H-2700, Dental

Revision 17-4; Effective December 1, 2017

Dental services that are not medically contraindicated for the individual may be allowable incurred medical expense (IME) deductions. Requests for dental IMEs must include the following:

  • a completed, signed Form H1263-B, Certification of No Medical Contraindication – Dental; and
  • an invoice or billing statement indicating the dental services provided, the date of the dental services, and the appropriate Current Dental Terminology (CDT) code(s).

A treatment plan is not required, but may be received along with an invoice or billing statement.

A treatment plan is a schedule of procedures and appointments needed to restore, step-by-step, an individual’s oral health.  The treatment plan must be presented to the individual for approval and should include:

  • a description of the individual’s condition;
  • the duration of the treatment plan as prescribed by the dentist; and
  • a list of the dental procedures recommended by the dentist, including:
    • a description of each service or procedure;
    • the appropriate Current Dental Terminology (CDT) code; and
    • the expected cost for each service.   

Invoice or Billing Statement - A summary of the dental services provided and the amount the individual is expected to pay the dentist. The invoice should include the:

  • date(s) of the dental service(s);
  • description of each dental procedure provided;
  • appropriate CDT code(s) for each dental procedure; and
  • cost for each dental procedure provided. 

Note: If the individual has dental insurance, the invoice must reflect any services covered by the dental insurance plan and clearly indicate the remaining balance after any adjustments.

Form H1263-B, submitted with a dental invoice, is only valid for the delivered services listed on the invoice.

Form H1263-B, submitted with a proposed treatment plan, is valid for up to 12 months for dental services:

  • identified on the dental treatment plan; and
  • delivered within 12 months of the date of the initial dental treatment.

All IME requests for dental services associated with a dental treatment plan must include an invoice indicating the dental services provided, the date the services were provided, and the appropriate CDT code(s).

Note: Additional dental services not listed on the original treatment plan and/or dental services provided past the 12 months require a new Form H1263-B.

Form H1263-B, signed by the attending physician, is verification that the requested dental services are not medically contraindicated. If Form H1263-B is received from a requester with a notation that the attending physician does not agree that the procedure is not medically contraindicated for the recipient, deny the IME request. Notify the provider and the recipient or recipient's authorized representative of the denial using the appropriate notice.

If Form H1263-B is received from a requester without a physician signature, do not process the IME. Notify the provider and the recipient or recipient's authorized representative of a delay in processing the deduction for the requested IME using Form H1052-IME, Notice of Delay in Decision for Incurred Medical Expense.

H-2710 Using the TX Dental IME Fee Schedule

Revision 23-4; Effective Dec. 1, 2023 

Determine the proper incurred medical expense (IME) deduction by comparing the fees submitted by a dental provider to the fees listed in the TX Dental IME Fee Schedule. Use the date(s) of service shown on the dental invoice to select the appropriate fee schedule. The fee schedule is available for staff use on the LOOP.

The TX Dental IME Fee Schedule is based on the American Dental Association (ADA) Survey of Fees at the 90th percentile for the West South Central Region, General Dentistry, and contains the ADA’s Current Dental Terminology (CDT) codes. The schedule is updated yearly and separates the CDT codes into routine and non-routine dental services.

Due to legal liabilities associated with the copyright for the ADA Survey of Fees, the TX Dental IME Fee Schedule is a view-only internal document. It is only accessible by HHS enterprise employees. Do not print, make copies, or distribute any of the TX Dental IME Fee Schedule.

The amount allowed for a code cannot exceed the amount listed on the TX Dental IME Fee Schedule. If the dental provider submits a charge with an amount greater than the maximum allowable amount listed for a code, allow the amount listed on the TX Dental IME Fee Schedule for that code as an IME deduction. If a dental provider submits a charge less than the amount allowed on the TX Dental IME Fee Schedule, allow the lesser amount as an IME deduction.

Examples:

  • The dental provider submits a charge for code D0272 with the amount of $60. The code D0272, under Radiographs, reflects a maximum of $55. Consider $55 as an IME deduction.
  • The dental provider submits a charge for code D0150 with the amount of $60. The code D0150, under Clinical Oral Evaluation, reflects a maximum of $107. Consider $60 as an IME deduction.

Any CDT code(s) listed on the TX Dental IME Fee Schedule may be allowable as an IME.

Contact the dental provider to resolve the discrepancy if the treatment plan received contains:

  • a discrepancy in the CDT code and description;
  • a CDT code not listed on the TX Dental IME Fee Schedule; or
  • no CDT code listed.

H-2720 Non-Allowable Deductions – Dental

Revision 21-3; Effective September 1, 2021

Dental services are not allowable IMEs for Medicaid recipients in intermediate care facilities for individuals with intellectual disabilities (ICFs/IID). A recipient in an ICF/IID receives dental care through the Medicaid program.

The following items are unallowable as an IME:

  • adjustments to the fees for X-rays or other procedures performed by mobile dentists;
  • sedation charges, CDT code D9248;
  • more than two times per year per patient for dental exams;
  • more than four times per year per patient for dental cleanings;
  • more than one time per year per patient for X-rays;
  • aesthetic treatments, CDT codes D9972, D9973, D9974 and D9975;
  • trip charges (house call fees), CDT codes D0171, D9410, D9430 and D9440, and finance charges (these are not reasonable medical expenses and cannot be considered when determining IMEs); and
  • further add-ons or increased fees for the initial denture and fittings.

Each of the following CDT codes should not be allowed more than two times per year per patient:

  • initial or routine exams (D0120, D0150, D0180);
  • problem focused exams (D0140, D0160, D0170);
  • scaling, root planning or debridement (D4341, D4342, D4346, D4355); and
  • Periodontal Maintenance (only for patients who have received active periodontal therapy in the previous 24 months) (D4910).

Each of the following CDT codes should not be allowed more than four times per year per patient:

  • dental cleanings (D1110);
  • topical fluoride treatments (D1204, D1206); and
  • Oral Hygiene Instructions (D1330).

H-2730 Reserved for Future Use

Revision 13-2, Effective June 1, 2013

H-2740 Reserved for Future Use

Revision 13-2, Effective June 1, 2013

H-2750 Codes Not on the TX Dental IME Fee Schedule

Revision 23-4; Effective Dec . 1, 2023

The TX Dental IME Fee Schedule is based on the American Dental Association (ADA) Survey of Dental Fees. The ADA Survey of Dental Fees Catalog is published every two years. Current Dental Terminology (CDT) codes can change between publications.

HHSC has a contract with a Texas-licensed dentist to ensure dental incurred medical expense (IME) determinations are appropriate and cost effective.

Follow regional procedures to submit clarification requests to the contracted dentist for review of CDT codes not on the TX Dental IME Fee Schedule until the TX Dental IME Fee Schedule is updated.

Encrypt external email communication with the contracted dentist per the Health Insurance Portability and Accountability Act (HIPAA). Use encrypted email which is available through the Options menu in Outlook when sending IME requests to the contracted dentist. Encrypt all email communication, including replies and forwards in the same conversation.

Note: Do not send any IME requests by regular email to the contracted dentist.

Staff without access to encryption email software must send IME requests by fax to the contracted dentist. Ensure the fax cover sheet has the fax number and region number for the requestor. The contracted dentist will respond by fax to the requestor. 

If a dental treatment plan contains CDT codes that are on the non-routine schedule and CDT codes that are not on either schedule, send the complete treatment plan or request to the contracted dentist for review.

H-2751 Hospice Recipients

Revision 23-4; Effective Dec. 1, 2023 

For hospice recipients with a dental incurred medical expense (IME), Current Dental Technology (CDT) codes notated with an asterisk (*) on the routine schedule can be allowed by staff without further review.

For CDT codes not marked with an asterisk, follow regional procedures to submit the request to the contracted dentist for clearance. The contracted dentist reviews each request for hospice recipients whether the CDT codes are routine or non-routine.

Before sending the request to the contracted dentist, get the following:

  • documentation from the hospice provider or attending practitioner about the prognosis; and
  • the reason for the dental request and how the dental services will benefit the recipient.

Encrypt all external email communication with the contracted dentist per the Health Insurance Portability and Accountability Act (HIPAA ). Use encrypted email which is available through the Options menu in Outlook when sending IME requests to the contracted dentist. Encrypt all email communication, including replies and forwards in the same conversation.

Note: Do not send any IME requests by regular email to the contracted dentist.

Staff without access to encryption email software must send the request by fax to the contracted dentist. Ensure the fax cover sheet has the fax number and region number of the requestor. The contracted dentist will respond by fax to the requestor.

H-2760 Replacement of Lost Dentures

Revision 10-3; Effective September 1, 2010

The replacement of dentures is an allowable incurred medical expense (IME) as long as the recipient/authorized representative provides written verification from the facility that the facility will not cover the replacement of lost dentures. The verification request for a facility’s written statement is to be sent to the recipient/authorized representative and not the dental provider. The recipient or the authorized representative is to provide the facility’s written statement to the MEPD specialist. The request for replacement of lost dentures is to be initiated by the recipient/authorized representative, not the dental provider.

H-2770 Emergency Dental Services

Revision 16-2; Effective June 1, 2016

STAR+PLUS managed care organizations are responsible for payment of emergency dental services for nursing facility recipients. Emergency dental services are not allowable incurred medical expenses.

H-2780 Reserved for Future Use

Revision 20-2; Effective June 1, 2020

H-2790 When the Co-Payment Adjustment is Not Used to Pay Dental Provider

Revision 10-3; Effective September 1, 2010

Payment for services in accordance with the agreed treatment plan is a matter between the recipient and the dental provider. The recipient or the recipient's payee is expected to actually pay the dental provider in a timely manner using the income from the co-payment adjustment.

If the MEPD specialist is notified the recipient has not appropriately used the income from the co-payment adjustment to pay the dental bill, the MEPD specialist consults with legal counsel as to the appropriate action to take.