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Division of Health Care Financing and Policy
Public Workshop Chuck Damon, RN
Brian Sandoval Governor
Marta Jensen Acting Administrator
Division of Health Care Financing and Policy
Medicaid Services Manual (MSM) Chapter 1000 - Dental
Proposed Revisions to Medicaid Services Manual 1000 - Dental
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Division of Health Care Financing and Policy
Agenda Welcome and Introductions Presentation of Proposed Revisions Public Comments Wrap Up and Adjourn
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Division of Health Care Financing and Policy
MSM 1000 Proposed Revisions • Introduction - Recommending Professional
Standards to care at the same level as the community at large. Additionally services must comply with materials approved by the American Dental Association (ADA), provided under the ADA code of Ethics and the use of ADA dental coding.
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Division of Health Care Financing and Policy
MSM 1000 Proposed Revisions • Introduction - proposing text for pregnant
recipients: the Medical providers and/or the Managed Care Organizations should provide dental referrals for recipient that are pregnant, for Pregnancy related services.
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Division of Health Care Financing and Policy
MSM 1000 Proposed Revisions • Section 1003.1 – Diagnostic and Preventive
Services (D0100 – D1999) Proposed language to promote routine, periodic
oral examinations and preventive treatment, fluoride treatment, sealant application in accordance with recommendations by the ADA and the American Academy of Pediatric Dentists (AAPD).
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Division of Health Care Financing and Policy
MSM 1000 Proposed Revisions • Section 1003.2 – Restorative Dentistry
Services (D2000 – D2999) Proposed language that all adhesives, liners,
bases, curing and occlusal adjustment are part of a filling and are included in either an amalgam or composite restoration. Language included to prevent un-bundling for restorations.
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Division of Health Care Financing and Policy
MSM 1000 Proposed Revisions • Section 1003.4 - Periodontic Services – (D4000
– D4999) Suggested language that Medical Provider
and/or Managed Care Organizations should provide a dental referral for recipients that are pregnant. This is to help prevent or reduce pregnancy related gingivitis and promote healthy outcomes during the pregnancy.
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Division of Health Care Financing and Policy
MSM 1000 Proposed Revisions • Periodontics – continued… Provide definition for Full Mouth Debridement D4355.
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Division of Health Care Financing and Policy
MSM 1000 Proposed Revisions • Section 1003.5 – Prosthodontic Services
(D5000 – D5999) Suggested removal of language to 1003.5.A.5,
there is no prior authorization required for partial dentures. Providers must maintain a copy of the New Employee of Nevada (NEON) documentation for retrospective review.
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Division of Health Care Financing and Policy
MSM 1000 Proposed Revisions • Section 1003.6 – Denture Embedding Proposed to add Nevada Revised Statute
reference regarding denture embedding, clarification of the requirement, remove language regarding claims denial related to denture embedding.
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Division of Health Care Financing and Policy
MSM 1000 Proposed Revisions • Section 1003.7 – Oral Surgery (D7000 –
D7999) Provided definitions for tooth extractions. Define elective tooth extractions that are not
covered by Nevada Medicaid.
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Division of Health Care Financing and Policy
MSM 1000 Proposed Revisions • Section 1003.8 – Orthodontics • Defines Medically Necessary Orthodontic
Automatic Qualifying Conditions • Handicapping Labio-Lingual Deviation
Indexing (HLD Scoring) will no longer be used.
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Division of Health Care Financing and Policy
MSM 1000 Proposed Revisions • Section 1003.8 – Orthodontics • Medically Necessary Orthodontic Automatic
Qualifying Conditions are deemed medically necessary and are qualified for reimbursement when it is part of a case involving treatment of cranio-facial anomalies, malocclusions caused by trauma or a severe malocclusion or craniofacial disharmony that included, but not limited to:
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Division of Health Care Financing and Policy
MSM 1000 Proposed Revisions • Overjet equal to or greater than 9 millimeters • Reverse overjet equal to or greater than 3.5 millimeters • Posterior crossbite with no functional occlusal contact • Lateral or anterior open bite equal to or greater than 4 millimeters • Impinging overbite with either palatal trauma or mandibular
anterior gingival trauma • One or more impacted teeth with eruption is impeded (excluding
third molars) • Defects of cleft lip or palate or other craniofacial anomalies or
trauma • Congenitally missing teeth (extensive hypodontia of at least one
tooth per quadrant (excluding third molars) • Anterior crossbite with soft tissue destruction
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Division of Health Care Financing and Policy
MSM 1000 Proposed Revisions • Section 1003.8 - Orthodontics • Defines the amount of dental appointments
required and percentage of missed appointments allowed for referral for orthodontic treatment
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Division of Health Care Financing and Policy
MSM 1000 Proposed Revisions • Section 1003.8 Orthodontics continued… • Defines service limitation for D8010, D8020,
D8040 (Transitional Treatment)and D8080 and D8090 (Comprehensive Treatment) to once per lifetime for each treatment plan.
• Defines Provider Responsibilities: – Type of providers that can provide orthodontic
services – Defines referral criteria related to appointment
attendance
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Division of Health Care Financing and Policy
MSM 1000 Proposed Revisions • Section 1003.8 Orthodontics • Provider Responsibilities – continued…
– Defines that active dental disease in submitted cases for Prior Authorization (PA) will be denied.
– Defines transfer of orthodontic cases between providers.
– Defines circumstance when orthodontic treatment may be discontinued.
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Division of Health Care Financing and Policy
MSM 1000 Proposed Revisions • Section 1003.8 Orthodontics – continued… • Recipient Responsibilities – (NEW Section)
– Referral appointment history – Attendance to appointments – Maintaining good oral hygiene – Provider notification
• appointments., changing providers • Changes in eligibility, or relocation
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Division of Health Care Financing and Policy
MSM 1000 Proposed Revisions • Section 1003.8 Orthodontics – continued… • Authorization Process
– Defines Medically Necessary Orthodontic Automatic Qualifying Conditions, and criteria for the significance for medical need.
– Provides instructions for required documentation, and forms for PA submittal.
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Division of Health Care Financing and Policy
MSM 1000 Proposed Revisions • Section 1003.9 Adjunctive General Services
(D9000 – D9999) • Provides definition for beginning and end
times for General and IV sedations, for claims submission.
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Division of Health Care Financing and Policy
MSM 1000 Proposed Revisions • Section 1003.19 – Conditions of Participation
– Propose to include language in this section “dental specialists must be dental specialties that are recognized and approved by the American Dental Association and the Nevada State Board of Dental Examiners”
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Division of Health Care Financing and Policy
MSM 1000 Proposed Revisions • New Section 1003.20 – Improper Billing
Practice. – Defines improper billing practices and provides
examples.
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Division of Health Care Financing and Policy
Contacts: Chuck Damon, RN Health Care Coordinator II Division of Health Care Financing and Policy Policy Development and Program Management – Dental Program Phone: 775-684-3771 E-mail: [email protected] Marti Cote Social Services Chief I Division of Health Care Financing and Policy Policy Development and Program Management Phone: 775-684-3748 E-mail: [email protected]
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Division of Health Care Financing and Policy
MSM 1000 Proposed Revisions • Questions????
• Public Comment
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