SECTION 317:30-5-695. Eligible dental providers and definitions

(a)   Eligible dental providers in Oklahoma's SoonerCare program are:

(1)   Individuals licensed as dentists under Title 59 of Oklahoma Statutes (O.S.), Sections (§§) 328.21, 328.22, and 328.23 (licensed dentists, specialty dentists and out of state dentists);

(2)   Individuals issued permits as dental interns under 59 O.S. § 328.26;

(3)   Individuals who are third and fourth year dental students at an accredited Oklahoma dental college; and

(4)   Any individual issued a license in another state as a dentist.

(b)   All eligible providers must be in good standing with regard to their license. Any revocation or suspension status of a provider referenced in subsection (a) above renders the provider ineligible for payment or subject to recoupment under SoonerCare.

(c)   Eligible providers must document and sign records of services rendered in accordance with guidelines found at Oklahoma Administrative Code (OAC) 317:30-3-15.

(d)   The American Dental Association's version of Code on Dental Procedures and Nomenclature (CDT) is used by the Oklahoma Health Care Authority (OHCA) to communicate information related to codes, and procedures for administration. Definitions, nomenclature, and descriptors as listed in the CDT will apply, with the exception of more specific definitions or limitations set forth.

(1)   "Decay" means carious lesions in a tooth; decomposition and/or dissolution of the calcified and organic components of the tooth structure.

(2)   "Images" means radiographs and diagnostic imaging that are part of the clinical record. Images should only be taken for clinical reasons as determined by the dentist and must be of diagnostic quality, properly identified, and dated.

(3)   "Medically necessary extractions" means, but is not limited to, an extraction of a tooth that has met medically necessary criteria due to the presence of pathology, trauma, severe periodontal involvement, significant caries, pain or infection.

(4)   "Medically necessary oral healthcare" means treatment deemed necessary by a physician or dentist when a patient's medical condition or treatment is or will be likely complicated by an untreated oral health problem.

(5)   "Palliative treatment" means action that relieves pain but is not curative. Palliative treatment is an all-inclusive service. No other codes are reimbursable on the same date of service.

(6)   "Radiographic caries" means dissolution of the calcified and organic components of tooth tissue that has penetrated the enamel and is approaching the dentinoenamel junction.

(7)   "Unbundling" means billing separately for several individual procedures that are included within one (1) CDT or Current Procedural Terminology (CPT) code.

(8)   "Upcoding" means reporting a more complex and/or higher cost procedure than actually performed.

[Source: Added at 12 Ok Reg 751, eff 1-5-95 through 7-14-95 (emergency); Added at 12 Ok Reg 3131, eff 7-27-95; Amended at 14 Ok Reg 2404, eff 4-2-97 (emergency); Amended at 15 Ok Reg 1528, eff 5-11-98; Amended at 16 Ok Reg 692, eff 12-31-98 (emergency); Amended at 16 Ok Reg 1429, eff 5-27-99; Amended at 17 Ok Reg 3201, eff 6-21-00 (emergency); Amended at 18 Ok Reg 1130, eff 5-11-01; Amended at 18 Ok Reg 2961, eff 5-17-01 (emergency); Amended at 19 Ok Reg 1067, eff 5-13-02; Amended at 23 Ok Reg 2489, eff 6-25-06; Amended at 24 Ok Reg 660, eff 2-1-07 (emergency); Amended at 24 Ok Reg 2088, eff 6-25-07; Amended at 25 Ok Reg 2759, eff 5-1-08 (emergency); Amended at 26 Ok Reg 2120, eff 6-25-09; Amended at 28 Ok Reg 1419, eff 6-25-11; Amended at 33 Ok Reg 826, eff 9-1-16; Amended at 35 Ok Reg 1453, eff 9-14-18; Amended at 37 Ok Reg 1607, eff 9-14-20]