DHS 107.065 History
History: Cr.
Register, September, 1991, No. 429, eff. 10-1-91; correction in (1) made under s.
13.92 (4) (b) 7., Stats.,
Register December 2008 No. 636.
DHS 107.07(1)(1)
Covered services; dentists and physicians. Except as provided under subs.
(2),
(3),
(4) and
(4m), all of the following dental services are covered services when provided by or under the supervision of a dentist or physician within the scope of practice of dentistry as defined in s.
447.01 (8), Stats.:
DHS 107.07(1)(j)3.
3. General anesthesia, intravenous conscious sedation, nitrous oxide, and non-intravenous conscious sedation.
DHS 107.07 Note
Note: Orthodontia may be covered under early and periodic screening, diagnosis and treatment (EPSDT) services. Please see s.
DHS 107.22 (4).
DHS 107.07(1m)
(1m) Covered services; dental hygienists. Except as provided under subs.
(2),
(3),
(4), and
(4m), all of the following dental services are covered services when provided by a dental hygienist who is individually certified under ch.
DHS 105 within the scope of dental hygiene as defined in s.
447.01 (3), Stats.:
DHS 107.07(2)(a)(a) All of the following dental services require prior authorization in order to be reimbursed under MA:
DHS 107.07(2)(a)4.a.
a. Surgical extractions of teeth and tooth roots for orthodontia, or for asymptomatic impacted teeth.
DHS 107.07(2)(a)4.d.
d. Other repair procedures including osteoplasty, alveoloplasty, and sialolithotomy.
DHS 107.07(2)(a)6.
6. General anesthesia, intravenous conscious sedation, nitrous oxide, and non-intravenous conscious sedation for recipients age 21 and over, where the treatment is not provided in a hospital or in an emergency situation.
DHS 107.07(2)(a)7.
7. Surgical or other dental services, including fixed prosthodontics in order to correct conditions that may reasonably be assumed to significantly interfere with a recipient's personal or social adjustment or employability.
DHS 107.07(2)(b)
(b) A provider who submits a request for prior authorization of dental services to the department shall identify the recipient's birth date and the items enumerated in s.
DHS 107.02 (3) (d).
DHS 107.07(3)
(3) Other limitations. All of the following limitations apply to the coverage of dental services under this section:
DHS 107.07(3)(a)
(a)
General limitations. The MA program may impose reasonable limitations on reimbursement of the services listed in subs.
(1) and
(1m) regarding any of the following:
DHS 107.07(3)(a)1.
1. Frequency of service per time period, including coverage of services in emergency situations only.
DHS 107.07(3)(a)3.
3. Required documentation, including pathology report or operative report.
DHS 107.07(3)(b)1.1. Reimbursement for dentures and partial dentures includes 6 months postdelivery care. If a prior authorization request for these services is approved, the recipient shall be eligible on the date the authorized treatment is started, which is the date the final impressions were taken. Once started, the service shall be reimbursed to completion, regardless of the recipient's eligibility.
DHS 107.07(3)(b)2.
2. Temporomandibular joint surgery is a covered service only when performed after all professionally accepted non-surgical medical or dental treatment has been provided, and the necessary non-surgical medical or dental treatment has been determined unsuccessful by the department's dental consultant.
DHS 107.07(3)(b)3.
3. The diagnostic work-up for orthodontic services shall be performed and submitted with the prior authorization request. If the request is approved, the recipient is required to be eligible on the date the authorized orthodontic treatment is started as demonstrated by the placement of bands for comprehensive orthodontia. Once started, the service shall be reimbursed to completion, regardless of the recipient's eligibility.
DHS 107.07(3)(b)4.
4. A non-covered service specified under sub.
(4) or
(4m) may be reimbursed if the department's dental consultant requests that the service be performed in order to review the request for prior authorization.
DHS 107.07(4)
(4) Non-covered services; dentists and physicians. The following dental services are not covered under MA whether or not the service is performed by a dentist; physician; or a person under the supervision of a dentist or physician:
DHS 107.07(4)(a)
(a) General services for purely aesthetic or cosmetic purposes.
DHS 107.07(4)(d)
(d) Tests and laboratory examinations, other than for diagnostic casts when required by the department.
DHS 107.07(4)(e)
(e) Oral hygiene instruction or training in preventive dental care as a separate procedure, including tooth brushing technique, flossing or use of special oral hygiene aids, tobacco cessation counseling, or nutritional counseling.
DHS 107.07(4)(f)4.
4. Endodontic filling materials that are not approved for use by the American Dental Association.
DHS 107.07(4)(L)
(L) Professional visits, other than for the oral evaluation of a nursing home resident, or hospital calls as noted in sub.
(1) (j) 4. DHS 107.07(4m)
(4m) Non-covered services; dental hygienists. The following services are not covered by MA whether or not the service is performed by a person under the supervision of a dentist or physician or by a dental hygienist who is individually certified under ch.
DHS 105:
DHS 107.07(4m)(b)
(b) Oral hygiene instruction or training in preventive dental care as a separate procedure, including tooth brushing technique, flossing or use of special oral hygiene aids, tobacco cessation counseling, or nutritional counseling.
DHS 107.07(5)
(5) Unusual circumstances. In certain unusual circumstances the department may request that a non-covered service be performed, including but not limited to diagnostic casts, in order to substantiate a prior authorization request. In these cases the service shall be reimbursed.
