5101:3-5-01 Dental program: general and co-payment provisions.

(A) Eligible providers of dental services.

(1) All individuals currently licensed under state of Ohio law to practice dentistry are eligible to participate in the Ohio medicaid program as a dental provider upon execution of the “Medicaid Provider Agreement” according to rule 5101:3-1-17.2 of the Administrative Code.

(2) A dentist’s professional association (group dental practice) is also considered eligible as a group dental practice if organized under sections 1785.01 to 1785.08 of the Revised Code, for the sole purpose of providing professional services.

(3) Dentists practicing and serving Ohio medicaid consumers outside of Ohio must be licensed by the dental examining board in their own state and must complete the “Medicaid Provider Agreement.”

(4) Other eligible providers of dental services include, but are not limited to, the following medicaid providers if the providers employ or have under contractual arrangement individuals licensed to practice dentistry:

(a) Fee-for-service ambulatory health care clinics as defined in Chapter 5101:3-13 of the Administrative Code.

(b) Outpatient health facilities as defined in Chapter 5101:3-29 of the Administrative Code.

(d) Federally qualified health centers as defined in Chapter 5101:3-28 of the Administrative Code.

(B) General anesthesia

(1) General anesthesia is reimbursable only when performed by a dentist who has an “Ohio state dental board permit.”

(2) Dentists practicing and serving Ohio medicaid consumers outside the state of Ohio must meet the requirements of the dental examining board in their own state for administering general anesthesia.

(1) Drugs are provided under the medicaid program only upon written prescription of a physician or dentist.

(2) Providers are required to print or stamp their seven-digit medicaid legacy number and ten digit national provider identifier (NPI) number on the prescription blank or give their provider numbers to the pharmacist on prescriptions telephoned directly to the pharmacy.

(3) Reimbursement for the cost of drugs for take-home use prescribed and dispensed by dentists shall be consistent with rule 5101:3-4-13 of the Administrative Code.

(D) Co-payments (except for medicaid consumers enrolled in the medicaid managed health care program).

(1) For dates of service on or after January 1, 2006, the department has adopted a medicaid co-payment of three dollars per date of service per provider in accordance with rules 5101:3-1-09 and 5101:3-1-60 of the Administrative Code. Services provided to a consumer on the same date of service by the same provider are subject only to one co-payment.

(2) The dental co-payments set forth in this rule also apply to consumers who are eligible under the disability medical assistance (DMA) program in accordance with rule 5101:3-23-01 of the Administrative Code, when the dental services provided are covered under the DMA program in accordance with Chapter 5101:3-23 of the Administrative Code.

(E) For dates of service as of January 1, 2006 through June 30, 2008, the department has adopted a modified dental benefit that is less in amount, scope and duration for consumers twenty-one years of age and older as specified by service category in rules 5101:3-5-02 to 5101:3-5-11 of the Administrative Code.

(F) Unless otherwise specified, reimbursement for covered dental services provided by eligible providers to eligible consumers is contained in appendix DD of rule 5101:3-1-60 of the Administrative Code.

(G) Reimbursement for some services covered under the medicaid program is available only upon obtaining prior authorization from the department as specified in accordance with rule 5101:3-1-31 of the Administrative Code. Dental services which require prior authorization are identified in Chapter 5101:3-5 of the Administrative Code. Prior authorization requests for dental services should be submitted utilizing as appropriate forms JFS 03612 (prior authorization for dental services) or JFS 03630 (referral evaluation criteria for comprehensive orthodontic treatment), appendix to this rule.

Appendix PRIOR AUTHORIZATION FOR DENTAL SERVICES

See Form at http://www.registerofohio.state.oh.us/pdfs/5101/3/5/5101$3-5-01_PH_FF_A_APP1_20080611_0925.pdf

Effective: 07/01/2008

R.C. 119.032 review dates: 10/16/2007 and 01/01/2013

Promulgated Under: 119.03

Statutory Authority: 5111.02

Rule Amplifies: 5111.01, 5111.0112, 5111.02, 5111.021

Prior Effective Dates: 4/7/77, 9/2/85, 2/1/88, 11/15/93, 12/29/95 (Emer), 3/21/96, 1/1/00, 10/1/03, 1/1/06