5101:3-5-11 Dental program: other covered services and limitations.

The following services are covered under the dental care program subject to the specified limitations.

(A) Anesthesia for dental procedures.

(1) "General anesthesia" is defined as a controlled state of unconsciousness accompanied by partial or complete loss of protective reflexes, inability to independently maintain an airway, inability to respond purposefully to physical stimulation or verbal command with resultant amnesia related to the surgical procedure.

(2) General anesthesia shall be reimbursed at a flat rate per consumer per date of service. A twenty-five dollar in-office incentive payment shall be added to the reimbursement for general anesthesia provided in an office setting.

(3) The administration of general anesthesia will be covered for surgical and restorative procedures when performed by an eligible provider as defined in rule 5101:3-5-01 of the Administrative Code. The cost of analgesic and local anesthetic agents is included in the fees associated with dental services reimbursed by the medicaid program.

(B) Dental services performed in long-term care facilities or private homes.

(1) Dental services rendered to consumers in long-term care facilities or private homes are covered in accordance with the coverage and limitations set forth in Chapter 5101:3-5 of the Administrative Code.

(2) An updated medical and dental history, diagnosis, prognosis, and treatment plan must be maintained in the provider's office. For consumers residing in long-term care facilities, a copy of this record must also be maintained in the facility.

(3) A record of the request for treatment, signed by the consumer, family member, responsible guardian, or attending physician, must be maintained in the consumer's permanent record at the long-term care facility and the provider's office.

(4) When requesting services that require prior authorization (PA), a copy of the request for treatment must be submitted with the PA request along with any study casts or radiographs that may be required. Additionally, when the PA request is for dentures or partials, a copy of the most recent nursing care plan must be submitted to the department with the request.

(C) Inpatient hospital services. All elective inpatient hospital admissions require preadmission certification in accordance with rule 5101:3-2-40 to 5101:3-2-42 of the Administrative Code.

(D) Therapeutic drug injection, by report. This procedure shall be authorized by report.

(E) Temporomandibular therapy.

(1) Effective for dates of service from January 1, 2006 through June 30, 2008, temporomandibular therapy services were not covered services for consumers twenty-one years of age and older.

(2) All treatment for temporomandibular joint therapy requires prior authorization.

(3) Panaromic radiographs, diagnostic casts, and a report of the clinical findings and symptoms must be submitted with each request for prior authorization.

(4) The fee allowed for the temporomandibular therapy includes six months of adjustments.

(F) Maxillofacial prosthetics. Prior authorization is required and must include a detailed treatment plan, full mouth radiographs, and hospital operative report, if applicable.

(G) Miscellaneous services. Unspecified adjunctive procedure, by report.

(1) Unusual and/or specialized treatment required to safeguard the health and welfare of the consumer.

(2) Prior authorization is required and must include detailed information on the difficulty and complications of the service and complete radiographs of the mouth, if indicated. An estimation of the usual fee charged for the service must also be submitted with the prior authorization request.

Effective: 07/01/2008
R.C. 119.032 review dates: 10/16/2007 and 01/01/2013
Promulgated Under: 119.03
Statutory Authority: 5111.0112 , 5111.02
Rule Amplifies: 5111.01 , 5111.02 , 5111.021
Prior Effective Dates: 1/2/02, 10/1/03, 1/1/06