§ 1149.52. Payment conditions for various dental services.
(a) The fee paid by the Department for an inpatient surgical service includes pre-operative and postoperative visits as designated in the MA Program fee schedule.
(b) The Department pays only one dentist for performing a particular surgical service or procedure.
(c) Payment is made at reduced rates for space maintainers, crowns and dentures specified in MA Program fee schedule, if one of the following conditions are met:
(1) The person was an eligible MA recipient at the first visit after prior authorization was obtained as specified in subsection (j) but became ineligible for MA before the appliance was delivered.
(2) The dentist was unable to deliver the item to the recipient, and the following conditions were met:
(i) When the appliance is completed, the dentist shall notify the recipient and make an appointment. If the dentist is unable to contact the patient after 30 days, in spite of repeated attempts which must be documented in the recipient’s dental record, the dentist shall also send a letter to the recipient’s last known address and to the Executive Director of the appropriate County Assistance Office.
(ii) If neither the dentist nor the County Assistance Office can locate the recipient within the 60 days after the appliance is completed, the dentist shall submit an invoice for the service performed in accordance with the instructions in the provider handbook.
(d) Payment is made for dental procedures performed in the short procedure unit of a hospital only if:
(1) The short procedure unit has been approved for participation in the MA Program.
(2) The nature of the surgery or the condition of the patient precludes performing the procedure in the dentist’s office or other outpatient setting.
(3) A physician or dentist has documented in the patient’s medical record the medical justification for performing the procedure in a short procedure unit setting.
(e) Payment is made to dentists for inpatient hospital visits only if the conditions established in § 1150.54(a) (relating to surgical services) are met and daily dental care is provided by the dentist for a condition or diagnosis unrelated to daily medical care provided by a physician.
(f) Payment is made for an outpatient dental consultation only if:
(1) The consultation is requested by the dentist or physician in charge of the case.
(2) The consultation prepares a written report of the examination that includes the patient’s dental history and if applicable, the patient’s medical history.
(3) Except in an emergency situation, as described in § 1101.67(c) (relating to prior authorization), the Department has approved a request for the consultation prior to the service being rendered.
(g) Payment for an inpatient dental consultation is made only if:
(1) The consultation is requested by the dentist or physician in charge of the case.
(2) The consultant prepares a written report of the examination that also includes the patient’s dental history and if applicable, the patient’s medical history.
(h) Payment for diagnostic radiological services performed in the dentist’s office is made only if the dentist performs an oral examination of the patient prior to the radiological service.
(i) Payment is made to the dentist for general anesthesia provided in the office only if the recipient has a diagnosed medical problem, noted in the remarks section of the invoice, where use of local anesthesia is contraindicated as the sole agent in completion of the procedure. A surgical procedure by an oral surgeon or pedodontist need not be documented but it must be indicated in the remarks section of the invoice that the procedure was performed by the appropriate practitioner. However, the remarks section of the invoice does not have to be completed if general anesthesia was specifically included as part of a prior authorization requirement and that request was approved before the procedure was initiated.
(j) Payment is made only if the Department has prior authorized the following:
(1) Complete or partial dentures.
(2) Space maintainers.
(3) Orthodontic services.
(4) Crowns.
(5) When more than one tooth is extracted for insertion of a prosthetic device.
(6) Multiple extractions of six or more teeth extracted during one visit or one period of hospitalization.
(7) Surgical extractions.
(8) Outpatient dental consultations except as noted in subsection (f)(3).
(k) The fees for dentures include relining and adjustments made during a period of 180 days following insertion of the dentures.
(l) Payment is made for restorative services based on the number of surfaces restored, not on the number of restorations made per surface. For example, two restorations on the same surface of a tooth is considered to be a single restoration of one tooth surface. Fees for services include local anesthesia, polishing, cement bases and necessary medications, if applicable.
(m) The fees for crowns include buildup of the natural crown using either composite or amalgam. Payment for permanent crowns is made for fully developed permanent teeth and deciduous molars with no permanent successor. However, payment is made for stainless steel and temporary plastic crowns when made for primary or developing permanent teeth and not made in conjunction with the construction of a permanent crown.
(n) The fee for root canal therapy includes an apicoectomy if it is performed by the same dentist within 180 days of initial treatment. If an apicoectomy is performed by another dentist within 180 days of the initial treatment, the dentist will receive the fee for an apicoectomy as specified in Chapter 1150 (relating to MA Program payment policies).
(o) Payment for dental services performed on a hospital inpatient basis are compensable if the individual has a concomitant medical illness or handicapping condition and dental services need to be provided. This justification has to be written in the remarks section of the invoice in order for payment to be approved.
(p) Payment for removal of superficial root fragments not completely covered by bone will be considered as a simple extraction or surgical extraction of tooth, erupted.
Source The provisions of this § 1149.52 adopted January 25, 1985, effective January 15, 1985, 15 Pa.B. 255; amended September 30, 1988, effective October 1, 1988, 18 Pa.B. 4418. Immediately preceding text appears at serial pages (96120) to (96122).
Cross References This section cited in 55 Pa. Code § 1149.55 (relating to payment conditions for orthodontic services.)
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