Utah Admin. Code R414-49-4 - Pregnant Members
This section defines the scope of dental services available to a pregnant member who is eligible for Traditional Medicaid.
(1) Dental services shall extend up to the
end of the 12th month after pregnancy ends.
(2) Dental services shall only be available
through an enrolled dental provider that complies with relevant laws and
policy.
(3) Dental services shall
only be provided within the parameters of generally accepted standards of
dental practice and may be subject to any limitation or exclusion established
by Medicaid.
(4) Dental services
may be subject to any limitation or exclusion of medical necessity and
utilization control considerations or conditions.
(5) Medicaid shall reimburse up to one
evaluation for each member each day, even if more than one provider is involved
from the same office or clinic. Medicaid may not cover multiple exams for the
same date of service.
(6) Medicaid
includes in the global payment, and may not reimburse separately, any denture
adjustment performed by the original provider within six months of a member
receiving a denture.
(7) Medicaid
may cover third-molar extractions when at least one of the third molars has
documented pathology that requires extraction. By discretion, a provider may
remove any remaining third molar during the same procedure.
(8) Medicaid shall cover the treatment of a
temporomandibular joint fracture but may not cover other temporomandibular
joint treatments.
(9) A laboratory
or pathologist must submit a claim directly to Medicaid for payment of
laboratory services.
(10) Medicaid
may not cover the following dental services:
(a) cast crowns, porcelain fused to metal, on
posterior permanent teeth or on primary teeth;
(b) consultation or second opinions not
requested by Medicaid;
(c) dental
implants;
(d) extraction of primary
teeth at or near the time of exfoliation, as evidenced by mobility or loosening
of the teeth;
(e) fixed bridges or
pontics;
(f) general anesthesia for
removal of an erupted tooth;
(g)
house calls;
(h) limited
orthodontic treatment, including removable appliance therapies;
(i) nitrous oxide analgesia;
(j) occlusal appliances, habit control
appliances, or interceptive orthodontic treatment;
(k) oral sedation for behavior management;
(I) osteotomies;
(m) procedures such as arthrostomy,
meniscectomy, or condylectomy;
(n)
pulpotomies or pulpectomies on permanent teeth, except in the case of an open
apex;
(o) removable appliances in
conjunction with fixed banded treatment;
(p) ridge augmentation;
(q) temporary dentures or temporary stayplate
partial dentures;
(r) tooth
transplantation;
(s) treatment for
temporomandibular joint syndrome, sequela, subluxation, or other therapies;
and
(t) services provided without
prior authorization.
(11)
A Medicaid member may choose to upgrade a covered service to a non-covered
service if the member assumes responsibility for the difference in fees for
covered anterior stainless steel crowns that are deciduous to non-covered
anterior stainless steel crowns with composite facings added or commercial or
lab-prepared facings.
Notes
State regulations are updated quarterly; we currently have two versions available. Below is a comparison between our most recent version and the prior quarterly release. More comparison features will be added as we have more versions to compare.
This section defines the scope of dental services available to pregnant members who are eligible for Traditional Medicaid. Dental services extend up to the end of the 12th month after pregnancy ends.
(1) Dental services are available only through an enrolled dental provider that complies with relevant laws and policy.
(2) The following coverage and limitations apply.
(a) Dental services are provided only within the parameters of generally accepted standards of dental practice and are subject to limitations and exclusions established by Medicaid.
(b) Dental services are subject to limitations and exclusions of medical necessity and utilization control considerations or conditions.
(c) Additional service limitations and exclusions are maintained in the Coverage and Reimbursement Code Look-up Tool and the Dental, Oral Maxillofacial, and Orthodontia Services Utah Medicaid Provider Manual. These limitations and exclusions are updated in the Medicaid Information Bulletin.
(d) Medicaid reimburses one evaluation for one member each day, even if more than one provider is involved from the same office or clinic. Medicaid does not cover multiple exams for the same date of service.
(e) Medicaid includes in the global payment, and does not reimburse separately, denture adjustments performed by the original provider within six months of a member receiving a denture.
(f) Medicaid may cover third-molar extractions when at least one of the third molars has documented pathology that requires extraction. By discretion, a provider may remove the remaining third molars during the same procedure.
(g) Medicaid covers the treatment of temporomandibular joint fractures but does not cover other temporomandibular joint treatments.
(h) The laboratory or pathologist must submit claims directly to Medicaid for payment of laboratory services.
(3) Medicaid does not cover the following types of dental services:
(a) cast crowns, porcelain fused to metal, on posterior permanent teeth or on primary teeth;
(b) pulpotomies or pulpectomies on permanent teeth, except in the case of an open apex;
(c) fixed bridges or pontics;
(d) any type of dental implant;
(e) tooth transplantation;
(f) ridge augmentation;
(g) osteotomies;
(h) vestibuloplasty;
(i) alveoloplasty;
(j) occlusal appliances, habit control appliances, or interceptive orthodontic treatment;
(k) treatment for temporomandibular joint syndrome, sequela, subluxation, or other therapies;
(l) procedures such as arthrostomy, meniscectomy, or condylectomy;
(m) nitrous oxide analgesia;
(n) house calls;
(o) consultation or second opinions not requested by Medicaid;
(p) services provided without prior authorization;
(q) general anesthesia for removal of an erupted tooth;
(r) oral sedation for behavior management;
(s) temporary dentures or temporary stayplate partial dentures;
(t) limited orthodontic treatment, including removable appliance therapies;
(u) removable appliances in conjunction with fixed banded treatment; and
(v) extraction of primary teeth at or near the time of exfoliation, as evidenced by mobility or loosening of the teeth.
(4) A Medicaid member may choose to upgrade a covered service to a non-covered service if the member assumes the responsibility for the difference in fees for covered anterior stainless steel crowns that are deciduous, to non-covered anterior stainless steel crowns with composite facings added or commercial or lab-prepared facings.