Kentucky Administrative Regulations › Title 907 - CABINET FOR HEALTH AND FAMILY SERVICES - DEPARTMENT FOR MEDICAID SERVICES › Chapter 1 - Medicaid Services › Section 907 KAR 1:126 - Dental services' coverage provisions and requirements

Current through Register Vol. 51, No. 1, July 1, 2024
RELATES TO: KRS 205.520, 205.622, 205.8451, 313.010, 313.040,
				369.102(8), 369.101 to 369.120, 415.152,  42 C.F.R. 400.203, 415.170, 415.172, 415.174, 438.2, 45 C.F.R. Parts 160, 164,  42 U.S.C. 1320d, 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 Kentucky Medicaid program
				provisions and requirements regarding the coverage of dental services.
Section 1. Definitions.
(1) "Comprehensive orthodontic" means a
			 medically necessary dental service for treatment of a dentofacial malocclusion
			 which requires the application of braces for correction.
(2) "Current Dental Terminology" or "CDT"
			 means a publication by the American Dental Association of codes used to report
			 dental procedures or services.
(3)
			 "Debridement" means a preliminary procedure that:
(a) Entails the gross removal of plaque and
			 calculus that interfere with the ability of a dentist to perform a
			 comprehensive oral evaluation;
(b)
			 Does not preclude the need for further procedures; and
(c) Is separate from a regular cleaning and
			 is usually a preliminary or first treatment when an individual has developed
			 very heavy plaque or calculus.
(4) "Department" means the Department for
			 Medicaid Services or its designee.
(5) "Direct practitioner interaction" means
			 the billing dentist or oral surgeon is physically present with and evaluates,
			 examines, treats, or diagnoses the recipient, unless the service can be
			 appropriately performed via telehealth pursuant to  907 KAR 3:170.
(6) "Disabling malocclusion" means a
			 condition that meets the criteria established in Section 13(7) of this
			 administrative regulation.
(7)
			 "Electronic signature" is defined by KRS 369.102(8).
(8) "Federal financial participation" is
			 defined by  42 C.F.R. 400.203.
(9)
			 "Implant" means a medical device that is surgically implanted into the jaw to
			 restore a person's ability to chew or appearance. An implant provides support
			 for artificial teeth including a crown, a bridge, or dentures.
(10) "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.
(11) "Integral" means that a
			 medical procedure represents a component of a more complex procedure performed
			 at the same time.
(12) "Locum
			 tenens dentist" means a substitute dentist:
(a) Who temporarily assumes responsibility
			 for the professional practice of a dentist participating in the Kentucky
			 Medicaid Program; and
(b) Whose
			 services are paid under the participating dentist's provider number.
(13) "Managed care organization"
			 means an entity for which the Department for Medicaid Services has contracted
			 to serve as a managed care organization as defined by  42 C.F.R. 438.2.
(14) "Medically necessary"
			 or "medical necessity" means that a covered benefit is determined to be needed
			 in accordance with  907 KAR 3:130.
(15) "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.
(16)
			 "Other licensed medical professional" or "OLMP" means a health care provider
			 other than a dentist who has been approved to practice a medical specialty by
			 the appropriate licensure board.
(17) "Prepayment review" or "PPR" means a
			 departmental review of a claim regarding a recipient who is not enrolled with a
			 managed care organization to determine if the requirements of this
			 administrative regulation have been met prior to authorizing payment.
(18) "Prior authorization" or "PA" means
			 approval that a provider shall obtain from the department before being
			 reimbursed for a covered service.
(19) "Provider" is defined by KRS 205.8451(7).
(20) "Public health
			 hygienist" means an individual who:
(a) Is a
			 dental hygienist as defined by KRS 313.010(6);
(b) Meets the public health hygienist
			 requirements established in KRS 313.040(8);
(c) Meets the requirements for a public
			 health registered dental hygienist established in  201 KAR 8:562; and
(d) Is employed by or through:
1. The Department for Public Health;
			 or
2. A governing board of
			 health.
(21)
			 "Recipient" is defined by KRS 205.8451(9).
(22) "Resident" is defined by  42 C.F.R. 415.152.
(23) "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.