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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 : 4.2.30 Emergency or Trauma Related Services for All THSteps Clients and Clients Who Are 5 Months of Age and Younger

4.2.30
THSteps clients who are birth through 5 months of age are not eligible for routine dental checkups; however:
Prior authorization is not required for emergency or trauma-related dental services. Claims for these dental services must be filed separately from nonemergency dental services. Only one emergency or trauma-related dental claim per client, per day, may be considered for reimbursement. Routine therapeutic procedures are not considered emergency or trauma-related procedures.
When submitting a claim for emergency or trauma-related dental services, the provider must:
Enter the word “Emergency” or “Trauma” in the description field (Block 30) of the claim form (also enter a brief description of the CDT procedure code used). Claims are subject to retrospective review. If no comments are indicated on the claim form, the payment may be recouped.
Check the appropriate box in Block 45, Treatment Resulting From, of the claim form (the options to check are Occupational Illness/Injury, Auto Accident, or Other Accident).
Documentation to support the diagnosis and treatment of trauma must be retained in the client’s record.
Note:
Indicating Trauma in the description field allows the provider to be reimbursed for treatment on an emergency, continuing, and long-term basis without regard to periodicity, subject to the client’s eligibility and program limitations. An exception to periodicity for THSteps dental services is granted automatically for immediate treatment and any future follow-up treatment, as long as each claim submitted for payment is marked “Trauma” in the Description field, Block 30, and the original date of treatment or incident is referenced in the Remarks field, Block 35.
Refer to:
Subsection 6.7, “2012 American Dental Association (ADA) Dental Claim Filing Instructions” in Section 6, “Claims Filing” (Vol. 1, General Information).
Subsection 4.1, “General Medicaid Eligibility” in Section 4, “Client Eligibility” (Vol. 1, General Information).
Subsection 9.3, “Doctor of Dentistry Practicing as a Limited Physician” in the Medical and Nursing Specialists, Physicians, and Physician Assistants Handbook (Vol. 2, Provider Handbooks).
Subsection 4.2.12, “Medicaid Dental Benefits, Limitations, and Fee Schedule” of this handbook.

Texas Medicaid & Healthcare Partnership
CPT only copyright 2014 American Medical Association. All rights reserved.