Dental Services Provider Manual Updates for Jan. 1, 2023
The South Carolina Department of Health and Human Services (SCDHHS) is issuing the policy updates and clarifications listed below for South Carolina Healthy Connections Medicaid dental providers effective for dates of service on or after Jan. 1, 2023.
Code Updates
The 2023 Current Dental Terminology (CDT) procedure codes listed below will be added under the South Carolina Medicaid State Plan. The services are applicable to all Healthy Connections Medicaid members eligible for dental benefits.
- Preventive Dental Benefit: codes D0372, D0373 and D0374 – tomosynthesis radiographic images; and,
- Emergency and Exceptional Conditions Benefit: code D7509 – marsupialization of odontogenic cyst
Restorative Services Benefit Limitations
Reimbursement for a restoration of a previously restored tooth will be adjusted based on surface combination as follows:
- For tooth surface F, I, L or B, adjustment will be based on a 36-month time period.
- For tooth surface M, O or D, adjustment will remain at 12-month time period.
This policy only applies to restorative services for Healthy Connections Medicaid members under 21 years of age and Intellectual Disability and Related Disabilities (ID/RD) waiver participants. This change will be made in the Restorative Services section in Appendix B of the Dental Services provider manual by Jan. 1, 2023.
Oral Surgery Benefit Limitations and Criteria
Prepayment review (PPR) for third molars soft tissue impaction (D7220) or partially bony impaction (D7230) will no longer be required. This policy applies only to Healthy Connections Medicaid
beneficiaries under 21 years of age and ID/RD waiver participants. Reimbursement for extraction of primary teeth (except removal of coronal remnants – D7111) will be based on exfoliation age-patterns. This change will be made to the Oral Surgery Services section in Appendix B of the Dental Services provider manual by Jan. 1, 2023.
Documentation Required for Exceptional Conditions
Dental services that are deemed necessary to be rendered in preparation for a major surgical procedure (organ transplant, heart valve replacement or total joint replacement) covered through the Exceptional Medical Conditions benefit require a referral form from the treating medical provider. Effective Jan. 1, 2023, the referral form must contain the individual national provider identifier (NPI) number of the referring provider.
This policy update will be enacted to comply with the Code of Federal Regulations 42 CFR 455.410, which requires SCDHHS to verify that all ordering, referring and prescribing providers (ORP) are enrolled providers in the Healthy Connections Medicaid program.
Dental Treatment Record
SCDHHS is clarifying and updating the current policy for documenting, reporting and maintaining dental treatment records in accordance with state and federal laws, rules and regulations. As a condition of participation in the Healthy Connections Medicaid dental program, providers are required to maintain records and provide access to records that fully disclose the medical necessity for treatment and the extent of services provided to Healthy Connections Medicaid members. Effective Jan. 1, 2023, SCDHHS is changing the period these records are required to be maintained from five years to four years. All required documentation must continue to be present in the member record prior to the provider filing a claim for reimbursement. Member records for claims filed on or after Jan. 1, 2023, will need to comply with the updated dental treatment records policy, which is available as a standalone document here. This policy will be detailed in Section 6: Reporting/Documentation of the Dental Services provider manual by Jan. 1, 2023. Claims filed prior to Jan. 1, 2023, should continue to comply with the dental records policy that is currently included in the Dental Services provider manual.
All policy changes and clarifications are referenced in the Dental Services Provider Manual Change Control Record.
Questions about this bulletin may be directed to the DentaQuest Provider Service Center at (888) 307-6553 or carolinaproviders@dentaquest.com.
Thank you for your continued support of the South Carolina Healthy Connections Medicaid program.