Utah Admin. Code R414-49-5 - Adult Members 21 Years of Age and Older and Not Eligible on the Basis of Pregnancy
This section defines the scope of dental services available to an adult member who is 21 years of age or older and not eligible on the basis of pregnancy.
(1) Services are
authorized by a federal waiver of Medicaid requirements approved by the Centers
for Medicare and Medicaid Services and allowed under Section 1115 of the Social
Security Act.
(2)
(a) Dental services shall only be available
through an enrolled dental provider that complies with relevant laws and
policy.
(b) Dental services shall
only be available through the University of Utah School of Dentistry and its
associated in-state provider network.
(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) consultation or second opinions not
requested by Medicaid;
(b) dental
implants;
(c) extraction of primary
teeth at or near the time of exfoliation, as evidenced by mobility or loosening
of the teeth;
(d) fixed bridges or
pontics;
(e) general anesthesia for
removal of an erupted tooth;
(f)
house calls;
(g) limited
orthodontic treatment, including removable appliance therapies;
(h) nitrous oxide analgesia;
(i) occlusal appliances, habit control
appliances, or interceptive orthodontic treatment;
(j) oral sedation for behavior
management;
(k)
osteotomies;
(l) procedures such as
arthrostomy, meniscectomy, or condylectomy;
(m) pulpotomies or pulpectomies on permanent
teeth, except in the case of an open apex;
(n) removable appliances in conjunction with
fixed banded treatment;
(o) ridge
augmentation;
(p) temporary dentures
or temporary stayplate partial dentures;
(q) tooth transplantation;
(r) treatment for temporomandibular joint
syndrome, sequela, subluxation, or other therapies; and
(s) services provided without prior
authorization.
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 blind or disabled members eligible for Traditional Medicaid who are 18 years of age or older, as defined in Subsection 1614(a), Social Security Act. Services are authorized by a federal waiver of Medicaid requirements approved by the Centers for Medicare and Medicaid Services, and allowed under Section 1115, Social Security Act.
(1) The following program access requirements apply.
(a) Dental services are available only through an enrolled dental provider that complies with relevant laws and policy.
(b) A dental provider may only perform services to this population through the University of Utah School of Dentistry (SOD) and its associated in-state provider network.
(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, and 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, not 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, and 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; and
(h) a 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) pulpotomies or pulpectomies on permanent teeth, except in the case of an open apex;
(b) fixed bridges or pontics;
(c) any type of dental implant;
(d) tooth transplantation;
(e) ridge augmentation;
(f) osteotomies;
(g) vestibuloplasty;
(h) alveoloplasty;
(i) occlusal appliances, habit control appliances, or interceptive orthodontic treatment;
(j) treatment for temporomandibular joint syndrome, sequela, subluxation, or other therapies;
(k) procedures such as arthrostomy, meniscectomy, or condylectomy;
(l) nitrous oxide analgesia;
(m) house calls;
(n) consultation or second opinions not requested by Medicaid;
(o) services provided without prior authorization;
(p) general anesthesia for removal of an erupted tooth;
(q) oral sedation for behavior management;
(r) temporary dentures or temporary stayplate partial dentures;
(s) limited orthodontic treatment, including removable appliance therapies;
(t) removable appliances in conjunction with fixed banded treatment; and
(u) extraction of primary teeth at or near the time of exfoliation, as evidenced by mobility or loosening of the teeth.