Or. Admin. Code § 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.
(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.
Notes
Statutory/Other Authority: ORS 413.042 & ORS 414.065
Statutes/Other Implemented: ORS 414.065
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