IDCS Comprehensive Health Plan

Dental and Orthodontic Service

Statement/Purpose

The Department of Child Safety Comprehensive Health Plan (DCS CHP) covers medically necessary dental services to improve and/or maintain the oral health of children and youth in DCS care.

Definitions

Dental Home: The dental home is the ongoing relationship between the dental provider and the member, inclusive of all aspects of oral health care delivered in a comprehensive, continuously accessible, coordinated, and family-centered way. The dental home should be established no later than 6 months of age to help children and their families institute a lifetime of good oral health. A dental home addresses anticipatory guidance and preventative, acute, and comprehensive oral health care and includes referral to dental specialist when appropriate, (American Academy of Pediatric Dentistry (AAPD).

Early and Periodic Screening, Diagnostic and Treatment (EPSDT): A comprehensive child health program of prevention, treatment, correction, and improvement of physical and behavioral health conditions for AHCCCS members under the age of 21. EPSDT services provide comprehensive health care through primary prevention, early intervention, diagnosis, medically necessary treatment, and follow-up care of physical and behavioral health conditions for AHCCCS members less than 21 years of age. EPSDT services include screening services, vision services, dental services, hearing services and all other medically necessary mandatory and optional services listed in Federal Law 42 U.S.C. 1396d(a) to correct or ameliorate defects and physical and mental illnesses and conditions identified in an EPSDT screening whether or not the services are covered under the AHCCCS State Plan. Limitations and exclusions, other than the requirement for medical necessity and cost effectiveness, do not apply to EPSDT services.

Health Care Decision Maker: An individual who is authorized to make health care treatment decisions for the patient. As applicable to the particular situation, this may include a parent of an unemancipated minor or a person lawfully authorized to make health care treatment decisions pursuant to A.R.S. title 14, chapter 5, article 2 or 3; or A.R.S. §§8-514.05, 36-3221, 36-3231 or 36-3281.

Informed Consent: Informed consent is a process by which a provider advises the member, caregiver, guardian or Health Care Decision Maker of the diagnosis, proposed treatment and alternate treatment methods and the associated risks and benefits of each treatment option as well as the associated risks and benefits of not receiving treatment.

Policy

DCS CHP members receive preventative and medically necessary oral health care in a timely manner based on best practice recommendations and in accordance with state and federal regulations and plan requirements.

DCS CHP collaborates with custodial agency representatives, caregivers and dental providers in an effort to increase required preventive screenings and services in accordance with the AHCCCS Dental Periodicity Schedule.

The DCS CHP dental benefit covers the application of fluoride varnish at EPSDT visits, by PCPs who have completed AHCCCS required training. Fluoride varnish application does not take the place of oral health visits with dental providers.

DCS CHP covers Teledentistry when provided by an AHCCCS registered dental Provider.

DCS CHP notifies members of covered dental services upon enrollment and through periodic outreach efforts. DCS CHP promotes appropriate dental care to members through education and outreach including, but not limited to, information disseminated through member handbooks, special mailings, and website.

DCS CHP covers oral health care services for members under 21 years of age, including:

• Oral health screenings conducted by the primary care physician (PCP), physician’s assistant, or nurse practitioner, as a part of the Early and Periodic Screening Diagnostic and Treatment (EPSDT) visit; however, this is not a substitute for direct referral to, and examination by, a dental provider. The oral health screening is intended to identify gross dental or oral lesions but is not a thorough clinical examination and does not involve making a clinical diagnosis resulting in a treatment plan. PCPs refer EPSDT members for appropriate services based on needs identified through the oral health screening process and for routine dental care based on the AHCCCS EPSDT Periodicity Schedule. Evidence of this referral is documented on the EPSDT Tracking Form and in the member’s medical record. Depending on the results of the oral health screening, referral to a dental provider is made within the following time frame;

  • Urgent-As expeditiously as the member’s health condition requires but no later than three business days of request.

  • Routine Care-within 45 calendar days of request.

• Teledentistry, which includes the provision of preventative and other approved therapeutic services by the AHCCCS registered Affiliated Practice Dental Hygienist. Teledentistry does not take the place of the in person comprehensive dental exam by the dentist. Limited exams may be conducted via teledentistry. Periodic and comprehensive examinations cannot be conducted by teledentisty alone.

Members are assigned to a Dental Home upon entry to the health plan or by 6 months of age and are encouraged to use the Dental Home to promote the management of oral health care in a comprehensive, continuously accessible, coordinated and family-centered way by a licensed dental provider. The concept of the Dental Home reflects the American Academy of Pediatric Dentistry (AAPD) and American Dental Association (ADA) policies, and best principles for the proper delivery of oral health care to all, with an emphasis on initiating preventive strategies during infancy.

DCS CHP dental benefit requires the Dental Home to provide comprehensive oral health care that includes:

• Comprehensive assessment for oral disease and conditions;

• Acute care and preventative services in accordance with the AHCCCS Dental Periodicity Schedule;

• Individualized preventative dental health program based upon the members caries, risk assessment and periodontal disease risk assessment;

• Anticipatory guidance about oral health related growth and development issues;

• Plan for acute dental trauma;

• Information about the proper care of the child’s teeth and gingiva;

• Dietary counseling; and

• Referrals to dental specialists when applicable.

The DCS CHP dental benefit covers the following dental services:

• Emergency dental services, treatment for pain, infection, swelling, injury;

• Extraction of symptomatic (including pain), infected and non-restorable primary and permanent teeth, as well as over retained symptomatic primary teeth;

• General anesthesia, conscious sedation or anxiolytics, when local anesthesia is contraindicated or when management of the child requires it;

• Preventative dental services including:

  • Diagnostic services including comprehensive and periodic examinations;

  • Two oral examinations and two prophylaxis and fluoride treatments per year (i.e. every 6 months) for all members up to 21 years of age. For members up to five (5) years of age, fluoride varnish may be applied four times a year (i.e., one every three months). Any additional examinations or treatments must meet medical necessity criteria;

  • Medically necessary radiology screening services for the diagnosis of dental abnormalities and/or pathology, including panoramic or full mouth x-rays, supplemental bitewing and occlusal or periapical films as recommended by the American Academy of Pediatric Dentistry;

  • Panorex films up to three times per provider for children between 3 and 20 years (additional Panorex films needed above this limit must meet medical necessity criteria);

  • Oral prophylaxis performed by a dental provider or dental hygienist which includes self-care oral hygiene instructions to member, caregiver, guardian, or designated representative;

  • Application of topical fluorides and fluoride varnish. (Prophylactic Fluoride Paste or Fluoride mouth rinses do not meet the AHCCCS standard for fluoride treatment);

  • Dental sealants for first and second molars, twice for first or second molars, per provider, allowing for three (3) years intervention between application up to fifteen (15) years of age. This includes the ADHS school based dental sealant program (https://www.azdhs.gov/prevention/womens-childrens-health/oral-health/dental-programs/index.php) and the participating providers. (additional applications must meet medical necessity criteria), and

  • Space maintainers when posterior primary teeth are lost and when deemed medically necessary.

• Therapeutic dental services that meet medical necessity criteria, are cost effective and include:

  • Periodontal procedures, scaling/root planning, curettage, gingivectomy, and osseous surgery;

  • Stainless steel crowns used for both primary and permanent posterior teeth (composite, prefabricated stainless steel crowns with a resin window or crowns with esthetic coatings are used for anterior primary teeth (precious or cast semi-precious crowns are not covered for children under 18 years of age);

  • Endodontic services including pulp therapy for permanent and primary teeth, except third molars (unless a third molar is functioning in place of a missing molar);

  • Restoration of carious permanent and primary teeth with accepted dental materials (cast or porcelain restorations for permanent teeth are not covered for members under 18 years of age and must be endodontically treated to be eligible);

  • Restorations of anterior teeth for children under the age of five when medically necessary (children, five years and over with primary anterior tooth decay are considered for extraction, if presenting with pain or severely broken-down tooth structure, or be considered for observation until the point of exfoliation as determined by the dental provider);

  • Removable dental prosthetics, including complete dentures and removable partial dentures.

Orthodontic services and orthognathic surgery are covered only when the services are medically necessary and determined to be the primary treatment of choice or an essential part of an overall treatment plan developed by both the PCP and the dental provider in consultation with each other. Documentation supporting medical need must be submitted to the plan from both the treating dentist and the members’ primary care physician.

Orthodontic services are not covered when the primary purpose is cosmetic.

Orthodontic services may be required:

• In addition to surgical treatment when congenital craniofacial or dentofacial malformations require reconstructive cranial correction or in the setting of trauma requiring surgical treatment;

• When there is skeletal discrepancy involving maxillary and/or mandibular structures;

• In the setting of a functional disturbance diagnosed to interfere with mastication, swallowing, speech and normal function of the jaw;

• When diagnosed significant weight loss due to an existing malocclusion.

The DCS CHP dental benefit is provided by AHCCCS registered dental providers.

DCS CHP dental benefit covers services provided by an affiliated dental hygienist when criteria outlined by ARS §32-1281; ARS §32-1289.01 and AHCCCS are met. The criteria are as follows:

• Both the dental hygienist and the dental provider in the affiliated practice relationship are registered AHCCCS providers who hold active licenses;

• The affiliated dental hygienist is registered with AHCCCS and is identified as the treating provider under his or her individual AHCCCS provider identification number/NPI number. When not working under and affiliated practice agreement no registration with AHCCCS is necessary;

• The affiliated practice dental hygienist maintains individual medical records of DCS CHP members in accordance with the Arizona State Dental Practice Act. At a minimum, this includes member identification, caregiver, guardian, or Health Care Decision Maker identification and designated representative identification, if applicable, signed authorization (parental/Health Care Decision Maker consent) for services, member medical history, and documentation of services rendered;

• The affiliated practice dental hygienist is reimbursed for providing services in accordance with state regulations, AHCCCS policy and provider agreement, and their affiliated practice agreement;

• Dental reimbursement for radiographs is restricted to providers who are qualified to perform both the exposure and the interpretation of dental radiographs.

Dental providers, including affiliated dental hygienists, obtain informed consent for examination and/or any preventative measure. This consent is required at the time of the initial examination and should be updated at each subsequent six (6) month follow up.

Separate written informed consent is required for any irreversible, invasive procedure including, but not limited to dental fillings, pulpotomy etc.

Dental providers are required to have a written treatment plan that is reviewed and signed by both the dental provider and the member’s guardian, caregiver or Health Care Decision Maker.

The member’s caregiver, guardian or Health Care Decision Maker is provided with a copy of the completed treatment plan and with updated copies when the treatment plan is revised.

Informed consents and treatment plans completed by providers address the following:

• Quality and consistent care;

• Best interest of the member;

• Easily understood by the member and/or the member’s caregiver, guardian, Health Care Decision Maker.

Informed consents and treatment plans are maintained in the member’s medical/dental record/chart and provided upon request for coordination, authorization or audit.

Procedure

Dental Home

DCS CHP members are assigned to a Dental Home upon enrollment or by 6 months of age.

DCS CHP members are assigned the Dental Home/Primary Care Dental Providers (PDP) similarly to the Primary Care Provider (PCP) methodology, in that caregivers select the dental provider. Members over the age of 6 months who have not been seen (i.e. had a claim submitted) by a dental provider, are assigned a dental provider in their zip code. If a claim is received that is different from the auto assigned provider, the Dental Home provider is updated to reflect that of the claim. If a caregiver requests a different Dental Home, DCS CHP may assist in the reassignment.

Fluoride Varnish

PCPs who have completed the AHCCCS required training may be reimbursed for fluoride varnish applications completed at the EPSDT visit. Fluoride varnish applications are covered for members who as early as six (6) months old and have at least one (1) tooth eruption. Additional varnish applications during an EPSDT visit are covered every 3 months during an EPSDT visit, up until the member’s fifth birthday.

The AHCCCS recommended training for fluoride varnish application is located at: https://www.aap.org/en/patient-care/oral-health/oral-health-education-and-training/ Refer to the website for training that covers caries-risk assessment, fluoride varnish, and counseling. Upon completion of the required training, providers shall submit a copy of their certificate to the health plan, as this is required prior to issuing payment for PCP applied fluoride varnish. This certificate may be used in the credentialing process to verify completion of training necessary for reimbursement.

Care Management

Care management related to dental services include identification of children with special health care needs and facilitating referrals to appropriate service providers. Care management also includes care coordination for members who have not received their preventative dental services.

Dental Authorizations

Prior Authorization (PA) requests for dental services are submitted in writing prior to delivery of the services.

Adhere to the Dental Uniform Prior Authorization List to assist with the appropriate PA determinations needed. Refer to the AHCCCS website under Resources: Guides–Manuals– Policies for the list. As noted DCS CHP is excluded from many of the list requirements.

If prior authorization was not obtained and the service is completed, the health plan retrospectively reviews the claim for medical necessity. However, this does not guarantee approval.

For emergency procedures, services are performed and the provider is instructed to submit the claim with documentation for Retrospective Authorization.

Providers request services utilizing ADA Dental Claim forms and are required to submit all appropriate supporting documentation and/or x-rays in accordance with AHCCCS guidelines. Providers have the option to submit PAs via fax, postal mail and electronically.

If the health plan is unable to decide based on the documentation provided, a request is made for the provider to submit additional documentation to substantiate medical necessity. Additional documentation may be requested from the member’s PCP in determining medical necessity. The procedures outlined in DCS CHP Policy HS-MM-09, Notice of Adverse Benefit Determination (NOA), Notice of Extension (NOE) and Notice of Provider Restriction are followed for these circumstances.

If on appeal a decision is reversed, authorization or provision of services are addressed promptly or as expeditiously as the member’s condition requires.

Orthodontic Authorizations

Prior authorization (PA) is required for comprehensive orthodontic consideration, including the Pre-Orthodontic Treatment (Orthodontia Consult) visit (D8660). The request must meet medical necessity. Limitations and exclusions, other than the requirement for medical necessity and cost effectiveness, do not apply to EPSDT services.

• Request for Comprehensive Orthodontic Treatment(D8070) (D8080) (D8090):

• The orthodontic dental provider completes the pre-authorized consultation. If the provider determines that orthodontia may be medically necessary, the provider submits the ADA Claim Form with:

  • CDT Dental Procedure codes, Diagnostic Cast (D0470), and

  • Request for Comprehensive Orthodontic Treatment (D8070) (D8080) (D8090).

• If comprehensive orthodontic services are requested, the provider submits ALL of the following, along with an ADA Claim Form including codes for the orthodontia services:

  • Diagnosis;

  • Duration of Treatment;

  • Diagnostic Cast;

  • Tracings;

  • Radiographs;

  • Photographs; and

  • Dentist’s Certification of Medical Necessity Form

• All documentation is reviewed in order to make the determination as to whether the request for Comprehensive Orthodontic Treatment sufficiently meets medical necessity. The dental provider and custodial agency representative are notified of the approval or denial.

If orthodontia is denied, orthodontia records are reimbursed.

If on appeal a decision is reversed, authorization or provision of services are addressed promptly or as expeditiously as the member’s condition requires.

Timeframes for Processing

Providers and/or members are notified of PA determinations within the standard and expedited timeframes required by AHCCCS and set forth in federal and state law and regulations as follows:

• Urgent or expedited PA requests are processed within 3 business days, with a possible extension of up to 14 calendar days if the member or provider requests the extension and the delay is in the member’s best interest or if additional information is required to make a decision.

• Routine or standard PA requests are processed within 14 calendar days or a Notice of Extension (NOE) may be sent which allows an additional 14 calendar days for a decision to be made or if additional information is required (see DCS CHP Policy HS-MM-09, Notice of Adverse Benefit Determination (NOA), Notice of Extension (NOE) and Provider Restriction Notice).

Reports

DCS CHP monitors the numbers of dental visits through the Center for Medicare and Medicaid services (CMS) and Healthcare Effectiveness Data Information Set (HEDIS) Performance Measures. This includes but is not limited to:

• The percentage of members receiving preventive dental services (CMS).

• Number of members receiving sealants on first molars by age 10 (CMS).

• Number of members receiving at least annual visits each year (HEDIS).