OAR 410-123-1490: Hospital Dentistry

(1) The purpose of hospital dentistry is to provide safe, efficient dental care when providing routine (non-emergency) dental services for members who present special challenges that require the use of general anesthesia or intravenous (IV) conscious sedation services in an: (a) Ambulatory Surgical Center (ASC); or (b) Inpatient or outpatient hospital setting. (2) The Authority reimbursement for hospital dentistry is limited to covered services and may be prorated if non-covered dental services are performed during the same hospital visit. (3) Hospital dentistry is intended for the following members: (a) Age three (3) and younger that have extensive dental needs; (b) Per OAR Chapter 410, Division 151, EPSDT beneficiaries are covered with the following conditions: (A) Acute situational anxiety, fearfulness, extreme uncooperative behavior; (B) An inability to communicate, such as a member with developmental or intellectual disability or a member who is pre-verbal; (C) A need for general anesthesia (or IV conscious sedation) to protect the developing psyche; (D) Sustained extensive orofacial or dental trauma; or (E) Physical, mental, or medically compromising conditions. (c) Non-EPSDT beneficiaries with: (A) Developmental disability or other severe cognitive impairment, and one (1) or more of the following characteristics that prevent routine dental care in an office setting: (i) Acute situational anxiety and extreme uncooperative behavior; or (ii) A physically compromising condition. (B) Sustained extensive orofacial or dental trauma; (C) A medically fragile condition, such as a medical or physical condition which requires monitoring during dental procedures (i.e., coronary disease, asthma, or chronic obstructive pulmonary disease (COPD), heart failure, serious blood or bleeding disorder, or unstable diabetes or hypertension); or (D) Have complex medical needs, contractures or other significant medical conditions potentially making the dental office setting unsafe for the member. (4) Hospital dentistry is not intended for: (a) Member convenience (Refer to OAR 410-120-1200); (b) A healthy, cooperative member with minimal dental needs; (c) Members who have successfully received previous dental treatments in office settings; or (d) Medical contraindication to general anesthesia or IV conscious sedation. (5) The following information must be included in the member's dental record: (a) Informed consent: Member, parental or guardian written consent must be obtained prior to the use of general anesthesia or IV conscious sedation; (b) Justification for the use of general anesthesia or IV conscious sedation, including the following considerations: (A) Alternative behavior management modalities; (B) Member’s dental needs; (C) Quality of dental care; (D) Quantity of dental care; (E) Member’s emotional development; and (F) Member’s physical considerations. (c) Documentation in the member's dental record must explain why, in the estimation of the dentist, the member may not be responsive to office treatment; (d) The Authority or CCO may require additional documentation when reviewing requests for Prior authorization (PA) of hospital dentistry services (Refer to OAR 410-123-1160); (e) The Authority shall require clinical documentation explaining why the dentist did not complete the previous treatment plan, if the dentist did not proceed with a previous hospital dentistry plan approved for the same member. (6) Hospital dentistry always requires PA according to OAR 410-123-1160. (7) For non-hospital or ASC setting anesthesia and sedation criteria refer to 410-123-1260(18).