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Dental Provider FAQ 

Select the Frequently Asked Question to view answer.
  1. What is an emergency dental service?

    Services for the relief of pain and infection are emergency dental services. As of July 1, 2012, HFS covers limited services needed to treat a dental emergency for clients 21 years of age and older. Covered  services are limited to  exams, X-rays,  sedation (if necessary) and extraction to remove  a tooth.

  2. What adult services are covered after July 1, 2012?

    Covered dental services include dental exams (D0140), X-rays (D0220, D0230, D0330), the extraction (D7140, D7210) and sedation (D9230, D92480) associated with emergency dental services.

  3. What dental services are available to pregnant women?

    Pregnant women under age 21 will continue to receive all the dental services available to children in Illinois due to EPSDT requirements. Pregnant women age 21 and over are considered adults. Consequently, only the emergency dental services are covered for them.

  4. Will fractured teeth, fractured jaw, and other traumatic injuries due to external trauma be covered under the Dental Program? How should the Provider bill in these instances?

    Fractured teeth, fractured jaws, and other traumatic injuries due to external trauma may be covered if they are medical injuries or conditions. The only dental treatment covered (under the dental benefit package) for traumatic injury is extraction. Other traumatic oral cases that are medical in nature may be billed as medical services by a physician or by a dentist who is enrolled with HFS as an Oral and Maxillofacial Surgeon. Enrollment information is available on the Medical Programs General Provider Enrollment Requirements page of the HFS Web site.

  5. Does the $3.65 copayment apply to emergency dental care for adults?

    No.

  6. If a patient is examined and given a prescription for antibiotics to take for several days before an impacted tooth can be extracted, will HFS pay a claim for the exam and X-rays done on a different date of service?

    Yes, claims for an exam (D0140) and X-rays (D0220, D0230, D0330) are also eligible for payment if provided no earlier than seven days prior to the extraction.  For example, if the exam was done on August 1st, the extraction would need to be done by August 7th in order for both services to pay. This delay allows a patient to receive necessary antibiotic treatment prior to the extraction. HFS will cover an exam (D0140) and X-rays (D0220, D0230, D0330), when an extraction (D7140, D7210) is completed on the same day or within seven days after those services are provided. Necessary sedation (D9230, D9248) will be covered if administered for the extraction. All services, whether performed on the same day or within the seven day period prior to the extraction, must be submitted on the same claim form. In addition, only services performed by the same provider or at the same location will be covered.

  7. If a patient comes in with an abscessed tooth on one day, dentist or FQHC does X-rays and exam and prescribes an antibiotic and pain meds and the person doesn’t come back to get tooth extracted. Will provider get paid for first visit?

    No, if the patient does not return for the extraction, the provider will not be paid.

  8. Can I charge a Medicaid recipient an amount to cover my cost of exam and X-ray when an extraction is not done during that visit? When the extraction is completed, I will refund the payment.

    HFS does not support this practice; however, exams and X-rays are not considered a Medicaid covered service until the extraction is completed. This must be clearly communicated (in writing) to your patient(s). Your patient(s) must be clearly informed that they are responsible for paying for the exam and X-ray fees if the extraction process cannot be completed during the visit. The patient must also be informed that the exam and X-ray fee will be fully refunded if/when the extraction is completed.

  9. How does an FQHC bill for adult emergency dental?

    An FQHC will be paid for an exam (D0140), X-rays (D0220, D0230, D0330), and sedation (D9230, D9248) when an extraction (D7140, D7210) is completed on the same day that services are provided. Claims for an exam (D0140) and X-rays (D0220, D0230, D0330) are also eligible for payment if provided within the seven-days period prior to the date of the extraction. This delay allows a patient to receive necessary antibiotic treatment prior to the extraction. All services, whether performed on the same day or within seven day prior to the extraction, must be billed at the FQHC’s encounter rate, D0999, and all services (exam, X-ray, sedation and extraction) must be listed on the same claim form. The FQHC will receive payment for one encounter, regardless of whether treatment required one visit by the patient or two.

  10. I am a Provider, but I do not do extractions. If I see a patient for the initial exam and X-rays and give a prescription then refer the patient to another provider for an extraction, will I get paid for the exam and X-rays?

    No, the exam, X-ray and extraction must be billed on the same claim form. The provider who performs the extraction will be paid for the exam and extraction.

  11. When will single appointment prior approvals end? Will the Provider receive payment if the service is provided after July 1, 2012?

    All open authorizations for services requiring a single appointment expire on June 30, 2012. The Provider will not be paid for any non-covered services after July 1, 2012.

  12. When will all open authorizations for services requiring multi-step procedures (multiple appointments) end? Will the Provider receive payment if the service is provided after July 1, 2012?

    All authorizations approved prior to June 30, 2012, must be completed or delivered by August 31, 2012, in order for the service to be paid.

  13. What are examples of multi-step procedures that will be paid for after July 1, 2012?

    These services are covered only if they are completed and/or delivered by August 31, 2012.

    Service Codes
    Dentures D5110, D5120, D5130, D5140
    Crowns D2740, D2750, D2751, D2752, D2790, D2791, D2792
    Root Canal Therapy D3310


  14. If prior approval has been granted for dentures or immediate dentures, will the Provider be paid?

    Yes, if the dentures were authorized prior to June 30, 2012, and delivered by August 31, 2012, the provider will be paid.

  15. If prior approval has been granted for dentures or immediate dentures, but the patient has not had their teeth extracted before July 1, 2012, will the Provider be paid for the extractions?

    Only if the extractions are considered an emergency dental service.

  16. Will denture relines, repairs or adjustments be paid for after July 1, 2012?

    No.

  17. How will the dental services offered through the Integrated Care program be affected by the SMART Act for beneficiaries 21 and over?

    Aetna and Illini Care are obligated to cover the same dental services covered by the adult dental program. Each plan will determine which, if any, additional services will be covered for integrated care beneficiaries. Contact your plan administrator to see what dental services are covered.

  18. When do claims need to be submitted to be considered for payment?

    To be eligible for payment consideration, a vendor's claim, either as an initial claim or as a resubmitted claim following prior rejection, must be received by DentaQuest no later than 180 days from the date of service on the claim.

  19. If primary insurance takes longer than 180 days to pay their portion, will Medicaid pay the balance after 180 days?

    According to the SMART Act, for claims for which HFS is not the primary payer, claims must be submitted to HFS within 180 days of final adjudication by the primary payer.