Oklahoma Administrative Code › Title 317 - Oklahoma Health Care Authority › Chapter 30 - Medical Providers-Fee for Service › Subchapter 5 - Individual Providers and Specialties › Part 79 - DENTISTS › Section 317:30-5-696 - Coverage by category

Current through Vol. 41, No. 20, July 1, 2024
Payment is made for dental services as set forth in this
					 Section.
(1)
Adults.
The
				  OHCA Dental Program provides basic medically necessary treatment. The services
				  listed below are compensable for members twenty-one (21) years of age and over
				  without prior authorization.
(A)
Comprehensive oral evaluation.
The comprehensive oral evaluation
				  may be performed when a member has not been seen by the same dentist for more
				  than thirty-six (36) months. The comprehensive oral evaluation must precede any
				  images, and chart documentation must include image interpretations, six-point
				  periodontal charting, and both medical and dental health history of the member.
				  The comprehensive treatment plan should be the final result of this
				  procedure.
(B)
Periodic oral
				  evaluation.
This procedure may be provided for a member once every six
				  (6) months. An examination must precede any images, and chart documentation
				  must include image interpretations, and both medical and dental health history
				  of member. The comprehensive treatment plan should be the final result of this
				  procedure.
(C)
Limited oral
				  evaluation.
This procedure is only compensable to the same dentist or
				  practice for two (2) visits prior to a comprehensive or periodic evaluation
				  examination being completed.
(D)
Images.
To be SoonerCare compensable, images must be of diagnostic
				  quality and medically necessary. A clinical examination must precede any
				  images. Documentation must indicate medical necessity and diagnostic findings.
				  Images must be properly labeled with date and member name. Periapical images
				  must include at least three (3) millimeters beyond the apex of the tooth being
				  imaged. Panoramic films are only compensable when chart documentation clearly
				  indicates reasons for the exposure based on clinical findings. This type of
				  panoramic film exposure is not to rule out or evaluate caries. Prior
				  authorization and a narrative detailing medical necessity are required for
				  additional panoramic films taken within three (3) years of the original
				  set.
(E)
Dental
				  prophylaxis.
Dental prophylaxis is provided once every six (6) months
				  along with topical application of fluoride.
(F)
Periodontal Maintenance.
This procedure is provided once every six (6) months for members who have a
				  history of periodontitis and are no longer eligible for oral
				  prophylaxis.
(G)
Smoking and
				  tobacco use cessation counseling.
Smoking and tobacco use cessation
				  counseling is covered per Oklahoma Administrative Code (OAC)
				  317:30-5-2(DD)
				  (i) through (iv).
(H)
Medically necessary extractions.
Medically necessary extractions,
				  as defined in OAC
				  317:30-5-695.
				  Tooth extraction must have medical need documented.
(I)
Medical and surgical
				  services.
Medical and surgical services performed by a dentist or
				  physician to the extent such services may be performed under State law when
				  those services would be covered if performed by a physician.
(J)
Additional services.
Additional covered services, which require a prior authorization, are outlined
				  in OAC
				  317:30-5-698.