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2012 Texas Medicaid Provider Procedures Manual

Children’s Services Handbook : 4. Texas Health Steps (THSteps) Dental : 4.2 Services, Benefits, Limitations, and Prior Authorization : 4.2.23 Hospitalization and ASC/HASC

Dental services performed in an ASC, HASC, or a hospital (either as an inpatient or an outpatient) may be benefits of THSteps based on the medical or behavioral justification provided, or if one of the following conditions exist:
To satisfy the preadmission history and physical examination requirements of the hospital, ASC, or HASC, a THSteps medical checkup for dental rehabilitation or restoration may be performed by the child’s primary care provider. Physicians who are not enrolled as THSteps medical providers must submit claims for the examination of a client before the procedure with the appropriate evaluation and management procedure code from the following table:
Refer to:
The dental provider must submit claims to TMHP using the ADA Dental Claim Form to be considered for reimbursement through THSteps Dental Services.
The dental provider is responsible for obtaining prior authorization for the services performed under general anesthesia. Hospitals, ASC’s, and anesthesiologists must obtain the prior authorization number from the dental provider.
Contact the individual HMO for precertification requirements related to the hospital procedure. If services are precertified, the provider receives a precertification number effective for 90 days.
In those areas of the state with Medicaid managed care, the provider should contact the managed care plan for specific requirements or limitations. It is the dental provider’s responsibility to obtain precertification from the client’s HMO or managed care plan for facility and general anesthesia services if precertification is required.
To be reimbursed by the HMO, the provider must use the HMO’s contracted facility and anesthesia provider. These services are included in the capitation rates paid to HMOs, and the facility or anesthesiologist risk nonpayment from the HMO without such approval. Coordination of all specialty care is the responsibility of the client’s primary care provider. The primary care provider must be notified by the dentist or the HMO of the planned services.
Dentists providing sedation or anesthesia services must have the appropriate current permit from the TSBDE for the level of sedation or anesthesia provided.
The dental provider must be in compliance with the guidelines detailed in General Information.

Texas Medicaid & Healthcare Partnership
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