Dental Care Provider Information

This section provides information for existing MA fee-for-service dental providers and those considering enrolling in the MA program, including the following:

• Covered MA dental services
• Provider enrollment
• Dental fee schedules and reimbursement rates
• Dental claims submission
• Helpful links for dental providers

If you require additional general information on the MA program, please review the Health Care/Medical Assistance Provider Information section.

Dental Services Provided in Medicaid

The scope of benefits for which MA recipients are eligible to differ according to recipients' benefits packages. MA covers the following:

• All medically necessary dental services for children under age 21 enrolled in MA.
• Medically necessary dental services for individuals 21 years of age or older enrolled in MA to include families with children who are eligible for MA and who meet the financial eligibility requirements for TANF, SSI or an optional State supplement. These services include diagnostic (exam & x-rays), preventive (prophys), restorations (amalgam and composite restorations), extractions, and other types of oral surgery. Diagnostic and preventive services are limited to 1 per 180 days per adult recipient. Additional oral evaluations and cleanings will require an approved Benefit Limit Exception (BLE). Complete and partial dentures are limited to one per lifetime without an approved BLE. Root canals (endodontic services), crowns and adjunctive services, and periodontal services require an approved benefit limit exception in order for the service to be covered. Refer to MAB 27-11-47 for more information.
• Dental services are also provided for adults for palliative treatment or if the condition of the patient requires services be provided in a short procedure unit (SPU), ambulatory surgical center (ASC) or inpatient hospital.
• Beneficiaries in nursing facilities and ICF-MR or ICF/ORC facilities are afforded the same coverage as adults and are not subject to the BLE requirements.

For regulatory information on Dentists' Services, refer to Chapter 1149 of the Medical Assistance Manual of the Pa. Code.

The Department has an online recipient Eligibility Verification System (EVS) that provides the most current eligibility status information on MA recipients. Providers can use information from EVS to make informed decisions regarding billing before rendering services. Providers may typically access EVS 24 hours-a-day, seven days a week.

Enrolling To Be An Approved MA Dental Provider

To be eligible to participate in the MA program, you must be currently licensed and registered or certified by the appropriate commonwealth agency. You must also sign a provider agreement provided by the Department. Additional provider enrollment information and applications can be found at PROMISe(TM) Provider Enrollment and Applications.

All providers enrolled with MA are eligible for payment for covered services provided to recipients enrolled in fee-for-service. If you wish to treat recipients enrolled in HealthChoices/Managed Care, you must enroll with one or more of the participating MCOs after you enroll in the MA program.

To enroll with participating MCOs, you must meet each of the credentialing requirements of the given MCO and sign a contract. For more information about individual credentialing requirements, contact the MCOs directly.

Dental Fee Schedules And Fees

Dentists are paid for services delivered to fee-for-service recipients according to the fees specified in the Office of Medical Assistance Programs Outpatient Fee Schedule unless the dentist typically charges the public less than that which is specified in the fee schedule for service. In such cases, the dentist will be paid the fee typically charged. The fee schedule provides a complete list of fees paid for each service and the limitation on services (i.e., no more than two check-ups per year).

Please note that the single contracted rates paid by the Department to the HealthChoices/Managed Care MCOs serve as payment for all covered services, including dental care. The Department does not regulate the fees paid to dentists for services to HealthChoices/Managed Care recipients. Therefore, fees for services provided to recipients in these programs may vary by MCO.

Fee-for-service dental claims can be submitted using the ADA Claim Form - Version 2012 (available from ADA.org) and can be submitted via hard copy or via electronic submission. The ADA Claim Form — Version 2012 Completion Aid, an item-by-item reference guide that will assist providers in successfully completing the ADA claim form. Managed care claims are filed directly through managed care organizations. Refer to the managed care organizations directly for claims submission information. NOTE: The ADA Claim Form - Version 2012 is not available for order on the MA 300X.

The Department offers Medical Assistance Billing Training free of charge to newly enrolled MA providers and their billing personnel and to currently enrolled providers that have hired new billing personnel and are experiencing serious billing difficulties. For additional information, refer to MA Bulletin 27-08-05.

Helpful Links For Dental Providers

Provided below are a series of links that will provide additional helpful information:

• Pennsylvania MEDICAID Managed Care Organization (MCO) Directory*
  Provides contact information for the HealthChoices programs
• Benefits Fraud
  Provides information about reporting overpayments or improper payments of MA funds and provides the most recent version of the Medicheck list. The Medicheck list provides dentists and other providers with a list of providers that are prohibited from prescribing, rendering or ordering services.
  
• Medicaid / Medical Assistance Bulletins
  Provides all Medical Assistance Bulletins released since January 1997. Medical Assistance Bulletins communicate new or revised policies such as changes to dental reimbursements or approved types dental services.
• PROMISe™ Dental Provider Handbook*
  Provides information about covered benefits, including dental benefits, eligible recipients, dental provider participation and more.
  
• MA Program Fee Schedule
  Provides outpatient fee schedules for specific provider types. These fee schedules are updated weekly.
• Dental Fee Schedule*
  Fee schedule for dental providers.

*These documents are in Adobe PDF format. You must have a copy of Adobe Acrobat Reader installed on your system to view them.