Ill. Admin. Code tit. 89, § 140.420 - Dental Services

Effective for dates of service on or after July 1, 2014, except as otherwise specified in this Section:

a) Except as outlined in subsection (b), payment for dental services shall be made only to enrolled licensed dentists.

b) Payment for oral health screening and fluoride varnish services shall be made to enrolled licensed dentists, and physicians or advance practice registered nurses (APRNs) who are trained and approved to provide oral health screening and fluoride varnish services.

c) Payment for comprehensive orthodontic care shall be made only to a dentist licensed for provision of those services.

d) Except as specified in subsections (e) and (f), payment shall be made for allowable dental services specified in Table D that are:

1) Necessary to relieve pain or infection, preserve teeth, or restore adequate dental function;

2) Diagnostic, preventive, or restorative services, endodontics, prosthodontics, orthodontics or oral surgery included in the Department's Schedule of Dental Procedures (see Table D); and

3) Performed by the dentist or under the direct supervision of the dentist, or for oral health screening and fluoride varnish services, performed by or under the direct supervision of an enrolled licensed dentist, physician or APRN.

e) Payment shall not be made for experimental dental care and procedures performed only for cosmetic reasons.

f) Effective for dates of service July 1, 2012 through June 30, 2014, notwithstanding other provisions of this Section or Section 140.421, dental services rendered to recipients age 21 years and older shall be limited to those dental services that are medically necessary to treat pain, infection, swelling, uncontrolled bleeding, or traumatic injury that can be treated by extraction and dental services that are medically necessary as a prerequisite for necessary medical care.

g) Payment should be made to All Kids School-Based Dental Program providers that administer out-of-office delivery of allowed preventive dental services in a school setting to children under 19 years of age. Dental providers must:

1) Be enrolled with HFS as a dental provider;

2) Be registered with the All Kids School-Based Dental Program;

3) Follow guidelines for the IDPH Calendar;

4) Have the ability to administer the allowed preventive dental services in the school setting;

5) Complete and maintain a Dental Record of the school visit for each child;

6) Complete an IDPH Proof of School Dental Examination Form;

7) Provide a completed School Follow up Form for the school to provide to the parent/guardian;

8) Provide a follow-up referral care plan for children that receive Caries Risk Assessment Codes of D0602 or D0603. The referral plan shall consist of one of the following referral options:

A) InsureKidsNow web site;

B) Follow-up care to the provider who provided service in school;

C) Follow-up care will be provided at school; or

D) School provider will have a case manager that assists children in getting follow-up care.

9) Include the Caries Risk Assessment Codes (D0601, D0602 or D0603) in the school dental service claims; and

10) Have an active collaborative agreement with a Public Health Dental Hygienist (PHDH), if applicable.

Notes

Ill. Admin. Code tit. 89, § 140.420

Amended at 37 Ill. Reg. 10282, effective June 27, 2013

Amended at 38 Ill. Reg. 23623, effective 12/2/2014 Amended at 46 Ill. Reg. 5229, effective 3/11/2022 Amended at 46 Ill. Reg. 5725, effective 3/25/2022