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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 : 4.2.15 Therapeutic Services

4.2.15
Medicaid reimbursement is contingent on compliance with the following limitations:
Refer to:
The total reimbursement for restorative services of a primary tooth over a 6-month period cannot exceed the fee for a stainless steel crown (with the exception of D2335 and D2933), when provided by the same dentists within a dental group. An exception will be considered when pre-treatment X‑ray images, intra-oral photos, and narrative documentation clearly support the medical necessity of the retreatment dental services during pre-payment review.
Restoration of a primary tooth through the use of a stainless steel crown is considered to be a once-in-a-lifetime restoration. An exception will be considered when pre-treatment X-ray images, intra-oral photos, and narrative documentation clearly support the medical necessity of the replacement of the stainless steel crown during pre-payment review.
All fees for tooth restorations include local anesthesia and pulp protective media, where indicated, without additional charges. These services are considered part of the restoration.
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 DOS. If the client did 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 Texas Medicaid. For records retention requirements, refer to subsection 4.3, “Documentation Requirements” in this handbook.
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 DOS by the same provider.

Texas Medicaid & Healthcare Partnership
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