Kentucky Administrative Regulations › Title 907 - CABINET FOR HEALTH AND FAMILY SERVICES - DEPARTMENT FOR MEDICAID SERVICES › Chapter 1 - Medicaid Services › Section 907 KAR 1:626 - Reimbursement of dental services

Current through Register Vol. 51, No. 1, July 1, 2024
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.