EPSDT Policy Clarification


The South Carolina Department of Health and Human Services (SCDHHS) is issuing this bulletin for guidance on the provision of medically necessary dental services to children under the age of 21.

Federal law at 42 U.S.C.§ 1396d(r) [§1905(r) of the Social Security Act (SSA)] requires state Medicaid programs to provide Early and Periodic Screening, Diagnostics, and Treatment (EPSDT) for recipients under 21 years of age. The scope of EPSDT benefits under the federal law covers any service that is medically necessary “to correct or ameliorate a defect, physical or mental illness, or a condition identified by screening,” whether or not the service is covered under the South Carolina State Plan for Medical Assistance (State Plan). The services covered under EPSDT are limited to those within the scope of the category of services listed in 42 U.S.C. § 1396d(a) [§1905(a) of the SSA]. Even if the service will not cure the recipient’s condition, it must be covered if the service is medically necessary to improve or maintain the recipient’s overall health.

EPSDT dental services include those provided at intervals that meet reasonable standards of dental practice and at intervals necessary to determine the existence of a suspected illness or condition. Services should be provided at as early an age as necessary to provide relief of pain and infections, restoration of teeth and maintenance of dental health. Dental care includes emergency, preventive and therapeutic services for dental disease, which, if left untreated, may become acute dental problems or may cause irreversible damage to the teeth or supporting structures. Descriptions of EPSDT services in the Social Security Act include, but are not limited to, the following:


  • Emergency services are those necessary to control bleeding, relieve pain, eliminate acute infection; operative procedures which are required to prevent pulpal death and the imminent loss of teeth; treatment of injuries to the teeth or supporting structures
  • (e.g. bone or soft tissues contiguous to the teeth); and palliative therapy for pericoronitis associated with impacted teeth. Routine restorative procedures and root canal therapy are not emergency services.
  • Preventive services include instruction in self-care oral hygiene procedures; oral prophylaxis (cleaning of teeth), both necessary as a precursor to the application of dental caries preventives where indicated, or independent of the application of caries preventives for patients 10 years of age or older; and professional application of dental sealants when appropriate to prevent pit and fissure caries.
  • Therapeutic services include pulp therapy for permanent and primary teeth; restoration of carious (decayed) permanent and primary teeth with silver amalgam, silicate cement, plastic materials and stainless steel crowns; scaling and curettage; maintenance of space for posterior primary teeth lost permanently and provision of removable prosthesis when masticatory function is impaired or when the existing prosthesis is unserviceable; and may include services when the condition interferes with employment training or social development.


In accordance with federal law, the South Carolina Healthy Connections dental benefit consists of both the State Plan approved services as well as any medically necessary EPSDT service for children under the age of 21. Fee schedules for all of the State Plan services and the most commonly billed non-State Plan EPSDT services are available for providers through the DentaQuest web portal at https://govservices.dentaquest.com. Providers that do not have access to the portal may contact DentaQuest at 888-307-6553 for assistance. Providers should obtain a prior authorization (PA) for all medically necessary non-State Plan EPSDT services; submitting documentation of medical necessity, including any films that will assist in this determination, to the Dental ASO for clinical review. Approved PA’s will be reimbursed based on the non-State Plan EPSDT fee schedule upon successful claims adjudication. Medicaid’s payment must be accepted as payment in full. PA’s that are denied will fall into two categories:

a) Medical necessity has been denied.

Medical necessity denials occur when the supporting documentation for the service was submitted on the PA but the content of the documentation was not sufficient to support the medical necessity of the requested service(s). The provider has two options in this case: first, resubmit the PA along with additional documentation supporting medical necessity; or second, proceed with the service delivery without Medicaid reimbursement. In the first case, the provider must wait until the PA has been approved to submit a claim to Medicaid. In the second case, no claim will be filed to Medicaid. Prior to the provision of the service however, the provider must obtain written approval from the beneficiary indicating their willingness to assume financial responsibility for the non-medically necessary service.

If the beneficiary assumes financial responsibility for the service, the provider may deliver the service and bill the beneficiary based on the provider’s usual and customary charges. NOTE: All beneficiaries and providers have the right to appeal any decision that delays, denies or reduces a dental benefit. Providers are prohibited from billing a beneficiary during the appeals process.

b) Medical necessity documentation is not submitted.

The provider must resubmit the PA request along with the required medical necessity documentation or the service may be provided free-of-charge to the beneficiary with no billing to Medicaid. Note: Claims submitted prior to receiving the PA approval will be denied due to the lack of medical necessity determination. The billing of beneficiaries is prohibited while the PA process is on-going and must follow the circumstances described in (a) above.

There has been no change to SCDHHS EPSDT policy. Based on provider and other feedback, this bulletin is intended to clarify claims submission policies related to EPSDT claims. The Dental Office Reference Manual and the provider web portal will be updated to clarify the EPSDT requirements and fee schedule as documented above.

Thank you for your continued support of the South Carolina Healthy Connections Medicaid program.

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