55 Pa. Code § 1149.52 - Payment conditions for various dental services
(a) The fee paid by the Department for an
inpatient surgical service includes pre-operative and postoperative visits as
designated in the MA Program fee schedule.
(b) The Department pays only one dentist for
performing a particular surgical service or procedure.
(c) Payment is made at reduced rates for
space maintainers, crowns and dentures specified in MA Program fee schedule, if
one of the following conditions are met:
(1)
The person was an eligible MA recipient at the first visit after prior
authorization was obtained as specified in subsection (j) but became ineligible
for MA before the appliance was delivered.
(2) The dentist was unable to deliver the
item to the recipient, and the following conditions were met:
(i) When the appliance is completed, the
dentist shall notify the recipient and make an appointment. If the dentist is
unable to contact the patient after 30 days, in spite of repeated attempts
which must be documented in the recipient's dental record, the dentist shall
also send a letter to the recipient's last known address and to the Executive
Director of the appropriate County Assistance Office.
(ii) If neither the dentist nor the County
Assistance Office can locate the recipient within the 60 days after the
appliance is completed, the dentist shall submit an invoice for the service
performed in accordance with the instructions in the provider
handbook.
(d)
Payment is made for dental procedures performed in the short procedure unit of
a hospital only if:
(1) The short procedure
unit has been approved for participation in the MA Program.
(2) The nature of the surgery or the
condition of the patient precludes performing the procedure in the dentist's
office or other outpatient setting.
(3) A physician or dentist has documented in
the patient's medical record the medical justification for performing the
procedure in a short procedure unit setting.
(e) Payment is made to dentists for inpatient
hospital visits only if the conditions established in §
1150.54(a)
(relating to surgical services) are met and daily dental care is provided by
the dentist for a condition or diagnosis unrelated to daily medical care
provided by a physician.
(f)
Payment is made for an outpatient dental consultation only if:
(1) The consultation is requested by the
dentist or physician in charge of the case.
(2) The consultation prepares a written
report of the examination that includes the patient's dental history and if
applicable, the patient's medical history.
(3) Except in an emergency situation, as
described in §
1101.67(c)
(relating to prior authorization), the Department has approved a request for
the consultation prior to the service being rendered.
(g) Payment for an inpatient dental
consultation is made only if:
(1) The
consultation is requested by the dentist or physician in charge of the
case.
(2) The consultant prepares a
written report of the examination that also includes the patient's dental
history and if applicable, the patient's medical history.
(h) Payment for diagnostic radiological
services performed in the dentist's office is made only if the dentist performs
an oral examination of the patient prior to the radiological service.
(i) Payment is made to the dentist for
general anesthesia provided in the office only if the recipient has a diagnosed
medical problem, noted in the remarks section of the invoice, where use of
local anesthesia is contraindicated as the sole agent in completion of the
procedure. A surgical procedure by an oral surgeon or pedodontist need not be
documented but it must be indicated in the remarks section of the invoice that
the procedure was performed by the appropriate practitioner. However, the
remarks section of the invoice does not have to be completed if general
anesthesia was specifically included as part of a prior authorization
requirement and that request was approved before the procedure was
initiated.
(j) Payment is made only
if the Department has prior authorized the following:
(1) Complete or partial dentures.
(2) Space maintainers.
(3) Orthodontic services.
(4) Crowns.
(5) When more than one tooth is extracted for
insertion of a prosthetic device.
(6) Multiple extractions of six or more teeth
extracted during one visit or one period of hospitalization.
(7) Surgical extractions.
(8) Outpatient dental consultations except as
noted in subsection (f)(3).
(k) The fees for dentures include relining
and adjustments made during a period of 180 days following insertion of the
dentures.
(l) Payment is made for
restorative services based on the number of surfaces restored, not on the
number of restorations made per surface. For example, two restorations on the
same surface of a tooth is considered to be a single restoration of one tooth
surface. Fees for services include local anesthesia, polishing, cement bases
and necessary medications, if applicable.
(m) The fees for crowns include buildup of
the natural crown using either composite or amalgam. Payment for permanent
crowns is made for fully developed permanent teeth and deciduous molars with no
permanent successor. However, payment is made for stainless steel and temporary
plastic crowns when made for primary or developing permanent teeth and not made
in conjunction with the construction of a permanent crown.
(n) The fee for root canal therapy includes
an apicoectomy if it is performed by the same dentist within 180 days of
initial treatment. If an apicoectomy is performed by another dentist within 180
days of the initial treatment, the dentist will receive the fee for an
apicoectomy as specified in Chapter 1150 (relating to MA Program payment
policies).
(o) Payment for dental
services performed on a hospital inpatient basis are compensable if the
individual has a concomitant medical illness or handicapping condition and
dental services need to be provided. This justification has to be written in
the remarks section of the invoice in order for payment to be
approved.
(p) Payment for removal
of superficial root fragments not completely covered by bone will be considered
as a simple extraction or surgical extraction of tooth, erupted.
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