Adult Preventative Dental Service

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Effective with dates of service beginning December 1, 2014, the South Carolina Department of Health and Human Services (SCDHHS) will implement an Adult Preventative Dental benefit. Medicaid enrolled dentists may seek reimbursement from the Fee-for-Service Healthy Connections program for preventative dental benefit services. These services are available to members age 21 and over that have full Healthy Connections benefits. Covered services include diagnostics, extractions, fillings and an annual cleaning, up to a maximum benefit of $750 per state fiscal year (July 1 through June 30). The $750 maximum benefit will be based on claim payments under the SCDHHS dental fee schedule.

Members with special needs diagnoses or members receiving treatment by an oral surgeon may also receive medically necessary sedation services, which are excluded from the annual maximum benefit amount, but require pre-payment review from DentaQuest.

This new adult benefit is in addition to the services currently covered for the treatment of exceptional medical services (Section 4.07 of the Dental Office Reference Manual) and for the provision of emergency medical CPT procedures by oral surgeons (Section 4.06 of the Dental Office Reference Manual). Exceptional medical services are not included in the annual maximum benefit limitation. Members that are enrolled in the Intellectually Disabled /Related Disabilities waiver (ID/RD), formerly known as Mentally Retarded/Related Disabilities waiver (MR/RD), are not limited to those services included in the adult preventative dental benefit. These members may continue to receive the full range of dental services as outlined in Exhibit C of the Dental Office Reference Manual.

Providers will be able to view an adult member's available benefit (the unused annual maximum benefit amount) on the DentaQuest web portal. SCDHHS encourages all providers to verify the member's eligibility and the amount of the dental benefit remaining for each adult member prior to the delivery of the service. Obtaining and filing a printed confirmation of eligibility and the remaining amount of benefit from the DentaQuest provider web portal on the date of treatment is strongly encouraged. The used portion of the annual maximum benefit will be updated following each payment cycle, currently on Fridays of most weeks in the year.

A listing of covered services is included as Attachment A to this bulletin. These services will be outlined in Exhibit B of the Dental Office Reference Manual once the benefit is effective.

SCDHHS requires a copayment from adult members toward the cost of their preventative (non-emergent care). Participating providers should collect a dental copayment on each date of service for adult members. The copayment amount is currently $3.40. Medicaid members may not be denied services if they are unable to pay the copayment at the time the services are rendered; however, this does not relieve members of the responsibility for the copayment. It is the provider's responsibility to collect the copayment from the beneficiary in order to receive full reimbursement for a service. The amount of the copayment will be deducted from the provider's Medicaid payment.

Effective with the implementation of the adult preventative dental benefit, SCDHHS will be adding D0274 for all covered populations (adults, children and ID/RD members) to allow providers to bill for four radiographic bitewing images. The reimbursement rate for this service is $27.51. Details on this code may be found in the December 1, 2014 version of the Dental Office Reference Manual.

Please refer any questions or concerns regarding this bulletin to the DentaQuest Provider Call Center at 888-307-6553. Thank you for your continued support of the South Carolina Healthy Connections Medicaid Program.

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