907 KAR 1:626 - Reimbursement of dental services
RELATES TO: KRS 205.520, 42 C.F.R. 440.100, 447.200-205, 42 U.S.C. 1396a -d
NECESSITY, FUNCTION, AND CONFORMITY: The Cabinet for Health and Family Services, Department for Medicaid Services, has the responsibility to administer the Medicaid Program. KRS 205.520(3) authorizes the cabinet, by administrative regulation, to comply with any requirement that may be imposed or opportunity presented by federal law to qualify for federal Medicaid funds. This administrative regulation establishes the reimbursement policies and requirements for covered dental services provided to a Medicaid recipient who is not enrolled with a managed care organization.
Section 1. Definitions.
(1) "Current Dental Terminology" or "CDT"
means a publication by the American Dental Association of codes used to report
dental procedures or services.
(2)
"Department" means the Department for Medicaid Services or its
designee.
(3) "Federal financial
participation" is defined in 42 C.F.R. 400.203.
(4) "Incidental" means that a medical
procedure:
(a) Is performed at the same time
as a primary procedure; and
(b)
1. Requires little additional practitioner
resources; or
2. Is clinically
integral to the performance of the primary procedure.
(5) "Integral" means that a
medical procedure represents a component of a more complex procedure performed
at the same time.
(6) "Managed care
organization" means an entity for which the Department for Medicaid Services
has contracted to serve as a managed care organization as defined in
42 C.F.R.
438.2.
(7) "Manually priced" or "MP" means that a
procedure is priced according to complexity.
(8) "Medically necessary" or "medical
necessity" means that a covered benefit is determined to be needed in
accordance with
907 KAR 3:130.
(9) "Mutually exclusive" means that two (2)
procedures:
(a) Are not reasonably performed
in conjunction with one (1) another during the same patient encounter on the
same date of service;
(b) Represent
two (2) methods of performing the same procedure;
(c) Represent medically impossible or
improbable use of CDT codes; or
(d)
Are described in CDT as inappropriate coding of procedure
combinations.
(10)
"Provider" is defined in
KRS
205.8451(7).
(11) "Recipient" is defined in
KRS
205.8451(9).
(12) "Timely filing" means receipt of a claim
by Medicaid:
(a) Within twelve (12) months of
the date the service was provided;
(b) Within twelve (12) months of the date
retroactive eligibility was established; or
(c) Within six (6) months of the Medicare
adjudication date if the service was billed to Medicare.
(13) "Usual and customary charge" means the
uniform amount which the individual dentist charges in the majority of cases
for a specific dental procedure or service.
Section 2. General Requirements. For the
department to reimburse for a dental service or item, the service or item shall
be:
(1) Provided:
(a) To a recipient; and
(b) By a provider who meets the conditions of
participation requirements established in
907 KAR 1:026;
(2) Covered in accordance with
907 KAR 1:026;
(3) Medically necessary; and
(4) A service or item authorized within the
scope of the provider's licensure.
Section 3. Reimbursement.
(1) Except as established in Section 4 or 5
of this administrative regulation, reimbursement for a covered service shall be
the lesser of the:
(a) Dentist's usual and
customary charge;
(b) Reimbursement
limits specified in this section;
(c) Manually-priced amount; or
(d) Amount established on the DMS Dental Fee
Schedule.
(2) If a rate
has not been established for a covered dental service, the department shall set
an upper limit for the procedure by:
(a)
Averaging the reimbursement rates assigned to the service by three (3) other
payer or provider sources; and
(b)
Comparing the calculated average obtained from these three (3) rates to rates
of similar procedures paid by the department.
(3) If cost sharing is required, the cost
sharing shall be in accordance with
907 KAR 1:604.
(4) For a service covered under Medicare Part
B, reimbursement shall be in accordance with
907 KAR 1:006.
(5) A service which is not billed within
timely filing requirements shall not be reimbursed.
(6) If performed concurrently, separate
reimbursement shall not be made for a procedure that has been determined by the
department to be incidental, integral, or mutually exclusive to another
procedure.
Section 4.
Oral Surgeons.
(1) A dental service that is
covered by the Kentucky Medicaid Program and provided by an oral surgeon shall
be reimbursed in accordance with this administrative regulation unless the
given service is:
(a) Not reimbursed pursuant
to this administrative regulation; and
(b) Reimbursed pursuant to
907 KAR 3:010.
(2) A dental service that is
covered by the Kentucky Medicaid Program and provided by an oral surgeon but
not reimbursed pursuant to this administrative regulation shall be reimbursed
in accordance with
907 KAR 3:010.
Section 5. Supplemental Payments.
(1) In addition to a payment made pursuant to
Section 3 of this administrative regulation, the department shall make a
supplemental payment to a dental school faculty dentist who is employed by a
state-supported school of dentistry in Kentucky.
(2) The supplemental payment shall be:
(a) In an amount that, if combined with other
payments made in accordance with this administrative regulation, does not
exceed the dentist's charge for the service the dentist has provided:
1. As a dental school faculty; and
2. For which the payment is made directly or
indirectly to the dental school;
(b) Based on the funding made available
through an intergovernmental transfer of funds for this purpose by a
state-supported school of dentistry in Kentucky; and
(c) Made on a quarterly basis.
Section 6. Not
Applicable to Managed Care Organizations. A managed care organization shall not
be required to reimburse in accordance with:
(1) This administrative regulation for a
service covered pursuant to:
(a)907 KAR 1:026; and
(b) This administrative regulation;
or
(2)
907 KAR 3:010 for a service
referenced in Section 5 of this administrative regulation that is reimbursed by
the department in accordance with
907 KAR 3:010.
Section 7. Federal Approval and
Federal Financial Participation. The department's reimbursement for services
pursuant to this administrative regulation shall be contingent upon:
(1) Federal financial participation for the
reimbursement; and
(2) Centers for
Medicare and Medicaid Services' approval of the reimbursement.
Section 8. Appeal Rights. An
appeal of a department decision regarding a Medicaid provider based upon an
application of this administrative regulation shall be in accordance with
907 KAR 1:671.
Section 9. Incorporation by Reference.
(1) "DMS Dental Fee Schedule", December 2015,
is incorporated by reference.
(2)
This material may be inspected, copied, or obtained, subject to applicable
copyright law:
(a) At the Department for
Medicaid Services, 275 East Main Street, Frankfort, Kentucky, Monday through
Friday, 8 a.m. to 4:30 p.m.; or
(b)
Online at the department's Web site located at
http://www.chfs.ky.gov/dms/incorporated.htm.
Notes
STATUTORY AUTHORITY: KRS 194A.030(2), 194A.050(1), 205.520(3)
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