On August 2, 2010, the South Carolina Department of Health and Human Services(SCDHHS) transitioned the administration of the Medicaid Dental Services program to DentaQuest, an Administrative Services Organization. DentaQuest will process all claims, give prior authorization for covered services requiring it and provide necessary oversight of all claims for cost containment and overutilization. DentaQuest will respond to all questions regarding claims processing, prior authorizations, eligibility, insurance coverage or information regarding the DentaQuest web portal. Providers should contact the DentaQuest provider telephone call center at: 1-888-307-6553 or by email to www.dentaquest.com.Dental services are covered for Medicaid beneficiaries from birth through the month of their 21st birthday, as well as for adults enrolled in the Mentally Retarded/Related Disabilities (MR/RD) Waiver program. Dental services are defined as any covered diagnostic, preventive, therapeutic, rehabilitative or corrective procedure that is medically necessary. Services include cleanings, x-rays, in office fluoride treatments (every 6 months), sealants, restorations (fillings), extractions, replacement of missing teeth (dentures and partials for beneficiaries 14-21) and some oral surgery procedures.

Special Circumstances for Adult Beneficiaries over age 21

On February 1, 2011, beneficiaries over age 21 were no longer eligible for general dental services including emergency services. Only under the following circumstances related to the treatment of medical conditions that as a part of the course of treatment require dental extractions to eliminate oral infection that can have a negative impact on the outcome of the treatment. A list of medical conditions that qualify as special circumstances, can be located in the Office Reference Manual(ORM) located on the DentaQuest web portal.

What's Covered

Dental services are defined as any covered diagnostic, preventive, therapeutic, rehabilitative or corrective procedure. For a comprehensive listing of covered procedures and specific guidelines, refer to the Office Reference Manual(ORM) located on the DentaQuest web portal.. Eligibility Medicaid beneficiaries from birth through the month of their 21st birthday and Mentally Retarded/Related Disabilities (MR/RD) Waiver beneficiaries are eligible for covered dental services.

Beneficiaries with pay category 55 (Family Planning Waiver) or 92 (Silver Card) are not eligible for dental services.

Waivers

Beneficiaries over the age of 21 years old who are enrolled in the MR/RD (Mentally Retarded/ Related Disabilities) Waiver program may receive the same covered dental services as those beneficiaries less than 21 years of age. To apply for this waiver, the beneficiary must contact the Department of Disabilities and Special Needs office in the county in which they reside. Go to the DDSN county office listings to find the appropriate county.

Broken/Cancelled/Missed Appointments

The Centers for Medicare and Medicaid Services (CMS) prohibit billing Medicaid beneficiaries for broken, missed or cancelled appointments. Providers cannot bill for scheduling appointments or holding appointment blocks. Medicaid programs are State designed and administered with Federal policy established by CMS. Federal requirements mandate that providers who participate in the Medicaid program must accept the payment of the agency as payment in full. According to the CMS Program Issuance transmittal Notice MCD-43-94, broken or missed appointments are considered part of the overall cost of doing business.

Orthodontics

Orthodontic Services are not a covered service by Medicaid. However, the Children's Rehabilitative Service (CRS), through DHEC, offers orthodontic services for Medicaid beneficiaries that have severe craniofacial anomalies such as cleft lip and cleft palate and syndrome's that affect dental and skeletal functional development. Referral to the program must come from a physician, dentist or other dental specialist. All orthodontic referrals must be made to the local county health department to the attention of the Children's Rehabilitative Service's (CRS) coordinator. For more information regarding the CRS program, call the dental program area at (803) 898-2568.

Links

• Report Fraud and Abuse:
  Email: fraudres@scdhhs.gov
  Hotline Phone Number (1-888-364-3224).


• Department of Disabilities and Special Needs (MR/RD Waiver):
  Website: www.state.sc.us/ddsn.
  Telephone, fax and e-mail addresses in Appendix of manual.


• Family Connections of SC:
  Phone Number: (803) 252-0914
  Website: www.familyconnectionsc.org.


• HIPAA Call Center for web-tool users:
  Website: www.scmedicaidprovider.org or call 1-888-289-0709


• Eligibility information for beneficiaries:
  1-888-549-0820


• DHEC (Children's Rehabilitative Service):
  Click on A to Z Subject Listing, Children's Services.


• South Carolina Dental Association:
  Phone number: (803) 750-2277 Website: www.scda.org. The website has a list of public assistance dental clinics.


• South Carolina State Board of Dentistry:
  Phone Number: (803) 896-4599
• The SC Department of Labor, and Licensing and Regulation website: www.llr.state.sc.us.