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.
Effective for dates of service on or after March 1, 2025, dental benefit criteria will change for Texas Health Steps.
The changes to dental benefit criteria are as follows:
- Procedure code D9994 will become a benefit covering patient education to improve oral health literacy.
- Procedure code D9995 will become a benefit to be billed with procedure codes D0120 and D0140 to indicate that the dental service was performed as teledentistry.
- First Dental Home (FDH) services may be reimbursed separately.
New Dental Services Benefit
Procedure code D9994 will become a benefit for clients who are 6 months through 35 months of age and may be reimbursed to federally qualified health centers (FQHC), Texas Health Steps dental, and local health department providers for services rendered in the office setting.
Procedure code D9995 will become a benefit for clients who are 3 years through 20 years of age when provided with procedure code D0120 and birth through 20 years of age when provided with procedure code D0140 and may be reimbursed to FQHC, Texas Health Steps dental, oral maxillofacial surgeons, and local health department providers for services rendered in the office setting.
First Dental Home
By providing a dental home for a client, the dental provider can help clients of all ages to receive the best oral health care. An FDH visit can be scheduled for clients as young as 6 months of age and is billed using procedure code D0145. The FDH visit includes but is not limited to:
- Oral examination.
- Caries risk assessment.
The following services may be reimbursed separately when provided during an FDH visit:
- Oral evaluation for a client who is 3 years of age or younger (procedure code D0145)
- Dental case management and patient education to improve oral health literacy (procedure code D9994) when providing dental anticipatory guidance
- Dental prophylaxis (procedure code D1120) if appropriate
- Topical fluoride application using fluoride varnish (procedure code D1206) if appropriate
Caries susceptibility tests are considered part of dental evaluation procedures and are not reimbursed separately.
Services billed under procedure code D0145 may be performed every 60 days for clients who are 6 months through 35 months of age for the same procedure by any provider.
Procedure code D0145 will be limited to individual dentists certified by the Texas Health Steps dental program to perform the service.
Services billed under procedure codes D1120 and D1206 may be performed every 60 days for clients 6 months through 35 months of age when provided on the same date of service as D0145 by any provider.
Procedure codes D1120 and D1206 will be limited to once every six months, any provider, for clients who are 35 months of age or older.
Procedure code D1208 will be limited to once every six months by any provider.
Teledentistry Services
When provided as a teledentistry service procedure code D0120 or D0140, must be billed with teledentistry procedure code D9995.
Teledentistry refers to the use of communication technology by a dentist to provide dental care services to a patient at a different physical location than the office setting.
Teledentistry services may be reimbursed by Texas Medicaid.
Texas Health Steps dental providers must follow the rules and regulations of the Texas Dental Practice Act and Texas Board of Dental Examiners (TSBDE) in regard to the practice of teledentistry and the work that may be delegated to a licensed dental hygienist or dental assistant.
Dental services delivered using teledentistry must meet the same standard of care as the same dental health service or procedure provided in an in-person setting.
For dental services delivered through a dental maintenance organization (DMO), providers must refer to the individual DMO benefit package for information on teledentistry services.
The service must be delivered using only synchronous real-time audiovisual technologies.
The client or parent/guardian must agree to receiving the teledentistry service.
Services provided through teledentistry outside of the frequency specified in the periodicity schedule may be reimbursed when medically necessary and criteria for procedure code D0120 or D0140 are met.
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.
- The teledentistry platform must be operated at the patient site by a dental hygienist trained in its operation.
A limited problem-focused oral evaluation (procedure code D0140) may be delivered as a teledentistry service when the following criteria are met:
- The client must be birth through 20 years of age.
- The teledentistry platform must be operated at the patient site by a dental assistant or hygienist trained in its operation.
Synchronous Teledentistry
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, additional documentation in the client’s dental record must indicate that the service was provided using synchronous real-time audiovisual technologies. The documentation must include 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 D8070 or D8080 by the same provider.
Procedure code D0120 will be denied when billed within six months of D0150 by the same provider.
Procedure code D9994 will be denied unless billed with procedure code D0145 on the same day by the same provider.
Procedure code D8660 will be denied when billed for the same date of service by the same provider as procedure code D0120, D0150, or D0160.
Procedure codes D0330, D0340, D0350, D0470, and D8660 will be denied when submitted with procedure codes D8070 and D8080.
Procedure code D0180 will be denied when billed on the same date of service by the same provider as procedure code D0120, D0140, D0150, D0160, or D0170.
For more information, call the TMHP Contact Center at 800-925-9126.