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)
New Caries Risk Assessment Dental Codes
The Oklahoma Health Care Authority has introduced coverage
of caries risk assessment dental codes D0601, D0602 and D0603. The concept of
risk-based dental caries management is not new and is based on the belief that
dentists can use certain indicators to classify caries risk status. Assessment
should allow for targeted patient/guardian education and engagement in the
caries prevention process. Use of this tool will also aid in more accurate
predictions of future caries experience and provide a basis to determine if
preventive services can be planned more appropriately with the data
Your evaluation of each individual member’s caries risk will determine
the correct D code to submit for reimbursement - depending upon whether the
member is found to be low, moderate or high risk. The updated form is
available for download on the OHCA website. Dentists are able to submit a
request for payment by completion and submission of the Oklahoma
Health Care Authority Caries Risk Assessment Form and signed instructions page. The completed caries risk assessment form should be uploaded
via the SoonerCare provider portal for authorization. All signatures and boxes
must be completed. The caries risk code submitted for payment must reflect the
findings on the completed form. The assessment may be reimbursed once per
member per year. Submission of the OHCA Caries Risk Assessment form is now required, in
addition to the DEN-2 form, when referring SoonerCare members for orthodontic
you have additional questions or comments, contact the OHCA Dental Unit at
Commonly Used Forms
Services Requiring Prior Authorizations
All requests must demonstrate medical
necessity. Providers have 7 days to submit additional information for any PAR that was pended for additional documentation. After 7 days, the PAR will "system cancel" and must submit a new PAR with all necessary documentation.
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 theProvider 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):
- Caries Risk Assessment
ADA claim form and DEN-6 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 printouts 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.
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.