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Limitation Criteria for First Dental Home Examinations Added to TMPPM and CSHCN Services Program Provider Manuals

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Note: Texas Medicaid managed care organizations (MCOs) must provide all medically necessary, Medicaid-covered services to Medicaid members who are enrolled in their MCO. Administrative procedures, such as prior authorization, precertification, referrals, and claims and encounter data filing, may differ from traditional Medicaid (fee-for-service) and from MCO to MCO. Providers should contact the member’s specific MCO for details.

Beginning June 1, 2023, the Texas Medicaid & Healthcare Partnership (TMHP) will update the Texas Medicaid Provider Procedures Manual (TMPPM) and the Children with Special Health Care Needs (CSHCN) Services Program Provider Manual to add limitation criteria for procedure code D0145 (first dental home examination). The criteria will state that procedure code D0145 is limited to one service per day and ten services per client lifetime with at least 60 days between visits by any provider.

The limitation will be added to:

  • The Texas Medicaid Provider Procedures Manual, Children’s Services Handbook, section 3.2.9 “First Dental Home”.
  • The Children with Special Health Care Needs Services Program Provider Manual, subsection 14.2.3.2 “Clinical Oral Evaluations” and subsection 14.2.3.4 “First Dental Home”.

For more information, call the TMHP Contact Center at 800-925-9126 or the TMHP-CSHCN Services Program Contact Center at 800-568-2413.