Effective for dates of service on or after December 1, 2025, dental benefit criteria will change for the Children with Special Health Care Needs (CSHCN) Services Program.
Changes will be made to:
- Dental services.
- First Dental Home services.
- Dental Prophylaxis services.
- Teledentistry services.
- Synchronous teledentistry services.
- Reimbursement.
Dental Services
Procedure code D9994 will become a benefit for clients who are 6 months through 35 months of age. Claims for reimbursement of procedure code D9994 may be payable to dentist, federally qualified health center (FQHC), and dentistry group providers for services rendered in the office setting.
Procedure code D9995 will become a benefit of the CSHCN Services Program, and claims for reimbursement may be payable to dentist, FQHC, and dentistry group providers for services rendered in the office setting.
First Dental Home Services
First Dental Home (FDH) providers can provide oral health care to clients who are 6 months of age or older. Providers must submit claims for reimbursement with procedure code D0145.
The FDH visit includes but is not limited to the following:
- Oral examination
- Caries risk assessment
The following services may be reimbursed separately when provided during an FDH visit:
- Oral examination for a client who is 3 years of age or younger (procedure code D0415)
- Dental case management and patient education to improve oral health literacy (procedure code D9994)
- Dental prophylaxis (procedure code D1120), if appropriate
- Topical fluoride application using fluoride varnish (procedure code D1206), if appropriate
Dental Prophylaxis Services
Procedure codes D1120 and D1206 may be performed every 60 days for clients who are 6 months through 35 months of age when provided on the same date of service as procedure code D0145 by any provider.
Procedure codes D1120 and D1206 will be limited to one service every six months, any provider, for clients who are 36 months of age or older.
Procedure code D1208 will be limited to once every six months by any provider.
Teledentistry Services
Teledentistry involves the use of telecommunication technology by a dentist to provide dental care services to a patient at a different site than the dental office.
Teledentistry services may be reimbursed through the CSHCN Services Program. Providers must comply with the Texas Dental Practice Act and the rules established by the Texas State Board of Dental Examiners (TSBDE) when delivering dental care through teledentistry. This includes any services that are performed by a licensed dental hygienist or dental assistant.
The client or their parent or guardian must give consent before the client receives teledentistry services. In addition, all teledentistry services must:
- Meet the same standard of care as services that are delivered in-person.
- Be delivered using synchronous real-time audiovisual technologies.
If teledentistry services are provided outside of the frequency limits specified in the periodicity schedule, they may be reimbursed when medically necessary and when they meet the criteria for procedure codes D0120 and D0140.
A periodic oral evaluation (procedure code D0120) may be delivered as a teledentistry service when the following criteria are met:
- The client must be 3 years through 20 years of age.
- A dental hygienist who is trained to operate the teledentistry platform must operate it at the patient site.
A limited problem-focused oral evaluation (procedure code D0140) may be delivered as a teledentistry service when a dental hygienist who is trained to operate the teledentistry platform operates it at the patient site.
Any subsequent dental evaluation visit following a teledentistry visit must be provided in-person.
Synchronous Teledentistry Services
Real-time encounter procedure code D9995 must be included on the claim form when procedure code D0120 or D0140 is provided as a teledentistry service. Procedure code D9995 is not separately reimbursable.
When procedure code D0120 or D0140 is provided as a teledentistry service, the client’s medical record must include documentation confirming that the provider used synchronous real-time audiovisual technologies. This documentation must specify the following:
- The name and credentials of the dental health care professional
- The location of the dentist at the time of service
Reimbursement
Procedure codes D0120, D0150, D0160, D0170, D0180, D1208, and D8660 will be denied when billed by any provider on the same date of service as procedure code D0145.
Procedure code D0160 will be denied if billed on the same date of service as procedure code D8080 by the same provider.
Procedure code D0120 will be denied when billed within six months of procedure code D0150 by the same provider.
Procedure code D0120 will be denied when billed within 30 days of procedure code D4266 or D4355 by the same provider.
Procedure code D1120 will be denied when billed within 30 days of procedure code D4355 by the same provider.
Procedure code D8660 will be denied as part of another service when billed for the same date of service by the same provider as procedure code D0120, D0150, or D0160.
Procedure code D9994 will be denied unless it is billed with procedure code D0145 on the same date of service by the same provider.
Procedure codes D0330, D0340, D0350, D0470, and D8660 will be denied when submitted with procedure code D8080.
Procedure code D0180 will be denied as part of another service when billed on the same date of service as procedure code D0120, D0140, D0150, D0160, or D0170.
For more information, call the TMHP-CSHCN Services Program Contact Center at 800-568-2413.