Form 2463, Emergency Dental Services

Instructions

Updated: 12/2010

Purpose

Providers must submit Form 2463 to the Texas Health and Human Services (HHS) to request authorization for reimbursement.

Procedure

The following are the requirements for claims submission for nursing facility (NF) emergency dental services. HHS will only authorize reimbursement for NF emergency dental services and will not reimburse routine dental services.

NF emergency dental services are limited to procedures necessary to control bleeding; relieve pain and eliminate acute infection; operative procedures which are required to prevent the imminent loss of teeth; treatment of injuries to the teeth or supporting structures. To be reimbursed for NF emergency dental services, the nursing facility must ensure that services meet the criterion outlined in Texas Administrative Code (TAC), §19.1401 and §19.1402.

In order for the reimbursement request to be considered, providers must submit all of the following documents:

• attending physician's order referring a resident for NF emergency dental services;
• dental claim requests on Form 2463;
• dentist invoice, as well as documents describing the service rendered (this only includes NF emergency dental services outlined in 40 TAC §19.1401 and §19.1402).

The following must be completed within one year from the date of service:

• a request for service authorization must be received and approved by HHS; and
• the provider must submit claims for payment.

Transmittal

All claims and documentation are mailed or faxed to:

Provider Claims Services, Mail Code W-400
P.O. Box 149030
Austin, TX 78714-9030

Fax: 512-438-2301

For process questions about authorization of Medicaid-certified NF emergency dental services, contact the Provider Claims Services Hotline at 512-438-2200, Option 1.

Detailed Instructions

CMS Provider No. — Enter the number that identifies the contract under which the individual is receiving NF services.

Nursing Facility — Enter the name of the NF submitting the request.

Address — Enter the address of the NF submitting the request.

Fax No. — Enter the area code and fax number of the NF.

Resident's Last Name — Enter the last name of the resident.

Resident's First Name — Enter the first name of the resident.

Resident's Medicaid No. — Enter the nine-digit Medicaid identification number assigned to the individual.

Area Code and Telephone No. — Enter the area code and telephone number of the NF.

Date of Service — Enter the date the individual received emergency dental services.

ADA Code — Enter a specific four-digit-plus-one-letter American Dental Association code for each item.

Procedure Provided — Enter a brief description of the service provided.

Number of Units — Enter the number of units.

Unit Base Rate — Enter a rate from the table below.

Line Item Total — Enter the total cost for line items.

Claim Total — Enter the total cost of emergency dental services requested.

Administrator Signature and Date — The form must be signed and dated by the administrator.

Dental Codes and Rates
D0140	Emergency Oral Exam	$19.16
D9110	Emergency Palliative Exam	$18.75
D0220	X-Rays First Exam	$12.82
D0230	X-Rays Second and Each Film	$11.74
D7140	Simple Extraction Single Tooth	$67.04
D7250	Extraction Root Removal – Exposed Roots	$92.50
D7210	Surgical Removal of Erupted Tooth	$102.81
D7220	Removal of Impacted Tooth-Soft Tissue	$157.50
D7230	Removal of Impacted Tooth – Partially Bony	$180.00
D7240	Removal of Impacted Tooth – Completely Bony	$300.00
D7241	Removal of Impacted Tooth – Completely Bony with Unusual Complications	$156.25
D7250	Surgical Removal of Resident Tooth Roots	$92.50
D7510	Incision and Drainage of Abscess-Intraoral Soft Tissue	$37.50
D7520	Incision and Drainage of Abscess-Extraoral Soft Tissue	$125.00
D9215	Local Anesthesia	$12.50
D9220	General Anesthesia – First 30 Minutes	$87.50
D9221	General Anesthesia – Each Additional 15 Minutes	$31.25