Chapter 5160-5 Dental Program

5160-5-01 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 professional dental group (group dental practice) is also considered eligible as a group dental practice if organized in accordance with rule 5101:3-1-17 of the Administrative Code, for the sole purpose of providing professional dental 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.

(c) 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.

(C) Drugs.

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

(2) Providers are required to print or stamp their 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.

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

(E) 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.

(F) Reimbursement for some services covered under the medicaid program is available only upon obtaining prior authorization from the Ohio department of job and family services (ODJFS) 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. A completed prior authorization request for such dental services is required for reimbursement consideration.

(1) All prior authorization requests must be submitted through the ODJFS web portal. Paper prior authorization requests will be returned to the provider unprocessed.

(2) Documentation necessary to complete the prior authorization request that cannot be uploaded and submitted through the ODJFS web portal, such as x-rays and dental molds, must be submitted separately.

Click to view Appendix

Effective: 08/02/2011
R.C. 119.032 review dates: 09/20/2010 and 08/01/2016
Promulgated Under: 119.03
Statutory Authority: 5111.02 , 5111.0112
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, 7/1/08

5160-5-02 Dental program: covered diagnostic services and limitations.

The following dental examination codes may be billed for any place of service in accordance with the coverage and limitations set forth in Chapter 5101:3-5 of the Administrative Code.

(A) Clinical oral examination.

(1) Comprehensive oral evaluation.

(a) The comprehensive oral evaluation is typically used by a general dentist and/or a specialist when evaluating a consumer comprehensively. It is a thorough evaluation and recording of the extraoral and intraoral hard and soft tissues. It may require interpretation of information acquired through additional diagnostic procedures. Additional diagnostic procedures should be reported separately.

A comprehensive oral evaluation would include the evaluation and recording of the consumer's dental and medical history and a general health assessment. It may typically include the evaluation and recording of dental caries, missing or unerupted teeth, restorations, occlusal relationships, periodontal conditions (including periodontal charting), hard and soft tissue anomalies, oral cancer screening, etc.

(b) The comprehensive oral evaluation shall be limited to one per provider-

consumer relationship.

(c) The comprehensive oral evaluation shall not occur in combination with the periodic oral evaluation.

(2) Periodic oral evaluation.

(a) This includes an evaluation performed on a consumer of record to determine any changes in the consumer's dental and medical health status since a previous comprehensive or periodic evaluation. This includes periodontal screening and may require interpretation of information acquired through additional diagnostic procedures. Report additional diagnostic procedures separately.

(b) Effective for dates of service on or after January 1, 2006, the periodic oral evaluation shall not occur more frequently than once every one hundred eighty days for consumers twenty-years of age and younger. Those exams occurring more frequently shall not be reimbursed by the department.

(c) Effective for dates of service from January 1, 2006 through June 30, 2008, the periodic oral evaluation shall not occur more frequently than once every three hundred sixty-five days for consumers twenty-one years of age and older. Effective for dates of service from July 1, 2008 through December 31, 2009, the periodic oral examination shall not occur more frequently than once every one hundred eighty days irrespective of the consumer's age. Those exams occurring more frequently shall not be reimbursed by the department.

(d) Effective for dates of service on or after January 1, 2010, the periodic oral evaluation shall not occur more frequently than once every three hundred sixty-five days for consumers twenty-one years of age and older.

(d)

(e) The periodic oral evaluation shall not occur in combination with the comprehensive oral evaluation and not before one hundred eighty days after the comprehensive oral evaluation.

(3) Limited oral evaluation - problem focused.

(a) An evaluation limited to a specific oral health problem or complaint. This may require interpretation of information acquired though additional diagnostic procedures.

(b) The limited oral evaluation - problem focused shall include any necessary palliative treatment.

(c) Evaluations solely for the purpose of adjusting dentures are noncovered except as specified in rule 5101:3-28-04 of the Administrative Code.

(d) The limited oral evaluation - problem focused may not be billed in conjunction with other dental procedures, with the exception of x-rays on the same date of service.

(B) Radiographs/diagnositc imaging (including interpretation). All radiographs, when presented to the department for review, shall be of diagnostic quality, properly mounted, properly exposed, clearly focused, clearly readable and free from defect for the area of the mouth on which the radiograph was performed.

(1) Intraoral, complete series (including bitewings).

(a) A complete series of radiographs shall consist of a minimum of twelve or more films. This shall include all periapical, bitewing, and occlusal film necessary for the diagnosis.

(b) A complete series of radiographs is allowed only once every five years. If a complete set of radiographs is required more frequently, prior authorization must be obtained.

(c) Periapical films shall show complete visibility of the periodontal ligament, crown and root structure in its entirety.

(2) Intraoral periapical, first film.

(3) Each additional intraoral periapical film.

(4) Intraoral occlusal film.

(5) Extraoral - first film. The extraoral film shall be allowed as an adjunct to complex treatment.

(6) Bitewing - single film.

(7) Bitewing - two films.

(8) Bitewing - three films.

(9) Bitewing - complete series, minimum of four films.

(a) The complete bitewing series is only reimbursable in the presence of erupted permanent second molars. Bitewing radiographs, in combination with other radiographs or when made alone, are allowed at six-month intervals providing they do not exceed the limitations set forth in paragraph (B) of this rule.

(b) Bitewing radiographs are permitted as frequently as at six month intervals, however, they are recommended at intervals of six to twenty four months, consistent with consumer risk for oral disease.

(c) Bitewing films shall show complete visibility of clinical crowns with no overlapping and cannot be substituted for periapical films in instances where endodontic treatment is necessary.

(10) Panoramic film.

(a) The panoramic film is an extraoral radiograph on which the maxilla and mandible are depicted on a single film.

(b) All bitewing and periapical film needed to render the necessary radiographic diagnosis is included in the fee for panoramic radiographs.

(c) Panoramic radiographs shall be permitted for consumers six years of age and older. If the dentist feels that it is medically necessary for a consumer under six years old to receive a panoramic radiograph, prior authorization must be obtained.

(d) Panoramic radiographs shall not be repeated more frequently than once every five years. If such radiographs are required more frequently, prior authorization must be obtained.

(e) Panoramic radiographs shall not occur in combination with a complete series of radiographs. A minimum of five years must elapse between the provision of panoramic radiographs and a complete series of radiographs, unless prior authorization is obtained.

(f) Panoramic films shall show complete visibility of tooth crowns, roots, bony and soft tissues in both arches with little or no overlapping of tooth crowns.

(11) Cephalometric film with tracing. Prior authorization shall be required for cephalometric films and tracings.

(12) Diagnostic photographs in conjunction with orthodontic treatment. Prior authorization shall be required for diagnostic photographs.

(13) Temporomandibular joint films. Prior authorization shall be required for temporomandibular joint films including submission of consumer history and treatment plan. Temporomandibular joint films to include four to six films are covered only if required by the department. Effective for dates of service from January 1, 2006 through June 30, 2008, temporomandibular joint films were covered only for consumers twenty-years of age and younger.

Effective: 01/01/2010
R.C. 119.032 review dates: 01/01/2013
Promulgated Under: 119.03
Statutory Authority: 5111.0112 , 5111.02 , Section 309.30.75 of Am. Sub.
H.B. 1, 128th G.A
Rule Amplifies: 5111.01 , 5111.02 , 5111.021 , Section 309.30.75 of
Am. Sub. H.B. 1, 128th G.A
Prior Effective Dates: 4/7/77, 12/21/77, 91/85 (Emer), 11/27/85 (Emer),
5/9/86, 2/1/88, 11/15/93, 12/29/95 (Emer), 3/21/96, 1/1/00, 10/1/03, 1/1/06, 12/29/06 (Emer), 3/29/07,
7/1/08

5160-5-03 Dental program: covered tests and laboratory examinations and limitations.

The following tests and laboratory examinations are covered under the dental care program subject to the specified limitations.

(A) Biopsy of oral tissue - hard (bone, tooth).

(B) Biopsy of oral tissue - soft (all others).

(C) For the medicaid program, "biopsy" is defined as the removal of tissue from the patient for microscopic examination for the purpose of diagnosis, estimation of prognosis, and treatment planning.

(D) Diagnostic casts.

(1) Prior authorization shall be required for diagnostic casts. The prior authorization request for the diagnostic cast may be submitted with the completed cast when the cast is submitted for prior authorization for the proposed treatment. Prior authorization for the cast and the proposed treatment may be requested on the same prior authorization form. Providers may submit diagnostic casts in digital format or as a physical cast.

(2) Diagnostic casts shall be approved by the department for the evaluation of requested treatments listed throughout this chapter which state that diagnostic casts are necessary.

Effective: 01/01/2006
R.C. 119.032 review dates: 09/29/2005 and 01/01/2011
Promulgated Under: 119.03
Statutory Authority: 5111.02
Rule Amplifies: 5111.01 , 5111.02
Prior Effective Dates: 4/7/77, 12/21/77, 5/9/86, 2/1/88, 1/1/00, 10/01/03

5160-5-04 Dental program: covered preventive services and limitations.

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

(A) Prophylaxis.

(1) Dental prophylaxis, adult.

(a) This shall include the necessary scaling and/or polishing procedures of the teeth to remove coronal plaque, calculus and stains of transitional or permanent dentition for consumers ages fourteen and older.

(b) Effective for dates of service on or after January 1, 2006, the dental prophylaxis shall not occur more frequently than once every one hundred eighty days for consumers twenty-years of age and younger. Those prophylaxes occurring more frequently than once every one hundred eighty days shall not be reimbursed by the department.

(c) Effective for dates of service from January 1, 2006 through June 30, 2008, the dental prophylaxis shall not occur more frequently than once every three hundred sixty-five days for consumers twenty-one years of age and older. Effective for dates of service from July 1, 2008 through December 31, 2009, the dental prophylaxis shall not occur more frequently than once every one hundred eighty days irrespective of the consumer's age. Those prophylaxes occurring more frequently than once every one hundred eighty days shall not be reimbursed by the department.

(d) Effective for dates of service on or after January 1, 2010, the dental prophylaxis shall not occur more frequently than once every three hundred sixty-five days for consumers twenty-one years of age and older.

(2) Dental prophylaxis, child.

(a) This shall include the necessary scaling and/or polishing procedures to remove coronal plaque, calculus and and stains of primary or transitional dentition for consumers only through age thirteen.

(b) The dental prophylaxis shall not occur more frequently than once every one hundred eighty days. Those prophylaxes occurring more frequently than once every one hundred eighty days shall not be reimbursed by the department.

(B) Topical application of fluoride .

(1) Topical fluoride treatments (includes sodium, stannous and acid phosphate fluoride foam, gel, varnish and in-office rinse) shall be allowed for consumers under the age of twenty-one.

(2) Treatment that incorporates fluoride with the polishing compound shall be considered part of the prophylaxis procedure and not a separate topical fluoride treatment.

(3) Topical application of fluoride to the prepared portion of a tooth prior to restoration, the use of self or home fluoride application procedures, and application of sodium fluoride as a desensitizing agent are not covered treatments.

(4) The topical application of fluoride is limited to one application per one hundred eighty days.

(C) Sealant - per tooth. Pit and fissure sealants shall be permitted on previously unrestored occlusal areas of permanent molars subject to the following limitations:

(1) Sealants shall be allowed on permanent first molars for consumers under age eighteen.

(2) Sealants shall be allowed on permanent second molars for consumers under age eighteen.

(D) Space maintenance (passive appliances).

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

(2) Space maintainer - fixed - unilateral.

(3) Space maintainer - fixed - bilateral.

(4) Space maintainer - removable - unilateral.

(5) Space maintainer - removable bilateral.

(6) The preservation of arch length should be the main consideration in the evaluation of a consumer for a space maintainer. Space maintainers are permitted after the loss of a young permanent tooth or the premature loss of a primary tooth when an indeterminant time exists before the eruption of the permanent tooth.

Effective: 03/28/2013
R.C. 119.032 review dates: 03/01/2014
Promulgated Under: 119.03
Statutory Authority: 5111.02 , Section 309.30.75 of Am. Sub. H.B. 1, 128th G.A.
Rule Amplifies: 5111.01 , 5111.02 , 5111.021 , Section 309.30.75 of Am. Sub. H.B. 1, 128th G.A.
Prior Effective Dates: /7/77, 12/21/77, 5/9/86, 2/1/88, 11/15/93, 1/1/00, 10/1/03, 1/1/06, 7/1/08, 12/31/08(Emer).3/31/09, 1/1/10, 12/31/12(Emer)

5160-5-05 Dental program: covered restorative services and limitations.

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

(A) Amalgam restorations (including polishing).

(1) Amalgam - one surface, primary or permanent.

(2) Amalgam - two surfaces, primary or permanent.

(3) Amalgam - three surfaces, primary or permanent.

(4) Amalgam - four or more surfaces, primary or permanent.

(5) Payment shall not be made for separate occlusal restorations, other than on maxillary molars. Reimbursement for occlusal surface restorations, other than on maxillary molars, includes one or more restorations on that surface.

(B) Pin retention-exclusive of amalgam restoration per tooth, in addition to restoration. A maximum of three pins per tooth restoration shall be allowed as a covered service.

(C) Bases and copalite or calcium hydroxide liners placed under a restoration will be considered part of the restoration and not reimbursable as separate procedures.

(D) Local anesthesia shall be included in the fee for all restorative services.

(E) Resin - based composite restorations - direct.

(1) Resin-based composite restorations - anterior.

(a) Resin-based composite - one surface, anterior.

(b) Resin-based composite - two surface, anterior.

(c) Resin-based composite - three surface, anterior.

(d) Resin-based composite - four or more surfaces or involving incisal angle

(anterior) .

(2) Resin-based composite restorations - posterior.

(a) Resin-based composite - one surface, posterior.

(b) Effective for dates of service on or after January 1, 2004, resin-based composite - two surfaces.

(c) Effective for dates of service on or after January 1, 2004, resin-based composite - three surfaces, posterior.

(d) Effective for dates of service on or after January 1, 2004, resin-based composite - four or more surfaces, posterior.

(3) Pin retention- - per tooth, in addition to restoration (resin-based composite). A maximum of three pins per tooth shall be allowed as a covered service.

(4) Resin-based composite restorations shall be permitted for anterior teeth and class I or class V restorations on posterior teeth.

(5) Effective for dates of service on or after January 1, 2004, resin-based composite restorations shall be permitted for class II restorations on posterior teeth.

(6) The fee for resin-based composite restorations shall include any necessary acid etching.

(F) Maximum reimbursement for restorations shall be limited to no more than three restorations per tooth regardless of the number of surfaces restored.

(G) Single surface resin-based composite restorations shall involve repair to decay into the dentin.

(H) A tooth with decay on three surfaces that can be restored with separate restorations in accordance with accepted standards of dental practice may be billed and will be reimbursed as separate restorations.

(I) Preventive resin restorations are not covered services.

(J) Crowns.

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

(2) Crown - porcelain fused to noble metal.

(a) Prior authorization is required for porcelain fused to noble metal crowns. A periapical radiograph of the involved tooth must be submitted with each request.

(b) The fee for crowns includes the temporary crown which is placed on the prepared tooth and worn while the permanent crown is being prepared.

(c) Porcelain with metal crowns shall be authorized only for permanent anterior teeth.

(3) Prefabricated stainless steel crown. Stainless steel crowns shall be allowed only for teeth where multisurface restorations are needed and amalgam restorations and other materials have a poor prognosis.

(a) Prefabricated stainless steel crown - primary tooth

(b) Prefabricated stainless steel crown - permanent tooth.

(4) Prefabricated stainless steel crown with resin window. Open face stainless steel crown with aesthetic resin facing or veneer.

(a) Prefabricated stainless steel crowns with resin window shall be covered for anterior teeth only.

(b) The fee for prefabricated stainless steel crowns with resin window includes any necessary composite restoration.

(5) Cast post and core in addition to crown.

(a) Prior authorization is required for crowns with a post and core. A periapical radiograph of the involved tooth must be submitted with each request.

(b) Crowns with a post and core shall be approved only for endodontically treated permanent anterior teeth without sufficient tooth structure to support a crown.

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: 4/7/77, 12/21/77, 5/9/86, 2/1/88, 11/15/93, 12/29/95
(Emer), 3/21/96, 1/1/00, 10/1/03, 1/1/06

5160-5-06 Dental program: covered endodontic services and limitations.

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

(A) Therapeutic pulpotomy and pulpal therapy.

(1) Therapeutic pulpotomy and pulpal therapy shall be covered only for consumers under the age of twenty-one.

(2) Theraputic pulpotomy and pulpal therapy as separate procedures shall not occur in combination with root canal therapy.

(3) The restoration for the completed pulpal therapy or pulpotomy shall be billed as a separate procedure.

(B) Endodonic therapy (complete root canal therapy).

(1) Anterior - tooth (excluding final restoration).

(2) Bicuspid - tooth (excluding final restoration).

(3) Molar - tooth (excluding final restoration).

(4) Endodontic therapy is covered only when the overall health of the dentition and periodontium is good except for the endodontically indicated tooth/teeth. Decay must be above the bone level. Radiographs, including periapical, must be clearly readable and show periapical radioluncency or widening of periodontal ligament and be accompanied with chronic pain (as evidenced by sensitivity to hot or cold, percussion or palpation) or presence of fistula associated with tooth or chronic infection. If pathology is not visible on radiograph, endodontic treatment must be evidenced by clinical documentation.

(5) Endodontic therapy is covered only for permanent teeth.

(6) All diagnostic tests, evaluations, radiographs, and postoperative treatment are included in the fee.

(C) Apicoectomy/periradicular services.

(1) Apicoectomy/periradicular services shall be a covered service on permanent teeth only.

(2) Prior authorization is required for apicoectomy/periradicular services. All available radiographs of the mouth, properly mounted and clearly readable, must be submitted with each request. A periapical view of the tooth and the periapical area involved must be included.

(D) Apexification/recalcification procedures.

(1) Apical closure.

(a) Apexification/recalcification/pulpal regeneration - initial visit (apical closure/calcific repair of perforations, root resorption, pulp space disinfection, etc.)

(i) Apexification/recalcification includes opening tooth, preparation of canal spaces, first placement of medication and necessary radiographs.

(ii) This procedure may include the first phase of endodontic (complete root canal) therapy.

(b) Apexification/recalcification/pulpal regeneration - interim medication replacement (apical closure/calcific repair of perforations, root resorption, pulp space disinfection, etc.)

This procedure is for visits in which the intra-canal medication is replaced with new medication and necessary radiographs.

(c) Apexification/recalcification - final visit (includes completed endodontic therapy - apical closure/calcific repair of perforations, root resorption, etc.)

(i) This procedure includes removal of intra-canal medication and procedures necessary to place final root canal filling material including necessary radiographs.

(ii) This procedure includes last phase of endodontic (complete root canal) therapy.

(2) Apical closure does not include endodontic (root canal) therapy.

(3) Prior authorization is required for each apexification/recalcification procedure.

Effective: 03/30/2011
R.C. 119.032 review dates: 01/07/2011 and 03/01/2016
Promulgated Under: 119.03
Statutory Authority: 5111.02
Rule Amplifies: 5111.01 , 5111.02
Prior Effective Dates: 4/7/77, 12/21/77, 5/9/86, 11/15/93, 1/1/00, 10/1/03, 1/1/06, 7/1/08, 12/31/08 (Emer), 3/31/09, 12/30/10 (Emer)

5160-5-07 Dental program: covered periodontic services and limitations.

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

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

(B) Gingivectomy or gingivoplasty - four or more contiguous teeth or tooth bounded spaces per quadrant. Prior authorization is required for gingivectomy and gingivoplasty services. Complete radiographs of the mouth and diagnostic casts must be submitted with each request.

(C) Gingivectomy or gingivoplasty surgery is not usually covered under the medicaid program. One exception to program coverage limitations is to correct severe hyperplasia or hypertrophic gingivitis associated with drug therapy or hormonal disturbances.

Effective: 03/31/2009
R.C. 119.032 review dates: 01/13/2009 and 03/01/2014
Promulgated Under: 119.03
Statutory Authority: 5111.02
Rule Amplifies: 5111.01 , 5111.02
Prior Effective Dates: 1/2/00, 10/1/03, 1/1/06, 7/1/08, 12/31/08 (Emer)

5160-5-08 Dental program: covered removable prosthodontic services and limitations.

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

(A) Complete dentures (including routine post-delivery care).

(1) Complete denture - maxillary.

(2) Complete denture - mandibular.

(3) All dentures must be prior authorized. In cases where the recipient is not edentulous prior to requesting dentures, complete radiographs of the mouth, properly mounted and clearly readable, must be submitted with each denture request. Radiographs must be taken prior to extractions. Radiographs are not necessary for those individuals edentulous prior to requesting dentures.

(4) The diagnosis for dentures shall be based on the total condition of the mouth, ability to adjust to dentures, and the desire to wear dentures. Natural teeth that have healthy bone, are sound, and do not have to be extracted must not be removed.

(5) Complete extractions must be deferred until authorization to construct the denture has been given, except in absolute emergency situations.

(6) The dental care program shall not authorize immediate dentures except in very unusual circumstances which must be documented and approved by the department.

(7) A denture, complete, partial, or combination thereof, shall not be replaced or remade within eight years except for very unusual circumstances.

(8) The dentist shall be responsible for constructing a complete functional denture. The fee for dentures includes all necessary corrections and adjustments for a period of six months after seating the denture.

(9) A preformed denture with teeth already mounted (that is, teeth already set in acrylic prior to initial impressions), forming a denture module, is not a covered service.

(10) A denture shall not be authorized when dental history reveals that any or all dentures made in recent years have been unsatisfactory for reasons that are not remediable because of psychological or physiological reasons.

(B) Partial dentures.

(1) Maxillary partial denture - cast metal framework with resin denture bases (including any conventional clasps, rests and teeth).

(2) Mandibular partial denture - cast metal framework with resin denture bases

(including any coventional clasps, rests and teeth).

(3) Maxillary partial denture - resin base (including conventional clasps, rests and teeth). This procedure includes acrylic resin base denture with resin or wrought wire clasps. This procedure is a covered service for patients age eighteen and younger.

(4) Mandibular partial denture-resin base (including any conventional clasps, rests and teeth). This procedure includes acrylic resin base denture with resin or wrought wire clasps. This procedure is a covered service for patients age eighteen and younger.

(5) All partial dentures must be prior-authorized. Complete radiographs of the mouth, properly mounted and clearly readable, must be submitted with each request.

(6) Partial dentures cannot be replaced, remade, or exchanged for complete dentures for a minimum period of eight years except for unusual situations when justification for the new dentures can be established.

(7) Partial dentures are authorized when several teeth are missing in the arch and the masticatory function is severely impaired or when anterior teeth are missing in the arch which will affect the appearance of the patient.

(8) The dentist shall be responsible for constructing a complete functional partial denture. The fee for a partial denture includes all necessary corrections and adjustments for a period of six months after seating the partial denture.

(C) Repairs to dentures.

(1) Repairs to complete dentures.

(a) Repair broken complete denture base.

(b) Replace missing or broken teeth - complete denture (each tooth).

(2) Repairs to partial dentures.

(a) Repair resin denture base.

(b) Repair cast framework.

(c) Repair or replace broken clasp.

(d) Replace broken teeth - per tooth.

(e) Add tooth to existing partial denture.

(f) Add clasp to existing partial denture.

(D) Denture reline procedures.

(1) Reline complete maxillary denture.

(2) Reline complete mandibular denture.

(3) Reline partial maxillary denture.

(4) Reline partial mandibular denture.

(5) The reline must consist of the readaptation of the denture to the present oral tissues using accepted dental practice standards and procedures. The denture must be processed and finished with materials chemically compatible with the existing denture base. Chairside self-curing materials are not allowed.

(6) A complete or partial denture reline shall not occur more frequently than once every four years and not before four years after construction of the complete or partial denture except for unusual circumstances which must be documented.

(7) All complete and partial denture relining procedures include six months of post-delivery care.

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: 4/7/77, 12/21/77, 5/9/86, 1/4/88, 11/15/93, 12/29/95 (Emer), 3/21/96, 1/1/00, 10/01/03, 1/1/06

5160-5-09 Dental program: covered oral surgery services and limitations.

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

(A) The decision to remove a tooth or teeth must be based on the tooth or teeth being too broken down to save, too poorly supported by alveolar bone to save, and/or the presence of some pathological condition which contraindicates saving. Extractions that render a consumer edentulous must be deferred until authorization to construct a denture has been given, except in absolute emergency situations.

(B) The extraction of an impacted tooth is authorized only when conditions arising from such an impaction warrant its removal. The prophylactic removal of an asymptomatic tooth or teeth exhibiting no overt clinical pathology is covered only when at least one tooth is symptomatic.

(C) Local anesthesia and routine postoperative care are included in the fee for extractions.

(D) Extractions (includes local anesthesia, suturing, if needed and routine postoperative care).

(1) Extraction, erupted tooth or exposed root (elevation and/or forceps removal).

(2) Extraction, erupted tooth or exposed root (elevation and/or forceps removal) may be billed only once per tooth.

(E) Surgical extraction.

(1) Removal of impacted tooth - soft tissue. A "soft tissue impaction" is any tooth which requires an incision of overlying soft tissue and removal of the tooth without necessity of removing the bone. Partial eruption of a tooth with portions of the crown located at or above the occlusal plane does not disqualify the tooth as a soft tissue impaction if the position is such that soft tissue does in fact cover portions of the occlusal surface, for example, distoangular position. This procedure shall be permitted for third molars only without prior authorization. All other procedures shall require prior authorization.

(2) Removal of impacted tooth - partially bony. A "partially bony impaction" is one where the crown of the tooth is partially covered by bone. This tooth may or may not be partially erupted. This type of impaction requires an incision of overlying soft tissue, elevation of a flap, removal of bone and removal of the tooth. Partial eruption of a tooth with portions of the crown located at or above the occlusal plane does not disqualify this tooth from being classified a partially bony impaction if bone does in fact cover the greatest convexity of the distal portion of the crown, for example, distoangular position within the ramus of the mandible. If not visible on radiograph, bony impaction must be evidenced from clinical documentation. A radiograph of the impaction must be maintained in the patient's clinical record.

(3) Removal of impacted tooth - completely bony. A "completely bony impaction" is one where the crown of the tooth is completely covered by bone or a substantial part of the tooth above the greatest convexity of the crown is covered by bone on both the mesial and distal sides as demonstrated radiographically. In the case of horizontally impacted lower third molars, to be classified as a completely bony impaction the central groove of the crown must not be located superior to the occlusal plane. This type impaction requires an incision of overlying soft tissue, elevation of a flap, removal of bone, and sectioning of the tooth, if necessary for removal. Prior authorization is required for all completely bony impactions including a radiograph of the impaction.

(4) Removal of impacted tooth - completely bony with unusual surgical complications. Prior authorization is required for all completely bony impactions including a radiograph of the impaction.

(5) Surgical removal of a residual tooth roots (cutting procedure). Prior authorization is required for this procedure.

(6) Surgical removal of a supernumerary tooth. Prior authorization is required for the surgical removal of a supernumerary tooth. Surgical removal of supernumerary teeth must be billed on a paper claim form using local level program code Y7255 until a CDT code is assigned for this procedure.

(F) Tooth reimplantation and/or stabilization of accidentally avulsed or displaced tooth and/or alveolus. This procedure shall be authorized by report. Submission of radiographs of the area and a detailed explanation of the findings and treatment are required for authorization.

(G) Alveoplasty - surgical perparation of ridges for dentures.

(1) Alveoplasty is a covered service only when provided in conjunction with the construction of a prosthodontic appliance.

(2) Alveoplasty in conjunction with extractions - per quadrant.

(3) Alveoplasty, not in conjunction with extractions - per quadrant.

(H) Surgical excision.

(1) Coverage of removal of cysts or tumors is on a by-report basis. Submission of radiographs of the area and detailed explanation of findings and treatment are required for authorization.

(2) Removal of benign odontogenic cyst or tumor- lesion diameter up to 1.25 cm.

(3) Removal of benign odontogenic cyst or tumor- lesion diameter greater than 1.25 cm.

(4) Removal of benign nonodontogenic cyst or tumor - lesion diameter up to 1.25 cm.

(5) Removal of benign nonodontogenic cyst or tumor- lesion diameter greater than 1.25 cm.

(6) Removal of lateral exostosis (maxilla or mandible).

(a) Prior authorization is required for all removal of lateral exostosis procedures.

(b) A study cast of the mouth with the area of surgery outlined must be submitted for prior authorization.

(I) Surgical incision.

(1) Incision and drainage of abscess - intraoral soft tissue.

(2) Incision and drainage of abscess - extraoral soft tissue.

(3) Coverage of incision and drainage of abscesses is on a by-report basis requiring submission of radiographs of the area and detailed explanation of findings and treatment.

(J) Treatment of fractures.

(1) The treatment of fractures should be billed to the department using codes from the "American Medical Association's Current Procedural Terminology (CPT)".

(2) Alveolus - open reduction, may include stabilization of teeth, may be billed as a CPT code or dental code.

(K) Other repair procedures.

(1) Frenulectomy - also known asfrenectomy or frenotomy - separate procedure not incidental to another procedure. Prior authorization is required and must include submission of complete radiographs of the mouth and study casts of the arch with outline of indicated surgery .

(2) Excision of hyperplastic tissue - per arch. Prior authorization is required and must include submission of complete radiographs of the mouth and study casts of the arch with the outline of the indicated surgery.

(L) Oral surgery services shall be billed to the department using procedure codes from either the surgery section, CPT codes or dental codes . Regardless of the code used, all claims must be submitted to the department on the appropriate claim type.

Effective: 03/30/2011
R.C. 119.032 review dates: 01/07/2011 and 03/01/2016
Promulgated Under: 119.03
Statutory Authority: 5111.02
Rule Amplifies: 5111.01 , 5111.02
Prior Effective Dates: 4/7/77, 12/21/77, 5/9/86, 1/4/88, 11/15/93, 1/1/00, 10/1/03, 1/1/06, 7/1/08, 12/30/10 (Emer)

5160-5-10 Dental program: covered orthodontic services and limitations.

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

(A) Surgical access of an unerupted tooth. Coverage is limited to situations whereby an orthodontic attachment is placed on the crown to facilitate eruption. Prior authorization is required. Complete radiographs must be submitted with each request.

(B) Minor treatments to control harmful habits.

(1) Fixed appliance therapy.

(2) Removable appliance therapy.

(3) Prior authorization is required on all tooth guidance appliances to control harmful habits including, but not limited to, thumb- and finger-sucking, tongue-thrusting, and bruxism. Complete radiographs and study models of the mouth must be submitted with each request.

(C) Comprehensive orthodontics.

(1) Coverage of comprehensive orthodontics is limited to the most severe handicapping orthodontic conditions. Coverage is further limited to consumers under age twenty-one. Only one course of orthodontic treatment per consumer, per lifetime is covered.

(2) Prior authorization is required for all comprehensive orthodontic treatment. Effective December 7, 2010, all prior authorization requests must be submitted through the Ohio department of job and family services (ODJFS) web portal. Paper prior authorization requests will be returned to the provider unprocessed.

Documentation necessary to complete the prior authorization request that cannot be uploaded and submitted through the ODJFS web portal, such as x-rays and dental molds, must be submitted separately.

The following must be included with the prior authorization request:

(a) A completed prior authorization request.

(b) Lateral and frontal photographs of consumer with lips together.

(c) Cephalometric film with lips together, including a tracing.

(d) A complete series of radiographs or a panoramic radiograph.

(e) Diagnostic models.

(f) Treatment plan, including projected length and cost of treatment.

(g) A completed referral evaluation criteria form (JFS 03630/appendix to this rule ). A consumer must demonstrate a minimum of five symptoms, with at least two of the symptoms appearing under dentofacial abnormality before the provider submits a request for consideration.

(3) Upon evaluation of all the documentation which includes study models, cephalometric film and tracing, radiographs, photographs, and the referral evaluation criteria form, the department will determine if the condition will be considered a severely handicapping orthodontic condition and covered by medicaid. If the case is denied, the prior authorization will be returned to the provider indicating that the orthodontic treatment will not be reimbursed by Ohio medicaid. However, an authorization will be issued for the payment of the photographs, cephalometric radiograph and tracing, and the diagnostic models. Full mouth radiographs and panoramic films do not require prior authorization and can be billed separately on a dental invoice by the dentist who provided the radiographs.

(4) The original prior authorization will cover the entire course of treatment as long as the consumer remains eligible for medicaid services. For those cases approved for treatment, the department will issue a prior authorization that approves payment for the records and the first quarter of treatment. Payment for subsequent quarters of orthodontic treatment will be made at the beginning of each quarter of active treatment through a maximum of eight quarters. Also, payment will be made for retention services after the active treatment is completed. The dentist, using the original prior authorization number, should bill the department every ninety days at the beginning of the quarter to receive payment for that quarter. At the end of the active treatment, the department can be billed one time per arch for retention service. Payment will not be made for active treatment after retention is begun.

(5) If the consumer becomes ineligible during the time that comprehensive orthodontic treatment is being rendered, the quarter payment will permit coverage to continue through the end of the authorized quarter of treatment. For example, if the prior authorized treatment quarter begins February first, and the consumer becomes ineligible as of March first, treatment is to continue through the remainder of the quarter for which payment has been made, (February first - April thirtieth). It will be the responsibility of the consumer and the dentist to determine a payment mechanism for subsequent quarters of treatment provided when the consumer is ineligible for medicaid.

(6) Payment for active treatment will be made for a maximum of eight quarters. In some cases more than eight quarters may be necessary to complete treatment. However, the fee associated with eight quarters of treatment is the maximum amount reimbursable and is considered payment-in-full. No additional reimbursement can be sought from the department, consumer, or other source if the treatment requires additional quarters.

Click to view Appendix

Effective: 08/02/2011
R.C. 119.032 review dates: 09/20/2010 and 08/01/2016
Promulgated Under: 119.03
Statutory Authority: 5111.02
Rule Amplifies: 5111.01 , 5111.02 , 5111.021
Prior Effective Dates: 4/7/77, 12/21/77, 5/9/86, 2/1/88, 11/15/93, 8/1/95, 12/29/99 (Emer), 10/1/03, 1/1/06, 7/1/08

5160-5-11 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