Dental Office Reference Manual Updates

PROVIDER ALERT

The South Carolina Department of Health and Human Services (SCDHHS) encourages all dental providers to review the latest version of the Dental Office Reference Manual (ORM) effective May 1, 2017.

The ORM includes clarifications to the following policy sections:

  1. Identification cards and agency logo (Section 2.01)
  2. Prior authorizations and pre-payment review (Section 3.01)
  3. Provision of EPSDT services for beneficiaries under the age 21 (Section 3.05)
  4. Place of service codes (Section 4.05)
  5. Out of state providers (Section 9.02)
  6. Additional resource forms (Appendix A, Section A-2)
  7. Pre-fabricated crown clinical criteria (Appendix C, Section C.02)
  8. Benefits limitations for codes D2929, D2930, D2931, D2932, D2934 (Exhibits A and C)
  9. Section 1- Provider Manual (Appendix E)
  10. Covered Benefits” tables (Exhibits A-C)
    1. Revisions to the 2017 CDT and CPT nomenclature and/or descriptor codes covered under the Medicaid State Plan
    2. New column

      SCDHHS added an additional column on the tables to separate the procedure codes that require pre-payment review from those that require a prior authorization. This will more clearly distinguish between services that require prior authorization and services that require pre-payment review. This clarification should reduce the administrative burden to the dental providers.

      Revised Table Headings:

      Code

      Description

      Age limitation

      Teeth covered

      Pre-payment review required

      Prior authorization required

      Benefit
      limitation

      Documentation required

    3. Clarified documentation required for each procedure code

      The documentation required for each procedure code is listed. A summary of these requirements is attached for your reference.

      *In the event of discrepancy between the Dental ORM and the Summary Document, the ORM shall be used to guide policy.

 

The Dental ORM is available in the provider manual section of the SCDHHS website, scdhhs.gov , and on the DentaQuest web portal, https://govservices.dentaquest.com/ . For questions regarding the Dental ORM updates, please contact the DentaQuest Provider Service Center at (888) 307-6553.

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

Summary of Documentation Required by Procedure Category
PROCEDURE CATEGORY PRE-PAYMENT REVIEW REQUIRED PRIOR AUTHORIZATIONREQUIRED DOCUMENTATION REQUIRED

Diagnostic &

Preventive

No

No

Proper documentation must be maintained in patient’s records. Refer to Appendix D-2: ”Dental Treatment Records.”

Restorative

No

No

Proper documentation must be maintained in patient’s records. Refer to Appendix C Section “Clinical Criteria” and Appendix D, Section D-2: “Dental Treatment Records.”

Endodontics (Pulpotomy)

No

No

Proper documentation must be maintained in patient’s records. Refer to Appendix C, Section C.03 “Clinical Criteria” and Appendix D, Section D-2: ”Dental Treatment Records.”

Endodontics

Yes

No

Detailed narrative of medical necessity and pre-op x-ray(s) must be submitted with the claim for review. Refer to Appendix C, Section C.03 “Clinical Criteria” Policy. Proper documentation and post-treatment radiographs must be maintained in patient’s records. Refer to Appendix D, Section D-2: ”Dental Treatment Records.”

Prosthodontics (Removable)

Yes

No

Detailed narrative of medical necessity and pre-operative diagnostic images such as radiographs or CT, must be submitted with the claim for review. Refer to Appendix C, Section C.05 “Clinical Criteria” Policy. Proper documentation must be maintained in patient’s records (Appendix D, Section D-2: ”Dental Treatment Records”).

Oral & Maxillofacial Surgery (Extractions)

No

No

Proper documentation must be maintained in patient’s records. Refer to Appendix C, “Clinical Criteria” and Appendix D, Section D-2: ”Dental Treatment Records.”

Oral and Maxillofacial Surgery

Yes

No

Detailed narrative of medical necessity, pathology report (specific procedure codes) and pre-operative diagnostic images such as radiographs, CT, intraoral photographs, must be submitted with the claim for review. Refer to Appendix C “Clinical Criteria” Policy. Proper documentation must be maintained in patient’s records (Appendix D, Section D-2: ”Dental Treatment Records”).

Sedation

Yes

No

Detailed narrative of medical necessity must be submitted with the claim for review. Include as necessary any documentation that supports the medical necessity. Refer to Appendix C “Clinical Criteria” Policy. Proper documentation must be maintained in patient’s records (Appendix D, Section D-2: ”Dental Treatment Records”).

Hospital Call

No

Yes

Detailed narrative of medical necessity must be submitted for prior authorization. Please include as necessary any documentation that supports the medical necessity. Refer to Appendix C “Clinical Criteria” Policy. Proper documentation must be maintained in patient’s records (Appendix D, Section D-2: ”Dental Treatment Records”).

Medical

(CPT Codes)

Yes

 

No

Detailed narrative of medical necessity must be submitted with the claim for review. Pre-operative diagnostic images such as radiographs, CT and/or intraoral photographs, must also be submitted with the claim for review for specific procedure codes. Please include as necessary any documentation that supports the medical necessity. Proper documentation must be maintained in patient’s records (Appendix D, Section D-2 :”Dental Treatment Records”).

Medical

(CPT Codes)

No

No

Proper documentation must be maintained in patient’s records. Refer to Appendix D-2: ”Dental Treatment Records.”

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