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CSHCN Services Program Provider Manual Update for Restorative Dental Services

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Beginning May 1, 2022, Texas Medicaid & Healthcare Partnership (TMHP) will update the Children with Special Health Care Needs (CSHCN) Services Program Provider Manual to add prior authorization and reimbursement language for restorative dental services.

The following language will be added to section 14.2.6.4, “Restorations”:

Restorations do not require prior authorization except for onlays and crowns.

Reimbursement for crowns and onlay restorations are payable once per client per tooth every ten years. Additional crowns and onlays may be considered for prior authorization and documentation of medical necessity.

A postoperative bitewing radiograph (for posterior teeth) or a postoperative periapical radiograph (for anterior teeth) will need to be submitted with claims for crowns and onlays that the provider submits to TMHP for reimbursement to verify that the services meet the standard of care.

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