Wrightway

 

Adult Dental

Provider Requirements and Service Limitations

From The May 2010 Florida Medicaid Provider Handbook

Information highlighted in yellow indicates a change since the July 2007 version of this handbook.

Adult Dental - Requirements To Receive


Adult dental services cover dental treatments and procedures that are not otherwise covered by the Medicaid Dental Services Program state plan services.

Adult dental services include diagnostic, preventive and restorative treatment; extractions; endodontics, periodontal and surgical procedures. The services strive to prevent or remedy dental problems that if left untreated could compromise a recipient’s health, by increasing the risk of infection or disease, or reducing food options, resulting in restrictive nutritional intake.

Emergency dental procedures to alleviate pain and or infection and full and partial dentures are covered by Medicaid state plan dental services.

This service is not available to individuals enrolled on the DD Waiver – Tier Four.

Limitations

Adult dental services are limited to recipients 21 years of age or older. Adult dental services will not duplicate dental services provided to adults by the Medicaid Dental Services Program. The Medicaid Dental Program state plan services provide dental services for recipients under the age of 21.

Adult cleanings are limited to two per year.

There is no limit in the number of emergency episodes per year or the number of teeth that may be extracted per emergency episode. Refer to the Florida Medicaid Dental Services Coverage and Limitations Handbook for additional information regarding Medicaid state plan coverage.

A recipient shall receive no more than ten units of this service per day. Note: The Florida Medicaid Dental Services Coverage and Limitations Handbook is available on the Medicaid fiscal agent’s Web site at www.mymedicaid-florida.com. Select Public Information for Providers, then Provider Support, and then Provider Handbooks. The handbook is incorporated by reference in 59G-4.060.

Documentation Requirements

Reimbursement* and monitoring documentation to be maintained by the provider:

  • 1. *Copy of claim(s) submitted for payment.
  • 2. All treatment records.

Documentation to be submitted to the waiver support coordinator by the provider:

  • 1. Copy of claims submitted at time of claim submission; and
  • 2. Copy of treatment plan. * Indicates reimbursement documentation.

Place of Service

Adult dental services shall be provided in the provider’s office or other setting, determined appropriate by the provider.

Special Considerations

Adult dental services are to be authorized only to prevent or remedy problems that could lead to a deterioration of the recipient’s health, thus placing the recipient at risk of an institutional placement. Second opinions are covered when extensive dental work is planned or there is a question about medical necessity of all the work planned.

Providers of adult dental services are paid for each date of service and shall prepare their bills accordingly. The provider will submit an invoice listing each procedure and negotiated cost. All procedures or treatments rendered on one day shall be totaled into one bill for payment.

Adult Dental Provider Requirements

Adult Dental Services Provider Requirements

Provider Qualifications Providers of adult dental services shall be dentists licensed in accordance
with Chapter 466, F.S.

Unlicensed dental interns and dental students of university based dental programs may provide services under the general supervision of a licensed dentist but cannot act as a treating provider or bill Medicaid for covered services. The licensed supervising dentist of the facility acts as the treating provider of a covered service. A dentist who has a teaching permit issued by the Florida Board of Dentistry as outlined in section 466.002, F.S. may also act as the treating provider of a covered service. The facility may bill Medicaid for covered services.