Read Microsoft Word - Texas Medicaid CHIP Provider Manual 02082012.docx text version

Delta Dental State Government Programs Texas Children's Medicaid and CHIP Dental Services

Provider Manual

March 2012

Delta Dental's Provider Hotline Toll-Free Telephone Numbers Medicaid Providers: 1-877-576-5899 CHIP Providers: 1-866-561-5891 Provider Hotline Days/Hours of Operation 8:00 a.m. to 7:00 p.m. Central Time Monday through Friday, excluding State of Texas Holidays Provider Websites Medicaid Providers: deltadentalins.com/tx-medicaid CHIP Providers: deltadentalins.com/tchip

CHMC-04 EN VER 5 NEW 03/12

This page intentionally left blank.

Dear Doctor, Thank you for enrolling in the Texas Children's Medicaid Dental Services and/or CHIP Dental Services program(s). We are pleased to provide you with this Texas Children's Medicaid and CHIP Dental Services Provider Manual. This provider manual serves as a "how to" guide for you and your staff. It gives you the following information:

Texas Children's Medicaid Dental Services and Texas CHIP Dental Services policies and procedures. Instructions for billing and obtaining member eligibility. A summary of additional obligations that are binding on Delta Dental and you.

If you have any questions about the contents of the provider manual or participation in the Texas Children's Medicaid Dental Services and/or Texas CHIP Dental Services programs, please call our toll-free Provider Hotline between 8 a.m. and 7 p.m. Central Time, Monday through Friday (excluding State of Texas holidays). The phone number for Medicaid providers is 1-877-576-5899 and the number for CHIP providers is 1-866-561-5891. For your convenience, our Provider Hotline phone numbers and our Texas Medicaid and CHIP website addresses are printed on the bottom of each page in the provider manual. Sincerely, DELTA DENTAL State Government Programs

Program Underwriter: Program Administrator:

DELTA DENTAL INSURANCE COMPANY DELTA DENTAL OF CALIFORNIA ­ State Government Programs

This page intentionally left blank.

Texas Children's Medicaid and CHIP Dental Services Provider Manual

TABLE OF CONTENTS

1.0 1.1 1.2 1.3 1.4 1.5 1.6 1.7 1.8 2.0 2.1 INTRODUCTION............................................................................................................1 Quick Reference List of Phone Numbers, Addresses, and Websites ..................2 Purchase of Additional Provider Manuals ..............................................................2 Objective of Programs ................................................................................................3 Definition of Dental Home ........................................................................................3 Role of Main Dental Home ........................................................................................4 Role of First Dental Home Initiative (Medicaid) ....................................................4 Becoming a First Dental Home Provider (Medicaid) ............................................6 Role of Member Advocates (Medicaid) ...................................................................6 COVERED SERVICES ....................................................................................................8 Covered Dental Services (Medicaid) ........................................................................8 2.1.1 Texas Health Steps ................................................................................................8 2.1.2 Children of Migrant Farmworkers ...................................................................10 2.1.3 Orthodontia Services ..........................................................................................10 2.2 2.3 2.4 Covered Dental Services (CHIP).............................................................................11 Emergency Dental Care ...........................................................................................12 Prior Authorizations .................................................................................................12 2.4.1 Prior Authorizations (Medicaid) ......................................................................12 2.4.2 Prior Authorizations (CHIP) .............................................................................13 3.0 3.1 3.2 3.3 3.4 QUALITY ASSESSMENT AND PERFORMANCE IMPROVEMENT ...............14 Practice Guidelines ...................................................................................................14 Focus Studies .............................................................................................................15 Quality of Care Reviews ..........................................................................................15 Corrective Actions and Hearing Process ...............................................................16 3.4.1 Notices of Proposed Corrective Actions ..........................................................16 3.4.2 Provider's Right to Request a Hearing ............................................................17 3.4.3 Hearing Process ...................................................................................................17 3.5 3.6 4.0 4.1 Prior Authorization/Special Claims Reviews ......................................................18 Utilization Management Reporting Requirements ..............................................18 PROVIDER ENROLLMENT .......................................................................................20 Enrollment Documents ............................................................................................20

Page i

Texas Children's Medicaid and CHIP Dental Services Provider Manual

4.2 4.3 4.4 4.5 5.0 5.1 5.2 5.3

Credentialing .............................................................................................................20 Re-Credentialing .......................................................................................................21 Provider Identification Numbers............................................................................21 National Provider Identifier ....................................................................................21 PROVIDER RESPONSIBILITIES ..............................................................................22 Availability and Accessibility .................................................................................22 Main Dental Home Responsibilities.......................................................................22 First Dental Home Initiative Responsibilities (Medicaid)...................................23 5.3.1 Caries Risk Assessment Tool .............................................................................25 5.3.2 Toothbrush Prophylaxis.....................................................................................25 5.3.3 Application of Fluoride Varnish .......................................................................26 5.3.4 Dental Anticipatory Guidance ..........................................................................26 5.3.5 Delegation of Components for First Dental Home Visits .............................27 5.3.6 Determining When Children Should Be Scheduled for Oral Health Visits27 5.3.7 Treatment Planning and Coordination ............................................................28 5.3.8 Documentation of the First Dental Home Visits ............................................28 5.3.9 Billing the First Dental Home Visits .................................................................29 5.3.10 Incorporating the First Dental Home Visits into Your Practice ...................30

5.4 5.5 5.6 5.7 5.8 5.9 5.10 5.11 5.12 5.13 6.0 6.1 6.2 6.3 6.4

General Anesthesia Form.........................................................................................30 Referral to Specialists Process .................................................................................31 Verification of Member Eligibility and/or Authorization for Service ..............31 Financial Responsibility or Optional Treatment Form ........................................32 Dental Records ..........................................................................................................33 Access to Second Opinion........................................................................................35 Justification Regarding Out-of-Network Providers .............................................35 Plan Termination .......................................................................................................36 Fraud and Abuse .......................................................................................................36 Professional Conduct................................................................................................37 Provider Hotline........................................................................................................38 Interactive Voice Response System ........................................................................39 Written Correspondence ..........................................................................................39 Provider Seminars .....................................................................................................40

PROVIDER SUPPORT SERVICES ............................................................................38

Page ii

Texas Children's Medicaid and CHIP Dental Services Provider Manual

6.5 6.6 7.0 7.1 7.2 7.3 8.0 8.1

Provider On-Site Visits .............................................................................................41 Sample Forms ............................................................................................................41 ROUTINE, THERAPEUTIC/DIAGNOSTIC, AND URGENT CARE DENTAL SERVICES .......................................................................................................................42 Definitions ..................................................................................................................42 Periodicity ..................................................................................................................42 Requirements for Scheduling Appointments .......................................................43 COORDINATION OF NON-CAPITATED SERVICES.........................................44 Services Not Covered by Delta Dental (Medicaid) ..............................................44 8.1.1 Early Childhood Intervention (ECI) Case Management/Service ................45 8.1.2 DSHS Case Management for Children and Pregnant Women ....................45 8.1.3 Texas School Health and Related Services (SHARS) .....................................46 8.1.4 HHSC's Medical Transportation ......................................................................46 8.1.5 Emergency Dental Services ...............................................................................47

8.2 9.0 9.1 9.2

Services Not Covered by Delta Dental/Emergency Dental Services (CHIP) ..47 PROVIDER COMPLAINTS AND APPEALS ..........................................................48 Medicaid Provider Complaints ...............................................................................48 9.1.1 Medicaid Provider Complaints to Delta Dental .............................................49 CHIP Provider Complaints .....................................................................................50 9.2.1 CHIP Provider Complaints to Delta Dental ....................................................50 9.2.2 CHIP Provider Complaints to Texas Department of Insurance...................51

9.3 10.0 10.1 10.2 10.3 10.4 10.5 10.6 10.7 10.8 11.0

Provider Appeals to Delta Dental ..........................................................................51 MEMBER COMPLAINTS AND APPEALS..............................................................53 Medicaid Member Complaints ...............................................................................54 Medicaid Member Appeals .....................................................................................56 Medicaid Member Expedited Appeals ..................................................................59 State Fair Hearings (Medicaid) ...............................................................................60 CHIP Member Complaints ......................................................................................62 CHIP Member Appeals ............................................................................................64 CHIP Member Expedited Appeals .........................................................................66 Independent Review Organization Reviews (CHIP)...........................................67

MEMBER ELIGIBILITY, ENROLLMENT, DISENROLLMENT, AND VALUEADDED BENEFITS (MEDICAID) .............................................................................68

Page iii

Texas Children's Medicaid and CHIP Dental Services Provider Manual

11.1 11.2 11.3 11.4 11.5 11.6 12.0

Eligibility Determination by HHSC .......................................................................68 Eligibility Verification ..............................................................................................68 Automatic Re-Enrollment ........................................................................................69 Disenrollment ............................................................................................................69 Plan Changes .............................................................................................................70 Added Benefits ..........................................................................................................70

MEMBER ELIGIBILITY, ENROLLMENT, DISENROLLMENT, AND VALUEADDED BENEFITS (CHIP) .........................................................................................72 Eligibility Determination by HHSC .......................................................................72 Eligibility Verification ..............................................................................................72 Re-Enrollment ............................................................................................................73 Disenrollment ............................................................................................................73 Plan Changes .............................................................................................................73 Added Benefits ..........................................................................................................74 Member Rights and Responsibilities (Medicaid) .................................................75 Member Rights and Responsibilities (CHIP) ........................................................77 Fraud Reporting ........................................................................................................79 Definitions of Billing and Claims Terms ...............................................................81 Overview of Delta Dental's Claims Processing System ......................................82 Time Frames for Submission of Claims, NOAs, and Claims Appeals .............83 Time Frames for Claims Payment ..........................................................................83 Billing and Claims Forms ........................................................................................84

12.1 12.2 12.3 12.4 12.5 12.6 13.0 13.1 13.2 13.3 14.0 14.1 14.2 14.3 14.4 14.5

MEMBER RIGHTS AND RESPONSIBILITIES ......................................................75

BILLING AND CLAIMS ADMINISTRATION ......................................................81

14.5.1 Claim/TAR Form ................................................................................................84 14.5.2 Notice of Authorization Form ...........................................................................92 14.5.3 Outstanding TARs ............................................................................................100 14.5.4 Explanation of Benefits Form ..........................................................................101 14.5.5 Claim Inquiry Form ..........................................................................................106 14.5.6 Claim Inquiry Response Form ........................................................................109 14.6 14.7 14.8 Electronic Claims Submission ...............................................................................111 Electronic Payment Services ..................................................................................111 Billing Intermediaries .............................................................................................112

Page iv

Texas Children's Medicaid and CHIP Dental Services Provider Manual

14.9 15.0

Cost-Sharing and Co-Payments (CHIP) ..............................................................112

14.10 Billing Members ......................................................................................................113 SPECIAL ACCESS REQUIREMENTS ....................................................................114 Interpreter/Translation Services ..........................................................................114 Delta Dental and Provider Coordination ............................................................114 Reading/Grade Level Consideration...................................................................115 Cultural Sensitivity .................................................................................................115 Direct Access to Specialists (Members with Special Health Care Needs) ......115 Access to Records ....................................................................................................116 Audit or Investigation ............................................................................................118 Communication with Members ............................................................................119 Form 1099 Earnings ................................................................................................119 Insurance ..................................................................................................................119 Laws, Rules, and Regulations ...............................................................................120 Liability .....................................................................................................................121 Marketing .................................................................................................................122 Payment Policies .....................................................................................................122 15.1 15.2 15.3 15.4 15.5 16.0 16.1 16.2 16.3 16.4 16.5 16.6 16.7 16.8 16.9

OTHER REQUIREMENTS ........................................................................................116

16.10 Privacy and Confidentiality of Member Information ........................................123 16.11 Termination of the Contracting Dentist Agreement ..........................................124 16.11.1 16.11.2 16.11.3 Termination by the Provider ......................................................................124 Termination by Delta Dental......................................................................124 Termination for Gifts or Gratuities ...........................................................125

16.12 Third-Party Recovery .............................................................................................126 16.13 Time Limitations for Billing ..................................................................................126 16.14 Updates to Provider Contact Information...........................................................127 17.0 18.0 TEXAS CHILDREN'S MEDICAID DENTAL SERVICES MANUAL OF CRITERIA (MOC) ........................................................................................................128 TEXAS CHIP DENTAL SERVICES MANUAL OF CRITERIA (MOC) ............224

Page v

Texas Children's Medicaid and CHIP Dental Services Provider Manual

Exhibits Exhibit A, Sample Claim/TAR Form Exhibit B, Sample Notice of Authorization (Delta Dental Copy) Exhibit C, Sample Notice of Authorization (Dentist Copy) Exhibit D, Sample Explanation of Benefits Exhibit E, Sample Claim Inquiry Form Exhibit F, Sample Claim Inquiry Response Form Attachments Attachment A: Texas Children's Medicaid Dental Services Manual of Criteria (MOC) Attachment B: Attachment C: Children's Medicaid Dental Services Managed Care Orthodontia Review Policy and Procedure. Orthodontic Continuations of Care Submission Form

Attachment D: Medicaid Orthodontic Criteria Form Attachment E: Attachment F: Attachment G: Texas CHIP Dental Services Manual of Criteria (MOC) Texas Medicaid and CHIP Dental Services Requiring Prior Authorization and/or x-rays Process of Care Evaluation Measures

Attachment H: Sample General Anesthesia Form Attachment I: Attachment J: Attachment K: Attachment L: Sample Private Pay Agreement Forms Waste, Abuse, and Fraud Reporting Form Claim/TAR/NOA Submission Checklist Codes, Messages, and Special Cases

Attachment M: Cost-Sharing Schedule (CHIP Members) Attachment N: Glossary

Page vi

Texas Children's Medicaid and CHIP Dental Services Provider Manual

1.0

INTRODUCTION

Delta Dental Insurance Company underwrites and Delta Dental of California's State Government Programs administers the Texas Health and Human Services Commission's (HHSC's) Texas Children's Medicaid and Children's Health Insurance Program (CHIP) Dental Services programs. These programs provide comprehensive dental benefit plans for children who reside in Texas. Eligible participants include:

Children birth through age 20 who are eligible for Medicaid Texas Health Steps Comprehensive Care Program services, including Supplemental Security Income recipients. Children enrolled in Texas CHIP.

This Texas Children's Medicaid and CHIP Dental Services Provider Manual contains information about Texas Children's Medicaid and CHIP Dental Services program coverage. It includes detailed information about program policies and procedures, instructions for completing claim forms and other related documents such as treatment authorization requests (TARs) and claim inquiry form (CIFs), and additional contract obligations that are binding on Delta Dental and you. You should consult this manual before seeking other sources of information. The criteria and policies contained in this provider manual are subject to change. When any changes in these criteria and/or policies occur, bulletins and revised pages will be issued to update the information in this provider manual. When you receive the bulletins and revised pages, carefully insert them as soon as possible according to the instructions provided with each revision. Taking this step will help ensure that your provider manual currents the most current information. The following terms are used throughout this provider manual:

You -- Refers to a participating provider in the Texas Children's Medicaid and/or CHIP Dental Services programs. We -- Refers to Delta Dental. Member -- Refers to a Texas Children's Medicaid and/or CHIP Dental Services member. If information applies to a Medicaid member only or a CHIP member only, we identify those specific instances throughout the provider manual. Program -- Refers to the Texas Children's Medicaid Dental Services and Texas CHIP Dental Services programs. If information applies to the Medicaid program only or the CHIP program only, we identify those specific instances throughout the provider manual. Authorized Representative -- Refers to any person or entity acting on behalf of the provider with the provider's written consent. May also refer to a person or entity acting on behalf of a member with the member's written consent.

Provider Hotline (CHIP): 1-866-561-5891 www.deltadentalins.com/tchip

Provider Hotline (Medicaid): 1-877-576-5899 www.deltadentalins.com/tx-medicaid

Page 1

Texas Children's Medicaid and CHIP Dental Services Provider Manual

1.1

QUICK REFERENCE LIST OF PHONE NUMBERS, ADDRESSES, AND WEBSITES

Below is a list of the toll-free Provider Hotline and Member Hotline phone numbers, Delta Dental's fax number for providers, our regular business hours/days, our mailing address, and our Texas Children's Medicaid and CHIP Dental Services program websites. Please note that there are separate phone numbers and websites for Medicaid and CHIP providers and members. Medicaid Provider Hotline (Medicaid): Member Hotline (Medicaid): Website (Medicaid): Provider Hotline (CHIP): Member Hotline (CHIP): Website (CHIP): 1-877-576-5899 1-877-535-5896 www.deltadentalins.com/tx-medicaid CHIP 1-866-561-5891 1-866-561-5892 www.deltadentalins.com/tchip

Delta Dental Fax Number for Providers 1-866-828-4122 Delta Dental Business Hours/Days Monday to Friday 8 a.m. to 7 p.m. Central Time (excluding State of Texas-approved holidays) Delta Dental Mailing Address Texas Children's Medicaid and CHIP Dental Services State Government Programs PO Box 537014 Sacramento, CA 95853-7014 For your convenience, our Provider Hotline phone numbers and our Texas Medicaid and CHIP website addresses are printed on the bottom of each page of this provider manual.

1.2

PURCHASE OF ADDITIONAL PROVIDER MANUALS

If you have received only a CD of this provider manual and would like a printed copy, please call our Provider Hotline. If you would like additional copies of the provider manual, please write to us at the address listed above.

Provider Hotline (Medicaid): 1-877-576-5899 www.deltadentalins.com/tx-medicaid

Provider Hotline (CHIP): 1-866-561-5891 www.deltadentalins.com/tchip

Page 2

Texas Children's Medicaid and CHIP Dental Services Provider Manual

For each copy, please enclose a check for $8 made payable to Delta Dental ­ State Government Programs.

1.3

OBJECTIVE OF PROGRAMS

The primary objective of the Texas Children's Medicaid and CHIP Dental Services programs is to create a comprehensive dental care system offering quality dental services to eligible Texas children.

1.4

DEFINITION OF DENTAL HOME

The American Academy of Pediatric Dentistry (AAPD) defines the dental home as "the ongoing relationship between the dentist and the patient, inclusive of all aspects of oral health care delivered in a comprehensive, continuously accessible, coordinated, familycentered way. Establishment of a dental home begins no later than 12 months of age and includes referral to dental specialists when appropriate." Children who have a dental home are more likely to receive preventive care, thus lowering the incidence of early childhood caries. A dental home should begin as soon as a child is enrolled in a dental service program. The AAPD advocates interaction with early intervention programs, schools, early childhood education and child care programs, members of the medical and dental communities, and other public and private community agencies to ensure awareness of age-specific oral health issues. For the Texas Children's Medicaid and CHIP Dental Services contract, we use the following terms to identify members' dental homes:

Main Dental Home -- This term refers to the dental home of: Texas CHIP members age birth through 18 who receive services in accordance with American Academy of Pediatric Dentistry (AAPD) recommendations. Texas Medicaid members age birth through 20 who receive services in accordance with the Texas Health Steps dental periodicity schedule. First Dental Home -- This term refers to the dental home of Texas Medicaid members between 6 months and 35 months of age. Until these Texas Children's Medicaid Dental Services program members reach age 3, the First Dental Home is the Main Dental Home. As soon as the member reaches age 3, the term "First Dental Home" is no longer used and First Dental Home requirements no longer apply.

With the exception of federally qualified health centers (FQHCs) and rural health clinics, the Main Dental Home or First Dental Home is an individual dentist and not a dental practice. For more information on the Main Dental Home, see Subsection 1.5, Role of Main Dental Home. For more information on the First Dental Home, see Subsection 1.6, Role of First Dental Home.

Provider Hotline (Medicaid): 1-877-576-5899 www.deltadentalins.com/tx-medicaid Provider Hotline (CHIP): 1-866-561-5891 www.deltadentalins.com/tchip

Page 3

Texas Children's Medicaid and CHIP Dental Services Provider Manual

1.5

ROLE OF MAIN DENTAL HOME

The Main Dental Home provider may provide services to both Texas Medicaid and Texas CHIP members. The Main Dental Home provider is not required to be Texas Health Steps-certified; however, if a Texas Medicaid member between 6 months and 35 months of age requires medically necessary treatment, the Main Dental Home provider should refer the member to a provider who is Texas Health Steps-certified. Parents and other care providers should establish a Main Dental Home for every child by 6 months of age. A Main Dental Home should provide:

Comprehensive oral health care, including acute care and preventive services. Comprehensive assessment for oral diseases and conditions. An individualized preventive dental health program based on a caries-risk assessment and a periodontal disease risk assessment. Anticipatory guidance about growth and development issues (e.g., teething, digit, or pacifier habits). A plan for acute dental trauma. Information about proper care of the child's teeth and gingiva (including the prevention, diagnosis, and treatment of disease of the supporting and surrounding tissues and the maintenance of health, function, and esthetics of those structures and tissues). Dietary counseling. Referrals to dental specialists when care cannot directly be provided within the dental home. Coordination of members' care with dental specialists.

For more information on the Main Dental Home, see Subsection 5.2, Main Dental Home Responsibilities.

1.6

ROLE OF FIRST DENTAL HOME INITIATIVE (MEDICAID)

The First Dental Home is a legislatively approved, Medicaid dental initiative aimed at improving the oral health of Medicaid-enrolled children from 6 months through 35 months of age by accomplishing these three goals:

Initiating early preventive dental services, even if the child does not have any erupted teeth. Providing simple, consistent messages that promote the importance of the child's oral health to parents and caregivers. Establishing dental homes for children beginning at 6 months of age or as early as possible after they enroll in Medicaid.

Provider Hotline (Medicaid): 1-877-576-5899 www.deltadentalins.com/tx-medicaid

Provider Hotline (CHIP): 1-866-561-5891 www.deltadentalins.com/tchip

Page 4

Texas Children's Medicaid and CHIP Dental Services Provider Manual

To effectively convey First Dental Home oral health information to parents, it is a requirement of First Dental Home that one parent be actively involved and be present in the dental treatment room throughout the entire visit with the child and dental team during all First Dental Home visits. This requirement gives the parent an opportunity to learn about his or her child's current oral health status and receive educational and anticipatory guidance while the dentist is performing an oral evaluation and preventive dental services. This interactive environment helps enhance the parent's understanding of the role they play in the oral health of their child. The parent, through knee-to-knee positioning of the parent and dentist, can also manage his or her child's movements during the visit and be able to comfort the child as needed. The First Dental Home visit includes, but is not limited to, the following:

Completion of oral health questionnaires. Review of oral health history. Review of dental history of the child/patient, primary caregiver, and sibling(s). Comprehensive oral evaluation. Caries risk assessment to determine the child's potential for development of severe EEC by identifying the: Oral health status of the child/patient. Oral health status of the primary caregiver and other family members. Potential bacterial transmission sources. Toothbrush dental prophylaxis. Oral hygiene instructions with the primary caregiver. Application of topical fluoride varnish. Dental anticipatory guidance to include: Age-appropriate information/education for parents/caregivers based on questionnaire responses, parent/caregiver interview, and caries risk assessment. Multi-topic overview of oral health environmental influences. Efforts to increase the parent/caregiver understanding about the importance of good oral health. Establishment of recall schedule as indicated below: Initial visit as early as 6 months of age. Recall visits as often as every 3 months for children at risk for early childhood caries (ECC), with a minimum of 60 days between recall visits and up to 10 visits between 6 months and 35 months of age. Treatment planning to be completed in your office or to include referral to a pediatric dentist, with the referral to include: Coordination/correspondence between the general dentist and pediatric dentist. Identification of which dentist will maintain the First Dental Home after restorative needs are completed.

Provider Hotline (Medicaid): 1-877-576-5899 www.deltadentalins.com/tx-medicaid

Provider Hotline (CHIP): 1-866-561-5891 www.deltadentalins.com/tchip

Page 5

Texas Children's Medicaid and CHIP Dental Services Provider Manual

For more information on the First Dental Home, see Subsection 5.3, First Dental Home Initiative Responsibilities (Medicaid).

1.7

BECOMING A FIRST DENTAL HOME PROVIDER (MEDICAID)

To become a First Dental Home Initiative provider, you must first complete either the online one-hour "First Dental Home" training module or equivalent in-person training through Texas Health Steps (for more information, go to www.txhealthsteps.com). HHSC offers First Dental Home training to providers who meet the following criteria:

Currently enrolled Texas Health Steps pediatric and general dentists. Dentists who have submitted a Texas Health Steps dental provider enrollment application.

Each First Dental Home provider must have a National Provider Identified (NPI) number and each practice location must have an individual Texas Provider Indicator (TPI) number. Dental team members are encouraged to participate in First Dental Home training. After you complete the training and submit the required information to Texas Health Steps, you will receive documentation from Texas Health Steps that certifies you as a First Dental Home Initiative provider. You must submit a copy of that documentation to Delta Dental. We will then update your file to identify you as a First Dental Home Initiative provider.

1.8

ROLE OF MEMBER ADVOCATES (MEDICAID)

Member advocates provide assistance to eligible Medicaid members. Member advocate responsibilities include:

Informing members of member rights and responsibilities. Informing members about the complaint and appeal process and assisting them as needed throughout the process. Monitoring the status of member complaints and appeals with which the member advocates have provided assistance. Informing members of the covered services available to them, including preventive services. Informing members of the non-capitated services available to them. Helping or referring members to community resources that are available to meet members' needs if services are not available from Delta Dental as medically necessary covered dental services. Making recommendations to Delta Dental management on any changes needed to improve either the care provided or the way care is delivered.

Provider Hotline (CHIP): 1-866-561-5891 www.deltadentalins.com/tchip

Provider Hotline (Medicaid): 1-877-576-5899 www.deltadentalins.com/tx-medicaid

Page 6

Texas Children's Medicaid and CHIP Dental Services Provider Manual

A Medicaid member advocate is available in each service area and through the Member Hotline. If a member asks you about how to contact a member advocate--or if you determine that the member might benefit from a member advocate's assistance--please refer the member to our Member Hotline (1-877-535-5896).

Provider Hotline (Medicaid): 1-877-576-5899 www.deltadentalins.com/tx-medicaid

Provider Hotline (CHIP): 1-866-561-5891 www.deltadentalins.com/tchip

Page 7

Texas Children's Medicaid and CHIP Dental Services Provider Manual

2.0

COVERED SERVICES

As a contracting dentist, you must understand and agree that:

Texas Children's Medicaid and CHIP Dental Services members are not subject to limitations or exclusions of covered dental benefits due to a pre-existing condition. HHSC is not liable or responsible for payment for covered services rendered pursuant to your Contracting Dentist Agreement.

2.1

COVERED DENTAL SERVICES (MEDICAID)

Covered dental services for Medicaid members and any applicable limitations are defined in Attachment A, Texas Children's Medicaid Dental Services Manual of Criteria. You may also access the Texas Medicaid Provider Procedures Manual at www.tmhp.com for a listing of limitations and exclusions. There are no copayments for Medicaid members. Dentists should verify eligibility coverage for the Texas Children's Medicaid Dental Services member at the time of offering dental services.

2.1.1

Texas Health Steps

Texas Health Steps is a comprehensive preventive care program that combines diagnostic screenings, communication and outreach, and medically necessary follow-up care including dental, vision, and hearing examinations for Medicaid-eligible children under the age of 21. Members have access to the traditional Medicaid member benefits, with the additions and requirements for appointment times for Texas Health Steps as discussed below. Texas Health Steps members are encouraged to visit a dental provider for routine dental checkups. Routine dental checkups do not require a referral. Dental checkups are required every 6 months for members, beginning at age 6 months through 20 years of age. The different types of Texas Health Steps services available to members are presented in the table below. Type of Service Preventive Services Description of Service Dental examinations (initial or periodic) Cleaning (prophylaxis) Oral health education Application of topical fluoride Application of sealants to certain teeth

Provider Hotline (CHIP): 1-866-561-5891 www.deltadentalins.com/tchip

Provider Hotline (Medicaid): 1-877-576-5899 www.deltadentalins.com/tx-medicaid

Page 8

Texas Children's Medicaid and CHIP Dental Services Provider Manual

Type of Service Treatment Services Emergency Services Dental

Description of Service Maintenance of space Restorations (fillings, crowns) Endodontic treatment (pulp therapy, root canals) Periodontic treatment (gum disease) Prosthodontics (full or partial dentures) Oral surgery (extractions) Implant services and maxilllofacial prosthetics Procedures necessary to control bleeding, relieve pain, and eliminate acute infection Procedures that are required to prevent imminent loss of teeth

Treatment of injuries to the teeth or supporting structures

Orthodontic Services (requires authorization) prior

Correction of cleft palate Crossbite therapy Treatment for severe handicapping malocclusion Treatment for facial accidents involving severe traumatic deviation

If dental checkups result in treatment requiring a facility or anesthesia charge, a request for authorization must be obtained for the recommended treatment. As a Texas Children's Medicaid Dental Services provider, you will receive training from Delta Dental in the following areas:

Texas Health Steps dental benefits, periodicity, and required elements of a dental checkup. Non-capitated medical transportation services available to Medicaid members such as rides to services by bus, taxi, van, and air, along with reimbursement for gas, mileage, meals, and lodging. The importance of updating contact information to ensure accurate provider directories and Medicaid Online Provider Lookup information.

Provider Hotline (CHIP): 1-866-561-5891 www.deltadentalins.com/tchip

Provider Hotline (Medicaid): 1-877-576-5899 www.deltadentalins.com/tx-medicaid

Page 9

Texas Children's Medicaid and CHIP Dental Services Provider Manual

Delta Dental's process for acceleration of Texas Health Steps dental services for Children of Migrant Farmworker members. Missed appointment referrals and assistance provided by the Texas Health Steps Outreach and Informing Unit. Administrative issues such as claims filing and services available to members. The requirements imposed on HHSC and Delta Dental under the Consent Decree and Corrective Action Orders entered in Frew v. Suehs.

For more information about Texas Health Steps--including how to enroll as a Texas Health Steps provider--please refer to the Texas Medicaid Provider Procedures Manual at www.tmhp.com.

2.1.2

Children of Migrant Farmworkers

Children of migrant farm workers who are due for a Texas Health Steps dental checkup can receive their periodic checkup on an accelerated basis prior to leaving the area. A checkup performed under this circumstance is considered an exception to periodicity Performing a make-up exam for a late Texas Health Steps dental checkup previously missed under the periodicity schedule is not considered an exception to periodicity nor an accelerated service. It is considered a late checkup.

2.1.3

Orthodontia Services

Comprehensive medically necessary orthodontic services are a covered benefit for Texas Medicaid members who have a severe handicapping malocclusion or special medical conditions including cleft palate, post-head trauma injury involving the oral cavity, and/or skeletal anomalies involving the oral cavity. See Attachment B, Texas Children's Medicaid Dental Services Managed Care Orthodontia Review Policy and Procedure, for detailed information on orthodontia services. Delta Dental has the option to re-review Texas Children's Medicaid Dental Services orthodontic cases that were authorized by TMHP prior to March 1, 2012 for medical necessity. Delta Dental's plan for transitioning cases previously authorized by TMHP to Delta Dental for continuation of care after March 1, 2012 complies with HHSC's orthodontic review policy and procedure (see Attachment B, Section 11.00, Orthodontic Services authorized by TMHP prior to March 1, 2012). As noted in Attachment B, Section 11.00, providers must submit the following documentation to Delta Dental for our review and consideration of payment for continuation of orthodontic care:

A completed Orthodontic Continuation of Care Form (see Attachment C, Orthodontic Continuation of Care Submission Form).

Provider Hotline (Medicaid): 1-877-576-5899 www.deltadentalins.com/tx-medicaid

Provider Hotline (CHIP): 1-866-561-5891 www.deltadentalins.com/tchip

Page 10

Texas Children's Medicaid and CHIP Dental Services Provider Manual

A completed Orthodontic Criteria Form (see Attachment D, Medicaid Orthodontic Criteria Form). A completed 2006 or greater ADA claim form listing the services to be rendered. A copy of the member's prior approval including the total approved case fee and payment structure. Detailed payment history. A copy of the original study models prior to the patient being banded. Panorex film.

The clinical criteria used in making the qualifying decision will be the criteria stated in Attachment B (Levels I, II, III and IIII). Should the request for continuation of payment be denied due to lack of medical necessity under the new clinical criteria, Delta Dental will authorize a treatment plan to deband the member.

2.2

COVERED DENTAL SERVICES (CHIP)

Covered dental services for CHIP members are subject to a $564.00 annual benefit limit unless an exception applies. Some benefits are subject to annual limits as defined in Attachment E, Texas CHIP Dental Services Manual of Criteria. Limitations are based on a 12-month coverage period. Orthodontic services are covered for Texas CHIP Members for pre-and post-surgical cases related to cleft palate, post-head trauma injury involving the oral cavity, and/or skeletal anomalies involving the oral cavity (see Attachment B). CHIP members who have exceeded the $564.00 annual benefit limit may continue to receive the following covered dental services in excess of the $564.00 annual benefit maximum:

The preventive services due under the 2009 American Academy of Pediatric Dentistry periodicity schedule (Volume 32, Issue Number 6 at pp. 93-100). Other medically necessary covered dental services approved by Delta Dental through a prior authorization process. These services must be necessary to allow a CHIP member to return to normal, pain-free and infection-free oral functioning. Typically this includes: Services related to the relief of significant pain or to eliminate acute infection. Services related to the treatment of traumatic clinical conditions. Services that allow the CHIP member to attain the basic human functions (e.g., eating and speaking).

Provider Hotline (Medicaid): 1-877-576-5899 www.deltadentalins.com/tx-medicaid

Provider Hotline (CHIP): 1-866-561-5891 www.deltadentalins.com/tchip

Page 11

Texas Children's Medicaid and CHIP Dental Services Provider Manual

Services that prevent a more serious and costly dental problem (i.e., that are delivered to ensure that the CHIP member's condition does not deteriorate within an imminent time frame).

Dentists should verify eligibility coverage for the Texas CHIP Dental Services member at the time of offering dental services.

2.3

EMERGENCY DENTAL CARE

Emergency dental services are limited to the following:

Procedures necessary to control bleeding, relieve pain, and eliminate acute infection. Operative procedures required to prevent imminent loss of teeth. Treatment of injuries to the teeth and supporting structures. Routine restorative procedures and root canal therapy are not emergency services.

Emergency services must be justified with documentation. The dentist's narrative documentation should describe the nature of the emergency, including relevant clinical information about the patient's condition and stating why the emergency services rendered were considered to be immediately necessary. The statement must be comprehensive enough to support a finding that an emergency existed. The physician or dentist having direct knowledge of the emergency described must sign the statement.

2.4

PRIOR AUTHORIZATIONS

Texas Medicaid and CHIP dental services that require prior authorization and/or xrays are listed in Attachment F, Texas Children's Medicaid and CHIP Dental Services Requiring Prior Authorization and/or X-Rays. The Texas Medicaid services are organized sequentially by procedure code, followed by the Texas CHIP services organized sequentially by procedure code. A summary of the Texas Medicaid prior authorization process is presented below in Subsection 2.4.1, Prior Authorizations (Medicaid). Additional information is presented in the Texas Children's Medicaid Dental Services Manual of Criteria in Attachment A. A summary of the Texas CHIP prior authorization process is presented below in Subsection 2.4.2, Prior Authorizations (CHIP). Additional information is presented in the Texas CHIP Dental Services Manual of Criteria in Attachment E.

2.4.1

Prior Authorizations (Medicaid)

Prior authorization is valid up to 90 days. Prior authorization is a condition for reimbursement; it is not a guarantee of payment. Post-treatment authorization will not be approved for codes that require mandatory prior authorization.

Provider Hotline (Medicaid): 1-877-576-5899 www.deltadentalins.com/tx-medicaid Provider Hotline (CHIP): 1-866-561-5891 www.deltadentalins.com/tchip

Page 12

Texas Children's Medicaid and CHIP Dental Services Provider Manual

Prior authorization is issued to the requesting provider only and is not transferable to another provider. If the client changes providers or if the provider stops practicing dentistry for whatever reason, a new prior authorization must be requested. Upon receipt of prior authorization of complete treatment plans, providers are to advise clients that they will be able to receive the approved treatment services (e.g. orthodontic adjustments, bracket replacements and retainers), even if they lose eligibility or reach 21 years of age. Approved orthodontic treatment must be initiated before the loss of eligibility and completed within 36 months of the authorization date. Some dental services provided to patients in hospitals, skilled nursing facilities, and intermediate care facilities are covered under the member's medical program. No verbal authorization will be granted by Delta Dental.

2.4.2

Prior Authorizations (CHIP)

Prior authorization for Texas CHIP dental services includes the following requirements:

Services must be performed during the valid authorization period. Failure of the patient to appear for a second scheduled pre-treatment screening examination may result in the denial of requested services. A notice of authorization (NOA) for payment must be submitted for payment no later than 95 days after the last services were performed. The patient must be eligible during the month in which procedure is actually performed.

During the processing of the TAR, it may be necessary for Delta Dental to screen the patient for clinical evaluation purposes. If this occurs, the dental office and the patient will be notified of the screening appointment with a regional dental consultant. To ensure attendance, it would be helpful for the dental office to remind the patient of the examination. Prior authorization is not transferable from one dental office to another. If, for some reason, the dentist who received prior authorization for a service is unable to complete that service, another dentist cannot perform the service until a new treatment plan is authorized under his or her own provider number. To expedite processing of a TAR with a change of provider, submit a new TAR with an attached statement from the member indicating a change of provider.

Provider Hotline (Medicaid): 1-877-576-5899 www.deltadentalins.com/tx-medicaid

Provider Hotline (CHIP): 1-866-561-5891 www.deltadentalins.com/tchip

Page 13

Texas Children's Medicaid and CHIP Dental Services Provider Manual

3.0

QUALITY ASSESSMENT AND PERFORMANCE IMPROVEMENT

Delta Dental is committed to continuous improvement in the service delivery and quality of clinical dental care provided to Texas Children's Medicaid and CHIP Dental Services program members. We maintain a comprehensive quality and utilization review program designed to identify, evaluate, and remedy problems relating to access to care, continuity and quality of care, utilization, and the cost of services. Our quality review program includes standards, policies, and procedures for credentialing and recredentialing dentists and other health care professionals and facilities providing covered dental services to Texas Medicaid and CHIP Dental Services members. Peer review panels and committees are used to conduct quality of care and utilization review in accordance with applicable state and federal laws and regulations. All quality and utilization review forms, records, and other information in Delta Dental's possession are the property of Delta Dental and shall remain confidential.

3.1

PRACTICE GUIDELINES

Delta Dental has established and follows quality of care guidelines that include recommendations developed by organizations and specialty groups such as the American Academy of Pediatric Dentistry, the American Academy of Endodontists, the American Academy of Periodontists, the American Association of Oral Surgeons, and the ADA and its constituent (state) components. We apply these guidelines equally to general practice dentists and specialists and use them to evaluate Texas Medicaid and CHIP Dental Services member care. Network providers shall comply with the standards and requirements of the Quality Assessment and Performance Improvement (QAPI) program as established by Delta Dental in accordance with HHSC requirements and as set forth in this provider manual. As a contracting dentist, you agree to comply with our Quality Assessment and Performance Improvement program requirements. You are required to integrate specialty care into the member's course of dental treatment by making timely referrals to a specialist when necessary or appropriate. You may not impose any limitations on the acceptance or treatment of Texas Medicaid and CHIP Dental Services members not imposed on other patients. You are required to maintain the dentist/patient relationship with the Texas Medicaid and CHIP Dental Services member and shall be solely responsible to the member for dental advice and treatment.

Provider Hotline (Medicaid): 1-877-576-5899 www.deltadentalins.com/tx-medicaid

Provider Hotline (CHIP): 1-866-561-5891 www.deltadentalins.com/tchip

Page 14

Texas Children's Medicaid and CHIP Dental Services Provider Manual

3.2

FOCUS STUDIES

Delta Dental collaborates with HHSC's external quality review organization (EQRO) to develop studies, surveys, or other analytical approaches that will be carried out by the EQRO. The purpose of the studies, surveys, or other analytical approaches is to assess the quality of care and service provided to members and to identify opportunities for Delta Dental's improvement. To facilitate this process, we will:

Supply claims data to the EQRO (or to another contractor identified by HHSC), in a format identified by HHSC. Supply dental records for focused clinical reviews to the EQRO or other designated contractor. Work collaboratively with HHSC and the EQRO to annually measure selected HEDIS measures that require chart reviews.

As noted in Subsection 16.1, Access to Records, contracting dentists agree to provide access to member records on request.

3.3

QUALITY OF CARE REVIEWS

Delta Dental conducts quality of care reviews to assess the quality of care provided by dentists. A quality of care review may result from multiple member complaints or an analysis of quality assessments, utilization reports, or patterns of care or conduct observed during claims processing. The review may include selective oral examinations of Texas Medicaid and CHIP Dental Services members/patients by regional consultants and/or a review of facilities (on-site) and detailed chart audits. Chart reviews are designed to evaluate the process and quality of care rendered to Texas Children's Medicaid and CHIP Dental Services patients. As needed, a sample of charts will assess the quality of care delivered and will take into account both the process of care (as documented in the dental records) and the outcome of care, as represented by the current status of the patient. Chart reviews are comprehensive, with criteria reflecting the standards presented in Attachment G, Process of Care Evaluation Measures. All assessment and clinical review findings are discussed with the dentist. Findings and recommendations are presented in an educational manner to inform and instruct the dentist and facility staff of program requirements and the procedures and to ensure compliance with Texas Medicaid and CHIP Dental Services standards of care. The dentist is subsequently provided with a letter noting deficiencies, if any, an overall rating and any scheduled future assessments. If significant deficiencies are noted, corrective action may be required prior to execution or renewal of the Contracting Dentist Agreement.

Provider Hotline (Medicaid): 1-877-576-5899 www.deltadentalins.com/tx-medicaid

Provider Hotline (CHIP): 1-866-561-5891 www.deltadentalins.com/tchip

Page 15

Texas Children's Medicaid and CHIP Dental Services Provider Manual

3.4

CORRECTIVE ACTIONS AND HEARING PROCESS

When specific cases of substandard quality of care are identified during the quality of care review process, a letter requesting corrective action will be mailed to the treating provider. Many forms of corrective action may be recommended, including but not limited to the following:

A quality correction letter indicating the deficiency or deficiencies and requiring changes to be implemented within a maximum of 60 days. The seriousness of the deficiency or deficiencies noted will dictate the number of days which the provider has to implement the required changes. Special prior authorization/claims review. Post-treatment reviews of patients by a regional dental consultant. Required attendance by the provider at training sessions or participation in continuing education programs. Restricted acceptance of new members until the provider has become compliant with all standards of care for a given amount of time. Recoupment of sums paid where billing discrepancies are found during reviews. Restriction of a provider's authorized scope of services. Referral to the State of Texas Board of Dental Examiners and/or the U.S. Department of Justice, Attorney General's Office. Termination of the Contracting Dentist Agreement.

3.4.1

Notices of Proposed Corrective Actions

Delta Dental will provide notice of the proposed corrective or adverse action at least 21 days prior to the effective date of the proposed action unless our dental director has initiated immediate action to avoid imminent danger to the health of a Texas Medicaid or CHIP Dental Services member. We will initiate the proposed or adverse action on the noted effective date if the provider does not request a hearing prior to the effective date of the proposed action. The Notice of Action includes the following information:

The proposed action to be taken. The reason for the proposed action. The effective date. The requirement that the action be reported to the state Board of Dental Examiners. The right of the provider to request a hearing by submitting a written request to Delta Dental prior to the effective date of the proposed action (or within 21 days of the notice, if the dental director has taken immediate action).

Provider Hotline (CHIP): 1-866-561-5891 www.deltadentalins.com/tchip

Provider Hotline (Medicaid): 1-877-576-5899 www.deltadentalins.com/tx-medicaid

Page 16

Texas Children's Medicaid and CHIP Dental Services Provider Manual

The procedures governing such hearings.

Notification that failure of the provider to request a hearing within the time required constitutes a waiver of the provider's right to a hearing, and Delta Dental will initiate the proposed action on the effective date.

3.4.2

Provider's Right to Request a Hearing

A provider may appeal any corrective or adverse action taken by Delta Dental, including:

Restriction in a provider's authorized scope of services or termination for cause of the Contracting Dentist Agreement. Any other action that results in a report to the state Board of Dental Examiners and/or the National Practitioner Data Bank.

If the provider does not request a hearing in writing by the effective date of the proposed action, the right to appeal is lost and Delta Dental shall impose or initiate the corrective or disciplinary action and furnish appropriate reports to state and federal agencies.

3.4.3

Hearing Process

If the provider requests a hearing, a written notice containing the following information will be mailed by the dental director to the provider no more than 60 days from the receipt of the request from the provider:

The place, time, and date of the hearing. The reason for the proposed action, including the acts or omissions with which the provider is charged. Copies of any non-privileged documents relevant to the proposed action that Delta Dental has in its possession or under its control. A request to inspect all relevant non-privileged documents that the provider has in his/her possession or control within 15 days after receipt of the notice of hearing. The names, credentials, and backgrounds of at least three participating Texas Medicaid and CHIP Dental Services dentists who will serve as members on the hearing panel. The name, credentials, and background of a licensed attorney who will serve as the hearing officer.

The hearing shall be conducted without the necessity of complying with formal rules of evidence or the presence of attorneys. Delta Dental will arrange to have a record made of the hearing. Delta Dental will have the initial duty to present evidence supporting its

Provider Hotline (Medicaid): 1-877-576-5899 www.deltadentalins.com/tx-medicaid Provider Hotline (CHIP): 1-866-561-5891 www.deltadentalins.com/tchip

Page 17

Texas Children's Medicaid and CHIP Dental Services Provider Manual

proposed action. Each party shall have the right to call, examine, and cross-examine witnesses, the right to present and rebut relevant evidence, and the right to submit a written statement at the conclusion of the hearing. Delta Dental shall have the burden of proof by a preponderance of the evidence that the corrective or disciplinary action is reasonable or warranted. The matter shall be decided by a majority vote of the hearing panel. The panel shall provide a written decision, including findings of fact and a conclusion based on the evidence produced. Delta Dental will mail a copy of the written decision to the provider. There is no administrative appeal of the decision of the hearing panel. A provider who is dissatisfied with the hearing panel's decision may seek a judicial remedy within one year after receiving notice of the decision.

3.5

PRIOR AUTHORIZATION/SPECIAL CLAIMS REVIEWS

As part of Delta Dental's Quality Assessment and Performance Improvement (QAPI) program, we may require selected providers to obtain prior authorization for some or all dental services. Providers may be required to submit additional x-rays and/or documentation to substantiate the need for the treatment requested or to demonstrate that the quality of the treatment performed is consistent with generally accepted standards of care. Providers may be randomly selected to obtain prior authorization or for special claims review as a result of utilization review or after consideration of other reasonable circumstances. Written notification will be sent to all selected providers at least 30 days in advance of prior authorization or special claims review requirements.

3.6

UTILIZATION MANAGEMENT REPORTING REQUIREMENTS

Delta Dental's Utilization Management department serves as the primary repository for all data related to the quality of services provided by Texas Medicaid and Texas CHIP Dental Services providers. A utilization analyst generates quarterly utilization reports from our automated system to assist in the identification of trends--specifically, underutilization and overutilization of services. These reports include, but are not limited to, provider profiles, provider-trended analyses, frequency of procedures performed, and claims analyses. Following analysis of all reports and data to identify providers with indicators of overor under-utilization of services and/or practice patterns inconsistent with normative data, a report summarizing the results is prepared for presentation to Delta Dental's UM Committee. The UM Committee evaluates the case report and determines whether aberrant practice patterns are a result of case mix (as with pediatric dentists) or other explainable conditions for a provider and whether member activity was unusual but appropriate for the particular situation. Results that do not appear to have a justifiable

Provider Hotline (Medicaid): 1-877-576-5899 www.deltadentalins.com/tx-medicaid Provider Hotline (CHIP): 1-866-561-5891 www.deltadentalins.com/tchip

Page 18

Texas Children's Medicaid and CHIP Dental Services Provider Manual

basis for deviation from norms are recommended for further review and may result in a process of care audit. Provider profiling activities include:

Developing provider-specific reports that include a multi-dimensional assessment of a provider's performance using clinical, administrative and member satisfaction indicators of care that are accurate, measurable, and relevant to the enrolled population. Establishing provider, group, statewide or regional benchmarks for areas profiled, where applicable. Providing feedback to individual providers regarding the results of their performance and the overall performance of the provider network.

Utilization analysts generate statistical reports each month to detect providers whose service patterns deviate from expected norms. Provider profiles compare each provider to all network dentists and also by type of service (e.g., diagnostic, preventive, operative, endodontics, oral surgery, periodontics, and prosthetics). Ratio reports identifying providers who exceed norms in terms of services per patient are generated from Delta Dental's system database. Based on the result of the ratio report analysis, additional drill-down reports are generated for providers who warrant further investigation to identify the basis for the aberrant statistical results. Quality assessment and utilization management staff also identify quality issues and trends through input from other departments during regularly scheduled staff meetings and review of member and provider complaints/appeals, satisfaction survey results and other feedback mechanisms.

Provider Hotline (Medicaid): 1-877-576-5899 www.deltadentalins.com/tx-medicaid

Provider Hotline (CHIP): 1-866-561-5891 www.deltadentalins.com/tchip

Page 19

Texas Children's Medicaid and CHIP Dental Services Provider Manual

4.0

PROVIDER ENROLLMENT

To receive payment for dental services rendered to Texas Medicaid and CHIP Dental Services program members, prospective providers must first apply to and be approved by Delta Dental as a network provider. The enrollment process is summarized below.

4.1

ENROLLMENT DOCUMENTS

Upon request, Delta Dental will send a prospective contracting dentist an enrollment packet, which includes a Contracting Dentist Agreement, a Provider Profile questionnaire, and related forms. The Provider Profile collects information that describes the dentist's practice and facility. The profile is accompanied by an Attestation Form, which certifies that all information contained in the profile is complete, accurate, and factual. After we receive the completed enrollment documents, our Dentist Network Administration and Contracting (DNAC) staff will verify that all data fields have been completed and enter the information into an administrative database system.

4.2

CREDENTIALING

Credentialing involves gathering and reviewing information from regulatory agencies, professional associations, and educational institutions to ensure that the prospective Texas Medicaid and CHIP Dental Services dentist is legally qualified to practice. Delta Dental uses proven credentialing criteria and guidelines to verify that the dentist meets and maintains the standards for program participation. To achieve this goal, we verify the following for each prospective contracting dentist:

A valid, current Texas dental license. The presence of acceptable professional liability (malpractice) insurance coverage. All permits and registrations are current, including Drug Enforcement Administration, conscious sedation, oral conscious sedation, and general anesthesia. Possession of certificates of specialty or proof of Board eligibility, as applicable. The absence of negative actions taken by the State Board of Dental Examiners and/or the absence of adverse peer review cases or decisions for all principals and associates. Curriculum vitae for each treating provider. Not included on HHSC Office of Inspector General's (OIG's) list of excluded providers. Not excluded from participation in the Medicaid program (Medicaid providers must also enter into and maintain a Medicaid provider agreement with HHSC or its agent to participate in the Medicaid program).

Provider Hotline (CHIP): 1-866-561-5891 www.deltadentalins.com/tchip

Provider Hotline (Medicaid): 1-877-576-5899 www.deltadentalins.com/tx-medicaid

Page 20

Texas Children's Medicaid and CHIP Dental Services Provider Manual

After the credentialing process has been completed, we will mail a counter-signed Contracting Dentist Agreement to the dentist along with a welcome packet. The welcome packet will include a welcome letter, Medicaid and/or CHIP Dental Scope of Benefits and fee schedule(s), and a CD that includes an electronic file of this provider manual.

4.3

RE-CREDENTIALING

The credentialing process is repeated every three years to verify that licenses and certifications remain current for each dentist. An automated system generates reminder reports and letters when credentialing documents expire. A Delta Dental credentialing specialist will contact you to initiate the re-credentialing process. The process should take no longer than 60 days to complete. You will be notified upon completion of the recredentialing process.

4.4

PROVIDER IDENTIFICATION NUMBERS

When you enroll in the Texas Medicaid and CHIP Dental Services programs, Delta Dental will assign you a unique 8-digit provider identification number (PIN). This PIN is a private access number for use by you and your office staff only. Do not give your PIN number to members. If you forget your PIN, call our Provider Hotline to request a new PIN. In addition, network acute care providers must have a Texas Provider Identification (TPI) number.

4.5

NATIONAL PROVIDER IDENTIFIER

Each Texas Medicaid and CHIP Dental Services provider must have a National Provider Identifier (NPI) in accordance with the timelines established in 45 Code of Federal Regulations (C.F.R.), Part 162, Subpart D. (For most providers, the NPI was required to be in place by May 23, 2007.)

Provider Hotline (Medicaid): 1-877-576-5899 www.deltadentalins.com/tx-medicaid

Provider Hotline (CHIP): 1-866-561-5891 www.deltadentalins.com/tchip

Page 21

Texas Children's Medicaid and CHIP Dental Services Provider Manual

5.0

PROVIDER RESPONSIBILITIES

Provider responsibilities are discussed in the following subsections:

5.1, Availability and Accessibility. 5.2, Main Dental Home Responsibilities. 5.3, First Dental Home Initiative Responsibilities (Medicaid). 5.4, General Anesthesia Form. 5.5, Referral to Specialists Process. 5.6, Verification of Member Eligibility and/or Authorization for Service. 5.7, Financial Responsibility or Optional Treatment Form. 5.8, Dental Records. 5.9, Access to Second Opinion. 5.10, Justification Regarding Out-of-Network Providers. 5.11, Plan Termination. 5.12, Fraud and Abuse. 5.13, Professional Conduct.

5.1

AVAILABILITY AND ACCESSIBILITY

To help ensure completion of your Texas Medicaid or CHIP Dental Services member's treatment plan, you should establish a system for contacting patients who miss or break scheduled appointments. Members should not wait for more than 15 to 30 minutes beyond the designated appointment time to begin care. If a patient is waiting for a scheduled appointment and the wait time goes beyond 15 minutes, an explanation for the delay should be given to the patient's representative with the option of rescheduling the appointment. You shall provide direction to you patients on how to obtain emergency services 24 hours per day, 7 days per week, including vacations and holidays. Appointments for urgent conditions should be scheduled within 24 hours and the patient should be informed that only the urgent condition will be treated at that time.

5.2

MAIN DENTAL HOME RESPONSIBILITIES

Texas defines a Main Dental Home as the dental provider who supports an ongoing relationship with the client that includes all aspects of oral health care delivered in a comprehensive, continuously accessible, coordinated, and family-centered way. Establishment of a client's Main Dental Home begins no later than 6 months of age and includes referrals to dental specialists when appropriate.

Provider Hotline (Medicaid): 1-877-576-5899 www.deltadentalins.com/tx-medicaid Provider Hotline (CHIP): 1-866-561-5891 www.deltadentalins.com/tchip

Page 22

Texas Children's Medicaid and CHIP Dental Services Provider Manual

The Dental Contractor must develop and maintain a network of Main Dental Home providers, consisting of general dentists and pediatric dentists, who will provide preventive care and refer members to specialty care as needed. With the exception of federally qualified health centers (FQHCs), the Main Dental Home is the individual "Main Dentist," not a dental practice. The Main Dentist's name is listed on the member's ID card. If the Main Dentist is not available (e.g., he or she is on vacation), the member can receive services from another dentist in that dental practice. Seeing another dentist if the Main Dentist is not available does not constitute a change in the member's Main Dental Home.

5.3

FIRST DENTAL HOME INITIATIVE RESPONSIBILITIES (MEDICAID)

In addition to establishing a network of Main Dental Home providers, Delta Dental implements a "First Dental Home Initiative" for Medicaid members. This initiative will enhance dental providers' ability to assist members and their primary caregivers in obtaining optimum oral health care through First Dental Home visits. The First Dental Home visit can be initiated as early as six (6) months of age and must include, but is not limited to, the following:

Comprehensive oral examination. Oral hygiene instruction with primary caregiver. Dental prophylaxis, if appropriate. Topical fluoride varnish application when teeth are present. Caries risk assessment. Dental anticipatory guidance. Medicaid members from six (6) through 35 months of age may be seen for dental checkups by a certified First Dental Home Initiative provider as frequently as every three (3) months if medically necessary.

The initial First Dental Home visit provides an introduction of the child and parent to the First Dental Home dental provider, the provider's staff, and the dental office's physical location and layout. After completion of the initial First Dental Home visit, the child is placed on a recall schedule based on the caries risk assessment results. At subsequent First Dental Home visits, you must complete all of the following:

Review and update of the child's health history. Review and update of the dental history for the child/patient, primary caregiver, and any siblings. Periodic oral evaluation performed by the First Dental Home dentist.

Provider Hotline (CHIP): 1-866-561-5891 www.deltadentalins.com/tchip

Provider Hotline (Medicaid): 1-877-576-5899 www.deltadentalins.com/tx-medicaid

Page 23

Texas Children's Medicaid and CHIP Dental Services Provider Manual

Updated caries risk assessment performed by the First Dental Home dentist. Toothbrush prophylaxis (rubber cup prophylaxis if indicated due to stain, and so forth). Topical fluoride varnish application. Dental anticipatory guidance provided to the parent or guardian, including oral hygiene instructions and nutritional guidance. Oral developmental milestones for the child. Confirmation of the child's dental recall schedule based on the results of the updated caries risk assessment. Any necessary referral to dental specialists.

To help you meet your First Dental Home provider responsibilities, the Texas Department of State Health Services (DSHS) makes the following First Dental Home materials available on their website at: (www.dshs.state.tx.us/dental/firstdentalhomemats.shtm):

Training Registration Form. PowerPoint Training. Visit Documentation. Oral Health History Questionnaire. Dental Risk Assessment Questionnaire. Caries Risk Assessment Tool. "Your Child's Teeth Are Important" brochure. Dental Anticipatory Guidance tool.

Details on First Dental Home Initiative responsibilities are presented in the following subsections:

5.3.1, Caries Risk Assessment Tool. 5.3.2, Toothbrush Prophylaxis. 5.3.3, Application of Fluoride Varnish. 5.3.4, Dental Anticipatory Guidance. 5.3.5, Delegation of Components for First Dental Home Visits. 5.3.6, Determining When Children Should be Scheduled for Oral Health Visits. 5.3.7, Treatment Planning and Coordination. 5.3.8, Documentation of the First Dental Home Visits. 5.3.9, Billing the First Dental Home Visits. 5.3.10, Incorporating the First Dental Home Visits Into Your Practice.

Provider Hotline (CHIP): 1-866-561-5891 www.deltadentalins.com/tchip

Provider Hotline (Medicaid): 1-877-576-5899 www.deltadentalins.com/tx-medicaid

Page 24

Texas Children's Medicaid and CHIP Dental Services Provider Manual

5.3.1

Caries Risk Assessment Tool

The purpose of the caries risk assessment is to determine the individual child's potential for development of severe early childhood caries (SECC). This decision is accomplished by identifying the oral health status of the child, the oral health status of the primary caregiver and other family members, and the potential sources of bacterial transmission. Additionally, the caries risk assessment directs dental anticipatory guidance content and serves as a basis to determine an appropriate recall periodicity schedule for the child. During the caries risk assessment, the First Dental Home dentist uses a Caries Risk Assessment Tool (see www.dshs.state.tx.us/dental/firstdentalhomemats.shtm) to help determine the individual child's risk of developing SECC. This assessment places the child in a low, medium, or high caries risk category, taking into account the dental health of the family, fluoride exposure, special health care needs, and previous access to dental services. Medicaid-enrolled children are inherently at a moderate-to-high risk for developing SECC. External factors--such as children in foster care and children with special health care needs--can also increase the likelihood of developing of SECC. Additionally, children who are 6 months through 35 months of age are experiencing changes to their mouths on a rapid basis. New primary teeth may be erupting until the child is 30 months of age and, as the teeth erupt, developmental irregularities in the enamel could place the child at increased risk for SECC. Therefore, children seen through the First Dental Home initiative should be placed on a three- to four-month recall schedule to facilitate the First Dental Home dentist's early identification of enamel defects, early cavitated lesions, application of topical fluoride varnish, and initiation of dental restorative services or referral to a pediatric dental specialist if indicated. At each and every First Dental Home visit, the First Dental Home dentist must perform an oral evaluation and caries risk assessment and document the results in the patient record.

5.3.2

Toothbrush Prophylaxis

The AAPD recommends a toothbrush prophylaxis for children under 3 years old as an effective way of cleaning the teeth. The use of a rubber cup and fine pumice removes the dental pellicle and fluoride-rich layer of the teeth. Unless calculus and stain are present, it is recommended that First Dental Home dentists perform a toothbrush prophylaxis. Using this procedure is also a way to educate the parent in oral hygiene practice. Parents often have difficulty brushing their child's teeth at home. You can show the parent positioning techniques at this time so they can accomplish effective brushing of their child's teeth at home.

Provider Hotline (Medicaid): 1-877-576-5899 www.deltadentalins.com/tx-medicaid Provider Hotline (CHIP): 1-866-561-5891 www.deltadentalins.com/tchip

Page 25

Texas Children's Medicaid and CHIP Dental Services Provider Manual

If you or the dental hygienist in your office cannot perform a prophylaxis because a child is unable to cooperate--and, therefore, you are unable to complete all of the components of the visit--you cannot bill for First Dental Home services. It is recommended that the child returns at a later date or refer the child to a pediatric dental specialist.

5.3.3

Application of Fluoride Varnish

Based on the AAPD recommendation and research, topical 5-percent sodium fluoride varnish is more effective than other fluorides, such as foams or gels, for children age 5 and younger as well as children with special health care needs. Therefore, a 5-percent topical sodium fluoride varnish must be applied at each First Dental Home visit if the child has erupted teeth. Fluoride varnish is available and most easily used in single unit doses. The pediatric dosage is available in 0.25 ml and 0.4 ml unit packaging that include the fluoride varnish and an applicator brush. Adult dosages are also available for occasions when you find, for example, that 0.4 ml is not enough for a child who has all 20 primary teeth. Fluoride varnish is available in several colors and flavors. The use of fluoride foam, gel, rinses, or fluoridated prophylaxis paste formulations in place of topical fluoride varnish application for First Dental Home visits is not allowed. There is no need to apply fluoride varnish:

When the child has no erupted teeth. With clinical findings, such as a tooth with pulp exposure (where application on the involved tooth would be contraindicated). If the parent objects. If fluoride varnish is not applied, a record of the reason must be entered on the First Dental Home documentation form or in the patient's record.

5.3.4

Dental Anticipatory Guidance

Dental anticipatory guidance provides the parent or guardian with information about oral health topics and why it is important for their child to have healthy primary teeth. It also provides the parent with information about daily activities and practices that can help promote good oral health for their child and themselves. The Dental Anticipatory Guidance forms are available as PDF files for printing in your office, or you can order the laminated versions in English and Spanish in quantities from the Texas Health Steps Resource Catalog. The anticipatory guidance forms are laminated, making them easy to disinfect between patients. The dental team uses these forms as a resource when they educate the parents

Provider Hotline (Medicaid): 1-877-576-5899 www.deltadentalins.com/tx-medicaid Provider Hotline (CHIP): 1-866-561-5891 www.deltadentalins.com/tchip

Page 26

Texas Children's Medicaid and CHIP Dental Services Provider Manual

during the First Dental Home visit. The forms are not intended to be given the parent to read. The dental anticipatory guidance provided during First Dental Home visits should be age-appropriate information and education for parents based on questionnaire responses, interviews with parents, the education level of the parent, findings during the oral evaluation, and the caries risk assessment. It includes a multi-topic overview of environmental influences on oral health and focuses on increasing the parents' understanding about the importance of good oral health.

5.3.5

Delegation of Components for First Dental Home Visits

The First Dental Home dentist must perform the oral evaluation and caries risk assessment at each First Dental Home visit. The First Dental Home dentist may delegate the remainder of the visit components to other dental team members such as the dental hygienist. The First Dental Home dentist may also give other dental team members First Dental Home visit responsibilities, such as completing the questionnaires. It is the responsibility of the First Dental Home dentist to periodically review the Dental Practice Act to determine which components of a First Dental Home visit he or she is allowed to delegate to dental team members.

5.3.6

Determining When Children Should Be Scheduled for Oral Health Visits

Children enrolled in Texas Medicaid are eligible to begin receiving preventive dental services, including First Dental Home visits, at 6 months of age. A Medicaid-enrolled child age 6 months through 35 months can begin First Dental Home visits in your dental practice at any time during this time span. The child can be a new patient to your practice or an existing patient who is under 3 years of age. Children who are at a moderate-to-high risk for developing SECC should be placed on a three-month-recall schedule. As your office staff schedules First Dental Home visits, note the following limitations:

There must be at least 60 days between First Dental Home visits. This period allows for some flexibility in scheduling. There is a maximum of 10 visits over the lifetime of the child. This requirement allows for a child to begin First Dental Home visits in the dental home at 6 months of age with a recall schedule of every three months until his or her 3rd birthday. After a child reaches his or her 3rd birthday, the dental periodicity schedule allows for periodic dental recall visits every six months.

Provider Hotline (Medicaid): 1-877-576-5899 www.deltadentalins.com/tx-medicaid

Provider Hotline (CHIP): 1-866-561-5891 www.deltadentalins.com/tchip

Page 27

Texas Children's Medicaid and CHIP Dental Services Provider Manual

Each Texas Health Steps medical checkup includes an inspection of the oral cavity by the performing provider. This evaluation involves lifting the child's lips, examining the soft tissues, and looking for the presence of white spots, brown spots, and plaque. The oral evaluation does not need to be charted per tooth, is not diagnostic, and does not replace a dental checkup. It is a thorough look at the child's mouth during the Texas Health Steps checkup with the goal of reinforcing the importance of oral health and the need to establish a dental home. It is required that providers make a dental referral beginning at 6 months of age and every six months thereafter. For established patients after the six-month medical checkup visit, the provider must confirm if a dental home has been established and is ongoing; if not, additional referrals must be made at subsequent medical checkup visits until the parent or caregiver confirms that a dental home has been established. The parent or caregiver may self-refer for a child's dental care at any age, including 12 months of age or younger.

5.3.7

Treatment Planning and Coordination

As with any patient, you may find a child has restorative needs that you are unable to treat. There will be times when, in the best interests of the child, you choose to refer the child to a pediatric dental specialist. When making a referral to a pediatric dental specialist, it is important to communicate with the pediatric dental office. The pediatric office needs to know:

When the most recent First Dental Home visit occurred in your office. What, if any, records including x-rays or intra-oral photographs are available. Whether or not the general or pediatric dentist will provide the dental home for the child after restorative treatment is rendered.

This decision requires communication, coordination, and correspondence between the referring general dentist and the pediatric dental specialist to whom you are referring the child. It is also important that you or someone on your staff informs the dental team of this decision. This coordination helps to ensure that the child continues to have regularly scheduled First Dental Home visits between the time of referral and completion of restorative needs.

5.3.8

Documentation of the First Dental Home Visits

Documentation of all First Dental Home visits is important. To assist you, the Department of Social and Health Services (DSHS) developed a First Dental Home documentation form (see the DSHS First Dental Home materials webpage). Keep the documentation form (or an equivalent) in the patient record for each First Dental Home

Provider Hotline (Medicaid): 1-877-576-5899 www.deltadentalins.com/tx-medicaid

Provider Hotline (CHIP): 1-866-561-5891 www.deltadentalins.com/tchip

Page 28

Texas Children's Medicaid and CHIP Dental Services Provider Manual

visit. If you have electronic records, scan the documentation form or add the components of this form into your records. It is important to record which parent or guardian accompanied the child to the First Dental Home appointment. For example, if the child's mother comes for the first visit and another caregiver comes for the second visit, this may change the result of the caries risk assessment as well as the anticipatory guidance. The difference depends on each person's level of understanding about the oral health needs of the child. You must document what takes place at each First Dental Home visit and also document whether a component is not completed during the visit. If the child does not yet have erupted teeth, toothbrush prophylaxis and fluoride varnish application are not feasible. You must record this information in the patient record. In these cases, it is expected that you will spend more time with the parent to educate him or her about what to expect in relation to tooth eruption, how to care for the mouth and gums, and additional anticipatory guidance including coping with teething. The following information is needed for the First Dental Home visit documentation form:

The date of the First Dental Home visit. The name of the primary caregiver present during First Dental Home visit. Each completed component of the First Dental Home visit. The Caries Risk Assessment results. If the parent refuses fluoride varnish, note that on the documentation form and/or in the patient record. Explain why any of the other components did not take place, if applicable.

5.3.9

Billing the First Dental Home Visits

For each and every First Dental Home visit, Current Dental Terminology (CDT) code D0145 is utilized. For First Dental Home purposes, the code D0145 is:

Considered an all-inclusive code for the required First Dental Home visit components (bundled code). Reimbursed at the approved rate for each and every complete First Dental Home visit.

Remember these important points about billing First Dental Home visits:

Only dentists who have completed the First Dental Home training may bill and be reimbursed using CDT code D0145.

Provider Hotline (CHIP): 1-866-561-5891 www.deltadentalins.com/tchip

Provider Hotline (Medicaid): 1-877-576-5899 www.deltadentalins.com/tx-medicaid

Page 29

Texas Children's Medicaid and CHIP Dental Services Provider Manual

The reimbursement for D0145 is an enhanced reimbursement as it is inclusive of dental procedures that Texas Medicaid has not traditionally reimbursed for routine preventive services (i.e., oral hygiene instruction and nutritional counseling). If you bill any other exam, prophylaxis, or fluoride codes with a First Dental Home visit, your claim will be denied. Radiographs, photographs, or any treatment performed on the same day as a First Dental Home visit may be billed in addition to D0145 on the same claim. If you are unable to complete the First Dental Home visit because of uncooperative behavior and referral is necessary, you can only bill for the dental services completed during the visit using the appropriate CDT code(s).

5.3.10 Incorporating the First Dental Home Visits into Your Practice

You are in a position to help reduce the incidence of severe early childhood caries for low-income children enrolled in Texas Medicaid. Other state health-care programs have also implemented First Dental Home. These programs are the Children with Special Health Care Needs Services Program and Title V/Maternal and Child Health contractors who offer dental services. Because dental decay is the most common infectious disease in childhood, the incidence of early childhood caries can be reduced significantly with early intervention. Consider setting aside one morning a week to provide preventive dental checkups for Medicaidenrolled children 6 months through 35 months of age. Talk with pediatricians and family medicine physicians within your community about your willingness and availability to provide dental checkups for this age group. You should find that seeing very young children can be a rewarding experience as you help to develop good dental patients who do not relate going to the dentist with a painful experience.

5.4

GENERAL ANESTHESIA FORM

You are responsible for determining whether a Medicaid member (age 20 or younger or in an ICF-MR) meets the minimum criteria necessary for receiving general anesthesia. Prior authorization is required for the use of general anesthesia while rendering treatment (to include the dental service fee, the anesthesia fee and facility fee), regardless of place of service. A medical check-up prior to a dental procedure requiring general anesthesia is considered an exception to periodicity requirements. A referral to the member's primary care physician is not required. Prior authorization is available for exceptions to periodicity. You must include all appropriate supporting documentation with the submittal.

Provider Hotline (Medicaid): 1-877-576-5899 www.deltadentalins.com/tx-medicaid

Provider Hotline (CHIP): 1-866-561-5891 www.deltadentalins.com/tchip

Page 30

Texas Children's Medicaid and CHIP Dental Services Provider Manual

For Medicaid members who require sedation or general anesthesia for dental therapy, you must include the following information in the member's dental record:

The medical evaluation justifying the need for anesthesia. Description of relevant behavior and reference scale. Other relevant narrative justifying the need for general anesthesia. The patient's demographics, including date of birth. Relevant dental and medical history. Dental radiographs, intraoral/perioral photography and/or diagram of dental pathology. Proposed dental plan of care. Consent signed by member's authorized representative giving permission for the proposed dental treatment and acknowledging that the reason for the use of intravenous sedation or general anesthesia for dental care has been explained. Completed Criteria for Dental Therapy Under General Anesthesia form (for a sample form, see Attachment H, Sample General Anesthesia Form). The authorized representative's dated signature on the Criteria for Dental Therapy Under General Anesthesia form attesting that he or she understands and agrees with the dentist's assessment of the child's behavior. Your attestation statement and signature, which may be put on the bottom of the form or included as a stand-alone form.

5.5

REFERRAL TO SPECIALISTS PROCESS

Main Dental Home providers must assess the dental needs of members for referral to specialty care providers and provide referrals as needed. Main Dental Home providers must coordinate members' care with specialty care providers after referral. In the event it is necessary to refer a member to a specialist for treatment, please be sure to refer the member to a contracting Texas Medicaid and CHIP Dental Services dentist. You may look in the Delta Dental Medicaid or CHIP Dental Services program provider directory to locate a Texas Medicaid and CHIP Dental Services specialist in your area. If you cannot locate a specialist in your area, you may call the Provider Hotline to facilitate a member referral to a specialist. Texas Medicaid and CHIP Dental Services members do not require authorization to see a dental specialist. Routine preventive care referrals must be provided within 30 days of request.

5.6

VERIFICATION OF MEMBER ELIGIBILITY AND/OR AUTHORIZATION FOR SERVICE

Provider Hotline (CHIP): 1-866-561-5891 www.deltadentalins.com/tchip

Provider Hotline (Medicaid): 1-877-576-5899 www.deltadentalins.com/tx-medicaid

Page 31

Texas Children's Medicaid and CHIP Dental Services Provider Manual

You are required to make a good faith effort to verify the Texas Medicaid and CHIP Dental Services member's identity. Each member will receive a member ID card that identifies him or her as a Texas Medicaid and CHIP Dental Services member, specifies pertinent information such as the member's identification number and effective date, and contains important information on contacting the Delta Dental Member Hotline. The member should present his or her ID card each time services are rendered. Please make a photocopy of the ID card for placement in the patient's dental record/chart. You should not accept any Texas Medicaid and CHIP Dental Services member ID card that has been altered in any way. If a patient presents a paper or plastic card that is photocopied or contains erasures, strikeouts, whiteouts, or type-overs or appears to have been altered in any other way, you should request that the patient obtain an unaltered Texas Medicaid and CHIP Dental Services member ID card prior to performing services. If you suspect a patient of abusing a Texas Medicaid and CHIP Dental Services member ID card, please call our Provider Hotline. Situations where abuse of the plan may be suspected include:

Use of another person's member ID card or presenting an altered card. Attempting to obtain excessive or inappropriate drugs.

5.7

FINANCIAL RESPONSIBILITY OR OPTIONAL TREATMENT FORM

The Texas Medicaid and CHIP Dental Services programs are designed to cover dental treatment using the most affordable method possible, while also delivering quality dental care to the patient. To ensure that members are aware of their financial obligations, you may not bill or collect from a member any charges in connection with a dental service--even though that service is not a covered dental service or is an optional treatment plan that is more expensive than is customarily provided--unless an executed Financial Responsibility or Optional Treatment Form has been obtained from the member or the member's legal representative prior to providing optional or noncovered benefits. For Texas Medicaid members, there is no yearly coverage limit. The member must pay for services that he or she receives:

Before the Delta Dental coverage starts. That are not covered by the plan or are optional. More often than is allowed by the plan. From a non-contracting dentist. That exceed the limits specified in the member's Evidence of Coverage section of the Texas Children's Medicaid Dental Services Member Handbook.

Provider Hotline (CHIP): 1-866-561-5891 www.deltadentalins.com/tchip

Provider Hotline (Medicaid): 1-877-576-5899 www.deltadentalins.com/tx-medicaid

Page 32

Texas Children's Medicaid and CHIP Dental Services Provider Manual

For Texas CHIP members, the yearly coverage limit is $564. The member must pay for services that he or she receives:

After reaching the yearly coverage limit (unless the service has been prior authorized by Delta Dental). Before the Delta Dental coverage starts. More often than is allowed by the plan. From a non-contracting dentist. That are not covered by the plan or are optional. That exceed the limits specified in the member's Evidence of Coverage section of the Texas CHIP Dental Services Member Handbook.

Note that preventive and therapeutic services are a Texas CHIP program benefit--even after the member's annual maximum has been exhausted--if you receive prior authorization from Delta Dental. If the member has exhausted the applicable annual maximum and the service has not been prior-authorized by Delta Dental, you may bill the member as follows:

At your customary fee or If you are contracted with Delta Dental Insurance Company (DDIC), at your approved DDIC fee schedule.

You agree to charge no more for optional treatment than the difference between your filed/approved Delta Dental fee for the optional treatment and the covered procedure. In addition, you and the member or his or her authorized representative must sign a document stating such financial agreement. While any financial responsibility or optional treatment form may be submitted, this provider manual includes a copy of Delta Dental's Private Pay Agreement form and TMHP's Private Pay Agreement form (see Attachment I, Sample Private Pay Agreement Forms). Delta Dental's form may be downloaded, in English or Spanish, from our websites. Texas Medicaid and CHIP dental services and the exclusions thereto are included in the manuals of criteria in Attachments A and E.

5.8

DENTAL RECORDS

You must keep and maintain, for a minimum period of five years from the date of service, all records that are necessary to fully disclose the type and extent of services provided to a Texas Medicaid and CHIP Dental Services member. A coherent dental record system with appropriate forms must be used. Throughout the patient evaluation, treatment, and follow-up care process, the patient's progress must be thoroughly

Provider Hotline (Medicaid): 1-877-576-5899 www.deltadentalins.com/tx-medicaid

Provider Hotline (CHIP): 1-866-561-5891 www.deltadentalins.com/tchip

Page 33

Texas Children's Medicaid and CHIP Dental Services Provider Manual

documented and charted in his or her dental records. The detailed record must reflect all aspects of patient care, including ancillary services. At a minimum, the dental record system must include the following:

Legible, understandable, and organized progress notes. Entries made in ink, signed, and dated by the treating provider. (Please note that computerized treatment records are acceptable.) Mounted radiographs (with date and patient identification clearly marked) that are retained with each patient's record. Recall system documentation for broken/missed appointments, indicating followup action taken and date of rescheduled appointment.

Progress notes should adequately describe and document:

Date(s) of service. Treatment/procedures rendered, including, as appropriate, materials, bases, varnishes, medicaments, impressions, temporaries, arch, quadrant, area, tooth number, and/or surface(s). Amount and type of anesthetic with vasoconstrictor used or if a local anesthetic was not used. Any prescription given the patient with the name of medication, quantity dispensed, and instructions for use. Any necessary post-operative or follow-up instructions, including precautions and limitations. Any specialty referral and documentation of results of the referral. If applicable, any untoward event or complication during treatment that could reasonably affect prognosis or precipitate significant post-operative pain, infection, dysfunction, or disability. For such cases, appropriate documentation includes the notification of the patient (or parent/guardian for a minor) and appropriate recommendations, which may include referring the patient, re-scheduling the patient for a post-op appointment, or modifying the treatment plan or schedule. Any provision of appropriate emergency care and scheduling of needed follow-up for definitive care. That treatment was provided in a timely manner consistent with the patient's individual dental needs and that appropriate treatment was rendered during each appointment. Broken or missed appointments and follow-up by the office to re-schedule. Next scheduled visit and recall schedule, if not documented elsewhere in the chart. That treatment plan(s) were completed or, if not, why treatment was not completed.

Provider Hotline (CHIP): 1-866-561-5891 www.deltadentalins.com/tchip

Provider Hotline (Medicaid): 1-877-576-5899 www.deltadentalins.com/tx-medicaid

Page 34

Texas Children's Medicaid and CHIP Dental Services Provider Manual

Identification of the treating dentist/hygienist by his or her signature or initials. If initials are used in a practice, each set must be unique within the office and there must be a legend available that accurately provides the full name of the treating dentist/hygienist. Summary of telephone communications with members or guardians, including attempts to schedule appointments, calls to cancel or reschedule appointments, and discussions relating to post-operative care and instructions.

The use of electronic medical records must conform to the requirements of HIPAA and other federal and state laws. Subject to compliance with applicable federal and state laws and professional standards regarding the confidentiality of dental records, you must assist Delta Dental in achieving continuity of care for members through the maximum sharing of members' dental records. Within 30 days of a written request by a member, you must be able to provide copies of the patient's dental records to any other dentist treating such member. Your obligations regarding dental records are further defined in other sections of this manual, as well as the Contracting Dentist Agreement.

5.9

ACCESS TO SECOND OPINION

Delta Dental may request a clinical evaluation by a regional dental consultant who conducts clinical examinations, prepares objective reports of dental conditions, and evaluates treatment that is proposed or has been provided for the purpose of providing Delta Dental with a second opinion. A second opinion may be required prior to treatment when necessary to make a benefit determination. Authorization for second opinions after treatment can be made if a member has a complaint regarding the quality of care provided. The member and the treating dentist will be notified when a second opinion is necessary and appropriate. When a second opinion is authorized through a regional dental consultant, all charges will be paid by Delta Dental. Members may otherwise obtain a second opinion about treatment from any contracting dentist they choose, and claims for the examination or consultation may be submitted for payment. Such claims will be paid in accordance with the benefits of the program.

5.10

JUSTIFICATION REGARDING OUT-OF-NETWORK PROVIDERS

Reimbursement for services provided to Texas Medicaid and CHIP Dental Services members outside of Texas is limited. Necessary out-of-state dental care, within the limits of the Texas Medicaid and CHIP Dental Services programs, is covered only under the following conditions:

When an emergency arises from accident, injury or illness.

Provider Hotline (CHIP): 1-866-561-5891 www.deltadentalins.com/tchip

Provider Hotline (Medicaid): 1-877-576-5899 www.deltadentalins.com/tx-medicaid

Page 35

Texas Children's Medicaid and CHIP Dental Services Provider Manual

Where the health of the individual would be endangered if care and services were postponed until it is feasible that the member returns to Texas. Where the health of the individual would be endangered if the member undertook travel to return to Texas. When it is customary practice in border communities for residents to use medical resources in adjacent areas outside the state. When an out-of-state treatment plan has been proposed by the member's attending physician and the proposed plan has been received, reviewed, and authorized by Delta Dental before the services are provided. (Delta Dental may authorize such outof-state treatment plans only when the proposed treatment is not available from resources and facilities within the state.)

Prior authorization is required for all out-of-state services, except for emergency services. No services are covered outside the United States, except for emergency services.

5.11

PLAN TERMINATION

Medicaid members are given the opportunity to request a termination or change enrollment from one dental plan to another at any time after their dental plan coverage begins and during annual re-enrollment. CHIP members are given the opportunity to request a termination or change enrollment from one dental plan to another within the first 90 days after their dental plan coverage begins. If a Medicaid or CHIP member requests a change from one dental plan to another, the change will be prospective and the effective date will be the first day of the month in which the member appears on the member eligibility file for the receiving dental plan.

5.12

FRAUD AND ABUSE

As a contracting dentist, you are subject to all state and federal laws and regulations relating to fraud, abuse, or waste in health care or dental care and the Medicaid and/or CHIP programs, as applicable. You must understand and agree to the following:

HHSC OIG and/or the Texas Medicaid Fraud Control Unit must be allowed to conduct private interviews of you and your employees, agents, contractors, and patients. Request for information from such entities must be complied with in the form and language requested. You and your employees, agents, and contractors must cooperate fully with such entities in making yourselves available in person for interviews, consultations, grand jury proceedings, pre-trial conferences, hearings, trials, and in any other process, including investigations at your own expense.

Provider Hotline (CHIP): 1-866-561-5891 www.deltadentalins.com/tchip

Provider Hotline (Medicaid): 1-877-576-5899 www.deltadentalins.com/tx-medicaid

Page 36

Texas Children's Medicaid and CHIP Dental Services Provider Manual

Compliance with these requirements will be at your own expense. You must cooperate and assist HHSC and any state or federal agency that is charged with the duty of identifying, investigating, sanctioning, or prosecuting suspected fraud, abuse, or waste. You must provide originals and/or copies of any and all information, allow access to premises, and provide records to the OIG, HHSC, the Centers for Medicare and Medicaid Services, the U.S. Department of Health and Human Services, Federal Bureau of Investigation, Texas Department of Insurance (TDI), the Texas Attorney General's Medicaid Fraud Control Unit, or other unit of state or federal government, upon request and free of charge. If you place required records in another legal entity's records, such as a hospital, you are responsible for obtaining a copy of these records for use by the above-named entities or their representatives. You must report any suspected fraud or abuse, including any suspected fraud and abuse committed by Delta Dental or a member, to the HHSC OIG.

If you receive annual Medicaid payments of at least $5 million, you must:

Establish written policies for all your employees, managers, officers, contractors, subcontractors, and agents. The policies must provide detailed information about the False Claims Act, administrative remedies for false claims and statements, any state laws about civil or criminal penalties for false claims, and whistleblower protections under such laws, as described in Section 1920(a)(68)(A). Include as part of such written policies detailed provisions regarding your policies and procedures for detecting and preventing fraud, waste, and abuse. Include in any employee handbook a specific discussion of the laws described in Section 1902(a)(68)(A), the rights of employees to be protected as whistleblowers, and your policies and procedures for detecting and preventing fraud, waste, and abuse.

5.13

PROFESSIONAL CONDUCT

While performing the services described in your Contracting Dentist Agreement, you agree to:

Comply with applicable state laws, rules, and regulations and HHSC's requests regarding personal and professional conduct generally applicable to the service locations and Otherwise conduct yourself in a businesslike and professional manner.

Provider Hotline (Medicaid): 1-877-576-5899 www.deltadentalins.com/tx-medicaid

Provider Hotline (CHIP): 1-866-561-5891 www.deltadentalins.com/tchip

Page 37

Texas Children's Medicaid and CHIP Dental Services Provider Manual

6.0

PROVIDER SUPPORT SERVICES

Information on provider services available through Delta Dental are discussed in the following subsections:

6.1, Provider Hotline. 6.2, Interactive Voice Response System. 6.3, Written Correspondence. 6.4, Provider Seminars. 6.5, Provider On-Site Visits. 6.6, Sample Forms.

6.1

PROVIDER HOTLINE

Below is a list of our toll-free Provider Hotline phone numbers, Delta Dental's regular business hours/days, our mailing address, and our Texas Medicaid and CHIP Dental Services program websites. Please note that there are separate phone numbers and websites for Medicaid and CHIP providers. Medicaid Provider Hotline (Medicaid): Website (Medicaid): Provider Hotline (CHIP): Website (CHIP): 1-877-576-5899 www.deltadentalins.com/tx-medicaid CHIP 1-866-561-5891 www.deltadentalins.com/tchip

Delta Dental Business Hours/Days Monday to Friday 8 a.m. to 7 p.m. Central Time (excluding State of Texas-approved holidays) Delta Dental's Interactive Voice Response System Hours/Days Monday to Friday 7 a.m. to 9 p.m. Central Time Saturday 10 a.m. to 2 p.m. Central Time When calling Delta Dental for information or inquiries, please have the following information available (as applicable):

Patient name. Patient ID number (the member ID number on the member's ID card issued by Delta Dental).

Provider Hotline (CHIP): 1-866-561-5891 www.deltadentalins.com/tchip

Provider Hotline (Medicaid): 1-877-576-5899 www.deltadentalins.com/tx-medicaid

Page 38

Texas Children's Medicaid and CHIP Dental Services Provider Manual

Patient's date of birth. Billing provider name. Delta Dental provider number. Billing provider address. Phone number, including area code. Type of treatment. Amount of claim or TAR. Date billed. Delta Dental's Document Control Number (DCN).

In compliance with HIPAA requirements, Delta Dental cannot release Texas Medicaid and CHIP Dental Services member or provider information unless the caller can verify specific identifying elements. If you are calling about provider information, you must give us the provider name, license number/provider number, and business address. If you are calling about member information, you must be able to verify the member name, member ID number and member date of birth. So that we may give you the best possible service and assistance, we ask that our Provider Hotline toll-free numbers be used only within your office. Do not give our Provider Hotline numbers to your patients. Your Texas Medicaid and CHIP Dental Services program patients should be advised to call our Member Hotline at 1-877-535-5896 (Medicaid members), 1-866-561-5892 (CHIP members) and 7-1-1 (hearing-impaired members). Either members or their authorized representatives may use these toll-free numbers. Authorized representatives must have the member's name, Texas Medicaid and CHIP Dental Services ID number, and date of birth in order to receive information from Delta Dental.

6.2

INTERACTIVE VOICE RESPONSE SYSTEM

When calling our Provider Hotline, you have the option of obtaining information through our easy-to-use interactive voice response (IVR) system. Information available through the IVR system includes Delta Dental's mailing address and member eligibility and financial information. On request, the IVR system can send information to your dental office via fax.

6.3

WRITTEN CORRESPONDENCE

Most dentist inquiries can be answered by calling our Provider Hotline. For your protection and confidentiality, Delta Dental recommends that certain inquiries and requests be made through written correspondence only. Types of inquiries and requests that should be sent to Delta Dental in writing include:

Provider Hotline (Medicaid): 1-877-576-5899 www.deltadentalins.com/tx-medicaid Provider Hotline (CHIP): 1-866-561-5891 www.deltadentalins.com/tchip

Page 39

Texas Children's Medicaid and CHIP Dental Services Provider Manual

A change or correction in your provider name/address or other information concerning your dental practice. A request for a detailed printout of your financial information, such as your year-todate earnings. A request to stop payment on or reissue a lost or stolen Texas Medicaid and CHIP Dental Services payment check.

All written inquiries and requests should include the:

Provider name. Delta Dental billing provider number. Date of request/inquiry. Signature of billing provider.

Your written correspondence should also include any other specific information that pertains to your inquiry or request. Please mail your correspondence to us at the address below. Delta Dental Mailing Address Texas Children's Medicaid and CHIP Dental Services State Government Programs PO Box 537014 Sacramento, CA 95853-7014 Upon receipt of your written correspondence, you will receive acknowledgment that your request has been received by Delta Dental and is being processed.

6.4

PROVIDER SEMINARS

Delta Dental conducts basic seminars statewide. Seminar attendees receive the most current information on all aspects of the Texas Medicaid and CHIP Dental Services programs. Basic seminars address the following topics:

General program purposes and goals. Program policies and procedures. An overview of Texas Health Steps services and contract requirements. Correct use of standard billing forms. Support services available to program providers.

An experienced, qualified instructor conducts each provider training seminar. There are no prerequisites for attendance at any seminar. Texas Medicaid and CHIP Dental Services provider training seminars are offered free of charge at convenient times and

Provider Hotline (Medicaid): 1-877-576-5899 www.deltadentalins.com/tx-medicaid Provider Hotline (CHIP): 1-866-561-5891 www.deltadentalins.com/tchip

Page 40

Texas Children's Medicaid and CHIP Dental Services Provider Manual

locations. Lists of available seminars are posted on Delta Dental's Texas Children's Medicaid Dental Services and Texas CHIP Dental Services websites. Seminars are also offered through web-based conferencing. To participate, you will need a PC, internet access, and a telephone.

6.5

PROVIDER ON-SITE VISITS

Dentists needing assistance with Texas Medicaid and CHIP Dental Services claims processing may request an office visit from a Delta Dental provider relations representative. We offer this service to help you and your office staff better understand our Texas Medicaid and CHIP Dental Services policies and procedures so you can more easily meet program requirements. To request an on-site visit by a provider representative, please call our Provider Hotline.

6.6

SAMPLE FORMS

As a Texas Medicaid and CHIP Dental Services provider, you will use some or all of the following forms:

Claim/treatment authorization form (claim/TAR). Notice of authorization form (NOA). Explanation of benefits form (EOB). Claim inquiry form (CIF). Claim inquiry response form (CIR). Provider billing intermediary form. General anesthesia form.

Sample forms, along with instructions for completing the forms, are included in this provider manual and on the CD you received from Delta Dental. The most current versions of the forms can be accessed from our provider website or by calling our Provider Hotline.

Provider Hotline (Medicaid): 1-877-576-5899 www.deltadentalins.com/tx-medicaid

Provider Hotline (CHIP): 1-866-561-5891 www.deltadentalins.com/tchip

Page 41

Texas Children's Medicaid and CHIP Dental Services Provider Manual

7.0

ROUTINE, THERAPEUTIC/DIAGNOSTIC, AND URGENT CARE DENTAL SERVICES

Definitions of routine, preventive, therapeutic, diagnostic, and urgent care/emergency services are present below, along with provider requirements for scheduling appointments with Texas Medicaid and CHIP Dental Services members.

7.1

DEFINITIONS

Routine Services --Services delivered to patients to promote good oral health and function by preventing or reducing the onset of oral diseases. Includes such services as initial and periodic examinations, appropriate radiographs, prophylaxis, and fluoride treatments and can include basic restorative or other non-urgent therapeutic services. Preventive Services -- The necessary procedures or techniques to assist in the prevention of dental disease or abnormalities. Therapeutic Services -- Beneficial therapy or treatment services provided to eliminate or control disease or other abnormal conditions. Can include multiple categories of treatment including basic restorations, laboratory processed crowns, surgical and non-surgical periodontal treatment, endodontic treatment, prosthodontic treatment, orthodontic treatment, implants, and oral and maxillofacial surgery treatment. Diagnostic Services -- The necessary procedures to assist the dentist in evaluating a patients existing oral conditions existing and assessing the dental treatment requirements. Assessment may include gathering of information through interview, observation, examination, and use of specific tests that allows a provider to diagnose existing conditions. Urgent Care/Emergency Services --Services required for alleviation of severe pain or immediate diagnosis and treatment of unforeseen medical conditions that, if not immediately diagnosed and treated, would lead to disability or death.

7.2

PERIODICITY

The dental provider may provide any medically necessary dental service such as emergency, diagnostic, preventive, therapeutic, and orthodontic services that is within the guidelines and limitations specified for each area as long as the client's eligibility is current for the month that dental services are being provided. This program has adopted the American Academy of Pediatric Dentistry's (AAPD) "Guideline on Periodicity of Examination, Preventive Dental Services, Anticipatory Guidance, and Oral Treatment for Children" to serve as a guide and reference for

Provider Hotline (Medicaid): 1-877-576-5899 www.deltadentalins.com/tx-medicaid

Provider Hotline (CHIP): 1-866-561-5891 www.deltadentalins.com/tchip

Page 42

Texas Children's Medicaid and CHIP Dental Services Provider Manual

dentists when scheduling and providing services to clients. These guidelines can be found on the AAPD website at http://www.aapd.org/. If a periodic dental checkup has been conducted within the last six months, the client still may be able to receive another periodic dental checkup in the same six-month period. Exceptions to the six-month periodicity schedule for dental checkup services may be approved for one of the following reasons:

Medically necessary service, based on risk factors and health needs (includes client's birth through 6 months of age). Required to meet federal or state exam requirements for Head Start, daycare, foster care, pre-adoption, or to provide a checkup prior to the next periodically-due checkup if the client will not be available when due. This includes clients whose parents are migrant or seasonal workers. Clients' choice to request a second opinion or change service providers (not applicable to referrals).

7.3

REQUIREMENTS FOR SCHEDULING APPOINTMENTS

You are required to ensure that covered dental services are available during regular business hours. Each dental office must provide dental services to Texas Medicaid and CHIP Dental Services members by appointment. Appointments are to be made during your normal business hours and within a reasonable time from the date of the member's request. In non-emergency cases, a reasonable waiting time for an appointment should not be more than three weeks. Follow-up care for established patients should be accommodated appropriately and according to professionally accepted standards. Appointments are to be made in compliance with the accessibility standards noted below.

Within 24 hours of request for urgent care, including urgent specialty care. Within 14 days of request for therapeutic and diagnostic care. Within 30 days of request for routine preventive care referrals.

Provider Hotline (Medicaid): 1-877-576-5899 www.deltadentalins.com/tx-medicaid

Provider Hotline (CHIP): 1-866-561-5891 www.deltadentalins.com/tchip

Page 43

Texas Children's Medicaid and CHIP Dental Services Provider Manual

8.0

COORDINATION OF NON-CAPITATED SERVICES

Delta Dental is responsible for referring members to non-capitated service providers, and provide coordination of care for non-capitated services. This coordination of care must include:

Identifying providers of medically necessary dental services. Helping the member access needed medically necessary dental services to the extent they are available to the member.

Delta Dental's coordination of care efforts for medically necessary dental services include establishing protocols for working with Medicaid and CHIP health plans for Medicaid and CHIP members, as well as protocols for reciprocal referral and communication of data and clinical information regarding the member. Delta Dental is responsible for informing providers that bills for all non-capitated services must be submitted to the CHIP or Medicaid health plans or HHSC's Claims Administrator, as appropriate.

8.1

SERVICES NOT COVERED BY DELTA DENTAL (MEDICAID)

The following Texas Medicaid programs and services are paid for by HHSC's claims administrator instead of Delta Dental. Medicaid members can get these services from Texas Medicaid providers. Summaries of the following programs and services are presented in the subsections below.

8.1.1, Early Childhood Intervention (ECI) Case Management/Service Coordination. 8.1.2, DSHS Case Management for Children and Pregnant Women. 8.1.3, Texas School Health and Related Services (SHARS). 8.1.4, HHSC's Medical Transportation. 8.1.5, Emergency Dental Services.

Either the member's medical plan or HHSC's claims administrator will pay for devices for craniofacial anomalies and for emergency dental services that a member gets in a hospital or ambulatory surgical center. This includes hospital, physician, and related medical services (e.g., anesthesia and drugs) for:

Treatment of dislocated jaw, traumatic damage to teeth, and removal of cysts. Treatment of oral abscess of tooth or gum origin. Treatment of craniofacial anomalies.

Provider Hotline (Medicaid): 1-877-576-5899 www.deltadentalins.com/tx-medicaid

Provider Hotline (CHIP): 1-866-561-5891 www.deltadentalins.com/tchip

Page 44

Texas Children's Medicaid and CHIP Dental Services Provider Manual

8.1.1

Early Childhood Intervention (ECI) Case Management/Service Coordination

Early Childhood Intervention (ECI) is a statewide program for families with children, birth to 3, with disabilities and developmental delays. ECI supports families to help their children reach their potential through developmental services. Services are provided by a variety of local agencies and organizations across Texas. ECI provides evaluations, at no cost to families, to determine eligibility and the need for services. Income is not a factor in determining eligibility. ECI determines eligibility for children birth to 36 months. Families with children enrolled in Medicaid or CHIP, or another public benefit program within the Family Cost Share program whose income is at or below 200 percent FPL, do not pay for any ECI services. Other families pay a cost share determined by a sliding fee scale based on family size and adjusted income after allowable deductions. The following services are provided at no cost regardless of income:

Evaluation/assessment. Development of the Individual Family Service Plan (IFSP). Case management. Translation and interpreter services, if needed. Services for children with auditory and visual impairments who are eligible for services from ECI and local school districts. Services for children in foster care or in conservatorship of the state.

As a Delta Dental network provider, you must cooperate and coordinate with local ECI programs to comply with federal and state requirement relating to IFSP development, review, and evaluation. Your responsibility is to understand and agree that any medically necessary health and behavioral health services contained in an IFSP must be provided to the member in the amount, duration, scope, and setting established in the IFSP. For more information regarding ECI services, please contact the Department of Assistive and Rehabilitative Services by phone (1-800-628-5115) or e-mail ([email protected]).

8.1.2

DSHS Case Management for Children and Pregnant Women

The Texas Department of State Health Services offer case management for:

Children age birth through 20 years with a health condition/health risk. High-risk pregnant women of all ages.

Provider Hotline (Medicaid): 1-877-576-5899 www.deltadentalins.com/tx-medicaid

Provider Hotline (CHIP): 1-866-561-5891 www.deltadentalins.com/tchip

Page 45

Texas Children's Medicaid and CHIP Dental Services Provider Manual

These case management services help children and high-risk pregnant women gain access to medical, social, educational and other health-related services. For more information, call Texas Health Steps toll-free at 1-877-847-8377.

8.1.3

Texas School Health and Related Services (SHARS)

Texas School Health and Related Services (SHARS) is a Medicaid financing program and is a joint program of the Texas Education Agency and HHSC. SHARS allows local school districts/shared services arrangements to obtain Medicaid reimbursement for certain health-related services provided to students in special education. Using existing state and local special education allocations as the state match, SHARS providers are reimbursed the federal share of the established reimbursement rate. School districts/shared services arrangements receive federal Medicaid money for SHARS services provided to students who meet all three of the following requirements. These students must:

Be Medicaid eligible. Meet eligibility requirements for special education described in the Individuals with Disabilities Education Act (IDEA). Have individual educational plans that prescribe the needed services.

Current SHARS services include assessment, audiology, counseling, school health services, medical services, occupational therapy, physical therapy, psychological services, speech therapy, special transportation, and personal care services. These services must be provided by qualified professionals under contract with or employed by the school district/shared service arrangement. Furthermore, the school district/shared service arrangement must be enrolled as Medicaid providers in order to bill Medicaid. For more information, call the Texas Education Agency at 1-512-463-9734.

8.1.4

HHSC's Medical Transportation

Medicaid members are eligible to receive medical transportation services through the Medicaid Transportation Program. This service includes rides for the member and his or her caretaker to and from the location where dental care will be provided. Ride options include bus, taxi, van, and air. In addition, the member and his or her caretaker can be reimbursed for gas, mileage, meals, and lodging when away from home. To arrange a ride, the member should call the Medicaid Transportation Program at 1877-633-8747 (toll-free) at least two days before the dental appointment. The program's hours of operation are 8 a.m. to 5 p.m. Monday through Friday. There are no limits for the services. Each trip must be scheduled and approved in advance.

Provider Hotline (Medicaid): 1-877-576-5899 www.deltadentalins.com/tx-medicaid

Provider Hotline (CHIP): 1-866-561-5891 www.deltadentalins.com/tchip

Page 46

Texas Children's Medicaid and CHIP Dental Services Provider Manual

8.1.5

Emergency Dental Services

Delta Dental is not responsible for emergency dental services provided to Medicaid members in a hospital or ambulatory surgical center setting. Either the member's medical plan or HHSC's claims administrator will pay for devices for craniofacial anomalies and for emergency dental services that a member gets in a hospital or ambulatory surgical center. This includes hospital, physician, and related medical services (e.g., anesthesia and drugs) for:

Treatment of dislocated jaw, traumatic damage to teeth, and removal of cysts. Treatment of oral abscess of tooth or gum origin. Treatment of craniofacial anomalies.

8.2

SERVICES NOT COVERED BY DELTA DENTAL/EMERGENCY DENTAL SERVICES (CHIP)

Some services are paid by CHIP medical plans instead of Delta Dental. These services include devices for craniofacial anomalies and emergency dental services that a member gets in a hospital or ambulatory surgical center. This includes hospital, physician, and related medical services (e.g., anesthesia and drugs) for:

Treatment of a dislocated jaw, traumatic damage to teeth, and removal of cysts. Treatment of oral abscess of tooth or gum origin. Treatment of craniofacial anomalies.

Provider Hotline (Medicaid): 1-877-576-5899 www.deltadentalins.com/tx-medicaid

Provider Hotline (CHIP): 1-866-561-5891 www.deltadentalins.com/tchip

Page 47

Texas Children's Medicaid and CHIP Dental Services Provider Manual

9.0

PROVIDER COMPLAINTS AND APPEALS

All provider complaint and appeal processes for the Texas Medicaid and CHIP Dental Services programs comply with the requirements of Delta Dental's contract with HHSC. HHSC reserves the right and retains the authority to make reasonable inquiries and to conduct investigations into provider complaints and appeals. Texas Medicaid and CHIP Dental Services providers have the right to file complaints directly with Delta Dental. A Medicaid provider may also file a complaint directly with HHSC. A CHIP may also file a complaint directly with TDI. Contact information for Delta Dental, HHSC, and TDI is provided in the table below. Delta Dental Texas Children's Medicaid and CHIP Dental Services State Government Programs PO Box 537014 Sacramento, CA 95853-7014 Provider Hotline (Medicaid): 1-877-576-5899 Provider Hotline (CHIP): 1-866-561-5891 HHSC Texas Health and Human Services Commission Provider Complaints Health Plan Operations, H-320 PO Box 85200 Austin, TX 78708 1-800-252-8263 E-mail: [email protected] TDI Texas Department of Insurance PO Box 149091 Austin, TX 78714-9091 Phone: 1-800-252-3439 (toll-free)

9.1

MEDICAID PROVIDER COMPLAINTS

All Medicaid provider complaints comply with the requirements of 42 C.F.R §438.414. Medicaid providers may file complaints with Delta Dental and/or HHSC, as summarized below.

Provider Hotline (Medicaid): 1-877-576-5899 www.deltadentalins.com/tx-medicaid

Provider Hotline (CHIP): 1-866-561-5891 www.deltadentalins.com/tchip

Page 48

Texas Children's Medicaid and CHIP Dental Services Provider Manual

9.1.1

Medicaid Provider Complaints to Delta Dental

If you call our Provider Hotline with a complaint (as defined in Section 10.1, Medicaid Member Complaints), we will make every effort to resolve the problem during the initial call. A complaint does not include a misunderstanding or problem of misinformation that can be promptly resolved by supplying correct information to your satisfaction. You may file a complaint by calling our Provider Hotline or completing a written complaint form. Those forms are available on request through the Provider Hotline and on our provider website. After we receive your written complaint, we will acknowledge it within five business days of receipt. Within 30 days of receipt, we will notify you of the resolution. Emergency complaints (involving serious or imminent threat to a patient's health) will be assigned the highest priority to be expedited and resolved within one business day. The resolution letter will include the following information:

The resolution of the complaint, including the specific dental and contractual reasons for our decision. The specialization of any dentist or other provider consulted. A complete description of the process for appeal, including the deadlines for the appeal process and the deadlines for the final decision on the appeal.

If you wish to dispute, appeal, or request reconsideration of payment of a claim that has been denied, adjusted, or contested by Delta Dental, you may submit a CIF (see Section 14.5.5, Claim Inquiry Form). If you are not satisfied with Delta Dental's decision regarding denial or modification of services, you may file an appeal (see Section 9.3, Provider Appeals to Delta Dental). If, after completing the complaint process, you believe that you did not receive full due process from Delta Dental, you may file a complaint or inquiry with HHSC. Their contact information is presented below. HHSC Contact Information Texas Health and Human Services Commission Provider Complaints Health Plan Operations, H-320 PO Box 85200 Austin, TX 78708 1-800-252-8263 E-mail: [email protected]

Provider Hotline (Medicaid): 1-877-576-5899 www.deltadentalins.com/tx-medicaid

Provider Hotline (CHIP): 1-866-561-5891 www.deltadentalins.com/tchip

Page 49

Texas Children's Medicaid and CHIP Dental Services Provider Manual

9.2

CHIP PROVIDER COMPLAINTS

You have the right to submit a complaint or appeal to Delta Dental and/or to the Texas Department of Insurance. An overview of the CHIP provider complaint/appeal process is presented below. Note that a complaint does not include a misunderstanding or problem of misinformation that can be promptly resolved by supplying correct information to your satisfaction. All CHIP provider complaints comply with the requirements of Chapter 843, Subchapter G of the Texas Insurance Code.

9.2.1

CHIP Provider Complaints to Delta Dental

You may file an oral or written complaint with Delta Dental if you wish to:

Dispute, appeal, or request reconsideration of payment of a claim(s) that has been denied, adjusted, or contested by Delta Dental. (In this situation, you may choose to submit a CIF rather than file a complaint; for information on submitting a CIF, see Subsection 14.5.5, How to Submit a Claim Inquiry Form). Dispute a request for reimbursement of an overpayment. Dispute any Delta Dental policy or procedure.

To file a complaint, call our Provider Hotline or download a CHIP provider complaint form from our Texas CHIP Dental Services website (www.deltadentalins.com/tchip). If you call our Provider Hotline, the customer service representative will make every effort to resolve the problem during your initial phone call. Delta Dental will acknowledge your written complaint within five working days of receipt. Within 30 days of receipt, we will notify you by letter of the complaint's resolution. The letter will:

Explain the resolution of the complaint. State the specific dental and contractual reasons for the resolution. State the specialization of any dentist or other provider consulted. Include a complete description of the process and required time frames for an appeal.

Emergency complaints (involving serious and imminent threat to patient health) will be assigned highest priority and will be expedited and resolved within one day.

Provider Hotline (Medicaid): 1-877-576-5899 www.deltadentalins.com/tx-medicaid

Provider Hotline (CHIP): 1-866-561-5891 www.deltadentalins.com/tchip

Page 50

Texas Children's Medicaid and CHIP Dental Services Provider Manual

9.2.2

CHIP Provider Complaints to Texas Department of Insurance

Any complainant who has attempted to resolve a complaint through the complaint process described above may file a complaint with the TDI. Their contact information is provided below. TDI Contact Information Texas Department of Insurance PO Box 149091 Austin, TX 78714-9091 Phone: 1-800-252-3439 (toll-free) Delta Dental will not engage in any retaliatory action (including termination or refusal to renew a Contracting Dentist Agreement) against a provider for filing a complaint or appealing a decision.

9.3

PROVIDER APPEALS TO DELTA DENTAL

In the event a provider is not satisfied with Delta Dental's decision regarding an Action (as defined in Section 10.1, Medicaid Member Complaints) or Delta Dental's resolution of a complaint (other than issues relating to a member's annual maximum or eligibility information provided to Delta Dental by Texas HHSC or its designee), the provider has the right to appeal the decision to an appeal panel. Within five business days after receipt of a request for an appeal, we will send the provider a letter acknowledging the date of receipt of the request and include a statement of the provider's rights to:

Submit a written appeal to an appeal panel. Appear before an appeal panel in person (or through a representative) in the area where the provider is located or at an agreed-upon location. To present alternative expert testimony. To present oral or written information. To question those responsible for the prior resolution.

The appeal panel will be composed of member representatives, contracting dentist representatives, and Delta Dental representatives in equal numbers. Contracting dentists cannot review a case in which they rendered care or a case they reviewed during our complaint or appeal process. The panel will include a contracting specialty care dentist if the quality of specialty care is at issue. Delta Dental employees who have been involved in the complaint/appeal process cannot serve as Delta Dental representatives on the appeal panel.

Provider Hotline (Medicaid): 1-877-576-5899 www.deltadentalins.com/tx-medicaid

Provider Hotline (CHIP): 1-866-561-5891 www.deltadentalins.com/tchip

Page 51

Texas Children's Medicaid and CHIP Dental Services Provider Manual

No later than five business days before the scheduled meeting of the appeal panel, unless the provider agrees otherwise, we shall provide to the provider or designated representative:

Any documentation to be presented to the panel by Delta Dental. The specialization of any providers consulted during the investigation of the appeal. The name and affiliation of each Delta Dental representative on the panel.

We will send the provider a written resolution of the appeal within 30 calendar days after receipt of an appeal. Investigation and resolution of appeals involving ongoing emergency dental services will be concluded in accordance with the dental immediacy of the case, but no later than 24 hours after receipt of request for appeal. Notice of our final decision will include a statement of the specific clinical and/or contract provision(s) on which the decision was based. It will also include contact information for HHSC (for Medicaid providers) and the Texas Department of Insurance (for CHIP) providers in the event that the provider believes that he or she did not receive full due process from Delta Dental and/or would like to file a complaint or inquiry.

Provider Hotline (Medicaid): 1-877-576-5899 www.deltadentalins.com/tx-medicaid

Provider Hotline (CHIP): 1-866-561-5891 www.deltadentalins.com/tchip

Page 52

Texas Children's Medicaid and CHIP Dental Services Provider Manual

10.0

MEMBER COMPLAINTS AND APPEALS

All member complaint and appeal processes for the Texas Medicaid and CHIP Dental Services programs comply with the requirements of Delta Dental's contract with HHSC. HHSC reserves the right and retains the authority to make reasonable inquiries and to conduct investigations into member complaints and appeals. A complaint can be submitted to Delta Dental in person, in writing, or verbally (see the contact information in the table below). The member or his or her authorized representatives may file a complaint. A provider may serve as an authorized representative. A Medicaid member also has the right to file a complaint directly with HHSC. A CHIP member also has the right to file a complaint directly with TDI. Contact information for Delta Dental, HHSC, and TDI is provided in the table below. Delta Dental Texas Children's Medicaid and CHIP Dental Services State Government Programs PO Box 537014 Sacramento, CA 95853-7014 Member Hotline (Medicaid): 1-877-535-5896 Member Hotline (CHIP): 1-866-561-5892 HHSC Texas Health and Human Services Commission Health Plan Operations ­ H-320 PO Box 85200 Austin, TX 78708-5200 Attn: Resolution Services 1-800-252-8263 TDI Texas Department of Insurance PO Box 149104 Austin, TX 78714-9104 1-800-252-3439 The subsections below provide overviews of the complaint, appeal, and expedited appeal process for Texas Medicaid and CHIP Dental Services members, the state fair hearing process for Medicaid members, and the independent review organization (IRO) review process for CHIP members. As appropriate, the subsections below include excerpts from the Medicaid and CHIP member handbooks relating to these processes.

Provider Hotline (Medicaid): 1-877-576-5899 www.deltadentalins.com/tx-medicaid

Provider Hotline (CHIP): 1-866-561-5891 www.deltadentalins.com/tchip

Page 53

Texas Children's Medicaid and CHIP Dental Services Provider Manual

10.1

MEDICAID MEMBER COMPLAINTS

"Complaint" means an expression of dissatisfaction expressed by a complainant, orally or in writing to Delta Dental, about any matter related to Delta Dental other than an Action. An "Action" may be any of the following:

The denial or limited authorization of a requested Medicaid service, including the type and level of service. The reduction, suspension, or termination of a previously authorized service. The denial in whole or in part of payment for service. The failure to provide services in a timely manner. The failure of Delta Dental to act within the time frames set forth in our contract with HHSC and 42 C.F.R. §438.408(b).

As provided by 42 C.F.R. §438.400, possible subjects for complaints include, but are not limited to, the quality of care of services provided and aspects of interpersonal relationships such as rudeness of a provider or employee or failure to respect the Medicaid member's rights. Member Handbook Information on Medicaid Member Complaints The Texas Children's Medicaid Dental Services Member Handbook contains the following information on member complaints. What is a complaint? A complaint means you are not happy with:

A service or any part of our operation. The way a service was provided. The outcome of a review or appeal, not due to medical need.

You do not have a complaint if:

You tell us you were given the wrong information and we then give you the correct information. We clear up a misunderstanding to your satisfaction.

What should I do if I have a complaint? Who do I call? We want to help. If you have a complaint, please call us at 1-877-535-5896 (toll-free) to tell us about your problem. Can someone from Delta Dental help me file a complaint?

Provider Hotline (Medicaid): 1-877-576-5899 www.deltadentalins.com/tx-medicaid Provider Hotline (CHIP): 1-866-561-5891 www.deltadentalins.com/tchip

Page 54

Texas Children's Medicaid and CHIP Dental Services Provider Manual

A Delta Dental Member Services Advocate can help you file a complaint. Most of the time, we can help you right away or within a few days at the most. What do I need to do to file a complaint and how long will the process take? Here is what will happen:

You send us a written complaint. We will send you a letter within 5 business days. Our letter will say that we received your written complaint. We will review the details of your complaint. We will send you an answer within 30 calendar days from the day we receive your written complaint. If you have an emergency complaint, we will respond within one day. (An emergency complaint involves a serious threat to health.)

Our response to your complaint will be in a letter. That letter will state:

Our decision about your complaint. The reasons for our decision. The specialty area of any dentist we asked to help us with your complaint. Information about filing an appeal.

If I don't like what happens with my complaint, who else can I call? You can call HHSC at 1-800-252-8263 (toll-free). How can I file a complaint with HHSC after I have gone through the Delta Dental complaint process? If you still have a complaint after you've gone through the Delta Dental complaint process, call HHSC at 1-800-252-8263 (toll-free). If you want to make your complaint in writing, please send it to the following address: Texas Health and Human Services Commission Health Plan Operations ­ H-320 PO Box 85200 Austin, TX 78708-5200 Attn: Resolution Services

Provider Hotline (Medicaid): 1-877-576-5899 www.deltadentalins.com/tx-medicaid

Provider Hotline (CHIP): 1-866-561-5891 www.deltadentalins.com/tchip

Page 55

Texas Children's Medicaid and CHIP Dental Services Provider Manual

10.2

MEDICAID MEMBER APPEALS

A Medicaid member has the right to file an appeal with Delta Dental if he or she does not agree with Delta Dental's decision about:

A benefit or level of service. A denial in whole or in part of payment for services. Failure to provide services in a timely manner. Reduction, suspension, or termination of a previously authorized service.

A Medicaid member does not have the right to an appeal if the services requested are not a covered benefit. He or she has the option to request a state fair hearing at any time during or after Delta Dental's appeal process. To ensure continuity of continuity of current authorized services, the member must file an appeal on or before the later of 10 days following Delta Dental's mailing of the notice of the action or the intended effective date of the action. The member may be required to pay the cost of the services furnished while the appeal is pending and if the final decision is adverse to the member. The member or his or her authorized representative must file an appeal with Delta Dental within 30 days from the date of the notice of the action. The member or anyone of his or her choosing (such as the provider) may represent the member during the appeal process. The appeal may be submitted orally or in writing. The time frame to resolve a standard appeal can be extended up to 14 calendar days in either of the following situations:

If the member or authorized representative requests an extension. If Delta Dental shows that there is a need for additional information and how the delay is in the member's interest.

Within 30 calendar days after receipt of an appeal, we will send the member a letter notifying him or her of the resolution. Investigation and resolution of appeals involving ongoing emergency dental services will be concluded in accordance with the dental immediacy of the case, but no later than 24 hours after receipt of the appeal request. A Medicaid member can get help filing an appeal by contacting our Member Hotline at 1-877-535-5896. A customer service representative or a member advocate will help the member initiate the appeal process. The member advocate will work with the member through the appeal's resolution.

Provider Hotline (Medicaid): 1-877-576-5899 www.deltadentalins.com/tx-medicaid

Provider Hotline (CHIP): 1-866-561-5891 www.deltadentalins.com/tchip

Page 56

Texas Children's Medicaid and CHIP Dental Services Provider Manual

Member Handbook Information on Medicaid Member Appeals The Texas Children's Medicaid Dental Services Member Handbook contains the following information on member appeals. What can I do if Delta Dental denies or limits a service for my child that the dentist has asked for? If you are not happy with Delta Dental's decision, you can file an appeal with Delta Dental. You can also file a request for a fair hearing with HHSC at any time. Here is HHSC's contact information: Texas Health and Human Services Commission Health Plan Operations ­ H-320 PO Box 85200 Austin, TX 78708-5200 Attn: Resolution Services Toll-Free: 1-800-252-8263 How will I find out if services for my child are denied? We will send your dentist a notice and your dentist should contact you. We will also send you a notice. What are the time frames for the appeal process? We will process a non-emergency appeal within 30 calendar days from the day we receive it. We can extend the time frame up to 14 calendar days if you ask for more time. We can also extend the time if we show that:

We need more information. Extending the time frame is in your best interest.

If we extend the time frame, we will send you a written notice with the reason for the delay. When can I ask for an appeal? You have the right to ask for an appeal if you are not happy with Delta Dental's decision about denying or modifying your services. You can appeal the denial of payment for services in whole or in part. However, you cannot appeal a decision related to member eligibility.

Provider Hotline (Medicaid): 1-877-576-5899 www.deltadentalins.com/tx-medicaid

Provider Hotline (CHIP): 1-866-561-5891 www.deltadentalins.com/tchip

Page 57

Texas Children's Medicaid and CHIP Dental Services Provider Manual

If you want to continue to receive authorized services, you must file the appeal on or before the later of 10 days:

After we mail you a notice or After the intended effective date of the proposed action.

Can I just ask for an appeal or does it have to be in writing? You can ask for an appeal by calling us or writing to us. If you call us, we will ask you to confirm your appeal request in writing. We will send you a one-page appeal form. The form must be signed by:

The person who has the Medicaid coverage or That person's representative.

For every non-expedited appeal, you must complete, sign, and return this form. If you are asking for an expedited appeal, you do not need to use the form. You can just call us. Can someone from Delta Dental help me file an appeal? Yes. Please call us at 1-877-535-5896 (toll-free). Tell us that you want to file an appeal. You can also get information and appeal forms on our website at www.deltadentalins.com/tx-medicaid. What is the appeal process? After we get your completed appeal form, we will send you a letter within 5 business days. The letter will explain your right to:

Submit a written appeal to an appeal panel. Appear before an appeal panel in person. Present information to help your case. Ask questions about the decision we made to modify or deny services.

At least 5 business days before the appeal panel meets, we will send you:

Information about who is on the appeal panel. Information about any dentists who helped us review your case. Copies of the information about your case that the appeal panel will review.

We may tell you the outcome of your appeal right away. We will always send you a written letter of the decision within 3 business days. The letter will include:

Provider Hotline (Medicaid): 1-877-576-5899 www.deltadentalins.com/tx-medicaid Provider Hotline (CHIP): 1-866-561-5891 www.deltadentalins.com/tchip

Page 58

Texas Children's Medicaid and CHIP Dental Services Provider Manual

Our decision about your appeal. The reasons for our decision. Contact information for HHSC.

If your appeal involves an emergency:

We will make a decision within one business day after receiving your request for appeal. The appeal will be reviewed by a dentist instead of the appeal panel (at your request).

What else can I do if I'm still not happy? We will first ask you to go through the appeal process. At any time during or after the appeal process, you can ask for a state fair hearing. To request a fair hearing, write to us at: Texas Children's Medicaid Dental Services Delta Dental Insurance Company PO Box 537014 Sacramento, CA 95853-7014

10.3

MEDICAID MEMBER EXPEDITED APPEALS

The time frame for resolution of a member's expedited appeal will be based on the member's medical emergency condition, procedure, or treatment. Resolution will not take more than one business day from the date we receive all the information necessary to review the member's appeal. Delta Dental will let the member know the final decision of the expedited appeal in writing within three business days. If a member or authorized representative asks for an expedited appeal that does not involve an emergency, ongoing hospitalization, or services that are already being provided, the member will be told that the appeal cannot be rushed. Delta Dental will continue to work on the appeal within the standard time frame and respond to the member within 30 days after the appeal was received. A Medicaid member can get help filing an expedited appeal by contacting our Member Hotline at 1-877-535-5896. A customer service representative or a member advocate will help the member initiate the expedited appeal process. The member advocate will work with the member through the expedited appeal's resolution.

Provider Hotline (Medicaid): 1-877-576-5899 www.deltadentalins.com/tx-medicaid

Provider Hotline (CHIP): 1-866-561-5891 www.deltadentalins.com/tchip

Page 59

Texas Children's Medicaid and CHIP Dental Services Provider Manual

Medicaid Member Handbook Information on Member Expedited Appeals The Texas Children's Medicaid Dental Services Member Handbook contains the following information on member expedited appeals. What is an expedited appeal? Ask for an expedited appeal when you don't have time for a standard appeal--when your child's life or health is in danger. When you ask for an expedited appeal, Delta Dental has to make a decision quickly based on the condition of your child's health. How do I ask for an expedited appeal? Call us at 1-877-535-5896 (toll-free) or write to us at: Texas Children's Medicaid Dental Services Delta Dental Insurance Company PO Box 537014 Sacramento, CA 95853-7014 Does my request for an expedited appeal have to be in writing? No. We will accept your request by phone or in writing. How long does an expedited appeal take? Within 3 calendar days after we receive your expedited appeal, we will:

Review it. Make a decision on it. Send you written notice of our decision.

What happens if Delta Dental says it won't do an expedited appeal? We will call you and tell you why we denied your request. We will also send you a letter with that information within two business days. Who can help me file an expedited appeal? We can help you file an expedited appeal. Call us at 1-877-535-5896 (toll-free).

10.4

STATE FAIR HEARINGS (MEDICAID)

Texas Children's Medicaid Dental Services program members have the right to ask for a fair hearing.

Provider Hotline (Medicaid): 1-877-576-5899 www.deltadentalins.com/tx-medicaid Provider Hotline (CHIP): 1-866-561-5891 www.deltadentalins.com/tchip

Page 60

Texas Children's Medicaid and CHIP Dental Services Provider Manual

Medicaid Member Handbook Information on State Fair Hearings Delta Dental's Texas Children's Medicaid Dental Services Member Handbook contains the following information on the state fair hearing process. Can I ask for a State Fair Hearing? If you, as a member of Delta Dental's Texas Children's Medicaid Dental Services dental plan, disagree with Delta Dental's decision, you have the right to ask for a fair hearing. You may name someone to represent you by writing a letter to Delta Dental and telling them the name of the person you want representing you. A provider may be your representative. What is the time frame for asking for a fair hearing? You or your representative must ask for the fair hearing within 90 days of the date on Delta Dental's letter that tells of the decision you are challenging. If you do not ask for the fair hearing within 90 days, you may lose your right to a fair hearing. How do I start the process? To ask for a fair hearing, you or your representative should either send a letter to Delta Dental at the address listed below or call us toll-free at 1-877-535-5896. Texas Children's Medicaid Dental Services Delta Dental Insurance Company PO Box 537014 Sacramento, CA 95853-7014 If you ask for a fair hearing within 10 days from the time you get the hearing notice from Delta Dental, you have the right to keep getting any service that Delta Dental denied; at least until the final hearing decision is made. If you do not request a fair hearing within 10 days from the time you get the hearing notice, the service that Delta Dental denied will be stopped. What happens next? If you ask for a fair hearing, you will get a packet of information letting you know the date, time, and location of the hearing. Most fair hearings are held by telephone. At that time, you or your representative can tell why you need the service that Delta Dental denied. HHSC will give you a final decision within 90 days from the date you asked for the hearing.

Provider Hotline (Medicaid): 1-877-576-5899 www.deltadentalins.com/tx-medicaid

Provider Hotline (CHIP): 1-866-561-5891 www.deltadentalins.com/tchip

Page 61

Texas Children's Medicaid and CHIP Dental Services Provider Manual

10.5

CHIP MEMBER COMPLAINTS

A Texas CHIP Dental Services member with a complaint concerning benefits, quality of care, modification or denial of a claim or TAR, or some other aspect of services must direct the complaint according to the procedures described in their member handbook. A summary of these procedures is presented here. Member Hotline customer service representatives will assist members in filling, understanding, and using the complaint or appeal process. Member advocates are available to provide these services for Medicaid members. A "complaint" means any dissatisfaction, expressed by a complainant, orally or in writing to Delta Dental, with any aspect of Delta Dental's operation, including but not limited to any of the following:

Dissatisfaction with plan administration, procedures related to review, or appeal of an adverse determination, as defined in Texas Insurance Code, Chapter 843, Subchapter G. The denial, reduction, or termination of a service for reasons not related to medical necessity. The way a service is provided.

The term does not include any misinformation that is resolved promptly by supplying the appropriate information or clearing up the misunderstanding to the satisfaction of the CHIP member. CHIP Member Handbook Information on Member Complaints The Texas CHIP Dental Member Handbook includes the following information on member complaints. What is a complaint? A complaint means you are not happy with:

A service or any part of our operation. The way a service was provided. The outcome of a review or appeal, not due to medical need or You tell us you were given the wrong information and we then give you the correct information. We clear up a misunderstanding to your satisfaction.

Provider Hotline (Medicaid): 1-877-576-5899 www.deltadentalins.com/tx-medicaid

Provider Hotline (CHIP): 1-866-561-5891 www.deltadentalins.com/tchip

Page 62

Texas Children's Medicaid and CHIP Dental Services Provider Manual

What should I do if I have a complaint? Who do I call? We want to help. If you have a complaint, please call us at 1-866-561-5892 (toll-free) to tell us about your problem. Can someone from Delta Dental help me file a complaint? A Delta Dental customer service representative can help you file a complaint. Most of the time, we can help you right away or within a few days at the most. What do I need to do to file a complaint and how long will the process take? Here is what will happen:

You send us a written complaint. We will send you a letter within 5 business days. Our letter will say that we received your written complaint. We will review the details of your complaint. We will send you an answer within 30 calendar days from the day we receive your written complaint. If you have an emergency complaint, we will respond within one day. (An emergency complaint involves a serious threat to health.)

Our response to your complaint will be in a letter. That letter will state:

Our decision about your complaint. The reasons for our decision. The specialty area of any dentist we asked to help us with your complaint. Information about filing an appeal.

If I don't like what happens with my complaint, who else can I call? You can call the Texas Department of Insurance at 1-800-252-3439 (toll-free). How can I file a complaint with the Texas Department of Insurance after I have gone through the Delta Dental complaint process? If you still have a complaint after you've gone through the Delta Dental complaint process, call the Texas Department of Insurance at 1-800-252-3439 (toll-free). If you want to make your complaint in writing, please send it to the following address:

Texas Department of Insurance

PO Box 149104 Austin, TX 78714-9104

Provider Hotline (Medicaid): 1-877-576-5899 www.deltadentalins.com/tx-medicaid Provider Hotline (CHIP): 1-866-561-5891 www.deltadentalins.com/tchip

Page 63

Texas Children's Medicaid and CHIP Dental Services Provider Manual

10.6

CHIP MEMBER APPEALS

When action at the dentist level fails to resolve a complaint, the member or the dentist should write or telephone Delta Dental, identify themselves and the dentist involved and specifically describe the disputed services action or inaction. CHIP Member Handbook Information on Member Appeals The Texas CHIP Dental Services Member Handbook contains the following information on member appeals. What can I do if Delta Dental denies or limits a service for my child that the dentist has asked for? If you filed a complaint and are not happy with the response, you can file an appeal with Delta Dental. You can also file a complaint with the Texas Department of Insurance at any time. How will I find out if services for my child are denied? We will send your dentist a notice and your dentist should contact you. We will also send you a notice. What are the time frames for the appeal process? If you have an emergency appeal, we will respond within 1 business day from the day we receive your request for appeal. We will process a non-emergency appeal within 30 calendar days from the day we receive it. When can I ask for an appeal? You have the right to ask for an appeal if you are not happy with the outcome of your complaint. However, you cannot appeal a decision related to:

The yearly coverage limit. Member eligibility.

Can I just ask for an appeal or does it have to be in writing? You can ask for an appeal in writing, or you can call and ask Delta Dental for an appeal. We will send you a one-page appeal form that you, your child's dentist, or someone else representing you can fill out and return to us. Can someone from Delta Dental help me file an appeal?

Provider Hotline (Medicaid): 1-877-576-5899 www.deltadentalins.com/tx-medicaid

Provider Hotline (CHIP): 1-866-561-5891 www.deltadentalins.com/tchip

Page 64

Texas Children's Medicaid and CHIP Dental Services Provider Manual

Yes. Please call us at 1-866-561-5892 (toll-free). Tell us that you want to file an appeal. You can also get information and appeal forms on our website at: www.deltadentalins.com/tchip. What is the appeal process? After we get your completed appeal form, we will send you a letter within 5 business days. The letter will explain your right to:

Submit a written appeal to an appeal panel. Appear before an appeal panel in person. Present information to help your case. Ask questions about the decision we made regarding your complaint.

At least 5 business days before the appeal panel meets, we will send you:

Information about who is on the appeal panel. Information about any dentists who helped us review your case. Copies of the information about your case that the appeal panel will review.

We may tell you the outcome of your appeal right away. We will always send you a written letter of the decision within 3 business days. The letter will include:

Our decision about your appeal. The reasons for our decision. Contact information for the Texas Department of Insurance.

If your appeal involves an emergency:

We will make a decision within one business day after receiving your request for appeal. The appeal will be reviewed by a dentist instead of the appeal panel (at your request).

What else can I do if I'm still not happy? If you are not happy with the outcome of the appeal, you can ask an Independent Review Organization to review your case. You can ask for the independent review any time during or after Delta Dental's appeals process.

Provider Hotline (Medicaid): 1-877-576-5899 www.deltadentalins.com/tx-medicaid

Provider Hotline (CHIP): 1-866-561-5891 www.deltadentalins.com/tchip

Page 65

Texas Children's Medicaid and CHIP Dental Services Provider Manual

10.7

CHIP MEMBER EXPEDITED APPEALS

The Texas Children's Medicaid Dental Services Member Handbook contains the following information on member expedited appeals. CHIP Member Handbook Information on Member Expedited Appeals The Texas CHIP Dental Services Member Handbook includes the following information on member expedited appeals. What is an expedited appeal? Ask for an expedited appeal when you don't have time for a standard appeal--when your child's life or health is in danger. When you ask for an expedited appeal, Delta Dental has to make a decision quickly based on the condition of your child's health. How do I ask for an expedited appeal? Call us at 1-866-561-5892 (toll-free) or write to us at:

Texas CHIP Dental Services Delta Dental Insurance Company PO Box 537014 Sacramento, CA 95853-7014

Does my request for an expedited appeal have to be in writing? No. We will accept your request by phone or in writing. How long does an expedited appeal take? Within 3 calendar days after we receive your expedited appeal, we will:

Review it. Make a decision on it. Send you written notice of our decision.

What happens if Delta Dental says it won't do an expedited appeal? We will call you and tell you why we denied your request. We will also send you a letter with that information within two business days. If we deny your request for an expedited appeal, we will process your request as a standard appeal. Who can help me file an expedited appeal? We can help you file an expedited appeal. Call us at 1-866-561-5892 (toll-free).

Provider Hotline (Medicaid): 1-877-576-5899 www.deltadentalins.com/tx-medicaid Provider Hotline (CHIP): 1-866-561-5891 www.deltadentalins.com/tchip

Page 66

Texas Children's Medicaid and CHIP Dental Services Provider Manual

10.8

INDEPENDENT REVIEW ORGANIZATION REVIEWS (CHIP)

Independent Review Organizations (IROs) are organizations certified by TDI under Insurance Code Chapter 4202. The purpose of an IRO is to provide an independent review of health care services that are denied by certain entities regulated by TDI on the basis that the services are not medically necessary or appropriate, or are experimental or investigational. The TDI developed a form (LHL009) for members to use to request that services denied by Delta Dental to be reviewed by an IRO. Instructions on how to obtain an LHL009 form are provided by Delta Dental when we mail the member our decision denying a health care service on the basis that the service is not medically necessary or appropriate or is experimental or investigational. In most cases, the member must request that a reconsideration or appeal be performed by Delta Dental before requesting an IRO review (unless the member has a lifethreatening condition). A request for an IRO review can be made after the first denial by Delta Dental. After the member obtains and completes the LHL009 form, it needs to be submitted to Delta Dental. Upon receipt of the form, we are required to submit the member's request for IRO review to TDI within one business day. After TDI receives the request from Delta Dental, we will assign the member's request for an independent review to a certified IRO and send notice of assignment letters to the IRO, member or authorized representative, provider. We will send all health records and related information to the assigned IRO within three working days. The IRO selects a qualified health care provider to review the medical records related to the denied service and provide an independent opinion as whether the denied service is medically necessary/appropriate or experimental and investigational. The IRO and the reviewer are required to certify their independence from any party that may be involved with the denial of the services The time frames for an Independent Review Organization (IRO)'s decision are as follows:

8 days for a life-threatening preauthorization/concurrent review case. 20 days for a non-life-threatening preauthorization/concurrent review case. 20 days for a retrospective review case.

The Independent Review Organization is required to provide a copy of its decision to TDI, the member or authorized representative, the provider, and Delta Dental.

Provider Hotline (Medicaid): 1-877-576-5899 www.deltadentalins.com/tx-medicaid

Provider Hotline (CHIP): 1-866-561-5891 www.deltadentalins.com/tchip

Page 67

Texas Children's Medicaid and CHIP Dental Services Provider Manual

11.0

MEMBER ELIGIBILITY, ENROLLMENT, DISENROLLMENT, AND VALUE-ADDED BENEFITS (MEDICAID)

Children who enroll in the Texas Children's Medicaid Dental Services program receive 12 months of continuous coverage. Families must re-enroll their children every 12 months. To qualify for Texas Children's Medicaid Dental Services, a child must be:

A Texas resident. A U.S. citizen or legal permanent resident (the citizenship or immigration status of the parents does not affect the child(ren)'s eligibility and is not reported on the application form). Under age 19. Be uninsured for at least 90 days (although there may be exceptions to this requirement). Living in a family that meets Texas Children's Medicaid Dental Services income requirements.

11.1

ELIGIBILITY DETERMINATION BY HHSC

Delta Dental does not perform member enrollment functions or determine the eligibility of patients. Eligibility for Texas Children's Medicaid Dental Services membership is determined by HHSC's Office of Eligibility Services. The eligibility information provided by Delta Dental to contracting offices reflects the eligibility information as Delta Dental has received it from HHSC or its designee. Your Medicaid patient will be covered until his/her name no longer appears on monthly eligibility information provided to Delta Dental. Therefore, it is vital that providers verify eligibility before initiating treatment to a patient.

11.2

ELIGIBILITY VERIFICATION

As discussed in Subsection 5.5, Verification of Member Eligibility and/or Authorization for Service, you are required to make a good faith effort to verify the member's identity by asking for the member's ID card. You have three additional options for verifying a Medicaid member's eligibility:

Contact our Provider Hotline -- Using Delta Dental's automated response option, you may enter a child's unique Texas Children's Medicaid Dental Services Member ID number and verify the member's eligibility and benefit history. Call the Automated Inquiry System -- The phone number for this traditional fee-forservice automated system is 1-800-925-9126. Eligibility information is available 23/7, with scheduled down time between 3 a.m. and 4 a.m. Central Time.

Provider Hotline (CHIP): 1-866-561-5891 www.deltadentalins.com/tchip

Provider Hotline (Medicaid): 1-877-576-5899 www.deltadentalins.com/tx-medicaid

Page 68

Texas Children's Medicaid and CHIP Dental Services Provider Manual

Log on to TexMed Connect -- Their website is: www.tmhp.com/Pages/EDI/EDI_TexMedConnect.aspx.

A dentist who declines to accept a Texas Children's Medicaid Dental Services patient must do so before accessing eligibility information. If the dentist is unwilling to accept an individual as a patient, the dentist has no authority to access the individual's confidential eligibility information. After eligibility verification has been established, you can decline to treat a Texas Children's Medicaid Dental Services member only under the following circumstances:

You are unable to provide the particular service(s) that the Medicaid member requires. The member is not eligible for dental services. The member is unable to present satisfactory identification with the Texas Children's Medicaid Dental Services ID card to verify that he or she is the individual to whom the card was issued.

11.3

AUTOMATIC RE-ENROLLMENT

To maintain Medicaid eligibility, the member must re-enroll every 6 months and, at the time of re-enrollment, the member may choose to switch dental plan. Medicaid members are given the opportunity to request a termination or change enrollment from one dental plan to another at any time after the dental program coverage begins. If a member requests a change from one dental plan to another, the change will be prospective. The effective date will be the first day of the month in which the member appears on the member eligibility file for the receiving dental plan.

11.4

DISENROLLMENT

Delta Dental has a limited right to request a Medicaid member's disenrollment without the member's consent. We must take reasonable measures to correct member behavior prior to requesting disenrollment. Reasonable measures may include providing education and counseling regarding the offensive acts or behaviors. HHSC must approve Delta Dental's request for disenrollment of a member for cause. HHSC may permit disenrollment of a member under the following circumstances:

The member misuses or loans his or her membership card to another person to obtain services. The member is disruptive, unruly, threatening, or uncooperative to the extent that the member's membership seriously impairs Delta Dental's or your ability to

Provider Hotline (CHIP): 1-866-561-5891 www.deltadentalins.com/tchip

Provider Hotline (Medicaid): 1-877-576-5899 www.deltadentalins.com/tx-medicaid

Page 69

Texas Children's Medicaid and CHIP Dental Services Provider Manual

provide services to the member or to obtain new members, and the member's behavior is not caused by a physical or behavioral health condition. The member steadfastly refuses to comply with managed care restrictions.

If you have a situation involving any of the above-listed circumstances and/or you have any concerns regarding a member, please call our Provider Hotline. You are prohibited for taking any retaliatory actions against a Medicaid member if he or she elects to change providers.

11.5

PLAN CHANGES

A Medicaid member can change his or her dental plan to another by contacting the HHSC Office of Eligibility Services at 1-800-647-6558. During the first 90 days after the member is enrolled in a dental plan, he or she can change to any other plan for any reason. For example, a member who has been enrolled in Plan A for 65 days can change to Plan B for any reason. After being in Plan B for 80 days, that member can change to Plan C for any reason. As long as the member changes plans within the first 90 days of being in any plan, he or she can change plans as many times as desired for any reason. After 90 days with a dental plan, the member can change to another plan once for any reason. If the member shows good cause, he or she can also change dental plans at any time. An example of good cause is that the member can't get the care he or she needs through the dental plan. If a member calls to change dental plans on or before the 15th of the month, the change will take place on the first day of the next month. If the member calls after the 15th of the month, the change will take place the first day of the second month after that. For example:

If the member asks to change plans on or before April 15, the change will take place on May 1. If the member asks to change plans after April 15, the change will take place on June 1.

11.6

ADDED BENEFITS

Delta Dental is proud to offer value-added services to Texas Children's Medicaid Dental Services members. Value-added services are any services that promote healthy lifestyles and improve dental outcomes among members. Texas Children's Medicaid Dental Services members are offered the following:

A dental care kit to promote oral health and help prevent tooth decay and periodontal disease.

Provider Hotline (CHIP): 1-866-561-5891 www.deltadentalins.com/tchip

Provider Hotline (Medicaid): 1-877-576-5899 www.deltadentalins.com/tx-medicaid

Page 70

Texas Children's Medicaid and CHIP Dental Services Provider Manual

Infant Kit (ages 0 to 1) -- Infant finger brush, brushing instructions, and an adult toothbrush for the caregiver. Toddler Kit (ages 2 to 4) -- Toddler tooth brush and a two-minute timer to encourage brushing. Child Kit (ages 4 to 12) -- Child toothbrush, a two-minute timer, and dental floss. Adult Kit (ages 12 to 18) -- Adult toothbrush, a two-minute timer, and dental floss. A dental mouth guard to each new member between the ages of 6 and 18 (to help prevent dental injuries while playing sports such as soccer, football, and basketball).

Members are informed of the value-added services that Delta Dental offers in our member welcome packet that is sent to each member upon enrollment. These benefits are limited to one dental care kit and one mouth guard per member. Additional information regarding our value-added services is available by calling our Provider Hotline or visiting our websites. The value-added services that Delta Dental offers to our members are reviewed and approved by HHSC and are subject to change.

Provider Hotline (Medicaid): 1-877-576-5899 www.deltadentalins.com/tx-medicaid

Provider Hotline (CHIP): 1-866-561-5891 www.deltadentalins.com/tchip

Page 71

Texas Children's Medicaid and CHIP Dental Services Provider Manual

12.0

MEMBER ELIGIBILITY, ENROLLMENT, DISENROLLMENT, AND VALUE-ADDED BENEFITS (CHIP)

Children who enroll in the Texas CHIP Dental Services program receive 12 months of continuous coverage. Families must re-enroll their children every 12 months. To qualify for Texas CHIP dental services, a child must be:

A Texas resident. A U.S. citizen or legal permanent resident (the citizenship or immigration status of the parents does not affect the child(ren)'s eligibility and is not reported on the application form). Under age 19. Be uninsured for at least 90 days (although there may be exceptions to this requirement). Living in a family that meets Texas CHIP Dental Services income requirements.

12.1

ELIGIBILITY DETERMINATION BY HHSC

Delta Dental does not perform member enrollment functions or determine the eligibility of patients. Eligibility for Texas CHIP Dental Services membership is determined by HHSC or its designee(s). The eligibility information provided by Delta Dental to contracting offices reflects the eligibility information as Delta Dental has received it from HHSC or its designee. Your CHIP patient will be covered until his/her name no longer appears on monthly eligibility information provided to Delta Dental. Therefore, it is vital that providers verify eligibility before initiating treatment to a patient.

12.2

ELIGIBILITY VERIFICATION

As discussed in Subsection 5.5, Verification of Member Eligibility and/or Authorization for Service, you are required to make a good faith effort to verify the member's identity by asking for the member's ID card. You have two additional options for verifying a CHIP member's eligibility:

Contact our Provider Hotline -- Using Delta Dental's automated response option, you may enter a child's unique Texas CHIP Dental Services Member ID number and verify and/or receive a fax-back of the following information: A child's membership in the Texas CHIP Dental Services program. A child's start and end dates of coverage. The status of a child's $564.00 benefit. Call the HHSC Office of Eligibility Services at 1-800-647-6558.

Provider Hotline (CHIP): 1-866-561-5891 www.deltadentalins.com/tchip

Provider Hotline (Medicaid): 1-877-576-5899 www.deltadentalins.com/tx-medicaid

Page 72

Texas Children's Medicaid and CHIP Dental Services Provider Manual

A dentist who declines to accept a CHIP patient must do so before accessing eligibility information. If the dentist is unwilling to accept an individual as a patient, the dentist has no authority to access the individual's confidential eligibility information. If eligibility is verified, you may not treat the CHIP member as a private-pay patient to avoid Texas CHIP Dental Services billing, obtaining prior authorization (when necessary), or complying with any other program requirement. In addition, upon obtaining eligibility verification, you cannot bill the Texas CHIP Dental Services member for any covered service. After eligibility verification has been established, you can decline to treat a Texas CHIP Dental Services member only under the following circumstances:

You are unable to provide the particular service(s) that the Texas CHIP Dental Services member requires. The member is not eligible for dental services. The member is unable to present satisfactory identification with the Texas CHIP Dental Services ID card to verify that he or she is the individual to whom the card was issued.

12.3

RE-ENROLLMENT

CHIP members with incomes at or below 185 percent of the federal poverty level (FPL) receive dental program coverage for 12 months. CHIP members with incomes above 185 percent FPL and up to and including 200 percent FPL receive dental program coverage for up to 12 months and are required to verify income eligibility at month 6 of their 12-month coverage period. Member eligibility for the CHIP program is determined by HHSC.

12.4

DISENROLLMENT

HHSC's Office of Eligibility Services enrolls and disenrolls members from dental plans. Members are not allowed to change dental plans after their first 90 days of coverage unless granted an exception for a "good cause" event. The Office of Eligibility Services determines "good cause" events that qualify a CHIP member to change dental plans. Additionally, CHIP members who have exhausted their annual benefit limits are not allowed to change dental plans. You are prohibited for taking any retaliatory actions against the CHIP member if they elect to change providers.

12.5

PLAN CHANGES

Members are allowed to make dental plan changes under the following circumstances:

Provider Hotline (Medicaid): 1-877-576-5899 www.deltadentalins.com/tx-medicaid Provider Hotline (CHIP): 1-866-561-5891 www.deltadentalins.com/tchip

Page 73

Texas Children's Medicaid and CHIP Dental Services Provider Manual

For any reason within 90 days of the enrollment in CHIP. For cause at any time. During the annual re-enrollment period.

CHIP members are given the opportunity to request a termination or change enrollment from one dental plan to another within the first 90 days after dental program coverage begins. If a member requests a change from one dental plan to another, the change will be prospective and the effective date will be the first day of the month in which the member appears on the member eligibility file for the receiving dental plan. HHSC will make the final decision on plan changes.

12.6

ADDED BENEFITS

Delta Dental is proud to offer value-added services to Texas CHIP Dental Services members. Value-added services are any services that promote healthy lifestyles and improve dental outcomes among members. Texas CHIP Dental Services members are offered the following:

A dental care kit to promote oral health and help prevent tooth decay and periodontal disease. Infant Kit (ages 0 to 1) -- Infant finger brush, brushing instructions, and an adult toothbrush for the caregiver. Toddler Kit (ages 2 to 4) -- Toddler tooth brush and a two-minute timer to encourage brushing. Child Kit (ages 4 to 12) -- Child toothbrush, a two-minute timer, and dental floss. Adult Kit (ages 12 to 18) -- Adult toothbrush, a two-minute timer, and dental floss. A dental mouth guard to each new member between the ages of 6 and 18 (to help prevent dental injuries while playing sports such as soccer, football, and basketball).

Members are informed of the value-added services that Delta Dental offers in our member welcome packet that is sent to each member upon enrollment. These benefits are limited to one dental care kit and one mouth guard per member. Additional information regarding our value-added services is available by calling our Provider Hotline or visiting our websites. The value-added services that Delta Dental offers to our members are reviewed and approved by HHSC and are subject to change.

Provider Hotline (Medicaid): 1-877-576-5899 www.deltadentalins.com/tx-medicaid

Provider Hotline (CHIP): 1-866-561-5891 www.deltadentalins.com/tchip

Page 74

Texas Children's Medicaid and CHIP Dental Services Provider Manual

13.0

MEMBER RIGHTS AND RESPONSIBILITIES

Member rights and responsibilities for Medicaid members and CHIP members are presented below.

13.1

MEMBER RIGHTS AND RESPONSIBILITIES (MEDICAID)

The Texas Children's Medicaid Dental Services Member Handbook contains the following list of Medicaid member rights and responsibilities. Member Rights: 1. You have the right to respect, dignity, privacy, confidentiality and nondiscrimination. That includes the right to: a. b. 2. Be treated fairly and with respect. Know that your dental records and discussions with your dentists will be kept private and confidential.

You have the right to a reasonable opportunity to choose a dental plan and dentist. You have the right to change to another plan or dentist in a reasonably easy manner. That includes the right to: a. b. c. d. e. Be told how to choose and change your dental plan and your dentist. Choose any dental plan you want that is available in your area and choose our dentist from that plan. Change your dentist. Change your dental plan without penalty. Be told how to change your dental plan or your dentist.

3.

You have the right to ask questions and get answers about anything you do not understand. That includes the right to: a. b. Have your dentist explain your dental care needs to you and talk to you about the different ways your dental care problems can be treated. Be told why care or services were denied and not given.

4.

You have the right to agree to or refuse treatment and actively participate in treatment decisions. That includes the right to: a. b. Work as part of a team with your dentist in deciding what dental care is best for you. Say yes or no to the care recommended by your dentist.

Provider Hotline (Medicaid): 1-877-576-5899 www.deltadentalins.com/tx-medicaid

Provider Hotline (CHIP): 1-866-561-5891 www.deltadentalins.com/tchip

Page 75

Texas Children's Medicaid and CHIP Dental Services Provider Manual

5.

You have the right to use each available complaint and appeal process through Delta Dental and through Medicaid, and get a timely response to complaints, appeals, and fair hearings. That includes the right to: a. b. c. d. Make a complaint to your dental plan or to the state Medicaid program about your dental care, your dentist or your dental plan. Get a timely answer to your complaint. Use the plan's appeal process and be told how to use it. Ask for a fair hearing from the state Medicaid program and get information about how that process works.

6.

You have the right to timely access to care that does not have any communication or physical access barriers. That includes the right to: a. b. c. Have telephone access to a dental professional 24 hours a day, 7 days a week to get any emergency or urgent care you need. Get dental care in a timely manner. Be able to get in and out of a dental care provider's office. This includes barrier-free access for people with disabilities or other conditions that limit mobility, in accordance with the Americans with Disabilities Act. Have interpreters, if needed, during appointments with your dentist and when talking to your dental plan. Interpreters include people who can speak in your native language, help someone with a disability, or help you understand the information. Be given information you can understand about your dental plan rules, including the dental care services you can get and how to get them.

d.

e. 7.

You have the right to not be restrained or secluded when it is for someone else's convenience, or is meant to force you to do something you do not want to do, or is to punish you. You have a right to know that dentists, hospitals, and others who care for you can advise you about your health status, medical care, and treatment. Your dental plan cannot prevent them from giving you this information, even if the care or treatment is not a covered service. You have a right to know that you are not responsible for paying for covered services. Doctors, hospitals, and others cannot require you to pay copayments or any other amounts for covered services.

8.

9.

Member Responsibilities: 1. You must learn and understand each right you have under the Medicaid program. That includes the responsibility to: a. Learn and understand your rights under the Medicaid program.

Provider Hotline (CHIP): 1-866-561-5891 www.deltadentalins.com/tchip

Provider Hotline (Medicaid): 1-877-576-5899 www.deltadentalins.com/tx-medicaid

Page 76

Texas Children's Medicaid and CHIP Dental Services Provider Manual

b. c. 2.

Ask questions if you do not understand your rights. Learn what choices of dental plans are available in your area.

You must abide by the dental plan's and Medicaid's policies and procedures. That includes the responsibility to: a. b. c. d. e. f. g. h. Learn and follow your dental plan's rules and Medicaid rules. Choose your dental plan and a dentist quickly. Make any changes in your dental plan and dentist in the ways established by Medicaid and by the dental plan. Keep your scheduled appointments. Cancel appointments in advance when you cannot keep them. Always contact your dentist first for your non-emergency dental needs. Be sure you have approval from your dentist before going to a specialist. Understand when you should and should not go to the emergency room.

3.

You must share information about your health with your primary care provider and learn about service and treatment options. That includes the responsibility to: a. b. c. Tell your dentist about your health. Talk to your dentist about your health care needs and ask questions about the different ways your dental care problems can be treated. Help your dentist get your dental records.

4.

You must be involved in decisions relating to service and treatment options, make personal choices, and take action to maintain your dental health. That includes the responsibility to: a. b. c. d. Work as a team with your dentist in deciding what dental care is best for you. Understand how the things you do can affect your dental health. Do the best you can to stay healthy. Treat dentists and staff with respect.

13.2

MEMBER RIGHTS AND RESPONSIBILITIES (CHIP)

The Texas CHIP Dental Service Member Handbook contains the following list of CHIP member rights and responsibilities. Member Rights:

Provider Hotline (Medicaid): 1-877-576-5899 www.deltadentalins.com/tx-medicaid

Provider Hotline (CHIP): 1-866-561-5891 www.deltadentalins.com/tchip

Page 77

Texas Children's Medicaid and CHIP Dental Services Provider Manual

1. 2. 3.

You have the right to get accurate, easy-to-understand information to help you make good choices about your child's dentists and other providers. You have the right to know how your dentists are paid. You have a right to know about what those payments are and how they work. You have the right to know how Delta Dental decides about whether a service is covered and/or medically necessary. You have the right to know about the people in Delta Dental's office who decide those things. You have the right to know the names of the dentists and other providers enrolled with Delta Dental and their addresses. You have the right to pick from a list of dentists that is large enough so that your child can get the right kind of care when your child needs it. You have the right to take part in all the choices about your child's dental care. You have the right to speak for your child in all treatment choices. You have the right to get a second opinion from another dentist enrolled with Delta Dental about what kind of treatment your child needs. You have the right to be treated fairly by Delta Dental dentists and other providers. You have the right to talk to your child's dentists and other providers in private, and to have your child's dental records kept private. You have the right to look over and copy your child's dental records and to ask for changes to those records. You have a right to know that dentists, hospitals, and others who care for your child can advise you about your child's health status, medical care, and treatment. Your dental plan cannot prevent them from giving you this information, even if the care or treatment is not a covered service. You have a right to know that you are only responsible for paying allowable co-payments for covered services, up to benefit maximum limits. Dentists, hospitals, and others cannot require you to pay any other amounts for covered services.

4. 5. 6. 7. 8. 9. 10.

11.

12.

Member Responsibilities: You and Delta Dental both have an interest in seeing your child's dental health improve. You can help by assuming these responsibilities: 1. You must try to follow healthy habits, such as encouraging your child to exercise, to stay away from tobacco, and to eat a healthy diet.

Provider Hotline (CHIP): 1-866-561-5891 www.deltadentalins.com/tchip

Provider Hotline (Medicaid): 1-877-576-5899 www.deltadentalins.com/tx-medicaid

Page 78

Texas Children's Medicaid and CHIP Dental Services Provider Manual

2. 3. 4. 5. 6.

You must become involved in the dentist's decisions about your child's treatments. You must work together with Delta Dental dentists and other providers to pick treatments for your child that you have all agreed upon. If you have a disagreement with Delta Dental, you must try first to resolve it using Delta Dental's complaint process. You must learn about what Delta Dental does and does not cover. You must read your Member Handbook to understand how the rules work. If you make an appointment for your child, you must try to get to the dentist's office on time. If you cannot keep the appointment, be sure to call and cancel it. You must report misuse of CHIP by dental and health care providers, other CHIP members, Delta Dental, or other CHIP plans.

7.

If you think you have been treated unfairly or discriminated against, call the U.S. Department of Health and Human Services (HHS) toll-free at 1-800-368-1019. You also can view information concerning the HHS Office of Civil Rights online at www.hhs.gov/ocr.

13.3

FRAUD REPORTING

The Texas Medicaid and CHIP Dental Service member handbooks include the following information on reporting waste, abuse, and fraud. Do you want to report waste, abuse, or fraud? Let us know if you think a doctor, dentist, pharmacist at a drug store, other health care provider, or a person getting benefits is doing something wrong. Doing something wrong could be waste, abuse, or fraud, which is against the law. For example, tell us if you think someone is:

Getting paid for Medicaid or CHIP services that weren't given or necessary. Not telling the truth about a medical condition to get medical treatment. Letting someone else use a Medicaid or CHIP Dental ID. Using someone else's Medicaid or CHIP Dental ID. Not telling the truth about the amount of money or resources he or she has to get benefits.

To report waste, abuse, or fraud, do one of the following:

Call the OIG Hotline at 1-800-436-6184 or

Provider Hotline (CHIP): 1-866-561-5891 www.deltadentalins.com/tchip

Provider Hotline (Medicaid): 1-877-576-5899 www.deltadentalins.com/tx-medicaid

Page 79

Texas Children's Medicaid and CHIP Dental Services Provider Manual

Visit https://oig.hhsc.state.tx.us/ and pick "Click Here to Report Waste, Abuse, and Fraud" to complete the online form. Call our Member Hotline. Visit http://deltadentalins.com/tx-medicaid/ (for Medicaid members) or http://deltadentalins.com/tchip/ (for CHIP members) and complete the waste, abuse, and fraud reporting form. Write to us at: Texas Children's Medicaid and CHIP Dental Services State Government Programs PO Box 537014 Sacramento, CA 95853-7014

To report waste, abuse, or fraud, gather as much information as possible. When reporting about a provider (a doctor, dentist, counselor, etc.), include:

Name, address, and phone number of provider. Name and address of the facility (hospital, nursing home, home health agency, etc.). Medicaid number of the provider and facility, if you have it and if applicable. Type of provider (doctor, dentist, therapist, pharmacist, etc.). Names and phone numbers of other witnesses who can help in the investigation. Dates of events. Summary of what happened.

When reporting about someone who gets benefits, include:

The person's name. The person's date of birth, social security number, or case number if you have it. The city where the person lives. Specific details about the waste, abuse, or fraud.

A copy of the waste, abuse, and fraud reporting form in presented in Attachment J, Waste, Abuse, and Fraud Reporting Form.

Provider Hotline (Medicaid): 1-877-576-5899 www.deltadentalins.com/tx-medicaid

Provider Hotline (CHIP): 1-866-561-5891 www.deltadentalins.com/tchip

Page 80

Texas Children's Medicaid and CHIP Dental Services Provider Manual

14.0

BILLING AND CLAIMS ADMINISTRATION

Delta Dental's primary function is to underwrite and process claims and TARs submitted by providers for dental services performed for eligible Medicaid and CHIP members. It is the intent of Delta Dental to process claims and TARs as quickly and efficiently as possible. To help you understand your role in expediting claims processing for the Texas Children's Medicaid Dental Services and the Texas CHIP Dental Services program(s), this subsection of the provider manual includes the following information:

Definitions of billing and claims terms. Overview of Delta Dental's claims processing system. Time frames for submitting claims and related documentation and for processing claims. Identification of claims forms and instructions for completing and understanding the forms.

Delta Dental will provide you with at least 90 days' notice prior to implementing any change in the claim guidelines presented below, unless the change is required by statute or regulation within a shorter time frame. We will also notify you in writing at least 30 days prior to the effective date of any change in claim processing or adjudication entities for the Texas Medicaid and CHIP Dental Services program. If we are unable to give you 30 days' notice, you will be granted a 30-day extension on you claims filing deadline to ensure that claims are routed to the correct processing center.

14.1

DEFINITIONS OF BILLING AND CLAIMS TERMS

The definitions of frequently used billing and claims terms are presented below.

Adjudicate -- To deny or pay a clean claim. Day -- A calendar day unless specified otherwise. Clean Claim -- A claim submitted by a provider for dental services rendered to a member, with documentation reasonably necessary for Delta Dental to process the claim in a timely manner that includes: For non-electronic claims, the required data elements set forth in Texas Administrative Code (T.A.C.) Title 28, Part 1, Chapter 21, Subchapter T, Rule 21.2802 and 21.2803. For electronic claims, in compliance with all applicable federal laws related to electronic health care claims and as noted in TAC Title 28, Part 1, Chapter 21, Subchapter T, Rule 21.2802 and 21.2803. Deficient Claim -- A submitted claim that does not meet the definition above.

Provider Hotline (CHIP): 1-866-561-5891 www.deltadentalins.com/tchip

Provider Hotline (Medicaid): 1-877-576-5899 www.deltadentalins.com/tx-medicaid

Page 81

Texas Children's Medicaid and CHIP Dental Services Provider Manual

Original Claim -- A claim submitted for dental care service provided to a particular individual on a particular date of service that has not been included in a previously submitted claim. Appealed Claim -- A claim submitted for the same dental care service provided to a particular individual on a particular date of service that was included in a previously submitted claim and was denied full or partial payment. Corrected Claim -- A claim containing clarifying or additional information necessary to correct a previously submitted claim. Duplicate Claim -- A claim submitted for the same dental care service provided to a particular individual on a particular date of service that was included in a previously submitted claim. The term does not include corrected claims, or claims submitted by a physician or provider at the request of Delta Dental. The type of claim (original, appealed, corrected, or duplicate) should be so noted on the claim.

14.2

OVERVIEW OF DELTA DENTAL'S CLAIMS PROCESSING SYSTEM

All incoming documents are received and sorted in the Delta Dental ­ State Government Program's mailroom. Claims and TARs are separated from other incoming documents and general correspondence and are assigned a Document Control Number (DCN). The DCN is a unique number containing 11 digits (e.g. 11 182 1 99001):

The first five digits of the DCN represent the Julian date of receipt. In the example shown above, "11" designates the year and "182" designates the 182nd day of that year. The sixth digit, "1," identifies the type of document (1 = claim or TAR, 8 = NOA). The remaining five digits of the DCN represent the sequential number assigned to the document.

Thus, the document assigned the DCN shown in the example above would be the first claim for payment received by Delta Dental ­ State Government Programs on the 182nd day of 2011, or July 1, 2011. Claims and TARs plus any attachments are then microfilmed or scanned, batched, and forwarded to Data Entry, where pertinent data from the forms are entered into the automated claims processing system. After data from the claim or TAR are entered into the system, the information is automatically edited for errors. Errors are highlighted on a display screen and the data entry operator validates the information entered against that contained on the original form. When necessary corrections are made and the operator confirms that the information entered is correct, the system prompts the operator as to the proper disposition of the claim or TAR.

Provider Hotline (Medicaid): 1-877-576-5899 www.deltadentalins.com/tx-medicaid Provider Hotline (CHIP): 1-866-561-5891 www.deltadentalins.com/tchip

Page 82

Texas Children's Medicaid and CHIP Dental Services Provider Manual

Information on a claim or TAR form is audited via a series of manual and automated transactions to determine whether the services listed should be approved, modified, or disallowed. If the claim data are determined to be satisfactory, the result is payment, with the issuance of an EOB form and a check. If the TAR data are determined to be satisfactory, the result is authorization of treatment, with the issuance of a NOA form. If the information submitted on the claim or TAR is not sufficient, the document may be denied.

14.3

TIME FRAMES FOR SUBMISSION OF CLAIMS, NOAS, AND CLAIMS APPEALS

You must file all claims for services provided to members. You must submit such claims to Delta Dental, on the required forms, within 95 days after the date services were performed. Payment of claims for services will be issued directly to the contracted billing dentist. To be considered for payment, NOAs must be received by Delta Dental not more than 95 days after the final service is performed. For appealed claims, providers must submit all appeals of denied claims and requests for adjustments on paid claims within 120 days from the date of disposition of the explanation of benefits (EOB) on which that claim appeared. Please see "Claim Inquiry Form" in this manual for instructions on submitting an appeal of a denied claim or a request for an adjustment of a paid claim.

14.4

TIME FRAMES FOR CLAIMS PAYMENT

You will be paid on a fee-for-service basis for dental services provided to members according to the fee schedule attached to the Texas Medicaid and CHIP Dental Services Contracting Dentist Agreement. Failure to follow the administrative requirements as outlined in this provider manual may result in denial of payment. Delta Dental will adjudicate (process and finalize to a paid or denied status) all claims within 30 days from the date the claim is received, regardless of whether the claim is clean, deficient, appealed, or corrected pursuant to being pended for additional information. Delta Dental will pay interest at an annual rate of 18 percent for the full period in which a clean claim remains unadjudicated beyond 30 days from the date of receipt.

Provider Hotline (Medicaid): 1-877-576-5899 www.deltadentalins.com/tx-medicaid

Provider Hotline (CHIP): 1-866-561-5891 www.deltadentalins.com/tchip

Page 83

Texas Children's Medicaid and CHIP Dental Services Provider Manual

14.5

BILLING AND CLAIMS FORMS

You must agree to complete and submit standard billing and claims forms on behalf of your Texas Medicaid and CHIP Dental Services patients and to do so without charge to the member or Delta Dental. The most frequently used forms are:

Claim/treatment authorization form (claim/TAR). Notice of authorization form (NOA). Explanation of benefits form (EOB). Claim inquiry form (CIF). Claim inquiry response form (CIR). Provider billing intermediary form.

Sample forms, along with instructions for completing the forms, are presented in the subsections below and are available on the CD you received from Delta Dental. The most current versions of the forms can be accessed from our provider website or by calling our Provider Hotline. Proper use and completion of the forms will expedite authorization or payment for covered services under the Texas Medicaid and CHIP Dental Services program. Before submitting a claim/TAR/NOA form to Delta Dental for payment or authorization, review the form using Attachment K, Claim/TAR/NOA Submission Checklist. Please make sure that all applicable areas of the forms are filled in completely and accurately. Mail the completed forms to us at the address noted below. If you have any questions about the claims process (including appeals), please call our Provider Hotline. Delta Dental Mailing Address Texas Children's Medicaid and CHIP Dental Services State Government Programs PO Box 537014 Sacramento, CA 95853-7014

14.5.1 Claim/TAR Form

The claim form is used to submit a claim for payment of services performed. In addition, the form may be used to request authorization of proposed treatment; such a request is referred to as a TAR. Therefore, throughout this provider manual, we refer to the claim form as the claim/TAR form. A TAR is a form of pre-determination. While covered benefits do not require prior authorization, a participating dental office may choose to submit a TAR to determine the possible coverage of services before they are rendered. Generally, a completed TAR

Provider Hotline (Medicaid): 1-877-576-5899 www.deltadentalins.com/tx-medicaid Provider Hotline (CHIP): 1-866-561-5891 www.deltadentalins.com/tchip

Page 84

Texas Children's Medicaid and CHIP Dental Services Provider Manual

requires the same information as a completed claim, except for the date of service and treating provider information. When submitting a claim, you may use Delta Dental's claim/TAR form or any ADAapproved claim form. Please be advised that some older versions of Delta Dental and ADA forms do not contain all the required elements for processing your claims. To ensure prompt payment, we suggest that you consider using a current version of the standard ADA form or you may download a claim form from http://deltadentalins.com/tchip/forms/claimform.pdf. Please ensure that whatever version you submit includes your tax identification number and your NPI number. Instructions for Completing the Claim/TAR Form Accurate and complete preparation of the claim/TAR form (see Exhibit A, Sample Claim/TAR Form) is essential for processing. Unless otherwise specified, all items must be completed. Please type, print, or handwrite the information requested. Please enter all dates using six numerical digits (e.g., MM/DD/YY). If you submit a document with both dated and undated claim service lines, the document will be processed as a TAR and payment of the dated claim service lines will not occur until after the completion of all authorized treatment. Therefore, you may wish to submit claims and TARs on separate documents. To submit a clean claim, please be sure to include all required information on each claim form. In the itemized instructions below, the numbers indicate the specific data field on Delta Dental's claim/TAR form where each piece of information should be entered. The same information is required if an ADA-approved form is used, however the layout of the forms may be different and the information may be found in a different data field. Field # Field 1. 2. Patient Name Patient Social Security Number Instructions Enter the patient's last name, first name, and middle initial. Enter the member's 9-digit Texas Medicaid ID number or 9-digit CHIP client identification number (CIN). The applicable ID number is found on the member's ID card. Completion of this item is required. Check "M" for male or "F" for female. Enter the patient's birth date. The birth date is used to help identify the patient.

3. 4.

Patient Sex Patient Birth Date

Provider Hotline (Medicaid): 1-877-576-5899 www.deltadentalins.com/tx-medicaid

Provider Hotline (CHIP): 1-866-561-5891 www.deltadentalins.com/tchip

Page 85

Texas Children's Medicaid and CHIP Dental Services Provider Manual

Field # Field 5. Patient ID Number

Instructions Enter the member's 9-digit Texas Medicaid ID number or 9-digit CHIP client identification number (CIN). The applicable ID number is found on the member's ID card. Completion of this item is required. Enter the patient's current address. If you assign a Dental Record Number or account number to a patient, enter the assigned number here; otherwise, you may leave this section blank. No information necessary. Check if "Yes" and indicate the number of films enclosed. All radiographs and any attachments must be identified with the patient's name, date the x-rays were taken, dentist's name, and provider number. Multiple radiographs must be mounted. Delta Dental will recycle duplicate x-rays that are marked "Do Not Return." To participate in the program for recycling duplicate x-rays, please affix a "Do Not Return" x-ray label on the outside of the x-ray envelope or on the x-ray mount. Check "Yes" if additional documents and/or documentation are attached to the claim/TAR form. Check "Yes" if the patient was in an accident or incurred an injury that resulted in the need for dental services. Check "Yes" if the patient was in an accident or incurred an injury that resulted in the need for dental services.

6. 7.

Patient Address Patient Dental Record Number Referring Provider Number Radiographs Attached? How Many?

8. 9.

10.

Other Attachments/ Documentation Accident/Injury?

11.

12.

Employment Related?

Provider Hotline (Medicaid): 1-877-576-5899 www.deltadentalins.com/tx-medicaid

Provider Hotline (CHIP): 1-866-561-5891 www.deltadentalins.com/tchip

Page 86

Texas Children's Medicaid and CHIP Dental Services Provider Manual

Field # Field 13. Other Dental Coverage?

Instructions Check "Yes" if the services performed are either fully or partially covered by a private or employer paid dental insurance carrier. You must bill the other insurance carrier prior to submitting the claim to Delta Dental. In the "Comments" section (item 34), furnish the full name and address of the other insurance carrier and name, the policyholder's member identification number (if available), and the policyholder's group number. Attach a copy of the other insurance carrier's EOB or denial letter. Enter the full name and address of the other insurance carrier. Enter the member's Texas Medicaid and CHIP Dental Services number. Field left intentionally blank. No information necessary for #16. Enter the billing provider's name. Enter the billing dentist's Delta Dental Texas Medicaid and CHIP Dental Services provider number. Enter the business NPI number. The Delta Dental provider number must be present and correct on all forms. Enter the service office address. Type or print the billing provider's name, service office address, and Delta Dental provider number exactly as recorded with Delta Dental. Check the appropriate box indicating where service was performed (claim) or will be performed (TAR). Options are Office, Home, Clinic/Dental School Clinic, SNF (Skilled Nursing Facility), ICF (Intermediate Care Facility), Hospital In-Patient, Hospital Out-Patient, Other (specify place of service).

14. 15. 16.

Name and Address of Other Carrier Delta Dental Group Number MF-O/ MaxillofacialOrthodontic Services? Billing Provider Name Provider ID Number

17. 18.

19.

Business NPI Number

20.

Mailing Address

21.

Place of Service

Provider Hotline (Medicaid): 1-877-576-5899 www.deltadentalins.com/tx-medicaid

Provider Hotline (CHIP): 1-866-561-5891 www.deltadentalins.com/tchip

Page 87

Texas Children's Medicaid and CHIP Dental Services Provider Manual

Field # Field 22. 23. X-Ray ID Number Identify Missing Tooth with "X"

Instructions For Delta Dental use only. Do not insert information. Use an "X" to indicate missing permanent teeth (excluding unerupted third molars) on the tooth chart. Radiographs that clearly depict all areas of both the maxillary and mandibular arches will substitute for the charting requirement. Charting of missing teeth for children aged zero through six years is not required.

24. Examination and Treatment

This area is designed to indicate what treatment was performed or is being requested. Accurate and complete information in these fields is vital. List treatment in tooth number sequence. Use one line to describe each separate service performed or requested. Use universal tooth code numbers 1 through 32 or letters A through T for tooth reference. Use arch codes "U" (upper) and "L" (lower). Use quadrant codes "UR" (upper right), "UL" (upper left), "LR" (lower right) and "LL" (lower left). Please use the following letters to identify each tooth surface: "M" for the mesial surface. "D" for the distal surface. "O" for the occlusal surface. "I" for the incisal surface. "L" for the lingual or palatal surface. "B" for the buccal surface. "F" for the facial surface. Furnish a brief description for each service. Whenever possible, please use the nomenclature for each procedure as defined in the ADA's Current Dental Terminology (CDT). Standard abbreviations are acceptable. Use ditto marks, brackets, or asterisks for any additional restorative service lines following the service line that contains documentation.

Provider Hotline (CHIP): 1-866-561-5891 www.deltadentalins.com/tchip

25.

Tooth Number or Letter; Arch; Quadrant

26.

Tooth Surfaces

27.

Description of Service

Provider Hotline (Medicaid): 1-877-576-5899 www.deltadentalins.com/tx-medicaid

Page 88

Texas Children's Medicaid and CHIP Dental Services Provider Manual

Field # Field 28. Date Service Completed (for payment claims only)

Instructions Indicate the date the service was performed, using six numerical digits (e.g., MM/DD/YY). If you submit a document with both dated and undated claim service lines, the document will be processed as a TAR and payment of the dated claim service lines will not occur until after the completion of all authorized treatment. Therefore, you may wish to submit claims and TARs on separate documents. For the procedures having multiple occurrences, indicate the number of occurrences of the procedure [e.g., multiple radiographs (procedure D0230)]. Use only the appropriate CDT-2011 codes consisting of D followed by four digits (e.g., DXXXX). Failure to submit documents using the CDT-2011 format may result in denial of payment or authorization. Enter your usual and customary fee for the procedure rather than the Texas Medicaid and CHIP Dental Services Schedule of Allowances fee. If there is more than one dentist at a service office billing under a single dentist's provider number, enter the provider number (the dentist's license number preceded by a "D") of the dentist who performed the service. The treating provider number should be entered on each claim line. All treating providers must be credentialed and enrolled as Texas Medicaid and CHIP Dental Services providers. Failure to enroll all treating providers will result in the denial of payment for those services performed by an un-enrolled provider. If there is only one dentist treating patients at a service office, the item "Treating Provider Number" does not need to be completed for any claim line. Use for additional clinical remarks necessary to

Provider Hotline (CHIP): 1-866-561-5891 www.deltadentalins.com/tchip

29.

Quantity

30.

Procedure Numbers

31.

Total Fee Charged

32.

Treating Provider Number (for payment claims only)

33.

Comments

Provider Hotline (Medicaid): 1-877-576-5899 www.deltadentalins.com/tx-medicaid

Page 89

Texas Children's Medicaid and CHIP Dental Services Provider Manual

Field # Field

Instructions document treatment or for requested information regarding other coverage, etc. If you complete this field, you do not need to include the remarks or use ditto marks on each restorative service line. Not applicable for the Texas Medicaid and CHIP Dental Services programs. The dollar amount of "other coverage" payments the provider has received for the listed procedures. If item 13 (OTHER DENTAL COVERAGE) is checked "YES," the amount received from the private dental insurance carrier must be entered. The EOB or denial from the private dental insurance carrier must be attached to the claim for payment. Enter the date the form is mailed using six numerical digits (e.g., MM/DD/YY). The dentist, or person authorized by the dentist, must sign his or her own name in this signature box, date the form, and include the treating provider's NPI number when requesting prior authorization or payment. The signature certifies that, to the best of the signer's knowledge, the information on the claim/TAR form and any attachments is accurate and complete and that the requested services were necessary to the health of the patient. The signature acknowledges the signer's understanding that payment for services rendered will be made from federal and/or state funds and that any falsification or concealment of a material fact may be prosecuted under federal and/or state laws.

34. 35. 36.

Total Fee Charged Patient Co-Pay Amount Other Coverage Amount (for payment claims only)

37. 38.

Date Billed Signature Block

Provider Hotline (Medicaid): 1-877-576-5899 www.deltadentalins.com/tx-medicaid

Provider Hotline (CHIP): 1-866-561-5891 www.deltadentalins.com/tchip

Page 90

Texas Children's Medicaid and CHIP Dental Services Provider Manual

Exhibit A, Sample Claim/TAR Form

Provider Hotline (Medicaid): 1-877-576-5899 www.deltadentalins.com/tx-medicaid

Provider Hotline (CHIP): 1-866-561-5891 www.deltadentalins.com/tchip

Page 91

Texas Children's Medicaid and CHIP Dental Services Provider Manual

After you have filled out the claim/TAR form, please do the following:

Review it for completeness and legibility. If the procedures performed require submission of x-rays: Place x-rays in an envelope and place behind the claim/TAR form. Affix a "Do Not Return" x-ray label on the outside of the x-ray envelope or on the xray mount. If you do not have a label, a handwritten note in the comments area of the document will suffice. Delta Dental will recycle duplicate x-rays that are marked "Do Not Return."

Place other attachments, if any, behind the claim/TAR form and before the x-ray envelope. Staple them to the back of the form in the upper right corner.

If you are submitting a claim and TAR together for the same patient, staple them together in the upper right corner and mail the forms in the purple-bordered envelopes. Mail the claim/TAR form and any attachments to Delta Dental.

Notification for Incomplete Prior Authorization Requests (Medicaid) If you submit a request for prior authorization that does not contain complete documentation and/or information, we will take the following steps: 1. We will return your request to you with a letter describing the documentation that needs to be submitted and, when possible, we will contact you by telephone to obtain the information needed to complete the prior authorization process. 2. If you do not provide us with the documentation/information within 16 business hours of our request, we will send a letter to the member explaining that the request cannot be acted upon until the documentation/information is provided. We will also send the member a copy of the letter we sent you requesting documentation/information. 3. If you do not provide us with the needed documentation/information within seven days of our letter to the member, we will send the member a letter informing him or her of the denial of the requested services and provide the member an opportunity to request an appeal through our internal appeals process and HHSC's fair hearing process.

14.5.2 Notice of Authorization Form

In the event a dental office chooses to submit for predetermination of benefits by submitting a TAR, the NOA is a computer-generated form that is sent to the dentist following the final processing of a TAR. We will issue you two copies of the NOA:

Provider Hotline (Medicaid): 1-877-576-5899 www.deltadentalins.com/tx-medicaid Provider Hotline (CHIP): 1-866-561-5891 www.deltadentalins.com/tchip

Page 92

Texas Children's Medicaid and CHIP Dental Services Provider Manual

One copy to be returned to Delta Dental upon completion of the treatment [see Exhibit B, Sample Notice of Authorization Form (Delta Dental Copy)]. One copy to be retained by your office [see Exhibit C, Sample Notice of Authorization Form (Dentist Copy)].

The NOA must be used to submit the case to Delta Dental for payment after completion of the authorized treatment. However, the NOA is not a guarantee of payment. Delta Dental can issue payment only if:

The member was eligible on the date of service. The member has not attained his or her annual maximum. No other factors have come to Delta Dental's attention that would change the estimated benefit payment (such as the existence of other coverage, or changes in the patient's oral health).

Provider Hotline (Medicaid): 1-877-576-5899 www.deltadentalins.com/tx-medicaid

Provider Hotline (CHIP): 1-866-561-5891 www.deltadentalins.com/tchip

Page 93

Texas Children's Medicaid and CHIP Dental Services Provider Manual

Exhibit B, Sample Notice of Authorization (Delta Dental Copy)

Provider Hotline (Medicaid): 1-877-576-5899 www.deltadentalins.com/tx-medicaid

Provider Hotline (CHIP): 1-866-561-5891 www.deltadentalins.com/tchip

Page 94

Texas Children's Medicaid and CHIP Dental Services Provider Manual

Exhibit C, Sample Notice of Authorization (Dentist Copy)

Provider Hotline (Medicaid): 1-877-576-5899 www.deltadentalins.com/tx-medicaid

Provider Hotline (CHIP): 1-866-561-5891 www.deltadentalins.com/tchip

Page 95

Texas Children's Medicaid and CHIP Dental Services Provider Manual

The NOA you receive will include the same information that was originally submitted by your office:

Authorized period of time (120 days). Patient information. Provider information. Procedures allowed, modified, disallowed. Allowances. Adjudication reason codes.

The following items on the NOA require completion by the dental office. The required items are listed as they are numbered on the NOA. Field Patient Identification Number Instructions Enter the patient's CIN as it appears on the Texas Medicaid and CHIP Dental Services identification card. Completion of this item is required. Radiographs Attached? How Many? Check if "Yes" and indicate the number of films enclosed. All radiographs and any attachments must be identified with the patient's name and date and the provider's name and dentist license number. Multiple radiographs must be mounted. If additional treatment not requiring prior authorization is added to the NOA, x-rays may be required to justify the additional service. (See Attachment L, Codes, Messages and Special Cases for a description of requirements for a specific procedure.) Other Attachments and/or Documentation Accident/Injury? Check if "Yes." Other attachments include related correspondence, periodontal charts, etc. Check "Yes" if the patient was in an accident or incurred

Provider Hotline (CHIP): 1-866-561-5891 www.deltadentalins.com/tchip

Provider Hotline (Medicaid): 1-877-576-5899 www.deltadentalins.com/tx-medicaid

Page 96

Texas Children's Medicaid and CHIP Dental Services Provider Manual

Field Employment Related?

Instructions an injury that resulted in the need for dental services. Additionally, if the patient's accident or injury was "Employment Related," check "Yes."

Other Dental Coverage?

Check "Yes" if the services performed are either fully or partially covered by a private or employer paid dental insurance carrier. You must bill the other insurance carrier prior to submitting the claim to Delta Dental. In the "COMMENTS" section (item 34), furnish the full name and address of the other insurance carrier and the policyholder's name, member ID number (if available), and group number. Attach a copy of the other insurance carrier's EOB or denial letter.

Delete

If treatment was not performed and you wish to delete the authorization, place an "X" in the column corresponding to the treatment not performed. Do not strike out the entire line. Failure to mark an "X" in box 41 for treatment not performed may result in a delay of payment for those services that were performed.

Date Service Performed

Indicate the date the service was performed. Use six numerical digits (e.g. MM/DD/YY).

Treating Provider Number

If there is more than one dentist at a service office billing under a single dentist's provider number, enter the provider number of the dentist who performed the service. The treating provider number should be entered

Provider Hotline (Medicaid): 1-877-576-5899 www.deltadentalins.com/tx-medicaid

Provider Hotline (CHIP): 1-866-561-5891 www.deltadentalins.com/tchip

Page 97

Texas Children's Medicaid and CHIP Dental Services Provider Manual

Field

Instructions on each claim line. All treating providers must be credentialed and enrolled in the Texas Medicaid and CHIP Dental Services. Failure to enroll all treating providers will result in the denial of payment for those services performed by an un-enrolled provider. If there is only one dentist treating patients at a service office, the item "TREATING PROVIDER NUMBER" does not need to be completed for any claim line.

Date Prosthesis Ordered

Not applicable for the Texas Medicaid and CHIP Dental Services.

Prosthesis Line Item

Not applicable for the Texas Medicaid and CHIP Dental Services.

Comments

Use for additional clinical remarks necessary to document treatment or for requested information regarding other coverage, etc.

Patient Co-payment Amount

Not applicable for the Texas Medicaid and CHIP Dental Services.

Other Coverage Amount The dollar amount of "other coverage" payments the (for payment claims only) provider has received for the listed procedure. If either item 13 (OTHER DENTAL COVERAGE) is checked "YES," the amount received from the private dental insurance carrier must be entered. The EOB or denial letter from the private dental insurance carrier must be attached to the claim for payment. Date Billed Enter the date the form is mailed using the six numeric digit format (e.g., MM/DD/YY).

Provider Hotline (Medicaid): 1-877-576-5899 www.deltadentalins.com/tx-medicaid

Provider Hotline (CHIP): 1-866-561-5891 www.deltadentalins.com/tchip

Page 98

Texas Children's Medicaid and CHIP Dental Services Provider Manual

Field Signature Block

Instructions The dentist, or person authorized by the dentist, must sign their own name in this signature box and date the form when requesting payment.

Additional services not requiring prior authorization may be added to the NOA. However, x-rays or documentation may be required to justify the additional services. After you have filled out the NOA, please do the following:

Review it for completeness and legibility. If the procedures performed require submission of x-rays: Place x-rays in an envelope and place behind the NOA form. Affix a "Do Not Return" x-ray label on the outside of the x-ray envelope or on the x-ray mount. If you do not have a label, a handwritten note in the comments area of the document will suffice. (Delta Dental will recycle duplicate x-rays that are marked "Do Not Return.") Multi-page NOAs should be returned together. Detach and send the top portion marked "DELTA COPY" to Delta Dental. Fill in the appropriate shaded areas on the bottom portion marked "DENTIST COPY." Retain that copy for your office records.

If multiple services are authorized on an NOA, do not submit the NOA for payment until all authorized services for which you wish to receive payment have been completed. NOA Time Frames and Extensions Authorizations are granted for 120 days. In situations when this time frame is insufficient to complete treatment, you may request an extension of time. Extensions are allowed only once if requested within the original 120-day authorization time period. If the authorization has expired, a new TAR must be submitted. Below are two examples of how to request an extension. Scenario #1: You have not performed any services and you wish to provide treatment.

Check the "Extension of Time Is Requested" box at the upper right-hand corner of the NOA. Do not sign the NOA. Mail the completed NOA to Delta Dental.

Provider Hotline (CHIP): 1-866-561-5891 www.deltadentalins.com/tchip

Provider Hotline (Medicaid): 1-877-576-5899 www.deltadentalins.com/tx-medicaid

Page 99

Texas Children's Medicaid and CHIP Dental Services Provider Manual

A new NOA with a new authorization period will be generated and sent to your office.

Scenario #2: You have performed some services and wish to receive payment for those services. You also wish to request an extension of time to complete the remaining treatment.

Check the "Delete" box (item 41) for services not performed. Sign and date the form in the signature block (item 39). Complete a new TAR for the remaining treatment. Attach the NOA on top of the TAR and mail both forms to Delta Dental.

Payment will be made for those services performed. A new NOA for the remaining treatment requested on the TAR will be generated and sent to your office. Re-Evaluation of a TAR Using a NOA Use the NOA to request re-evaluation of modified or disallowed procedures that were requested with a TAR. Re-evaluation of modified or denied procedures may be requested only once, and the request must be received within the original 120-day authorization period. To request re-evaluation of a TAR, follow these steps:

Check the box marked "Re-Evaluation is Required" at the upper right corner of the NOA. Do not sign the NOA. Include documentation and enclose x-rays as necessary. Send the NOA and any supporting documentation to Delta Dental.

If the information submitted is sufficient to allow authorization of the treatment, a new NOA will be generated and sent to your office. If, upon reconsideration, Delta Dental upholds the original decision to disallow payment of the claim or authorization of treatment, the provider may request an appeal.

14.5.3 Outstanding TARs

Because TARs can remain outstanding in the automated system for an extended length of time, Delta Dental may deny authorization or payment of duplicate services submitted on a new claim or TAR from the same or different dental office. The adjudication reason code for this denial is #300: Procedure recently authorized to a same/different provider. Delta Dental may reconsider denial of authorization or payment of services duplicated on an outstanding TAR under the following circumstances:

Provider Hotline (Medicaid): 1-877-576-5899 www.deltadentalins.com/tx-medicaid Provider Hotline (CHIP): 1-866-561-5891 www.deltadentalins.com/tchip

Page 100

Texas Children's Medicaid and CHIP Dental Services Provider Manual

Written notification from the patient stating that he or she will not be returning to the original dentist's office. Closure of the original dentist's office. Sale of the original dentist's practice. Death of the original dentist. Refusal of the original dentist to return the NOA. Treatment (such as extraction) was provided on an emergency basis by one dentist when authorization for the same treatment was granted previously to a different dentist.

For reconsideration of denial of authorization or payment under these circumstances, please follow these guidelines:

Obtain a written statement from your patient that treatment will not be provided by the original dentist. For an EOB showing denial of payment, attach your patient's statement to the EOB and follow the normal procedures for the CIF. For an NOA showing denial of treatment authorization, attach your patient's statement and any other supporting documentation to the NOA, and submit the NOA with necessary x-rays to obtain reauthorization of the services.

Delta Dental will send to your office a new NOA showing the approved and allowed services. Delta Dental will void the original TAR. We will also send a new NOA to the original provider with the previously authorized procedures disallowed. Disallowed services will be indicated with Adjudication Reason Code 555 ("Authorization of this line is no longer valid") due to one of the following reasons:

Patient is/was being treated elsewhere. Treatment was performed as an emergency. A new claim/TAR is being processed.

14.5.4 Explanation of Benefits Form

The EOB is a computer-generated statement that accompanies each check sent to Texas Medicaid and CHIP Dental Services providers. It lists all paid and denied claims that have been adjudicated or adjusted during the payment cycle, as well as non-claimsspecific information. Claims and TARs that have been in process over 18 days are also listed.

Provider Hotline (Medicaid): 1-877-576-5899 www.deltadentalins.com/tx-medicaid

Provider Hotline (CHIP): 1-866-561-5891 www.deltadentalins.com/tchip

Page 101

Texas Children's Medicaid and CHIP Dental Services Provider Manual

Below is an explanation of each item shown in Exhibit D, Sample Explanation of Benefits. Each item listed below is numbered to correspond to the numbered items in Exhibit D. Line Item Reference lines preceded by an "R" Reference lines preceded by a "C" Provider Number Provider's Name and Address Check Number Date Page Number Status Code Definition Explanation/Description Contain member information. Contain claim information for the listed patient. The provider's Delta Dental ID number. The provider's name and billing address. Number of the check issued with the EOB. Date EOB was issued. Page number of the EOB. The status code used to identify each claim line ("P" = Paid, "D" = Denied, and "A" = Adjusted). Patient Name Each member (patient) is listed once per category. Patient ID Number Sex The member's ID number. The sex code for each recipient ("M" = male and "F" = female). Birth Date Document Control Number (DCN) Birth date of each member. The number assigned to each claim by Delta Dental. Tooth Code List the tooth number, letter, arch or quadrant on which the procedure was performed. Procedure Code The code listed on a claim line that identifies the procedure performed. This code may be

Provider Hotline (Medicaid): 1-877-576-5899 www.deltadentalins.com/tx-medicaid Provider Hotline (CHIP): 1-866-561-5891 www.deltadentalins.com/tchip

Page 102

Texas Children's Medicaid and CHIP Dental Services Provider Manual

Line Item

Explanation/Description different from the procedure code submitted on the claim or TAR because the procedure code may have been modified by a professional or paraprofessional for successful adjudication of the claim.

Date of Service Status

The date the service was performed. Identifies the status of each claim line. These codes are explained in Attachment L under "EOB Claims In Process Reason Codes."

Reason Code

This code explains why a claim was either paid at an amount other than billed, changed, altered during processing, or denied. The reason codes and a written explanation of each one are printed on the EOB.

Amount Billed Allowed Amount

The amount billed for each claim line. The amount allowed for each claim line. This amount is the lesser of the billed amount or the amount allowed by the Schedule of Allowances.

Co-Payment

The amount the patient paid toward a copayment obligation for procedures rendered.

Other Coverage Amount Paid

The amount paid by another carrier. The total amount paid to a provider after deductions, if applicable.

Claims Specific

These amounts are the totals for all adjudicated claim lines listed on the EOB. Only printed on

Provider Hotline (Medicaid): 1-877-576-5899 www.deltadentalins.com/tx-medicaid

Provider Hotline (CHIP): 1-866-561-5891 www.deltadentalins.com/tchip

Page 103

Texas Children's Medicaid and CHIP Dental Services Provider Manual

Line Item Non-Claims Specific

Explanation/Description the last page of the EOB. The (a) payables amount, (b) levy amounts, and (c) accounts receivable amounts. Only printed on the last page of the EOB.

Check Amount

The amount of the check that accompanies this EOB.

Provider Hotline (Medicaid): 1-877-576-5899 www.deltadentalins.com/tx-medicaid

Provider Hotline (CHIP): 1-866-561-5891 www.deltadentalins.com/tchip

Page 104

Texas Children's Medicaid and CHIP Dental Services Provider Manual

Exhibit D, Sample Explanation of Benefits

Provider Hotline (Medicaid): 1-877-576-5899 www.deltadentalins.com/tx-medicaid

Provider Hotline (CHIP): 1-866-561-5891 www.deltadentalins.com/tchip

Page 105

Texas Children's Medicaid and CHIP Dental Services Provider Manual

14.5.5 Claim Inquiry Form

The CIF (see Exhibit E, Sample Claim Inquiry Form), may be used to inquire about the status of a claim or TAR or to request re-evaluation of a modified or denied claim. Any other type of inquiry or request (e.g., check inquiries) should be handled through correspondence. Before sending a CIF, please call our Provider Hotline. We may be able to answer your inquiry immediately. CIFs may be obtained free of charge from Delta Dental. Instructions for Completing the CIF Instructions for completing the CIF are presented below. Use one CIF for one claim or TAR inquiry. Please print or type all information. Field Billing Provider Name Provider Number Service Office Address Telephone Number Explanation/Description Enter the dentist's name. Enter the Delta Dental provider number. Enter address of the billing provider. Enter area code and telephone number of billing provider. City, State, ZIP Code Enter the city, state, and ZIP code where the service office is located. Patient Name Enter the patient's last name, first name, and middle initial. Document Control Number (for claim reevaluation only) Patient ID Number Enter the DCN of the document in question. Enter the patient's 9-digit member ID number. Patient Dental Record Number If you assign a dental record number or account number to a patient, enter the assigned number that will be referenced

Provider Hotline (Medicaid): 1-877-576-5899 www.deltadentalins.com/tx-medicaid

Provider Hotline (CHIP): 1-866-561-5891 www.deltadentalins.com/tchip

Page 106

Texas Children's Medicaid and CHIP Dental Services Provider Manual

Field

Explanation/Description on any subsequent correspondence from Delta Dental.

Date Billed

Enter the date the claim or the TAR was originally mailed to Delta Dental.

Patient Group Number

Enter the member's participating group number.

Inquiry Reason (check only one box)

Indicate if this inquiry is seeking the status of a claim or TAR ("tracer") or is requesting a re-evaluation of a claim.

Remarks

Use this area to provide any additional information needed to justify the inquiry being made. Include x-rays if appropriate. Prior to completing the CIF, please review the manual of criteria section of this manual to determine the specific criteria, time limitations, and submission requirements of the procedure in question.

Signature

The provider, or person authorized by the provider, must sign and date the form. Rubber stamp signatures are not acceptable.

Provider Hotline (Medicaid): 1-877-576-5899 www.deltadentalins.com/tx-medicaid

Provider Hotline (CHIP): 1-866-561-5891 www.deltadentalins.com/tchip

Page 107

Texas Children's Medicaid and CHIP Dental Services Provider Manual

Exhibit E, Sample Claim Inquiry Form

Provider Hotline (Medicaid): 1-877-576-5899 www.deltadentalins.com/tx-medicaid

Provider Hotline (CHIP): 1-866-561-5891 www.deltadentalins.com/tchip

Page 108

Texas Children's Medicaid and CHIP Dental Services Provider Manual

CIF Time Limitations Claim/TAR Status Claims for full payment must be submitted not more than 95 days after the services were performed. Providers must submit all appeals of denied claims, requests for adjustments on paid claims, and CIFs within 120 days from the date of disposition of the EOB on which that claim appears. If the status of a claim or TAR does not appear on the EOB in the "Documents-in-Process" section within one month after the claim was submitted, you should complete a CIF, check the appropriate box under "Claim/TAR Tracer" and send it to Delta Dental. Claim Re-Evaluations For Delta Dental to request reconsideration of a payment denial or modification, the dentist should begin by submitting a CIF within 120 days from the date of disposition of the EOB on which that claim appears. The EOB contains the codes necessary to determine the reason(s) why payment of a claim was disallowed. Similarly, the NOA lists the codes and reason(s) for denial or modification of a TAR. (Attachment L includes a complete listing of the codes.) If you submit a CIF, be sure to include any additional x-rays or documentation pertinent to the procedure under reconsideration. Also include the document control number (DCN) when submitting any inquiry or request for re-evaluation of a processed claim. Check the box on the CIF marked "Claim Re-Evaluation Only." Remember to send a separate CIF for each inquiry. A dental office should wait until the status of a processed claim appears on the EOB before submitting a CIF for re-evaluation. The EOB will give the reason why the claim was modified or disallowed. Please review this information carefully to determine whether additional x-rays or documentation should be submitted along with the CIF. Prior to completing the CIF, please review the appropriate MOC to determine the specific criteria, time limitations, and submission requirements of the procedure in question. A response to your re-evaluation request will appear on the EOB in the "Adjusted Claims" section.

14.5.6 Claim Inquiry Response Form

Upon resolution of the CIF seeking the status of a claim or TAR, Delta Dental will issue a Claim Inquiry Response (CIR). The CIR is a computer-generated form (see Exhibit F, Sample Claim Inquiry Response Form), used to explain the status of the claim or TAR.

Provider Hotline (Medicaid): 1-877-576-5899 www.deltadentalins.com/tx-medicaid

Provider Hotline (CHIP): 1-866-561-5891 www.deltadentalins.com/tchip

Page 109

Texas Children's Medicaid and CHIP Dental Services Provider Manual

Exhibit F, Sample Claim Inquiry Response Form

Provider Hotline (Medicaid): 1-877-576-5899 www.deltadentalins.com/tx-medicaid

Provider Hotline (CHIP): 1-866-561-5891 www.deltadentalins.com/tchip

Page 110

Texas Children's Medicaid and CHIP Dental Services Provider Manual

When the CIR is received, it will be printed with the same information submitted by your office and will identify the patient name, patient member's ID number, patient dental record or account number (if applicable), DCN, and the date billed. The section entitled "In Response to Your Delta Dental Inquiry" will contain a status code and a typed explanation of that code. The status codes are listed in Attachment L in the table titled "Claim Inquiry Response (CIR) Status Codes and Messages."

14.6

ELECTRONIC CLAIMS SUBMISSION

To get started with electronic claims submission, please contact our Provider Hotline or write to Delta Dental at the address below. We will walk you through the necessary steps to set up your office to submit claims electronically. Delta Dental Mailing Address Texas Children's Medicaid and CHIP Dental Services State Government Programs PO Box 537014 Sacramento, CA 95853-7014

14.7

ELECTRONIC PAYMENT SERVICES

Delta Dental offers direct deposit of your Texas Medicaid and CHIP Dental Services payments to your checking or savings account. To begin participating in direct deposit, you must complete and sign a Direct Deposit Enrollment Form. You may request a form by calling Delta Dental's Provider Hotline or by writing to us at the address above. Instructions for completing the Direct Deposit Enrollment Form are contained on the back of the form. Mail the completed form to Delta Dental at the address shown above. Please be sure to sign and date the form; it must contain the provider's original signature to be accepted for processing. Upon receipt of your Direct Deposit Enrollment Form, Delta Dental will verify that your bank participates in electronic funds transfer. To verify your account information, Delta Dental will send a "test" deposit to your bank; you will notice a "zero" deposit to your account for that payment date. The direct deposit process usually takes three to four weeks to complete. During this time, you will continue to receive your Texas Medicaid and CHIP Dental Services payment checks through the mail. Each time Delta Dental deposits a payment directly to your account, a statement confirming the amount of the deposit will appear on your EOB. Remember to contact Delta Dental if you wish to change or discontinue direct deposit for your payment checks. If you change banks or close your account, you must provide

Provider Hotline (Medicaid): 1-877-576-5899 www.deltadentalins.com/tx-medicaid Provider Hotline (CHIP): 1-866-561-5891 www.deltadentalins.com/tchip

Page 111

Texas Children's Medicaid and CHIP Dental Services Provider Manual

Delta Dental with written authorization to discontinue direct deposit of your Texas Medicaid and CHIP Dental Services checks.

14.8

BILLING INTERMEDIARIES

A billing intermediary may include any entity such as a partnership, corporation, sole proprietorship, or individual that is contracted with a dentist to bill on his or her behalf. A dentist's salaried employees are not considered billing intermediaries. If you use a billing intermediary for claims preparation and submission, you must complete a Provider Billing Intermediary Notification Form and send it to Delta Dental. Please use this form to notify Delta Dental of the initiation, renewal, or termination of a billing intermediary contract. The billing intermediary you choose to submit Texas Medicaid and CHIP Dental Services claims to Delta Dental must register with us by completing a Billing Intermediary Registration Form. Upon registration, we will assign a registration number that the billing service must include on all claims submitted. To obtain a Provider Billing Intermediary Notification Form and/or Billing Intermediary Registration Form, call our Provider Hotline or write to us at the address below. Delta Dental Mailing Address Texas Children's Medicaid and CHIP Dental Services State Government Programs PO Box 537014 Sacramento, CA 95853-7014 When a dentist notifies Delta Dental of billing service arrangements, Delta Dental will acknowledge the notification within 10 days. Delta Dental will also notify a dentist when one of the following occurs:

A billing intermediary notifies Delta Dental that it has contracted with a dentist. A billing intermediary notifies Delta Dental that it has terminated its contract with a dentist. A billing intermediary that submits Texas Medicaid and CHIP Dental Services claims for a dentist notifies Delta Dental that it is withdrawing its registration as a billing intermediary.

14.9

COST-SHARING AND CO-PAYMENTS (CHIP)

You are responsible for collecting at the time of service any applicable CHIP copayments or deductibles in accordance with CHIP cost-sharing limitations. Effective March 1, 2012, CHIP members will be required to pay an office visit co-payment for

Provider Hotline (Medicaid): 1-877-576-5899 www.deltadentalins.com/tx-medicaid Provider Hotline (CHIP): 1-866-561-5891 www.deltadentalins.com/tchip

Page 112

Texas Children's Medicaid and CHIP Dental Services Provider Manual

each non-preventive dental visit. To determine the applicable co-payment, see Attachment M, Cost-Sharing Schedule (CHIP Members).

14.10

BILLING MEMBERS

As a contracting dentist, you understand and agree to the following:

You must not charge cost-sharing or deductibles to CHIP members of Native America tribes or Alaskan Natives. You must not charge co-payments or deductibles to a CHIP member with an ID card that indicates the member has met his or her cost-sharing obligation for the balance of his or her term of coverage. Co-payments are the only amounts that you may collect from CHIP members, except for costs associated with unauthorized non-emergency services provided to members by out-of-network providers for non-covered services. You may not submit a claim to or demand or otherwise collect reimbursement from a member or from any other persons on behalf of the member for any covered dental service, regardless of whether or not payment was issued by Delta Dental. This prohibition does not apply to co-payments (for CHIP members only), collection of charges for optional treatment, treatment provided after the member's annual maximum has been reached, non-covered services, or third-party collections according to your Contracting Dentist Agreement. You are prohibited from billing or collecting any amount from a Medicaid member for dental services provided pursuant to the Contracting Provider Agreement. Federal and state laws provide severe penalties for any provider who attempts to bill or collect any payment from a Medicaid recipient for a covered service. You may not bill or collect from a member any charges in connection with an optional or non-covered dental service unless an executed Financial Responsibility or Optional Treatment form has been obtained from the member or the member's legal representative. Completion of this form ensures that members are aware of their financial obligations. Contracting dental offices may use any form for this purpose as long as it specifically includes the fees associated with the optional or non-covered service. Samples of private pay agreement forms are included in Attachment I.

Provider Hotline (Medicaid): 1-877-576-5899 www.deltadentalins.com/tx-medicaid

Provider Hotline (CHIP): 1-866-561-5891 www.deltadentalins.com/tchip

Page 113

Texas Children's Medicaid and CHIP Dental Services Provider Manual

15.0

SPECIAL ACCESS REQUIREMENTS

Special access requirements are addressed in the following subsections:

15.1, Interpreter/Translation Services. 15.2, Delta Dental and Provider Coordination. 15.3, Reading/Grade Level Consideration. 15.4, Cultural Sensitivity. 15.5, Direct Access to Specialists (Members with Special Health Care Needs).

15.1

INTERPRETER/TRANSLATION SERVICES

In addition to staffing Spanish and English bilingual Member Hotline customer service representatives, Delta Dental assists providers in dealing with Limited English Proficient (LEP) patients. You can access an interpreter's services at any time using the AT&T language line, which provides services in over 150 languages. To help you communicate with Texas Medicaid and CHIP Dental Services program members, you can also receive face-to-face interpreting services in your dental office. These services are provided free of charge to contracting dentists. For more information, call our Provider Hotline.

15.2

DELTA DENTAL AND PROVIDER COORDINATION

Delta Dental is committed to ongoing coordination with Texas Medicaid and CHIP Dental Services members to help ensure that members receive high-quality dental care. We refer members to contracting dentists for covered services and provide coordination of care for non-covered services. Coordination of care includes:

Identifying providers of medically necessary dental services. Helping members access needed medically necessary dental services to the extent they are available to the member.

We emphasize the importance of ongoing coordination with providers as part of our provider training curricula. In addition, one-on-one interactions with providers occur when providers call our Provider Hotline, during on-site visits by provider relations representatives, and when Delta Dental case management staff and/or Medicaid member advocates interact with providers to help ensure that members with special health care needs receive services.

Provider Hotline (Medicaid): 1-877-576-5899 www.deltadentalins.com/tx-medicaid

Provider Hotline (CHIP): 1-866-561-5891 www.deltadentalins.com/tchip

Page 114

Texas Children's Medicaid and CHIP Dental Services Provider Manual

15.3

READING/GRADE LEVEL CONSIDERATION

Member materials for Delta Dental's Texas Medicaid and CHIP Dental Service members have been written at or below a 6th-grade reading level, as measured by the FleschKincaid reading ease test.

15.4

CULTURAL SENSITIVITY

Delta Dental has designed and implemented a cultural and linguistics program that has two primary goals:

To help members and providers understand each another regardless of native language. To ensure equal access to care to all members of all cultural backgrounds.

We work on an ongoing basis to help providers achieve cultural sensitivity and cultural competence. Resources available to providers include a provider education packet, bilingual glossaries of dental terminology, and cultural competency workshops. These tools, paired with member education resources--such as member newsletters, document translation, and community outreach--help us to achieve mutual understanding between members and providers.

15.5

DIRECT ACCESS TO SPECIALISTS (MEMBERS WITH SPECIAL HEALTH CARE NEEDS)

Delta Dental defines special needs as any medically compromising condition that may affect the provision of dental treatment. Case management services are handled by Delta Dental's Member Services department, which serves as a liaison between members with special health care needs, their dental providers and, when appropriate, their medical providers. A contracting dentist may contact our Member Hotline to facilitate case management services for Texas Medicaid and CHIP Dental Services members whose medical conditions classify them as special needs patients. Case management includes, but is not limited to, ensuring that members with special health care needs have direct access to specialist providers as appropriate to their condition and identified health needs (e.g., a standing referral to a specialty physician).

Provider Hotline (Medicaid): 1-877-576-5899 www.deltadentalins.com/tx-medicaid

Provider Hotline (CHIP): 1-866-561-5891 www.deltadentalins.com/tchip

Page 115

Texas Children's Medicaid and CHIP Dental Services Provider Manual

16.0

OTHER REQUIREMENTS

Other requirements applicable to Texas Medicaid and CHIP Dental Services providers are presented in the following subsections:

16.1, Access to Records. 16.2, Audit or Investigation. 16.3, Communication with Members. 16.4, Form 1099 Earnings. 16.5, Insurance. 16.6, Laws, Rules, and Regulations. 16.7, Liability. 16.8, Marketing. 16.9, Payment Policies. 16.10, Privacy and Confidentiality of Member Information. 16.11, Termination of the Contracting Dentist Agreement. 16.12, Third-Party Recovery. 16.13, Time Limitations for Billing. 16.14, Updates to Provider Contact Information.

For a list of terms and definitions used throughout this provider manual, see Attachment N, Glossary.

16.1

ACCESS TO RECORDS

As a Texas Medicaid and CHIP Dental Services contracting dentist, you are required to ensure that an accurate and complete patient dental record is established and maintained. Upon request, you must provide information from a member's dental record to Delta Dental for purposes of authorization or other quality and utilization review activities. You must also allow Delta Dental's authorized personnel, its designated representatives, accreditation and review organizations, and government agencies on-site access to such records during regular business hours. If requested, you must provide HHSC with the following records according to timelines, definitions, formats, and instructions specified by HHSC:

All information required under the Contracting Dentist Agreement, including but not limited to the reporting requirements related to your performance of obligations under the agreement.

Provider Hotline (Medicaid): 1-877-576-5899 www.deltadentalins.com/tx-medicaid

Provider Hotline (CHIP): 1-866-561-5891 www.deltadentalins.com/tchip

Page 116

Texas Children's Medicaid and CHIP Dental Services Provider Manual

Any information in your possession sufficient to permit HHSC to comply with the federal Balance Budget Act of 1997 or any other federal or state laws, rules and regulations.

Your Contracting Dentist Agreement with Delta Dental specifies that, upon receipt of a record review request from the HHSC OIG or another state or federal agency authorized to conduct compliance, regulatory, or program integrity functions, a provider must provide, at no cost to the requesting agency, the records requested within 24 hours of the request. If the OIG or another state or federal agency representative reasonably believes that the requested records are about to be altered or destroyed or that the request may be completed at the time of the request and/or in less than 24 hours, the provider must provide the records requested at the time of the request and/or in less than 24 hours. The request for record review includes, but is not limited to:

Clinical medical or dental member records. Other records pertaining to the member. Any other records of services provided to Medicaid or other health and human services program recipients and payment made for those services. Documents related to diagnosis, treatment, service, lab results, and charting. Billing records and invoices. Documentation of delivery items, equipment, or supplies. Radiographs and study models related to orthodontia services. Business and accounting records with backup support documentation. Statistical documentation. Computer records and data. Contracts with providers and subcontractors.

Failure to produce the records or make the records available for the purpose of reviewing, examining, and securing custody of the records may result in OIG imposing sanctions against the provider as described in 1 T.A.C. Chapter 371 Subchapter G. The requirements for access to dental records are contained on the back of the Texas Medicaid and CHIP Dental Services treatment forms. Before you sign a Texas Medicaid and CHIP Dental Services treatment form, it is important that you read and understand the information on the back of the form. When you sign the form and submit it to Delta Dental, you are certifying your agreement to comply with all of these requirements. If you have any questions about these requirements, please call the Provider Hotline.

Provider Hotline (Medicaid): 1-877-576-5899 www.deltadentalins.com/tx-medicaid

Provider Hotline (CHIP): 1-866-561-5891 www.deltadentalins.com/tchip

Page 117

Texas Children's Medicaid and CHIP Dental Services Provider Manual

16.2

AUDIT OR INVESTIGATION

You are required to provide the following entities or their designees with prompt, reasonable, and adequate access to the Contracting Dentist Agreement and any records, books, documents, and papers that are related to the agreement and/or your performance of responsibilities under the agreement:

The U.S. Department of Health and Human Services or its designee. The Comptroller General of the United States or its designee. Managed care organization personnel from HHSC or its designee. The Office of Inspector General. The Medicaid Fraud Control Unit of the Texas Attorney General's Office or its designee. Any independent verification and validation contractor, audit firm, or quality assurance contractor acting on behalf of HHSC. The Office of the State Auditor of Texas or its designee. A state or federal law enforcement agency. A special or general investigating committee of the Texas Legislature or its designee. Any other state or federal entity identified by HHSC, or any other entity engaged by HHSC.

You must provide access to the location or facility where such records, books, documents, and papers are maintained. You must provide such access in reasonable comfort, furnishings, equipment, and other conveniences necessary to fulfill the following described purposes:

Examination. Audit. Investigation. Contract administration. The making of copies, excerpts, or transcripts. Any other purpose HHSC deems necessary for contract enforcement or to perform its regulatory functions.

You must understand and agree that the acceptance of funds under this contract acts as acceptance of the authority of the State Auditor's Office (SAO), or any successor agency, to conduct an investigation in connection with those funds. You must further agree to cooperate fully with the SAO or its successor in the conduct of the audit or investigation, including providing all records requested.

Provider Hotline (Medicaid): 1-877-576-5899 www.deltadentalins.com/tx-medicaid

Provider Hotline (CHIP): 1-866-561-5891 www.deltadentalins.com/tchip

Page 118

Texas Children's Medicaid and CHIP Dental Services Provider Manual

16.3

COMMUNICATION WITH MEMBERS

Delta Dental is prohibited from imposing restrictions on your free communication with a member about the member's medical conditions, treatment options, Delta Dental's referral policies, and other Delta Dental policies, including financial incentives or arrangements and all dental plans with whom you contract.

16.4

FORM 1099 EARNINGS

For tax purposes, Delta Dental uses Form 1099 to report earnings to the Internal Revenue Service (IRS) for each billing provider who has received payment from Delta Dental during the year. Federal law requires that Delta Dental mail 1099 forms by January 31 of each year to reflect earnings from January 1 through December 31 of the previous year. It is the dentist's responsibility to make certain that Delta Dental has the correct billing provider name, address, and taxpayer identification number (TIN) or social security number (SSN) that corresponds exactly to the information the IRS has on file. If this information does not correspond exactly, Delta Dental is required by law to apply a 31percent withholding to all future payments made to the billing provider. To verify how your tax information is registered with the IRS, please refer to the preprinted label on IRS Form 941, "Employer's Quarterly Federal Tax Return" or any other IRS-certified document. You may also contact the IRS to verify how your business name and TIN or SSN are recorded. If you do not receive your 1099 form or if your tax or earnings information is incorrect, please contact Delta Dental's Provider Hotline for the appropriate procedures for reissuing a correct 1099 form.

16.5

INSURANCE

You must maintain the following insurance coverage while you are providing covered services to Texas Medicaid and CHIP Dental Services members:

Professional liability (malpractice) insurance of $100,000 per occurrence and $300,000 in the aggregate, or the limits required by any hospital at which you have admitting privileges. Workers' compensation coverage in the amounts required by Texas law. Comprehensive liability insurance, including bodily injury coverage of $100,000 per occurrence. Comprehensive liability insurance, including property damage coverage of $25,000 per occurrence.

Provider Hotline (Medicaid): 1-877-576-5899 www.deltadentalins.com/tx-medicaid

Provider Hotline (CHIP): 1-866-561-5891 www.deltadentalins.com/tchip

Page 119

Texas Children's Medicaid and CHIP Dental Services Provider Manual

16.6

LAWS, RULES, AND REGULATIONS

You are subject to all state and federal laws, rules, regulations, waivers, policies, guidelines, court-ordered consent decrees, settlement agreements or other court orders that apply to the Contracting Dentist Agreement, HHSC/Delta Dental contract, the Texas Medicaid and CHIP Dental Services program, and all persons or entities receiving state and federal funds. Any violation by a dentist of a state or federal law relating to the delivery of services pursuant to the Contracting Dentist Agreement or any violation of the HHSC/Delta Dental contract could result in liability for money damages, and/or civil or criminal penalties and sanctions under state and/or federal law. You must understand and agree that the following laws, rules, and regulations, and all amendments and modifications thereto, apply to your agreement:

Environmental protection laws. Pro-Children Act of 1994 (20 U.S.C. §6081 et seq.) regarding the provision of a smoke-free workplace and promoting the non-use of all tobacco products. National Environmental Policy Act of 1969 (42 U.S.C. §4321 et seq.) and Executive Order 11514 ("Protection and Enhancement of Environmental Quality") relating to the institution of environmental quality control measures. Clean Air Act and Water Pollution Control Act regulations (Executive Order 11738, "Providing for Administration of the Clean Air Act and Federal Water Pollution Control Act with Respect to Federal Contracts, Grants, and Loans"). State Clean Air Implementation Plan (42 U.S.C. §740 et seq.) regarding conformity of federal actions to State Implementation Plans under §176 (c) of the Clean Air Act. Safe Drinking Water Act of 1974 (21 U.S.C. §349; 42 U.S.C. §300F TO 300J) relating to protection of underground sources of drinking water. State and federal anti-discrimination laws. Title VI of the Civil Rights Act of 1964 (42 U.S.C. §2000d et seq.) and, as applicable, 45 C.F.R. Part 80 or 7 C.F.R. Part 15. Section 504 of the Rehabilitation Act of 1973. Americans with Disabilities Act of 1990. Age Discrimination Act of 1975 (42 U.S.C. §6101-6107). Title IX of the Education Amendments of 1972 (20 U.S.C. §1681-1688). Food Stamp Act of 1977 (7 U.S.C. §200 et seq.). Executive Order 13279, and its implementing regulations at 45 C.F.R. Part 87 or 7 C.F.R. Part 16. The HHS agency's administrative rules, as set forth in the T.A.C. to the extent applicable to the provider agreement.

Provider Hotline (CHIP): 1-866-561-5891 www.deltadentalins.com/tchip

Provider Hotline (Medicaid): 1-877-576-5899 www.deltadentalins.com/tx-medicaid

Page 120

Texas Children's Medicaid and CHIP Dental Services Provider Manual

The Immigration Reform and Control Act of 1986 (8 U.S.C. §1101 et seq.) and the Immigration Act of 1990 (8 U.S.C. §1101, et seq.) regarding employment verification and retention of verification forms. The Health Insurance Portability and Accountability Act of 1996 (Public Law 104191). The Health Information Technology for Economic and Clinical Health Act (HITECH ACT) at 42 U.S.C. 17931 et seq.

In addition, you are prohibited from including language in any contract/agreement you have with Texas Medicaid and CHIP Dental Services members that limits the member's ability to context claims payment issues or that binds the member to the insurer's interpretation of the contract terms.

16.7

LIABILITY

Delta Dental has the sole responsibility for payment of covered services rendered pursuant to Texas Medicaid and CHIP dental services, and HHSC is not liable or responsible for such payment. If Delta Dental becomes insolvent or ceases operations, your sole recourse against Delta Dental will be through Delta Dental's bankruptcy, conservatorship, or receivership estate. Texas Medicaid and CHIP Dental Services members may not be held liable for Delta Dental's debts in the event of Delta Dental's insolvency and you may not take any action directly or indirectly against a Texas Medicaid and CHIP Dental Services member to collect payment for any debts resulting from the provision of covered dental services. HHSC does not assume liability for the actions of, or judgments rendered against, Delta Dental, its employees, agents or subcontractors. There is no right of subrogation, contribution, or indemnification against HHSC for any duty owned to you by Delta Dental or any judgment rendered against Delta Dental. HHSC's liability to you, if any, will be governed by the Texas Tort Claims Act, as amended or modified (Tex. Civ. Pract. & Rem. Code §101.001 et seq.). Delta Dental will initiate and maintain any action necessary to stop you or your employee, agent, assign, trustee, or successor-in-interest from maintaining an action against HHSC, an HHS agency, or any member to collect payment from HHSC, an HHS agency, or any member, excluding payment for non-covered services. Additionally, this provision does not restrict a CHIP provider from collecting payment for services that exceed a CHIP member's benefit cap.

Provider Hotline (Medicaid): 1-877-576-5899 www.deltadentalins.com/tx-medicaid

Provider Hotline (CHIP): 1-866-561-5891 www.deltadentalins.com/tchip

Page 121

Texas Children's Medicaid and CHIP Dental Services Provider Manual

16.8

MARKETING

You are required to comply with HHSC's marketing policies and procedures as set forth in Chapter 4.3 of HHSC's Uniform Managed Care Marketing Policy and Procedure Manual (see www.hhsc.state.tx.us/medicaid/umcm/Chp4/4.3.pdf). You are prohibited from engaging in direct marketing to members that is designed to increase enrollment in a particular health plan. This prohibition should not constrain you from engaging in permissible marketing activities consistent with broad outreach objectives and application assistance.

16.9

PAYMENT POLICIES

Delta Dental will initiate and maintain any action necessary to stop a contracting dentist or his or her employee, agent, assign, trustee, or successor-in-interest from maintaining an action against HHSC, an HHS agency, or any member to collect payment from HHSC, an HHS agency, or any member, excluding payment for non-covered services. This provision does not restrict a CHIP provider from collecting allowable co-payment and deductible amounts from CHIP members. Additionally, this provision does not restrict a CHIP provider from collecting payment for services that exceed a CHIP member's benefit cap. Payment made by Delta Dental according to the guidelines of the Texas Medicaid and CHIP Dental Services program must be accepted by the provider as payment in full for covered services. A contracting dentist may not submit a claim to, or demand, or otherwise collect reimbursement from a Medicaid or CHIP member for any covered dental service regardless of whether payment was issued by Delta Dental. There is no member liability and a provider may not seek payment from a member in the event that payment or authorization is denied because the provider failed to comply with Delta Dental administrative requirements. It is the responsibility of the billing provider to comply with all administrative requirements as outlined in this manual. Failure to do so may result in denial of payment. Delta Dental will only pay for the lowest cost procedure that will correct the dental problem. For example, Delta Dental cannot allow a porcelain crown when a restoration would correct the dental problem (refer to Non-Covered and Optional Services for information on payment for services more expensive than those allowed by Delta Dental). The dentist must inform members of the costs for non-covered services prior to rendering such services and must obtain a signed private pay form from such a member.

Provider Hotline (Medicaid): 1-877-576-5899 www.deltadentalins.com/tx-medicaid

Provider Hotline (CHIP): 1-866-561-5891 www.deltadentalins.com/tchip

Page 122

Texas Children's Medicaid and CHIP Dental Services Provider Manual

A dental office cannot charge Delta Dental more than it charges a private patient for the services performed. The dental office should list its usual and customary fee when filling out the claim, TAR, or NOA.

16.10

PRIVACY AND CONFIDENTIALITY OF MEMBER INFORMATION

The privacy of patient health information continues to be at the forefront of the health care industry. Consumer demand for the protection of health information to retain privacy and deter identity theft has led to the passage of state and federal laws that affect how benefit-related information is handled. Delta Dental has adopted the Health Insurance Portability and Accountability Act (HIPAA) of 1996 into our daily business practices. HIPAA has brought many changes to the way Delta Dental conducts business--including implementing new code sets and a screening process for anyone wanting to obtain member information through the tollfree telephones. Delta Dental will continue to make HIPAA a priority in our daily business practices as we protect Texas Medicaid and CHIP Dental Services members' health information. As a contracting dentist, you understand and agree to the following:

In compliance with HIPAA, you must protect the confidentiality of memberprotected health information, including patient records. You must comply with all applicable federal and state laws, including the HIPAA Privacy and Security Rule governing the use and disclosure of protected health information. You are required to treat all information that is obtained through the performance of Texas Medicaid and CHIP dental services as confidential information to the extent that confidential treatment is provided under state and federal laws, rules, and regulations. This includes, but is not limited to, information relating to applicants or recipients of HHSC programs. You are prohibited from using such information in any manner except as is necessary for the proper discharge of obligations and securing of rights under your Contracting Dentist Agreement. You may not transfer an identifiable Texas Medicaid and CHIP Dental Services member's records, including a patient chart, to another entity or person without the written consent from the Texas Medicaid and CHIP Dental Services member or someone authorized to act on his or her behalf. However, HHSC may request and you must honor a request to transfer a member's record to another agency if HHSC determines that the transfer is necessary to protect either the confidentiality of the record or the health and welfare of the member.

Provider Hotline (Medicaid): 1-877-576-5899 www.deltadentalins.com/tx-medicaid

Provider Hotline (CHIP): 1-866-561-5891 www.deltadentalins.com/tchip

Page 123

Texas Children's Medicaid and CHIP Dental Services Provider Manual

16.11

TERMINATION OF THE CONTRACTING DENTIST AGREEMENT

Your Contracting Dentist Agreement with Delta Dental includes Delta Dental's process for terminating a provider contract. (For CHIP providers, the process must comply with the Texas Insurance Code and Texas Department of Insurance regulations). Either party may terminate the Contracting Dentist Agreement upon 30 days' written notice. Delta Dental may immediately terminate the agreement in a case involving:

Imminent harm to patient health. An action by a state medical or dental board, another medical or dental licensing board, or another licensing board or government agency that effectively impairs the provider's ability to practice medicine, dentistry, or another profession. Fraud or malfeasance.

16.11.1 Termination by the Provider

When a dentist terminates participation in the Texas Medicaid and CHIP Dental Services program, the dentist shall have the continuing obligation to schedule appointments and honor any existing appointments of Texas Medicaid and CHIP Dental Services members until the date of termination. Unless Delta Dental makes other reasonable and medically appropriate provisions for the performance of services, the dentist is obligated to complete all covered dental services begun prior to termination. Notice of voluntary dis-enrollment should be sent to Delta Dental.

16.11.2 Termination by Delta Dental

Termination of a network provider's Contracting Dentist Agreement is a last resort. If Delta Dental terminates a provider's agreement, we must follow the procedures (including those for significant traditional providers) outlined in §843.306 of the Texas Insurance Code. Where corrective action is recommended, our priority is to work with the provider to improve performance and compliance with all Delta Dental policies and protocols defined in the Contracting Dentist Agreement, Addendum, and this provider manual. Delta Dental is willing to provide reasonable forms of support to a dentist who shows sincere intent to correct deficiencies. Peer review of professional competency or conduct may result in a proposed adverse action for "medical disciplinary cause or reason" affecting a provider's continued participation in the Texas Medicaid and CHIP Dental Services program. A "medical disciplinary cause or reason" means an aspect of a provider's competence or

Provider Hotline (Medicaid): 1-877-576-5899 www.deltadentalins.com/tx-medicaid Provider Hotline (CHIP): 1-866-561-5891 www.deltadentalins.com/tchip

Page 124

Texas Children's Medicaid and CHIP Dental Services Provider Manual

professional conduct that is reasonably likely to be detrimental to the delivery of patient care. Delta Dental's Texas Medicaid and CHIP Dental Services dental director may immediately initiate corrective action against a provider for identified medical disciplinary cause, or any other reason where the dental director reasonably believes that the failure to take such action may result in imminent danger to the health of any individual. The dental director will confirm that the dentist is provided with a Notice of Action and explanation of hearing rights without delay. The time frames for the termination process are as follows:

At least 90 days before the effective date of the proposed termination of the provider's contract, Delta Dental must provide a written explanation to the provider of the reasons for termination. No later than 30 days following receipt of the termination notice, a provider may request a review of Delta Dental's proposed termination by an advisory review panel, except in a case in which there is imminent harm to patient health, an action against a license, or fraud or malfeasance. Within 60 days following receipt of the provider's request for review and before the effective date of the termination, the advisory review panel must make its formal recommendation and Delta Dental must communicate its decision to the provider.

The advisory review panel must be composed of physicians and providers, as those terms are defined in §843.306 of the Texas Insurance Code, including at least one representative in the provider's specialty or a similar specialty, if available, appointed to serve on Delta Dental's standing quality assurance committee or utilization review committee. The decision of the advisory review panel must be considered by Delta Dental but is not binding on Delta Dental. Delta Dental must provide to the provider, on request, a copy of the recommendation of the advisory review panel and Delta Dental's determination.

16.11.3 Termination for Gifts or Gratuities

In addition, you may not offer or give anything of value in violation of state law to any officer or employee of the State of Texas or HHSC. A "thing of value" means any item of tangible or intangible property that has a monetary value of more than $50.00 and includes, but is not limited to, cash, food, lodging, entertainment, and charitable contributions. The term does not include contributions to public office holders or candidates for public office that are paid and reported in accordance with state and/or federal law. Delta Dental may terminate a dentist from participation in the Texas Medicaid and CHIP Dental Services program at any time for violation of this requirement.

Provider Hotline (Medicaid): 1-877-576-5899 www.deltadentalins.com/tx-medicaid Provider Hotline (CHIP): 1-866-561-5891 www.deltadentalins.com/tchip

Page 125

Texas Children's Medicaid and CHIP Dental Services Provider Manual

16.12

THIRD-PARTY RECOVERY

Delta Dental is authorized to engage in third-party recovery actions for claims resulting from the care and/or treatment of members. You may not interfere with or place any liens upon the State of Texas's right or Delta Dental's right, acting as the state's agent, to recovery from third-party resources. CHIP coverage is secondary when coordinating benefits with all other insurance coverage. Coverage provided under CHIP will pay benefits for medically necessary covered dental services that remain unpaid after all other insurance coverage has been paid.

16.13

TIME LIMITATIONS FOR BILLING

There are time limitations for billing for services provided to Texas Medicaid and CHIP Dental Services members. Delta Dental must receive a claim no later than 95 days after the service was performed to consider the claim for payment. The time limitation for billing will be applied to each date of service. Delta Dental may receive and process late claims upon review of substantiating documentation that justifies the late submittal of a claim. The following is a list of reasons delayed submissions are acceptable when circumstances are beyond the control of the provider. A patient did not identify himself or herself to a provider as a Texas Medicaid and CHIP Dental Services member at the time services were performed. The provider must submit the claim for payment within 95 days after the date certified by the provider that the patient first did identify himself or herself as a member. The date so certified on the claim must be no later than one year after the month in which services were performed. The maximum time period for submission of a claim involving other coverage is one year from the date of service, to allow sufficient time for the provider to obtain proof of payment or non-liability of the other insurance carrier. If a delay in submitting a claim for payment was caused by circumstances beyond the control of the provider, Delta Dental may extend the period of submission for one year from the date of service. Specific circumstances which would be considered beyond the control of the provider and under which such an extension may be granted include the following:

Delay or error in the certification or determination of Delta Dental eligibility by HHSC. Damage to, or destruction of, the provider's business office or records by natural disaster, including fire, flood, earthquake, or circumstances involving such a disaster that have substantially interfered with the timely processing of bills.

Provider Hotline (CHIP): 1-866-561-5891 www.deltadentalins.com/tchip

Provider Hotline (Medicaid): 1-877-576-5899 www.deltadentalins.com/tx-medicaid

Page 126

Texas Children's Medicaid and CHIP Dental Services Provider Manual

Delay of required authorization by Delta Dental. Delay by Delta Dental in supplying billing forms to the provider. Other circumstances clearly beyond the control of the provider that have been reported to the appropriate law enforcement or fire agency, where applicable. Special circumstances, such as court or hearing decisions.

16.14

UPDATES TO PROVIDER CONTACT INFORMATION

If you have any changes to your contact information--including, but not limited to, name, address, telephone number, business type, tax identification number, and additions/deletions of treating providers--you must update that information with Delta Dental and TMHP. To notify Delta Dental, do one of the following:

Call our Provider Hotline. You will be sent a change form to complete and return to us. Go online to www.deltadentalins.com/tx-medicaid (for Medicaid providers) or www.deltadentalins.com/tchip (for CHIP providers) and complete/submit the provider information change form.

Write to us at the address below. Delta Dental Mailing Address Texas Children's Medicaid and CHIP Dental Services State Government Programs PO Box 537014 Sacramento, CA 95853-7014 To notify TMHP, go online to www.tmhp.com/pages/Medicaid/Medicaid_forms.aspx and complete/return the Provider Information Change Form.

Provider Hotline (Medicaid): 1-877-576-5899 www.deltadentalins.com/tx-medicaid

Provider Hotline (CHIP): 1-866-561-5891 www.deltadentalins.com/tchip

Page 127

Texas Children's Medicaid and CHIP Dental Services Provider Manual

17.0

TEXAS CHILDREN'S MEDICAID DENTAL SERVICES MANUAL OF CRITERIA (MOC)

Attachment A: the Texas Children's Medicaid Dental Services Manual of Criteria, incorporates, by reference, State of Texas regulations governing the Texas Children's Medicaid Dental Services program. The Texas Children's Medicaid Dental Services MOC begins on the following page.

Provider Hotline (Medicaid): 1-877-576-5899 www.deltadentalins.com/tx-medicaid

Provider Hotline (CHIP): 1-866-561-5891 www.deltadentalins.com/tchip

Page 128

Texas Children's Medicaid Dental Services Manual of Criteria

TABLE OF CONTENTS

INTRODUCTION....................................................................................................................133 Documentation Requirements ..........................................................................................134 PREVENTATIVE SERVICES (PROCEDURES D0120-D1555) .......................................135 Diagnostics (D0120-D0180) ................................................................................................135 Radiographs (D0210-D0350) ..............................................................................................136 Bitewing Radiographs (D0270-D0274) .............................................................................138 Cone Beam (D0360-D0363) ................................................................................................139 Other Services/By Report (D0415-D0502).......................................................................140 Dental Prophylaxis (D1110-D1120) ..................................................................................141 Topical Fluoride/Fluoride Varnish Treatment (D1203-D1206) ...................................141 Nutritional Counseling for Control of Dental Disease (D1310) ...................................142 Tobacco Counseling for Control and Prevention of Oral Disease (D1320) ................142 Oral Hygiene Instructions (D1330) ...................................................................................142 Dental Sealants (D1351) .....................................................................................................142 Space Maintainers (D1510-D1555) ....................................................................................143 RESTORATIVE SERVICES (PROCEDURES D2140-D2999) ..........................................144 Amalgam Restorations (D2140-D2161) ............................................................................145 Composite Resin, Acrylic, Synthetic or Plastic Restorations (D2330-D2394) .............146 Gold Foil Restorations (D2410-D2430) .............................................................................147 Inlay/Onlay Restorations (D2510-D2664) .......................................................................148 Laboratory-Processed Crowns (D2710-D2794) ...............................................................149 Recementation (D2910-D2920) ..........................................................................................150 Prefabricated Crowns (D2930-D2934) ..............................................................................151 Other Restorative Services (D2940-D2999) ......................................................................151 Post and Core Procedures (D2952­D2954 and D2957) ..................................................152 ENDODONTIC SERVICES (PROCEDURES D3110-D3999) ..........................................155 Pulp Cap (D3110-D3120) ....................................................................................................155 Therapeutic Pulpotomy (D3220) .......................................................................................156 Endodontic Therapy/Primary Teeth (D3230-D3240) ....................................................156 Endodontic Therapy/Permanent Teeth (D3310-D3348) ...............................................157 Apexification/Recalcification (D3351-D3353) ................................................................157

Provider Hotline (Medicaid): 1-877-576-5899 www.deltadentalins.com/tx-medicaid Provider Hotline (CHIP): 1-866-561-5891 www.deltadentalins.com/tchip

Page 129

Texas Children's Medicaid Dental Services Manual of Criteria

Apicoectomy/Periradicular Services (D3410-D3950) ....................................................158 PERIODONTIC SERVICES (PROCEDURES D4210-D4999) ..........................................160 REMOVABLE PROSTHODONTIC SERVICES (PROCEDURES D5110-D5899) ......165 Complete Dentures (Including Routine Post-Delivery Care) (D5110-D5140) ...........165 Partial Dentures (Including Routine Post-Delivery Care) (D5211-D5281) .................165 Denture Adjustments (D5410-D5422) ..............................................................................166 Repairs to Complete and Partial Dentures (D5510-D5671) ..........................................166 Denture Rebase/Reline Procedures (D5710-D5761) ......................................................167 Interim Prosthesis (D5810-D5821) ....................................................................................169 Other Services and/or By Report Procedures (D5820-D5899) .....................................169 MAXILLOFACIAL PROSTHETIC SERVICES (PROCEDURES D5911-D5951) .........171 IMPLANT SERVICES (PROCEDURES D6010-D6100) ....................................................174 FIXED PROSTHODONTIC SERVICES (PROCEDURES D6210-D6999) .....................176 Fixed Partial Denture Pontics (D6210-D6252) ................................................................178 Fixed Partial Denture Retainers ­ Inlays/Onlays (D6545-D6548) ...............................178 Fixed Partial Denture Retainers ­ Crowns (D6720-D6792) ...........................................178 Other Services and/or Service By Report (D6920-D6999) ............................................179 ORAL SURGERY SERVICES (PROCEDURES D7111-D7999) .......................................181 Surgical Extractions (D7210-D7250) .................................................................................181 Other Surgical Procedures (D7260-D7283) ......................................................................182 Biopsy of Oral Tissue (Procedure D7285-D7286) ...........................................................183 Alveoloplasty (D7310-D7320)............................................................................................183 Vestibuloplasty (D7340-D7350).........................................................................................183 Excision of Benign Tumor (D7410-D7414) ......................................................................184 Surgical Excision of Intra-Osseous Lesions (D7440-D7465)..........................................184 Surgical Incisions (D7510-D7560) .....................................................................................185 Treatment of Fractures ­ Simple (D7670) ........................................................................185 Reduction of Dislocation and Management (D7820-D7899) ........................................185 Repair of Traumatic Wounds (D7910-D7912) .................................................................185 Other Services and/or By Report Services (D7960-D7999)...........................................186 ADJUNCTIVE GENERAL SERVICES (PROCEDURES D9110-D9999) .......................187 Anesthesia (D9210-D9248) .................................................................................................187 Professional Consultations (D9310) .................................................................................189 Professional Visits (D9410-D9440) ....................................................................................189

Provider Hotline (Medicaid): 1-877-576-5899 www.deltadentalins.com/tx-medicaid Provider Hotline (CHIP): 1-866-561-5891 www.deltadentalins.com/tchip

Page 130

Texas Children's Medicaid Dental Services Manual of Criteria

Drugs (D9610-D9630) .........................................................................................................190 Miscellaneous Services (D9910-D9999) ............................................................................190 GENERAL ANESTHESIA ......................................................................................................193 ORTHODONTIC SERVICES ................................................................................................196 Diagnostics (D0330-D0470) ................................................................................................201 Appliance Removal (D7997) ..............................................................................................201 Interceptive Orthodontic Treatment (D8050-D8080) .....................................................201 Treatment to Control Harmful Habits (D8210-D8220) ..................................................202 Other Services and/or By Report Services (D8660-D8999)...........................................202 Special Orthodontic Appliances (Procedures D8210-D8220) .......................................202

Provider Hotline (Medicaid): 1-877-576-5899 www.deltadentalins.com/tx-medicaid

Provider Hotline (CHIP): 1-866-561-5891 www.deltadentalins.com/tchip

Page 131

Texas Children's Medicaid Dental Services Manual of Criteria

NOTES:

Provider Hotline (Medicaid): 1-877-576-5899 www.deltadentalins.com/tx-medicaid

Provider Hotline (CHIP): 1-866-561-5891 www.deltadentalins.com/tchip

Page 132

Texas Children's Medicaid Dental Services Manual of Criteria

INTRODUCTION

This document is a compilation of criteria that apply to dental services for the Texas Children's Medicaid Dental Services program. It is designed to provide assistance to dentists treating members and to dental consultants in determining service authorization and payment under the authority of and subject to Texas Health and Human Services Commission (HHSC) provisions and applicable state and federal regulations. This document sets forth program benefits and clearly defines limitations, exclusions, and special documentation requirements. These criteria are designed to ensure that program funds are spent on services that are medically necessary and are in substantial compliance with HHSC regulations. The criteria published in this manual, while not exhausting the range of possibilities or combinations of circumstances, will nonetheless help to standardize the provider's and consultant's exercise of professional judgment. If the clinical condition of the patient reflects the criteria required by this manual and such information is fully documented by the provider, the consultant may grant approval if in his/her professional judgment the service request is reasonable and consistent with the patient's dental needs and conforms to the program's intent. Without sufficient acceptable diagnostic information, the consultant has no option but to deny approval or defer a decision. The necessity for the consultant to obtain adequate information and, thereby, to make a judgment on dental necessity is an integral part of the prior authorization and payment process. While the manual contains prior authorization and payment information, it is not an instruction guide in the proper completion of prior authorization or payment requests. Prior authorization of radiographs shall not be required for payment of a procedure unless expressly stated in this manual of criteria. These criteria are intended to:

Assist providers in requesting authorization and payment, and documenting the need for such services or items. Improve the quality of care and cost efficiency of dental services given to patients. Avoid provision of unnecessary or excessive items or services to patients. Promote objectivity and uniformity in appropriate treatment of dental conditions. Ensure that the covered dental benefit level is for the least costly dentally appropriate alternative. If a more costly, optional alternative is chosen by the applicant, the applicant will be responsible for all charges in excess of the covered dental benefit.

Provider Hotline (CHIP): 1-866-561-5891 www.deltadentalins.com/tchip

Provider Hotline (Medicaid): 1-877-576-5899 www.deltadentalins.com/tx-medicaid

Page 133

Texas Children's Medicaid Dental Services Manual of Criteria

Assist the dental consultant's review of prior authorization and payment requests. Promote uniform and consistent review of prior authorization and payment requests.

DOCUMENTATION REQUIREMENTS

Preoperative and postoperative radiographs are not required unless specifically requested. When x-rays are requested, they should be no older than 12 months.

Provider Hotline (Medicaid): 1-877-576-5899 www.deltadentalins.com/tx-medicaid

Provider Hotline (CHIP): 1-866-561-5891 www.deltadentalins.com/tchip

Page 134

Texas Children's Medicaid Dental Services Manual of Criteria

PREVENTATIVE SERVICES (PROCEDURES D0120-D1555)

Clinical Oral Evaluations 1. Procedure codes D0140, D0160, D0170, and D0180 are limited dental codes and may be paid in addition to a comprehensive oral exam (procedure code D0150) or periodic oral exam (procedure code D0120), when submitted within a six-month period. 2. A claim for procedure code D0140, D0160, D0170, or D0180 must include documentation of medical necessity on the claim. These claims are subject to retrospective review. Documentation must include: The client complaint supporting medical necessity for the examination. The specific area of the mouth that was examined or the tooth involved. A description of what was done during the visit. Supporting documentation of medical necessity which may include, but is not limited to, radiographs or photographs.

DIAGNOSTICS (D0120-D0180)

D0120: Periodic oral evaluation ­ established patient

Limited to one every six months by the same provider. Denied if billed on the same date of service as procedure D0145. A benefit for members birth to age 20.

D0140: Limited oral evaluation ­ problem focused

Limited to one service per day by the same provider or to two services per day by different providers. Denied when submitted for the same DOS as D0160 by the same provider. A benefit for members birth to age 20.

D0145: Oral evaluation for a patient under 3 years of age and counseling with primary caregiver

Limited to one service a day and 10 times a lifetime, with a minimum of 60 days between dates of service. Procedure codes D0120, D0150, D0160, D0170, D0180, D8660, D1120, D1203, or D1206 will be denied when billed by any provider on the same date of service. A benefit for members between 6 months and 35 months of age.

Provider Hotline (Medicaid): 1-877-576-5899 www.deltadentalins.com/tx-medicaid

Provider Hotline (CHIP): 1-866-561-5891 www.deltadentalins.com/tchip

Page 135

Texas Children's Medicaid Dental Services Manual of Criteria

Providers must be certified by the Department of State Health Services' Oral Health Program staff to perform this procedure.

D0150: Comprehensive oral evaluation ­ new or established patient

Limited to one every three years by the same provider. Denied when billed on the same date of service as procedure D0145. A benefit for members ages birth through 20.

D0160: Detailed and extensive oral evaluation ­ problem focused, by report

A benefit for members ages 1 through 20. Limited to one service per day by the same provider. Denied when submitted for the same DOS as D0145 by any provider.

D0170: Re-evaluation ­ limited, problem focused (established patient, not postoperative visit)

Limited to one service per day by the same provider. This procedure will be denied when billed on the same date of service as procedures D0140, D0145, or D0160. A benefit for members birth and above.

D0180: Comprehensive periodontal evaluation ­ new or established patient

Limited to once per lifetime per provider; may not be paid on the same day as procedure codes D0120, D0140, D0150, D0160, or D0170. Denied when billed on the same DOS as D0145. A benefit for members ages 13 and above. The code is used for periodontal evaluation.

RADIOGRAPHS (D0210-D0350)

General Policies 1. According to accepted dental practice standards, the lowest number of radiographs needed to provide the diagnosis should be taken. In November 2004, the American Dental Association (ADA), in conjunction with the U.S. Food and Drug Administration, established "Guidelines for Prescribing Dental Radiographs" to include types of encounters relevant to the client's age and dental developmental stage. The guidelines can be found at www.ada.org/sections/professionalResources/pdfs/topics_radiography_chart.pdf.

Provider Hotline (Medicaid): 1-877-576-5899 www.deltadentalins.com/tx-medicaid

Provider Hotline (CHIP): 1-866-561-5891 www.deltadentalins.com/tchip

Page 136

Texas Children's Medicaid Dental Services Manual of Criteria

2. A panoramic x-ray (D0330) with four bitewing radiographs (D0274) may be considered equivalent to the complete or full-mouth series (D0210). 3. The total cost of periapicals and/or other radiographs cannot exceed the payment for a complete intraoral series. 4. Radiographs are covered when taken in compliance with state and federal regulations for radiation hygiene. 5. A minimum of eight films is required to be considered a full-mouth series. Adults and children who are 12 years of age or older require 12 to 20 radiographs, as is appropriate. D0210: Intraoral ­ complete series (including bitewings)

Limited to one service every three years by the same provider. Not allowed as an emergency service. A benefit for members ages 2 and above.

D0220: Intraoral ­ periapical first film

Limited to once per day by the same provider. A benefit for members ages 1 through 20.

D0230: Intraoral ­ periapical each additional film

The total cost of periapicals and other radiographs cannot exceed the payment for a complete intraoral series. A benefit for members ages 1 through 20.

D0240: Intraoral ­ occlusal film

Limited to two services per day by the same provider. A benefit for members age birth through 20.

D0250: Extraoral ­ first film

Limited to once per day by the same provider. A benefit for members ages 1 through 20.

D0260: Extraoral ­ each additional film

A benefit for members ages 1 through 20.

Provider Hotline (Medicaid): 1-877-576-5899 www.deltadentalins.com/tx-medicaid

Provider Hotline (CHIP): 1-866-561-5891 www.deltadentalins.com/tchip

Page 137

Texas Children's Medicaid Dental Services Manual of Criteria

BITEWING RADIOGRAPHS (D0270-D0274)

General Policies 1. Limited to one service a day by the same provider. 2. A benefit for members ages 1 through 20. D0270: Bitewing ­ single film D0272: Bitewings ­ two films D0273: Bitewings ­ three films D0274: Bitewings ­ four films D0277: Vertical bitewings ­ 7 to 8 films

Not payable within 36 months of D0210 or D0330. A benefit for members ages 2 through 20. Limited to one service per day by the same provider.

D0290: Posterior-anterior or lateral skull and facial bone survey film

A benefit for members ages 1 through 20.

D0310: Sialography

A benefit for members ages 1 through 20.

D0320: Temporomandibular joint arthrogram, including injection

A benefit for members ages 1 through 20.

D0321: Other temporomandibular joint films, by report

A benefit for members ages 1 through 20.

D0322: Tomographic survey

A benefit for members ages 1 through 20.

D0330: Panoramic film

Limited to one service a day, any provider, and limited to one service every three years by the same provider. Not allowed on emergency claims unless third molars or a traumatic condition is involved.

Provider Hotline (CHIP): 1-866-561-5891 www.deltadentalins.com/tchip

Provider Hotline (Medicaid): 1-877-576-5899 www.deltadentalins.com/tx-medicaid

Page 138

Texas Children's Medicaid Dental Services Manual of Criteria

A panoramic x-ray (D0330) with four bitewing radiographs (D0274) may be considered equivalent to the complete or full-mouth series (D0210). For members age 2 or younger, must document the necessity of a panoramic film.

D0340: Cephalometric film

Not reimbursable separately when a comprehensive orthodontic or crossbite therapy workup performed. A benefit for members ages 1 through 20.

D0350: Oral/facial photographic images

Limited to one service a day by the same provider. Not reimbursable separately when a comprehensive orthodontic or crossbite therapy workup performed. Procedure code D0350 must be used to submit claims for photographs and will be accepted only when diagnostic-quality radiographs cannot be taken. A benefit for members age birth through 20.

CONE BEAM (D0360-D0363)

1. Prior authorization is required for procedure codes D0360, D0362, and D0363. 2. Procedures D0360, D0362, and/or D0363 in any combination are limited to three services per year. 3. Cone beam imaging is used to determine the best course of treatment for cleft palate repair, skeletal anomalies, post-trauma care, implanted or fixed prosthodontics, and orthodontic or orthognathic procedures. Cone beam imaging is limited to initial treatment planning, surgery, and post-surgical follow-up. To obtain prior authorization, a prior authorization form must be submitted with documentation supporting medical necessity and appropriateness. Required documentation includes, but is not limited to, presenting conditions, medical necessity, and the status of the member's treatment.

Provider Hotline (Medicaid): 1-877-576-5899 www.deltadentalins.com/tx-medicaid

Provider Hotline (CHIP): 1-866-561-5891 www.deltadentalins.com/tchip

Page 139

Texas Children's Medicaid Dental Services Manual of Criteria

D0360: Cone beam CT ­ craniofacial data capture D0362: Cone beam ­ two-dimensional image reconstruction using existing data; includes multiple images D0363: Cone beam ­ three-dimensional image reconstruction using existing data; includes multiple images

OTHER SERVICES/BY REPORT (D0415-D0502)

D0415: Collection of microorganisms for culture and sensitivity

A benefit for members ages 1 through 20.

D0425: Caries susceptibility tests Not reimbursable separately. Considered part of other dental procedures. D0460: Pulp vitality tests

Limited to one service a day by the same provider. Included in the fee for any endodontic procedure performed on the same date of service. Not benefited on primary teeth. D0460 not allowed when submitted for the same DOS as any endodontic procedures. A benefit for members ages 1 through 20.

D0470: Diagnostic casts

Not reimbursable separately when performed in conjunction with a laboratory processed crown, fixed prosthodontics, diagnostic workup, or crossbite therapy. A benefit for members ages 1 through 20.

D0472-D0474 and D0480: Oral pathology laboratory

By pathology laboratories only.

D0502: Other oral pathology procedures, by report

A benefit for members ages 1 through 20.

D0999: Unspecified diagnostic procedure

A benefit for members ages 1 through 20.

Provider Hotline (CHIP): 1-866-561-5891 www.deltadentalins.com/tchip

Provider Hotline (Medicaid): 1-877-576-5899 www.deltadentalins.com/tx-medicaid

Page 140

Texas Children's Medicaid Dental Services Manual of Criteria

DENTAL PROPHYLAXIS (D1110-D1120)

General Policies 1. Oral prophylaxis means the preventive dental procedure of scaling and polishing, which includes complete removal of calculus (supra- and sub-gingival), soft deposits, plaque, stains, and smoothing of unattached tooth surfaces. 2. Limited to one prophylaxis per client per 6-month period (includes oral health instructions). If billed on emergency claim, procedure code will be denied. 3. Procedures D1110 and D1120 are not payable on the same DOS as any D4000 series periodontal procedure code. D1110: Prophylaxis ­ adult Members 13 years of age and above. D1120: Prophylaxis ­ child

Members ages 6 months through 12. Not payable on the same date of service as procedure D0145.

TOPICAL FLUORIDE/FLUORIDE VARNISH TREATMENT (D1203-D1206)

General Policies 1. If performing fluoride treatments, procedure codes D1203 and D1204 must be submitted on the same DOS as the cleaning (D1110 and D1120). 2. Includes oral health instructions. 3. Procedures D1203, D1204 and D1206 are denied when billed on the same DOS as any D4000 series periodontal procedure code. 4. Procedures D1203 and D1206 are denied when billed on the same DOS as procedure code D0145. 5. Topical fluoride means prescription strength fluoride designed solely for the use in the dental office, the application includes fluoride gel or liquid, which is applied separately from prophylaxis paste by means of a tray, swabs or rinsing. Incorporating fluoride with the polishing compound is part of the prophylaxis procedure and is not separately reimbursable. D1203: Topical application of fluoride ­ child

Members ages 6 months through 12 years.

Provider Hotline (Medicaid): 1-877-576-5899 www.deltadentalins.com/tx-medicaid

Provider Hotline (CHIP): 1-866-561-5891 www.deltadentalins.com/tchip

Page 141

Texas Children's Medicaid Dental Services Manual of Criteria

D1204: Topical application of fluoride ­ adult

Members ages 13 through 20.

D1206: Topical fluoride varnish; therapeutic application for moderate to high caries risk patients

Members ages 6 months through 20 years.

NUTRITIONAL COUNSELING FOR CONTROL OF DENTAL DISEASE (D1310)

Denied as part of all preventative, therapeutic and diagnostic dental procedures. A client requiring more involved nutrition counseling should be referred to their primary care physician.

TOBACCO COUNSELING FOR CONTROL AND PREVENTION OF ORAL DISEASE (D1320)

Not a dental benefit. A client requiring tobacco counseling may be referred to their primary care physician.

ORAL HYGIENE INSTRUCTIONS (D1330)

General Policies 1. Oral hygiene instruction is denied when billed on the same day as dental prophylaxis (D1110, D1120) and/or topical fluoride treatments (D1203, D1204, and D1206) by the same provider. 2. Procedure code D1330 is limited to once per client, per year by any provider 3. Requires documentation of the type of instructions, number of appointments, and content of instructions. This procedure is payable only for medically necessary situations that are non-routine. This procedure refers to services above and beyond routine brushing and flossing instruction and requires that additional time and expertise have been directed toward the client's care. 4. Members age 1 and above.

DENTAL SEALANTS (D1351)

General Policies 1. Dental sealants are designed for the prevention of pit and fissure caries. Sealants may be applied to the occlusal fissures and buccal and lingual pits of posterior teeth on a tooth that is free of caries and free of restorations on the surface to be sealed. 2. Sealants are reimbursed per tooth regardless of the number of surfaces.

Provider Hotline (Medicaid): 1-877-576-5899 www.deltadentalins.com/tx-medicaid Provider Hotline (CHIP): 1-866-561-5891 www.deltadentalins.com/tchip

Page 142

Texas Children's Medicaid Dental Services Manual of Criteria

3. Sealants are a benefit when applied on primary or permanent teeth. 4. Dental sealants and replacement sealants are limited to every three years per tooth. 5. Sealants are not allowed on the same DOS as any D4000 series periodontal procedure code. 6. Members ages birth through 20.

SPACE MAINTAINERS (D1510-D1555)

General Policies 1. Space maintainers are a benefit of Texas Medicaid after premature loss of primary or secondary molars (Teeth A, B, I, J, K, L, S, and T) for clients who are 1 through 12 years of age, and after loss of permanent molars (Teeth 3, 14, 19, and 30) for clients who are 3 through 20 years of age. 2. Limit of one space maintainer is reimbursed per tooth, per lifetime. 3. When procedure code D1510 or D1515 have been previously reimbursed, the recementation of a space maintainer (D1550) may be considered to the same or different provider. 4. Replacement space maintainers may be considered upon appeal with documentation supporting medical necessity. 5. Removal of a fixed space maintainer may not be performed by the same dentist/dental office that placed the appliance. 6. Please indicate the tooth number(s) on the claim. D1510: Space maintainer ­ fixed & unilateral D1515: Space maintainer ­ fixed & bilateral D1520: Space maintainer ­ removable & unilateral D1525: Space maintainer ­ removable & bilateral D1550: Recementation of space maintainer

Members ages 1 through 20.

D1555: Removal of space maintainer (not by dentist who placed appliance)

Members ages 1 through 20.

Provider Hotline (Medicaid): 1-877-576-5899 www.deltadentalins.com/tx-medicaid

Provider Hotline (CHIP): 1-866-561-5891 www.deltadentalins.com/tchip

Page 143

Texas Children's Medicaid Dental Services Manual of Criteria

RESTORATIVE SERVICES (PROCEDURES D2140-D2999)

General Policies 1. Restorations and therapeutic care are provided based on medical necessity and reimbursed only for therapeutic reasons and not preventive purposes. Restorative services shall be benefits when medically necessary and when carious activity has extended through the dentoenamel junction (DEJ). Restorations provided due to attrition, abrasion, abfraction, erosion, or wear or for cosmetic purposes are not benefits. 2. Any restoration placed on a tooth in which carious activity has not extended through the DEJ is considered a sealant and should not be billed as a D1351. 3. All fees for tooth restorations include local anesthesia and pulp protective media, where indicated, without additional charges. These services are considered part of the restoration. 4. A multiple surface restoration cannot be submitted as two or more separate onesurface restorations. 5. More than one restoration on a single surface is considered a single restoration. 6. The total restorative fee per tooth on primary teeth cannot exceed the fee for a stainless steel crown. (Exception D2335 and D2933). 7. Direct pulp caps may be reimbursed separately from any final tooth restoration performed on the same tooth on the same DOS by the same provider. 8. Prior authorization is required for any combination of inlays/onlays or permanent crowns that exceed the limit of four inlays/onlays or permanent crowns. X-rays are required when submitting for prior authorization. 9. Laboratory-processed crowns are benefits for permanent teeth for members ages 13 and above will be predicated upon a supportable three-year prognosis. 10. Laboratory-processed crowns and indirectly fabricated restorations are considered to be an optional benefit unless the tooth is damaged by decay or fracture to the point that it cannot be restored with amalgam or resin. 11. Longevity is essential and a lesser service will not suffice because extensive coronal destruction is supported by a narrative documentation, or is radiographically demonstrated and treatment is beyond intercoronal restoration. 12. Laboratory-processed crowns on endodontically treated teeth are covered only after satisfactory completion of the root canal therapy. 13. A laboratory-processed crown will not be allowed when periodontal bone support appears to be inadequate due to the unfavorable prognosis for the tooth.

Provider Hotline (Medicaid): 1-877-576-5899 www.deltadentalins.com/tx-medicaid

Provider Hotline (CHIP): 1-866-561-5891 www.deltadentalins.com/tchip

Page 144

Texas Children's Medicaid Dental Services Manual of Criteria

14. A temporary restoration while the final restoration is being fabricated is part of, and included in the fee for the final restoration. 15. All dental restorations and prosthetic appliances that require lab fabrication may be submitted for reimbursement using the date the final cementation was made as the DOS. 16. If a patient does not return for final seating of the restoration or appliance, a narrative must be included on the claim form. If the client returns to the office after the claim has been filed, the dentist is obligated to attempt to seat the restoration or appliance at no cost to the client. 17. Laboratory processed crowns, inlay/onlay restorations and gold foil procedures are benefits for members ages 13 and above. 18. Stainless steel crowns and permanent all-metal cast crowns are not reimbursed on anterior permanent teeth (6-11, 22-27).

AMALGAM RESTORATIONS (D2140-D2161)

General Policies 1. Amalgam restorations are a benefit on primary teeth # A ­ T, and permanent posterior teeth; teeth #1, 2, 3, 4, 5, 12, 13, 14, 15, 16, 17, 18, 19, 20, 21, 28, 29, 30, 31 and 32. 2. Procedures D2140 and D2150 are benefits from birth. 3. Procedures D2160 and D2161 are benefits for members ages 1 and above. D2140: Amalgam ­ one surface, primary D2140: Amalgam ­ one surface, permanent D2150: Amalgam ­ two surfaces, primary D2150: Amalgam ­ two surfaces, permanent D2160: Amalgam ­ three surfaces, primary D2160: Amalgam ­ three surfaces, permanent D2161: Amalgam ­ four or more surfaces, primary D2161: Amalgam ­ four or more surfaces, permanent

Provider Hotline (Medicaid): 1-877-576-5899 www.deltadentalins.com/tx-medicaid

Provider Hotline (CHIP): 1-866-561-5891 www.deltadentalins.com/tchip

Page 145

Texas Children's Medicaid Dental Services Manual of Criteria

COMPOSITE RESIN, ACRYLIC, SYNTHETIC OR PLASTIC RESTORATIONS (D2330D2394)

General Policies 1. The total fee for resin restorations on primary teeth are limited to the fee for a stainless steel crown (exceptions: D2335 and D2933). 2. Procedures D2330, D2331, D2332, D2335 and D2390 are benefits on primary anterior teeth and permanent anterior teeth only: Teeth C, D, E, F, G, H, M, N, O, P, Q, R and 6, 7, 8, 9, 10, 11, 22, 23, 24, 25, 26, and 27. 3. Procedures D2330 and D2335 include any of the plastic, resin, acrylic, or compositetype materials. Procedure D2335 represents the maximum allowable fee for a single anterior tooth, including restoring the incisal angle. 4. Procedures D2390, D2391, D2392, D2393 and D2394 are benefits on primary and permanent posterior teeth only; teeth # A, B, I, J, K, L, S, T, and #1, 2, 3, 4, 5, 12, 13, 14, 15, 16, 17, 18, 19, 20, 21, 28, 29, 30, 31 and 32. 5. Restoration of non-carious lesions is not a benefit, except when necessary in conjunction with traumatic fractures that require treatment. 6. Tooth preparation, acid etching, adhesives (including resin bonding agents), liners and bases and curing are included as part of the restoration. 7. Procedures D2330, D2331, D2390 and D2392 are benefits from birth. 8. Procedures D2332, D2335, D2393 and D2394 are benefits for members ages 1 year and above.

Provider Hotline (Medicaid): 1-877-576-5899 www.deltadentalins.com/tx-medicaid

Provider Hotline (CHIP): 1-866-561-5891 www.deltadentalins.com/tchip

Page 146

Texas Children's Medicaid Dental Services Manual of Criteria

D2330: Resin-based composite ­ one surface, anterior D2331: Resin-based composite ­ two surfaces, anterior D2332: Resin-based composite ­ three surfaces, anterior D2335: Resin-based composite ­ four or more surfaces or involving incisal angle ( anterior) D2390: Resin-based composite crown, anterior D2391: Resin-based composite ­ one surface, posterior, primary D2391: Resin-based composite ­ one surface, posterior, permanent D2392: Resin-based composite ­ two surfaces, posterior, primary D2392: Resin-based composite ­ two surfaces, posterior, permanent D2393: Resin-based composite ­three or more surfaces, posterior, primary D2393: Resin-based composite ­ three or more surfaces, posterior, permanent D2394: Resin-based composite ­ four or more surfaces, posterior, primary

GOLD FOIL RESTORATIONS (D2410-D2430)

D2410: Gold foil ­ one surface

A benefit for permanent teeth only. A benefit for members ages 13 through 20.

D2420: Gold foil ­ two surfaces

A benefit for permanent teeth only. A benefit for members ages 13 through 20.

D2430: Gold foil ­ three surfaces

A benefit for permanent teeth only. A benefit for members ages 13 through 20.

Provider Hotline (Medicaid): 1-877-576-5899 www.deltadentalins.com/tx-medicaid

Provider Hotline (CHIP): 1-866-561-5891 www.deltadentalins.com/tchip

Page 147

Texas Children's Medicaid Dental Services Manual of Criteria

INLAY/ONLAY RESTORATIONS (D2510-D2664)

General Policies 1. For procedure codes D2510 through D2664, inlay/onlay (permanent teeth only). 2. Porcelain is allowed on all permanent teeth. 3. Onlays are payable only when the tooth would otherwise qualify for a crown based on the degree of breakdown and one or more cusps requires coverage. 4. Prior authorization is required for any combination of inlays/onlays or permanent crowns that exceed the limit of four inlays/onlays or permanent crowns. X-rays are required when submitting for prior authorization. 5. Procedures D2510 through D2664 are benefits for members ages 13 through 20. 6. A provisional crown, procedure D2799, is included in the fee for inlay/onlay procedures and not allowed as a separate procedure. D2510: Inlay, metallic ­ one surface D2520: Inlay, metallic ­ two surfaces D2530: Inlay, metallic ­ three or more surfaces D2542: Onlay, metallic ­ two surfaces D2543: Onlay, metallic ­ three surfaces D2544: Onlay, metallic ­ four or more surfaces D2610: Inlay, porcelain/ceramic ­ one surface D2620: Inlay, porcelain/ceramic ­ two surfaces D2630: Inlay, porcelain/ceramic ­three or more surfaces D2642: Onlay, porcelain/ceramic ­ two surfaces D2643: Onlay, porcelain/ceramic ­ three surfaces D2644: Onlay, porcelain/ceramic ­ four or more surfaces D2650: Inlay, resin-based composite ­ one surface

Provider Hotline (Medicaid): 1-877-576-5899 www.deltadentalins.com/tx-medicaid

Provider Hotline (CHIP): 1-866-561-5891 www.deltadentalins.com/tchip

Page 148

Texas Children's Medicaid Dental Services Manual of Criteria

D2651: Inlay, resin-based composite ­ two surfaces D2652: Inlay, resin-based composite ­ three or more surfaces D2662: Onlay, resin-based composite ­ two surfaces D2663: Onlay, resin-based composite ­ three surfaces D2664: Onlay, resin-based composite ­ four or more surfaces

LABORATORY-PROCESSED CROWNS (D2710-D2794)

General Policies For procedure codes D2710 through D2799, single crown restorations (permanent teeth only) the following limitations apply: 1. Porcelain is allowed on all teeth. 2. X-rays are required when submitting a claim for a laboratory-processed crown. 3. Prior authorization is required for any combination of inlays/onlays or permanent crowns that exceed the limit of four. X-rays are required when submitting for prior authorization. 4. Prior authorization will not be given when teeth do not require a crown, when there is untreated periodontal or endodontic disease, or rampant caries. 5. Stainless steel crowns and permanent all-metal cast crowns are not reimbursed on anterior permanent teeth (teeth numbers 6-11 and 22-27). 6. A laboratory processed crown is a benefit for members ages 13 and older. 7. A provisional crown, procedure D2799 is included in the fee for a laboratory processed crown and not allowed as a separate procedure. 8. For laboratory-processed crowns on anterior teeth: a. The replacement of any existing restoration must be necessary due to caries, fracture, or missing tooth structure. b. At least 50 percent of the incisal angle must require replacement due to decay or fracture. 9. For laboratory-processed crowns on posterior teeth, the tooth must exhibit at least three surfaces that have decay or an existing restoration, including at least one missing or undermined cusp (on a bicuspid) and at least two missing or undermined cusps (on a molar).

Provider Hotline (Medicaid): 1-877-576-5899 www.deltadentalins.com/tx-medicaid

Provider Hotline (CHIP): 1-866-561-5891 www.deltadentalins.com/tchip

Page 149

Texas Children's Medicaid Dental Services Manual of Criteria

D2710: Crown, resin-based composite (indirect) D2720: Crown, resin with high noble metal D2721: Crown, resin with predominantly base metal D2722: Crown, resin with noble metal D2740: Crown, porcelain/ceramic substrate D2750: Crown, porcelain fused to high noble metal D2751: Crown, porcelain fused to predominantly base metal D2752: Crown, porcelain fused to noble metal D2780: Crown, 3/4 cast high noble metal D2781: Crown, 3/4 cast predominantly base metal D2782: Crown, 3/4 cast noble metal D2783: Crown, 3/4 porcelain/ceramic D2790: Crown, full cast high noble metal D2791: Crown, full cast predominantly base metal D2792: Crown, full cast noble metal D2794: Crown, titanium

RECEMENTATION (D2910-D2920)

D2910: Recement inlay

A benefit for members ages 13 and above.

D2915: Recement indirectly fabricated or prefabricated post and core

A benefit for members ages 4 and above.

D2920: Recement crown

A benefit for members ages 1 through 20.

Provider Hotline (Medicaid): 1-877-576-5899 www.deltadentalins.com/tx-medicaid

Provider Hotline (CHIP): 1-866-561-5891 www.deltadentalins.com/tchip

Page 150

Texas Children's Medicaid Dental Services Manual of Criteria

PREFABRICATED CROWNS (D2930-D2934)

D2930: Prefabricated stainless steel crown ­ primary tooth

A benefit for members birth through age 20.

D2931: Prefabricated stainless steel crown ­ permanent tooth

A benefit for members ages 1 through 20.

D2932: Prefabricated resin crown

A benefit for members ages 1 through 20. A benefit for primary teeth only, A ­ T.

D2933: Prefabricated stainless steel crown with resin window

A benefit for members birth through age 20. Limited to anterior primary teeth only; teeth #s C-H and M-R.

D2934: Prefabricated esthetic coated stainless steel crown ­ primary tooth

A benefit for members birth through age 20. Limited to anterior primary teeth only; teeth #s C-H and M-R.

OTHER RESTORATIVE SERVICES (D2940-D2999)

D2940: Sedative filling

Procedure D2940 is not allowed on the same date of service as a permanent restoration on the same tooth. A benefit for members birth through age 20.

D2950: Core buildup, including any pins

Provider payments received in excess of $45.00 for restorative work performed within six months of a crown procedure on the same tooth will be deducted from the subsequent crown procedure reimbursement. A benefit for permanent teeth only; teeth #s 1- 32. Not allowed on primary teeth. A core is generally indicated if all of the following conditions are met: A significant portion of tooth structure (50 percent or more) is fractured or carious. The preparation is at or below the gingival crest.

Provider Hotline (Medicaid): 1-877-576-5899 www.deltadentalins.com/tx-medicaid

Provider Hotline (CHIP): 1-866-561-5891 www.deltadentalins.com/tchip

Page 151

Texas Children's Medicaid Dental Services Manual of Criteria

Less than 3 mm of sound dentin remains vertically above the preparation line in opposing walls where the crown margins will be located. Procedures involving replacement of tooth structure for purposes of pulpal insulation, undercut elimination, casting bulk reduction, or for any purposes other than obtaining adequate retention shall not be considered a "build-up." A benefit for members ages 4 and above.

D2951: Pin retention ­ per tooth, in addition to restoration

A benefit for permanent teeth only; teeth #s 1- 32. Not allowed on primary teeth. A benefit for members ages 4 and above.

POST AND CORE PROCEDURES (D2952­D2954 AND D2957)

1. Post and core, in addition to crown, is payable only on an endodontically treated tooth. Fees for post and cores are denied when radiographs indicate an absence of endodontic treatment, incompletely filled canal space, or unresolved pathology associated with the involved tooth. 2. If insufficient tooth structure remains to support a crown restoration after endodontic treatment, a post is indicated to retain the core over which a crown can be placed. However, a post and core is not a strength-enhancing device and is not warranted when sufficient tooth structure remains in an anterior tooth. 3. A post cannot be placed unless prior endodontic treatment has been completed successfully. If sufficient supporting tooth structure remains, a post and core is not necessary. A post includes the build-up. D2952: Post and core in addition to crown ­ indirectly fabricated

Not payable in conjunction with procedure D2950. A benefit for permanent teeth only; teeth #s 1-32. Not allowed on primary teeth. Endodontic treatment must be adequately completed and the tooth free of pathology. A benefit for members ages 13 and above.

D2953: Each additional indirectly fabricated post ­ same tooth

Must be submitted in conjunction with procedure D2952. A benefit for permanent teeth only; teeth #s 1-32. Not allowed on primary teeth. A benefit for members ages 13 and above.

Provider Hotline (Medicaid): 1-877-576-5899 www.deltadentalins.com/tx-medicaid

Provider Hotline (CHIP): 1-866-561-5891 www.deltadentalins.com/tchip

Page 152

Texas Children's Medicaid Dental Services Manual of Criteria

D2954: Prefabricated post and core in addition to crown

Not payable in conjunction with procedure D2950. Not payable in conjunction with procedure codes D2952 or D3950 on the same tooth. A benefit for permanent teeth only; teeth #s 1- 32. Not allowed on primary teeth. A benefit for members ages 13 and above. Endodontic treatment must be adequately completed and the tooth free of pathology.

D2955: Post removal (not in conjunction with endodontic therapy)

Post removal is included in fee for endodontic retreatment (D3346, D3347, D3348). A benefit for permanent teeth only; teeth #s 1- 32. Not allowed on primary teeth. A benefit for members ages 4 and above.

D2957: Each additional prefabricated post ­ same tooth

Procedure D2957 must be billed in conjunction with procedure D2954. A benefit for permanent teeth only; teeth #s 1- 32. Not allowed on primary teeth. A benefit for members ages 13 and above.

D2960: Labial veneer (resin laminate) ­ chairside

Please submit an x-ray for D2960. A benefit for members ages 13 and above.

D2961: Labial veneer (resin laminate) ­ laboratory

Please submit an x-ray for D2961. A benefit for members ages 13 and above.

D2962: Labial veneer (porcelain laminate) ­ laboratory

Please submit an x-ray for D2962. A benefit for members ages 13 and above.

D2970: Temporary crown (fractured tooth)

Please submit an x-ray when submitting a claim for D2970. May be reimbursed once per lifetime for each tooth, any provider. A benefit for members ages 13 and above.

Provider Hotline (Medicaid): 1-877-576-5899 www.deltadentalins.com/tx-medicaid

Provider Hotline (CHIP): 1-866-561-5891 www.deltadentalins.com/tchip

Page 153

Texas Children's Medicaid Dental Services Manual of Criteria

D2971: Additional procedures to construct new crown under existing partial denture framework

Must be submitted with request for laboratory-processed crown (D2710­D2794) on the same tooth. Maximum of four per lifetime for each tooth. A benefit for members ages 13 and above.

D2980: Crown repair, by report

A benefit for permanent teeth only; teeth #s1- 32. Not allowed on primary teeth. A benefit for members ages 1 through 20.

D2999: Unspecified restorative procedure, by report

A benefit for members ages 1 through 20.

Provider Hotline (Medicaid): 1-877-576-5899 www.deltadentalins.com/tx-medicaid

Provider Hotline (CHIP): 1-866-561-5891 www.deltadentalins.com/tchip

Page 154

Texas Children's Medicaid Dental Services Manual of Criteria

ENDODONTIC SERVICES (PROCEDURES D3110-D3999)

General Policies 1. Therapeutic pulpotomy (procedure code D3220) and apexification and recalcification procedures (procedure codes D3351, D3352, and D3353) are considered part of the root canal (procedure codes D3310, D3320, and D3330) or retreatment of a previous root canal (procedure codes D3346, D3347, and D3348). When therapeutic pulpotomy or apexification and recalcification procedures are submitted with root canal codes, the reimbursement rate is adjusted to ensure that the total amount reimbursed does not exceed the total dollar amount allowed for the root canal procedure. 2. Reimbursement for a root canal includes all appointments necessary to complete the treatment. Pulpotomy and radiographs performed pre, intra, and postoperatively are included in the root canal reimbursement. Root canal therapy that has only been initiated, or taken to some degree of completion, but not carried to completion with a final filling, may not be submitted as a root canal therapy code. It must be submitted using code D3999 with a narrative description of what procedures were completed in the root canal therapy, including why the treatment could not be completed. 3. Documentation supporting medical necessity must be kept in the client's record and include the following: the medical necessity as documented through periapical radiographs of tooth treated showing pre-treatment, during treatment, and posttreatment status; the final size of the file to which the canal was enlarged; and the type of filling material used. Any reason that the root canal may appear radiographically unacceptable must be documented in the client's record.

PULP CAP (D3110-D3120)

D3110: Pulp cap ­ direct (excluding final restoration)

Procedure codes D3110 and D3120 will not be reimbursed when submitted with the following procedure codes for the same tooth, for the same DOS, by the same provider: D2952, D2953, D2954, D2955, D2957, D2980, D2999, D3220, D3230, D3240, D3310, D3320, or D3330. Limited to ages 1 and above.

D3120: Pulp cap ­ indirect (excluding final restoration)

Procedure codes D3110 and D3120 will not be reimbursed when submitted with the following procedure codes for the same tooth, for the same DOS, by the same provider: D2952, D2953, D2954, D2955, D2957, D2980, D2999, D3220, D3230, D3240, D3310, D3320, or D3330.

Provider Hotline (CHIP): 1-866-561-5891 www.deltadentalins.com/tchip

Provider Hotline (Medicaid): 1-877-576-5899 www.deltadentalins.com/tx-medicaid

Page 155

Texas Children's Medicaid Dental Services Manual of Criteria

Limited to ages 1 and above.

THERAPEUTIC PULPOTOMY (D3220)

D3220: Therapeutic pulpotomy (excluding final restoration) ­ removal of pulp coronal to the dentinocemental junction and application of medicament.

Denied when performed within six months of D3230, D3240, D3310, D3320, or D3330 for the same primary tooth, same provider. Denied when performed within six months of D3310, D3320, or D3330 on the same permanent tooth, same provider. When therapeutic pulpotomy or apexification and recalcifcation procedures are submitted with root canal codes, the reimbursement rate is adjusted to ensure that the total amount reimbursed does not exceed the total dollar amount allowed for the root canal procedures.

D3221: Pulpal debridement, primary and permanent teeth

Denied as global fee to any endodontic procedure.

ENDODONTIC THERAPY/PRIMARY TEETH (D3230-D3240)

General Policies 1. Primary teeth with insufficient root structure, internal resorption, furcal performation, or extensive periapical pathosis are not indicated for nonsurgical endodontic treatment. When a pulpectomy or pulpotomy is billed and radiographs reveal any of the above, the service is not allowed.

2. The pulp must be extirpated completely. 3. Must include the placement of a resorbable filling. 4. Includes pulpectomy, cleaning and filling of canals with resorbable material.

D3230: Pulpal therapy (resorbable filling) ­ anterior, primary tooth (excluding final restoration)

Procedure D3230 is a benefit on anterior primary teeth only; teeth # C-H and M-R. Limited to ages 1 and above.

D3240: Pulpal therapy (resorbable filling) ­ posterior, primary tooth (excluding final restoration)

Procedure D3240 is a benefit on primary posterior teeth only; Teeth # A, B, I, J, K, L, S, and T.

Provider Hotline (CHIP): 1-866-561-5891 www.deltadentalins.com/tchip

Provider Hotline (Medicaid): 1-877-576-5899 www.deltadentalins.com/tx-medicaid

Page 156

Texas Children's Medicaid Dental Services Manual of Criteria

Limited to ages 1 and above.

ENDODONTIC THERAPY/PERMANENT TEETH (D3310-D3348)

General Policies 1. Reimbursement for root canal therapy includes all appointments necessary to complete the treatment. Pulpotomy and radiographs performed pre-, intra-, and post-operatively are included in the fee for the root canal procedure. 2. Prosthetic considerations such as remaining crown-to-root ratio, length of space of bridgework if used as an abutment, location, number, and quality of endodontically treated abutments for fixed or removable prosthodontic appliance abutments. 3. The tooth must have a reasonable longevity prognosis of at least five years. The tooth must have an acceptable periodontal status and sufficient tooth structure to allow a final restoration. 4. When a radiograph indicates that obturation of an endodontically treated tooth has been performed without the use of a biologically acceptable, nonresorbable, semisolid or solid core material, the fees for endodontic therapy and/or restoration of the tooth are disallowed. 5. Endodontic therapy is limited to members ages 6 and above. 6. Root canal therapy that has only been initiated, or taken to some degree of completion, but not carried to completion with a final filling, may not be billed as a root canal therapy code. It must be billed using code D3999 with a narrative description of what procedures were completed in the root canal therapy. 7. Procedures D3331, D3332 and D3333 are not payable. Retreatment procedures should be submitted using the appropriate code for endodontic retreatment. D3310: Endodontic therapy, anterior tooth (excluding final restoration) D3320: Endodontic therapy, bicuspid tooth (excluding final restoration) D3330: Endodontic therapy, molar tooth (excluding final restoration) D3346: Retreatment of previous root canal therapy ­ anterior D3347: Retreatment of previous root canal therapy ­ bicuspid D3348: Retreatment of previous root canal therapy ­ molar

APEXIFICATION/RECALCIFICATION (D3351-D3353)

General Policies

Provider Hotline (Medicaid): 1-877-576-5899 www.deltadentalins.com/tx-medicaid Provider Hotline (CHIP): 1-866-561-5891 www.deltadentalins.com/tchip

Page 157

Texas Children's Medicaid Dental Services Manual of Criteria

1. Apexification is only benefitted on permanent teeth with incomplete root canal development or for the repair of a perforation. 2. Apexification/apexogenesis is defined as a technique for encouraging continued root formation and apical closure in teeth with incomplete apical development when the pulp is affected by trauma or caries. 3. Use procedure code D3351 for the initial visit and D3352 for interim visits. If more than two interim visits are necessary, please provide narrative documentation. 4. Apexification and recalcification procedures (procedure codes D3351, D3352, and D3353) are considered part of the root canal (procedure codes D3310, D3320, and D3330) or retreatment of a previous root canal (procedure codes D3346, D3347, and D3348). When apexification and recalcification procedures are submitted with root canal codes, the reimbursement rate is adjusted to ensure that the total amount reimbursed does not exceed the total dollar amount allowed for the root canal procedure. 5. Apexification/recalcification procedures are limited to members ages 6 and above. D3351: Apexification/recalification - initial visit (apical closure/calcific repair of perforations, root resorption, etc.) D3352: Apexification/recalification - interim medication replacement (apical closure/calcific repair of perforations, root resorption, etc.) D3353: Apexification/recalification - final visit (includes completed root canal therapy - apical closure/calcific repair of perforations, root resorption, etc.)

APICOECTOMY/PERIRADICULAR SERVICES (D3410-D3950)

General Policies 1. Apicoectomy/periradicular surgery, procedures D3410, D3421 and D3425, are defined as the excision of the apical portion of the root of a previously endodontically treated tooth to remove the diseased tissue. 2. Apicoectomy/periradicular surgery is limited to members ages 6 and above. D3410: Apicoectomy/periradicular surgery ­ anterior D3421: Apicoectomy/periradicular surgery ­ bicuspid (first root) D3425: Apicoectomy/periradicular surgery ­ molar (first root) D3426: Apicoectomy/periradicular surgery ­ (each additional root)

Provider Hotline (Medicaid): 1-877-576-5899 www.deltadentalins.com/tx-medicaid

Provider Hotline (CHIP): 1-866-561-5891 www.deltadentalins.com/tchip

Page 158

Texas Children's Medicaid Dental Services Manual of Criteria

D3430: Retrograde filling per root D3450: Root amputation - per root

A benefit for posterior permanent teeth only.

D3460: Endodontic endosseous implant

Prior authorization is required. Please submit x-rays along with request for prior authorization. A benefit for members ages 16 through 20.

D3470: Intentional reimplantation (including necessary splinting)

A benefit for permanent teeth; includes necessary splinting. Please provide narrative documentation. A benefit for members ages 6 through 20.

D3910: Surgical procedure for isolation of tooth with rubber dam

D3910 is benefitted in conjunction with D3310, D3320, D3330, D3346, D3347, D3348, D3351, D3352, and/or D3353. A benefit for members ages 1 through 20.

D3920: Hemisection (including any root removal), not including root canal therapy

A benefit for members ages 6 through 20.

D3950: Canal preparation and fitting of preformed dowel or post

D3950 is a benefit for permanent teeth in conjunction with prefabricated or indirectly fabricated post and core procedures. A benefit for members ages 6 through 20.

D3999: Unspecified endodontic procedure, by report

Please provide narrative documentation to describe the services performed. A benefit for members ages 1 through 20.

Provider Hotline (Medicaid): 1-877-576-5899 www.deltadentalins.com/tx-medicaid

Provider Hotline (CHIP): 1-866-561-5891 www.deltadentalins.com/tchip

Page 159

Texas Children's Medicaid Dental Services Manual of Criteria

PERIODONTIC SERVICES (PROCEDURES D4210-D4999)

General Policies 1. Procedure codes D1110, D1120, D1203, D1204, D1206, and D1351 are not payable when billed on the same date of service as any D4000 series periodontal procedure codes. 2. Unless otherwise noted, periodontal treatment, when a benefit, is limited to members ages 13 and above. Procedures D4230 and D4231 are benefitted for members ages 1 through 20. 3. Procedure codes D4266 and D4267, if denied upon initial submission, may be appealed with documentation of medical necessity. a. Medical necessity (for sites other than third molar sites) are: Medical or dental history documenting morbid condition (e.g., juvenile diabetes, cleft palate, avulsed tooth or teeth, traumatic oral injuries). Intra- or extra-oral radiographs of treatment site(s). If not radiographically evident, intraoral photographs are optional unless requested pre-operatively. Periodontal probing depths. Number of intact walls associated with an angular bony defect. Bone graft and barrier material used. b. Medical necessity for third molar sites includes: Medical or dental history documenting need due to inadequate healing of bone following third molar extraction, including the date of third molar extraction. Secondary procedure several months post-extraction. Position of the third molar pre-operatively. Post-extraction probing depth to document continuing bony defect. Post-extraction radiographs documenting continuing bony defect. Bone graft and barrier material used. 4. Procedure codes D4210 and D4211, when billed for clients 12 years of age or younger, will be initially denied, but may be appealed with documentation of medical necessity. 5. Preoperative and postoperative photographs may be required for the following procedure codes if medical necessity is not evident upon initial submission: D4240, D4241, D4245, D4266, and D4267. 6. Procedure D4265 is denied as global to all other procedures.

Provider Hotline (Medicaid): 1-877-576-5899 www.deltadentalins.com/tx-medicaid

Provider Hotline (CHIP): 1-866-561-5891 www.deltadentalins.com/tchip

Page 160

Texas Children's Medicaid Dental Services Manual of Criteria

7. For procedures D4210­D4211 and D4240­D4241: a. Must be at least type II periodontal disease (4 mm or greater pocket depth). b. The long-term prognosis of the area must be favorable. Mobility, clinical attachment loss, furcation involvement, and osseous defect morphology can affect the prognosis. c. Documented change in the patient's condition since the date of any previous periodontal treatment. D4210: Gingivectomy or gingivoplasty ­ four or more contiguous teeth or tooth bounded spaces per quadrant D4211: Gingivectomy or gingivoplasty ­ one to three contiguous teeth or tooth bounded spaces per quadrant D4230: Anatomical crown exposure ­ four or more contiguous teeth per quadrant D4231: Anatomical crown exposure ­ one to three teeth per quadrant D4240: Gingival flap procedure, including root planing ­ four or more contiguous teeth or tooth bounded spaces per quadrant D4241: Gingival flap procedure, including root planing ­ one to three contiguous teeth or tooth bounded spaces per quadrant

Procedure D4241 is limited to once per year.

D4245: Apically Positioned Flap D4249: Clinical crown lengthening ­ hard tissue

A six- to eight-week healing period following crown lengthening before final tooth preparation, impression making, and fabrication of a final restoration is required. Surgical crown lengthening may be benefitted when required to prevent a restoration from impinging on the biologic width of the periodontal attachment. Requires a minimum of 3 mm of sound tooth structure coronal to the osseous crest.

D4260: Osseous surgery (including flap entry and closure) ­ four or more contiguous teeth or tooth bounded spaces per quadrant

Reporting of procedures D4260­D4261 requires the submission of complete periodontal charting that indicates at least case type III periodontal disease (5 mm or greater pocket depth, moderate to severe bone loss).

Provider Hotline (Medicaid): 1-877-576-5899 www.deltadentalins.com/tx-medicaid

Provider Hotline (CHIP): 1-866-561-5891 www.deltadentalins.com/tchip

Page 161

Texas Children's Medicaid Dental Services Manual of Criteria

D4261: Osseous surgery (including flap entry and closure) ­ one to three contiguous teeth or tooth bounded spaces per quadrant

Reporting of procedures D4260­D4261 requires the submission of complete periodontal charting that indicates at least case type III periodontal disease (5 mm or greater pocket depth, moderate to severe bone loss). Procedure D4261 is limited to once per year.

D4266: Guided tissue regeneration ­ resorbable barrier, per site

May be considered upon submission of an appeal with the following documentation: pre-operative radiographs that show evidence of the bony defect; intra-oral photographs may be submitted, if the bony defect is not evident on radiographs; periodontal probing depths documenting bony defect.

D4267: Guided tissue regeneration ­ nonresorbable barrier, per site (includes membrane removal)

May be considered upon submission of an appeal with the following documentation: pre-operative radiographs that show evidence of the bony defect; intra-oral photographs may be submitted, if the bony defect is not evident on radiographs; periodontal probing depths documenting bony defect.

D4270: Pedicle soft tissue graft procedure D4271: Free soft tissue graft procedure (including donor site surgery) D4273: Subepithelial connective tissue graft procedures, per tooth

This procedure is performed to create or augment gingiva, to obtain root coverage or to eliminate frenum pull, or to extend the vestibular fornix.

D4274: Distal or proximal wedge procedure (when not performed in conjunction with surgical procedures in the same anatomical area)

This procedure is performed in an edentulous area adjacent to a periodontally involved tooth. Gingival incisions are used to allow removal of a tissue wedge to gain access and correct the underlying osseous defect and to permit close flap adaptation.

D4275: Soft tissue allograft

Limited to once per day.

Provider Hotline (Medicaid): 1-877-576-5899 www.deltadentalins.com/tx-medicaid

Provider Hotline (CHIP): 1-866-561-5891 www.deltadentalins.com/tchip

Page 162

Texas Children's Medicaid Dental Services Manual of Criteria

D4276: Combined connective tissue and double pedicle graft, per tooth

Prior authorization is required. Please submit radiograph, periodontal charting, or narrative description of clinical circumstances. Not payable in addition to D4273 or D4275 on the same DOS.

D4320: Provisional splinting ­ intracoronal

A benefit for members ages 1 through 20.

D4321: Provisional splinting ­ extracoronal

A benefit for members ages 1 through 20.

D4341: Periodontal scaling and root planing ­ four or more teeth per quadrant

Procedure D4341 is not allowed if provided within 21 days of D4355. Procedure D4341 is not when billed on the same DOS as other D4000 series codes or with D1110, D1120, D1203, D1204, D1206, D1351, D1510, D1515, D1520 or D1525. Reporting of this service requires the submission of complete periodontal charting that indicates at least case type II periodontal disease (4 mm or greater pocket depth).

D4342: Periodontal scaling and root planing ­ one to three teeth, per quadrant

Procedure D4342 is not when billed on the same DOS as other D4000 series codes or with D1110, D1120, D1203, D1204, D1206, D1351, D1510, D1515, D1520 or D1525. Reporting of this service requires the submission of complete periodontal charting that indicates at least case type II periodontal disease (4 mm or greater pocket depth).

D4355: Full mouth debridement to enable comprehensive evaluation and diagnosis

Procedure D4355 is not payable if provided within 21 days of procedure D4341. Procedure D4355 is denied when billed on the same DOS as other D4000 series codes or with procedures D1110, D1120, D1203, D1204, D1206, D1351, D1510, D1515, D1520 or D1525. Procedures D4355 is the gross removal of plaque and calculus that interferes with the ability to perform an oral evaluation. By definition, D4355 is not allowed subsequent to an oral evaluation.

Provider Hotline (Medicaid): 1-877-576-5899 www.deltadentalins.com/tx-medicaid

Provider Hotline (CHIP): 1-866-561-5891 www.deltadentalins.com/tchip

Page 163

Texas Children's Medicaid Dental Services Manual of Criteria

D4381: Localized delivery of antimicrobial agents via a controlled release vehicle into diseased crevicular tissue, per tooth, by report

This procedure does not replace conventional or surgical therapy required for debridement, respective procedures, or regenerative therapy. The use of controlledrelease chemotherapeutic agents is an adjunctive therapy or for cases in which systemic disease or other factors preclude conventional or surgical therapy. Procedure D4381 is not allowed if conventional therapy such as periodontal surgery, scaling, or root planing or periodontal maintenance has been or can be performed.

D4910: Periodontal maintenance

Procedure D4910 is payable only following active periodontal therapy by any provider as evidenced either by a submitted claim for procedure code D4240, D4241, D4260, or D4261 or by evidence through client records of periodontal therapy while not Medicaid-eligible. Procedure D4910 is not payable within 90 days after D4355, not payable on same DOS as any evaluation procedure.

D4920: Unscheduled dressing change (by someone other than treating dentist)

Unscheduled dressing changes by the same dentist or by a dentist at the same location, are considered part of, and included in the fees for periodontal surgery.

D4999: Unspecified periodontal procedure, by report

Provider Hotline (Medicaid): 1-877-576-5899 www.deltadentalins.com/tx-medicaid

Provider Hotline (CHIP): 1-866-561-5891 www.deltadentalins.com/tchip

Page 164

Texas Children's Medicaid Dental Services Manual of Criteria

REMOVABLE PROSTHODONTIC SERVICES (PROCEDURES D5110-D5899)

Removable prostheses are benefits, using standard procedures, which exclude precision attachments, implants, or other specialized techniques. The covered dental benefit for partial dentures will be limited to the charges for a cast chrome or acrylic denture if this would satisfactorily restore an arch. If a more elaborate or precision appliance is chosen by the patient and the dentist, and is not necessary to satisfactorily restore an arch, the patient will be responsible for all additional charges. Removable prosthodontic services include routine post-delivery care for six months following initial insertion.

COMPLETE DENTURES (INCLUDING ROUTINE POST-DELIVERY CARE) (D5110D5140)

D5110: Complete denture ­ maxillary

Limited to members ages 3 and above.

D5120: Complete denture ­ mandibular

Limited to members ages 3 and above.

D5130: Immediate denture ­ maxillary

Limited to members ages 13 and above.

D5140: Immediate denture ­ mandibular

Limited to members ages 13 and above.

PARTIAL DENTURES (INCLUDING ROUTINE POST-DELIVERY CARE) (D5211D5281)

D5211: Maxillary partial denture ­ resin base (including any conventional clasps, rests and teeth)

Limited to members ages 6 and above.

D5212: Mandibular partial denture ­ resin base (including any conventional clasps, rests and teeth)

Limited to members ages 6 and above.

Provider Hotline (Medicaid): 1-877-576-5899 www.deltadentalins.com/tx-medicaid

Provider Hotline (CHIP): 1-866-561-5891 www.deltadentalins.com/tchip

Page 165

Texas Children's Medicaid Dental Services Manual of Criteria

D5213: Maxillary partial denture ­ cast metal framework with resin denture bases (including any conventional clasps, rests and teeth)

Limited to members ages 9 and above.

D5214: Mandibular partial denture ­ cast metal framework with resin denture bases (including any conventional clasps, rests and teeth)

Limited to members ages 9 and above.

D5281: Removable unilateral partial denture - one piece cast metal (including clasps and teeth)

Limited to members ages 8 and above.

DENTURE ADJUSTMENTS (D5410-D5422)

D5410: Adjust complete denture ­ maxillary

Limited to members ages 3 and above.

D5411: Adjust complete denture ­ mandibular

Limited to members ages 3 and above.

D5421: Adjust partial denture ­ maxillary

Limited to members ages 6 and above.

D5422: Adjust partial denture ­ mandibular

Limited to members ages 6 and above.

REPAIRS TO COMPLETE AND PARTIAL DENTURES (D5510-D5671)

General Policies Cost of repairs cannot exceed replacement costs. The allowable amount for any combination of procedures D5510­D5671 cannot exceed the cost of a replacement complete or partial denture. D5510: Repair broken complete denture base

Please provide an arch code. Limited to members ages 3 and above.

Provider Hotline (Medicaid): 1-877-576-5899 www.deltadentalins.com/tx-medicaid

Provider Hotline (CHIP): 1-866-561-5891 www.deltadentalins.com/tchip

Page 166

Texas Children's Medicaid Dental Services Manual of Criteria

D5520: Replace missing or broken teeth - complete denture (each tooth)

Limited to members ages 3 and above.

D5610: Repair resin denture base

Please provide an arch code. Limited to members ages 3 and above.

D5620: Repair cast framework

Limited to members ages 6 and above.

D5630: Repair or replace broken clasp

Limited to members ages 6 and above.

D5640: Replace broken teeth ­ per tooth

Limited to members ages 6 and above.

D5650: Add tooth to existing partial denture

Please provide the tooth number(s) being replaced. Limited to members ages 6 and above.

D5660: Add clasp to existing partial denture

Limited to members ages 6 and above.

D5670: Replace all teeth and acrylic on cast metal framework (maxillary)

Will be denied as part of procedure codes D5211, D5213, D5281, and D5640. Limited to members ages 6 and above.

D5671: Replace all teeth and acrylic on cast metal framework (mandibular)

Will be denied as part of procedure codes D5212, D5214, D5281, and D5640. Limited to members ages 6 and above.

DENTURE REBASE/RELINE PROCEDURES (D5710-D5761)

D5710: Rebase complete maxillary denture

Limited to members ages 4 and above.

Provider Hotline (Medicaid): 1-877-576-5899 www.deltadentalins.com/tx-medicaid

Provider Hotline (CHIP): 1-866-561-5891 www.deltadentalins.com/tchip

Page 167

Texas Children's Medicaid Dental Services Manual of Criteria

D5711: Rebase complete mandibular denture

Limited to members ages 4 and above.

D5720: Rebase maxillary partial denture

Limited to members ages 7 and above.

D5721: Rebase mandibular partial denture

Limited to members ages 7 and above.

D5730: Reline complete maxillary denture (chair side)

Limited to members ages 4 and above.

D5731: Reline complete mandibular denture (chair side)

Limited to members ages 4 and above.

D5740: Reline maxillary partial denture (chair side)

Limited to members ages 7 and above.

D5741: Reline mandibular partial denture (chair side)

Limited to members ages 7 and above.

D5750: Reline complete maxillary denture (laboratory)

Limited to members ages 4 and above.

D5751: Reline complete mandibular denture (laboratory)

Limited to members ages 4 and above.

D5760: Reline maxillary partial denture (laboratory)

Limited to members ages 7 and above.

D5761: Reline mandibular partial denture (laboratory)

Limited to members ages 7 and above.

Provider Hotline (Medicaid): 1-877-576-5899 www.deltadentalins.com/tx-medicaid

Provider Hotline (CHIP): 1-866-561-5891 www.deltadentalins.com/tchip

Page 168

Texas Children's Medicaid Dental Services Manual of Criteria

INTERIM PROSTHESIS (D5810-D5821)

D5810: Interim complete denture (maxillary)

Limited to members ages 3 and above.

D5811: Interim complete denture (mandibular)

Limited to members ages 3 and above.

D5820: Interim partial denture (maxillary)

Limited to members ages 3 and above.

D5821: Interim partial denture (mandibular)

Limited to members ages 3 and above.

OTHER SERVICES AND/OR BY REPORT PROCEDURES (D5820-D5899)

General Policies Procedures D5867 and D5875 are denied as part of any repair or modification of any removable prosthetic. D5850: Tissue conditioning, maxillary

Limited to members ages 3 and above.

D5851: Tissue conditioning, mandibular

Limited to members ages 3 and above.

D5860: Overdenture ­ complete, by report

Please provide an arch code. Limited to members ages 4 and above.

D5861: Overdenture ­ partial, by report

Please provide an arch code. Limited to members ages 4 and above.

D5862: Precision attachment, by report

Please provide the quadrant code.

Provider Hotline (CHIP): 1-866-561-5891 www.deltadentalins.com/tchip

Provider Hotline (Medicaid): 1-877-576-5899 www.deltadentalins.com/tx-medicaid

Page 169

Texas Children's Medicaid Dental Services Manual of Criteria

Limited to members ages 4 and above.

D5899: Unspecified removable prosthodontic procedure, by report

Limited to members ages 1 and above.

Provider Hotline (Medicaid): 1-877-576-5899 www.deltadentalins.com/tx-medicaid

Provider Hotline (CHIP): 1-866-561-5891 www.deltadentalins.com/tchip

Page 170

Texas Children's Medicaid Dental Services Manual of Criteria

MAXILLOFACIAL PROSTHETIC SERVICES (PROCEDURES D5911-D5951)

General Policies 1. For the purpose of this section, maxillofacial dental services means anatomic and functional reconstruction of those regions of the mandible and maxilla and associated structures that are missing or defective because of surgical intervention, trauma (other than simple or compound fractures), pathology, developmental or congenital malformations, and the diagnosis and treatment of temporomandibular joint dysfunction. 2. Please provide a copy of an operative report, surgical report, or copy of the patient treatment record with claims for maxillofacial prosthetic services. 3. All maxillofacial prosthetic services include medication, repair, or adjustments for the same date of service delivery. 4. Maxillofacial surgical and prosthetic services and temporomandibular joint (TMJ) dysfunction services requests may be audited individually to determine necessity and reasonableness relative to the intent of the regulations. 5. All maxillofacial surgical and prosthetic services, TMJ dysfunction services, and orthodontic services require prior authorization, please submit a pre-treatment authorization request, except for diagnostic services and those services rendered on an emergency basis. 6. Procedures D5951-D5960 require prior authorization. 7. Procedures D5911­D5937 and D5982-D5999 are limited to members ages 1 and above.

Provider Hotline (Medicaid): 1-877-576-5899 www.deltadentalins.com/tx-medicaid

Provider Hotline (CHIP): 1-866-561-5891 www.deltadentalins.com/tchip

Page 171

Texas Children's Medicaid Dental Services Manual of Criteria

D5911: Facial moulage (sectional) D5912: Facial moulage (complete) D5913: Nasal prosthesis D5914: Auricular prosthesis D5915: Orbital prosthesis D5916: Ocular prosthesis D5919: Facial prosthesis D5922: Nasal septal prosthesis D5923: Ocular prosthesis, interim D5924: Cranial prosthesis D5925: Facial augmentation implant prosthesis D5926: Nasal prosthesis, replacement D5927: Auricular prosthesis, replacement D5928: Orbital prosthesis, replacement D5929: Facial prosthesis, replacement D5931: Obturator prosthesis, surgical D5932: Obturator prosthesis, definitive D5933: Obturator prosthesis, modification D5934: Mandibular resection prosthesis with guide flange D5935: Mandibular resection prosthesis without guide flange D5936: Obturator prosthesis, interim D5937: Trismus appliance (not for TMD treatment)

Not to be used for temporo-mandibular dysfunction (TMD) treatment.

Provider Hotline (Medicaid): 1-877-576-5899 www.deltadentalins.com/tx-medicaid

Provider Hotline (CHIP): 1-866-561-5891 www.deltadentalins.com/tchip

Page 172

Texas Children's Medicaid Dental Services Manual of Criteria

D5951: Feeding aid D5952: Speech aid prosthesis, pediatric D5953: Speech aid prosthesis, adult D5954: Palatal augmentation prosthesis D5955: Palatal lift prosthesis, definitive D5958: Palatal lift prosthesis, interim D5959: Palatal lift prosthesis, modification D5960: Speech aid prosthesis, modification D5982: Surgical stent D5983: Radiation carrier D5984: Radiation shield D5985: Radiation cone locator D5986: Fluoride gel carrier D5987: Commissure splint D5988: Surgical splint D5999: Unspecified maxillofacial prosthesis, by report

Provider Hotline (Medicaid): 1-877-576-5899 www.deltadentalins.com/tx-medicaid

Provider Hotline (CHIP): 1-866-561-5891 www.deltadentalins.com/tchip

Page 173

Texas Children's Medicaid Dental Services Manual of Criteria

IMPLANT SERVICES (PROCEDURES D6010-D6100)

General Policies 1. Prior authorization is required for all implant services. Exception: procedure codes D6092 and D6093 do not require prior authorization. 2. Periapical radiographs are required for each tooth involved. 3. Implants are a benefit when: At least one abutment tooth meets the criteria for a laboratory processed crown. Space cannot be filled with removable partial denture. The purpose is to prevent the drifting of teeth in all dimensions (anterior, posterior, lateral, and the opposing arch). 4. Procedures D6053 and D6054 are denied as global to other services 5. Implant procedures, when a benefit, are limited to members ages 16 and above. D6010: Surgical placement of implant body: endosteal implant

Includes second stage surgery and placement of healing cap. Prior authorization is required.

D6040: Surgical placement: eposteal implant

Prior authorization is required.

D6050: Surgical placement: transosteal implant

Prior authorization is required.

D6055: Dental implant supported connecting bar

Prior authorization is required.

D6056: Prefabricated abutment - includes placement

Includes placement. May include the removal of a temporary healing cap or replacement with an abutment of alternate design.

D6057: Custom abutment - includes placement

Includes placement. May include the removal of a temporary healing cap or replacement with an abutment of alternate design.

Provider Hotline (Medicaid): 1-877-576-5899 www.deltadentalins.com/tx-medicaid

Provider Hotline (CHIP): 1-866-561-5891 www.deltadentalins.com/tchip

Page 174

Texas Children's Medicaid Dental Services Manual of Criteria

D6080: Implant maintenance procedures, including removal of prosthesis, cleansing of prosthesis and abutments and reinsertion of prosthesis

Prior authorization is required. Procedure D6080 is a benefit once per date of service.

D6090: Repair implant supported prosthesis, by report

Prior authorization is required. Please describe the type of prosthesis and the necessary repair(s).

D6092: Recement implant/abutment supported crown

Limited to once per year for each tooth.

D6093: Recement implant/abutment supported fixed partial denture

Limited to once per year for each tooth.

D6095: Repair implant abutment, by report

Prior authorization is required. Please describe the type of repair(s) necessary.

D6100: Implant removal, by report

Prior authorization is required.

D6199: Unspecified implant procedure, by report

Prior authorization is required.

Provider Hotline (Medicaid): 1-877-576-5899 www.deltadentalins.com/tx-medicaid

Provider Hotline (CHIP): 1-866-561-5891 www.deltadentalins.com/tchip

Page 175

Texas Children's Medicaid Dental Services Manual of Criteria

FIXED PROSTHODONTIC SERVICES (PROCEDURES D6210D6999)

General Policies 1. Fixed prosthodontic services require prior authorization, diagnostic periapical Xrays must be submitted along with the Treatment Authorization Request. 2. To obtain prior authorization for implants and fixed prosthodontics, a prior authorization form together with documentation supporting medical necessity and appropriateness must be submitted. Required documentation includes, but is not limited to: Appropriate pretreatment radiographs. Necessary radiographs of each involved tooth, such as periapical views. Panoramic films are inadequate to document caries. Documentation supporting that the mouth is free of disease; no untreated periodontal or endodontic disease, or rampant caries. Documentation supporting only one virgin abutment tooth; at least one tooth must require a crown unless a Maryland Bridge is being considered. Tooth Identification (TID) System noting only permanent teeth. Documentation supporting that a removable partial is not a viable option to fill the space between the teeth. 3. Fixed prosthodontic services are a benefit when: At least one abutment tooth meets the criteria for a laboratory processed crown. The space cannot be adequately restored with a removable partial denture. The purpose is to prevent the drifting of teeth in all dimensions (anterior, posterior, lateral, and the opposing arch). 4. Prior authorization will not be given when films show two abutment teeth (virgin teeth do not require a crown, except for Maryland Bridge) or there is untreated periodontal or endodontic disease, or rampant caries which would contraindicate the treatment. 5. Prosthetic appliances should have a longevity prognosis of at least a five-year period. Exceptions may be made when there is such extensive loss of remaining teeth or change in supporting tissues that the existing fixed bridge, partial denture, or complete denture cannot be made satisfactory. 6. Porcelain is allowed on all teeth. 7. A benefit for members ages 16 and above.

Provider Hotline (Medicaid): 1-877-576-5899 www.deltadentalins.com/tx-medicaid

Provider Hotline (CHIP): 1-866-561-5891 www.deltadentalins.com/tchip

Page 176

Texas Children's Medicaid Dental Services Manual of Criteria

8. Authorization for laboratory processed fixed partial dentures and pontics may be granted where longevity is essential and a lesser service will not suffice. 9. Replacement of an existing fixed partial denture is covered only when it cannot be made satisfactory by repair. 10. Each abutment or pontic constitutes a unit in a bridge. 11. Procedure D6253, D6600-D6615 are denied as global to all other procedures. 12. Post-treatment authorization will not be approved for codes that require mandatory prior authorization.

Provider Hotline (Medicaid): 1-877-576-5899 www.deltadentalins.com/tx-medicaid

Provider Hotline (CHIP): 1-866-561-5891 www.deltadentalins.com/tchip

Page 177

Texas Children's Medicaid Dental Services Manual of Criteria

FIXED PARTIAL DENTURE PONTICS (D6210-D6252)

D6210: Pontic ­ cast high noble metal D6211: Pontic ­ cast predominantly base metal D6212: Pontic ­ cast noble metal D6240: Pontic ­ porcelain fused to high noble metal D6241: Pontic ­ porcelain fused to predominantly base metal D6242: Pontic ­ porcelain fused to noble metal D6245: Pontic ­ porcelain/ceramic D6250: Pontic ­ resin with high noble metal D6251: Pontic ­ resin with predominantly base metal D6252: Pontic ­ resin with noble metal

FIXED PARTIAL DENTURE RETAINERS ­ INLAYS/ONLAYS (D6545-D6548)

D6545: Retainer ­ cast metal for resin bonded fixed prosthesis D6548: Retainer ­ porcelain/ceramic for resin bonded fixed prosthesis

FIXED PARTIAL DENTURE RETAINERS ­ CROWNS (D6720-D6792)

D6720: Crown ­ resin with high noble metal D6721: Crown ­ resin with predominantly base metal D6722: Crown ­ resin with noble metal D6740: Crown ­ porcelain/ceramic D6750: Crown ­ porcelain fused to high noble metal D6751: Crown ­ porcelain fused to predominantly base metal D6752: Crown ­ porcelain fused to noble metal D6780: Crown ­ 3/4 cast high noble metal D6781: Crown ­3/4 cast predominantly base metal

Provider Hotline (Medicaid): 1-877-576-5899 www.deltadentalins.com/tx-medicaid Provider Hotline (CHIP): 1-866-561-5891 www.deltadentalins.com/tchip

Page 178

Texas Children's Medicaid Dental Services Manual of Criteria

D6782: Crown ­ 3/4 cast noble metal D6783: Crown ­ 3/4 porcelain/ceramic D6790: Crown ­ full cast high noble metal

Permanent posterior teeth only.

D6791: Crown ­ full cast predominantly base metal

Permanent posterior teeth only.

D6792: Crown ­ full cast noble metal

Permanent posterior teeth only.

OTHER SERVICES AND/OR SERVICE BY REPORT (D6920-D6999)

D6920: Connector bar

Please provide an arch code.

D6930: Recement fixed partial denture D6940: Stress breaker D6950: Precision attachment D6970: Cast post and core in addition to fixed partial denture retainer

Use Procedure D6970 rather than D2952 when billing for an indirectly fabricated post in conjunction with a fixed bridge.

D6972: Prefabricated post and core in addition to fixed partial denture retainer

Use Procedure D6972 rather than D2954 when billing for a prefabricated post in conjunction with a fixed bridge.

D6973: Core build-up for retainer, including any pins D6975: Coping ­ metal D6976: Each additional indirectly fabricated post - same tooth

If submitted, this procedure must be used in conjunction with procedure D6970.

Provider Hotline (Medicaid): 1-877-576-5899 www.deltadentalins.com/tx-medicaid

Provider Hotline (CHIP): 1-866-561-5891 www.deltadentalins.com/tchip

Page 179

Texas Children's Medicaid Dental Services Manual of Criteria

D6977: Each additional prefabricated post - same tooth

If submitted, this procedure must be used in conjunction with procedure D6972.

D6980: Fixed partial denture repair, by report

Please provide the quadrant code of the partial denture being repaired.

D6999: Unspecified fixed prosthodontic procedure, by report

Please provide narrative documentation of the service(s) provided.

Provider Hotline (Medicaid): 1-877-576-5899 www.deltadentalins.com/tx-medicaid

Provider Hotline (CHIP): 1-866-561-5891 www.deltadentalins.com/tchip

Page 180

Texas Children's Medicaid Dental Services Manual of Criteria

ORAL SURGERY SERVICES (PROCEDURES D7111-D7999)

General Policies 1. All oral surgery procedures include local anesthesia, suturing, if needed, and visits for routine postoperative care. The fees for oral surgery procedures include local anesthesia and routine post-operative visits. 2. An x-ray is required for procedures D7230­D7241. 3. The fee for extractions includes the excision of associated minor cystic or inflamed tissue. 4. Classification for extractions and surgical extractions of impacted teeth is based on the anatomical position of the tooth rather than the surgical technique employed in removal. 5. Procedures D7210­D7441, D7465-D7971, and D7980-D7999 are limited to members ages 1 and above. 6. Procedures D7287, D7415, D7471, D7473-D7490, are denied as global to all other procedures. 7. The following codes can be submitted for both primary and permanent teeth: D7140, D7210, D7220, D7230, D7240, D7241, D7250, D7285, D7286, and D7510. All other oral surgery procedures are benefitted for permanent teeth only. D7111: Extraction, coronal remnants ­ deciduous tooth D7140: Extraction, erupted tooth or exposed root (elevation and/or forceps removal)

A benefit for the uncomplicated removal of a primary or permanent tooth. Includes routine removal of tooth structure, minor smoothing of socket bone, and closure, as necessary. A benefit for the removal of any tooth by elevation and/or forceps where the mucoperiosteum is not detached.

SURGICAL EXTRACTIONS (D7210-D7250)

D7210: Surgical removal of erupted tooth requiring elevation of mucoperiosteal flap and removal of bone and/or section of tooth

Includes removal of the roots of a previously erupted tooth missing its clinical crown.

D7220: Removal of impacted tooth ­ soft tissue

Occlusal surface of tooth covered by soft tissue.

Provider Hotline (CHIP): 1-866-561-5891 www.deltadentalins.com/tchip

Provider Hotline (Medicaid): 1-877-576-5899 www.deltadentalins.com/tx-medicaid

Page 181

Texas Children's Medicaid Dental Services Manual of Criteria

D7230: Removal of impacted tooth ­ partial bony

Part of crown covered by bone.

D7240: Removal of impacted tooth ­ complete bony

Most or all of crown covered by bone.

D7241: Removal of impacted tooth ­ complete bony with unusual surgical complications

Requires an operative report describing unusual factors such as nerve dissection or separate closure of maxillary sinus.

D7250: Surgical removal of residual tooth roots (cutting procedure)

Involves tissue incision and removal of bone to remove a permanent or primary

tooth root left in the bone from a previous extraction, caries, or trauma. Usually some degree of soft and/or hard tissue healing has occurred. Not payable to same provider within six months of extraction procedure.

OTHER SURGICAL PROCEDURES (D7260-D7283)

D7260: Oroantral fistula closure

Procedure D7260 requires prior authorization. Please provide narrative documentation and/or photographs describing the need for this service. Procedure D7260 is benefitted for teeth (area) 1­16.

D7261: Primary closure of a sinus perforation

Procedure D7261 is not paid when performed on the same date as D7260.

D7270: Tooth reimplantation and/or stabilization of accidentally evulsed or displaced tooth D7272: Tooth transplantation (includes reimplantation from one site to another and splinting and/or stabilization)

Requires prior authorization. Please document the donor tooth number and the tooth number of the reimplantation site. X-rays required. Please submit x-rays of both the donor tooth and reimplantation site. Procedure D7272 includes splinting and stabilization.

Provider Hotline (CHIP): 1-866-561-5891 www.deltadentalins.com/tchip

Provider Hotline (Medicaid): 1-877-576-5899 www.deltadentalins.com/tx-medicaid

Page 182

Texas Children's Medicaid Dental Services Manual of Criteria

D7280: Surgical access of an unerupted tooth

Procedure D7280 is a benefit for permanent teeth only.

D7282: Mobilization of erupted or malpositioned tooth to aid eruption

Permanent teeth only. Procedure D7282 is not paid if performed on the same date procedure D7280.

D7283: Placement of device to facilitate eruption of impacted tooth

BIOPSY OF ORAL TISSUE (PROCEDURE D7285-D7286)

D7285: Biopsy of oral tissue ­ hard (bone, tooth) D7286: Biopsy of oral tissue ­ soft D7290: Surgical repositioning of teeth D7291: Transseptal fiberotomy/supra crestal fiberotomy, by report

Procedure D7291 is a benefit for members ages 4 and up.

ALVEOLOPLASTY (D7310-D7320)

D7310: Alveoplasty in conjunction with extractions ­ four or more teeth or tooth spaces, per quadrant D7320: Alveoplasty not in conjunction with extractions ­ four or more teeth or tooth spaces, per quadrant

VESTIBULOPLASTY (D7340-D7350)

D7340: Vestibuloplasty ­ ridge extension (secondary epithelialization) D7350: Vestibuloplasty ­ ridge extension (including soft tissue grafts, muscle reattachment, revision of soft tissue attachment and management of hypertrophied and hyperplastic tissue)

Surgical excision of reactive inflammatory lesions (scar tissue or localized congenital lesions)

Provider Hotline (Medicaid): 1-877-576-5899 www.deltadentalins.com/tx-medicaid

Provider Hotline (CHIP): 1-866-561-5891 www.deltadentalins.com/tchip

Page 183

Texas Children's Medicaid Dental Services Manual of Criteria

EXCISION OF BENIGN TUMOR (D7410-D7414)

General Policies 1. The incidental removal of cysts/lesions attached to the root(s) of a simple extraction is considered part of the extraction or surgical fee. Procedures D7410-D7414 are not allowed in conjunction with other extraction procedures. 2. Please identify the area of the lesion. 3. A benefit only as separate procedure, not in conjunction with an extraction, apicoectomy, tuberosity reduction, or excision of any body part. The removal of cysts/lesions in conjunction with an extract of a tooth or other surgical procedure is considered part of the extraction or surgical fee. D7410: Excision of benign lesion up to 1.25 cm D7411: Excision of benign lesion greater than 1.25 cm D7413: Excision of malignant lesion up to 1.25 cm D7414: Excision of malignant lesion greater than 1.25 cm

SURGICAL EXCISION OF INTRA-OSSEOUS LESIONS (D7440-D7465)

General Policies 1. The incidental removal of cysts/lesions attached to the root(s) of an extracted tooth is considered part of the extraction or surgical fee. The removal of cysts/lesions in conjunction with an extract of a tooth or other surgical procedure is considered part of the extraction or surgical fee. Procedures D7440-D7465 are not allowed in conjunction with extraction procedures. 2. Please identify the area of the lesion. D7440: Excision of malignant tumor ­ lesion diameter up to 1.25 cm D7441: Excision of malignant tumor ­ lesion diameter greater than 1.25 cm D7450: Removal of benign odontogenic cyst or tumor ­ lesion diameter up to 1.25 cm D7451: Removal of benign odontogenic cyst or tumor ­ lesion diameter greater than 1.25 cm

Provider Hotline (Medicaid): 1-877-576-5899 www.deltadentalins.com/tx-medicaid

Provider Hotline (CHIP): 1-866-561-5891 www.deltadentalins.com/tchip

Page 184

Texas Children's Medicaid Dental Services Manual of Criteria

D7460: Removal of benign nonodontogenic cyst or tumor ­ lesion diameter up to 1.25 cm D7461: Removal of benign nonodontogenic cyst or tumor ­ lesion diameter greater than 1.25 cm D7465: Destruction of lesion(s) by physical or chemical method, by report D7472: Removal of torus palatinus

Prior authorization is required. Please submit a panoramic radiograph or photograph and provide narrative documentation of the need for this service.

SURGICAL INCISIONS (D7510-D7560)

D7510: Incision and drainage of abscess ­ intraoral soft tissue D7520: Incision and drainage of abscess ­ extraoral soft tissue D7530: Removal of foreign body from mucosa, skin, or subcutaneous alveolar tissue D7540: Removal of reaction producing foreign bodies, musculoskeletal system D7550: Partial ostectomy/sequestrectomy for removal of non-vital bone D7560: Maxillary sinusotomy for removal of tooth fragment or foreign body

TREATMENT OF FRACTURES ­ SIMPLE (D7670)

D7670: Alveolus closed reduction may include stabilization of teeth

REDUCTION OF DISLOCATION AND MANAGEMENT (D7820-D7899) (Other TMJ Dysfunctions)

D7820: Closed reduction of dislocation D7880: Occlusal orthotic device, by report D7899: Unspecified TMJ therapy

Please provide narrative documentation of the nature of the service provided.

REPAIR OF TRAUMATIC WOUNDS (D7910-D7912)

General Policies

Provider Hotline (Medicaid): 1-877-576-5899 www.deltadentalins.com/tx-medicaid Provider Hotline (CHIP): 1-866-561-5891 www.deltadentalins.com/tchip

Page 185

Texas Children's Medicaid Dental Services Manual of Criteria

A benefit to suture any soft tissue wound or injury occurring accidentally. Not payable in conjunction with any other oral surgery or emergency procedure.

D7910: Suture of recent small wounds up to 5 cm D7911: Complicated suture - up to 5 cm D7912: Complicated suture - greater than 5 cm

OTHER SERVICES AND/OR BY REPORT SERVICES (D7960-D7999)

D7960: Frenulectomy (frenectomy or frenotomy) ­ separate procedure D7970: Excision of hyperplastic tissue ­ per arch D7971: Excision of pericoronal gingiva D7972: Surgical reduction of fibrous tuberosity

A benefit for teeth numbers 1, 16, 17 and 32 only. Procedure D7972 is not paid if performed on the same date as procedure D7971. Procedure D7972 is a benefit for members ages 13 and up.

D7980: Sialolithotomy D7983: Closure of salivary fistula D7997: Appliance removal (not by dentist who placed appliance), includes removal of archbar

Per arch, appliance removal (not by the dentist who placed the appliance). Includes removal of arch bar. Prior authorization is required.

D7999: Unspecified oral surgery procedure, by report

Please provide narrative documentation of the nature of the service provided.

Provider Hotline (Medicaid): 1-877-576-5899 www.deltadentalins.com/tx-medicaid

Provider Hotline (CHIP): 1-866-561-5891 www.deltadentalins.com/tchip

Page 186

Texas Children's Medicaid Dental Services Manual of Criteria

ADJUNCTIVE GENERAL SERVICES (PROCEDURES D9110D9999)

D9110: Palliative (emergency) treatment of dental pain ­ minor procedure 1. A benefit when an emergency exists, provided the claim: Is accompanied by an emergency justification statement. Shows the specific treatment performed (i.e., tooth letter or number, temporary filling, opened canal for drainage, soft tissue treatment, etc.). 2. Payable by visit regardless of service(s) provided and the fee includes all treatment provided other than required x-rays. 3. A benefit for members ages 1 and above. D9120: Fixed partial denture sectioning

Fixed partial denture procedures are a benefit for members ages 16 to 20. Please submit a quadrant code.

ANESTHESIA (D9210-D9248)

General Policies 1. Any anesthesia type services are paid only to the provider. The dental provider is responsible for determining whether the minimum criteria necessary for receiving general anesthesia has been met. 2. A local anesthesia fee is not paid in addition to other restorative, operative, or surgical procedure fees. 3. Prior authorization is required for the use of general anesthesia. Please refer to page 193 for criteria for dental therapy under anesthesia. 4. Dental general anesthesia may be reimbursed once every six months per client per provider. 5. Anesthesia procedures are limited to members ages 1 and above. D9210: Local anesthesia not in conjunction with operative or surgical procedures

Claim form narrative should describe the situation if used as a diagnostic tool. Procedure D9210 is denied if performed in conjunction with procedure D9248.

D9211: Regional block anesthesia

Procedure D9211 is denied if performed in conjunction with procedure D9248.

Provider Hotline (CHIP): 1-866-561-5891 www.deltadentalins.com/tchip

Provider Hotline (Medicaid): 1-877-576-5899 www.deltadentalins.com/tx-medicaid

Page 187

Texas Children's Medicaid Dental Services Manual of Criteria

D9212: Trigeminal division block anesthesia

Procedure D9212 is denied if performed in conjunction with procedure D9248.

D9215: Local anesthesia

Claim form narrative should explain how the a therapeutic procedure was but could not be completed, and needs to identify the anesthesia. Procedure D9215 is denied if performed in conjunction with procedure D9248.

D9220: Deep sedations/general anesthesia ­ first 30 minutes

Procedure D9220 may be billed twice within a 12-month period. Procedure D9220 is denied if performed in conjunction with procedure D9248.

D9221: Deep sedations/general anesthesia ­ each additional 15 minutes

Procedure D9221 must be submitted in conjunction with procedure D9220. Procedure D9221 is denied if performed in conjunction with procedure D9248.

D9230: Analgesia, anxiolysis, inhalation of nitrous oxide

Procedure D9230 is limited to once per patient, per day. Procedure D9230 is denied if performed in conjunction with procedure D9248.

D9241: Intravenous conscious sedation/analgesia ­ first 30 minutes

May be considered for reimbursement for additional conscious sedation services. Procedure D9241 is denied if performed in conjunction with procedure D9248.

D9242: Intravenous conscious sedation/analgesia-each additional 15 minutes

Procedure D9242 must be billed in conjunction with procedure D9241. Procedure D9242 may be considered for reimbursement for additional conscious sedation services. Procedure D9242 is denied if performed in conjunction with procedure D9248.

D9248: Non-intravenous conscious sedation

Procedure D9248 may be billed twice within a 12-month period. Providers must comply with all TSBDE rules and AAPD guidelines, including maintaining a current permit to provide non-intravenous (IV) conscious sedation.

Provider Hotline (Medicaid): 1-877-576-5899 www.deltadentalins.com/tx-medicaid

Provider Hotline (CHIP): 1-866-561-5891 www.deltadentalins.com/tchip

Page 188

Texas Children's Medicaid Dental Services Manual of Criteria

PROFESSIONAL CONSULTATIONS (D9310)

D9310: Consultation (diagnostic service provided by dentist or physician other than requesting dentist or physician)

An oral evaluation by a specialist of any type who is also providing restorative or surgical services should be billed as D0160. Limited to members ages 1 and above.

PROFESSIONAL VISITS (D9410-D9440)

D9410: House/extended care facility call

Narrative required on claim form. Place of service must be included. D9410 includes visits to nursing homes, long-term care facilities, hospice sites, institutions, etc. Not benefitted for services provided in the dental office. Limited to members ages 1 and above.

D9420: Hospital call

One charge per hospital case, one case per client in a 12-month period. Documentation supporting the reason that dental services could not be performed in the office setting must be retained in the client's record and may be subject to retrospective review and recoupment. Limited to members ages 1 and above.

D9430: Office visit for observation (during regularly scheduled hours) ­ no other services performed

During regularly scheduled hours, no other services performed. Visits for routine postoperative care are included in all therapeutic and oral surgery fees. Limited to members ages 1 and above.

D9440: Office visit ­ after regularly scheduled hours

Visits for routine postoperative care are included in all therapeutic and oral surgery fees. Limited to members ages 1 and above.

Provider Hotline (Medicaid): 1-877-576-5899 www.deltadentalins.com/tx-medicaid

Provider Hotline (CHIP): 1-866-561-5891 www.deltadentalins.com/tchip

Page 189

Texas Children's Medicaid Dental Services Manual of Criteria

DRUGS (D9610-D9630)

General Policies 1. Procedure code D9630 is not payable for take home fluorides or drugs. 2. Prescriptions should be given to clients to be filled by the pharmacy for these medications as the pharmacy is reimbursed by the Medicaid Vendor Drug Program. 3. Procedure code D9630 is payable for medications (antibiotics, analgesics, etc.) administered to a client in the provider's office. 4. Documentation of dosage and route of administration must be provided in the Remarks section of the claim. D9610: Therapeutic parenteral drug, single administration

Limited to members ages 1 and above. Procedure D9610 may not be billed with D9220 or D9221.

D9612: Therapeutic parenteral drugs, two or more administrations, different medications

Limited to members ages 1 and above.

D9630: Other drugs and/or medicaments, by report

Includes, but is not limited to, oral antibiotics, oral analgesic, and oral sedatives administered in the office. Procedure D9630 may not be submitted in conjunction with procedure codes D9220, D9221, D9230, D9241, D9248, D9610, and D9920. Limited to members ages 1 and above.

MISCELLANEOUS SERVICES (D9910-D9999)

D9910: Application of desensitizing medicament

Procedure D9910 is limited to once per whole mouth application. Procedure D9910 is not for use as a fluoride procedure. Procedure D9910 is not to be used for bases, liners, or adhesives under or with restorations. Limited to once per year.

Provider Hotline (Medicaid): 1-877-576-5899 www.deltadentalins.com/tx-medicaid

Provider Hotline (CHIP): 1-866-561-5891 www.deltadentalins.com/tchip

Page 190

Texas Children's Medicaid Dental Services Manual of Criteria

D9920: Behavior management, by report

The provider must indicate the client's medical diagnosis of intellectual disability using one of the following diagnosis codes or indicate that the client is ICF-MR eligible in the Remarks field of the claim form: 317 - Mild intellectual disability (IQ 50-70). 3180 - Moderate intellectual disability (IQ 35-49). 3181 - Severe intellectual disability (IQ 20-34). 3182 - Profound intellectual disability (IQ under 20). 319 - Unspecified intellectual disability. Documentation supporting the medical necessity and appropriateness of dental behavior management must be retained in the client's chart and available to state agencies upon request, and is subject to retrospective review. Documentation of medical necessity must include: A current physician statement addressing the intellectual disability. The statement must be signed and dated within one year prior to the dental behavior management. A description of the service performed (including the specific problem and the behavior management technique applied). Personnel and supplies required to provide the behavioral management. The duration of the behavior management (including session start and end times). Dental behavior management is not reimbursed with an evaluation, prophylactic treatment, or radiographic procedure. Denied if submitted with D9248.

D9930: Treatment of complications (post-surgical) - unusual circumstances, by report D9940: Occlusal guard, by report

Ages 13 and up.

D9950: Occlusion analysis ­ mounted case

Ages 13 and up.

D9951: Occlusal adjustment ­ limited

Procedure D9951 is considered a full mouth procedure. Ages 13 and up. Procedure D9951 is limited to once per year, per patient.

Provider Hotline (Medicaid): 1-877-576-5899 www.deltadentalins.com/tx-medicaid

Provider Hotline (CHIP): 1-866-561-5891 www.deltadentalins.com/tchip

Page 191

Texas Children's Medicaid Dental Services Manual of Criteria

D9952: Occlusal adjustment ­ complete

Procedure D9952 is considered a full mouth procedure Ages 13 and up Procedure D9951 is payable once per lifetime, per patient

D9970: Enamel microabrasion

Limited to once service per day, any provider Ages 13 and up

D9974: Internal bleaching ­ per tooth

Must submit an x-ray demonstrating adequate endodontic treatment Claim for procedure D9974 must include documentation of medical necessity Ages 13 and up

D9999: Unspecified adjunctive procedure, by report

Provider Hotline (Medicaid): 1-877-576-5899 www.deltadentalins.com/tx-medicaid

Provider Hotline (CHIP): 1-866-561-5891 www.deltadentalins.com/tchip

Page 192

Texas Children's Medicaid Dental Services Manual of Criteria

GENERAL ANESTHESIA

The dental provider is responsible for determining whether a client meets the minimum criteria necessary for receiving general anesthesia. A local anesthesia fee is not paid in addition to other restorative, operative, or surgical procedure fees. Prior authorization is required for the use of general anesthesia while rendering treatment (to include the dental service fee, the anesthesia fee and facility fee), regardless of place of service. A medical check-up prior to a dental procedure requiring general anesthesia is considered an exception to periodicity requirements. A referral to the client's primary care physician is not required. Prior authorization is available for exceptions to periodicity. Providers must include all appropriate supporting documentation with the submittal. The criteria for general anesthesia applies only to treatment of clients who are 20 years of age or younger or ICF-MR. The dental provider is required to maintain the following documentation in the client's dental record:

The medical evaluation justifying the need for anesthesia. Description of relevant behavior and reference scale. Other relevant narratives justifying the need for general anesthesia. Relevant dental and medical history. Dental radiographs, intraoral/perioral photography and/or diagram of dental pathology. Proposed dental plan of care. Consent signed by parent/guardian giving permission for the proposed dental treatment and acknowledging that the reason for the use of IV sedation or general anesthesia for dental care has been explained. Completed Criteria for Dental Therapy Under General Anesthesia form (see sample on the following page; this sample is also presented as Attachment D, Sample General Anesthesia Form in this provider manual). The parent/guardian dated signature on the Criteria for Dental Therapy Under General Anesthesia form attesting that they understand and agree with the dentist's assessment of their child's behavior. Dentist's attestation statement and signature, which may be put on the bottom of the Criteria for Dental Therapy Under General Anesthesia form or included in the record as a stand-alone form.

Dental general anesthesia may be reimbursed once every six months per client per provider. Dental rehabilitation/restoration services requiring general anesthesia are

Provider Hotline (Medicaid): 1-877-576-5899 www.deltadentalins.com/tx-medicaid

Provider Hotline (CHIP): 1-866-561-5891 www.deltadentalins.com/tchip

Page 193

Texas Children's Medicaid Dental Services Manual of Criteria

performed in an outpatient facility. Surgical services related to dental services must be coded as shown on the Criteria for Dental Therapy under General Anesthesia Form.

Provider Hotline (Medicaid): 1-877-576-5899 www.deltadentalins.com/tx-medicaid

Provider Hotline (CHIP): 1-866-561-5891 www.deltadentalins.com/tchip

Page 194

Texas Children's Medicaid Dental Services Manual of Criteria

Provider Hotline (Medicaid): 1-877-576-5899 www.deltadentalins.com/tx-medicaid

Provider Hotline (CHIP): 1-866-561-5891 www.deltadentalins.com/tchip

Page 195

Texas Children's Medicaid Dental Services Manual of Criteria

ORTHODONTIC SERVICES

Orthodontic services for cosmetic purposes only are not a benefit. Orthodontic services are limited to the treatment of children 12 years of age or older with severe handicapping malocclusion, children birth through 20 years of age with cleft palate, or other special medically necessary circumstances as outlined in Benefits and Limitations below. Orthodontic services include the following:

Correction of severe handicapping malocclusion as measured on the Handicapping Labiolingual Deviation (HLD) Index. Refer to pages 206-207 for information on how to score the HLD. A minimum score of 26 points is required for full banding approval (only permanent dentition cases are considered). Exception: Retained deciduous teeth and cleft palates with gross malocclusion that will benefit from early treatment. Cleft palate cases do not have to meet the HLD 26-point scoring requirement. However, it is necessary to submit a sufficient narrative and/or outline of the proposed treatment plan when requesting authorization for orthodontic services on cleft palate cases. Crossbite therapy. Head injury involving severe traumatic deviation.

The following limitations apply to orthodontic services:

Orthodontic services for cosmetic purposes only are not a benefit. Orthognathic surgery, to include extractions, required or provided in conjunction with the application of braces must be completed while the client is eligible in order for reimbursement to be considered. Except for D8660, all orthodontic procedures require prior authorization for consideration of reimbursement. Prior authorization is issued to the requesting provider only and is not transferable to another provider. If the client changes providers or if the provider stops practicing dentistry for whatever reason, a new prior authorization must be requested.

The following procedure codes, policies, and limitations are applied to the processing and payment of orthodontic services. Procedure code D8660 is allowed when:

The client is referred to an orthodontist for a determination of whether orthodontic services are indicated and to determine the appropriate time to initiate such services. The client is referred to an orthodontist and elects to receive services from another orthodontic provider because of justifiable reasons.

Provider Hotline (CHIP): 1-866-561-5891 www.deltadentalins.com/tchip

Provider Hotline (Medicaid): 1-877-576-5899 www.deltadentalins.com/tx-medicaid

Page 196

Texas Children's Medicaid Dental Services Manual of Criteria

Repeat visits at different age levels are required to determine the appropriate time to initiate orthodontic treatment. Procedure code D8680 is payable for one retainer per arch, per lifetime, and each retainer may be replaced once because of loss or breakage (prior authorization is required). Procedure code D8670 should be billed only when an adjustment to the appliances is provided and may not be billed before the date the orthodontic adjustment was performed. The number of visits for monthly adjustments to the appliances is restricted to the number that was authorized in the treatment plan. However, the number of monthly visits may be amended with appropriate documentation of medical necessity while the client is eligible. Procedure code D8670 is paid only in conjunction with a history of braces (code D8080), unless special circumstances exist. All orthodontic codes and appliances are global fees. Separate fees for adjustments to retainers are not payable. The appropriate code should be billed for those appliances required as part of the treatment of cleft palate cases.

Special orthodontic appliances may also be used with full banding and crossbite therapy with approval.

Procedure codes D5951, D5952, D5953, D5954, D5955, D5958, D5959, and D5960 are to be used as applicable with documentation of medical necessity. Otherwise, use the appropriate special orthodontic appliance code. Full banding is allowed on permanent dentition only, and treatment should be accomplished in one stage and is allowed once per lifetime.

Exception: Cases of mixed dentition when the treatment plan includes extractions of remaining primary teeth or cleft palate.

Crossbite therapy is allowed for primary, mixed, or permanent dentition. Providers must not request crossbite correction (limited orthodontics) for a mixed dentition client when there is a need for full banding in the adult teeth. Crossbite therapy is an inclusive charge for treating the crossbite to completion, and additional reimbursement is not provided for adjustments or maintenance. If a case is not approved, the dentist may file a claim for payment of the diagnostic workup necessary to obtain the authorization using procedure codes D0330, D0340, D0350, and D0470. The dentist may receive payment under these procedure codes for no more than two cases out of every ten cases denied. The dentist should determine if the client's condition meets orthodontic benefit criteria before performing a diagnostic workup.

Provider Hotline (CHIP): 1-866-561-5891 www.deltadentalins.com/tchip

Provider Hotline (Medicaid): 1-877-576-5899 www.deltadentalins.com/tx-medicaid

Page 197

Texas Children's Medicaid Dental Services Manual of Criteria

Procedure codes D8080, D8050, and D8060 are limited to one per lifetime. Comprehensive orthodontic services (procedure code D8080) are restricted to clients who are 12 years of age or older or clients who have exfoliated all primary dentition. Crossbite therapy includes diagnostic cast services.

Mandatory Prior Authorization for Orthodontic Services Prior authorization is required for all orthodontic services except for procedure code D8660. The prior authorization request must contain the DOS that the orthodontic diagnostic tools were produced. If the request is approved, the date that the records were produced is considered to be the date on which orthodontic treatment begins. If orthodontic treatment is medically indicated, providers are responsible for obtaining prior authorization for a complete orthodontic treatment plan while the client is eligible for members 20 years of age or younger. Submission of diagnostic casts are required when requesting prior authorization for procedure codes D8050, D8060, or D8080. Prior authorization is a condition for reimbursement; it is not a guarantee of payment. Upon receipt of prior authorization of complete treatment plans, providers are to advise clients that they will be able to receive the approved treatment services (e.g. orthodontic adjustments, bracket replacements and retainers), even if they lose eligibility or reach 21 years of age. Approved orthodontic treatment must be initiated before the loss of eligibility and completed within 36 months of the authorization date. Requests for orthodontic services must be accompanied by all of the following documentation:

An orthodontic treatment plan. The treatment plan must include all procedures required to complete full treatment (such as, extractions, orthognathic surgery, upper and lower appliance, monthly adjustments, anticipated bracket replacements, appliance removal if indicated, special orthodontic appliances, etc.). The treatment plan should incorporate only the minimal number of appliances required to properly treat the case. Requests for multiple appliances to treat an individual arch are reviewed for duplication of purpose. Cephalometric radiograph with tracing models. Completed and scored HLD sheet with diagnosis of Angle class (26 points required for approval of non-cleft palate cases). Facial photographs. Full series of radiographs or a panoramic radiograph; diagnostic-quality films are required (copies are accepted and radiographs will not be returned to the provider).

Provider Hotline (CHIP): 1-866-561-5891 www.deltadentalins.com/tchip

Provider Hotline (Medicaid): 1-877-576-5899 www.deltadentalins.com/tx-medicaid

Page 198

Texas Children's Medicaid Dental Services Manual of Criteria

Any additional pertinent information as determined by the dentist or requested for crossbite therapy require properly trimmed models to be retained in the office and must demonstrate the following criteria: Posterior teeth. Not end to end, but buccal cusp of upper teeth should be lingual to buccal cusp of lower teeth. Anterior teeth. The incisal edge of upper should be lingual to the incisal of the opposing arch. The dentist should be certain that radiographs, photo-graphs, and other information are properly packaged to avoid damage.

Completion of Treatment Plan If a client reaches 21 years of age or loses eligibility before the authorized orthodontic treatment is completed, reimbursement is provided to complete the orthodontic treatment that was authorized and initiated while the client was 20 years of age or younger, Program eligible, and completed within 36 months. Any orthodontic-related service requested (e.g., extractions or surgeries) must be completed before the loss of client eligibility. Services cannot be added or approved after eligibility has expired. Premature Removal of Appliances The overall fee for orthodontic treatment (D8080) includes the removal of orthodontic brackets and/or treatment appliances. Procedure code D7997 may be used only when the appliances were placed by a different provider with an unaffiliated practice (not a partner or office-sharing arrangement) and one of the following conditions exist:

There is documentation of a lack of cooperation from the client. The client requests premature removal and a release form has been signed by the parent, guardian, or client if he is at least 18 years of age. Providers must keep a copy of the release form on file and are responsible for this documentation during a review process.

Transfer of Orthodontic Services Prior authorization issued to a dental provider for orthodontic services is not transferable to another dental provider. The new provider must submit a new prior authorization request in order to be approved to complete the orthodontic treatment initiated by the original provider. The following supporting documentation must accompany the new request for orthodontia services and must include the DOS the orthodontic diagnostic tools were produced:

All of the documentation as required for the original provider.

Provider Hotline (CHIP): 1-866-561-5891 www.deltadentalins.com/tchip

Provider Hotline (Medicaid): 1-877-576-5899 www.deltadentalins.com/tx-medicaid

Page 199

Texas Children's Medicaid Dental Services Manual of Criteria

The reason the client left the previous provider, if known. An explanation of the treatment status. A compete treatment plan addressing all procedures for which authorization is being requested (such as the number of monthly adjustments or retainers required to complete the case). A full diagnostic workup (D8080) with an HLD Index. The score of 26 points will be modified according to any progress achieved.

Exception: The prior authorization requests for clients who initiate orthodontic services before becoming eligible do not require models or the HLD score sheet, nor does the client have to meet the HLD Index of 26 points. However, a complete plan of treatment is required. Note: Clients who initiate orthodontic services privately (e.g. pay out of pocket for the orthodontic workup and/or initial banding, etc.) while eligible due to not meeting the HLD index 26-points, are not eligible to have their orthodontic services transferred to and reimbursed. To request prior authorization for completion of the orthodontic treatment initiated by another provider, complete a Prior Authorization Request Form and send it with the complete plan of treatment and appropriate documentation for orthodontic services and/or crossbite therapy to Delta Dental. Comprehensive Orthodontic Treatment Comprehensive orthodontic services (procedure code D8080) are restricted to clients who are 12 years of age or older or clients who have exfoliated all primary dentition. National procedure codes do not allow for any work in progress or partial billing by separating the three orthodontic components: diagnostic workup, orthodontic appliance (upper), or orthodontic appliance (lower). Special Orthodontic Appliances As with all orthodontic services, all removable or fixed special orthodontic appliances must be prior authorized. All removable or fixed special orthodontic appliances must be billed with procedure code D8210 or D8220. Dental models must be submitted when requesting prior authorization of a thumbsucking or tongue thrust appliance. To ensure appropriate claims processing, the DPC remarks code (local procedure code) reflecting the specific service is also required. The appropriate remarks codes must be entered on the authorization request form. Failure to follow the following steps will cause the claims to deny. Failure to enter the appropriate procedure code will not result in claim denial;

Provider Hotline (Medicaid): 1-877-576-5899 www.deltadentalins.com/tx-medicaid Provider Hotline (CHIP): 1-866-561-5891 www.deltadentalins.com/tchip

Page 200

Texas Children's Medicaid Dental Services Manual of Criteria

however, manual intervention is required to process the claim, which may result in a delay of payment. When submitting claims for orthodontic procedures, use the following procedure codes:

DIAGNOSTICS (D0330-D0470)

D0330: Panoramic film D0340: Cephalometric film D0350: Oral/facial photographic images D0470: Diagnostic cast D7280: Surgical access to an unerupted tooth

Ages 1 and up.

APPLIANCE REMOVAL (D7997)

D7997: Appliance removal (not payable to dentist who placed appliance)

Includes removal of arch bar and premature removal of braces. Ages 1 and up. Not payable to the dentist who placed the appliance(s).

INTERCEPTIVE ORTHODONTIC TREATMENT (D8050-D8080)

D8050: Interceptive orthodontic treatment of the primary dentitions

Payable once per lifetime.

D8060: Interceptive orthodontic treatment of the transitional dentition

Payable once per lifetime.

D8080: Comprehensive orthodontic treatment of the adolescent dentition

Payable once per lifetime.

Provider Hotline (Medicaid): 1-877-576-5899 www.deltadentalins.com/tx-medicaid

Provider Hotline (CHIP): 1-866-561-5891 www.deltadentalins.com/tchip

Page 201

Texas Children's Medicaid Dental Services Manual of Criteria

TREATMENT TO CONTROL HARMFUL HABITS (D8210-D8220)

D8210: Removable appliance therapy D8220: Fixed appliance therapy

OTHER SERVICES AND/OR BY REPORT SERVICES (D8660-D8999)

D8660: Pre-orthodontic treatment visit

Denied if billed on same date of service as D0145. If billed within 6 months of D8080, D8080 reimbursement will be reduced by amount paid for D8660.

D8670: Periodic orthodontic treatment visit (as part of contract) D8680: Orthodontic retention ­ removal of appliances, construction and placement of retainer(s) D8690: Orthodontic treatment (alternative billing to a contract fee) D8693: Rebonding or recementing; and/or repair, as required, of fixed retainers D8999: Unspecified orthodontic procedure, by report

SPECIAL ORTHODONTIC APPLIANCES (PROCEDURES D8210-D8220)

As with all orthodontic services, all removable or fixed special orthodontic appliances must be prior authorized. The prior authorization request must include both the CDT code and remarks code. All removable or fixed special orthodontic appliances must be billed with CDT code D8210 or D8220. Dental models must be submitted when requesting prior authorization of a thumb-sucking or tongue thrust appliance. To ensure appropriate claims processing, the DPC remarks code (local procedure code) reflecting the specific service is also required. The appropriate remarks codes must be entered on the authorization request form. Failure to follow the following steps will cause the claims to deny. Failure to enter the DPC remarks code and the appropriate procedure code will not result in claim denial; however, manual intervention is required to process the claim, which may result in a delay of payment. For paper claim submissions, providers must enter the local procedure code in Block 35 (Remarks) of the 2006 ADA claim form.

Provider Hotline (Medicaid): 1-877-576-5899 www.deltadentalins.com/tx-medicaid

Provider Hotline (CHIP): 1-866-561-5891 www.deltadentalins.com/tchip

Page 202

Texas Children's Medicaid Dental Services Manual of Criteria

For electronic submissions, providers enter the DPC remarks code in the Comments field to ensure correct authorization, accurate records, and reimbursement. The following table identifies the appropriate DPC remarks codes to use when requesting authorization or billing for procedure code D8210 or D8220: Procedure Code

D8220* D8220* D8220* D8220* D8210* D8210* D8210* D8210* D8220* D8210* D8210* D8220* D8210* D8210* D8220* D8220* D8210* D8220* D8220* D8220* D8220* D8210* D8210* D8210* D8220* D8220* D8210* D8220* D8220* D8220* D8220*

Remarks Code

DPC1000D DPC1001D DPC1002D DPC1003D DPC1004D DPC1005D DPC1006D DPC1007D DPC1008D DPC1010D DPC1011D DPC1012D DPC1013D DPC1014D DPC1015D DPC1016D DPC1017D DPC1018D DPC1019D DPC1020D DPC1021D DPC1022D DPC1023D DPC1024D DPC1025D DPC1026D DPC1027D DPC1028D DPC1029D DPC1030D DPC1031D

Remarks Code Description Special Orthodontic Appliances

Appliance with horizontal projections Appliance with recurved springs Arch wires for crossbite correction (for total treatment) Banded maxillary expansion appliance Bite plate/bite plane Bionator Bite block Bite-plate with push springs Bonded expansion device Chateau appliance (face mask, palatal exp and hawley) Coffin spring appliance Crib Dental obturator, definitive (obturator) Dental obturator, surgical (obturator, surgical stayplate, immediate temporary obturator) Distalizing appliance with springs Expansion device Face mask (protraction mask) Fixed expansion appliance Fixed lingual arch Fixed mandibular holding arch Fixed rapid palatal expander Frankel appliance Functional appliance for reduction of anterior openbite and crossbite Headgear (face bow) Herbst appliance (fixed or removable) Inter-occlusal cast cap surgical splints Intrusion arch Jasper jumpers Lingual appliance with hooks Mandibular anterior bridge Mandibular bihelix (similar to a quad helix for mandibular expansion to attempt nonextraction treatment)

D8210*

DPC1032D

Mandibular lip bumper

Provider Hotline (CHIP): 1-866-561-5891 www.deltadentalins.com/tchip

Provider Hotline (Medicaid): 1-877-576-5899 www.deltadentalins.com/tx-medicaid

Page 203

Texas Children's Medicaid Dental Services Manual of Criteria

Procedure Code

D8220* D8210* D8210* D8210* D8210* D8210* D8220* D8220* D8220* D8220* D8210* D8210* D8210* D8220* D8220* D8220* D8220* D8210* D8210* D8210* D8210* D8220* D8210* D8220* D8220* D8220* D8210* D8210* D8210* D8210* D8210* D8210* D8220* D8210* D8210* D8210* D8220* D8210* D8210*

Remarks Code

DPC1036D DPC1037D DPC1038D DPC1039D DPC1040D DPC1041D DPC1042D DPC1043D DPC1044D DPC1045D DPC1046D DPC1047D DPC1048D DPC1049D DPC1050D DPC1051D DPC1052D DPC1053D DPC1054D DPC1055D DPC1056D DPC1057D DPC1058D DPC1059D DPC1060D DPC1061D DPC1062D DPC1063D DPC1064D DPC1065D DPC1066D DPC1067D DPC1068D DPC1069D DPC1070D DPC1071D DPC1072D DPC1073D DPC1074D

Remarks Code Description

Mandibular lingual 6x6 arch wire Mandibular removable expander with bite plane (crozat) Mandibular ricketts rest position splint Mandibular splint Maxillary anterior bridge Maxillary bite-opening appliance with anterior springs Maxillary lingual arch with spurs Maxillary and mandibular distalizing appliance Maxillary quad helix with finger springs Maxillary and mandibular retainer with pontics Maxillary Schwarz Maxillary splint Mobile intraoral Arch-Mia (similar to a Bihelix for nonextraction treatment) Modified quad helix appliance Modified quad helix appliance (with appliance) Nance appliance Nasal stent Occlusal orthotic device Orthopedic appliance Other mandibular utilities Other maxillary utilities Palatal bar Post-surgical retainer Quad helix appliance held with transpalatal arch horizontal projections Quad helix maintainer Rapid palatal expander (RPE), such as quad Helix, Haas, or Menne Removable bite plate Removable mandibular retainer Removable maxillary retainer Removable prosthesis Sagittal appliance 2 way Sagittal appliance 3 way Stapled palatal expansion appliance Surgical arch wires Surgical splints (surgical stent/wafer) Surgical stabilizing appliance Thumbsucking appliance, requires submission of models Tongue thrust appliance, requires submission of models Tooth positioner (full maxillary and mandibular) Provider Hotline (CHIP): 1-866-561-5891 www.deltadentalins.com/tchip

Provider Hotline (Medicaid): 1-877-576-5899 www.deltadentalins.com/tx-medicaid

Page 204

Texas Children's Medicaid Dental Services Manual of Criteria

Procedure Code

D8210* D8220* D8220*

Remarks Code

DPC1075D DPC1076D DPC1077D

Remarks Code Description

Tooth positioner with arch Transpalatal arch Two bands with transpalatal arch and horizontal projections forward D8220* DPC1078D Appliance * = Services payable to an FQHC for a client encounter.

Provider Hotline (Medicaid): 1-877-576-5899 www.deltadentalins.com/tx-medicaid

Provider Hotline (CHIP): 1-866-561-5891 www.deltadentalins.com/tchip

Page 205

Texas Children's Medicaid Dental Services Manual of Criteria

Provider Hotline (Medicaid): 1-877-576-5899 www.deltadentalins.com/tx-medicaid

Provider Hotline (CHIP): 1-866-561-5891 www.deltadentalins.com/tchip

Page 206

Texas Children's Medicaid Dental Services Manual of Criteria

Provider Hotline (Medicaid): 1-877-576-5899 www.deltadentalins.com/tx-medicaid

Provider Hotline (CHIP): 1-866-561-5891 www.deltadentalins.com/tchip

Page 207

Texas Children's Medicaid and CHIP Dental Services Provider Manual

Attachment B: Children's Medicaid Dental Services Managed Care Orthodontia Review Policy and Procedure

Subject: Effective Date: Orthodontia Review Policy and Procedure March 1, 2012

Date Last Revised: December 20, 2011

Purpose The Dental Contractors established a managed care policy and process to ensure consistent and equitable determination of orthodontic coverage for the children's Medicaid dental services. Comprehensive medically necessary orthodontic services are a covered benefit for Texas Medicaid Members who have a severe handicapping malocclusion or special medical conditions including cleft palate, post-head trauma injury involving the oral cavity, and/or skeletal anomalies involving the oral cavity. Orthodontic services are covered for Texas CHIP Members for pre-and post surgical cases related to cleft palate, post-head trauma injury involving the oral cavity, and/or skeletal anomalies involving the oral cavity. Definitions Severe handicapping malocclusion is defined as an occlusion that is severely functionally compromised and is described in detail in Levels I, II, III, and IV. Orthodontic terminology and extent of orthodontic services are based on the American Dental Association's Current Dental Terminology (CDT) definitions and explanations of the orthodontic codes utilized within this policy. The following definitions of dentition established by the CDT manual are recognized by the Children's Medicaid dental services: Primary Dentition: Teeth developed and erupted first in order of time. Transitional Dentition: The final phase of the transition from primary to adult teeth, in which the deciduous molars and canines are in the process of shedding and the permanent successors are emerging. Adolescent Dentition: The dentition that is present after the normal loss of primary teeth and prior to cessation of growth that would affect orthodontic treatment. Adult Dentition: The dentition that is present after the cessation of growth that would affect orthodontic treatment.

Provider Hotline (Medicaid): 1-877-576-5899 www.deltadentalins.com/tx-medicaid Provider Hotline (CHIP): 1-866-561-5891 www.deltadentalins.com/tchip

Page 208

Texas Children's Medicaid and CHIP Dental Services Provider Manual

Policy The Dental Contractors recognize four orthodontic service levels for severe handicapping malocclusion, and each requires a different amount of time for treatment. These levels require different levels of skill, orthodontic procedures, and time for completion of the treatment plan. All Members must be banded prior to their nineteenth (19th) birthday. 1.00 Level I: Dedicated to resolution of early signs of handicapping malocclusion in the early mixed dentition which may significantly impact the health of the developing dentition, alveolar bone, and symmetrical growth of the skeletal framework. (Presence of the maxillary and mandibular permanent molars, and the maxillary and mandibular incisors fully erupted, and deciduous teeth shall constitute the early mixed dentition.)

1.01 1.02

Anterior crossbite that is associated with clinically apparent severe gingival inflammation and/or gingival recession, or severe enamel wear. Posterior crossbite with an associated midline deviation and asymmetric closure pattern. Dental cross bites, other than the above described shall not be eligible for treatment in Level I. Level I orthodontic services must be completed within 12 months unless an exception is granted. Exceptions to the expected treatment time may allow for additional treatment months for one of the following circumstances: The Member is the child of a migrant farm worker The Member's orthodontic services were delayed as a result of temporarily being in state custodial care (foster care). Providers must use the following procedure code for Level I banding: Description Limited orthodontic treatment of the transitional dentition.

1.03

Procedure Code D8020

2.00

Level II: Dedicated to resolution of handicapping malocclusion in the transitional dentition; the final phase of the transition from primary to adolescent dentition wherein the succadaneous permanent teeth are emerging or about to emerge. 2.01 Qualification for treatment at Level II requires submission of documentation to support the classification of handicapping malocclusion. FOUR of the following conditions shall be clearly apparent in the supporting documentation:

Provider Hotline (Medicaid): 1-877-576-5899 www.deltadentalins.com/tx-medicaid

Provider Hotline (CHIP): 1-866-561-5891 www.deltadentalins.com/tchip

Page 209

Texas Children's Medicaid and CHIP Dental Services Provider Manual

A. Full cusp Class II malocclusion with the distal buccal cusp of the maxillary first molar occluding in the mesial buccal groove of the mandibular first molar. B. Full cusp Class III malocclusion with the maxillary first molar occluding in the embrasure distal to the mandibular first molar or on the distal incline of mandibular molar distal buccal cusp. C. Overbite measurement shall be in excess of 5 mm. D. Overjet measurement shall be in excess of 8 mm. E. More than four congenitally absent teeth, one or more of which shall include an anterior tooth/ or teeth. F. Anterior crowding shall be in excess of 6 mm. in the mandibular arch. G. Anterior cross bite of more than two of the four maxillary incisors. H. Generalized spacing in both arches of greater than 6 mm. in each arch with documentation to support periodontal concerns and not strictly esthetics. I. Recognition of early impacted maxillary canine or canines. Radiographs shall support the diagnosis demonstrating a severe mesial angulation of the erupting canine and the crown of the canine superimposed and crossing the image of the maxillary lateral incisor. 2.02 2.03 Level II orthodontic services must be completed within 24 months unless an exception is granted. Exceptions to the expected treatment time may allow for additional treatment months for one of the following circumstances: 2.04 The Member is the child of a migrant farm worker The Member's orthodontic services were delayed as a result of temporarily being in state custodial care (foster care).

Providers must use the following procedure code for Level II banding: Description Interceptive orthodontic treatment of the transitional dentition.

Procedure Code D8060

Provider Hotline (Medicaid): 1-877-576-5899 www.deltadentalins.com/tx-medicaid

Provider Hotline (CHIP): 1-866-561-5891 www.deltadentalins.com/tchip

Page 210

Texas Children's Medicaid and CHIP Dental Services Provider Manual

3.00

Level III: Dedicated to resolution of handicapping malocclusion in the adolescent dentition; complete eruption of the permanent dentition with the possible exception of full eruption of the second molars. 3.01 Qualification for treatment at Level III requires submission of documentation to support the classification of handicapping malocclusion. FOUR of the following conditions shall be clearly apparent in the supporting documentation. A. B. C. Full cusp Class II molar malocclusion as described in Level II. Full cusp Class III molar malocclusion as described in Level II. Cuspid impaction; unerupted with radiographic evidence to support a diagnosis of impaction (lack of eruptive space, angularly malposed, totally imbedded in the bone) as compared to ectopically erupted canine which may be malposed but has erupted into the oral cavity and is not a qualifying element). Ectopic tooth position of any tooth completely blocked out of the dental arch. Anterior open bite shall demonstrate that all maxillary and mandibular incisors have no occlual contact and are separated by a measurement in excess of 6 mm. Posterior open bite shall demonstrate a vertical separation by a measurement in excess of 5 mm. of several posterior teeth and not be confused with the delayed natural eruption of a few teeth. Posterior cross bite with an associated midline deviation and mandibular shift, a Brodie bite with a mandibular arch totally encumbered by an overlapping buccally occluding maxillary arch, or a posterior maxillary arch totally lingually malpositioned to the mandibular arch shall qualify. Anterior cross bite shall include more than two incisors in cross bite and demonstrate gingival inflammation, gingival recession, or severe enamel wear. Over bite shall be in excess of 5 mm. Overjet shall be in excess of 8 mm.

D. E.

F.

G.

H.

I. J. 3.02 3.03

Level III orthodontic services must be completed within 36 months unless an exception is granted. Exceptions to the expected treatment time may allow for additional treatment months for one of the following circumstances: The Member is the child of a migrant farm worker

Provider Hotline (CHIP): 1-866-561-5891 www.deltadentalins.com/tchip

Provider Hotline (Medicaid): 1-877-576-5899 www.deltadentalins.com/tx-medicaid

Page 211

Texas Children's Medicaid and CHIP Dental Services Provider Manual

3.04

The Member's orthodontic services were delayed as a result of temporarily being in state custodial care (foster care).

Providers must use the following procedure code for Level III banding: Description Comprehensive orthodontic treatment of the transitional dentition. (1 of D8070, D8080 or D8090 per lifetime) Comprehensive orthodontic treatment of the adolescent dentition. (1 of D8070, D8080 or D8090 per lifetime) Comprehensive orthodontic treatment of the adult dentition. (1 of D8070, D8080 or D8090 per lifetime)

Procedure Code D8070 D8080 D8090 4.00

Level IV: Dedicated to resolution of handicapping malocclusion in the adult dentition; complete eruption of the permanent dentition. 4.01 Qualification for treatment at level IV requires submission of documentation to support the classification of handicapping malocclusion. Documentation shall be submitted by an Oral Surgeon justifying the medical necessity of a surgical approach to treatment. A. B. 4.02 Non-functional Class II malocclusion. Non-functional Class III malocclusion

Models, panorex, Cephalogram, and photos shall be submitted with the above requested documentation for review. The correction of the malocclusion shall be beyond that of orthodontics alone and shall require pre-orthodontic and post-orthodontic procedures in conjunction with orthognathic surgery. The patient's medical needs shall be based on function and not esthetics. Level IV orthodontic services must be completed within 48 months unless an exception is granted. Exceptions to the expected treatment time may allow for additional treatment months for one of the following circumstances: The Member is the child of a migrant farm worker The Member's orthodontic services were delayed as a result of temporarily being in state custodial care (foster care).

4.03 4.04

4.05

Providers must use the following procedure code for Level IV banding:

Provider Hotline (Medicaid): 1-877-576-5899 www.deltadentalins.com/tx-medicaid

Provider Hotline (CHIP): 1-866-561-5891 www.deltadentalins.com/tchip

Page 212

Texas Children's Medicaid and CHIP Dental Services Provider Manual

Procedure Code D8090 5.00

Description Comprehensive orthodontic treatment of the adult dentition.

Other Orthodontic Services: 5.01 The following procedure codes are used to bill for other orthodontic services: Description Periodic orthodontic treatment visit - the number of monthly adjustments will vary based on which level was approved. Debanding - Orthodontic retention (removal of appliances, construction and placement of retainers). Repair of orthodontic appliance- 1 per lifetime. Replacement of lost or broken retainer - 1 per lifetime. Documentation of medical necessity needed. Rebonding or recementing; and/or repair, as required, of fixed retainers- Documentation of medical necessity needed.

Procedure Code D8670 D8680 D8691 D8692 D8693 6.00

Provider Requirements: 6.01 All dental providers must comply with the rules and regulations of the Texas State Board of Dental Examiners (TSBDE), including the standards for documentation and record maintenance that are stated in the TSBDE Rules 108.7 Minimum Standards of Care, General and 108.8 Records of Dentist. Dentists (DDS, DMD) who want to provide any of the four levels of orthodontic services addressed in this policy must be enrolled as a dentist or orthodontist in THSteps and must have the qualifications listed below for the relevant level of service: Qualifications Completion of pediatric dental residency; or a minimum of 200 hours of continuing dental education in orthodontics. Dentists who are orthodontic board certified or orthodontic board eligible.

6.02

Level of Orthodontic Service Level I or II

Level I, II, III, or IV 6.03

Provider Type 90 ­ Orthodontist: Board eligible or board certified by an ADA recognized orthodontic specialty board. This provider type is eligible to provide Level I-IV.

Provider Hotline (Medicaid): 1-877-576-5899 www.deltadentalins.com/tx-medicaid

Provider Hotline (CHIP): 1-866-561-5891 www.deltadentalins.com/tchip

Page 213

Texas Children's Medicaid and CHIP Dental Services Provider Manual

6.04

Provider Type 48 ­ Texas Health Steps ­ Dental: In order to perform and be reimbursed for Level I and II, provider must attest to either: A. Completion of pediatric specialty residency. B. Minimum of 200 hours of continuing dental education in orthodontics.

6.05 7.00

A general dentist must attest to completion of a minimum of 200 hours of continuing dental education in orthodontics.

Orthodontic Prior Authorization Requirements 7.01 The following documentation must be submitted with the request for prior authorization: A. B. C. D. E. F. G. ADA 2006 or newer claim form with service codes noted Duplicate diagnostic models Radiographs (x-rays) Cephalometric x-ray with tracings Photographs Treatment plan For CHIP Members Only ­ a copy of the medical prior authorization approval letter for surgery

8.00

Completion of Comprehensive Orthodontic Services 8.01 8.02 Prior authorization is required for completion of services (last payment) and must be reviewed for proof of completion of case. The following documentation must be submitted with the request for prior authorization: A. B. C. 8.03 Post treatment panorex film Photographs A signed statement from the treating Provider indicating that treatment is complete

Providers must use the following procedure code for debanding: Description Orthodontic Retention (removal of appliances, construction and placement of retainer(s))

Procedure Code D8680 9.00

Transfer of Comprehensive Orthodontic Services

Provider Hotline (CHIP): 1-866-561-5891 www.deltadentalins.com/tchip

Provider Hotline (Medicaid): 1-877-576-5899 www.deltadentalins.com/tx-medicaid

Page 214

Texas Children's Medicaid and CHIP Dental Services Provider Manual

9.01

Prior authorization issued to a provider for orthodontic services is not transferable to another provider. The new provider must request a new prior authorization to complete the treatment initiated by the original provider. The new provider must obtain his/her own records. The following supporting documentation of medical necessity must be submitted with the request for transfer of services: A. B. C. All of the documentation that is required for the original request, The reason the Member left the previous provider, Narrative noting the treatment status.

9.02

10.00 Continuation of Orthodontic Case Initiated through a Private Arrangement 10.01 Continuation of a case for a Member that began treatment through a private arrangement will be considered for prior authorization if the Member began treatment prior to becoming Medicaid eligible. 10.02 Continuation of a case for a Member that began treatment through a private arrangement will not be considered for prior authorization if the Member began treatment while Medicaid eligible and will be denied. 10.03 The following information is required for consideration of payment for continuation of care cases: A. B. C. D. A completed Orthodontic Continuation of Care Form A completed 2006 or greater ADA claim form listing the services to be rendered A copy of the Member's prior approval including the total approved case fee and payment structure Detailed payment history

10.04 If the Member is private pay, fee for service or transferring from a commercial insurance and now is Medicaid or CHIP eligible; the following information is required: A. B. C. D. A completed Orthodontic Continuation of Care Form A completed 2006 or greater ADA claim form listing the services to be rendered A copy of the Member's prior approval including the total approved case fee and payment structure Detailed payment history

Provider Hotline (CHIP): 1-866-561-5891 www.deltadentalins.com/tchip

Provider Hotline (Medicaid): 1-877-576-5899 www.deltadentalins.com/tx-medicaid

Page 215

Texas Children's Medicaid and CHIP Dental Services Provider Manual

E. F.

A copy of the original study models prior to the patient being banded Panorex film

11.00 Orthodontic Services authorized by TMHP prior to March 1, 2012 11.01 The Dental Contractor has the option to re-review any and/or all orthodontic cases authorized by TMHP prior to March 1, 2012 for medical necessity. 11.02 The following information is required for review and consideration of payment for continuation of care: A. B. C. D. E. F. A completed Orthodontic Continuation of Care Form A completed 2006 or greater ADA claim form listing the services to be rendered A copy of the Member's prior approval including the total approved case fee and payment structure Detailed payment history A copy of the original study models prior to the patient being banded Panorex film

11.03 The clinical criteria used in making the qualifying decision will be the criteria stated in this document (Level I, II, III and IIII). 11.04 Should the request for continuation of payment be denied due to lack of medical necessity under the new clinical criteria; the Dental Contractor will authorize a treatment plan. 12.00 Premature Termination of Comprehensive Orthodontic Services 12.01 Premature termination of comprehensive orthodontic treatment by the originally treating provider is included in the comprehensive services. 12.02 Premature termination of orthodontic services includes all of the following: A. B. C. D. Removal of brackets and arch wires Other special orthodontic appliances Fabrication of special orthodontic appliances Delivery of orthodontic retainers

Provider Hotline (CHIP): 1-866-561-5891 www.deltadentalins.com/tchip

Provider Hotline (Medicaid): 1-877-576-5899 www.deltadentalins.com/tx-medicaid

Page 216

Texas Children's Medicaid and CHIP Dental Services Provider Manual

12.03 Premature removal of an orthodontic appliance must be prior authorized. A release form must be signed by the parent or legal guardian, or by the Member if he/she is 18 years of age or older or an emancipated minor. A copy of the signed release form and a completed prior authorization request form must be submitted, and one of the following must be documented on the prior authorization request: A. B. C. The Member is uncooperative or is non-compliant The Member requested the removal of the orthodontic appliance(s) The Member has requested the removal due to extenuating circumstances to include, but not limited to: 1. Incarceration 2. Mental health complications with a recommendation from the treating physician 3. Foster Care placement 4. Child of a Migrant Farm Worker, with the intent to complete treatment at a later date if Medicaid eligibility for orthodontic services continues

NOTE: A Member for whom removal of an appliance has been authorized due to the above, will be eligible for completion of their Medicaid orthodontic services if the services are re-initiated while Medicaid eligible. Should the Member choose to have the appliances removed for reasons other than listed above, the Member will not be eligible for any additional Medicaid orthodontic services. 12.04 The requesting provider is responsible for removal of the orthodontic appliances, final records, and fabrication and delivery of retainers at the time of premature removal or at any future time should the Member present to the treating provider's office. 12.05 Providers must use the following procedure code for premature debanding: Procedure Code D8680 13.00 Reimbursement: 13.01 An initial payment equal to 25% of the total case amount is payable when bands are placed. Providers must bill with the appropriate prior authorized procedure code.

Provider Hotline (Medicaid): 1-877-576-5899 www.deltadentalins.com/tx-medicaid Provider Hotline (CHIP): 1-866-561-5891 www.deltadentalins.com/tchip

Description Orthodontic Retention (removal of appliances, construction and placement of retainer(s))

Page 217

Texas Children's Medicaid and CHIP Dental Services Provider Manual

13.02 Providers must bill the appropriate monthly adjustment code (D8670). The total number of monthly adjustments allowed will vary by level but will account for a total of 50% of the case amount. 13.03 The last payment equal to 25% of the total case amount is payable when the treatment is complete. Providers must bill with the appropriate prior authorized procedure code (D8680). 14.00 General Information: 14.01 Providers may prior authorize for additional services that may be deemed medically necessary due to overall health of the patient or extenuating circumstances. Each case will be reviewed and evaluated on a case by case basis for medical necessity. For example, debanding in regular treatment would limit retainers and appliance removal to a single episode however in the case of cleft palate, craniofacial and head trauma with dental consequences; the case may involve multiple courses of treatment and would gain additional consideration based on the circumstances. 14.02 Orthodontic services that are performed solely for cosmetic purposes are not a benefit of Texas Medicaid. 14.03 Members enrolled in the Dental Contractor's plan for at least one month and are receiving orthodontic treatment and either ages out or loses eligibility; the Dental Contractor is responsible for completion of payment for the course of treatment. The only exception is if the Member is disenrolled with cause, but is still Medicaid eligible. 14.04 There will be no payment for denied cases. 14.05 Orthodontic consultation (D9310) is limited to once per provider or location per lifetime. Code D9310 is only allowed when an orthodontic case is not being submitted for prior authorization review. Code D9310 is allowed when a Member is referred to a provider and opts to seek orthodontic treatment from a different provider. 14.06 Payment for banding includes the initial work up.

Provider Hotline (Medicaid): 1-877-576-5899 www.deltadentalins.com/tx-medicaid

Provider Hotline (CHIP): 1-866-561-5891 www.deltadentalins.com/tchip

Page 218

Texas Children's Medicaid and CHIP Dental Services Provider Manual

Attachment C: Orthodontic Continuation of Care Submission Form

Date: Patient Information Last Name: Mailing Address: City: State: ZIP: First Name:

Phone Number (including area code): Date of Birth: Plan Name: Dental Provider Information Provider Name: Provider NPI #: Mailing Address: City: State: ZIP: Location ID #: Plan Type: Member ID #:

Phone Number (including area code): Previous Vendor and Previous Treatment/Payment Information Name of Previous Vendor Who Issued Original Approval: Case Rate Approved By Previous Vendor: Amount Paid for Dates of Service That Occurred Prior to March 1, 2012: Amount Owed for Dates of Service That Occurred Prior to March 1, 2012: Balance Expected for Future Dates of Service: Banding Date: Number of Adjustments Remaining:

Please see next page for list of additional information required. If you have any questions, please call us at:

1-877-576-5899 (Texas Medicaid Provider Hotline) 1-866-561-5891 (Texas CHIP Provider Hotline)

Provider Hotline (Medicaid): 1-877-576-5899 www.deltadentalins.com/tx-medicaid

Provider Hotline (CHIP): 1-866-561-5891 www.deltadentalins.com/tchip

Page 219

Texas Children's Medicaid and CHIP Dental Services Provider Manual

Please submit orthodontia treatment documentation to Delta Dental if you meet all of the following criteria: You are a participating provider in Delta Dental's Texas Children's Medicaid Dental Services provider network. The member's orthodontia treatment was prior-authorized by Texas Medicaid & Healthcare Partnership (TMHP) prior to March 1, 2012. The member's orthodontia treatment began prior to March 1, 2012. Additional Information Required: Delta Dental requires the following information for possible payment of continuation of care cases that were prior authorized from another Medicaid DMO: Completed Orthodontic Continuation of Care Form Completed Medicaid Orthodontic Criteria Form Completed 2006 (or more recent) ADA form listing services to be rendered Copy of the member's prior approval, including the total approved case fee, banding fee, and periodic orthodontic treatment fees Treatment plan

If the member is private pay, fee for service, or transferring from a commercial insurance program, the following documentation is required: Completed Orthodontic Continuation of Care Form Completed Medicaid Orthodontic Criteria Form Original study models Panorex Completed 2006 (or more recent) ADA form Treatment plan. Detailed payment history

Samples of forms are included in the provider manual and are available online at deltadentalins.com/tx-medicaid/. Please mail all required documentation to us at: Texas Children's Medicaid and CHIP Dental Services State Government Programs PO Box 537014 Sacramento, CA 95853-7014

Provider Hotline (Medicaid): 1-877-576-5899 www.deltadentalins.com/tx-medicaid

Provider Hotline (CHIP): 1-866-561-5891 www.deltadentalins.com/tchip

Page 220

Texas Children's Medicaid and CHIP Dental Services Provider Manual

Attachment D: Medicaid Orthodontic Criteria Form

The attached orthodontic criteria form must be completed and returned to Delta Dental in compliance with our re-review of orthodontic treatment that was in process and prior-authorized prior to March 1, 2012. Member Name: Member ID#: Provider Name: Level I Orthodontic Treatment: Procedure D8010 ­ Limited treatment of the primary dentition Procedure D8020 ­ Limited treatment of the transitional dentition Procedure D8210 ­ Removable appliance therapy Procedure D8220 ­ Fixed appliance therapy Limited orthodontic services are a benefit when medically necessary due to the following (please check the conditions that apply): Anterior crossbite that is associated with clinically apparent severe gingival inflammation and/or gingival recession, or severe enamel wear. Posterior crossbite with an associated midline deviation and asymmetric closure pattern. Level II Orthodontic Treatment Procedure D8050 - Interceptive orthodontic treatment of the primary dentition Procedure D8060 - Interceptive orthodontic treatment of the transitional dentition Qualification for treatment at Level II requires submission of documentation to support the classification of handicapping malocclusion. FOUR of the following conditions shall be clearly apparent. Each condition is counted as one discrepancy and not two or three of the same discrepancy. Please check the conditions that apply: Member Date of Birth: Provider ID#:

Provider Hotline (Medicaid): 1-877-576-5899 www.deltadentalins.com/tx-medicaid

Provider Hotline (CHIP): 1-866-561-5891 www.deltadentalins.com/tchip

Page 221

Texas Children's Medicaid and CHIP Dental Services Provider Manual

Full cusp Class II malocclusion with the distal buccal cusp of the maxillary first molar occluding in the mesial buccal groove of the mandibular first molar. Full cusp Class III malocclusion with the maxillary first molar occluding in the embrasure distal to the mandibular first molar or on the distal incline of mandibular molar distal buccal cusp. Overbite measurement shall be in excess of 5 mm. Overjet measurement shall be in excess of 8 mm. More than four congenitally absent teeth, one or more of which shall include an anterior tooth/ or teeth. Anterior crowding shall be in excess of 6 mm. in the mandibular arch. Anterior cross bite of more than two of the four maxillary incisors. Generalized spacing in both arches of greater than 6 mm in each arch with documentation to support periodontal concerns and not strictly esthetics. Recognition of early impacted maxillary canine or canines. Radiographs shall support the diagnosis demonstrating a severe mesial angulation of the erupting canine and the crown of the canine superimposed and crossing the image of the maxillary lateral incisor. Level III Orthodontic Treatment Procedure D8070 ­ Comprehensive orthodontic treatment of the transitional dentition Procedure D8080 ­ Comprehensive orthodontic treatment of the adolescent dentition Qualification for treatment at Level III requires submission of documentation to support the classification of handicapping malocclusion. FOUR of the following conditions shall be clearly apparent in the supporting documentation. Please check the conditions that apply: Full cusp Class II molar malocclusion as described in level II. Full cusp Class III molar malocclusion as described in level II. Cuspid impaction; unerupted with radiographic evidence to support a diagnosis of impaction (lack of eruptive space, angularly malposed, totally imbedded in the bone) as compared to ectopically erupted canine which may be malposed but has erupted into the oral cavity and is not a qualifying element). Ectopic tooth position of any tooth completely blocked out of the dental arch. Anterior open bite shall demonstrate that all maxillary and mandibular incisors have no occlusal contact and are separated by a measurement in excess of 6 mm.

Provider Hotline (Medicaid): 1-877-576-5899 www.deltadentalins.com/tx-medicaid

Provider Hotline (CHIP): 1-866-561-5891 www.deltadentalins.com/tchip

Page 222

Texas Children's Medicaid and CHIP Dental Services Provider Manual

Posterior open bite shall demonstrate a vertical separation by a measurement in excess of 5 mm. of several posterior teeth and not be confused with the delayed natural eruption of a few teeth. Posterior cross bite with an associated midline deviation and mandibular shift, a Brodie bite with a mandibular arch totally encumbered by an overlapping buccally occluding maxillary arch, or a posterior maxillary arch totally lingually malpositioned to the mandibular arch shall qualify. Anterior cross bite shall include more than two incisors in cross bite and demonstrate gingival inflammation, gingival recession, or severe enamel wear. Over bite shall be in excess of 5 mm. Overjet shall be in excess of 8 mm. Level Four Procedure D8090 ­ Comprehensive orthodontic treatment of the adult dentition Level four is a high-level severe handicapping malocclusion that will require orthognathic surgery or cleft palate repair. To be considered as having a high-level severe handicapping malocclusion, and to qualify for level four orthodontic treatment, the client must have documentation of medical necessity indicating one of the following conditions is present; please check the conditions that apply:

Non-functional Class II malocclusion. Non-functional Class III malocclusion. Orthognathic surgery.

Provider Signature____________________________ Date _____________________

Provider Hotline (Medicaid): 1-877-576-5899 www.deltadentalins.com/tx-medicaid

Provider Hotline (CHIP): 1-866-561-5891 www.deltadentalins.com/tchip

Page 223

Texas Children's Medicaid and CHIP Dental Services Provider Manual

18.0

TEXAS CHIP DENTAL SERVICES MANUAL OF CRITERIA (MOC)

Attachment E: Texas CHIP Dental Services Manual of Criteria, incorporates, by reference, State of Texas regulations governing the Texas CHIP Dental Services program. The Texas CHIP Dental Services MOC begins on the following page.

Provider Hotline (Medicaid): 1-877-576-5899 www.deltadentalins.com/tx-medicaid

Provider Hotline (CHIP): 1-866-561-5891 www.deltadentalins.com/tchip

Page 224

Texas CHIP Dental Services Manual of Criteria

TABLE OF CONTENTS

INTRODUCTION....................................................................................................................229 SCHEDULE OF CHIP DENTAL SERVICES ......................................................................231 PREVENTATIVE SERVICES (PROCEDURES D0120­D0150).......................................232 D0120: Periodic Oral Evaluation.......................................................................................232 D0140: Limited Oral Evaluation ­ Problem Focused.....................................................232 D0150: Complete Examination, New or Established Patient........................................232 RADIOGRAPHS (PROCEDURES D0210­D0330) ............................................................233 D0210: Intraoral Complete Series (Including Bitewings) ..............................................234 D0220: Intraoral Periapical, First Film .............................................................................234 D0230: Intraoral Periapical, Each Additional Film ........................................................235 D0270: Bitewings, Single Film ...........................................................................................235 D0272: Bitewings, Two Films ............................................................................................235 D0274: Bitewings, Four Films ............................................................................................235 D0330: Panoramic ­ Film ...................................................................................................235 CLEANINGS (PROCEDURES D1110­D1351) ...................................................................236 D1110: Prophylaxis .............................................................................................................236 D1120: Prophylaxis .............................................................................................................236 D1203: Topical Application of Fluoride ­ Child .............................................................236 D1204: Topical Application of Fluoride ­ Adult ............................................................236 D1351: Sealants ....................................................................................................................236 SPACE MAINTENANCE, PASSIVE APPLIANCES (PROCEDURES D1510­1525) ..237 D1510: Space Maintainer ­ Fixed Unilateral ...................................................................237 D1515: Space Maintainer ­ Fixed Bilateral ......................................................................237 D1520: Space Maintainer ­ Removable Unilateral .........................................................237 D1525: Space Maintainer ­ Removable Bilateral ............................................................237 RESTORATIVE SERVICES (PROCEDURES D2140­D2934) .........................................238 AMALGAM RESTORATIONS (PROCEDURES D2140­D2161) ...................................240 D2140: Amalgam One Surface, Primary or Permanent .................................................240 D2150: Amalgam Two Surfaces, Primary or Permanent...............................................240 D2160: Amalgam Three Surfaces, Primary or Permanent ............................................240 D2161: Amalgam Four or More Surfaces, Primary or Permanent ...............................240 COMPOSITE RESIN RESTORATIONS (PROCEDURES D2330­D2394) ...................241

Provider Hotline (Medicaid): 1-877-576-5899 www.deltadentalins.com/tx-medicaid Provider Hotline (CHIP): 1-866-561-5891 www.deltadentalins.com/tchip

Page 225

Texas CHIP Dental Services Manual of Criteria

D2330: Resin-Based Composite, One Surface, Anterior ................................................241 D2331: Resin-Based Composite, Two Surfaces, Anterior ..............................................241 D2332: Resin-Based Composite, Three Surfaces, Anterior ...........................................241 D2335: Resin-Based Composite, Four or More Surfaces ...............................................241 D2391: Resin-Based Composite, One Surface Posterior ................................................241 D2392: Resin-Based Composite, Two Surfaces Posterior ..............................................241 D2393: Resin-Based Composite, Three Surfaces Posterior............................................241 D2394: Resin-Based Composite, Four or More Surfaces Posterior ..............................241 CROWNS (PROCEDURES D2710­D2792) .........................................................................242 D2710: Crown, Resin-Based Composite (Indirect) .........................................................243 D2720: Crown, Resin with High Noble Metal ................................................................243 D2721: Crown, Resin with Predominantly Base Metal .................................................243 D2722: Crown, Resin with Noble Metal ..........................................................................243 D2740: Crown, Porcelain/Ceramic Substrate .................................................................243 D2750: Crown, Porcelain Fused to High Noble Metal ..................................................243 D2751: Crown, Porcelain Fused to Predominantly Base Metal ....................................243 D2752: Crown, Porcelain Fused to Noble Metal ............................................................243 D2790: Crown, Full Cast High Noble Metal ...................................................................243 D2791: Crown, Full Cast Predominantly Base Metal.....................................................244 D2792: Crown, Full Cast Noble Metal .............................................................................244 OTHER RESTORATIVE SERVICES (PROCEDURES D2930­D2931)..........................245 D2930: Prefabricated Stainless Steel Crown ­ Primary Tooth ......................................245 D2931: Prefabricated Stainless Steel Crown ­ Permanent Tooth .................................245 ENDODONTIC PROCEDURES (PROCEDURES D3220­D3430) .................................246 D3220: Therapeutic Pulpotomy (Excluding Final Restoration) ...................................247 D3230: Pulpal Therapy, Resorbable Filling, Anterior Primary Tooth .........................247 D3240: Therapeutic Pulpotomy ­ Resorbable Filling ....................................................248 ROOT CANALS (PROCEDURES D3310­D3330) .............................................................249 D3310: Endodontic Therapy, Anterior Tooth (Excluding Final Restoration) ............250 D3320: Endodontic Therapy, Bicuspid Tooth (Excluding Final Restoration) ............250 D3330: Endodontic Therapy, Molar Tooth (Excluding Final Restoration) .................250 PERIODONTIC SERVICES (PROCEDURES D4210­D4341) .........................................251 D4210: Gingivectomy or Gingivoplasty ..........................................................................251 D4341: Periodontal Scaling and Root Planing ................................................................251

Provider Hotline (Medicaid): 1-877-576-5899 www.deltadentalins.com/tx-medicaid Provider Hotline (CHIP): 1-866-561-5891 www.deltadentalins.com/tchip

Page 226

Texas CHIP Dental Services Manual of Criteria

D4355: Full Mouth Debridement ......................................................................................251 PROSTHODONTIC SERVICES (PROCEDURES D5110­D5214) .................................252 D5110: Complete Denture ­ Maxillary (Upper) .............................................................252 D5120: Complete Denture ­ Mandibular (Lower) .........................................................252 D5211: Maxillary Partial Denture ­ Resin Base ..............................................................252 D5212: Mandibular Partial Denture ­ Resin Base ..........................................................252 D5213: Maxillary Partial Denture .....................................................................................252 D5214: Mandibular Partial Denture .................................................................................252 EXTRACTIONS (PROCEDURES D7140­D7240) ..............................................................253 D7140: Extraction, Erupted Tooth or Exposed Root ......................................................254 SURGICAL EXTRACTIONS (PROCEDURES D7210­D7240) .......................................255 D7210: Surgical Removal of Erupted Tooth ....................................................................255 D7220: Removal of Impacted Tooth ­ Soft Tissue ..........................................................255 D7230: Removal of Impacted Tooth ­ Partial Bony .......................................................256 D7240: Removal of Impacted Tooth ­ Complete Bony..................................................256 REGIONAL SCREENING PREOPERATIVE EXAMINATIONS ..................................257 REASONABLE AND NECESSARY CONCEPT ................................................................258

Provider Hotline (Medicaid): 1-877-576-5899 www.deltadentalins.com/tx-medicaid

Provider Hotline (CHIP): 1-866-561-5891 www.deltadentalins.com/tchip

Page 227

Texas CHIP Dental Services Manual of Criteria

NOTES:

Provider Hotline (Medicaid): 1-877-576-5899 www.deltadentalins.com/tx-medicaid

Provider Hotline (CHIP): 1-866-561-5891 www.deltadentalins.com/tchip

Page 228

Texas CHIP Dental Services Manual of Criteria

INTRODUCTION

This document is a compilation of criteria for the Texas Children's Health Insurance Program (CHIP) Dental Services program. It is designed to provide assistance to dentists treating CHIP members and to dental consultants in determining service authorization and payment under the authority of and subject to Texas Health and Human Services Commission (HHSC) provisions and applicable state and federal regulations. This document sets forth program benefits and clearly defines limitations, exclusions, and special documentation requirements. These criteria are designed to ensure that program funds are spent on services that are medically necessary and are in substantial compliance with HHSC regulations. The criteria published in this manual, while not exhausting the range of possibilities or combinations of circumstances, will nonetheless help to standardize the provider's and consultant's exercise of professional judgment. If the clinical condition of the patient reflects the criteria required by this manual and such information is fully documented by the provider, the consultant may grant approval if in his/her professional judgment the service request is reasonable and consistent with the dental needs of the patient and conforms to the intent of the program. Without sufficient acceptable diagnostic information, the consultant has no option but to deny approval or defer a decision. The necessity for the consultant to obtain adequate information and, thereby, to make a judgment on dental necessity is an integral part of the prior authorization and payment process. The scope of CHIP dental benefits developed by HHSC can be found in this manual of criteria. While the manual contains prior authorization and payment information, it is not an instruction guide in the proper completion of prior authorization or payment requests. Prior authorization of radiographs shall not be required for payment of a procedure unless expressly stated in this manual. The criteria in this manual are intended to:

Assist providers in requesting authorization/payment and documenting the need for such services or items. Improve the quality of care and cost efficiency of dental services given to patients. Avoid provision of unnecessary or excessive items or services to patients. Promote objectivity and uniformity in appropriate treatment of dental conditions. Ensure that the covered dental benefit level is for the least costly dentally appropriate alternative. If a more costly optional alternative is chosen by the

Provider Hotline (Medicaid): 1-877-576-5899 www.deltadentalins.com/tx-medicaid

Provider Hotline (CHIP): 1-866-561-5891 www.deltadentalins.com/tchip

Page 229

Texas CHIP Dental Services Manual of Criteria

member, the member will be responsible for all charges in excess of the covered dental benefit. Assist the dental consultant's review of prior authorization and payment requests. Promote uniform and consistent review of prior authorization and payment requests.

Provider Hotline (Medicaid): 1-877-576-5899 www.deltadentalins.com/tx-medicaid

Provider Hotline (CHIP): 1-866-561-5891 www.deltadentalins.com/tchip

Page 230

Texas CHIP Dental Services Manual of Criteria

SCHEDULE OF CHIP DENTAL SERVICES

The scope of dental benefits for the Texas CHIP Dental Services program developed by HHSC is described in the following pages. Covered dental services are subject to a $564 annual benefit limit unless an exception applies. In addition, some of the benefits identified in the schedule below are subject to annual limits. Limitations are based on a 12-month coverage period. Services Provided After the Annual Maximum Has Been Exhausted CHIP members who have exhausted the $564 annual benefit limit continue to receive the following covered dental services in excess of the $564 annual benefit maximum:

The preventive services due under the 2009 American Academy of Pediatric Dentistry periodicity schedule (Volume 32, Issue Number 6 at pp. 93-100). Other medically necessary covered dental services approved by Delta Dental through a prior authorization process. These services must be necessary to allow a CHIP member to return to normal, pain-free, and infection-free oral functioning. Typically, this includes: Services related to the relief of significant pain or to eliminate acute infection. Services related to treat traumatic clinical conditions. Services that allow the CHIP member to attain the basic human functions (e.g., eating and speech). Services that prevent a condition from seriously jeopardizing the CHIP member's health/functioning or deteriorating in an imminent timeframe to a more serious and costly dental problem.

Provider Hotline (Medicaid): 1-877-576-5899 www.deltadentalins.com/tx-medicaid

Provider Hotline (CHIP): 1-866-561-5891 www.deltadentalins.com/tchip

Page 231

Texas CHIP Dental Services Manual of Criteria

PREVENTATIVE SERVICES (PROCEDURES D0120­D0150)

D0120: PERIODIC ORAL EVALUATION

Includes examination of all hard and soft tissue of the oral cavity, including periodontal charting and oral cancer exam.

D0140: LIMITED ORAL EVALUATION ­ PROBLEM FOCUSED

An evaluation limited to a specific oral health problem or complaint. This may require interpretation of information acquired through additional diagnostic procedures. A benefit if there is documentation of need for the provider to take time out to see the patient for a specific reason.

D0150: COMPLETE EXAMINATION, NEW OR ESTABLISHED PATIENT

A benefit once per patient per dentist for the initial examination when the claim form indicates a complete examination was rendered. Limited to one per member per dentist. Subsequent submissions of D0150 will be the equivalent of periodic oral evaluations (D0120).

Provider Hotline (Medicaid): 1-877-576-5899 www.deltadentalins.com/tx-medicaid

Provider Hotline (CHIP): 1-866-561-5891 www.deltadentalins.com/tchip

Page 232

Texas CHIP Dental Services Manual of Criteria

RADIOGRAPHS (PROCEDURES D0210­D0330)

General Policies 1. 2. 3. According to accepted standards of dental practice, the lowest number of radiographs needed to provide the diagnosis should be taken. Radiographs are covered when taken in compliance with state and federal regulations for radiation hygiene. All films or paper copies should be of diagnostic quality, especially if the image is magnified and labeled right/left side of the mouth. X-rays must be current and the x-ray must be dated and labeled with the member's name, provider's name, and member ID number. Generally, the quality of panographic radiographs alone may be insufficient for diagnosis in periodontics, endodontics, prosthetics, and restorative dentistry. Single radiographs are a benefit when necessary and commensurate with the signs and symptoms exhibited by the patient. When taken on the same date of service, the following combination of x-rays will be processed as a complete series (Procedure D0210): a. b. c. d. 6. Procedure D0220 plus 10 of Procedure D0230 or Procedure D0220 plus Procedure D0270 plus 9 of Procedure D0230 or Procedure D0272 plus 9 of Procedure D0230 or Procedure D0274 plus 7 of Procedure D0220/D0230.

4.

5.

If radiographs are not submitted with the treatment form for procedures requiring radiographs because the member or authorized representative refused to have radiographs taken, a statement to this effect must be included in order to determine scope and level of benefits. When radiographs are required as a condition of payment for a procedure and radiographs are medically contraindicated, narrative documentation shall include a statement of the medical contraindication. Diagnostic dental radiographs are medically contraindicated when additional exposure to ionizing radiation would complicate or be detrimental to a patient's existing medical or physical condition. Examples include, but are not limited to, the following: a. The first trimester of pregnancy. b. Recent application of therapeutic doses of ionizing radiation to the head and neck areas. c. Hypoplastic or aplastic anemics.

7.

Provider Hotline (Medicaid): 1-877-576-5899 www.deltadentalins.com/tx-medicaid

Provider Hotline (CHIP): 1-866-561-5891 www.deltadentalins.com/tchip

Page 233

Texas CHIP Dental Services Manual of Criteria

d. When a patient's inability to respond to commands or directions would necessitate sedation or anesthesia in order to accomplish the radiographic procedures. e. Other medical conditions precluding the use of ionizing radiation in the oral and maxillofacial area, which are justified in writing by the patient's attending physician. 8. Delta Dental will recycle duplicate x-rays that are marked "Do Not Return" and are submitted with treatment authorization requests (TARs), claims for payment, notices of authorization (NOAs), and claim inquiry forms (CIFs). Delta Dental will recycle the duplicate x-rays following claims processing instead of returning them to the dental office. Duplicate x-rays will not be stored. To participate in the program for recycling duplicate x-rays, please affix a "Do Not Return" x-ray label on the outside of the x-ray envelope or on the x-ray mount. If you do not have a label, a handwritten note in the "Comments" area of the document will suffice. Submit duplicate, non-returnable x-rays only when the procedures on the document require x-rays as documentation for payment or authorization. To request labels, please call our Provider Hotline.

9. 10.

D0210: INTRAORAL COMPLETE SERIES (INCLUDING BITEWINGS)

A complete series is a benefit once per patient in a 36-month period. The following combination of x-rays may be billed as a complete series: 14 periapical radiographs plus bitewings. Panographic radiograph plus bitewings. Panographic radiograph plus periapical radiographs. The fee for any of the above combinations shall not exceed the fee for Procedure D0210. Any combinations of the x-ray combinations listed above and taken on the same date of service will be processed as a complete series (Procedure D0210). A panographic film (Procedure D0330), taken in conjunction with a complete intraoral series is not a separate benefit. Only those combinations of services listed in the second bullet item above may be billed as Procedure D0210. Any lesser combination of films should be billed using the appropriate procedure code for periapicals and bitewings.

D0220: INTRAORAL PERIAPICAL, FIRST FILM

The procedure applies to the first periapical film, including oral evaluation and diagnosis.

Provider Hotline (CHIP): 1-866-561-5891 www.deltadentalins.com/tchip

Provider Hotline (Medicaid): 1-877-576-5899 www.deltadentalins.com/tx-medicaid

Page 234

Texas CHIP Dental Services Manual of Criteria

If bitewing films are provided, all periapical films are considered additional to the bitewing and should be billed as Procedure D0230. Periapical films provided in conjunction with a panoramic film on the same date of service are considered a complete intraoral series and will be processed as Procedure D0210.

D0230: INTRAORAL PERIAPICAL, EACH ADDITIONAL FILM

When the fee submitted for any combination of intraoral x-rays in a series meets or exceeds the fee for a complete intraoral series, Delta Dental considers the films to be the equivalent of a complete series (Procedure D0210). Periapical films provided in conjunction with a panoramic film on the same date of service are considered a complete intraoral series and will be processed as Procedure D0210.

D0270: BITEWINGS, SINGLE FILM

Single bitewing x-rays are allowed on an emergency or episodic basis.

D0272: BITEWINGS, TWO FILMS

Not a benefit for edentulous area.

D0274: BITEWINGS, FOUR FILMS

Not a benefit for edentulous area.

D0330: PANORAMIC ­ FILM

Panoramic radiographs are benefits only once for members ages 5 through 9 and once for members ages 10 through 18, except when documented as essential for follow-up or postoperative care in a treatment series. Limited to one per five years. Procedure D0330 is not a benefit on the same day of service as Procedure D0210 (Intraoral, Complete Series). Periapical films provided in conjunction with a panoramic film on the same date of service are considered a complete intraoral series and will be processed as Procedure D0210.

Provider Hotline (Medicaid): 1-877-576-5899 www.deltadentalins.com/tx-medicaid

Provider Hotline (CHIP): 1-866-561-5891 www.deltadentalins.com/tchip

Page 235

Texas CHIP Dental Services Manual of Criteria

CLEANINGS (PROCEDURES D1110­D1351)

Oral prophylaxis means the preventive dental procedure of scaling and polishing, which includes complete removal of calculus (supra- and sub-gingival), soft deposits, plaque, stains, and smoothing of unattached tooth surfaces.

D1110: PROPHYLAXIS

Members ages 13 through 18.

D1120: PROPHYLAXIS

Members ages 1 through 12.

D1203: TOPICAL APPLICATION OF FLUORIDE ­ CHILD D1204: TOPICAL APPLICATION OF FLUORIDE ­ ADULT D1351: SEALANTS

Dental sealants are a dental procedure designed for the prevention of pit and fissure caries on occlusal, buccal, or lingual surfaces that are free of non-incipient decay and restorations on the tooth surfaces to be sealed for permanent first and second molars. Dental sealants are limited to once per tooth per lifetime, regardless of the number of surfaces sealed. Dental sealants may be applied by licensed dentists or auxiliary personnel who are authorized to apply sealants. Sealants are not payable when placed on a previously restored tooth surface. Sealants are a benefit for permanent first and second molars and maxillary premolars (teeth numbers 2, 3, 4, 5, 12, 13, 14, 15, 18, 19, 30, and 31). Any professionally accepted material, including resin-based composites, may be used to place a sealant. If the restoration does not penetrate the dentoenamel junction, Delta Dental considers the service to be a dental sealant.

Provider Hotline (Medicaid): 1-877-576-5899 www.deltadentalins.com/tx-medicaid

Provider Hotline (CHIP): 1-866-561-5891 www.deltadentalins.com/tchip

Page 236

Texas CHIP Dental Services Manual of Criteria

SPACE MAINTENANCE, PASSIVE APPLIANCES (PROCEDURES D1510­1525)

D1510: SPACE MAINTAINER ­ FIXED UNILATERAL D1515: SPACE MAINTAINER ­ FIXED BILATERAL D1520: SPACE MAINTAINER ­ REMOVABLE UNILATERAL D1525: SPACE MAINTAINER ­ REMOVABLE BILATERAL

Provider Hotline (Medicaid): 1-877-576-5899 www.deltadentalins.com/tx-medicaid

Provider Hotline (CHIP): 1-866-561-5891 www.deltadentalins.com/tchip

Page 237

Texas CHIP Dental Services Manual of Criteria

RESTORATIVE SERVICES (PROCEDURES D2140­D2934)

General Policies 1. 2. 3. Restorative services shall be benefits when medically necessary and when carious activity has extended through the dentoenamel junction. Restorations provided due to attrition, abrasion, abfraction, erosion, or wear or for cosmetic purposes are not benefits. All restored surfaces on a single tooth will be considered connected if performed on the same date. Payment may be made for a particular surface on a single tooth only once in each episode of treatment, regardless of the number or combinations of restorations placed. Prior authorization is not required for amalgam and composite restorative services or pre-fabricated crowns. The program provides amalgam, composite resin, acrylic, synthetic, or plastic restorations or stainless steel crowns for treatment of caries. If the tooth can be satisfactorily restored with such material, a laboratoryprocessed crown is considered optional dental treatment. Tooth and soft tissue preparation, temporary restorations, cement bases, amalgam or acrylic build-ups, impressions, pulp cap, and local anesthesia shall be considered components of and included in the fee for a completed restorative service. Restorations in primary teeth, with no permanent successors, serving as permanent teeth in adults are payable at permanent tooth rates. All amalgam and resin restorations are benefits once per tooth in a 12-month period. A provider is responsible for replacement restorations necessary within the first 12 months, except when failure or breakage results from circumstances beyond the control of the provider and is documented. Restorations are payable by tooth type, either primary or permanent. Occlusal adjustments or corrections are included in the fee for any restorative service involving occlusal surfaces. Select therapeutic services provided after the member has exceeded his or her annual maximum require prior authorization. Therapeutic services performed after the member's annual maximum has been exceeded will not be allowed without prior authorization. Therapeutic services may be authorized only when necessary in one or more of the following situations: a. To relieve significant pain or eliminate acute infection.

b. To treat traumatic conditions.

4. 5.

6.

7. 8.

9. 10. 11.

Provider Hotline (Medicaid): 1-877-576-5899 www.deltadentalins.com/tx-medicaid

Provider Hotline (CHIP): 1-866-561-5891 www.deltadentalins.com/tchip

Page 238

Texas CHIP Dental Services Manual of Criteria c. To prevent a condition from seriously jeopardizing a member's health/functioning from deteriorating.

12. Please include x-rays and appropriate narrative documentation describing the need for select therapeutic services (see # 11 above). Services will not be authorized without x-rays and associated documentation.

Provider Hotline (Medicaid): 1-877-576-5899 www.deltadentalins.com/tx-medicaid

Provider Hotline (CHIP): 1-866-561-5891 www.deltadentalins.com/tchip

Page 239

Texas CHIP Dental Services Manual of Criteria

AMALGAM RESTORATIONS (PROCEDURES D2140­D2161)

D2140: AMALGAM ONE SURFACE, PRIMARY OR PERMANENT D2150: AMALGAM TWO SURFACES, PRIMARY OR PERMANENT D2160: AMALGAM THREE SURFACES, PRIMARY OR PERMANENT D2161: AMALGAM FOUR OR MORE SURFACES, PRIMARY OR PERMANENT

Provider Hotline (Medicaid): 1-877-576-5899 www.deltadentalins.com/tx-medicaid

Provider Hotline (CHIP): 1-866-561-5891 www.deltadentalins.com/tchip

Page 240

Texas CHIP Dental Services Manual of Criteria

COMPOSITE RESIN RESTORATIONS (PROCEDURES D2330­ D2394)

(ACRYLIC, SYNTHETIC, OR PLASTIC) General Policies 1. Procedures D2330 and D2335 shall include any of the plastic, resin, acrylic, or composite-type materials. Procedure D2335 represents the maximum allowable fee for a single anterior tooth, including restoring the incisal angle. Proximal restorations in anterior teeth are considered single surface restorations. Procedure D2330 and D2335 are limited to restorations on anterior teeth only. Class V restorations are considered to be single surface restorations. Restoration of non-carious lesions is not a benefit, except when necessary in conjunction with traumatic fractures that require treatment. Reimbursement will be made for a composite/resin restoration only if the tooth has been mechanically prepared for the restoration. Resin-based composite refers to a broad category of materials including, but not limited to composites. May include bonded composite, light-cured composite, etc. Tooth preparation, acid etching, adhesives (including resin bonding agents), liners, bases, and curing are included as part of the restoration.

2. 3. 4. 5. 6. 7.

D2330: RESIN-BASED COMPOSITE, ONE SURFACE, ANTERIOR D2331: RESIN-BASED COMPOSITE, TWO SURFACES, ANTERIOR D2332: RESIN-BASED COMPOSITE, THREE SURFACES, ANTERIOR D2335: RESIN-BASED COMPOSITE, FOUR OR MORE SURFACES (OR INVOLVING THE INCISAL ANGLE ­ ANTERIOR) D2391: RESIN-BASED COMPOSITE, ONE SURFACE POSTERIOR D2392: RESIN-BASED COMPOSITE, TWO SURFACES POSTERIOR D2393: RESIN-BASED COMPOSITE, THREE SURFACES POSTERIOR D2394: RESIN-BASED COMPOSITE, FOUR OR MORE SURFACES POSTERIOR

Provider Hotline (Medicaid): 1-877-576-5899 www.deltadentalins.com/tx-medicaid Provider Hotline (CHIP): 1-866-561-5891 www.deltadentalins.com/tchip

Page 241

Texas CHIP Dental Services Manual of Criteria

CROWNS (PROCEDURES D2710­D2792)

General Policies 1. 2. X-rays are required for laboratory-processed crowns. Laboratory-processed plastic, or plastic with metal, crowns are benefits for permanent teeth for members of all ages if medically necessary pursuant to criteria 2a and 2b below. Laboratory-processed crowns are benefits for permanent teeth for members if medically necessary pursuant to criteria 2a and 2b below. The overall condition of the mouth, patient attitude, oral health status, arch integrity, and prognosis of remaining teeth shall be considered. The tooth and the remaining teeth must be no more involved than Periodontal Case Types II and III. Allowance will be predicated upon a supportable 3-year prognosis. Longevity is essential and a lesser service will not suffice because extensive coronal destruction is supported by a narrative documentation or is radiographically demonstrated and treatment is beyond intercoronal restoration. The program provides amalgam, composite resin, acrylic, synthetic, or plastic restorations or stainless steel crowns for treatment of caries. If the tooth can be satisfactorily restored with such material, a laboratoryprocessed crown is considered optional dental treatment. Laboratory-processed crowns are generally allowable only once in a 5-year period. Stainless steel crowns (Procedures D2930 to D2931) are limited to once per tooth per lifetime. Stainless steel crowns are a benefit on primary teeth when the tooth has had a pulpotomy or pulpectomy or when the tooth may not be adequately restored with other materials. Laboratory-processed crowns on endodontically treated teeth are covered only after satisfactory completion of the root canal therapy. The fee for laboratory-processed crowns includes tooth and soft tissue preparation, amalgam or acrylic build-ups, temporary restoration, cement base, insulating bases, impressions, local anesthesia, and all associated laboratory costs. Occlusal adjustments or corrections are included in the fee for any restorative service involving occlusal surfaces.

3. 4.

5.

6.

7. 8. 9.

10. 11.

12.

Provider Hotline (Medicaid): 1-877-576-5899 www.deltadentalins.com/tx-medicaid

Provider Hotline (CHIP): 1-866-561-5891 www.deltadentalins.com/tchip

Page 242

Texas CHIP Dental Services Manual of Criteria

13. 14. 15.

Payment for a laboratory-processed crown will be made only upon final cementation of the crown. The fee for a crown includes any recementation or repair by the same dental office within 6 months after placement. A plastic or resin crown used as a temporary restoration while the final restoration is being fabricated is part of, and included in the fee for, the final restoration.

D2710: CROWN, RESIN-BASED COMPOSITE (INDIRECT)

X-ray required.

D2720: CROWN, RESIN WITH HIGH NOBLE METAL

X-ray required.

D2721: CROWN, RESIN WITH PREDOMINANTLY BASE METAL

X-ray required.

D2722: CROWN, RESIN WITH NOBLE METAL

X-ray required.

D2740: CROWN, PORCELAIN/CERAMIC SUBSTRATE

X-ray required.

D2750: CROWN, PORCELAIN FUSED TO HIGH NOBLE METAL

X-ray required.

D2751: CROWN, PORCELAIN FUSED TO PREDOMINANTLY BASE METAL

X-ray required.

D2752: CROWN, PORCELAIN FUSED TO NOBLE METAL

X-ray required.

D2790: CROWN, FULL CAST HIGH NOBLE METAL

X-ray required.

Provider Hotline (Medicaid): 1-877-576-5899 www.deltadentalins.com/tx-medicaid

Provider Hotline (CHIP): 1-866-561-5891 www.deltadentalins.com/tchip

Page 243

Texas CHIP Dental Services Manual of Criteria

D2791: CROWN, FULL CAST PREDOMINANTLY BASE METAL

X-ray required.

D2792: CROWN, FULL CAST NOBLE METAL

X-ray required.

Provider Hotline (Medicaid): 1-877-576-5899 www.deltadentalins.com/tx-medicaid

Provider Hotline (CHIP): 1-866-561-5891 www.deltadentalins.com/tchip

Page 244

Texas CHIP Dental Services Manual of Criteria

OTHER RESTORATIVE SERVICES (PROCEDURES D2930­D2931)

General Policies 1. Stainless steel crowns are a benefit when the tooth has had a pulpotomy or pulpectomy or when the tooth may not be adequately restored with other materials. Procedures D2930 and D2931 are limited to one per tooth per lifetime. Amalgam, resin, acrylic, or any other type of buildup is considered part of the preparation for the restoration. A plastic or resin crown used as a temporary restoration while the final restoration is being fabricated is part of, and included in the fee for the final restoration.

2. 3. 4.

D2930: PREFABRICATED STAINLESS STEEL CROWN ­ PRIMARY TOOTH D2931: PREFABRICATED STAINLESS STEEL CROWN ­ PERMANENT TOOTH

Provider Hotline (Medicaid): 1-877-576-5899 www.deltadentalins.com/tx-medicaid

Provider Hotline (CHIP): 1-866-561-5891 www.deltadentalins.com/tchip

Page 245

Texas CHIP Dental Services Manual of Criteria

ENDODONTIC PROCEDURES (PROCEDURES D3220­D3430)

General Policies 1. Includes those procedures that provide complete root canal filling on permanent teeth and pulpotomies (pulpectomies) on both deciduous and permanent teeth. Root canal therapy is covered if medically necessary. It is medically necessary: a. When pathology is present. b. When the tooth is non-vital. c. When the pulp has been compromised by caries, trauma or accident that may lead to the death of the pulp. d. When the therapy meets the criteria set forth in this manual. 2. The prognosis of the affected tooth, other remaining teeth, and the type of final restoration allowable will be evaluated in considering root canal therapy. Payment for root canal treatment includes, but is not limited to, any of all of the following procedures: Any incision and drainage or open and medicating procedure necessary in relation to the root canal therapy. a. b. c. d. e. f. 5. Vitality test. Radiographs required during treatment. Culture. Medicated treatment. Final filling of canal(s). Final treatment radiographs(s).

3. 4.

The initial opening into the canal, sealing of the access opening, all treatment visits, and routine post-operative visits are included in the fee for the completed endodontic treatment. Necessary postoperative care is included in the fee for the completed endodontic procedure. Root canal therapy is not a benefit when extraction is appropriate for a tooth with a fractured root, external or internal resorption. Root canal treatment must be completed prior to payment. The date of service on the payment request should reflect the final treatment date.

6. 7. 8. 9.

Provider Hotline (Medicaid): 1-877-576-5899 www.deltadentalins.com/tx-medicaid

Provider Hotline (CHIP): 1-866-561-5891 www.deltadentalins.com/tchip

Page 246

Texas CHIP Dental Services Manual of Criteria

10. 11.

Cement bases and insulating liners are considered part of restorations and are included in the fee for the completed restoration(s). Permanent restoration for an endodontically treated tooth is a benefit when the coverage criteria specified in this manual for the particular restoration are met. A non-resorbable filling material and a resorbable paste or cement should be used (silver points are not acceptable). Films taken as part of the root canal therapy are part of and included in the fee for the completed endodontic therapy. Root canal benefits are limited to once per tooth per lifetime. Select therapeutic services provided after the member has exceeded his or her annual maximum require prior authorization. Therapeutic services performed after the member's annual maximum has been exceeded will not be allowed without prior authorization. Therapeutic services may be authorized only when necessary in one or more of the following situations: a. To relieve significant pain or eliminate acute infection. b. To treat traumatic conditions. c. To prevent a condition from seriously jeopardizing a member's health/functioning from deteriorating. Please include x-rays and appropriate narrative documentation describing the need for select therapeutic services (see #14 above). Services will not be authorized without x-rays and associated documentation.

12. 13. 14. 15.

16.

D3220: THERAPEUTIC PULPOTOMY (EXCLUDING FINAL RESTORATION) REMOVAL OF PULP CORONAL TO THE DENTIOCEMENTAL JUNCTION AND APPLICATION OF MEDICAMENT

A single procedure payable for the total service regardless of the number of treatment stages. Any acceptable and recognized method is a benefit where the procedure is justified and the coronal portion of the pulp is completely extirpated. Procedure D3220 may be performed on primary or permanent teeth. This is not to be billed as the first stage of root canal therapy. Not payable in conjunction with procedures D3310-D3330.

D3230: PULPAL THERAPY, RESORBABLE FILLING, ANTERIOR PRIMARY TOOTH

A benefit without prior authorization for a primary tooth. The pulp must be extirpated completely.

Provider Hotline (CHIP): 1-866-561-5891 www.deltadentalins.com/tchip

Provider Hotline (Medicaid): 1-877-576-5899 www.deltadentalins.com/tx-medicaid

Page 247

Texas CHIP Dental Services Manual of Criteria

Must include the placement of a resorbable filling.

D3240: THERAPEUTIC PULPOTOMY ­ RESORBABLE FILLING EXCLUDING FINAL RESTORATION, PRIMARY FIRST AND SECOND MOLARS

A benefit without prior authorization for a primary tooth. The pulp must be extirpated completely. Must include the placement of a resorbable filling.

Provider Hotline (Medicaid): 1-877-576-5899 www.deltadentalins.com/tx-medicaid

Provider Hotline (CHIP): 1-866-561-5891 www.deltadentalins.com/tchip

Page 248

Texas CHIP Dental Services Manual of Criteria

ROOT CANALS (PROCEDURES D3310­D3330)

General Policies 1. 2. Procedures D3310, D3320 and D3330 are benefits for any permanent tooth and subject to criteria for coverage set forth in this manual. Root canal therapy is a benefit for permanent teeth when: a. Medically necessary and the final post-treatment restoration of the treated tooth will afford acceptable retention longevity and b. Missing teeth do not jeopardize the integrity or masticatory function of the dental arches and c. The tooth is necessary to maintain adequate masticatory function and d. Periodontal condition of the tooth and the remaining teeth must be no more involved than Periodontal Case Types II and III, defined as: Type I Gingivitis: Inflammation of the gingiva, characterized clinically by gingival hyperplasia, edema, retractability, gingival pocket formation, pocket depth less than 4mm and no bone loss. Type II Early Periodontitis: Progression of gingival inflammation into the alveolar bone crest and early bone loss resulting in moderate pocket formation (4-6mm). Type III Moderate Periodontitis: A more advanced state with increased destruction of periodontal structures associated with moderate to deep pockets (5-8mm), moderate to severe bone loss and tooth mobility. e. Extraction of the tooth is not an acceptable alternative because it is established that preservation of the tooth is medically necessary (e.g., hemophiliac). 3. All endodontic treatment procedures include the removal of posts, silver point, and previous root canal filling material and any procedures necessary to prepare the canals and place the canal filling. Requests for authorization for payment of the final restoration of a tooth receiving root canal therapy cannot be acted upon until satisfactory completion of the root canal therapy is documented. Films taken as part of the root canal therapy are part of and included in the fee for the completed endodontic therapy. Root canal benefits are limited to once per tooth per lifetime.

4.

5. 6.

Provider Hotline (Medicaid): 1-877-576-5899 www.deltadentalins.com/tx-medicaid

Provider Hotline (CHIP): 1-866-561-5891 www.deltadentalins.com/tchip

Page 249

Texas CHIP Dental Services Manual of Criteria

D3310: ENDODONTIC THERAPY, ANTERIOR TOOTH (EXCLUDING FINAL RESTORATION) D3320: ENDODONTIC THERAPY, BICUSPID TOOTH (EXCLUDING FINAL RESTORATION) D3330: ENDODONTIC THERAPY, MOLAR TOOTH (EXCLUDING FINAL RESTORATION)

Provider Hotline (Medicaid): 1-877-576-5899 www.deltadentalins.com/tx-medicaid

Provider Hotline (CHIP): 1-866-561-5891 www.deltadentalins.com/tchip

Page 250

Texas CHIP Dental Services Manual of Criteria

PERIODONTIC SERVICES (PROCEDURES D4210­D4341)

D4210: GINGIVECTOMY OR GINGIVOPLASTY FOUR OR MORE CONTIGUOUS TEETH PER QUADRANT

OR

TOOTH BOUNDED SPACES

D4341: PERIODONTAL SCALING AND ROOT PLANING FOUR OR MORE TEETH PER QUADRANT D4355: FULL MOUTH DEBRIDEMENT TO ENABLE COMPREHENSIVE EVALUATION AND DIAGNOSIS

Provider Hotline (Medicaid): 1-877-576-5899 www.deltadentalins.com/tx-medicaid

Provider Hotline (CHIP): 1-866-561-5891 www.deltadentalins.com/tchip

Page 251

Texas CHIP Dental Services Manual of Criteria

PROSTHODONTIC SERVICES (PROCEDURES D5110­D5214)

D5110: COMPLETE DENTURE ­ MAXILLARY (UPPER) D5120: COMPLETE DENTURE ­ MANDIBULAR (LOWER) D5211: MAXILLARY PARTIAL DENTURE ­ RESIN BASE (INCLUDING ANY CONVENTIONAL CLASPS, RESTS AND TEETH) D5212: MANDIBULAR PARTIAL DENTURE ­ RESIN BASE (INCLUDING ANY CONVENTIONAL CLASPS, RESTS, AND TEETH) D5213: MAXILLARY PARTIAL DENTURE CAST METAL FRAMEWORK WITH RESIN DENTURE BASES (INCLUDING ANY CONVENTIONAL CLASPS, RESTS, AND TEETH) D5214: MANDIBULAR PARTIAL DENTURE CAST METAL FRAMEWORK WITH RESIN DENTURE BASES (INCLUDING ANY CONVENTIONAL CLASPS, RESTS, AND TEETH)

Provider Hotline (Medicaid): 1-877-576-5899 www.deltadentalins.com/tx-medicaid

Provider Hotline (CHIP): 1-866-561-5891 www.deltadentalins.com/tchip

Page 252

Texas CHIP Dental Services Manual of Criteria

EXTRACTIONS (PROCEDURES D7140­D7240)

General Policies 1. Extraction of asymptomatic teeth is not a benefit. The following includes, but is not all inclusive of, conditions that may be considered symptomatic when documented: a. Fully bony impacted supernumerary teeth, mesiodens, or teeth unerupted because of lack of alveolar ridge length. b. Teeth that are involved with a cyst, tumor, or other neoplasm. c. Unerupted teeth that are distorting the normal alignment of erupted teeth or causing the resorption of the roots of other teeth. d. The extraction of all remaining teeth in preparation for a full prosthesis, but only when authorized. e. Misaligned tooth (teeth) that cause the exacerbation of periodontal disease in adjacent teeth/areas. f. Extractions of primary teeth required to minimize malocclusion or misalignment when there is adequate space to allow normal eruption of the permanent tooth (teeth). g. Perceptible radiologic pathology that fails to elicit symptoms. h. Extractions that are required to complete medically necessary orthodontic dental services. 2. Routine postoperative visits (within 30 days following surgical procedure) are considered part of, and included in, the global fee for the surgical procedure. Extractions of asymptomatic deciduous teeth that appear by radiographic evaluation ready to exfoliate naturally are not a benefit. The fees for oral surgery procedures include local anesthesia and routine post-operative visits. The fee for extractions includes the excision of associated minor cystic or inflamed tissue. X-rays are required for procedures D7210, D7220, D7230, and D7240. Select therapeutic services provided after the member has exceeded his or her annual maximum require prior authorization. Therapeutic services performed after the member's annual maximum has been exceeded will not be allowed without prior authorization. Therapeutic services may be authorized only when necessary in one or more of the following situations: a. To relieve significant pain or eliminate acute infection. b. To treat traumatic conditions.

Provider Hotline (Medicaid): 1-877-576-5899 www.deltadentalins.com/tx-medicaid Provider Hotline (CHIP): 1-866-561-5891 www.deltadentalins.com/tchip

3. 4. 5. 6. 7.

Page 253

Texas CHIP Dental Services Manual of Criteria

c. To prevent a condition from seriously jeopardizing a member's health/functioning from deteriorating. 8. Please include x-rays and appropriate narrative documentation describing the need for select therapeutic services (see # 7 above). Services will not be authorized without x-rays and associated documentation.

D7140: EXTRACTION, ERUPTED TOOTH OR EXPOSED ROOT (ELEVATION AND/OR FORCEPS REMOVAL)

A benefit for the uncomplicated removal of a primary or permanent tooth. Includes routine removal of tooth structure, minor smoothing of socket bone, and closure, as necessary. A benefit for the removal of any tooth by elevation and/or forceps where the mucoperiosteum is not detached.

Provider Hotline (Medicaid): 1-877-576-5899 www.deltadentalins.com/tx-medicaid

Provider Hotline (CHIP): 1-866-561-5891 www.deltadentalins.com/tchip

Page 254

Texas CHIP Dental Services Manual of Criteria

SURGICAL EXTRACTIONS (PROCEDURES D7210­D7240)

General Policies 1. 2. Surgical removal of impacted teeth is a covered benefit only when evidence of pathology exits. Diagnostic periapical or panorex x-ray depicting the entire subject tooth is required for all surgical extraction procedures and must be submitted with the claim. The level of payment for extraction of an impacted permanent tooth shall be based on the degree or amount of the crown of the tooth, which is covered by tissue as evidenced by the diagnostic radiographs. Classification of impactions is based on the anatomical position of the tooth rather than the surgical technique employed in removal. The procedure number shall be adjusted to agree with the severity of impaction as evidenced by the diagnostic radiographs unless otherwise modified by report.

3.

4.

D7210: SURGICAL REMOVAL OF ERUPTED TOOTH REQUIRING REMOVAL OF BONE AND/OR SECTION OF TOOTH INCLUDING ELEVATION OF MUCOPERIOSTEAL FLAP IF INDICATED

AND

X-ray required. A benefit when removal of any erupted tooth requires: The retraction of a mucoperiosteal flap and

The removal of substantial alveolar bone in order to effect the extraction. Examples include, when documented, but are not limited to: Crown undermined by caries which prohibits normal forceps technique. Divergent, thin, curved, or brittle roots which require separate and individual manipulation or extraction. Hypercementosis.

Partial ankylosis. The fee for multiple surgical extractions includes any necessary alveoloplasty.

D7220: REMOVAL OF IMPACTED TOOTH ­ SOFT TISSUE

X-ray required. A benefit if: A permanent tooth is removed by the open method.

Provider Hotline (Medicaid): 1-877-576-5899 www.deltadentalins.com/tx-medicaid

Provider Hotline (CHIP): 1-866-561-5891 www.deltadentalins.com/tchip

Page 255

Texas CHIP Dental Services Manual of Criteria

The major portion or all of the crown of the tooth is covered by mucogingival tissue and the major portion or the entire crown of the tooth is not covered by alveolar bone.

D7230: REMOVAL OF IMPACTED TOOTH ­ PARTIAL BONY

X-ray required. A benefit if removal of alveolar bone to expose any portion of the crown of the permanent tooth is necessary to effect extraction by the open method.

D7240: REMOVAL OF IMPACTED TOOTH ­ COMPLETE BONY

X-ray required. A benefit if removal of alveolar bone to expose the major portion of the crown of the permanent tooth is necessary to effect extraction by the open method.

Provider Hotline (Medicaid): 1-877-576-5899 www.deltadentalins.com/tx-medicaid

Provider Hotline (CHIP): 1-866-561-5891 www.deltadentalins.com/tchip

Page 256

Texas CHIP Dental Services Manual of Criteria

REGIONAL SCREENING PREOPERATIVE EXAMINATIONS

General Policies 1. When the need is determined by a dental consultant, a preoperative examination by a regional dental consultant: a. May be used to verify existing conditions and the necessity for requested services and b. Shall be used only when other means of verification are not available to establish necessity. 2. 3. It is the responsibility of the treating provider to supply sufficient diagnostic material to establish the necessity for the requested services. The dental consultant's responsibility is to approve only those procedures identified as necessary from the diagnostic material or other documentation submitted. Clinical examinations shall not be routinely used to gather information, which should be supplied by the provider. The provider shall be requested to supply necessary additional information when needed. Clinical examinations shall not be used for those cases where the outcome of screening will not alter the decision. Clinical examinations may be used for review and control of unusual treatment patterns (e.g., cases involving suspected over-utilization and requests for stainless steel crowns where more conservative measures appear more appropriate).

4.

5. 6.

Provider Hotline (Medicaid): 1-877-576-5899 www.deltadentalins.com/tx-medicaid

Provider Hotline (CHIP): 1-866-561-5891 www.deltadentalins.com/tchip

Page 257

Texas CHIP Dental Services Manual of Criteria

REASONABLE AND NECESSARY CONCEPT

Dental services that are reasonable and necessary for the prevention, diagnosis, and treatment of dental disease, injury, or defect are covered to the extent specified in this section when fully documented to be dentally necessary. The underlying principle of whether a service is reasonable and necessary is whether or not the requested service or item, which is a program benefit, meets the following criteria:

Is appropriate and necessary for the symptoms, diagnosis, or treatment of the dental condition. Is provided for the diagnosis or direct care and treatment of the dental condition. Meets the standards for good dental practice within the dental community in the service area. Is not primarily for the convenience of the member or dentist. Is the most appropriate level of service that can safely be provided.

Authorization shall be granted or reimbursement made only for the least costly covered service appropriate to the presenting adverse condition.

Provider Hotline (Medicaid): 1-877-576-5899 www.deltadentalins.com/tx-medicaid

Provider Hotline (CHIP): 1-866-561-5891 www.deltadentalins.com/tchip

Page 258

Texas Children's Medicaid and CHIP Dental Services Provider Manual

Attachment F: Texas Medicaid and CHIP Dental Services Requiring Prior Authorization and/or X-rays Texas Children's Medicaid Dental Services

Procedure Codes D0360­D0363 D2510­D2664 Procedure Description Cone beam Inlay/Onlay Restorations Prior Authorization Required? Yes Inlays/onlays or permanent crowns that exceed the limit of four Inlays/onlays or permanent crowns that exceed the limit of four No No No No Yes Yes Yes Yes Yes Yes Yes Yes X-Rays Required? No Yes, with prior authorization

D2710­D2794

Laboratory Processed Crowns

Yes

D2960 D2961 D2962 D2970 D3460 D4276 D5951 D5952 D5953 D5954 D5955 D5958

Labial veneer (resin laminate) ­ chairside Labial veneer (resin laminate) ­ laboratory Labial veneer (porcelain laminate) ­ laboratory Temporary crown (fractured tooth) Endodontic endosseous implant Combined connective tissue and double pedical graft, per tooth Feeding aid Speech aid prosthesis, pediatric Speech aid prosthesis, adult Palatal augmentation, prosthesis Palatal lift prosthesis, definitive Palatal life prosthesis, interim

Yes Yes Yes Yes Yes No No No No No No No

Provider Hotline (Medicaid): 1-877-576-5899 www.deltadentalins.com/tx-medicaid

Provider Hotline (CHIP): 1-866-561-5891 www.deltadentalins.com/tchip

Page 259

Texas Children's Medicaid and CHIP Dental Services Provider Manual

Texas Children's Medicaid Dental Services, continued

Procedure Codes D5959 D5960 D6010 D6040 D6050 D6055 D6080 Procedure Description Palatal lift prosthesis, modification Speech aid prosthesis, modification Surgical placement of implant body: endosteal implant Surgical placement: eposteal implant Surgical placement: transosteal implant Dental implant supported connecting bar Implant maintenance procedures, including removal of prosthesis, cleansing of prosthesis and abutments, and reinsertion of prosthesis Repair implant-supported prosthesis, by report Implant removal, by report Repair implant abutment, by report Unspecified implant procedure, by report Fixed Partial Denture Pontics Fixed Partial Dental Retainers-- Inlays/Onlays Fixed Partial Dental Retainers-- Crowns Oralantral fistula closure Tooth transplantation (includes reimplantation from one site to another and splinting and/or stabilization) Removal of torus palatinus Prior X-Rays Authorization Required? Required? Yes Yes Yes Yes Yes Yes No No No No No No

Yes

No

D6090 D6100 D6095 D6199 D6210-D6253 D6545-D6548 D6720-D6792 D7260 D7272

Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes

No No No No Yes Yes Yes No Yes No

D7472

Provider Hotline (Medicaid): 1-877-576-5899 www.deltadentalins.com/tx-medicaid

Provider Hotline (CHIP): 1-866-561-5891 www.deltadentalins.com/tchip

Page 260

Texas Children's Medicaid and CHIP Dental Services Provider Manual

Texas CHIP Dental Services

Prior Authorization Required After Annual Maximum Has Been Reached? Yes Yes Yes Yes

Procedure Code/s

Procedure Description

X-Rays Required?

D7997

Appliance removal (not by dentist who placed appliance), including removal of archbar Orthodontic Treatment (see Manual of criteria) General Anesthesia Amalgam and Resin-Based Composite Restorations (select therapeutic services) Laboratory Processed Crowns Endodontic Procedures (select therapeutic services) Extraction

No Yes No Yes, with prior authorization Yes, always Yes, with prior authorization Yes, with prior authorization Yes, always

D8020-D8999 D9220-D9221 D2140-D2391

D2710-D2792 D3220-D3430

Yes Yes

D7140

Yes

D720-D7240

Surgical Extraction of Impacted Teeth (select therapeutic services)

Yes

Provider Hotline (Medicaid): 1-877-576-5899 www.deltadentalins.com/tx-medicaid

Provider Hotline (CHIP): 1-866-561-5891 www.deltadentalins.com/tchip

Page 261

Texas Children's Medicaid and CHIP Dental Services Provider Manual

Attachment G: Process of Care Evaluation Measures

Delta Dental's process of care evaluation measures are presented in Attachment G. Review Criteria

I. DOCUMENTATION

Reviewer Evaluation Measures

A. Medical History Information collected General medical history with information pertaining to general health and appearance, systemic disease, allergies, reactions to anesthetics. Should include a list of any current medications and/or treatment. Yes/No format is recommended. Name, telephone number of physician and person to contact in emergency. Should be uniform and conspicuously located on the portion of the chart used during treatment and should reflect current history. Patient comments, DDS notes, or consultation with a physician should be documented in the chart. Dentist must sign and date all baseline medical histories after review with patient. Patient must sign and date all baseline medical histories. Documentation of any cultural, language, physical access needs, etc. Documentation of medical history updates at appropriate intervals. Must be signed by the patient and the provider. Acceptable on medical history form or in the progress notes. Should reflect changes or no changes. Recommend update be done annually. Documentation that the patient was seen only for emergency or limited care, and is not a regular patient of this office. Documentation of pertinent information relative to patient's dental history, chief complaint, etc.

Medical alert

Medical follow-up

Doctor signature and date Patient signature and date Special needs Periodic update

B. Emergency Treatment

C. Dental History

D. Documentation of Intra/Extra Oral Exam

Provider Hotline (Medicaid): 1-877-576-5899 www.deltadentalins.com/tx-medicaid

Provider Hotline (CHIP): 1-866-561-5891 www.deltadentalins.com/tchip

Page 262

Texas Children's Medicaid and CHIP Dental Services Provider Manual

Review Criteria Status of teeth/existing conditions

a.

b.

c.

d. e. f. Status of periodontal a. b. c. Soft tissue exam a. b. c.

Reviewer Evaluation Measures Grid or narrative of existing condition: noncarious, carious, broken or fractured teeth and existing restorations. No problems or no treatment needed could be noted as WNL. Grid or narrative of existing conditions, missing teeth, crowns or existing bridges. New decay should be noted. "WNL" can be used to indicate no treatment needed. Evidence of TMJ exam is recommended. Evaluation of occlusion should be documented. Documentation of need for any oral surgery and/ or impaction needing removal. Existing prosthesis evaluation. Age and condition. Documentation of any obvious endodontic pathology. Condition of gingival tissue, calculus, plaque, bleeding on probing, etc. Evidence of probing should be documented. Case type of periodontal conditions (Class I-V). Evidence that oral cancer exam was done. Updated at recall or periodic intervals. Note of any anatomical abnormalities.

E. Progress Notes Legible and in ink Provider should be reminded that progress notes are a legal document; all should be in ink, legible and should be in detail. Correction should be made by lining out. No white-out. Documentation of any follow-up instructions to patient, recommendations for future care. Documentation of patient leaving the practice and reasons, if known. Documentation if any records forwarded, etc. All notes must be organized chronologically, legible and information easily retrievable. All entries must be signed (initialed) and dated by the treating provider. Notation in progress notes as to type and amount of anesthetics used. Note "no anesthesia used" for applicable situations.

Provider Hotline (CHIP): 1-866-561-5891 www.deltadentalins.com/tchip

Chart organization Signed and dated by provider Anesthetics

Provider Hotline (Medicaid): 1-877-576-5899 www.deltadentalins.com/tx-medicaid

Page 263

Texas Children's Medicaid and CHIP Dental Services Provider Manual

Review Criteria Prescriptions

Reviewer Evaluation Measures Medications prescribed for the patient are documented in the progress notes or copies of all prescriptions are kept in the chart. Note an Rx given on phone. Recommended that dental lab prescriptions be documented in the progress notes or a copy kept in the chart.

II. QUALITY OF CARE A. Radiographs Quantity/frequency a. Adequate number of radiographs to make an appropriate diagnosis and treatment plan, per FDA guidelines. b. Recall x-rays should be based on FDA guidelines. Depends on complexity of care, caries, susceptibility, amount, and type of treatment and time since last exposure. c. Whenever possible, radiographs should not be taken if recent acceptable films are available from another source. d. Any refusal of radiographs should be documented. a. Lack of overlapping contact, cone cuts, chemical stains. b. Good contrast, not over/underdeveloped. a. Lack of cone cuts and chemical stains. b. Good contrast, not over/underdeveloped. c. All apices visible without elongation or foreshortening. Good contrast, not over/underdeveloped, no chemical stains or static lines. Recent radiographs must be mounted, labeled, and dated for reviewing and comparison with past radiographs.

Technical quality - BWXs

Technical quality - PAs

Technical quality panoramic Mounted, labeled and dated B. Diagnosis Initial complaint or emergency treatment Other pathology

Caries Periodontics

Chief complaint was diagnosed, triaged, and treated in a timely manner. Documentation of any other pathology (i.e., abnormal anatomical abnormalities on radiographs or from the clinical exam). A qualitative evaluation of existing caries from clinical and radiographic findings. A qualitative evaluation of existing conditions

Provider Hotline (CHIP): 1-866-561-5891 www.deltadentalins.com/tchip

Provider Hotline (Medicaid): 1-877-576-5899 www.deltadentalins.com/tx-medicaid

Page 264

Texas Children's Medicaid and CHIP Dental Services Provider Manual

Review Criteria Endodontics Crowns Missing teeth/prosthetics Impactions/surgery Specialty referrals and consultations

Reviewer Evaluation Measures from clinical and radiographic findings. A qualitative evaluation of existing conditions from clinical and radiographic findings. A qualitative evaluation of existing conditions from clinical and radiographic findings. A qualitative evaluation of existing conditions from clinical and radiographic findings. A qualitative evaluation of existing conditions from clinical and radiographic findings. a. Proper and timely referral for oral surgery, endodontics, periodontics, pedodontics, or orthodontics. b. Documentation of any verbal or written communication with specialists. c. Referral documentation should support diagnosis by recording clinical symptoms and conditions (vitality testing, hot/cold sensitivity), broken or fractured teeth, probing, transillumination, etc.

C. Treatment Plan Present and in ink a. Comprehensive documentation of patient needs and treatment recommendations, all documentation in ink. b. Consistent with diagnosis and clinical exam. c. Alternative treatment plans should be documented. d. Consultations and referrals should be noted when necessary. Consistent with diagnostic and examination findings, and in compliance with recognized accepted professional standards. Case should be sequenced in order of need. A possible sequence follows: a. Relief of pain, discomfort and infection. b. Elimination of irritation and /or traumatic condition. c. Prophylaxis and instruction in preventive care. d. Treatment of extensive caries and pulpal inflammation. e. Endodontic therapy. f. Periodontal treatment. g. Elimination of remaining caries and

Provider Hotline (CHIP): 1-866-561-5891 www.deltadentalins.com/tchip

Appropriateness

Sequenced

Provider Hotline (Medicaid): 1-877-576-5899 www.deltadentalins.com/tx-medicaid

Page 265

Texas Children's Medicaid and CHIP Dental Services Provider Manual

Review Criteria h. i. j. k. Informed consent a.

b.

c. III. OUTCOMES OF CARE A. Preventive services Prophylaxis Oral hygiene instruction Fluoride

Reviewer Evaluation Measures necessary extractions. Sealants were treatment planned where appropriate. Replacement of missing teeth, other restorative treatment. Referral to specialist for elective care. Placement of patient on recall schedule with documentation of progress notes. Documentation that treatment plan has been reviewed with the patient and that the patient understands the risks, benefits and alternatives to care. An appropriate form signed by the patient is recommended. Documentation that all patients' questions were answered. Documentation of any refusal of recommended care.

Documentation that service was performed in a timely manner. Documentation of instructions given patient. Documentation of fluoride treatments, as appropriate to age of patient and caries incidence. Systems in place for timely recall of patient.

Recall B. Operative Services Margins Contours Contact Restorative outcome

Recall radiographs (BWXs and anterior PAs) used to evaluate past care. Recall radiographs (BWXs and anterior PAs) used to evaluate past care. Recall radiographs (BWXs and anterior PAs) used to evaluate past care. a. Prognosis good for appropriate longevity. b. No subsequent unplanned treatment. Unplanned treatment-redo of recent restorations due to fracture, extraction, RCT, etc.

C. Crown and Bridge Services

Provider Hotline (Medicaid): 1-877-576-5899 www.deltadentalins.com/tx-medicaid

Provider Hotline (CHIP): 1-866-561-5891 www.deltadentalins.com/tchip

Page 266

Texas Children's Medicaid and CHIP Dental Services Provider Manual

Review Criteria Margins Contours Contact Restorative outcome

Reviewer Evaluation Measures Recall radiographs (BWXs and anterior PAs) used to evaluate past care. Recall radiographs (BWXs and anterior PAs) used to evaluate past care. Recall radiographs (BWXs and anterior PAs) used to evaluate past care. a. Prognosis good for appropriate longevity. b. No subsequent unplanned treatment. Unplanned treatment-redo of recent crowns or bridges, RCT, extractions, etc.

D. Endodontic Services Canal obturation Radiographic evaluation of treatment to determine that canal(s) is/are properly filled and well condensed. Evidence of rubber dam use on working x-rays and/or documentation in progress notes. a. Prognosis good for appropriate longevity. b. No subsequent unplanned treatment, extraction of recently completed endodontic treatment. c. Documentation of final restoration. d. Recall follow-up recommend with PA x-ray. Evidence that appropriate probing has been done. Recommendation is 2 quadrants per visit maximum, with local anesthetic as appropriate. Recall follow-up recommended with appropriate radiographs or probing. a. Care was done in a timely manner, including adjustments. b. Prognosis good for appropriate longevity. a. Comprehensive documentation of treatment done, materials used, and any noteworthy occurrences during the procedure. b. Documentation of post-operative instruction to patient. c. Documentation of any needed postoperative care.

Rubber dam use Follow-up/outcome

E. Periodontic Services Pocket charting Treatment per visit Follow-up/outcome

F. Prosthetic Services

G. Surgical Services

IV. CONTINUITY OF CARE A. Overall Efficiency

Provider Hotline (Medicaid): 1-877-576-5899 www.deltadentalins.com/tx-medicaid Provider Hotline (CHIP): 1-866-561-5891 www.deltadentalins.com/tchip

Page 267

Texas Children's Medicaid and CHIP Dental Services Provider Manual

Review Criteria Treatment interval Treatment per visit Follow-up documentation

Reviewer Evaluation Measures Appropriate time between appointments. Too many procedures or too few, per appointment. Appropriate amount of care done each appointment. a. Failed and canceled appointments are entered on the progress notes. b. Next planned treatment is entered on the progress notes. Rating of dentist on overall delivery of services. If an addendum is present it must be signed by the patient.

B. Overall Patient Care C. Patient Addendum

Provider Hotline (Medicaid): 1-877-576-5899 www.deltadentalins.com/tx-medicaid

Provider Hotline (CHIP): 1-866-561-5891 www.deltadentalins.com/tchip

Page 268

Texas Children's Medicaid and CHIP Dental Services Provider Manual

Attachment H: Sample General Anesthesia Form

Provider Hotline (Medicaid): 1-877-576-5899 www.deltadentalins.com/tx-medicaid

Provider Hotline (CHIP): 1-866-561-5891 www.deltadentalins.com/tchip

Page 269

Texas Children's Medicaid and CHIP Dental Services Provider Manual

Attachment I: Sample Private Pay Agreement Forms

Attachment I presents samples of the following two documents:

Delta Dental's private pay agreement between providers and members. TMHP's private pay agreement form.

Provider Hotline (Medicaid): 1-877-576-5899 www.deltadentalins.com/tx-medicaid

Provider Hotline (CHIP): 1-866-561-5891 www.deltadentalins.com/tchip

Page 270

Texas Children's Medicaid and CHIP Dental Services Provider Manual

TMHP 2011 Texas Medicaid Provider Procedures Manual, Section B4.3, Private Pay Agreement

Private Pay Agreement

I understand _______________________(insert name of provider) is accepting me as a private pay patient for the period of _____________ (insert date/s), and I will be responsible for paying for any services I receive. The provider will not file a claim to Medicaid for services provided to me.

Signed: ____________________________________

Provider Hotline (Medicaid): 1-877-576-5899 www.deltadentalins.com/tx-medicaid

Provider Hotline (CHIP): 1-866-561-5891 www.deltadentalins.com/tchip

Page 271

Texas Children's Medicaid and CHIP Dental Services Provider Manual

Attachment J: Waste, Abuse, and Fraud Reporting Form

Delta Dental's Waste, Abuse, and Fraud Reporting Form is presented on this page and the following page. This form is also available on the Texas Medicaid provider website.

Provider Hotline (Medicaid): 1-877-576-5899 www.deltadentalins.com/tx-medicaid

Provider Hotline (CHIP): 1-866-561-5891 www.deltadentalins.com/tchip

Page 272

Texas Children's Medicaid and CHIP Dental Services Provider Manual

Provider Hotline (Medicaid): 1-877-576-5899 www.deltadentalins.com/tx-medicaid

Provider Hotline (CHIP): 1-866-561-5891 www.deltadentalins.com/tchip

Page 273

Texas Children's Medicaid and CHIP Dental Services Provider Manual

Attachment K: Claim/TAR/NOA Submission Checklist

Attached is Delta Dental's Claim/TAR/NOA submission checklist.

Submission for Claim (Payment)

Have you ...

Completed the claim/TAR form? Listed the date services were performed? Placed only x-rays in an x-ray envelope? Included any remarks or attachments necessary to document this payment request? Provided the appropriate signature and date in the signature block?

Submission for Treatment Authorization Request (TAR)

Have you ...

Completed the claim/TAR form? Checked your provider manual for those procedures that require prior authorization? Placed only x-rays in an x-ray envelope? Included any remarks or attachments necessary to document this TAR? Provided the appropriate signature and date in the signature block?

Submission for Notice of Authorization (NOA) ­ For Payment

Have you ...

Listed the date of service? Checked the "delete" column for services not performed? Indicated any additions not requiring prior authorization? Included any necessary x-rays or documentation? Filled in all shaded areas, if applicable? Provided the appropriate signature and date in the signature block?

Submission for Notice of Authorization (NOA) ­ For Extension of Time or Re-evaluation

Have you ...

Checked "Extension of Time is Requested" or "Re-evaluation is Requested" box at upper right corner, where appropriate? Enclosed your NOA in a mailing envelope?

X-Rays

Have you ...

Mounted, dated and labeled with the patient and dentist's name, and the povider Number? Labeled "left" and "right"? Checked them for diagnostic quality?

Provider Hotline (Medicaid): 1-877-576-5899 www.deltadentalins.com/tx-medicaid

Provider Hotline (CHIP): 1-866-561-5891 www.deltadentalins.com/tchip

Page 274

Texas Children's Medicaid and CHIP Dental Services Provider Manual

Attachment L: Codes, Messages, and Special Cases

To supplement the Texas Children's Medicaid Dental Services Manual of Criteria in Attachment A and the Texas CHIP Dental Services Manual of Criteria in Attachment E, this attachment presents a list of reason codes, messages, and special cases. The categories of reason codes, messages, and special cases presented in this attachment include: Diagnostic

Adjudication Reason Code 001 002 008 009 019 020 022 022a 027 028 029 Description Comprehensive examination is a benefit for the initial examination once per member, per provider. Additional examinations are payable as a periodic exam. Examinations are a benefit once in a six-month period to the same provider. Procedure was not adequately documented. Please resubmit with narrative documentation. Procedure not a benefit when specific services other than x-rays/photographs are provided on the same day. Procedures have been modified per age of member and description of service to allow benefits. Procedure is limited to twice in a full 12- month period. Full mouth or panographic x-rays are a benefit once in a 36-month period. Panographic x-rays are a benefit once in a 5-year period. Bitewing x-rays are not a benefit for edentulous areas. Bitewing x-rays are a benefit once in a 6-month period. Payment/authorization denied due to undated x-rays. Please resubmit with recent dated x-rays. a. Payment/authorization denied. Final endodontic radiograph is dated prior to the completion date of the endodontic treatment. An adjustment has been made for the maximum allowable x-rays/photos. a. Combination of x-rays is equal to a full mouth series. b. Single periapical x-rays are limited to 20 in any consecutive 12-month period. X-rays disallowed. Test/treatment and postoperative x-rays are included in the fee for the completed endodontic treatment. Emergency procedures and denture adjustments cannot be prior authorized. Dental sealants are payable only once per tooth per lifetime, regardless of the number of surfaces sealed. Procedures are a benefit only when the tooth surfaces to be sealed are free of decay and/or restorations.

030

032 034 037 038

Oral Surgery

Adjudication Reason Code 043 046 048 049 050 Description Resubmit a new authorization request following completion of surgical procedure(s) that may affect prognosis of treatment plan as submitted. Post-operative visits (within 30 days) are considered part of, and included in, the global fee for the surgical procedure. Extraction of asymptomatic teeth is not a benefit. Extractions are not payable for deciduous teeth near exfoliation. Surgical extraction procedure(s) or degrees of impaction(s) have been modified to conform to x-ray appearance and/or surgical approach. a. Based on a consultant's evaluation, this tooth does not appear to be a completely bony impaction. Allowance made for partially bony impaction. Provider Hotline (CHIP): 1-866-561-5891 www.deltadentalins.com/tchip

Provider Hotline (Medicaid): 1-877-576-5899 www.deltadentalins.com/tx-medicaid

Page 275

Texas Children's Medicaid and CHIP Dental Services Provider Manual

Diagnostic

Adjudication Reason Code Description b. Based on a consultant's evaluation, this tooth does not appear to be a completely bony impaction. Allowance made for soft tissue impaction. Request for payment of root tip extraction cannot be granted as extraction of the same tooth number has previously been paid to your office. Routine alveolectomy procedures in conjunction with extractions of teeth are included as part of the extraction procedure. a. This procedure is not payable within six months of extractions in the same quadrant. Diagnostic x-rays fully depicting subject tooth (teeth) are required for intraoral surgical procedures. Please resubmit with x-rays depicting the entire tooth and apex.

052 054

055

Periodontics

Adjudication Reason Code 075 Description Procedure must be documented as to the nature of the emergency /periodontal condition and the definitive treatment provided.

Endodontics

Adjudication Reason Code 091 092 Description Procedure(s) require diagnostic radiographs depicting entire subject tooth. Please resubmit with x-rays showing apices of tooth. Payment request for root canal treatment and apicoectomy must be accompanied by a dated final treatment radiograph and includes necessary postoperative care within 90 days. Endodontic procedure is not payable when: a. Root canal filling underfilled. b. Root canal filling overfilled. c. Incomplete apical treatment due to inadequate retrograde fill and/or sealing of the apex. d. Root canal filling is under condensed. e. Root canal has been filled with silver points. Silver points are not an acceptable filling material. f. Root canal therapy has resulted in the gross destruction of the root or crown. Crowns/onlays on endodontically treated teeth may be authorized following the satisfactory completion of root canal therapy. Please submit your request for authorization on a separate form with the final endodontic radiograph. Root canal procedure(s) are not a benefit in conjunction with a full denture procedure. Need for root canal procedure not evident per x-ray appearance, clinical evaluation or documentation submitted. Please resubmit request with narrative documentation indicating the need for root canal treatment. Procedure is not a benefit for endodontically treated teeth.

093

094

096 097

100

Provider Hotline (Medicaid): 1-877-576-5899 www.deltadentalins.com/tx-medicaid

Provider Hotline (CHIP): 1-866-561-5891 www.deltadentalins.com/tchip

Page 276

Texas Children's Medicaid and CHIP Dental Services Provider Manual

Restorative Dentistry

Adjudication Reason Code 110 111 112 113 Description Procedure is the maximum allowance for all restorations placed in a single tooth for each episode of treatment. Payment is made for a surface once in each episode of treatment regardless of the number or combinations of restorations placed on a single tooth. Single surface restorations on the same tooth will be considered as connected for payment purposes. Tooth does not meet Manual of Criteria requirements for laboratory­processed crowns/onlays. The tooth may be restored with a more conservative restorative material (i.e., amalgam, composite, etc.). a. Per history, x-rays or photos, it has been determined that this tooth has been recently restored with a restoration or stainless steel crown. b. Per x-rays, documentation, or clinical evaluation, arch is developmentally immature; the adjacent and opposing teeth are not fully erupted. Please reevaluate for a more conservative restoration (i.e., SSC, amalgam, or composite). Tooth preparation, gingival tissue preparation, temporary restorations, cement bases, insulating bases, impressions, and local anesthesia are considered components of and are included in the fee for a completed restoration. Amalgam or plastic build-ups are included in the allowance for the completed restorations. Restorations and/or therapeutic pulpotomies are not a benefit for primary teeth near exfoliation. Payment/authorization cannot be made as caries not clinically verified by a regional screening consultant. Panographic-type radiographs alone are insufficient for authorization/payment of laboratory-processed crowns, periodontic procedures, endodontic procedures, operative procedures, or removable partial dentures. Diagnostic material (narrative or radiographic) does not substantiate immediate need for restoration(s) (e.g., penetration of dento-enamel junction). Radiograph does not depict the entire crown or tooth (teeth) to verify requested surfaces or procedure(s). Please resubmit with an x-ray depicting the entire tooth and root. Radiograph(s) indicate additional surfaces require treatment. a. Decay on mesial. b. Decay on distal Replacement restorations are not a benefit within 12 months on primary and permanent teeth, unless the need for the replacement restoration is beyond the control of the provider Procedure is a benefit once per tooth per lifetime. Restorations and/or pulpotomies in deciduous lower incisors are not payable when the child is over 5years of age. Procedure is not a benefit for a permanent tooth when a stainless steel or laboratory-processed crown is used to restore the tooth. Procedure is a benefit when necessary to retain a laboratory-processed crown in endodontically treated devitalized permanent teeth. Crowns are a benefit once in a full 5-year period except when special circumstances are documented. Payment for a crown/onlay is made only upon final cementation. Procedure is a benefit only in cases of extensive coronal destruction. Procedure not allowed due to denial of root canal filled with silver points.

114

115 117 119 120

121 123

124

125

125a 126 127 128 129 130 131 133

Provider Hotline (Medicaid): 1-877-576-5899 www.deltadentalins.com/tx-medicaid

Provider Hotline (CHIP): 1-866-561-5891 www.deltadentalins.com/tchip

Page 277

Texas Children's Medicaid and CHIP Dental Services Provider Manual

Prosthodontics

Adjudication Reason Code 163 166 168A 168B 176 Adjudication Reason Code 194 196 Description Patient returning to original provider for corrections and/or modifications of requested procedure(s). The procedure change reflects a benefit that can be authorized and may be provided at your discretion. Patient does not wish extractions or any other dental services at this time. Patient has selected different provider for treatment. Per x-rays, insufficient space present for procedure(s) requested.

Space Maintainers

Description Tongue thrusting and thumb sucking appliances are not benefits of this program. Orthodontic services, including tooth guidance appliances, are not a benefit of this program.

Miscellaneous

Adjudication Reason Code 258 Description Benefits for this procedure could not be determined because it was submitted with an unrecognized procedure code or with an inadequate/conflicting narrative description. Please resubmit with full information, including the procedure code in CDT format. The required tooth, surface, arch code or quadrant is not a benefit as coded. a. Please resubmit with the tooth code. b. Please resubmit with a surface code. c. Please resubmit with an arch code. d. Please resubmit with the quadrant code. Procedure is not a benefit of this program. Procedure is not included as an allowable service for the age of the member per your provider contract. Procedure requested is not a benefit for children. Procedure requested is not a benefit for adults. Procedure requested is not a benefit for primary teeth. Procedure requested is not a benefit for permanent teeth. Payment and/or prior authorization disallowed. a. X-rays are not current. Unable to evaluate treatment. b. Lack of x-rays. Please resubmit with dated, current x-rays. c. X-rays or photographs are non-diagnostic for procedure requested. Please resubmit with dated, current, diagnostic x-rays. d. Procedure requires current x-rays of the remaining teeth for evaluation of the arches. Please resubmit with at a minimum bitewing x-rays that demonstrate arch integrity. e. Lack of postoperative x-rays. Please resubmit with dated, post-operative x-rays. f. Procedure requires current periapical x-rays of all remaining teeth. Please resubmit with dated periapical x-rays of all remaining teeth. g. Unable to evaluate treatment. Duplicate x-rays or copies not labeled left or right. Please resubmit with x-rays clearly labeled and dated. h. X-rays submitted to establish arch integrity are non-diagnostic. Please resubmit with at a minimum bitewing x-rays that demonstrate arch integrity. i. Bitewing x-rays are not included. Please resubmit with bitewing x-rays.

260

261 261B 262 263 264 265 266

Provider Hotline (Medicaid): 1-877-576-5899 www.deltadentalins.com/tx-medicaid

Provider Hotline (CHIP): 1-866-561-5891 www.deltadentalins.com/tchip

Page 278

Texas Children's Medicaid and CHIP Dental Services Provider Manual

Prosthodontics

Adjudication Reason Code 267 Description Documentation insufficient/not submitted. Services disallowed. a. Please resubmit with a complete narrative for this procedure. b. Benefits for this procedure could not be determined because it was submitted with an inadequate/conflicting narrative description of service. Please resubmit with full information. c. Documentation is illegible. Per x-rays, clinical evaluation or photos, the need for procedure not evident. Procedure denied for one of the following reasons: a. Included in the global fee for another procedure. b. Not allowable in conjunction with another procedure. c. Adjunctive to a denied procedure. The service is modified to correct inconsistencies or errors in one or more of the following: the procedure code, tooth number, surface(s) or similar services listed more than once. Procedure requested is disallowed due to any of the following: a. Bone loss, mobility and periodontal pathology. b. Apical radiolucency and/or caries penetrate pulp chamber. c. Arch lacks integrity. d. Evidence or history of recurrent or rampant caries. e. Tooth/teeth is/are in state of poor repair or have poor longevity prognosis. f. Gross destruction of crown or root. g. Tooth has no occlusal function and/or is hyper-erupted. h. The replacement of tooth structure lost by attrition or abrasion is not a covered benefit. Tooth not present on x-ray. a. Per x-ray, tooth is unerupted. b. X-rays and/or documentation reveal that tooth number may be incorrect. The procedure has been modified/disallowed to reflect the maximum benefit under this program. The procedure has been modified/disallowed to reflect the maximum benefit under this program. Charges in excess of the covered dental benefit are the member's responsibility. Procedures, appliances, or restorations (other than those for replacement of structure loss from caries) that alter, restore, or maintain occlusion are not benefits. Procedure(s) beyond scope of program. If you wish, submit alternate treatment plan. Services solely for esthetic purposes are not benefits. By-report procedure documentation missing or insufficient for payment calculations. Degree of procedure/service determined from submitted by-report information. Radiographs reveal that additional procedures are necessary before authorization of the requested service(s) may be made. a. Restorative treatment incomplete. b. Crown treatment incomplete. c. Endodontic treatment incomplete. d. Additional tooth/teeth need extraction(s). e. Extraction of the third molar/adjacent tooth should be completed prior to crown placement. Procedure does not show evidence of a reasonable period of longevity. a. Submit alternate treatment plan, if you wish. Our records indicate this procedure has previously been rendered.

268 269

270

271

272

275 275A

276 279 281 282 283 284

285 286

Provider Hotline (Medicaid): 1-877-576-5899 www.deltadentalins.com/tx-medicaid

Provider Hotline (CHIP): 1-866-561-5891 www.deltadentalins.com/tchip

Page 279

Texas Children's Medicaid and CHIP Dental Services Provider Manual

Prosthodontics

Adjudication Reason Code 287 Description Allowance made for alternate procedure per documentation, clinical examination, xrays and/or photos. a. Due to patient's age, allowance made for permanent restoration(s) on an over­ retained primary tooth. Procedure cannot be considered an emergency. Procedure requires prior authorization. There is no member liability for covered services requiring prior authorization for which the billing provider failed to submit the necessary TAR. Emergency procedures may be completed without prior authorization if documentation supports the need. Procedures rendered by out-of-network providers require prior authorization. All services performed in a skilled nursing or intermediate care facility, except initial diagnostic and emergency services, require prior authorization. Per date of service, procedure was completed prior to date of authorization. Per clinical examination, documentation, or x-rays, the procedure requiring authorization was already completed. Per x-rays or clinical examination, procedure requested is inadequate to correct problem. Please submit alternate treatment plan. a. X-rays reveal open, underformed apices. Authorization for root canal therapy will be considered after radiographic evidence of apex closure following apexification. b. Re-evaluate for apicoectomy. Authorization disallowed as the patient did not appear for a scheduled clinical examination. Payment cannot be made for services provided after initial receipt date as patient failed scheduled screening appointment. Per clinical examination, patient exhibits lack of motivation to maintain oral hygiene necessary to justify requested services. A fee for completion of forms is not payable as a separate benefit; this service is included in the fee for covered services. Our records indicate that an extraction has been rendered/authorized for the same tooth. Procedure recently authorized to your office. a. Procedure recently authorized to a different provider. Procedure is not a benefit as coded. Use only one tooth number, one date of service, and one procedure number per line. Please resubmit with the needed data, such as tooth number, tooth surfaces, arch, or quadrant. Procedure not a benefit for the tooth/arch/quad indicated. Procedure requested allowed based on first level appeal or treatment re-evaluation. Payment for procedure disallowed per post-operative x-ray evaluation and/or clinical examination. a. Poor quality of treatment. b. Procedure not completed as billed. Procedure disallowed due to a member identification conflict. Please resubmit for payment with a copy of the member ID. Procedures being denied on this claim/TAR due to: a. Extraction procedure(s) previously paid/authorized for the same tooth/arch. Member information has been corrected

288 289

289A 290 291 292 293

294 295 296 298 299A 300 302

305 306A 307

308 309 310

Provider Hotline (Medicaid): 1-877-576-5899 www.deltadentalins.com/tx-medicaid

Provider Hotline (CHIP): 1-866-561-5891 www.deltadentalins.com/tchip

Page 280

Texas Children's Medicaid and CHIP Dental Services Provider Manual

Payment Policy

Adjudication Reason Code 315 Description Payment disallowed. Request received later than 95 days after the service was performed. A contracting provider may not demand reimbursement from a Texas Medicaid and CHIP Dental Services member for any covered dental service. Payment disallowed. Request received over 95 days after the service was performed. A contracting provider may not demand reimbursement from a Texas Medicaid and CHIP Dental Services member for any covered dental service. Request for extension is not granted. Resubmit undated service(s) on a new TAR form. Member eligibility not established for dates of services. Treating or billing provider number not on file. All treating and billing providers must be credentialed and enrolled as Delta Dental State Government Programs providers. Treating/billing provider or service office not enrolled for date of services. All treating and billing providers must be credentialed and enrolled in Delta Dental State Government Programs. Member not eligible for dental benefits under this program. Any questions, contact Delta Dental SGP Member Services. Out-of-state services require authorization or an emergency certification statement; payment cannot be made for non-emergency treatment. Authorization period for this procedure as indicated on the top portion of the NOA form has expired. Payment cannot be made as prior authorization made to another dentist. Authorization for services is not transferable. Treating provider not associated to this service office. All treating providers must be credentialed and enrolled as Delta Dental State Government Programs providers. Request for partial payment is not granted. Delete undated services and submit them on a new TAR form. Extension of time is granted once after the original TAR authorization without justification of need for extension. Authorized services are not a benefit if patient becomes ineligible during authorized period. Payment cannot be made for procedures with dates of service after the date document was received by Delta Dental. If the submitted date of service is incorrect, please resubmit with the correct date of service. a. Payment disallowed. Date of service is after receipt date of first NOA page(s). Out-of-country services require an emergency certification statement. Billing provider name does not match our files; payment/authorization cannot be made. All billing providers must be credentialed and enrolled in Delta Dental State Government Programs. Please resubmit with corrected/accurate provider information. Member not eligible for dental benefits. The procedure is not a benefit for the age of the member. This procedure is a duplicate of a previously paid claim. If you are requesting readjudication for a dated, allowed procedure, submit a CIF. The denial of this procedure does not extend the time limit to request re-adjudication; you have up to 95 days from the date of the EOB on the original claim. This procedure is a duplicate of a previously denied procedure. If you are requesting re-adjudication for a dated, denied procedure, submit a CIF. This denied, duplicate procedure does not extend the time limit to request re-adjudication; you have up to 120 days from the date of the EOB denial of the original claim. (If you are requesting re-evaluation of an undated, denied procedure, submit the NOA.) Treating provider required for procedure; none submitted. Please resubmit with treating provider information. Provider Hotline (CHIP): 1-866-561-5891 www.deltadentalins.com/tchip

316

317 318 319 320

321 322 323 324 325 328 329 331 333

334 335

336 337 340

341

342

Provider Hotline (Medicaid): 1-877-576-5899 www.deltadentalins.com/tx-medicaid

Page 281

Texas Children's Medicaid and CHIP Dental Services Provider Manual

Payment Policy

Adjudication Reason Code 343 Description Billing provider is required to submit a TAR for these services unless they were performed as a necessary part of an emergency situation. If the services were necessary due to an emergency condition, please resubmit with complete narrative documentation. Treating provider is required to submit a TAR for these services unless they were performed as a necessary part of an emergency situation. If the services were necessary due to an emergency condition, please resubmit with complete narrative documentation. Payment cannot be made for procedures with invalid dates of service. Please resubmit with a complete date of service. a. Procedure requires a date of service; please resubmit with date of service. Billing provider is not a group and cannot submit claims for other treating providers. Authorization previously denied. Payment cannot be made. The billed procedure cannot be paid because there is an apparent discrepancy between it and a service already performed on the same day by the same DDS. The billed procedure cannot be paid because there is an apparent discrepancy between it and a service previously processed/performed by the same dentist on the same day in the same arch. Billed procedure is not payable. Our records indicate the date of service is prior to the date on which a related procedure was provided for this patient. Billed procedure is not payable. Our records indicate the date of service is prior to the date on which a related procedure was provided by your office for this patient. The billed service is disallowed because of an apparent discrepancy with a related procedure billed by your office for the same tooth on the same day. The billed service on this tooth is disallowed because of an apparent discrepancy with a related procedure already provided. The line item is a duplicate of a previous line item on the same claim. Procedure deleted/disallowed per provider request. Payment for procedure has been recovered per post-payment claims review. Payment for procedure disallowed per clinical post-payment review. Sign Notice of Authorization for payment of dated lines. CSL has not been paid; NOA never returned for payment. Our records indicate Delta Dental is secondary. Benefits for this claim could not be determined because of missing primary coverage information. Please resubmit along with an EOB or denial from the primary carrier. Re-evaluation denied. Insufficient documentation and/or x-rays not submitted. Please sign for payment of dated services and submit a new TAR. Fee adjustment, since other coverage exists for this claim. Fee adjustment, since third-party liability exists for this claim. Fee adjustment, since procedure co-payment(s) exists for this claim. Fee adjustment, since services were not provided as billed. Fee adjustment due to findings of professional peer review. This procedure does not require a referral. Member may contact any network provider. Authorization of this line no longer valid. a. Patient is/was being treated elsewhere. b. Treatment was performed as an emergency. c. A new claim or TAR is being processed. Member has exceeded maximum dollar limit.

344

345

346 347 348 349

350 351 352 353 354 357 358 359 360 361 362

375 380 381 382 383 384 396 555

999

Provider Hotline (Medicaid): 1-877-576-5899 www.deltadentalins.com/tx-medicaid

Provider Hotline (CHIP): 1-866-561-5891 www.deltadentalins.com/tchip

Page 282

Texas Children's Medicaid and CHIP Dental Services Provider Manual

Regional Screening

Adjudication Reason Code 601 607 Description Per clinical examination, existing health condition prohibits requested procedure(s). Per clinical examination, payment for procedure disallowed. a. Poor quality of treatment. b. Procedure not completed as billed. Per clinical examination, tooth does not meet Manual of Criteria requirements for laboratory-processed crowns. The tooth may be restored with a more conservative restorative material (i.e. amalgam, composite, etc.). a. Per clinical examination it has been determined that this tooth has been recently restored with a restoration or stainless steel crown. b. Per clinical evaluation, arch is developmentally immature; the adjacent and opposing teeth are not fully erupted. Please reevaluate for a more conservative restoration ( i.e., SSC, amalgam, or composite). Payment/authorization cannot be made as caries not clinically verified by a regional screening consultant. Per x-rays and/or clinical examination, additional surface (s) requires treatment. a. Decay on mesial. b. Decay on distal. c. Decay on facial/buccal. d. Decay on lingual. Per clinical examination, resubmit a new authorization request following completion of surgical procedure(s) that may affect prognosis of treatment plan as submitted. Per clinical examination, bruxism is identified and is not a benefit of this program. Per clinical examination, extraction of asymptomatic teeth is not a benefit. Per clinical examination, surgical extraction procedure(s) or degree of impaction(s) have been modified. Based on clinical examination, this tooth does not appear to be a completely bony impaction. Allowance made for partially bony impaction. Based on clinical examination, this tooth does not appear to be a completely bony impaction. Allowance made for soft tissue impaction. Based on clinical examination, allowance made for a surgical extraction. Based on clinical examination, allowance made for procedure D7140; extraction, erupted tooth, or exposed root. Per clinical examination, the need for procedure not evident. Per clinical examination, patient does not wish extractions or any other dental services at this time. Per clinical examination, patient has selected/wishes to select a different provider. Per clinical examination, procedure denied for one of the following reasons: a. Included in the global fee for another procedure billed. b. Not allowable in conjunction with another procedure. c. Adjunctive to a denied procedure. Per x-rays and/or clinical examination, procedure requested is disallowed due to the following: a. Bone loss, mobility, periodontal pathology. b. Apical radiolucency and/or caries penetrate pulp chamber. c. Arch lacks integrity. d. Evidence or history of recurrent or rampant caries. e. Tooth/teeth is/are in state of poor repair or have poor longevity prognosis. f. Gross destruction of crown or root. g. Tooth has no occlusal function and/or is hyper-erupted. h. The replacement of tooth structure lost by attrition or abrasion is not a covered benefit. Per clinical examination, tooth/teeth not present. Provider Hotline (CHIP): 1-866-561-5891 www.deltadentalins.com/tchip

613

619 624

643 647 648 650

668 668A 668B 669

671

672

Provider Hotline (Medicaid): 1-877-576-5899 www.deltadentalins.com/tx-medicaid

Page 283

Texas Children's Medicaid and CHIP Dental Services Provider Manual

Payment Policy

Adjudication Reason Code 672B 672C 674 Description Per x-rays and/or clinical examination, tooth number may be incorrect. Per x-rays and/or clinical examination, tooth number may be incorrect. Tooth number changed by consultant as suggested by x-rays/exam. Please resubmit if incorrect. Per clinical examination, incomplete treatment plan submitted. a. Inadequate opposing dentition present to provide benefits for prosthetic appliance. Per clinical examination, insufficient space present for procedure(s) requested. Per clinical examination, services solely for esthetic purposes are not benefits. Per clinical examination, additional procedures are necessary before authorization of the requested service(s) may be made. a. Restorative treatment incomplete. b. Crown treatment incomplete. c. Endodontic treatment incomplete. d. Additional tooth/teeth need extraction(s). e. Extraction of the third molar/adjacent tooth should be completed prior to crown placement. Per clinical examination, procedure does not show evidence of a reasonable period of longevity. a. Submit alternative treatment plan, if you wish. Per clinical examination, allowance made for alternate procedure. Per clinical examination, documentation, or x-rays, procedure already been completed. Per clinical examination, procedure requested is inadequate to correct problem. a. Tooth has open, underformed apices. Authorization for root canal will be considered after radiographic evidence of apex closure following apexification. b. Re-evaluate for apicoectomy. Authorization disallowed as the patient did not appear for a scheduled clinical examination. Per clinical examination, patient exhibits lack of motivation to maintain oral hygiene necessary to justify requested services. Need for root canal procedure not evident per x-ray appearance, clinical evaluation or documentation submitted. Member has exceeded their annual maximum benefits.

676 680 684

685

687 692 693

694 696 697 999

The following codes indicate why a claim or TAR is in process in the automated processing system. EOB "Claims in Process"

Reason Codes Data Validation (DV) Recipient Verification (RV) Provider Verification (PV) Professional Review (PR) Regional Screening (RS) Description Document is awaiting review of keyed data against document information. Document is awaiting validation of Member information. Document is awaiting validation of Provider information. Document is scheduled for professional review. Document is scheduled for a Regional Screening review.

Provider Hotline (Medicaid): 1-877-576-5899 www.deltadentalins.com/tx-medicaid

Provider Hotline (CHIP): 1-866-561-5891 www.deltadentalins.com/tchip

Page 284

Texas Children's Medicaid and CHIP Dental Services Provider Manual

These codes identify the reason for receivables or payables shown on an EOB. Payable Code Description

1 3 4 5 9 1 2 3 5 Replacement Check. Interim Payment. Quality Review Adjustment. Overpayment of a Cash Receipt. Prior Underpayment.

Receivable Code Description

Quality Review Adjustment. Negative Claim Adjustment. Interim Payments. Overpayment Adjustment.

The following codes represent reasons why a claim is being processed for readjudication. Claim Correction Codes

Correction Code 01 02 20 22 23 25 27 29 30 39 50 60 61 62 63 64 65 66 70 71 72 73 76 95 96 Description Paid wrong provider number. Treating provider license number missing. Corrected tooth number or arch code. Quantity of service provided or corrected. Corrected procedure code/fee. Corrected date of service. Other coverage amount provided or corrected. Corrected place of service. New or additional documentation submitted. Denial upheld. See related adjudication/policy code. Fair hearing decision. Readjudication based upon peer review decision. Per post-payment screening, services below standard. Per post-payment screening or quality review, service(s) not performed. Readjudication based upon professional re-evaluation. Readjudication of original underpayment based on Delta Dental quality review. Readjudication of original overpayment based on Delta Dental quality review. Original payment incorrect due to processing error--Erroneous Payment Correction (EPC) system. KDE input error. Provider claim preparation error. Claim not received within 95 days from last date of service. Overpayment. CIF not submitted for reconsideration within 95 days of the EOB date. Original payment of claim adjusted per quality review. Readjudication of original payment based on Delta Dental review.

Provider Hotline (Medicaid): 1-877-576-5899 www.deltadentalins.com/tx-medicaid

Provider Hotline (CHIP): 1-866-561-5891 www.deltadentalins.com/tchip

Page 285

Texas Children's Medicaid and CHIP Dental Services Provider Manual

These codes represent reasons why an entire document is being denied. The use of these codes causes all lines of the document to be denied. Claim/TAR Policy Codes and Messages

Policy Code 01 02 03 04 05 06 07 10 Message Duplicate claims/TARs from same/different providers cannot be processed. Payment disallowed. Exceeds 95-day billing limit. Providers must submit claims within ninety-five days after the services were performed. NOA cannot be paid. Date of service is outside of authorization period. Cannot process total claim; Member eligibility not established. Payment disallowed. Exceeds 95-day billing limit. Cannot adjust claim received 95 days or more after adjudication date. Primary carrier paid more than this program allows. TAR/claim cannot be processed; no services were entered. Please resubmit with the necessary data, such as procedure code in CDT format, tooth number, tooth surfaces, arch, or quadrant. TAR/claim/NOA cannot be processed without valid provider signature. Procedure codes are unknown or not a benefit of this program. Please resubmit with codes in CDT format. Authorized services cannot be transferred between providers; claim denied. Procedure service data not submitted. Please resubmit with the necessary data, such as procedure code, tooth number, tooth surfaces, arch, or quadrant. All required member data not submitted; cannot process TAR/claim. Please resubmit along with a copy of the member ID. Authorized services cannot be transferred between members; claim denied. Time extension denied; payment denied. Billing provider ID not on file; all billing and treating providers must be enrolled in this program. Out-of-state/country service covered only for emergencies. Member eligibility not established for the dates of service. Patient information on TAR/claim does not match eligibility file. Please resubmit with a copy of the member's Delta Dental SGP plan ID card and, if the member is a minor, a copy of the parent/guardian ID. Provider requested document be deleted. Document deleted; payment has been processed to a duplicate claim for these services have been submitted by your office. Provider name does not match Delta Dental file; no payment/authorization. All billing providers must be credentialed and enrolled in Delta Dental State Government Programs. Please resubmit with corrected/accurate provider information. Member not on eligibility file; payment denied. Please resubmit with a copy of the member's Delta Dental SGP plan ID card and, if the member is a minor, a copy of the parent/guardian ID. Billing provider and member not on file. Claim or TAR denied. Member eligibility cannot be confirmed. Check member ID for program name. Please resubmit with a copy of the member's Delta Dental SGP plan ID card and, if the member is a minor, a copy of the parent/guardian ID. Billing provider or service office not enrolled for dates of service. TAR/claim denied. X-rays appear to be of another person. Payment disallowed. Please resubmit along with a copy of the member's Delta Dental SGP plan ID card. Ensure all x-rays and documentation are for this member. Authorization disallowed, patient did not appear for a clinical screening. Authorization/payment disallowed. Procedure(s) are non-benefits for HMPP #155. Emergency services documentation is insufficient/not submitted. Please resubmit Provider Hotline (CHIP): 1-866-561-5891 www.deltadentalins.com/tchip

11 12 15 17 18 19 20 22 24 25 26

27 27a. 28

29

30 31

32 34

36 38 41

Provider Hotline (Medicaid): 1-877-576-5899 www.deltadentalins.com/tx-medicaid

Page 286

Texas Children's Medicaid and CHIP Dental Services Provider Manual

Claim/TAR Policy Codes and Messages

Policy Code Message along with a complete narrative describing the nature of the emergency and the treatment provided. Payment for claim disallowed per utilization review. Our records indicate Delta Dental is secondary. Benefits for this claim could not be determined because of missing primary coverage information. Please resubmit along with an EOB or denial from the primary carrier. Procedures do not require a referral. Member may contact any network provider.

43 44

52

The CIR form is a computer-generated form used to respond to a provider's CIF. In addition to provider and patient information, the response will appear as a status code and explanation to the CIF. Claim Inquiry Response (CIR) Status Codes and Messages

Status Code 01 02 04 05 08 09 11 12 13 14 15 18 19 20 21 22 23 24 26 27 28 30 31 32 33 34 35 38 93 94 95 99 Message Claim never received; please submit new claim. Claim in process; awaiting final adjudication. Claim under professional review. Claim processed EOB ______ DT ______ $______ Insufficient documentation; procedure disallowed. Requires prior authorization. Claim not received within 95 days from the date the service was performed. Claim has been readjudicated for payment. Submit original NOA for re-evaluation. TAR never received; please submit new TAR. TAR in process; awaiting adjudication. NOA has been processed. NOA expired; please submit a new TAR. Procedure not a benefit of program. Procedure previously paid to the same or other office. Procedure is adjunctive to another procedure. NOA has been readjudicated. Procedures not performed within 120-day time limitation. Lack of beneficiary eligibility; claim disallowed. Other coverage payment exceeds schedule of maximum allowances (SMA). Denial upheld. Procedure(s) not allowed based on professional review. Incomplete treatment plan submitted; denial upheld. Exceeded 95-day limitation; denial upheld. Per documentation; claim in process. Per our records, x-rays returned at time of processing. Signature missing; adjustment/correction cannot be made. Please complete CIF for each claim inquiry. Original claim overpayment adjusted due to quality review. Original claim underpayment adjusted due to quality review. Original payment incorrectly adjusted by Erroneous Payment Correction (EPC) system. Insufficient information to process.

Provider Hotline (Medicaid): 1-877-576-5899 www.deltadentalins.com/tx-medicaid

Provider Hotline (CHIP): 1-866-561-5891 www.deltadentalins.com/tchip

Page 287

Texas Children's Medicaid and CHIP Dental Services Provider Manual

Other Coverage and Codes In cases where a member has dual coverage for dental benefits, Delta Dental is considered the secondary carrier and can only pay up to the maximum amount allowed for covered benefits. Delta Dental will make payment only if the primary carrier pays less than the maximum Delta Dental allowance. The fact that a patient has other coverage does not change the prior authorization requirements. The dental office should submit for prior authorization indicating the name of the primary carrier. Delta Dental will process the prior authorization, and an NOA will indicate the amount Delta Dental would pay as if there were no other coverage. When completing the TAR, be sure to include the following: Item 13. Other Dental Coverage? Check "YES," indicating patient has other dental insurance coverage. Item 33. Comments: Provide full name and address of other coverage carrier and name, member identification number, and group number of the policyholder. Item 10. Attachments: Include a copy of other coverage carrier's EOB, RA, or proof of denial. The dental office must submit an EOB/RA or proof of denial letter from the other carrier along with the treatment form if the patient has other dental coverage. Item 36. Other Coverage Amount: Fill in amount to be paid by other coverage carrier.

Provider Hotline (Medicaid): 1-877-576-5899 www.deltadentalins.com/tx-medicaid

Provider Hotline (CHIP): 1-866-561-5891 www.deltadentalins.com/tchip

Page 288

Texas Children's Medicaid and CHIP Dental Services Provider Manual

Attachment M: Cost-Sharing Schedule (CHIP Members)

Enrollment Fee (for 12-month enrollment period) At or below 150% of FPL* Above 150% up to and including 185% of FPL Above 185% up to and including 200% of FPL Co-Pays (per visit): At or below 100% of FPL Office Visit Non-Emergency ER Generic Drug Brand Drug Facility Co-Pay, Inpatient (per admission) Cost-Sharing Cap Co-Pays (per visit): Above 100% up to and including 150% of FPL Office Visit Non-Emergency ER Generic Drug Brand Drug Facility Co-Pay, Inpatient (per admission) Cost-Sharing Cap Co-Pays (per visit): Above 150% up to and including 185% of FPL Office Visit Non-Emergency ER Generic Drug Brand Drug Facility Co-Pay, Inpatient (per admission) Cost-Sharing Cap Co-Pays (per visit): Above 185% up to and including 200% of FPL Office Visit Non-Emergency ER Generic Drug Brand Drug Facility Co-Pay, Inpatient (per admission) Cost-Sharing Cap

*

Charge $0 $35 $50 Charge $3 $3 $0 $5 $35 5% (of family's income)** Charge $5 $5 $0 $5 $35 5% (of family's income)** Charge $20 $75 $10 $35 $75 5% (of family's income)** Charge $25 $75 $10 $35 $125 5% (of family's income)**

The Federal poverty level (FPL) refers to income guidelines established annually by the federal government. ** Per 12-month term of coverage. Provider Hotline (Medicaid): 1-877-576-5899 www.deltadentalins.com/tx-medicaid Provider Hotline (CHIP): 1-866-561-5891 www.deltadentalins.com/tchip

Page 289

Texas Children's Medicaid and CHIP Dental Services Provider Manual

Attachment N: Glossary

Attached is a list of terms and definitions used in the Texas Children's Medicaid and CHIP Dental Services provider manual. Term Adjudication: Definition A term that refers to the final resolution of a claim or TAR in the Delta Dental claims processing system. Adjudication Reason Code: Amount Billed: Applicant: A code specific to a claim service line reflecting the reason for modification or denial. The amount the provider has billed for each claim line. A person over the age of 18 years who is a natural or adoptive parent, legal guardian or caretaker, relative, foster parent or stepparent with whom the child resides, who applies for coverage under the program on behalf of a child. Arch Integrity: There is arch integrity when there are sufficient proximate natural teeth in a restorable condition that would afford the opposing arch adequate or satisfactory occlusion for masticatory function. Attachment: X-rays or other documentation submitted with a claim, TAR or NOA. Benefit: Dental care services covered by the Texas Medicaid and CHIP Dental Services program. Billing Intermediary: Any entity, such as a partnership, corporation, sole proprietorship or individual (not a member of the dentist's office staff) that is contracted with a dentist to bill Delta Dental on the dentist's behalf. Billing Provider: The dentist who bills or requests authorization for services on the treatment form. Charting: Identifying the missing permanent tooth or teeth on the tooth

Provider Hotline (Medicaid): 1-877-576-5899 www.deltadentalins.com/tx-medicaid

Provider Hotline (CHIP): 1-866-561-5891 www.deltadentalins.com/tchip

Page 290

Texas Children's Medicaid and CHIP Dental Services Provider Manual

Term

Definition chart on the claim or TAR. The form submitted by the provider that requests payment for services performed.

Claim Form:

Claim Inquiry Form (CIF):

A form used by a provider to inquire about the status of a claim or TAR or to request re-evaluation of a modified or denied claim.

Claim Inquiry Response (CIR): Claims In Process:

A computer­generated form used by Delta Dental to respond to a provider inquiry about the status of a claim or TAR. Documents remaining in the Delta Dental automated claims processing system beyond 18 calendar days and awaiting final adjudication. A list of in-process documents for your office can be found on the last page of your Delta Dental Explanation of Benefits (EOB) form.

Clean Claim:

A claim submitted by a dental provider for services rendered to a Texas Medicaid and CHIP Dental Services member, with documentation reasonably necessary for Delta Dental to process the claims.

Correspondence Reference Number (CRN): Date of Service: Delta Dental's Schedule of Allowances: Disallowed:

An 11-digit number assigned to each incoming CIF or correspondence that identifies it throughout the processing system. The date when a dental service is completed. A listing of procedure codes with descriptions and maximum amounts allowed for reimbursement of services. A claim may be disallowed for a variety of reasons, including but not limited to ineligibility of the provider or recipient, submission of non-Delta Dental covered services, or submission of non-prior authorized services.

Document Control

A unique 11-digit number assigned to each claim or TAR and

Provider Hotline (CHIP): 1-866-561-5891 www.deltadentalins.com/tchip

Provider Hotline (Medicaid): 1-877-576-5899 www.deltadentalins.com/tx-medicaid

Page 291

Texas Children's Medicaid and CHIP Dental Services Provider Manual

Term Number (DCN):

Definition used to identify the document throughout the processing system.

Dual Coverage: Emergency Services:

See Other Coverage. Emergency services are those health care services required for alleviation of severe pain or immediate diagnosis and treatment of unforeseen medical conditions that, if not immediately diagnosed and treated, would lead to disability or death.

Enrollment and Credentialing:

The application process for a dentist who wishes to become a provider of services under the Texas Medicaid and CHIP Dental Services program.

Explanation of Benefits (EOB):

A statement accompanying each payment to providers that itemizes the payments and explains the adjudication status of the claims.

Julian Date:

Claims received by Delta Dental are dated using the Julian calendar, in which a number is assigned to a day rather than using the month/day/year format. Julian calendar dates are 001 to 365 (366 for a leap year).

Manual of Criteria:

The document that defines criteria for the utilization of dental services under the Texas Medicaid and CHIP Dental Services programs. It provides parameters to dentists treating Texas Medicaid and CHIP Dental Services members. It sets forth program benefits and clearly defines limitations, exclusions and special documentation requirements.

Medicaid:

A state-option medical assistance program that includes federal matching funds to states to implement a single comprehensive medical care program.

Member:

A person certified to receive Texas Medicaid and CHIP Dental Services benefits.

Provider Hotline (Medicaid): 1-877-576-5899 www.deltadentalins.com/tx-medicaid

Provider Hotline (CHIP): 1-866-561-5891 www.deltadentalins.com/tchip

Page 292

Texas Children's Medicaid and CHIP Dental Services Provider Manual

Term Member Identification Card:

Definition A permanent paper identification card issued to a person certified to receive Texas Medicaid and CHIP Dental Services benefits. The card identifies the person by name and includes an identification number and signature.

Narrative Documentation:

A written statement that describes an event, condition, or symptom. For example, acceptable documentation to substantiate the need for a restorative procedure would include a tooth letter or number, tooth surface location of decay or lesion, or degree or extent of decay (caries) [e.g., "penetration to or through the dento-enamel junction (DEJ)"]. To facilitate the complete documentation requirement, the following is suggested: Place documentation on a line of service basis. Use ditto marks, brackets, or asterisks in the "description of service" space for all additional restorative service lines following the service line that contains documentation. As an alternative, write "all decay (lesions, cavities) penetrates to or through the DEJ" under "COMMENTS" (space 33). If you do this, you need not place the statement or use ditto marks on each restorative service line.

Notice of Authorization (NOA): Other Coverage:

A computer-generated form sent to providers in response to their request for authorization of services. When a member's dental services are also fully or partially covered under other state or federal dental care programs or under other contractual or legal entitlements (e.g., a private group or individual indemnification program).

Participating Dental Plan:

Any of the following plans that are lawfully engaged in providing, arranging, paying for, or reimbursing the cost of personal dental services under insurance policies or contracts

Provider Hotline (Medicaid): 1-877-576-5899 www.deltadentalins.com/tx-medicaid

Provider Hotline (CHIP): 1-866-561-5891 www.deltadentalins.com/tchip

Page 293

Texas Children's Medicaid and CHIP Dental Services Provider Manual

Term

Definition or membership contracts, in consideration of premiums or other periodic charges payable to it and that contract with the board to provide coverage to program subscribers.

Participating Plan:

A participating health, participating dental, or participating vision care plan.

Period of Longevity:

The period of longevity in dentistry is considered to be the length or duration of acceptable service. Except when special circumstances are documented, the period of longevity for Delta Dental's purposes is generally considered to be: 12 months for restorations in primary teeth. 12 months for restorations in permanent teeth. 5 years for laboratory-processed crowns.

Prior Authorization:

A request by a provider for Delta Dental to authorize services before they are performed. Providers receive a notice of authorization (NOA) from Delta Dental, which they use to bill for services after they are performed.

Procedure Code:

A code number that identifies specific medical or dental services with allowed amounts listed on the Schedule of Allowances.

Program: Provider:

Texas Medicaid and CHIP Dental Services. An individual dentist, dental group, dental school, or dental clinic enrolled in the Texas Medicaid and CHIP Dental Services program to provide health care and/or dental services to Texas Medicaid and CHIP Dental Services-eligible members.

Provider Hotline (Medicaid): 1-877-576-5899 www.deltadentalins.com/tx-medicaid

Provider Hotline (CHIP): 1-866-561-5891 www.deltadentalins.com/tchip

Page 294

Texas Children's Medicaid and CHIP Dental Services Provider Manual

Term Provider Manual:

Definition A reference guide prepared by Delta Dental ­ State Government Programs and distributed to all providers enrolled in the Texas Medicaid and CHIP Dental Services program. It contains the criteria for dental services, program benefits, policies, and instructions for completing forms used in the Texas Medicaid and CHIP Dental Services program.

Regional Consultant:

A licensed dentist who reviews claims and treatment authorization requests (TARs) at the request of Delta Dental and provides clinical evaluations as to their merits.

Regional Screening Reports: Remote Dentures, Complete:

Reports submitted by regional consultants who participate in the Delta Dental regional screening network. A dental prosthesis constructed to replace the complete loss of the natural dentition and associated structures of the maxilla and/or mandible, other than when the prosthesis is inserted immediately following the removal of the remaining natural teeth.

Standard of Care:

You and your staff should render dental services to members in an economic and efficient manner consistent with professional standards of dental care generally accepted in the dental community. The least costly professionally accepted ethical treatment should initially define the course of treatment to be presented to the member/patient. You must not discriminate in the treatment of members. You must make services available to members in the same manner as for nonmembers. For more information, please call our Provider Hotline or attend a provider training seminar.

Surface: Third-Party Liability:

Refers to portions of teeth to be restored. When Texas Medicaid and CHIP Dental Services are also the

Provider Hotline (Medicaid): 1-877-576-5899 www.deltadentalins.com/tx-medicaid

Provider Hotline (CHIP): 1-866-561-5891 www.deltadentalins.com/tchip

Page 295

Texas Children's Medicaid and CHIP Dental Services Provider Manual

Term

Definition object of an action involving tort liability of a third party, worker's compensation award, or casualty insurance claim payment.

Tooth Code: Treating Provider:

A code that identifies each tooth by a number or letter. The dentist whose services are billed under the billing provider's name and license number. The treating provider is also referred to as the "rendering provider." The treating provider can be the same as or different from the billing provider.

Treatment Authorization Request (TAR): Treatment Plan:

The blue form used by a provider when requesting authorization to perform a service. TARs are required for certain services and under special circumstances. A statement of the services to be performed for the patient. Dental history, clinical examination, and diagnosis are used as the basis to arrive at a logical plan to eliminate or alleviate the patient's dental symptoms, problems, and diseases and prevent further degenerative changes.

Treatment Series:

A treatment series means all care, treatment, or procedures provided to a member by an individual practitioner on one occasion (one date of service).

Provider Hotline (Medicaid): 1-877-576-5899 www.deltadentalins.com/tx-medicaid

Provider Hotline (CHIP): 1-866-561-5891 www.deltadentalins.com/tchip

Page 296

Information

Microsoft Word - Texas Medicaid CHIP Provider Manual 02082012.docx

306 pages

Find more like this

Report File (DMCA)

Our content is added by our users. We aim to remove reported files within 1 working day. Please use this link to notify us:

Report this file as copyright or inappropriate

159795


You might also be interested in

BETA
Medicaid & CHIP
Provider News Apr 2004
TEXAS MEDICAID