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. Please
Compliance for the Dental Professional from the Centers for Medicare &
Medicaid Services (CMS) to learn about compliance facilitation and good
documentation procedures, as well as access a Program Integrity Toolkit.
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
• 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-13D | Dental Prior Authorization
- 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
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:
P.O. Box 548804
Oklahoma City, OK 73154
We are unable to accept faxed PA
How to submit dental PAs on the
Provider Portal (Tutorial)
General Dental Prior Authorizations
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:
comprehensive treatment plan,
right and left mounted bitewing
x-rays or panoramic x-ray, and
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
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):
ADA claim form and HLD-1 form;
model images or Study Models (images preferred);
- Referral letter from
the member’s general dentist;
description of any oral maxillofacial anomaly;
length of treatment;
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;
x-rays with tracing, and panoramic film, with a request for prior
authorization of comprehensive orthodontic treatment;
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.
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.
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,
Dental Periodicity Schedule
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.