROGRAM - means the Children's Comprehensive Dental Health Program.

1.5 PRACTITIONER - means any duly licensed dentist.

1.6 ELIGIBLE PERSON - means a resident of the state from birth to age eighteen whose legal, liable relative or guardian is a Vermont resident with an eligible person.

1.7 ELIGIBLE INCOME - means $ 12,500 or less per year of Household Income as defined in Section 5961(4) of Title 32, not counting $ 1000 for each dependent who has not attained the age of majority.

1.8 PRIOR AUTHORIZATION - means approval of the Division of Dental Health of all treatment plans and the fees to be paid for services listed, before treatment is initiated.

1.9 PAYMENT AUTHORIZATION - means approval for payment by the Division of Dental Health for dental services provided.

1.10 EMERGENCY TREATMENT - means those palliative dental services necessitated immediately by pain, infection, hemorrhage or trauma.

1.11 PATIENT - means an eligible person under or awaiting dental care.

1.12 SEVERELY HANDICAPPING MALOCCLUSION - means those conditions of tooth arrangement and/or jaw relationship which present a hazard to the health of tooth supporting structure, a mechanically inefficient masticatory function or a grossly unaesthetic arrangement.

1.13 PULPOTOMY - means complete extirpation of the coronal portion of the tooth's pulp and its replacement with a tissue-compatible radio-opaque material.

1.14 ORTHODONTIST - means a practitioner who is qualified by reason of American Dental Association accredited postgraduate training in orthodontics.

Section 2.0 GENERAL POLICY

In administering the Children's Comprehensive Dental Health Program, the point of contact between eligible persons or participating dentists and the Program will be the Division of Dental Health, which will respond to inquiries regarding eligibility and process requests for prior authorization and request for payment. Pre-operative and postoperative review are an integral part of this process.

2.1 CONDITIONS OF PARTICIPATION

A. The fees established by the Agency of Human Services for the Children's Comprehensive Dental Health Program for the services itemized on the authorization request form are to be accepted by the practitioner as the maximum allowable charge for each service rendered. Under no circumstances can an additional charge be made to the eligible person for treatment costs exceeding those approved by the Division.

B. The practitioner shall initiate the process of prior authorization by itemizing a complete clinical description of the recommended services on the authorization request form and submitting it with appropriate radiographs to the Division.

C. The practitioner will initiate the process for payment authorization by submitting a signed payment request form showing dates of completion of services provided.

2.2 PROVIDER ELIGIBILITY

A. Participating Practitioner - any licensed dentist in the State of Vermont or in the jurisdiction where an eligible person seeks care and who complies with the Conditions of Participation and the Fee Schedule of this program is eligible to provide dental care.

B. Orthodontic services for treatment of crippling malocclusion are to be provided by an orthodontist or alternatively by a practitioner who may qualify by demonstrating experience and competence in the treatment of this condition to the Agency of Human Services. An out-of-state orthodontics consultant will be appointed by the Commissioner to recommend criteria for necessary experience and to review the qualifications of applicant practitioners who choose to participate in the program.

2.3 PATIENT ELIGIBILITY

The participating dentist should establish that persons presenting themselves for treatment are in fact eligible at the time of examination. The identification card issued by the Division of Dental Health specifies the termination date, the reimbursement level, and the names and identification numbers of the eligible children.

Section 3.0 STANDARDS OF SERVICE

These standards describe briefly the extent of sevices usually covered by the program.

The dental services provided under the Children's Comprehensive Dental Health Program shall consist of those basic services essential for the prevention and control of dental diseases, education of the patient and maintenance of oral health. Departure from these essential basic services may be authorized by the Division when necessary to protect and preserve dental function.

All services provided under the program are subject to review for quality and appropriateness.

3.1 DIAGNOSIS

A. EXAMINATION - This service will include: visual and tactile examination of the contents and contiguous structures of the oral cavity, charting of recommended services, itemizing a treatment plan and completing the authorization request form. This service will be covered on the initial visit and semi-annually thereafter.

B. RADIOGRAPHS - Radiographs necessary to achieve satisfactory diagnosis for fundamental dental services will be approved. They must be of good diagnostic quality, dated, identified and mounted. Requested retakes shall be provided by the practitioner at no extra charge.

Post-operative radiographs are required when requesting payment for endodontic procedures.

C. STUDY MODELS - require prior approval.

D. EMERGENCY TREATMENT - This procedure is intended to meet the limited demands that may arise from the exigencies of dental practice. Services rendered must be itemized when submitting for payment.

3.2 PREVENTIVE SERVICES

A. PROPHYLAXIS - This includes scaling and is limited to once every six months.

B. SPACE MAINTAINERS - Unilateral space maintenance is limited to children under age 12 years, with one or more missing primary second molars, and where succedaneous tooth eruption is expected to be delayed for at least one year following placement. Bilateral space maintenance is limited to children under 12 years, with two or more missing primary second molars, and where succedaneous tooth eruption is expected to be delayed for at least one year following placement.

C. SEALANTS - This service will be allowed for first and second permanent molars whose occlusal surfaces have not been previously restored. Reapplication of sealants will not be covered within five (5) years of the last application.

3.3 RESTORATIVE PROCEDURES

A. AMALGAM RESTORATIONS - Cavity preparations must have an outline sufficient for retention and to conform with the principles of prevention.

No fee will be paid for permanent restorations in primary teeth with more than two-thirds of the root structure resorbed.

B. COMPOSITE RESIN RESTORATIONS - The fee for restoration of a single anterior tooth can not exceed the maximum allowable fee, regardless of the surfaces involved. A Class III restoration for a mesial or distal lesion is a one surface restoration even though a labial or lingual approach is used. Pins may be used in anterior teeth only where involvement of the incisal angle limits retentive potential of cavity preparation. Composite resin restorations placed in posterior teeth will be approved at the rate applicable for comparable amalgam restorations.

C. CROWNS - Crowns may be approved if the health of the remaining dentition warrants and/or the retention of a conventional restoration with or without pins, due to extensive loss of tooth structure, will not be adequate. Cast core is applicable upon evidence of completion of successful endodontic procedures.

D. FIXED PROSTHESES - This is beyond the scope of the State's programs. It is not approved except in cases requiring cleft palate stabilization or other unusual conditions. It is not approved for occlusal or periodontal stabilization.

3.4 ENDODONTICS

A. PULP CAPPING - Cases with small vital exposures, where the prognosis is favorable, should be pulp capped and permanently filled at the same sitting. Pulp capping is, therefore, incident integral to the restoration and is not reimbursable as a separate procedure.

B. PULPOTOMY - This service is defined as the complete removal of the coronal portion of the pulp and its replacement with a radio-opaque tissue compatible restorative material. Permanent teeth with radiographically demonstrated incomplete apical formation where the prognosis is favorable may be treated in this manner. Primary molars may be treated except in advanced root resorption (two-thirds) or in the presence of bifurcation infection. If a pre-operative film is not submitted, a post-operative film may be required.

C. ROOT CANAL THERAPY - All root canal therapy for children needing three or more teeth to be treated endodontically must have prior authorization. Request for authorization must be accompanied by a diagnosis and treatment plan supported by sufficient radiographs of good diagnostic quality, dated, identified and mounted. A postoperative radiograph must be sumitted with request for payment.

D. APICOECTOMY - This service must be requested with supportive evidence as in root canal therapy above. It will also include the removal of periapical pathological tissue. As a separate procedure, sufficient time following root canal treatment should be allowed to validate actual need for this service.

3.5 PROSTHODONTICS

A. FULL DENTURES - If a patient has natural teeth or none, radiographs are required to be submitted with the treatment plan. If immediate prosthesis is part of the treatment plan, so state.

If the patient is wearing dentures and the dentist is requesting new dentures, the age and condition of the present dentures and the reason why they cannot be rebased or reproduced must be stated.

B. PARTIAL DENTURES - The participating dentist must submit a current full-mouth series of radiographs of good diagnostic quality, dated, identified and suitably mounted. All carious teeth must be functionally restored and supporting tissues in good health. The design of the denture must be outlined, including teeth to be replaced and the teeth to be clasped.

Design of the prosthesis and material used should be as simple as possible, consistent with basic principles of prosthodontics.

C. DENTURE REPAIRS - All routine denture repairs may be performed as patient needs dictate.

3.6 ORAL SURGERY AND EXODONTIA

These services are applicable to primary and permanent dentitions. Prior authorization is required, except in emergency situations. The use of analgesic and local anesthetic agents is not reimbursable. When there are specific management problems with children who are developmentally disabled, very young (under six), emotionally disturbed or mentally retarded, a fee will be authorized.

Analgesia, local anesthetics and suture removal are included in the authorized fee. When alveolectomy or alveoloplasty is performed in conjunction with extraction, it is not reimbursed as a separate procedure.

3.7 ORTHODONTICS

A. An examination will be made by a qualified practitioner or orthodontist who will complete and submit a modified Champus Evaluation Form to the Division of Dental Health for eligibility determination.

B. If the patient is eligible for treatment, diagnostic records and a detailed treatment plan must be submitted for prior authorization by the qualified practitioner or orthodontist.

C. For purposes of case review, the qualified practitioner or orthodontist may be requested to submit progress or finished case models at time of request for payment.

3.8 PERIODONTICS

Periodontics require special authorization.

3.9 PAYMENT FOR SERVICES

Payment will be made only for services rendered by or under the direct supervision of practitioners holding a D.D.S. or D.M.D. degree in accordance with the fee schedule established by Section 2462.1 of the Welfare Assistance Manual.

Payment requests submitted by dentists for services rendered must represent treatment actually completed. Orthodontists or qualified practitioners may bill semiannually. Payment request for dental services rendered must be listed on an authorization request form and should be type-written or printed legibly and signed by the providing qualified practitioner or orthodontist. All spaces must be filled out. Services should be accurately and specifically defined by use of the indicated system of tooth number and surface lettering.

Since State funds are involved, there are definite limitations regarding their use. Occasionally, a reasonable deviation from the established fee schedule will be allowed in cases of unusual difficulty. Additional detailed information will be required to justify the deviation.

4.0 PROGRAM EVALUATION

The Agency of Human Services will continuously monitor the services provided by this program and special efforts will be made to assure that the program is meeting the needs it was intended to serve and to assess its impact upon dental health generally.

The process of data collection and storate is essential to continual program modifications. The constant input of data into the system via standard billing forms, supplemented by special studies, will allow evaluation of the utilization and the quality of the dental services being provided. This same information will aid in program management and cost effectiveness evaluations.

5.0 GRIEVANCE PROCEDURE

Any person aggrieved by a determination made by the Division of Dental Health shall be entitled to appeal that determination to the Secretary of Human Services or his designee. The decision on appeal shall be made on the basis of the record by a hearing officer not involved in the original determination, after a hearing at which the aggrieved person has had an opportunity to present written and/or oral evidence and to challenge the evidence offered by the Division.

I. Diagnositic
CLINICAL ORAL EXAMINATION
00110	Initial Oral Examination	0	7
00120	Periodic Oral Examination	0	7
00130	Emergency Oral Examination	0	7
RADIOGRAPHS
00210	Radiographs - complete series	0	18
00220	Intraoral - periapical - first film	0	5
00230	Intraoral - periapical - ea. addit. film	0	2
00240	Intraoral - occlusal film	0	5
00250	Extraoral - first film	0	5
00260	Extraoral X-ray - each additional film	0	2
00270	Bitewing - 1 film	0	5
00272	Bitewings - 2 films	0	7
00274	Bitewings - 4 films	0	11
00330	Panoramic film	0	13
00340	Cephalometric X-ray	1	25
00470	Diagnostic models	1	15
00471	Diagnostic photographs	1	15
00999	Unspecified diagnostic procedure, by report	1	**
II. Preventive
PROPHYLAXIS
01110	Prophylaxis - adult	0	20
01120	Prophylaxis - child	0	15
SEALANTS
01351	Sealant, per tooth	0	10
SPACE MANAGEMENT THERAPY
01510	Space maintainer - fixed - unilateral	0	60
01515	Space maintainer - fixed - bilateral	0	120
01525	Space maintainer - removable, bilateral	1	120
01550	Recementation of space maintainer	0	11
II. Restorative
AMALGAM
02110	Amalgam restoration - 1 surface - Primary	0	18
02120	Amalgam restoration - 2 surfaces - Primary	0	24
02130	Amalgam restoration - 3 surfaces - Primary	0	30
02131	Amalgam restoration - 4+ surfaces - Primary	0	36
02140	Amalgam restoration - 1 surface - Permanent	0	18
02150	Amalgam restoration - 2 surfaces - Permanent	0	24
02160	Amalgam restoration - 3 surfaces - Permanent	0	30
02161	Amalgam restoration - 4+ surfaces - Permanent	0	36
RESIN
02330	Resin - 1 surface	0	22
02331	Resin - 2 surfaces	0	30
02332	Resin - 3 surfaces	0	38
02335	Resin - 4+ surfaces or involving incisal angle	0	46
CAST CROWNS
02720	Crown - resin with high noble metal	1	162
02740	Crown - porcelain/ceramic substrate	1	162
02750	Crown - porcelain fused to high noble metal	1	162
02751	Crown - porcelain fused to base metal	1	162
02752	Crown - Porcelain fused to noble metal	1	162
02790	Crown - full cast high noble metal	1	162
02791	Crown - full cast base metal	1	162
02792	Crown - full cast noble metal	1	162
02920	Recement crown	0	11
PREFABRIACTED CROWNS
02930	Prefabricated stainless steel crown - Primary	0	45
02931	Prefabricated stainless steel crown - Permanent	0	45
02932	Prefabricated resin crown	0	45
OTHER RESTORATIVE PROCEDURES
02940	Sedative filling	0	10
02950	Crown buildup, including any pins	1	55
02951	Pin retention per tooth	0	6
02952	Cast post and core	1	55
02954	Prefabricated post & core	1	55
02960	Labial veneer - laminate	1	40
02980	Crown repair, by report	1	**
02999	Unspecified restorative procedure, by report	1	**
III. Endodontics and Pulpal Therapy
PULPOTOMY
03220	Therapeutic pulpotomy	0	25
ROOT CANAL THERAPY
03310	Root canal - 1 canal	0	120
03320	Root canal - 2 canals	0	150
03330	Root canal - 3 canals	0	180
PERIAPICAL SERVICES
03350	Apexification	1	125
03410	Apicoectomy (per tooth) - first tooth	1	150
03420	Apicoectomy - performed in conjunction with endodontic procedure, per root	1	50
03450	Root amputation - per root	1	20
OTHER ENDODONTIC PROCEDURES
03910	Surgical Procedure for isolation of tooth with rubber dam	1	20
03920	Hemisection (including any root removal), not including root canal therapy	1	50
03940	Recalcification or repair (perforations, root resorption, etc.)	1	50
03960	Bleaching nonvital discolored teeth	1	25
03999	Unspecified endodontic procedure, by report	1	**
IV. Periodontics
SURGICAL SERVICES
04210	Gingivectomy or Gingivoplasty - per quadrant	1	30
04220	Gingival curettage, by report	1	15
04240	Gingival flap procedure, including root planning - per quadrant	1	54
04260	Osseous Surgery - per quadrant	1	90
04270	Pedicle soft tissue graft procedure	1	**
04271	Free soft tissue graft procedure (including donor site)	1	**
04272	Apically repositioning flap procedure	1	**
04280	Periodontal Pulpal Procedure	1	**
ADJUNTIVE PERIODONTAL SERVICES
04320	Provisional splinting - intracoronal	1	**
04321	Provisional splinting - extracoronal	1	**
04340	Periodontal scaling & root planning - entire mouth	1	60
04341	Periodontal scaling & root planning - per quadrant	1	15
04999	Unspecified periodontal procedure, by report	1	**
V. Removable Prosthetics
COMPLETE DENTURES
05110	Complete Upper Denture	1	189
05120	Complete Lower Denture	1	189
05130	Immediate Upper Denture	1	226
05140	Immediate Lower Denture	1	226
PARTIAL DENTURES
05211	Upper partial - acrylic base (including any conventional clasps and rests)	1	170
05212	Lower partial - acrylic base (including any conventional clasps and rests)	1	170
05213	Upper partial - predominantly base cast base with acrylic saddles (including any conventional clasps and rests)	1	200
05214	Lower partial - predominantly base cast base with acrylic saddles (including any conventional clasps and rests)	1	200
ADJUSTMENT TO DENTURES
05410	Adjust complete denture - upper	0	8
05411	Adjust complete denture - lower	0	8
05421	Adjust partial denture - upper	0	8
05422	Adjust partial denture - lower	0	8
DENTURE REPAIRS
05510	Repair broken complete denture base	0	20
05520	Replace missing or broken teeth	0	20
05610	Repair acrylic saddle or base	0	**
05620	Repair cast framework	0	**
05630	Repair or replace broken clasp	0	**
05640	Replace broken teeth - per tooth	0	20
05650	Add tooth to existing partial denture	0	**
DENTURE RELINE
05730	Reline upper complete denture (chairside)	1	58
05740	Reline upper partial denture (chairside)	1	58
05750	Reline upper complete denture (laboratory)	1	63
05760	Reline upper partial denture (laboratory)	1	63
OTHER PROSTHODONTIC SERVICES
05820	Temporary partial-stayplate (upper)	1	75
05821	Temporary partial-stayplate (lower)	1	75
05899	Unspecified removable prosthetic procedure, by report	1	**
VI. Fixed Prosthodontics
BRIDGE PONTICS
06210	Pontic - cast high noble metal	1	162
06211	Pontic - cast predominantly base metal	1	162
06212	Pontic - cast noble metal	1	162
06240	Pontic - porcelain fused to high noble metal	1	162
06242	Pontic - porcelain fused to noble metal	1	162
06545	Cast metal retainer for acid etched bridge	1	120
CROWNS, FIXED BRIDGES
06750	Crown - porcelain fused to high noble metal	1	162
06751	Crown - fused to predominantly base metal	1	162
06752	Crown - porcelain fused to noble metal	1	162
06790	Crown - full cast high noble metal	1	162
06791	Crown - full cast predominantly base metal	1	162
06792	Crown - full cast noble metal	1	162
OTHER PROSTHODONTIC SERVICES
06930	Recement Bridge	0	15
06970	Cast post and core in addition to bridge retainer	1	55
06972	Prefabricated post and core in addition to bridge retainer	1	55
06980	Bridge repair, by report	1	**
06999	Unspecified prosthodontic procedures	1	**
VII. Oral Surgery
EXTRACTIONS
07110	Extraction, single tooth	0	20
07120	Extraction, each additional tooth	0	20
07130	Root removal - exposed roots	0	20
SURGICAL EXTRACTIONS
07210	Surgical removal of erupted tooth requiring elevation of muco-periosteal flap and removal of bone and/or section of tooth	0	27
07220	Removal of impacted tooth - soft tissue	0	27
07230	Removal of impacted tooth - partially bony	0	38
07240	Removal of impacted tooth - completely bony	0	60
07250	Surgical removal of residual tooth roots (cutting procedure)	0	24
OTHER SURGICAL PROCEDURES/SPLINTS
07260	Oroantral fistula closure	1	**
07880	Occlusal orthotic appliance (TMJ splint)	1	120
07999	Unspecified surgical procedures, by report	1	**
VIII. Orthodontics
MINOR TREATMENT FOR TOOTH GUIDANCE
08110	Removable Appliance Therapy	1	**
08120	Fixed Appliance Therapy	1	**
TREATMENT TO CONTROL HARMFUL HABITS
08210	Removable Appliance Therapy - Habit	1	**
08220	Fixed Appliance Therapy	1	**
INTERCEPTIVE ORTHODONTIC AND MINOR TOOTH MOVEMENT
08360	By Removable Appliance Therapy	1	**
08370	By Fixed Appliance Therapy	1	**
COMPREHENSIVE ORTHODONTICS
08460	Class I malocclusion, transitional dentition	1	**
08470	Class II malocclusion, transitional dentition	1	**
08480	Class III malocclusion, transitional dentition	1	**
08560	Class I malocclusion, permanent dentition	1	**
08570	Class II malocclusion, permanent dentition	1	**
08580	Class III malocclusion, permanent dentition	1	**
08650	Treatment of a typical or extended skeletal case	1	**
OTHER ORTHODONTIC SERVICES
08750	Post treatment stabilization	1	**
08999	Unspecified orthodontic procedure, by report	1	**
IX. Adjunctive Services
PALLIATIVE TREATMENT
09110	Emergency palliative treatment of dental pain - minor procedures	0	23
PATIENT MANAGEMENT
09220	General anesthesia - 30 minutes	0	45
09221	General anesthesia - each additional 15 minutes	0	15
09240	Intravenous sedation	0	15
09420	Hospital call	1	**
09630	Other drugs (sedative premedication for management), by report	0	10
09920	Behavior management, by report	0	6
OCCLUSAL THERAPY
09940	Occlusal guards, by report	0	60
09950	Occlusal analysis - mounted case	1	**
09951	Occlusal adjustment - limited	1	**
09952	Occlusal adjustment - complete	1	**
UNSPECIFIED CARE
09999	Unspecified adjunctive procedure, by report	1	**

13-006 Code Vt. R. 13-140-006-X

Effective Date: December 28, 1988 (SOS Rule Log # 88-62)

Statutory Authority: 33 V.S.A. § 3302