PROVIDER MANUAL FOR DENTAL SERVICES

1 PROVIDER MANUAL FOR DENTAL SERVICES Published By: Division of medical SERVICES North Dakota Department of Human SERVICES 600 E Boulevard Ave, Dept 325 Bismarck, ND 58505-0250 January 2022 ND Medicaid January 2022 2 TABLE OF CONTENTS SUMMARY OF CHANGES .. 3 KEY CONTACTS .. 4 INTRODUCTION .. 6 THIRD PARTY LIABILITY (TPL) .. 7 SERVICES TO AN INDIVIDUAL WITH A DEVELOPMENTAL DISABILITY .. 8 ANESTHESIA GUIDELINES .. 9 DENTAL SERVICE AUTHORIZATION (SA) .. 10 CLINICAL ORAL EXAMINATIONS .. 11 DIAGNOSTIC IMAGING .. 11 DENTAL PROPHYLAXIS .. 11 CROWNS-SINGLE RESTORATION ONLY .. 11 ENDODONTIC THERAPY .. 12 NON-SURGICAL PERIODONTAL SERVICE .. 12 DENTURES (complete and partials).

2 12 PARTIAL DENTURES .. 13 INTERIM PROSTHESIS .. 13 PROSTHODONTICS, FIXED .. 13 ORTHODONTICS .. 14 ORTHODONTIC PROCEDURES .. 15 GENERAL TIPS FOR BILLING .. 17 GENERAL TIPS FOR VOIDING AND REPLACING A CLAIM .. 18 AUTOMATED VOICE RESPONSE SYSTEM (AVRS) .. 19 FEES .. 21 GENERAL PRINCIPLES OF DENTAL RECORD DOCUMENTATION .. 22 CDT CODE ON DENTAL PROCEDURES AND NOMENCLATURE .. 25 PROCEDURES WITH TIME LIMITATIONS .. 25 EXPLANATION OF SYMBOLS .. 26 BILLING CODES .. 26 ND Medicaid January 2022 3 SUMMARY OF CHANGES The January 2022 ND Medicaid DENTAL MANUAL updates contain various changes that are detailed below. While DENTAL providers should review changes that are specific to their specialty, all enrolled Medicaid providers are responsible to understand and comply with program requirements contained in generic chapters such as PROVIDER enrollment, PROVIDER information, Medicaid eligibility of a member, noncovered Medicaid SERVICES , and primary care case management.

3 These chapters are contained in the ND Medicaid General Information for Providers MANUAL and can be found here: . 1. The CDT 2022 Code Updates have been updated throughout the entire MANUAL . 2. The orthodontic procedures section has been updated to reflect the deletion of procedure code D8060 as ND Medicaid will be accepting code D8020 or D8030 in place of code D8060. 3. The Fluoride Varnish limits have been updated from 2 per calendar year to 3 per calendar year effective 1-1-2022. 4. Denture adjustments have been updated to per calendar year 5. The Occlusal Orthotic Device (D7880) and the Occlusal Guards (D9944-D9946) have been updated to per calendar year. 6. The DENTAL Service Authorization section had minor revisions to web-based submissions and retro authorization submissions.

4 ND Medicaid January 2022 4 KEY CONTACTS Hours for key contacts are 8:00 to 5:00 Monday through Friday (Central Time). PROVIDER Enrollment (701) 277-6999 (701) 433-5956 (fax) Send written inquiries to: Noridian Healthcare Solutions Attn: ND Medicaid PROVIDER Enrollment PO Box 6055 Fargo, ND 58108-6055 or e-mail inquiries to: NDMedicaidEnrollment Third Party Liability For questions about private insurance, Medicare, or other third-party liability: (800) 755- 2604 (701) 328-2347 Send written inquiries to: Third Party Liability Unit medical SERVICES ND Dept. of Human SERVICES 600 E Boulevard Ave-Dept 325 Bismarck ND 58505-0250 or e-mail inquiries to: Call Center For questions about member eligibility, payments, denials or general claims questions: (701) 328-7098 (877) 328-7098 or e-mail inquiries to: Coordinated SERVICES Program Inquiries regarding coordinated SERVICES program recipients: (800) 755-2604 (701) 328-2346 or e-mail inquiries to: ND Medicaid January 2022 5 Surveillance/Utilization Review To report suspected ND Medicaid PROVIDER fraud and abuse: (701) 328-4024 (800) 755-2604 Send written inquiries to: Fraud and Abuse Surveillance/Utilization Review medical SERVICES ND Dept.

5 Of Human SERVICES Dept 325 600 E Boulevard Ave Bismarck ND 58505-0250 Or e-mail inquiries to: SHS Inquiries and to obtain forms Special Health SERVICES ND Department of Health Dept 401 600 E Boulevard Ave Bismarck BD 58505-0200 (701) 328-2436 Service Authorization For questions and inquiries: ND Medicaid January 2022 6 INTRODUCTION This billing MANUAL is designed to aid providers in billing the North Dakota Medicaid and Special Health SERVICES (SHS) programs. Included are general items of interest to providers, specific claim form billing instructions and procedures to follow when voiding and replacing a claim. When filing claims with the ND Medicaid program, the PROVIDER agrees to accept ND Medicaid payment as payment in full.

6 The PROVIDER CANNOT BILL the recipient for any part of the bill unless the remittance advice indicates a recipient liability applies to the SERVICES , or it is a non-covered service. Please contact the medical SERVICES office with questions. Addresses and telephone numbers are listed in the Key Contacts section of this MANUAL . Any disputes or questions on claims should be directed to the ND Medicaid call center at 701-328-7098. ND Medicaid January 2022 7 THIRD PARTY LIABILITY (TPL) Please refer to the General Information for Providers MANUAL . ND Medicaid January 2022 8 SERVICES TO AN INDIVIDUAL WITH A DEVELOPMENTAL DISABILITY Individuals with a developmental disability (DD) may require an extra amount of time and a greater number of personnel to provide routine DENTAL care.

7 The Department will provide additional compensation to dentists who treat individuals who need extra care; therefore, providers will receive the standard fee for the DENTAL SERVICES provided plus a special payment for the extra time needed. The policy does require providers to document the extra time and extra staff required to provide SERVICES to DD recipients. The PROVIDER is to use procedure code D9920 and enter the extra usual and customary charge associated with the SERVICES provided to the DD recipient. Procedure Code D9920 does require a service authorization (SA) effective October 1, 2015. The Department will pay the extra charge based on the established fee schedule. If the PROVIDER provides a service to an individual with a developmental disability who requires extra time, the DENTAL PROVIDER must submit the Request for Extra Time Individuals with Developmental Disabilities form (SFN 64).

8 The form must be signed by the DD PROVIDER , guardian, or caregiver. The form is available on our website at The form may be downloaded for PROVIDER use. This service is only allowed/reimbursed when performed in an office setting. Any additional questions regarding this policy can be addressed by contacting the ND Medicaid call center at (701) 328-7098. ND Medicaid January 2022 9 ANESTHESIA GUIDELINES North Dakota Medicaid will reimburse procedure codes: D9222 deep sedation/general anesthesia first 15 minutes D9223 deep sedation/general anesthesia each 15 minute increment D9239 intravenous moderate (conscious) sedation/analgesia first 15 minutes D9243 intravenous moderate (conscious) sedation/analgesia each 15-minute increment D9223 and D9243 are allowed up to eight units and must all be billed on one line Documentation in the anesthesia record must support the start and stop times for units billed.

9 North Dakota Medicaid does not reimburse for code D9248 (Non-intravenous conscious sedation). CRNA SERVICES and medication must be billed on a CMS-1500 claim form and will be edited by National Correct Coding Initiative (NCCI) edits. This policy does not apply to recipients with a developmental disability who have been approved for D9920 behavior management. ND Medicaid January 2022 10 DENTAL SERVICE AUTHORIZATION (SA) A service authorization (SA) must be obtained for procedures for ND Medicaid eligible recipients before SERVICES are started. The Department will refuse payment for any covered service or procedures for which a SA is required but not obtained. Retro service authorizations may be submitted for consideration up to 90 days from the date of service.

10 The DENTAL office must demonstrate good cause for the failure to secure the required service authorization request prior to the date SERVICES were rendered. To view a complete list of all SERVICES that require service authorization and the documentation requirements for the service, see the Codes Requiring Service Authorizations spreadsheet on the ND Medicaid website found here: . 1. Since endodontics could be an emergency service, no service authorization is required for recipients under 21. Radiographs must accompany the service authorization for members age 21 and older. 2. All SA forms submitted must use appropriate codes, procedures, and usual and customary fees. 3. When a web-based SA is submitted, all supporting documentation must be attached to the SA electronically.