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Texas Health Steps Therapeutic Dental Benefit Changes Effective September 1, 2020

Last updated on 7/17/2020

Note: Texas Medicaid managed care organizations (MCOs) must provide all medically necessary, Medicaid-covered services to eligible clients. Administrative procedures such as prior authorization, pre-certification, referrals, and claims/encounter data filing may differ from traditional Medicaid (fee-for-service) and from MCO to MCO. Providers should contact the client's specific MCO for details.

Effective for dates of service on or after September 1, 2020, therapeutic dental benefit criteria will change for Texas Health Steps.

Prior Authorization

Each distinct dental procedure code to be performed that requires prior authorization must be listed on the Texas Health Steps Dental Mandatory Prior Authorization Request Form. Repetitive dental procedure codes must be listed to indicate the total quantity to be performed. Claims submitted with unauthorized procedure codes will be denied, but may be appealed with documentation of medical necessity.

Procedure code D7283 is for permanent dentition only (tooth identification [TID] 2-15 and 18-31) and requires prior authorization. To obtain prior authorization, the following items must be submitted: a prior authorization request form, a copy of an authorized Medicaid orthodontic treatment plan, and a current panoramic radiograph to determine medical necessity.

Procedure code D7280 will be denied unless billed with an authorized procedure code D7283 for the same tooth, on the same day, by the same provider.

Crowns, inlays, endodontic endosseous implants, and fixed prosthodontics require mandatory prior authorization.

Reimbursement

Procedure codes D2140, D2150, D2330, D2331, D2390, D2391, and D2392 are benefits under Texas Health Steps Dental for clients who are birth through 20 years of age and clients who are 21 years of age and older residing in an intermediate care facility for individuals with intellectual or developmental disabilities (ICF-IID) facility.

Procedure codes D2160, D2161, D2332, D2335, D2393, and D2394 are benefits under Texas Health Steps Dental for clients who are 1 year through 20 years of age and clients who are 21 years of age and older residing in and ICF-IID facility.

The following dental restoration procedure codes will be limited to once per rolling year, for the same TID, by the same provider:

Procedure Codes

D2140

D2150

D2160

D2161

D2330

D2331

D2332

D2391

D2392

D2393

D2394

     

Procedure codes D2335 and D2390 when provided to primary teeth will be limited to once per lifetime, same TID, any provider, and will be denied if any of the following anterior restorations have been paid within a rolling year, for the same TID, by the same provider as:

Procedure Codes

D2140

D2150

D2160

D2161

D2330

D2331

D2332

D2335

D2390

D2930

D2932

D2933

D2934

 

Total reimbursement for direct restorations on primary teeth cannot exceed the total dollar amount for a prefabricated stainless steel crown on a primary tooth, procedure code D2930, per TID, per date of service. Total reimbursement for direct restorations on permanent teeth cannot exceed the total dollar amount for a prefabricated stainless steel crown on a permanent tooth, procedure code D2931, per TID, per date of service. This limitation does not apply to procedure code D2335 for primary or permanent teeth.

Direct Restorations and Other Restorative Services

Procedure codes D2931 and D2932 are a benefit for Texas Health Steps Dental for clients who are 1 year through 20 years of age and clients who are 21 years of age and older residing in an ICF-IID facility.

Procedure code D2932 is a benefit for primary teeth C-H and M-R, and all permanent teeth.

Procedure codes D2933 and D2934 are a benefit for primary teeth C-H and M-R only.

Direct restoration of a primary tooth with the use of a prefabricated crown will be considered as a once in a lifetime restoration, same TID, any provider. Exceptions may be considered when pre-treatment X-ray images, intra-oral photos, and narrative documentation clearly support the medical necessity for the replacement of the prefabricated crown procedure codes D2930, D2932, D2933, and D2934 during pre-payment review.

Procedure code D2930 will be denied if the following procedure codes have been billed within a rolling year, for the same TID, by the same provider:

Procedure Codes

D2140

D2150

D2160

D2161

D2330

D2331

D2332

D2335

D2390

D2391

D2392

D2393

D2394

 

Procedure codes D2933 and D2934 will be denied if the following procedure codes have been billed within a rolling year, for the same TID, by the same provider:

Procedure Codes

D2140

D2150

D2160

D2161

D2330

D2331

D2332

D2335

D2390

         

Procedure codes D2931 and D2932 will be denied if the following procedure codes have been billed within a rolling year, for the same TID, by the same provider:

Procedure Codes

D2140

D2150

D2160

D2161

D2330

D2331

D2332

D2335

D2390

D2391

D2392

D2393

D2394

D2931

D2932

           

Dental Anesthesia

All providers must have the appropriate anesthesia permit when proceeding with the procedure codes D9211, D9212, D9222, D9223, D9230, D9239, D9243, and D9248.

For more information, call the TMHP Contact Center at 800-925-9126.