Alabama Administrative Code Chapter 560-X-15 — Dental Services

560 Alabama Medicaid Agency

Ala. Admin. Code r. 560-X-15-.01 Dental Program - General

(1)

(a) The availability of certain dental health care services for eligible children under age 21 is required through the Alabama Medicaid Program as part of the Early and Periodic Screening, Diagnosis, and Treatment (EPSDT) Program.

(b) Certain dental services are provided to pregnant Medicaid eligible individuals over 21.

(2) Dental providers must be licensed to practice in the state in which the service is provided. Dentists are exempt from a contract requirement at the present time, but must enroll with the fiscal agent and be assigned a provider number for each office location. Each claim filed constitutes a contract with the Alabama Medicaid Agency, and represents that the services provided and fees charged are usual and customary by community standards and payment.

(3) Dental Services are defined as any diagnostic, preventive, or corrective procedures administered by or under the direct supervision of a dentist licensed to practice in the state the service is provided. Such services include treatment of the teeth and the associated structures of the oral cavity, and of disease, injury, or impairment which may affect the oral or general health of the individual. Such services shall maintain a high standard of quality and shall be within the reasonable limits of those services which are customarily available and provided to most persons in the community.

(4) Patient Identification

(a) The Alabama Medicaid Agency issues a plastic Medicaid Eligibility Card to persons when they are first eligible for benefits.

(b) The provider must verify eligibility through the fiscal agent office. The recipient or responsible adult is required to present this card with some form of identification when requesting services.

(c) It is most important that a provider's staff verify a Medicaid recipient's eligibility, since claims submitted on ineligible persons cannot be paid by Medicaid.

(d) Chapter One, General, Alabama Medicaid Agency Administrative Code, contains information about the identification of Medicaid recipients.

(5) Providers who agree to accept Medicaid payment must agree to do so for all covered services rendered during a particular visit. The dentist agrees when billing Medicaid for a covered service that the dentist will accept as payment in full the amount paid by Medicaid for that service and that no additional charge will be made. Providers may not bill Medicaid recipients they have accepted as patients for covered services. The dentist shall not charge or bill the recipient for cancelled or missed appointments. Conditional collections from patients made before Medicaid pays, which are to be refunded after Medicaid pays, are not permissible. The dentist may bill the patient for services rendered in the following circumstances:

(a) when benefits are exhausted for the set limit or

(b) when the service is a Medicaid non-covered benefit.

Refer to Chapter One, General Alabama Medicaid Agency Administrative Code, for further information regarding Providers Rights and Responsibilities.

History

• Author: Tina Edwards, Dental Program
• Authority: State Plan, Attachment 3.1-A, page 1.2, 4.b(4); Title XIX, Social Security Act; 42 C.F.R. §§441.57.
• Rule effective October 1, 1982. Amended effective April 12, 1984; June 8, 1985. Emergency rule effective December 1, 1986. Amended effective March 12, 1987. Emergency rule effective April 1, 1991. Amended effective June 12, 1991; January 13, 1993. Amended: Filed September 6, 2000; effective October 11, 2000. Amended: Filed May 12, 2004; effective June 16, 2004. Amended: Filed January 18, 2023; effective May 15, 2023.

Ala. Admin. Code r. 560-X-15-.02 Covered Dental Services

A listing of the covered dental procedures and their limitations are included in the Alabama Medicaid Provider Manual, Chapter 13, which is provided by the fiscal agent.

History

• Author: Tina Edwards, Dental Program
• Authority: State Plan; Title XIX, Social Security Act; 42 C.F.R. §§401, et seq.
• Rule effective October 1, 1982. Emergency rule effective April 1, 1991. Amended effective June 12, 1991. Amended: Filed September 6, 2000; effective October 11, 2000. Amended: Filed May 12, 2004; effective June 16, 2004.

Ala. Admin. Code r. 560-X-15-.03 Limitations

(1) Dental care is provided to Medicaid eligible individuals who are under age 21 and are eligible for treatment under the EPSDT Program. Complete details on coverage limitations are contained in Chapter 13 of the Alabama Medicaid Provider Manual. Below are general guidelines.

(2) Dental care under this Program is available either as a result of the EPSDT Referral or as a result of request/need by the recipient. Conditions for each situation are as follows:

(a) EPSDT Referral. If the EPSDT Screening Provider determines a recipient requires dental care or if the recipient is 3 years of age or older and is not currently under the care of a dentist, the recipient must be referred to an enrolled dentist for diagnosis and/or treatment. After the recipient's dental care is initiated, the Consultant's portion of the general referral form must be completed by the dentist and the appropriate copy must be returned to the screening provider.

(b) Recipient Seeking Treatment. If a recipient who has not been screened through the EPSDT Program requests dental care, care may be provided without having an EPSDT Referral. In this situation, after the required care is completed, the dentist should advise the recipient to seek an EPSDT provider to obtain a complete medical assessment.

(3) Dental care is provided to pregnant Medicaid eligbile individuals over 21. Complete details on coverage limitations are contained in Chapter 13 of the Alabama Medicaid Provider Billing Manual.

(4) A periodic oral examination is limited to once every six months for eligible Medicaid recipients under age 21.

(5) Dental sealants are covered by Medicaid, and are limited to one application per tooth in a recipient's lifetime. Refer to Chapter 13 of the Alabama Medicaid Provider Manual for specific limitations.

(6) Orthodontia is covered by Medicaid and is limited to medically necessary orthodontic services for eligible and qualified recipients. The services must be provided as a continuation of treatment initiated through multidisciplinary clinics administered by Alabama Children's Rehabilitation Service or other qualified clinics enrolled in the Medicaid Dental Program as a contract vendor. All medically necessary orthodontic treatment must be prior authorized by Medicaid.

(7) Radiological procedures are limited to those required to make a diagnosis. The radiographs should show all areas where treatment is anticipated. All x-ray films must be properly mounted suitable for interpretation and identification, with the patient's name, date, name of dentist, and marked "left" and "right." Specific limitations are outlined in Chapter 13 of the Alabama Medicaid Provider Manual.

History

• Author: Dr. Danny Rush, Dental Program
• Authority: State Plan, Attachment 3.1-A, page 1.2, 4.b(4); Title XIX, Social Security Act; 42 C.F.R. §441.57.
• Rule effective October 1, 1982. Amended effective June 8, 1985. Emergency rule effective December 1, 1986. Amended effective March 12, 1987. Emergency rule effective March 10, 1987. Amended effective June 10, 1987. Emergency rule effective April 1, 1988. Amended effective June 10, 1988. Emergency rule effective February 9, 1989. Amended effective March 14, 1989; July 1, 1989. Emergency rule effective April 1, 1991. Amended effective June 12, 1991; April 14, 1992. Amended: Filed September 6, 2000; effective October 11, 2000. Amended: Filed May 12, 2004; effective June 16, 2004. Amended: Filed January 18, 2023; effective May 15, 2023.

Ala. Admin. Code r. 560-X-15-.04 Examination (Repealed 10/11/00)

(Repealed)

History

• Authority: State Plan; Title XIX, Social Security Act; 42 C.F.R. §§401, et seq.
• Rule effective October 1, 1982. Emergency rule effective April 1, 1991. Amended effective June 12, 1991. Repealed: Filed September 6, 2000; effective October 11, 2000.

Ala. Admin. Code r. 560-X-15-.05 Prior Authorization

(1) Certain services require prior authorization. Refer to Chapter 13 of the Alabama Medicaid Provider Manual.

History

• Author: Sharon Bean, Dental Program
• Authority: State Plan; Title XIX, Social Security Act; 42 C.F.R. §§401, et seq.
• Rule effective October 1, 1982. Amended effective May 9, 1984; January 8, 1985; August 9, 1985. Emergency rule effective April 1, 1991. Amended effective June 12, 1991; January 13, 1993. Amended: Filed September 6, 2000; effective October 11, 2000. Repealed and New Rule: Filed May 12, 2004; effective June 16, 2004.

Ala. Admin. Code r. 560-X-15-.06 Participation Requirements

(1) Dental clinics administered by the Alabama Department of Public Health may participate in the program if they are approved by and enter into a vendor agreement (contract) with Medicaid. Providers who meet the Alabama Medicaid Agency enrollment requirements are eligible to participate in the Alabama Medicaid Agency program. An enrollment application may be requested from the Medicaid fiscal agent or downloaded from the Medicaid website at www.medicaid.alabama.gov. Completed enrollment applications should be returned to Provider Enrollment at the address indicated on the form. Providers must complete an enrollment or an additional location enrollment application for each practice location.

(2) The Alabama Medicaid Agency will make payment for services to licensed, enrolled dental providers. All providers must meet the requirements to practice dentistry as set forth by the Alabama Dental Practice Act, Code of Ala. 1975, Section 34-9-6.

(3) In accordance with federal law, Medicaid providers shall ensure that no person will, on the grounds of race, color, creed, national origin, age or handicap, be denied the benefits of, be excluded from participation in, or be subjected to discrimination under any program of services provided by the Agency. Compliance with Federal Civil Rights and Rehabilitation Acts is required of a provider participating in the Alabama Medicaid Program.

(4) Direct payments are made for allowance charges to providers for covered medical services and supplies furnished eligible Medicaid recipients.

(5) Refer to Chapter 20 concerning third party insurance carriers.

History

• Author: Charles D. Rush, DMD, Dental Program
• Authority: State Plan; Title XIX, Social Security Act; 42 C.F.R. §§400,100, 441.56.
• Rule effective October 1, 1982. Amended effective March 14, 1989; July 1, 1989. Emergency rule effective April 1, 1991. Amended effective June 12, 1991; April 14, 1992. Amended: Filed September 6, 2000; effective October 11, 2000. Amended: Filed May 12, 2004; effective June 16, 2004. Amended: Filed September 11, 2018; effective October 26, 2018.

Ala. Admin. Code r. 560-X-15-.07 Assuring High Quality Care

Under the provisions of Federal and State law, Medicaid must establish a mechanism to ensure that all such care is of good quality and that service(s) for which billing was made conforms to that which was done. See Chapter 2, Rule No. 560-X-2-.01(2)(d) and (3) for criteria.

History

• Author: Tina Edwards, Dental Program
• Authority: State Plan; Title XIX, Social Security Act; 42 C.F.R. §§401, et seq.
• Rule effective October 1, 1982. Amended: Filed May 12, 2004; effective June 16, 2004.
• Editor's note: Previous Rule 560-X-15-.07, Reimbursement, was repealed and Rule 560-X-15-.09, was renumbered as per certification filed May 12, 2004; effective June 16, 2004. No text was changed just renumbered.

Ala. Admin. Code r. 560-X-15-.08 Submitted Charges

(1) Fees submitted shall not exceed usual, customary, and reasonable rates paid by the non-Medicaid population of the community.

(2) The provider shall not charge Medicaid for services rendered on a no-charge basis to the general public.

(3) If the provider offers discounts or rebate to the general public, a like amount shall be adjusted to the credit of Medicaid on the Medicaid claim form, or such other method as Medicaid may prescribe.

(4) Orthodontic services provided as a continuation of treatment initiated through multidisciplinary clinics administered by Alabama Children’s Rehabilitation Service (CRS) or other qualified multidisciplinary clinics are reimbursable if the clinics are approved by and enter into a vendor agreement (contract) with Medicaid. Fees paid for the services shall not exceed the reasonable rates established in the Medicaid statewide profile for medically necessary orthodontic services.

History

• Author: Tina Edwards, Dental Program
• Authority: State Plan; Title XIX, Social Security Act; 42 C.F.R. §§401, et seq.
• Emergency rule effective April 1, 1991. Rule effective June 12, 1991. Amended: Filed May 12, 2004; effective June 16, 2004.
• Editor's note: Previous Rule 560-X-15-.08, Non-Covered Services – (Including But Not Limited To The Following), was repealed and Rule 560-X-15-.10, was renumbered as per certification filed May 12, 2004; effective June 16, 2004.

Ala. Admin. Code r. 560-X-15-.09 Mobile Dental Clinics

(1) A mobile dental facility or portable dental operation (Mobile Dental Clinic) is any self-contained facility in which dentistry or dental hygiene is practiced which may be moved, towed, or transported from one location to another.

(2) Mobile Dental Clinics shall comply with all Medicaid rules and regulations as set forth in the State Plan, Alabama Medicaid Administrative Code, Code of Federal Regulations and applicable Medicaid billing manuals.

(3) In order to enroll as a Mobile Dental Clinic, an operator shall:

(a) obtain a certificate of registration issued by the Board of Dental Examiners (the Board); and

(b) complete an Alabama Medicaid Provider Enrollment application.

(4) Mobile Dental Clinics shall comply with the following consent requirements:

(a) The operator of a Mobile Dental Clinic shall not perform services on a minor without the signed consent from the parent or guardian. The consent form shall be established by the Board.

(b) The consent form shall inquire whether the prospective patient has received dental care from a licensed dentist within one year and if so, the consent form shall request the name, address, and phone number of the dental home. If the information provided to the operator does not identify a dental home for the prospective patient, the operator shall contact the Alabama Medicaid Agency for assistance in identifying a dental home for Medicaid eligible patients. If this information is provided to the operator, the operator shall contact the designated dental home by phone, facsimile, or electronic mail and notify the dental home of the prospective patient's interest in receiving dental care from the operator. If the dental home confirms that an appointment for the prospective patient is scheduled with the dentist, the operator shall encourage the prospective patient or his or her guardian to seek care from the dental home.

(c) The consent form shall document that the patient, or legal guardian, understands the prospective patient has an option to receive dental care from either the Mobile Dental Clinic or his or her designated dental home if applicable.

(d) The consent form shall require the signature of a parent or legal guardian.

(5) Each Mobile Dental Clinic shall maintain a written or electronic record detailing all of the following information for each location where services are performed:

(a) The street address of the service location.

(b) The dates of each session.

(c) The number of patients served.

(d) The types of dental services provided and the quantity of each service provided.

(e) Any other information requested by rule of the Board or Medicaid.

(6) At the conclusion of each patient's visit to the Mobile Dental Clinic, the patient shall be provided with a patient information sheet which shall also be provided to any individual or entity to whom the patient has consented or authorized to receive or access the patient's records. The information sheet shall include at a minimum the following information:

(a) The name of the dentist or dental hygienist, or both, who performed the services.

(b) A description of the treatment rendered, including billing service codes and fees associated with treatment and tooth numbers when appropriate.

(c) If applicable, the name, address, and telephone number of any dentist to whom the patient was referred for follow-up care and the reason for such referral.

(d) The name, address, and telephone number, if applicable, of a parent or guardian of the patient.

(7) Mobile Dental Clinics shall comply with the following requirements for Emergency Follow-up Care:

(a) The operator shall maintain a written procedure for emergency follow-up care for patients treated in a Mobile Dental Clinic, which includes arrangements for treatment and follow-up care by a qualified dentist in a dental facility that is permanently established within a 50-mile radius of where mobile services are provided.

(b) An operator who either is unable to identify a qualified dentist in the area or is unable to arrange for emergency follow-up care for patients otherwise shall be obligated to provide the necessary follow up via the Mobile Dental Clinic or the operator may choose to provide the follow-up care at his or her established dental practice location in the state or at any other established dental practice in the state which agrees to accept the patient.

(c) An operator who fails to arrange or provide follow-up care as required herein shall be considered to have abandoned the patient, and will subject the operator and any dentist or dental hygienist, or both, who fail to provide the referenced follow-up treatment to termination as a Medicaid provider.

(8) The provider shall not charge Medicaid for services rendered on a no-charge basis to the general public.

(9) A Mobile Dental Clinic that accepts or treats a patient but does not refer patients for follow-up treatment when such follow-up treatment is clearly necessary, shall be considered to have abandoned the patient and will subject the operator and any dentist or dental hygienist, or both, who fails to provide the referenced follow-up treatment to termination as a Medicaid provider.

(10) Mobile Dental Clinics shall comply with the following requirements for sale or cessation of operation:

(a) In the event a Mobile Dental Clinic is to be sold, the current provider shall inform the Board and Medicaid, at least 10 days prior to the sale being completed and shall disclose the purchaser to the Board and Medicaid, via certified mail within 10 days after the date the sale is finalized.

(b) The provider shall notify the Board and Medicaid, at least 30 days prior to cessation of operation. Such notification shall include the final day of operation, and a copy of the notification shall be sent to all patients and shall include the manner and procedure by which patients may obtain their records or transfer those records to another dentist.

(c) It is the responsibility of the provider to take all necessary action to ensure that the patient records are available to the patient, a duly authorized representative of the patient, or a subsequent treating dentist. For purposes of this subsection, a patient shall mean any individual who has received any treatment or consultation of any kind within two years of the last date of operation of the Mobile Dental Clinic.

History

• Author: Leigh Ann Hixon, Dental Program
• Authority: State Plan Attachment 4.19-B; Title XIX, Social Security Act; 42 CFR Section 440.100; Alabama Act No. 2008-279.
• New Rule: Filed June 20, 2008; effective September 15, 2008.