Kentucky Administrative Regulations › Title 907 - CABINET FOR HEALTH AND FAMILY SERVICES - DEPARTMENT FOR MEDICAID SERVICES › Chapter 1 - Medicaid Services › Section 907 KAR 1:026E - 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 and
				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) "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.
(10) "Integral" means that a
			 medical procedure represents a component of a more complex procedure performed
			 at the same time.
(11) "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.
(12) "Medically necessary" or "medical
			 necessity" means that a covered benefit is determined to be needed in
			 accordance with
			 907 KAR 3:130.
(13) "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.
(14)
			 "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.
(15) "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.
(16) "Prior authorization" or "PA" means
			 approval that a provider shall obtain from the department before being
			 reimbursed for a covered service.
(17) "Provider" is defined by
			 KRS
			 205.8451(7).
(18) "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.
(19)
			 "Recipient" is defined by
			 KRS
			 205.8451(9).
(20) "Resident" is defined by
			 42 C.F.R.
			 415.152.
(21) "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.