OHCA Services for Dental Providers
SoonerCare (Oklahoma Medicaid) pays for preventative, diagnostic and restorative services for eligible members. Please visit Medicaid Compliance for the Dental Professional from the Centers for Medicare & Medicaid Services (CMS) to learn about compliance facilitation and good documentation procedures, as well as access a Program Integrity Toolkit.
The Oklahoma Health Care Authority (OHCA) is governed by the Oklahoma Administrative Rules 317:30-5 and uses the dental codes identified in the Current Dental Terminology (CDT) Manual.
OAR 317:30-5 PART 79. DENTISTS
- 317:30-5-695. Eligible dental providers and definitions
- 317:30-5-695.1. Payment of eligible providers
- 317:30-5-695.2. Payment for dental interns and students
- 317:30-5-696. Coverage by category
- 317:30-5-696.1. Conscious Sedation
- 317:30-5-697. Oral surgery procedures
- 317:30-5-698. Services requiring prior authorization
- 317:30-5-699. Restorations
- 317:30-5-700. Orthodontic services
- 317:30-5-700.1. Orthodontic prior authorization
- 317:30-5-701. Surface identification
- 317:30-5-703. Tooth numbering system
- 317:30-5-704. Billing instructions
- 317:30-5-705. Billing
• Dental Fees - (you must agree to the terms for usage before downloading the PDF file)
The Oklahoma Health Care Authority has introduced coverage of caries risk assessment dental codes D0601, D0602 and D0603. The concept of risk-based dental caries management is not new and is based on the belief that dentists can use certain indicators to classify caries risk status. Assessment should allow for targeted patient/guardian education and engagement in the caries prevention process. Use of this tool will also aid in more accurate predictions of future caries experience and provide a basis to determine if preventive services can be planned more appropriately with the data obtained.
Your evaluation of each individual member’s caries risk will determine the correct D code to submit for reimbursement - depending upon whether the member is found to be low, moderate or high risk. All signatures and boxes must be completed. The caries risk code submitted for payment must reflect the findings on the completed form. The assessment may be reimbursed once per member per year. Submission of the OHCA Caries Risk Assessment Form is now required, in addition to the DEN-2 form, when referring SoonerCare members for orthodontic treatment.
If you have additional questions or comments, contact the OHCA Dental Unit at (405) 522-7401.
Training Documents & Resources
- Dental Claims Submissions 2021
- Dental Updates and Changes
- Dental Training - Medical Documentation
- Current Dental Prior Authorization Training (May 2022)
- Quick Reference Guide - Oklahoma Medicaid Benefits
- Special Processed Claims - ADA Dental Nov 2020
All requests must demonstrate medical necessity and contain the minimum document requirement for review. Prior Authorizations Requests (PAR) must be submitted electronically via provider portal. If a prior authorization is missing the minimum documents required, OHCA reviewers will cancel authorization for insufficient documentation. Provides must resubmit a new PAR with all required documentation.
Minimum required records to be submitted with each dental PAR are:
- A comprehensive treatment plan containing members treatment history and clinical notes,
- Right and left mounted bitewing x-rays or panoramic x-ray, and
- Periapical films of tooth/teeth involved displaying 3mm beyond the apex of the tooth as stated in policy.
X-rays and/or images must be identified by the tooth number and include date of exposure, member name, member ID, provider name, and provider ID. All x-rays or images, regardless of the media, must be submitted together with a completed and signed comprehensive treatment plan that details all needed treatment at the time of examination. The film/print must also clearly identify the requested service. If you are requesting periodontal services, please also send periodontal charting. Records will not be returned.
Please note that providers are notified via the OHCA Provider Portal as to whether services are denied or approved. A letter is also mailed to the member’s family.
Orthodontic Prior Authorizations
The following information is required to process all requests for comprehensive orthodontics (braces):
- Caries Risk Assessment;
- Current ADA claim form;
- DEN-6 HLDD form;
- 3-D model images or Study Models (images preferred);
- Panoramic x-ray;
- DEN-2 Referral Form from the member’s general dentist;
- Detailed description of any oral maxillofacial anomaly and estimated length of treatment;if diagnosed as a surgical case, submit an oral surgeon's written opinion that orthognathic surgery is indicated and the surgeon is willing to provide this service;
- Intraoral photographs showing teeth in centric occlusion and/or photographs of trimmed anatomically occluded diagnostic casts. A lingual view of casts may be included to verify impinging overbites;
- Cephalometric x-rays with tracing.
X-rays and/or images must should be identified by the tooth number and include date of exposure, member name, member ID, provider name, and provider ID. All x-rays or images, regardless of the media, must be submitted together with a completed and signed comprehensive treatment plan that details all needed treatment at the time of examination. The film/print must also clearly identify the tooth number for requested service. Records will not be returned. Please note that providers are notified via the OHCA Provider Portal as to whether services are denied or approved. A letter is also mailed to the member’s family.
OHCA’s dedicated staff within Dental Unit/Provider Services will assist dental providers with questions regarding prior authorizations. Please call 405-522-7401 for assistance.
The OHCA Dental Advisory Committee on Periodicity (DACP) intends this guideline to help providers make clinical decisions concerning preventive oral health care for infants, children, and adolescents. Because each child is unique, these recommendations are designed for the care of children who have no contributory medical conditions and who are developing normally. These recommendations will need to be modified for children with special health care needs or if disease or trauma manifests variations from the normal. The American Academy of Pediatric Dentistry (AAPD) and DACP emphasize the importance of very early professional intervention and the continuity of care based on the individualized needs of the child.
Dental benefits are available for adult SoonerCare members served through the In-Home Supports Waiver or Community Waiver. Adults with developmental disabilities served in these waivers are evaluated by their case managers for initial services such as a general exam, cleaning and x-rays. Requests for additional treatment may now be directed to the case manager to include up to $1,000 per plan of care in services.
All services must be prior authorized by the member’s case manager. The Oklahoma Department of Human Services Developmental Disabilities Services has prepared information packets about the benefits to distribute to interested dental providers. Packets are available upon request from Julie Whitworth at the DHS state office, 405-521-2237.
Out of State Services
Beginning Sept. 1, 2019 the Oklahoma Health Care Authority (OHCA) will enact changes to the agency’s out-of-state (OOS) services policies. These changes will continue to ensure members have access to quality care while controlling program costs. They will not impact routine medical care for SoonerCare members.
In 2019 the Oklahoma legislature passed HB 2341, which limited SoonerCare members’ services to in-state providers when possible. These changes to OOS services will allow OHCA to maintain compliance with federal and state regulations.
These revisions clearly define coverage and reimbursement for services rendered by providers that are physically located outside of Oklahoma. The policy also outlines provider participation requirements and documentation requirements for out of state service requests.
For more information on Out-of-State Services go to http://www.okhca.org/OOSproviders.