Dental

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 (see also Perinatal Dental Access Program below). We use the dental codes identified in the Current Dental Terminology Manual. We are governed by the Oklahoma Administrative Rules 317:30-5.

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
  • DEN-1 | Perinatal Dental Confirmation of Pregnancy Form
  • HLD-1 | Index of Malocclusion Form

Services Requiring Prior Authorizations

All requests must demonstrate medical necessity.

OHCA staffs a Dental Prior Authorization Unit within Provider Services to assist dental providers with prior authorizations. Please call 405-522-7401 for assistance.

Prior Authorization Requests must be mailed to: 
OHCA Dental Unit 
2401 NW 23rd St., St 1A 
Oklahoma City, OK  73107 

We are unable to accept faxed or online PA submissions.

General Dental Prior Authorizations

Request for prior authorization should be filed on the currently approved American Dental Association (ADA) claim form accompanied by sufficient documentation, i.e., study models (where indicated), radiographs 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 Prior Authorization request 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. Each film/print must be identified as to left and right. The film/print must clearly identify the requested service. Tooth or teeth numbers with surfaces involved should be listed, and x-rays mounted and identified with member’s name and SoonerCare number, provider group’s name and SoonerCare provider ID, and the rendering dentist’s name and SoonerCare ID. This should be stapled to the claim form. If you are requesting periodontal services please also send periodontal charting. Records will not be returned.

Please note that providers will be notified via Provider Secure Site indicating services were denied or approved. A letter is mailed to the member’s family.

Orthodontic Prior Authorizations

Request for prior authorization 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/records are 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 images or study models, and panoramic x-rays are required for evaluation of minor orthodontics (orthodontic appliances). Please note that providers will be notified via Provider Secure Site indicating services were denied or approved. A letter is mailed to the member’s family.

Radiographs (X-rays)

Please note the guidelines from the American Dental Association and the Food and Drug Administration regarding radiographs. OAR 317:30-5-696(3)(D) requires that all x-rays be medically necessary. Non-routine dental procedures require a prior authorization. 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 request for a prior authorization has been 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 secure website. These notes will indicate the reason for the denial. Reconsiderations should address the reasons for the denial.  Reconsiderations require the same documentation as the initial prior authorization request, AND additional supporting documentation (narrative, x-rays, etc).

Dental Periodicity Schedule

The Oklahoma Health Care Authority 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 AAPD and DACP emphasizes the importance of very early professional intervention and the continuity of care based on the individualized needs of the child.

Dental Questions Asked by Parents

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.