SECTION 317:30-5-696. Coverage by category

  Payment is made for dental services as set forth in this Section.

(1)   Adults.

(A)   Dental coverage for adults is limited to:

(i)   Medically necessary extractions, as defined in Oklahoma Administrative Code (OAC) 317:30-5-695. Tooth extraction must have medical need documented;

(ii)   Limited oral examinations and medically necessary images, as defined in OAC 317:30-5-695, associated with the extraction or with a clinical presentation with reasonable expectation that an extraction will be needed;

(iii)   Smoking and tobacco use cessation counseling; and

(iv)   Medical and surgical services performed by a dentist or physician to the extent such services may be performed under State law when those services would be covered if performed by a physician.

(B)   Payment is made for dental care for adults residing in private intermediate care facilities for individuals with intellectual disabilities (ICF/IID) and who have been approved for ICF/IID level of care, similar to the scope of services available to individuals under age twenty-one (21).

(C)   Limited dental services are available for members who meet all medical criteria, but need dental clearance to obtain organ transplant approval. Providers must obtain prior authorization before delivery of dental service, with the exception of evaluation and extractions. All requests must be filed on the currently approved American Dental Association (ADA) form and must include diagnostic images, six-point periodontal charting, narratives and comprehensive treatment plans. The Oklahoma Health Care Authority (OHCA) will notify the provider of determination using OHCA Prior Authorization Request Decision form. Prior authorized services must be billed exactly as they appear on the prior authorization request. The following dental services are available:

(i)   Comprehensive oral evaluation;

(ii)   Two (2) bitewing images;

(iii)   Prophylaxis;

(iv)   Flouride application;

(v)   Limited restorative procedures; and

(vi)   Periodontal scaling/root planing.

(2)   Home and community-based services (HCBS) waiver for the intellectually disabled. All providers participating in the HCBS must have a separate contract with the OHCA to provide services under the HCBS. Dental services are defined in each waiver and must be prior authorized.

(3)   Children. The OHCA Dental Program provides the basic medically necessary treatment. The services listed below are compensable for members under twenty-one (21) years of age without prior authorization. All other dental services must be prior authorized. Anesthesia services are covered for children in the same manner as adults. All providers performing preventive services must be available to perform needed restorative services for those members receiving any evaluation and preventive services.

(A)   Comprehensive oral evaluation. This procedure should precede any images, and chart documentation must include image interpretations, caries risk assessment and both medical and dental health history of member. The comprehensive treatment plan should be the final result of this procedure.

(B)   Periodic oral evaluation. This procedure may be provided for a member of record once every six (6) months. An examination should precede any images, and chart documentation must include image interpretations, caries risk assessment, and both medical and dental health history of member. The comprehensive treatment plan should be the final result of this procedure.

(C)   Limited oral evaluation. This procedure is only compensable to the same dentist or practice for two (2) visits prior to a comprehensive or periodic evaluation examination being completed.

(D)   Images. To be SoonerCare compensable, images must be of diagnostic quality and medically necessary. A clinical examination must precede any images, and chart documentation must include member history, prior images, caries risk assessment, the six-point periodontal charting, and both dental and general health needs of the member. The referring dentist is responsible for providing properly identified images of acceptable quality with a referral, if that provider chooses to expose and submit for reimbursement prior to referral. Periapical images must include at least three (3) millimeters beyond the apex of the tooth being imaged. Panoramic films and two (2) bitewings are considered full mouth images. Full mouth images as noted above or traditional [minimum of twelve (12) periapical films and two (2) posterior bitewings] are allowable once in a three (3) year period and must be of diagnostic quality. Individually listed intraoral images by the same dentist/dental office are considered a complete series if the number of individual images equals or exceeds the traditional number for a complete series. Panoramic films are only compensable when chart documentation clearly indicates reasons for the exposure based on clinical findings. This type of exposure is not to rule out or evaluate caries. Prior authorization and a detailed medical need narrative are required for additional panoramic films taken within three (3) years of the original set.

(E)   Dental sealants. Tooth numbers 2, 3, 14, 15, 18, 19, 30 and 31 must be caries free on the interproximal and occlusal surfaces to be eligible for this service. This service is available through eighteen (18) years of age and is compensable once every thirty-six (36) months if medical necessity is documented.

(F)   Interim caries arresting medicament application. This service is available for primary and permanent teeth once every one hundred eighty-four (184) days for two (2) occurrences per tooth in a lifetime. The following criteria must be met for reimbursement:

(i)   A member is documented to be unable to receive restorative services in the typical office environment within a reasonable amount of time;

(ii)   A tooth that has been treated should not have any non-carious structure removed;

(iii)   A tooth that has been treated should not receive any other definitive restorative care for three (3) months following an application;

(iv)   Reimbursement for extraction of a tooth that has been treated will not be allowed for three (3) months following an application; and

(v)   The specific teeth treated and number and location of lesions must be documented.

(G)   Dental prophylaxis. This procedure is provided once every one hundred eighty-four (184) days along with topical application of fluoride.

(H)   Stainless steel crowns for primary teeth. The use of any stainless steel crowns is allowed as follows:

(i)   Stainless steel crowns are allowed if:

(I)   The child is five (5) years of age or under;

(II)   Seventy percent (70%) or more of the root structure remains; or

(III)   The procedure is provided more than twelve (12) months prior to normal exfoliation.

(ii)   Stainless steel crowns are treatment of choice for:

(I)   Primary teeth treated with pulpal therapy, if the above conditions exist;

(II)   Primary teeth where three (3) surfaces of extensive decay exist; or

(III)   Primary teeth where cuspal occlusion is lost due to decay or accident.

(iii)   Preoperative periapical images and/or written documentation explaining the extent of decay must be available for review, if requested.

(iv)   Placement of a stainless steel crown is allowed once for a minimum period of twenty-four (24) months. No other restoration on that tooth is compensable during that period of time. A stainless steel crown is not a temporizing treatment to be used while a permanent crown is being fabricated.

(I)   Stainless steel crowns for permanent teeth. The use of any stainless steel crowns is allowed as follows:

(i)   Stainless steel crowns are the treatment of choice for:

(I)   Posterior permanent teeth that have completed endodontic therapy if three (3) or more surfaces of tooth is destroyed;

(II)   Posterior permanent teeth that have three (3) or more surfaces of extensive decay; or

(III)   Where cuspal occlusion is lost due to decay prior to age sixteen (16) years.

(ii)   Preoperative periapical images and/or written documentation explaining the extent of decay must be available for review, if requested.

(iii)   Placement of a stainless steel crown excludes placement of any other type of crown for a period of twenty-four (24) months. No other restoration on that tooth is compensable during that period of time.

(J)   Pulpotomies and pulpectomies.

(i)   Therapeutic pulpotomies and pulpal debridement are allowable once per lifetime. Pre-and post-operative periapical images must be available for review, if requested. Therapeutic pulpotomies and pulpal debridement is available for the following:

(I)   Primary molars having at least seventy percent (70%) or more of their root structure remaining or more than twelve (12) months prior to normal exfoliation;

(II)   Tooth numbers O and P before age five (5) years;

(III)   Tooth numbers E and F before six (6) years;

(IV)   Tooth numbers N and Q before five (5) years;

(V)   Tooth numbers D and G before five (5) years.

(ii)   Therapeutic pulpotomies and pulpal debridement are allowed for primary teeth if exfoliation of the teeth is not expected to occur for at least one (1) year or if seventy percent (70%) or more of root structure is remaining.

(K)   Endodontics. Payment is made for the services provided in accordance with the following:

(i)   This procedure is allowed when there are no other missing anterior teeth in the same arch requiring replacement.

(ii)   The provider documents history of member's improved oral hygiene and flossing ability in records.

(iii)   Prior authorization is required for members who have a treatment plan requiring more than two (2) anterior and/or any posterior root canals.

(iv)   Pre and post-operative periapical images must be available for review.

(v)   Pulpal debridement may be performed for the relief of pain while waiting for the decision from the OHCA.

(vi)   Providers are responsible for any follow-up treatment required due to a failed root canal therapy for twenty-four (24) month post completion.

(vii)   Endodontically treated teeth should be restored to limited occlusal function and all contours should be replaced. These teeth are not automatically approved for any type of crown.

(L)   Space maintainers. Certain limitations apply with regard to this procedure. Providers are responsible for recementation of any maintainer placed by them for six (6) months post insertion.

(i)   Band and loop type space maintenance. This procedure must be provided in accordance with the following guidelines:

(I)   This procedure is compensable for all primary molars where permanent successor is missing or where succedaneous tooth is more than 5mm below the crest of the alveolar ridge.

(II)   First primary molars are not allowed space maintenance if the second primary and first permanent molars are present and in cuspal interlocking occlusion regardless of the presence or absence of normal relationship.

(III)   If there are missing posterior teeth bilaterally in the same arch, under the above guidelines, bilateral space maintainer is the treatment of choice.

(IV)   The teeth numbers shown on the claim should be those of the missing teeth.

(V)   Post-operative bitewing images must be available for review.

(VI)   Bilateral band and loop space maintainer is allowed if member does not have eruption of the four (4) mandibular anterior teeth in position or if sedation case that presents limitations to fabricate other space maintenance appliances.

(ii)   Lingual arch bar. Payment is made for the services provided in accordance with the following:

(I)   Lingual arch bar is used when permanent incisors are erupted and the second primary molar (K or T) is missing in the same arch.

(II)   The requirements are the same as for band and loop space maintainer.

(III)   Pre and post-operative images must be available.

(M)   Analgesia. Analgesia services are reimbursable in accordance with the following:

(i)   Inhalation of nitrous oxide. Use of nitrous oxide is compensable for four (4) occurrences per year and is not separately reimbursable, if provided on the same date by the same provider as IV sedation, non-intravenous conscious sedation, or general anesthesia. The medical need for this service must be documented in the member's record.

(ii)   Non-intravenous conscious sedation. Non-intravenous conscious sedation is not separately reimbursable, if provided on the same date by the same provider as analgesia, anxiolysis, inhalation of nitrous oxide, IV sedation, or general anesthesia. Non-intravenous conscious sedation is reimbursable when determined to be medically necessary for documented handicapped members, uncontrollable members or justifiable medical or dental conditions. The report must detail the member's condition. No services are reimbursable when provided primarily for the convenience of the member and/or the dentist, it must be medically necessary.

(N)   Pulp caps. Indirect and direct pulp cap must be ADA accepted calcium hydroxide or mineral trioxide aggregate (MTA) materials, not a cavity liner or chemical used for dentinal hypersensitivity. Indirect and direct pulp cap codes require specific narrative support addressing materials used, intent and reasons for use. Application of chemicals used for dentinal hypersensitivity is not allowed as indirect pulp cap. Utilization of these codes is verified by post payment review.

(O)   Protective restorations. This restoration includes removal of decay, if present, and is reimbursable for the same tooth on the same date of service with a direct or indirect pulp cap, if needed. Permanent restoration of the tooth is allowed after sixty (60) days unless the tooth becomes symptomatic and requires pain relieving treatment.

(P)   Smoking and tobacco use cessation counseling. Smoking and tobacco use cessation counseling is covered when performed utilizing the five (5) intervention steps of asking the member to describe his/her smoking, advising the member to quit, assessing the willingness of the member to quit, assisting with referrals and plans to quit, and arranging for follow-up. Up to eight (8) sessions are covered per year per individual who has documented tobacco use. It is a covered service when provided by physicians, physician assistants, nurse practitioners, certified nurse midwives, Oklahoma State Health Department (OSDH) and Federally Qualified Health Center (FQHC) nurses, and maternal/child health licensed clinical social workers with a Tobacco Treatment Specialist Certification (TTS-C). Chart documentation must include a separate note that addresses the 5A's, separate signature, and the member specific information addressed in the five (5) steps and the time spent by the practitioner performing the counseling. Anything under three (3) minutes is considered part of a routine visit.

(Q)   Diagnostic casts and/or oral/facial images. Diagnostic casts and/or oral/facial images may be requested by OHCA or representatives of OHCA. If cast and/or images are received they will be considered supporting documentation and may be used to make a determination for authorization of services. Submitted documentation used to base a decision will not be returned. Providers will be reimbursed for either the study model or images.

(i)   Documentation of photographic images must be kept in the client's medical record and medical necessity identified on the submitted electronic or paper claim.

(ii)   Oral/facial photographic images are allowed under the following conditions:

(I)   When radiographic images do not adequately support the necessity for requested treatment.

(II)   When photo images better support medical necessity for the requested treatment rather than diagnostic models.

(III)   If a comprehensive orthodontic workup has not been performed.

(iii)   For photographic images, the oral/facial portfolio must include a view of the complete lower arch, complete upper arch, and left and right maximum intercuspation of teeth.

(I)   Maximum intercuspation refers to the occlusal position of the mandible in which the cusps of the teeth of both arches fully interpose themselves with the cusps of the teeth of the opposing arch.

(II)   Intercuspation defines both the anterior-posterior and lateral relationships of the mandible and the maxilla, as well as the superior-inferior relationship known as the vertical dimension of occlusion.

(iv)   Study models or photographic images not in compliance with the above described diagnostic guidelines will not be compensable. The provider may be allowed to resubmit new images that adhere to the diagnostic guidelines. If the provider does not provide appropriate documentation, the request for treatment will be denied.

[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 15 Ok Reg 3822, eff 6-24-98 (emergency); Amended at 16 Ok Reg 692, eff 12-31-98 (emergency); Amended at 16 Ok Reg 1429, eff 5-27-99; Amended at 19 Ok Reg 2134, eff 6-27-02; Amended at 19 Ok Reg 2922, eff 7-1-02 (emergency); Amended at 20 Ok Reg 1193, eff 5-27-03; Amended at 20 Ok Reg 1924, eff 6-26-03; 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 530, eff 2-1-09 (emergency); Amended at 26 Ok Reg 2121, eff 6-25-09; Amended at 28 Ok Reg 1419, eff 6-25-11; Amended at 29 Ok Reg 1107, eff 6-25-12; Amended at 31 Ok Reg 665, eff 7-1-14 (emergency); Amended at 31 Ok Reg 1670, eff 9-12-14; Amended at 32 Ok Reg 1088, eff 8-27-15; Amended at 33 Ok Reg 51, eff 10-1-15 (emergency); Amended at 33 Ok Reg 832, eff 9-1-16; Amended at 34 Ok Reg 699, eff 9-1-17; Amended at 35 Ok Reg 116, eff 10-4-17 (emergency); Amended at 35 Ok Reg 1453, eff 9-14-18; Amended at 37 Ok Reg 1607, eff 9-14-20]