TMPPM 2008 > Texas Medicaid Services > Dental > Benefits and Limitations

19.15.4 Therapeutic Services

19.15.4.1 Medicaid Reimbursement Limitations

Medicaid reimbursement is contingent on compliance with the following limitations:

•For documentation requirements, refer to "Documentation Requirements" .

•Total restorative fee per tooth on primary teeth cannot exceed $156.06, the fee for a stainless steel crown. (Exception: D2335)

•All fees for tooth restorations include local anesthesia and indirect pulp protective media, including bases where indicated, without additional charges. These services are considered part of the restoration.

•More than one restoration on a single surface is considered a single restoration.

•To be considered as a multiple surface restoration, the restoration must show definite crossing of the plane of each surface listed for each primary and permanent tooth completed.

•A multiple surface restoration cannot be billed as two or more separate one-surface restorations.

•Restorations and therapeutic care are provided as a Medicaid service based on medical necessity and reimbursed only for therapeutic reasons and not preventive purposes (refer to CDT).

All dental restorations and prosthetic appliances that require lab fabrication may be submitted for reimbursement using the date the final impression was made as the date of service. If the client does not return for final seating of the restoration or appliance, a narrative must be included on the claim form and in the client's chart in lieu of a postoperative radiograph. The 95-day filing deadline is in effect from the date of the final impression. If the client returns to the office after the claim has been filed, the dentist is obligated to attempt to seat the restoration or appliance at no cost to the client or the Texas Medicaid Program. For records retention requirements, refer to "Documentation Requirements" .

Direct pulp caps may be reimbursed separately from any final tooth restoration performed on the same tooth (as noted by the TID) on the same date of service by the same provider.