Dental

 

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 What We Do

SoonerCare (Oklahoma Medicaid) pays for preventative, diagnostic and restorative services for eligible members under the age of 21. Some limited exams, limited x-rays and emergency extractions are covered for eligible recipients age 21 and over.  

The Oklahoma Health Care Authority (OHCA) is governed by the Oklahoma Administrative Rules 317:30-5 and uses the dental codes identified in the Current Dental Terminology (CDT) Manual.  

OAR 317:30-5 PART 79. DENTISTS

Fee Schedules

• Dental Fees - (you must agree to the terms for usage before downloading the PDF file)

Commonly Used Forms

  •  DEN-5 | Ortho Dismissal Request Form   
  •  DEN-4 | Orthodontic Expectations Agreement
  •  DEN-3 | Change of Dental Provider Request Form
  •  DEN-2 | Referral for Orthodontic Treatment Form
  •  HCA-15 | CMS-1500, Dental, Crossover Part B Paid Claim Adjustment Request Form
  •  HCA-17 | Claim Inquiry Form
  •  HLD-1 | Index of Malocclusion Form

Services Requiring Prior Authorizations

All requests must demonstrate medical necessity. 

OHCA’s dedicated staff within Provider Services will assist dental providers with prior authorizations. Please call 405-522-7401 for assistance. 

PA requests must be mailed to: 
OHCA Dental Unit 
4345 N. Lincoln Blvd.
Oklahoma City, OK  73105
 

We are unable to accept faxed PA submissions. 

How to submit dental PAs on the Provider Portal (Tutorial) 

General Dental Prior Authorizations

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PA requests (PARs) should be filed on the currently approved American Dental Association (ADA) claim form accompanied by sufficient documentation (e.g.., study models where indicated, radiographs or images to substantiate need, and documentation that the requested services would be within the scope of the OHCA Dental Program). 

Minimum required records to be submitted with each dental PAR are: 

1.      comprehensive treatment plan, 

2.      right and left mounted bitewing x-rays or panoramic x-ray, and 

3.      periapical films of tooth/teeth involved or the edentulous areas if not visible in the bitewings.  

X-rays and/or images must be identified by the tooth number and include date of exposure, member name, member ID, provider name, and provider ID. All x-rays or images, regardless of the media, must be submitted together with a completed and signed comprehensive treatment plan that details all needed treatment at the time of examination and a completed current ADA form requesting all treatments requiring PA.  The film/print must also clearly identify the requested service. If you are requesting periodontal services, please also send periodontal charting. Records will not be returned. 

Please note that providers are notified via the OHCA Provider Portal as to whether services are denied or approved. A letter is also mailed to the member’s family. 

Orthodontic Prior Authorizations

Orthodontic PA requests should be submitted on the current ADA claim form accompanied by sufficient documentation to ensure that the requested services would be within the scope of the OHCA Dental Program. 

In order to efficiently process your requests for minor and comprehensive orthodontia (all D8000 series), please be sure to place the following in ONE BOX or ENVELOPE: 

The following information is required to process all requests for comprehensive orthodontics (braces): 

  • Current ADA  claim form and HLD-1 form;  
  • 3-D model images or Study Models (images preferred); 
  • Panoramic x-ray; 
  • Referral letter from the member’s general dentist; 
  • Detailed description of any oral maxillofacial anomaly; 
  • Estimated length of treatment; 
  • Intraoral photographs showing teeth in centric occlusion and/or photographs of trimmed anatomically occluded diagnostic casts. A lingual view of casts may be included to verify impinging overbites; 
  • Cephalometric x-rays with tracing, and panoramic film, with a request for prior authorization of comprehensive orthodontic treatment; 
  • If diagnosed as a surgical case, submit an oral surgeon's written opinion that orthognathic surgery is indicated and the surgeon is willing to provide this service 

If you are sending several requests at once, they may be sent in one large box or envelope, but please DO NOT SEPARATELY MAIL the paperwork from the other documentation. Records will not be returned. 

Please note that  study models, film, digital media or printoust must be of sufficient quality to clearly demonstrate for the reviewer the pathology which is the basis for the minor orthodontics (orthodontic appliances) requested. . Providers are notified via the OHCA Provider Portal Secure Site as to whether services are denied or approved. A letter is also mailed to the member’s family. 

 

Radiographs (X-rays) 

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Please note the guidelines from the ADA and the Food and Drug Administration (FDA) regarding radiographs. OAR 317:30-5-696(3)(D) requires that all x-rays be medically necessary. Non-routine dental procedures require PA. X-rays must be identified by left and right sides with the date, member name, member ID, provider name, and provider ID. 

Reconsiderations

If a PAR is denied, the provider may resubmit the request for reconsideration.  

Please check the notes associated with the denial including the External Notes that can be found on the PA Management page of the OHCA Provider Portal. These notes will indicate the reason for the denial. Reconsiderations should address the reasons for the denial. Additionally, reconsiderations require the same documentation as the initial PA request AND supplementary supporting documentation (narrative, x-rays, etc.). 

Dental Periodicity Schedule

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The OHCA Dental Advisory Committee on Periodicity (DACP) intends this guideline to help providers make clinical decisions concerning preventive oral health care for infants, children, and adolescents. Because each child is unique, these recommendations are designed for the care of children who have no contributory medical conditions and who are developing normally. These recommendations will need to be modified for children with special health care needs or if disease or trauma manifests variations from the normal. The American Academy of Pediatric Dentistry (AAPD) and DACP emphasize the importance of very early professional intervention and the continuity of care based on the individualized needs of the child. 

Services for Waiver Members with Developmental Disabilities

Dental benefits for adult SoonerCare members served through the In-Home Supports Waiver or Community Waiver have been expanded. Adults with developmental disabilities served in these waivers are evaluated by their case managers for initial services such as a general exam, cleaning and x-rays. Requests for additional treatment may now be directed to the case manager to include up to $1,000 in services such as fillings and root canals in the plan of care year.  

All services must be prior authorized by the member’s case manager. The Oklahoma Department of Human Services Developmental Disabilities Services Division has prepared information packets about the expanded benefits to distribute to interested dental providers. Packets are available upon request from the local DDSD nurse or Julie Whitworth at the DHS state office, 405-521-2237.