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Provider Notice issued 10/05/12
Dental Office Reference Manual (DORM)
| To: | All HFS-Enrolled Denal Providers, FQHCs and Certified Local Health Departments |
| Date: | October 5, 2012 |
| Re: | Dental Office Reference Manual (DORM) |
The purpose of this informational notice is to notify you of the changes in the Dental Office Reference Manual (DORM). Following is an outline of the changes:
| Issue | Purpose |
|---|---|
| Policy update on EPSDT services for children – define EPSDT in Attachment A(page 49) | A policy clarification is required to assure providers understand Early Periodic Screening, Diagnosis and Treatment (EPSDT) dental services. Per Section 1905(r)(3)(A) of the Social Security Act, children’s’ dental services are to be provided at intervals which meet reasonable standards of practice, or at such other intervals, indicated as medically necessary. Additionally, the statute requires that dental services shall at a minimum include relief of pain and infections, restoration of teeth and maintenance of dental health. Also, for other necessary healthcare diagnostic services, treatment, and other measures to correct or ameliorate defects, illness and conditions discovered by the screening services shall be covered under EPSDT. |
| Prior authorization for EPSDTservices – Exhibit A(page 109) and Attachment D (page 52) | If there are dental services that the dentist deems medically necessary above and beyond what is published in the DORM benefit tables and the dental periodicity schedule, the dental provider should submit for prior authorization of the requested EPSDT services on the ADA Claim Form. This shall be done by checking EPSDT/Title XIX in Type of Transaction (Box #1), identifying the recommended procedure codes (Box #29), providing a description of services (Box #30) and then submitting for prior authorization medical necessity review. |
| Adult dental benefit changes – Exhibit B(pages 139-143) | Save Medicaid Access and Resources Together (SMART) Act (pdf) requires changes to the Healthcare and Family Services (HFS) Dental Program. Public Act 97-0689, Section 5-5f.(b)(v) (elimination and limitations of medical assistance services), states that the Department shall limit adult dental services to emergencies. An emergency is defined as a situation deemed medically necessary to treat pain, infection, swelling, uncontrolled bleeding, or traumatic injury that can be treated by extraction only. |
| Updated timely filing limits for claim submission – Section 5.10 (page 21) | Effective on claims with dates of service on or after July 1, 2012, the timely filing requirement for the HFS Dental Program is 180 calendar days from the date of service. |
| Update language on orthodontic treatment and eligibility – Exhibit A (page 135) | Clarified the language to assure providers understand that they should check a child’s eligibility before starting and during orthodontic treatment. Since treatment generally lasts for two years or more, it is important to start treatment early enough so that the child does not age out before the treatment is complete. |
If you have questions regarding the changes to the DORM, please contact your DentaQuest provider representative or the DentaQuest Provider Relations Hotline at 1-888-281-2076. DentaQuest will mail CDs of the DORM and it will also be posted to the DentaQuest provider Web portal and on the HFS Dental Web page. Provider training will be scheduled in the next 60 days to answer your questions.