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CSHCN Dental Therapeutic Services Benefit Changes, Effective September 1, 2020

Last updated on 8/14/2020

Effective for dates of service on or after September 1, 2020, therapeutic dental benefit criteria will change for the Children with Special Health Care Needs (CSHCN) Services Program.

Prior Authorization

Each distinct dental procedure code to be performed that requires prior authorization must be listed on the CSHCN Services Program Prior Authorization Request for Dental or Orthodontia Services Form. Repetitive dental procedure codes must be listed to indicate the total quantity to be performed.

Procedure code D7283 is for permanent dentition only (tooth identification [TID] 2-15 and 18-31) and requires prior authorization. To obtain prior authorization, a copy of the orthodontic treatment plan must be submitted along with a current panoramic radiograph to determine medical necessity and a CSHCN Services Program Prior Authorization Request for Dental or Orthodontia Services Form.

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.

Restorations

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, for the same TID, to 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, D2931, D2392, D2933, D2934

Total reimbursement for direct restorations cannot exceed the total dollar amount allowed for a stainless steel crown, per TID, per date of service. This limitation does not apply to procedure code D2335.

Procedure code D2932 is a benefit for primary teeth C-H, 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 through the use of a prefabricated crown will be considered as a once in a lifetime restoration, same TID, by 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, or 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

For more information, call the TMHP-CSHCN Services Program Contact Center at 800-568-2413.