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December 2016 Texas Medicaid Provider Procedures Manual

Children’s Services Handbook : 4 Texas Health Steps (THSteps) Dental : 4.2 Services, Benefits, Limitations, and Prior Authorization : 4.2.10 Periodicity for THSteps Dental Services : 4.2.10.1 Exceptions to Periodicity

4.2.10.1
If a periodic dental checkup has been conducted within the last six months, the client still may be able to receive another periodic dental checkup in the same six-month period by any provider. For THSteps clients, exceptions to the six-month periodicity schedule for dental checkup services may be approved for one of the following reasons:
Required to meet federal or state exam requirements for Head Start, daycare, foster care, preadoption, or to provide a checkup prior to the next periodically-due checkup if the client will not be available when due. This includes clients whose parents are migrant or seasonal workers.
Subsequent therapeutic services necessary to complete a case for clients who are 5 months of age and younger when initiated as emergency services, for trauma, or early childhood caries.
It is the provider’s responsibility to verify that the client is eligible for the date that dental services are to be provided. Eligibility may be verified through www.YourTexasBenefitsCard.com, TexMedConnect, or the TMHP Contact Center.
When the need for an exception to periodicity is established, a narrative explaining the reason for the exception to periodicity limitations must be documented in the client’s file and on the claim submission. For claims filed electronically, check “yes” when prompted. For claims filed on paper, place comments in Block 35.
For ICF-IID clients who are 21 years of age and older, the periodicity schedule for preventive dental procedures (exams, prophylaxis, fluoride, and radiographs) does not apply.

Texas Medicaid & Healthcare Partnership
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