OAR 410-123-1260: Temporary rule language in effect until 09/22/2026. Coverage, Limitations, Exclusions

(1) The Oregon Health Authority (Authority) offers Medicaid dental/denturist benefits on a Fee-For-Service (FFS) basis: (a) Providers must be licensed to practice dentistry and enrolled as a Medicaid provider as required by OAR 410-120-1260; (b) All billing and rendering providers must comply with OAR Chapter 410 Division 120 rules and these Chapter 410, Division 123 rules which provide direction in the delivery of dental services and in the preparation of dental care claims; and (c) For additional requirements for Coordinated Care Organizations (CCOs) refer to OAR 410-141-3835. (2) This rule incorporates the Oregon Health Evidence Review Commission (HERC) Prioritized List of Health Services (Prioritized List), included through the stated Funding Line, unless otherwise excluded in rule, and including all line items, diagnostic and treatment codes, guideline notes, statements of intent, coding specifications and annotations (refer to OAR 410-141-3830): (a) Providers must comply with the Authority rules for dental services covered by the Oregon Health Plan (OHP) which include the: (A) Funded lines on the Prioritized List as defined in OAR 410-141-3830 found at www.oregon.gov/oha/hpa/dsi-herc/pages/prioritized-list.aspx; and (B) Approved ancillary codes found at data.oregon.gov/Health-Human-Services/Group-6060-Ancillary-Services/fq2m-i6ix/about_data. (b) Providers may consult the: (A) Oregon Medicaid Dental Services billing code supplemental reference at https://data.oregon.gov/Health-Human-Services/Oregon-Medicaid-Dental-Services/495m-gmu2/about_data as a tool to assist with billing for services. Use of this supplemental reference is for guidance purposes only and must not serve as the sole basis for authorization or denial of services; and (B) Medical-Dental Fee Schedule found on the OHP Fee-for-Service Fee Schedule site found at www.oregon.gov/oha/hsd/ohp/pages/fee-schedule.aspx. (3) The providers rendering services and receiving payment for any of the services identified in these Chapter 410, Division 123, rules must make records available for audit, as required by OAR 410-123-1620. (4) All Oregon Administrative Rules (OARs), Medicaid covered services, in Chapter 410 must be followed. (5) All coverage limitations and exclusions are subject to Early and Periodic Screening, Diagnostic, and Treatment (EPSDT) review as required by Chapter 410, Division 151. (6) Covered dental and oral health services provided in non-dental settings including medical, community and school settings by providers who are medical providers such as physicians and nurses. Criteria and limitations are as follows: (a) Dental Screening of a patient (D0190) – including state or federally mandated screenings, are limited observations performed as mass screenings or EPSDT well-child and preventative care visits, to identify individuals who have suspected oral health needs and who must be seen by a dentist for diagnosis. Providers must hold a certificate of completion of the Smiles for Life or First Tooth training; and (b) Dental Assessments (D0191) – are limited clinical inspections performed to identify possible signs of oral systemic disease, malformation, or injury, and the potential need for referral diagnosis and treatment. Providers must hold a certificate of completion of the Smile for Life or First Tooth training; (c) Application of topical fluoride (99128, 99188, D1206, D1208), requires providers to hold a certificate of completion of the Smiles for Life or First Tooth training; (A) The application of topical fluoride may be delegated by providers to staff, in accordance to their professional boards’ scope of practice; (B) For EPSDT beneficiaries – limited to twice (2) every 12 months; (C) For non-EPSDT beneficiaries – limited to once (1) every 12 months; (D) Additional applications may be available, up to a total of four (4) per member within a 12 month period, when high-risk conditions or dental health factors are clearly documented in chart notes for members who: (i) Have high-risk dental conditions due to disease process, medications, other medical treatments or conditions, or rampant caries; (ii) Are pregnant or 12 months postpartum; (iii) Have physical disabilities and cannot perform adequate daily dental health care; (iv) Have developmental disabilities or other severe cognitive impairment and cannot perform adequate daily dental health care; or (v) Are under seven (7) years old with high-risk dental health factors, such as poor dental hygiene, deep pits and fissures in teeth, severely crowded teeth, poor diet, etc. (d) Application of silver diamine fluoride (0792T) by a physician or other healthcare professional is a covered benefit when the member has non-cavitated caries. Providers must hold a certificate of completion of the Smiles for Life or First Tooth training; (A) For all members – limited to two (2) applications per 12 months; and (B) Documentation of need must be included on submitted claims. (7) Diagnostic services (CDT codes D0100 – D0999): (a) Dental screenings (D0190) and dental assessments (D0191) do not take the place of the need for comprehensive dental evaluations and exams; (A) For EPSDT beneficiaries – a maximum of twice (2) every 12 months; (B) For non-EPSDT beneficiaries – a maximum of once (1) every 12 months; (C) Reimbursable only if an exam (D0120-D0180) is not performed on the same date of service at the same place of service; (D) The assessment tool used for D0190 and D0191 must be endorsed by the American Dental Association, the American Academy of Pediatric Dentistry, the Association of State and Territorial Dental Directors, or the American Academy of Pediatrics; (E) Referrals for identified dental needs or for the establishment of a dental home are to be made to the member’s primary care dentist for FFS members, or to the member’s CCO (or dental subcontractor); and (F) Anticipatory guidance and counseling on good dental hygiene practices and nutrition is to be provided to the member’s caregiver. (b) The Authority requires dental subcontractors and dental providers to conduct an intake screening of individuals who are enrolled in the Veterans Dental Program within 60 days of the enrolled individual contacting the dental subcontractor or dental provider. This intake screening requires one of the following services being provided, as clinically appropriate: (A) D0150 – comprehensive oral evaluation of a new or established patient; (B) D0180 – comprehensive periodontal evaluation of a new or established patient; or (C) D0120 – periodic oral evaluation of an established patient, if the individual enrolled in the Veterans Dental Program is an established patient. (c) Caries risk assessment and documentation (D0601, D0602, D0603) are not separately reimbursable but should be documented in the member’s chart. (d) Referrals: (A) If, during the screening process (periodic or inter-periodic), a dental, medical, substance abuse, or medical condition is discovered, the member must be referred to an appropriate provider for further diagnosis and/or treatment; (B) The screening provider must explain the need for the referral to the member, member's parent, or guardian; (C) If the member, member's parent, or guardian agrees to the referral, assistance in finding an appropriate provider and making an appointment shall be offered; and (D) The member’s FFS provider or the CCO shall make available care coordination as needed. (e) Clinical Dental evaluations (Exams) for: (A) EPSDT beneficiaries (refer to Division 151): (i) The Authority covers exams (D0120, D0145, D0150, or D0180) a maximum of twice (2) every 12 months. These codes are not billable if D0191 is billed for the same date of service, at the same place of service. Limitations are as follows: (I) D0150: once (1) every 12 months when performed by the same practitioner; (II) D0180: once (1) every 12 months; and (ii) The Authority must reimburse D0160 only once (1) every 12 months when performed by the same practitioner. (B) Non-EPSDT beneficiaries, the Authority covers exams (D0120, D0150, D0160, or D0180) once (1) every 12 months; (C) For problem-focused exams (urgent or emergent problems), the Authority covers D0140 for the initial exam and D0170 for related problem-focused follow-up exams. D0140 and D0170 are not covered for routine dental visits; (D) The Authority only covers dental exams performed by medical practitioners when the medical practitioner is an oral surgeon. The surgeon may hold a dual degree, but must bill as an oral surgeon; (E) The evaluation, diagnosis, and treatment planning components of the exam are the responsibility of the licensed provider. The Authority may not reimburse dental exams when performed by a dental hygienist (with or without an expanded practice permit). (f) The Authority covers diagnostic imaging as follows: (A) Intraoral – complete series (D0210) – One (1) time every five (5) years, unless D0330 has been billed within the five (5) year period; (B) Intraoral – first image (D0220) – One (1) time every 12 months; (C) Intraoral – additional images (D0230) – Under age six (6), maximum of five (5) times every 12 months. Not to exceed five (5) times on the same date of service for any provider. Radiographs may be billed separately one (1) time every 12 months; (D) Intraoral – occlusal image (D0240) – One (1) time every 12 months. Not to exceed four (4) times on the same date of services for any provider; (E) Extraoral images (D0250 and D0251) – One (1) time every 12 months; (F) Bitewing single image (D0270) – Maximum of two (2) times every 12 months if not billing D0272; (G) Bitewing two images (D0272) – Under age six (6), maximum of one (1) time every 12 months if not billing D0270 twice; (H) Bitewing, multiple images (D0273, D0274 and D0277) – One (1) time every 12 months; (I) Other TMJ images (D0321) – By Report; (J) Dental tomographic survey (D0322) – One (1) time every 12 months; (K) Panoramic image (D0330) – One (1) time every five (5) years, unless D0210 has been billed within the five (5) year period; (L) Cone beam CT capture (D0364, D0365, D0366, D0367) – Only when performed as part of the pre-orthodontic treatment examination; and (M) 3d print of 3d surface scan (D0396). (g) The Authority covers panoramic radiographic image (D0330) or intra-oral complete series (D0210) once (1) every five (5) years, but both cannot be done within the five (5) year period; (h) Members must be a minimum of six (6) years old for billing intra-oral complete series. The minimum standards for reimbursement of intra-oral complete series are: (A) For members age six (6) through 11 a minimum of 10 periapical and two (2) bitewings for a total of 12 films; and (B) For members ages 12 and older a minimum of 10 periapical and four (4) bitewings for a total of 14 films. (i) If fees for multiple single radiographs exceed the allowable reimbursement for an intraoral-complete series (full mouth), the Authority must reimburse for the complete series; (j) Additional films are covered if medically necessary and dentally appropriate (e.g., fractures); (k) If the Authority determines the number of radiographs to be excessive, payment for some or all radiographs of the same tooth or area shall be denied; (l) The exception to these limitations is if the member is new to the office or clinic and the office or clinic is unsuccessful in obtaining radiographs from the previous dental office or clinic. Supporting documentation outlining the provider's attempts to receive previous records must be included in the member's records; and (m) Digital radiographs, if printed, must be on photo paper to assure sufficient diagnostic quality of images. (8) Preventative Services (CDT codes D1000-D1999): (a) Topical application of fluoride (D1206, D1208, 99128, 99188): (A) For EPSDT beneficiaries, limited to twice (2) every 12 months; (B) For non-EPSDT beneficiaries, limited to once (1) every 12 months; (C) Additional topical fluoride treatments are available, up to a total of four (4) treatments per member within a 12 month period, when high-risk conditions or dental health factors are clearly documented by D0603 in chart notes for members who: (i) Have high-risk dental conditions due to disease process, medications, other medical treatments or conditions, or rampant caries; (ii) Are pregnant or 12 months postpartum; (iii) Have physical disabilities and cannot perform adequate daily dental health care; (iv) Have developmental disabilities or other severe cognitive impairment and cannot perform adequate daily dental health care; or (v) Are under seven (7) years old with high-risk dental health factors, such as poor dental hygiene, deep pits, and fissures in teeth, severely crowded teeth, poor diet, etc. (D) Fluoride limits include any combination of fluoride varnish or other topical fluoride. (b) Dental sealants (D1351) are covered for EPSDT beneficiaries as follows: (A) Members age 16 and older require PA; (B) Only permanent molars (additional teeth require PA); (C) Only one (1) sealant treatment per tooth every five (5) years, except when visible evidence of clinical failure; and (D) The original provider is responsible for any repair or replacement during the 36-month period of initial sealant placement. (c) Dental prophylaxis (D1110, D1120) are not covered by the Authority if provided on the same date of service as D4355, D4346 or D4910. Coverage is as follows: (A) EPSDT beneficiaries, limited to twice (2) per 12 months; (B) Non-EPSDT beneficiaries, limited to once (1) per 12 months; and (C) Additional prophylaxis benefit provisions are available for persons with high-risk dental conditions due to disease process, pregnancy, medications, or other medical treatments or conditions, severe periodontal disease, rampant caries and for persons with disabilities who cannot perform adequate daily dental health care. (d) Silver diamine fluoride (SDF) application (D1354, D1355): (A) Is covered for all members; (B) The Authority reimburses per application, not per tooth; (C) Is limited to two (2) applications per year. Additional applications for EPSDT beneficiaries is allowable with approved PA; (D) Requires that the tooth or teeth numbers be included on the claim; (E) Use D1354 when SDF is applied for the treatment (rather than prevention) of caries. The treated tooth or teeth must be; (i) Covered with topical application of fluoride; or (ii) Covered with an interim direct restoration (D2940) or a permanent restoration when medically necessary and dentally appropriate. (F) When SDF is applied for the treatment of caries by a non-dental professional (0792T), refer to the guidance in the earlier section of this rule. Coverage is limited to two (2) applications per year. (e) Immunization counseling (D1301) is covered as described in 410-123-1262. (f) The Authority covers Tobacco counseling for the control and prevention of oral disease (D1320) for services provided during a dental visit, when using the Five-A approach outlined below, limited to a maximum of 10 services within a three (3) month period, when the following is provided: (A) ASK: Identify the member’s tobacco-use status at each visit and record information in the chart; (B) ADVISE: Using a strong personalized message, advise members on their dental health conditions related to tobacco use and give direct advice to quit using tobacco and seek help; (C) ASSESS: Refer member to external resources or internal counseling and intervention protocol if the tobacco user is willing to make a quit attempt; (D) ASSIST: Provide counseling and pharmacotherapy to help member quit tobacco, if dental provider chooses to assist; and (E) ARRANGE: Schedule follow-up contact, in person or by telephone, preferably within the first week after the quit date if dental provider chooses to arrange. (g) The Authority covers Nutritional counseling (D1310) and Counseling for high risk substance use (D1321) for services provided during a dental visit using the Five-A approach outlined below. Each of these services is limited to two (2) services within a 12 month period, when the following is provided: (A) ASK: Identify the member’s behavior; (B) ADVISE: Urge the member to change behavior; (C) ASSESS: Determine the member’s willingness to make change; (D) ASSIST: Help the member with a plan and resources, if dental provider chooses; and (E) ARRANGE: Schedule follow-up support, if dental provider chooses. (h) Space maintenance (passive appliances) are: (A) Covered for EPSDT beneficiaries; and (B) Not replaceable when lost or damaged. (9) The Authority’s coverage limitations of restorative, periodontic, and prosthetic treatments include the following: (a) Documentation must be included in the member’s charts to support the treatment; (b) Treatments must be consistent with the prevailing standard of care and may be limited as follows, when: (A) Prognosis is unfavorable; (B) Treatment is impractical; (C) A lesser cost procedure achieves the same ultimate result; or (D) The treatment has specific limitations outlines in this rule. (c) Periodontal health needs to be stable and supportive of a prosthetic. Prosthetic treatment, including porcelain fused to metal crowns and porcelain/ceramic crowns are limited until documented by examination; (A) Rampant caries is arrested; and (B) A period of adequate dental hygiene and periodontal stability is demonstrated. (10) Restorative Services (CDT codes D2000-D2999): (a) Amalgam and resin-based composite restorations, direct: (A) Resin-based composite crowns on anterior teeth (D2390) are only covered for EPSDT beneficiaries, and members who are pregnant; (B) The Authority reimburses posterior composite restorations at the same rate as amalgam restorations; (C) The Authority limits payment of posterior composite restorations to once (1) every five (5) years, per tooth; (D) The Authority limits payment of covered restorations to the maximum restoration fee of four (4) surfaces per tooth. Refer to the ADA CDT codebook for definitions of restorative procedures; (E) Providers must combine and bill multiple surface restorations as one line per tooth using the appropriate code. Providers may not bill multiple surface restorations performed on a single tooth on the same day on separate lines. For example, if tooth #30 has a buccal amalgam and a mesial-occlusal-distal (MOD) amalgam, then bill MOD, B, using code D2161 (four (4) or more surfaces); (F) The Authority shall not reimburse for an amalgam or composite restoration and a crown on the same tooth; (G) Interim direct restorations (D2940) on primary dentition are covered to restore and prevent progression of dental caries. They are not definitive restorations and are not to be used as a base or liner under a restoration; (H) Reattachment of tooth fragment is covered once in the lifetime of a tooth when there is no pulp exposure and no need for endodontic treatment; (I) The Authority reimburses for a surface not more than once (1) in each treatment episode regardless of the number or combination of restorations; and (J) The restoration fee includes payment for occlusal adjustment and polishing of the restoration. (b) Indirect crowns and related services: (A) The fee for the crown includes payment for preparation of the gingival tissue; (B) The Authority covers crowns only when there is significant loss of clinical crown, no other restorations restore function, the crown-to-root ratio is 50:50 or better, and the tooth is restorable to function without other surgical procedures. Endodontic therapy alone (with or without a post) is not a consideration, nor are aesthetics; (C) The Authority covers core buildup only when: (i) Necessary to retain a cast restoration due to extensive loss of tooth structure from caries or a fracture; (ii) Done in conjunction with a crown; and (iii) More than 50 percent of the tooth structure is remaining for coverage of the core buildup. (D) Reimbursement of retention pins is per tooth, not per pin; (E) Payment shall be made only upon final cementation; (F) Partial payment will not be made for an undelivered crown; (G) Prefabricated stainless steel crowns are allowed only for anterior primary teeth and posterior permanent or primary teeth; (H) The Authority covers the following only for EPSDT beneficiaries, and for members who are pregnant: (i) Prefabricated resin crowns for anterior teeth, permanent or primary; (ii) Prefabricated resin crowns for posterior teeth, permanent or primary, once (1) per tooth in a five (5) year period; (iii) Prefabricated stainless-steel crowns with resin window are allowed only for anterior teeth, permanent or primary; (iv) Prefabricated post and core in addition to crowns; (v) Crowns (resin-based composite — D2710 and D2712, porcelain fused to metal (PFM) — D2751 and D2752, and porcelain ceramic – D2740 as follows: (I) Limited to teeth numbers 6–11, 22, and 27 only, if dentally appropriate; (II) Limited to four (4) in a seven (7) year period. This limitation includes any replacement crowns allowed; and (III) Rampant caries are arrested, and the member demonstrates a period of adequate dental hygiene before prosthetics are proposed. (vi) Porcelain fused to metal crowns (D2751, D2752), and porcelain ceramic crowns (D2740) must meet the following additional criteria: (I) The Dental Practitioner has attempted all other dentally appropriate restoration options and documented failure of those options; (II) Written documentation in the member’s chart indicates that PFM is the only restoration option that restores function; (III) The Dental Practitioner submits radiographs to the Authority for review. History, diagnosis, and treatment plan may be requested; (IV) The member has documented stable periodontal status with clinical attachment loss within 1–3 millimeters. If PFM crowns are placed with pocket depths of 4 millimeters and over, documentation must be maintained in the member’s chart of the dentist’s findings supporting stability and why the increased pocket depths shall not adversely affect expected long-term prognosis; (V) The crown has a favorable long-term prognosis; and (VI) If the tooth to be crowned is a clasp/abutment tooth in partial denture, both prognosis for the crown itself and the tooth’s contribution to partial denture must have favorable expected long-term prognosis. (I) Crown replacement coverage is as follows: (i) D2710, D2712, D2740, D2751, D2752 are limited to once (1) every seven (7) years; (ii) All other covered crowns are limited to once (1) every five (5) years; and (iii) Exceptions to the above limitations due to acute trauma are based on the following factors: (I) Extent of crown damage; (II) Extent of damage to other teeth or crowns; (III) Extent of impaired mastication; (IV) Tooth is restorable without other surgical procedures; and (V) If loss of tooth may result in coverage of removable prosthetic. (J) Crown repair requires PA and is limited to anterior teeth. (11) Endodontic Services (CDT codes D3000-D3999): (a) All radiographic images taken during the course of root canal therapy and all post-treatment radiographic images are included in the fee for the root canal procedure. At least one (1) pre-treatment radiographic image demonstrating the need for the procedure, and one (1) post-treatment radiographic images that demonstrates the result of the treatment, must be maintained in the member’s record; (b) The Authority covers endodontic therapy as follows only when the crown-to-root ration is 50:50 or better and if the tooth is restorable to function with direct or indirect restoration without other surgical procedures: (A) For EPSDT beneficiaries: all primary teeth, permanent anterior teeth, premolars, first molars and second molars; (B) For members who are pregnant or 12 months postpartum: permanent anterior teeth, premolars, and first molars; and (C) For non-pregnant adults: anterior teeth and premolars. (c) Endodontic retreatment and apicoectomy: (A) The Authority does not cover retreatment of a previous root canal or apicoectomy for premolars or molars; (B) The Authority limits either a retreatment or an apicoectomy (but not both procedures for the same tooth) to symptomatic anterior teeth when: (i) Crown-to-root ratio is 50:50 or better; (ii) The tooth is restorable without other surgical procedures; or (iii) If loss of tooth shall result in the need for removable prosthodontics. (C) Retrograde filling is covered only when done in conjunction with a covered apicoectomy of an anterior tooth. (d) The Authority does not allow separate reimbursement for open-and-drain as a palliative procedure when the root canal is completed on the same date of service or if the same practitioner or Dental Practitioner in the same group practice completed the procedure; (e) Apexification/recalcification procedures: (A) The Authority limits payment for apexification to permanent teeth only; (B) D3351-D3353 are limited to once (1) per tooth; and (C) Covered only for EPSDT beneficiaries, or members who are pregnant or 12 months postpartum. (12) Periodontic Services (CDT codes D4000-D4999): (a) The Authority does not reimburse the following codes if performed on the same date of service D1110, D1120, D4210, D4211, D4341, D4346, D4355, and D4910. (b) Surgical periodontal services: (A) Gingivectomy/Gingivoplasty (D4210, D4211) coverage is limited to severe gingival hyperplasia where enlargement of gum tissue occurs that prevents access to dental hygiene procedures (e.g., Dilantin hyperplasia), and includes six (6) months routine postoperative care; and (B) Gingivectomy or gingivoplasty to allow for access for restorative procedure, per tooth (D4212) is considered part of the restoration and is not separately billable. (c) Non-surgical periodontal services: (A) Periodontal scaling and root planing (D4341, D4342) is allowed once (1) every two (2) years; (i) A maximum of two (2) quadrants on one date of service is payable, except in extraordinary circumstances supported by documentation; (ii) Quadrants are not limited to physical area, but are further defined by the number of teeth with pockets of 5 mm or greater: (B) Single implants may count as an additional tooth when billing, the maximum number per quadrant and pocket depth requirements still apply; (C) Full mouth debridement (D4355) allowed once (1) every two (2) years; and (D) Scaling in the presence of generalized moderate or severe gingival inflammation, full mouth, after dental evaluation (D4346) is allowed once (1) every two (2) years. (d) Periodontal maintenance (D4910) is allowed once (1) every six (6) months: (A) Following periodontal therapy (surgical or non-surgical) that is documented to have occurred within the past three (3) years; and (B) Additional periodontal maintenance requires PA and may be requested when: (i) Medically necessary and dentally appropriate, including situations involving periodontal disease during pregnancy; and (ii) The member’s medical record is submitted and supports the need for increased periodontal maintenance (chart notes, pocket depths and radiographs). (e) Records must clearly document the clinical indications for all periodontal procedures, including current pocket depth charting and radiographs; (13) Prosthodontics, Removable (CDT codes D5000-D5899): (a) The Authority covers complete dentures once (1) every 10 years, only if medically necessary and dentally appropriate, with PA approval; (A) Coverage is for only one of the following options (not both); (i) Complete dentures (D5110, D5120); or (ii) Immediate dentures (D5130, D5140); (B) The Authority’s 10-year coverage limitation for complete dentures applies regardless of the member’s OHP or CCO enrollment status at the time the member received the denture; and (C) The member’s periodontal health needs to be stable and supportive of a prosthetic. (b) The fee for the denture includes payment for adjustments during the six (6) month period following the delivery of the denture. Adjustments and repairs needed beyond six (6) months from the delivery of the denture are covered by the Authority as follows: (A) A maximum of four (4) times per year for: (i) Adjustments to dentures, per arch (D5410, D5411); (ii) Replacement of missing or broken teeth, each tooth (D5520); and (B) A maximum of two (2) times per year for broken complete denture base (D5511, D5512). (c) The Authority covers partial dentures once (1) every five (5) years, only if medically necessary and dentally appropriate, with PA approval; (A) Coverage is for only one of the following options: (i) Partial denture resin base (D5211, D5212); (ii) Immediate partial denture (D5221, D5222) or (iii) Interim partial dentures (D5820, D5821); (B) The Authority’s five (5) year coverage limitation for partial dentures applies regardless of the member’s OHP or CCO enrollment status at the time the member’s last partial was received; (C) Periodontal health needs to be stable and supportive of a prosthetic; (D) Interim partial dentures (also referred to as “flippers”) are covered only if the member has one (1) or more anterior teeth missing; (E) Partial dentures and immediate partial dentures are covered as follows: (i) For EPSDT members: The member must have one (1) or more anterior teeth missing or four (4) or more missing posterior teeth per arch with resulting space equivalent to the loss demonstrating inability to masticate. Third molars are not a consideration when counting missing teeth; (ii) For non-EPSDT members: The member must have one (1) or more missing anterior teeth or six (6) or more missing posterior teeth per arch with documentation by the provider of resulting space causing serious impairment to mastication. Third molars are not a consideration when counting missing teeth; (F) The Practitioner must note the teeth to be replaced and the teeth to be clasped with requesting PA; (G) The Authority does not approve resin partial dentures (D5211, D5212) if stainless steel crowns are used as abutments; and (H) Partial dentures are not to be used in lieu of space maintainers. (d) The fee for the partial denture includes payment for adjustments during the six (6) month period following delivery. Adjustments and repairs needed beyond six (6) months after delivery of the partial denture as follows: (A) A maximum of four (4) times per year for: (i) Adjustments to partial dentures, per arch (D5421, D5422) (ii) Replace broken tooth on a partial denture, each tooth (D5640) (iii) Add tooth to existing partial denture (D5650); (B) A maximum of two (2) times per year for: (i) Repair resin partial denture base (D5611, D5612); (ii) Repair cast partial framework (D5621, D5622); (iii) Repair or replace broken retentive/clasping materials, per tooth (D5630); and (iv) Add clasp to existing partial denture, per tooth (D5660); (C) Replacement of all partial denture teeth and acrylic on cast metal framework (D5670, D5671), with PA approval; (i) A maximum of once (1) per five (5) years per arch; (ii) When five (5) or more years have passed since the partial denture was originally delivered; and (iii) Is considered replacement of the partial denture so a new denture shall not be reimbursed for another five (5) years. (e) For denture reimbursement; (A) The member must have active coverage on the date of the final impression; (B) The dentures must be delivered within 45 days of the date of the final impression; and (C) The claim includes both the date of the final impression and the date of delivery. If the member loses OHP coverage during the time that the denture is being fabricated, submit the claim using the date of the final impression. (f) The Authority may cover reasonable and necessary replacement of medically necessary and dentally appropriate covered dentures, including those purchased or in used before the member enrolled with OHP; (g) Replacement of dentures is covered involving the provision of the medically necessary and dentally appropriate item when: (A) The item cannot be made clinically serviceable by a less costly procedure (e.g., reline, rebase, repair, tooth replacement); (B) The loss of the item is due to circumstance beyond the member’s control (e.g., irreparable damage referring to a specific accident, natural disaster, or situation); (C) There is a change in the member’s condition that warrants a new item (e.g., cases of acute trauma, catastrophic illness that directly or indirectly affects the dental condition and results in additional tooth loss). This pertains to, but is not limited to, cancer and periodontal disease resulting from pharmacological, surgical, and medical treatment for conditions mentioned earlier; and (D) There is coverage for the specific item as identified in Chapter 410, Division 123. (h) The Authority may not cover replacement of dentures: (A) When cases suggest malicious damage, culpable neglect, or wrongful disposition of the denture; or (B) In the presence of untreated severe periodontal disease. (i) Replacement of a partial denture with a complete denture is payable five (5) years after the partial denture placement; (j) The Authority covers denture rebase procedures (D5710, D5711, D5720, D5721) as follows, only if a reline does not adequately solve the problem: (A) For EPSDT members: once (1) every three (3) years; (B) For non-EPSDT members: once (1) every five (5) years when there is documentation of a current, failed reline procedure; (C) Exceptions to these limitations may be considered by the Authority for conditions as listed for warranting replacement of partial and complete dentures; and (D) Untreated severe periodontal disease may not warrant rebase procedures. (k) The Authority covers denture reline (direct) procedures (D5730, D5731, D5740, D5741) as follows: (A) For EPSDT members: once (1) every three (3) years; (B) For non-EPSDT members: once (1) every five (5) years; (C) A new or replacement complete or partial denture(s) on the same arch are not reimbursable for 12 months after the reline; and (D) Exceptions to these limitations may be considered by the Authority for conditions as listed for warranting replacement of partial and complete dentures. (l) The Authority covers denture reline (indirect) laboratory procedures (D5750, D5751, D5760, D5761) six (6) months after placement of any denture as follows: (A) For EPSDT members: once (1) every three (3) years; (B) For non-EPSDT members: once (1) every five (5) years; (C) A new or replacement denture on the same arch is not reimbursable for 12 months after the reline; and (D) Exceptions to these limitations may be considered by the Authority for conditions as listed for warranting replacement of partial and complete dentures. (m) The Authority covers tissue conditioning (D5850, D5851) for all members once: (A) Per denture unit in conjunction with immediate dentures; and (B) Prior to new denture placement. (14) Maxillofacial Prosthetic Services (CDT codes D5900-D5999): (a) Fluoride gel carrier is limited to those members whose severity of dental disease causes the increased cleaning and fluoride treatments allowed in rule to be insufficient. The Dental Practitioner must document failure of those options prior to use of the fluoride gel carrier; and (b) All other maxillofacial prosthetics are medical services; (A) Bill for medical maxillofacial prosthetics using the professional (CMS1500, DMAP 505, 837D or 837P) claim format; (B) For members receiving services through a CCO, bill medical maxillofacial prosthetics to the CCO; and (C) For members receiving medical services through FFS, bill the Authority. (15) Prosthodontics, Fixed (CDT codes D6200-D6999): Surgical removal of implant body (D6100) and Removal of implant body (D6105) are covered for all members, per Guideline Note 123, when there is: (a) Advanced peri-implantitis with bone loss and mobility, abscess; or (b) Implant fracture. (16) Oral & Maxillofacial Surgery (D7000-D7999): Billing Procedures: (a) Bill on a dental claim form using CDT codes for procedures that are directly related to the teeth and the structures directly supporting teeth; (b) The Medical/Surgical Program is responsible for all dental health procedures performed due to an underlying medical condition (i.e., procedures on or in preparation for treatment of the jaw, tongue, roof of mouth). Such procedures must be billed using ICD-10, HCPCS and CPT billing codes using the professional (CMS1500, DMAP 505 or 837P) claim format; (c) The following services are covered based on severity and included situations deemed to cause gingival recession or movement of the gingival margin when frenum is placed under tension: (A) Buccal/labial frenectomy (frenulectomy) (D7961), refer to Guideline Note 48; (i) Maxillary labial frenulectomy is not covered until age 12; and (ii) Not billable if member has received D7963; (B) Lingual frenectomy (frenulectomy) (D7962), refer to Guideline Note 48 and 139, is not covered until age 12 unless ankyloglossia is interfering with breastfeeding; or (C) Frenuloplasty (D7963), refer to Guideline Note 48; (i) Once (1) per lifetime per quadrant; and (ii) Not billable if member has received D7961. (d) Emergency tracheotomy (D7990) is an ancillary code reimbursable for all members; (e) All ancillary and diagnosis codes must be used for services that are medically necessary and dentally appropriate; and (f) Alveoloplasty not in conjunction with extractions (D7320, D7321) is reimbursable for EPSDT beneficiaries, and for members who are pregnant or 12 months postpartum. (17) Orthodontics (CDT Codes D8000-D8999): (a) The Authority covers orthodontia services and extractions to treat cleft palate with airway obstruction, cleft palate and/or cleft lip, or deformities of the head, and handicapping malocclusions (HM), not for cosmetic purposes, when: (A) The member has a craniofacial anomaly health condition that is included on a covered line of the Prioritized List of Health Services; (B) The Authority approves the PA request for orthodontic treatment: and (C) EPSDT qualification for the OHP Orthodontic benefit is determined when; (i) Dental Appropriateness as demonstrated when the member has a malocclusion; and (ii) Medical Necessity for the orthodontic treatment is demonstrated when the member meets the automatic qualifying criteria and/or a score of 26 or higher on the Handicapping Labiolingual Deviation (HLD) score index. (b) Pre-orthodontic treatment examinations (D8660) must be provided by a licensed dentist. (c) Pre-orthodontic treatment examinations (D8660) do not require PA. Coverage is for members whose clinical presentation and preliminary comprehensive or periodic exam findings strongly suggest that they may qualify for orthodontic treatment under HM criteria, as established by the Authority. The imaging required for evaluation is not to be billed separately. Coverage is: (A) Once (1) per member, per provider, in a 12 month period (not on the same day as another routine or general dental evaluation or examination); and (B) When submitted alongside the following documentation to justify the need for treatment: (i) The Authority-approved HLD Index California Modified Scoring Form (completed, scored, and signed); (ii) Intra-oral and extra-oral photographs of diagnostic quality, adhering to American Association of Orthodontists (AAO) standards, capturing key aspects of the malocclusion; (iii) Panoramic radiographs or cephalometric images including tracings that document skeletal and dental relationships crucial for evaluating the severity of malocclusion; and (iv) A comprehensive narrative of medical necessity, explicitly stating how the malocclusion significantly impacts the member's oral health, airway, or overall functional capacity. (d) PA approval for comprehensive orthodontic treatment (D8070, D8080, D8090, D8091), must meet the criteria in Guideline Note 169 of the Prioritized List of Health Service. (e) Comprehensive orthodontic treatment must be completed by a licensed dentist who has: (A) Completed a Commission of Dental Accreditation (CODA) orthodontic fellowship or residency program; (B) Certified additional orthodontic training, a minimum of 30 hours of orthodontic continuing education (CE) in the past three (3) years that was approved by the American Dental Association Continuing Education Recognition Program (ADA CERP); or (C) Completed five (5) comprehensive orthodontic treatment cases in the past three (3) years, verified by case logs and patient outcomes. (f) Orthodontic treatment must begin while the member is an EPSDT beneficiary, or immediately after, if surgical corrections that were started during the member’s EPSDT beneficiary period for covered conditions were not completed during that period. (g) Payment for comprehensive orthodontic treatment includes all appliances, repairs, and all follow-up visits. (h) The Authority pays for orthodontia in one (1) lump sum upon beginning of treatment; (A) If the member transfers to another orthodontist during treatment, or treatment is terminated, the Authority shall recover the overpayment (refer to OAR 410-120-1397) based on the length of the treatment plan from the first date of service (DOS); and (B) Providers may discontinue orthodontic treatment of a member in cases including poor dental hygiene, continued missed appointments, or if treatment is a detriment to the member. (i) Licensed dentists providing orthodontic treatment may: (A) Submit PA requests for the extractions and/or bond surgeries that are documented as needed in the member’s orthodontic treatment plan; and (B) Refer members to enrolled specialists for extractions and/or bond surgeries when such services are beyond the scope of the member’s primary care dentist. (j) As long as the orthodontist continues treatment, the Authority may not require a refund even though the member may become ineligible for medical assistance sometime during the treatment period. (k) Care navigation assistance for members must be made available during transfer of care in situations such as provider changes. (18) Adjunctive General and Other Services (CDT codes D9000-D9999): (a) Fixed partial denture sectioning (D9120) is covered only when extracting a tooth connected to a fixed prosthesis and a portion of the fixed prosthesis is to remain intact and serviceable, preventing the need for more costly treatment; (b) Anesthesia and sedation: (A) The Authority reimburses administration of general anesthesia or IV sedation only for those members with concurrent needs: age; physical, medical, or mental status; or degree of difficulty of the procedure; and (B) The Authority reimburses providers with a current permit to administer General Anesthesia or IV Sedation as follows: (i) For each 15-minute period, up to two and a half hours on the same day of service in a dental office setting, and up to three and a half hours on the same day of service in a hospital setting and ASC; (ii) Each 15-minute period represents a quantity of one (1). Enter this number in the quantity column. (C) The Authority reimburses administration of Nitrous Oxide per date of service, not by time; (D) Enteral and Non-intravenous parenteral conscious sedation with or without coadministration of Nitrous Oxide are covered only for EPSDT beneficiaries as follows: (i) Members age 13 and older require PA; (ii) Limited to four (4) times per year; and (iii) Includes payment for monitoring and Nitrous Oxide; (E) Upon request, providers must submit a copy of their permit to administer Anesthesia, Analgesia, and Sedation to the Authority; and (F) The Authority covers CPT 00170 (anesthesia services during procedures on the mouth). When billing for services provided in conjunction with dental treatments in the office setting, use the professional claim format using an appropriate non-facility Place of Service code. (c) House/extended care facility call (D9410) is limited to urgent or emergent dental visits that occur outside of a dental office. This code is not reimbursable for provision of preventive services or for services provided outside of the office for the provider’s or facility’s convenience. (19) Sleep Apnea Services: (a) Sleep apnea devices and appliances may be placed or fabricated by a general dentist or specialist although they are considered medical services; (b) Bill for sleep apnea services using medical billing codes on the professional claim form unless guidance specifies otherwise; (c) Custom sleep apnea appliance fabrication and placement (D9947) must be billed on a dental claim form (see HERC Guideline Notes 27 and 36 for criteria), and is replaceable at the end of the five (5) year reasonable useful lifetime; (d) The Authority does not cover adjustments for dental sleep apnea appliances. The adjustments are considered part of the normal follow-up care within the first 90 days after provision of the device, and are included as services of (D9947); and (e) Dental sleep apnea repairs (D9949) are covered when necessary and appropriate to make item serviceable. If the expense for repairs exceeds the estimated expense of purchasing another item, no payment must be made for the excess. (20) Dental care access standards for pregnant members: (a) Dental care benefits for pregnant members shall continue for 12 months following the end of pregnancy; and (b) For additional dental care benefit for members who are pregnant or 12 months postpartum, refer to OAR 410-123-1510. (21) Services considered incidental, integral to the primary service rendered, part of another service, or included in routine post-op or follow-up care are not eligible for separate reimbursement. (a) Participating providers may not balance bill members for these services; (b) Not all services included in the Current Dental Terminology (CDT) codebook are covered by the Authority; (c) These services must not be listed as combined with another procedure; and (d) Under the Medicare Physician Fee Schedule, the Centers for Medicare and Medicaid Services (CMS) issued regulations in 2024 for payment for dental services that are inextricably linked to certain covered medical services, such as dental exams and necessary treatments prior to organ transplants, cardiac valve replacements, valvuloplasty procedures, and treatments for head and neck cancers. Such services should be billed directly to Medicare. (22) The following services are not eligible for separate reimbursement: (a) Alveolectomy/Alveoloplasty in conjunction with extractions; (b) Cardiac and other monitoring; (c) Caries risk assessment and documentation (D0601-D0603); (d) Curettage and root planing — per tooth is not eligible for separate reimbursement unless the service is significant and separately identifiable; (e) Diagnostic casts (D0470); (f) Direct pulp cap (D3110); (g) Discing; (h) Dressing change; (i) Electrosurgery; (j) Equilibration; (k) Gingival curettage — per tooth (D4220); (l) Gingival irrigation (D4921); (m) Gingivectomy or gingivoplasty to allow for access for restorative procedure, per tooth (D4212); (n) Indirect pulp cap (D3120); (o) Local anesthesia; (p) Medicated pulp chambers; (q) Occlusal adjustments (D9951, D9952); (r) Occlusal analysis; (s) Odontoplasty; (t) Oral hygiene instruction (D1330); (u) Periodontal charting, probing; (v) Post removal; (w) Polishing fillings; (x) Post extraction treatment for alveolaritis (dry socket treatment) if done by the provider of the extraction; (y) Pulp vitality tests (D0460); (z) Smooth broken tooth; (aa) Special infection control procedures; (bb) Surgical procedure for isolation of tooth with rubber dam (D3910); (cc) Surgical splint (D5988); (dd) Surgical stent (D5982); (ee) Suture removal; (ff) Testing for cracked tooth (D0461); and (gg) Teledentistry (D9995, D9996). (23) The following general categories of dental services are not covered for any member, unless coverage is specified or member is an EPSDT beneficiary and meets requirements of OAR Chapter 410, Division 151, as several of these services are considered elective or “cosmetic” in nature (i.e., done for the sake of appearance): (a) Desensitization; (b) Implant and implant services (See Prioritized List Guideline Notes 123 and 169); (c) Mastique or veneer procedure; (d) Orthodontic treatment; (e) Overhang removal; (f) Procedures, appliances, or restorations solely for aesthetic or cosmetic purposes; (g) Temporomandibular joint (TMJ) dysfunction treatment; and (h) Tooth bleaching. (24) Current Dental Terminology, © 2025 American Dental Association. All rights reserved.