Dental – General Payment Policies
All dental procedures are considered to be outpatient procedures. These procedures are not compensable on an inpatient basis unless there is medical justification which is documented in the patient’s medical record. Provider types 27 – Dentist and 31 – Physician are the only provider types eligible to receive payment for dental services. Provider type31 (Physician) is eligible for payment only for procedure codes D7450 through D7471, D7960 and D7970. (This doesnot exclude provider type 27 – Dentist.) Provider type27 (Dentist) who is a board certified or board eligible orthodontist is the only provider type eligible for payment oforthodontic services.
Provider type31 (Physician) is the only provider type eligible for theanesthesiaallowance when provided in a hospital shortprocedure unit, ambulatory surgical center, emergency room or inpatient hospital. Provider type 27 (Dentist) is eligible for payment only for procedure codes D9220 for Deep Sedation/General Anesthesia and D9221Deep Sedation/General Anesthesia- each additional 15 minutes, D9230 for Analgesia, Anxiolysis, Inhalation of Nitrous Oxide, D9241for Intravenous Conscious Sedation, or D9248 for Non-intravenous Conscious Sedation provided in a dentist’s office or a dentalclinic. A copy of the practitioners current anesthesia permit must be on file with the Department.
Individuals age 21 and older are eligible for crowns under certain situations and criteria. Crown coverage is limited to one crown pertooth for five years and is limited to four per calendar year with no more than two crowns per arch. Procedure Code D2710; crown- resin (indirect) is limited to one crown per three years. Procedure codes D2710 through D2791 are compensable only for fully developed permanent teeth and primary teeth with no permanent successors. Payment is not made for prefabricated and/or self-curing dental materials. Procedure codes D2390;D2930 – D2934 are crowns for primary or developing permanent teeth only, and are not compensable withconstruction of a permanent crown. Procedure codes D2390;D2930 – D2934 are payable for individuals under 21 years of age only.