5300, Dental Utilization Review of Dental Services

Revision 17-1; Effective November 1, 2017

HHSC may choose to use a Texas licensed dentist to review a CLASS IPC that includes dental services to obtain needed expert opinion. HHSC staff may consult with a licensed dentist concerning dental services proposals if:

  • the cost of dental treatment exceeds a $2,000 limit;
  • a decision regarding medical need is required;
  • a determination regarding cost effectiveness is needed; or
  • a determination if the dental service requested is an allowable service.

The dentist identified by HHSC to perform dental UR may request additional items (e.g., x-rays, etc.) from the dentist who developed the dental treatment plan, as necessary. The HHSC dentist may contact the treating dentist by telephone, or by using secure e-mail if it is a matter of missing information or clarification. HHSC staff will keep a record of any additional information requested by the HHSC dentist to perform dental UR from the treating dentist, as well as the rationale provided by the HHSC dentist for denying or approving the request.
The HHSC dentist may make cost effectiveness determinations based on the most recently issued version of the Survey of Dental Fees published by the American Dental Association (ADA).