CHAPTER 1149. DENTISTS’ SERVICES

GENERAL PROVISIONS

Sec.


1149.1.    Policy.
1149.2.    Definitions.

SCOPE OF BENEFITS


1149.21.    Scope of benefits for the categorically needy.
1149.22.    Scope of benefits for the medically needy.
1149.23.    Scope of benefits for State Blind Pension recipients.
1149.24.    Scope of benefits for General Assistance recipients.

PROVIDER PARTICIPATION


1149.41.    Participation requirements.
1149.42.    Ongoing responsibilities of providers.
1149.43.    Requirements for dental records.
1149.43a.    Clarification of the terms ‘‘in writing’’, ‘‘written’’ and ‘‘signature’’—statement of policy.

PAYMENT FOR DENTISTS’ SERVICES


1149.51.    General payment policy.
1149.52.    Payment conditions for various dental services.
1149.54.    Payment policies for orthodontic services.
1149.55.    Payment conditions for orthodontic services.
1149.56.    Payment limitations for orthodontic services.
1149.57.    Noncompensable services and items.

UTILIZATION


1149.71.    Scope of claims review procedures.

ADMINISTRATIVE SANCTIONS


1149.81.    Provider misutilization.

Authority

   The provisions of this Chapter 1149 issued under sections 403(a) and (b), 443.4, 443.6 and 509 of the Public Welfare Code (62 P.S. § §  403(a) and (b), 443.4, 443.6 and 509), unless otherwise noted.

Source

   The provisions of this Chapter 1149 adopted January 25, 1985, effective January 15, 1985, 15 Pa.B. 255, unless otherwise noted.

Cross References

   This chapter cited in 55 Pa. Code §  1101.31 (relating to scope); 55 Pa. Code §  1150.56b (relating to payment policy for observation services—statement of policy); and 55 Pa. Code §  1163.51 (relating to general payment policy).

GENERAL PROVISIONS


§ 1149.1. Policy.

 The Medical Assistance Program provides payment for dentists’ services rendered to eligible recipients by dentists enrolled as providers under the MA Program. Payment for dentists’ services is subject to this chapter, Chapter 1101 (relating to general provisions) and the limitations established in Chapter 1150 (relating to MA Program payment policies) and the MA Program fee schedule.

Source

   The provisions of this §  1149.1 adopted January 25, 1985, effective January 15, 1985, 15 Pa.B. 255; amended September 30, 1988, effective October 1, 1988, 18 Pa.B. 4418. Immediately preceding text appears at serial page (96116).

§ 1149.2. Definitions.

 The following words and terms, when used in this chapter, have the following meanings, unless the context clearly indicates otherwise:

   Approved institution—A university, college or hospital whose dental school program is approved by the American Dental Association or a Canadian university whose dental school program is recognized by the American Dental Association.

   Board certified or Board eligible orthodontist—A dentist who has successfully completed the full curriculum of advanced education in orthodontics at an approved institution or an orthodontic hospital residency program which is accredited by the Commission on Accreditation of Dental and Dental Auxiliary Education Programs of the American Dental Association.

   Dental laboratory—A laboratory, comprised of dental technicians, and engaged in the business of constructing, altering, repairing or duplicating dentures, plates, partial plates, bridges, splints and orthodontic or prosthetic appliances.

   Dental technician—An individual not licensed to practice dentistry in this Commonwealth but engaged in the business of constructing, altering, repairing or duplicating dentures, plates, partial plates, bridges, splints and orthodontic or prosthetic appliances from a prescription by a dentist.

   Dentist—An individual licensed under the laws of the Commonwealth to practice dentistry within the scope of The Dental Law (63 P.S. § §  120—130g).

   Oral and maxillofacial surgeon—A dentist who limits his practice to the part of dental care which deals with the diagnosis, the surgical and adjunctive treatment of diseases, injuries and defects of the oral and maxillofacial region.

   Pedodontist—A dentist who limits his practice to the diagnosis and treatment of conditions of the teeth and mouth in children.

Authority

   The provisions of this §  1149.2 amended under sections 201(2), 403(b), 443.1, 443.3, 443.6, 448 and 454 of the Public Welfare Code (62 P. S. § §  201(2), 403(b), 443.1, 443.3, 443.6, 448 and 454).

Source

   The provisions of this §  1149.2 adopted January 25, 1985, effective January 15, 1985, 15 Pa.B. 255; amended December 11, 1992, effective January 1, 1993, 22 Pa.B. 5995; amended August 26, 2005, effective August 29, 2005, 35 Pa.B. 4811. Immediately preceding text appears at serial pages (276148) to (276149).

Cross References

   This section cited in 55 Pa. Code §  1149.43 (relating to requirements for dental records); and 55 Pa. Code §  1149.55 (relating to payment conditions for orthodontic services).

SCOPE OF BENEFITS


§ 1149.21. Scope of benefits for the categorically needy.

 Categorically needy adult recipients are eligible for all medically necessary dental services, subject to the conditions and limitations established in this chapter, Chapters 1101 and 1150 (relating to general provisions; and MA Program payment policies) and the MA Program fee schedule. Categorically needy recipients under 21 years of age are eligible for all medically necessary dental services.

Authority

   The provisions of this §  1149.21 amended under sections 201(2), 403(b), 443.1, 443.3, 443.6, 448 and 454 of the Public Welfare Code (62 P. S. § §  201(2), 403(b), 443.1, 443.3, 443.6, 448 and 454).

Source

   The provisions of this §  1149.21 adopted January 25, 1985, effective January 15, 1985, 15 Pa.B. 255; amended September 30, 1988, effective October 1, 1988, 18 Pa.B. 4418; amended December 11, 1992, effective January 1, 1993, 22 Pa.B. 5995; amended August 26, 2005, effective August 29, 2005, 35 Pa.B. 4811. Immediately preceding text appears at serial page (276149).

Cross References

   This section cited in 55 Pa. Code §  1149.57 (relating to noncompensable services and items).

§ 1149.22. Scope of benefits for the medically needy.

 Medically needy adult recipients are eligible for medically necessary dental services only when provided in an inpatient, ambulatory surgical center, or short procedure unit setting, and subject to the conditions and limitations established in this chapter and Chapters 1101 and 1150 (relating to general provisions; and MA Program payment policies) and the MA Program fee schedule. Medically needy recipients under 21 years of age are eligible for all medically necessary dental services.

Authority

   The provisions of this §  1149.22 amended under sections 201(2), 403(b), 443.1, 443.3, 443.6, 448 and 454 of the Public Welfare Code (62 P. S. § §  201(2), 403(b), 443.1, 443.3, 443.6, 448 and 454).

Source

   The provisions of this §  1149.22 adopted January 25, 1985, effective January 15, 1985, 15 Pa.B. 255; amended September 30, 1988, effective October 1, 1988, 18 Pa.B. 4418; amended August 26, 2005, effective August 29, 2005, 35 Pa.B. 4811. Immediately preceding text appears at serial pages (276149) to (276150).

§ 1149.23. Scope of benefits for State Blind Pension recipients.

 (a)  Except as noted in subsection (b), State Blind Pension recipients are eligible for all medically necessary dental services, subject to the conditions and limitations established in this chapter, Chapters 1101 and 1150 (relating to the general provisions; and MA Program payment policies) and the MA Program fee schedule.

 (b)  State Blind Pension recipients are not eligible for radiological services or inpatient dental services. State Blind Pension recipients are eligible for radiological services and inpatient surgical procedures and emergency dental services if they qualify as categorically needy or medically needy recipients.

Authority

   The provisions of this §  1149.23 amended under sections 201(2), 403(b), 443.1, 443.3, 443.6, 448 and 454 of the Public Welfare Code (62 P. S. § §  201(2), 403(b), 443.1, 443.3, 443.6, 448 and 454).

Source

   The provisions of this §  1149.23 adopted January 25, 1985, effective January 15, 1985, 15 Pa.B. 255; amended September 30, 1988, effective October 1, 1988, 18 Pa.B. 4418; amended December 11, 1992, effective January 1, 1993, 22 Pa.B. 5995; amended August 26, 2005, effective August 29, 2005, 35 Pa.B. 4811. Immediately preceding text appears at serial page (276150).

§ 1149.24. Scope of benefits for GA recipients.

 (a)  GA chronically needy and nonmoney payment recipients, age 21 to 65, are eligible for medically necessary dental services subject to the conditions and limitations established in this chapter, Chapters 1101 and 1150 (relating to general provisions; and MA Program payment policies) and the MA Program fee schedule.

 (b)  GA medically needy only recipients, age 21 to 65, are eligible for medically necessary dental services only when provided in an inpatient, ambulatory surgical center, or short procedure unit setting, and subject to the conditions and limitations established in this chapter and Chapters 1101 and 1150 (relating to general provisions; and MA Program payment policies) and the MA Program fee schedule.

Authority

   The provisions of this §  1149.24 amended under sections 201(2), 403(b), 443.1, 443.3, 443.6, 448 and 454 of the Public Welfare Code (62 P. S. § §  201(2), 403(b), 443.1, 443.3, 443.6, 448 and 454).

Source

   The provisions of this §  1149.24 adopted December 11, 1992, effective January 1, 1993, 22 Pa.B. 5995; amended August 26, 2005, effective August 29, 2005, 35 Pa.B. 4811. Immediately preceding text appears at serial page (276150).

PROVIDER PARTICIPATION


§ 1149.41. Participation requirements.

 Participation requirements are established in § §  1101.41—1101.43 (relating to participation).

Source

   The provisions of this §  1149.41 adopted January 25, 1985, effective January 15, 1985, 15 Pa.B. 255.

§ 1149.42. Ongoing responsibilities of providers.

 In addition to the ongoing responsibilities established in §  1101.51 (relating to ongoing responsibilities of providers), dentists shall:

   (1)  Establish and maintain dental records in accordance with §  1149.43 (relating to requirements for dental records).

   (2)  Submit to the Department upon request copies of dental records, as described in §  1149.43.

Source

   The provisions of this §  1149.42 adopted January 25, 1985, effective January 15, 1985, 15 Pa.B. 255.

§ 1149.43. Requirements for dental records.

 In addition to the recordkeeping requirements set forth in Chapter 1101 (relating to general provisions), dentists shall maintain a dental record for each MA recipient in accordance with the following requirements:

   (1)  The record shall contain a tooth chart indicating the condition of the patient’s teeth as observed on the initial oral examination. The dentist shall clearly indicate on the tooth chart:

     (i)   Missing permanent teeth.

     (ii)   Permanent teeth to be extracted.

     (iii)   Teeth to be restored by surface.

   (2)  The record shall note the condition of the oral supporting tissues.

   (3)  For each service rendered, the record shall note:

     (i)   The type of service.

     (ii)   The date the service was rendered.

     (iii)   The tooth number or letter, if applicable.

     (iv)   The surfaces restored, if applicable.

     (v)   The types of material used in the final restoration, if applicable.

     (vi)   The type, concentration and amount of any anesthetic agent used in providing a service, if applicable.

   (4)  The record shall contain a proposed plan of treatment, if applicable.

   (5)  If dental radiographs are taken, they shall be part of the patient’s record and shall be properly processed, dated and identified with the patient’s name.

   (6)  If radiographs are requested by the Department for prior authorization purposes, the radiographs shall be properly mounted and include the patient’s name, case number and the provider’s name. If radiographs are requested for a record review or for an onsite review, sufficient time will be agreed upon between the provider and the Department to allow the radiographs to be properly mounted.

   (7)  Documentation of prescriptions for drugs shall be part of the patient’s record whether prescribed orally or in writing and shall contain:

     (i)   The date of the prescription.

     (ii)   The drug, dose and amount prescribed.

     (iii)   Instructions for the administration of the drug.

     (iv)   The prescriber’s name.

   (8)  If the services of a dental technician or dental laboratory, or both, are used as defined in §  1149.2 (relating to definitions), the dentist shall furnish the dental technician or the dental laboratory with a written prescription which shall contain the following items listed in The Dental Law (63 P. S. § §  120—130b):

     (i)   The name and address of the dental laboratory technician or dental laboratory.

     (ii)   The patient’s name or identification number. If a number is used, the patient’s name shall be written on the prescription retained by the dentist.

     (iii)   The date on which the prescription was written.

     (iv)   A prescription for the work to be done with diagrams if necessary.

     (v)   A specification of the type and quality of materials to be used.

     (vi)   The signature of the dentist and the dentist’s license number.

     (vii)   A copy of the prescription shall be maintained as part of the patient’s record.

   (9)  Pathology reports are required for surgical excision services.

   (10)  Pre-operative X-rays are required for surgical services.

   (11)  Postoperative X-rays are required for endodontic procedures.

Source

   The provisions of this §  1149.43 adopted January 25, 1985, effective January 15, 1985, 15 Pa.B. 255.

Cross References

   This section cited in 55 Pa. Code §  1149.42 (relating to ongoing responsibilities of providers); 55 Pa. Code §  1149.43a (relating to clarification of the terms ‘‘in writing’’, ‘‘written’’ and ‘‘signature’’—statement of policy); and 55 Pa. Code §  1149.57 (relating to noncompensable services and items).

§ 1149.43a. Clarification of the terms ‘‘in writing’’, ‘‘written’’ and ‘‘signature’’—statement of policy.

 (a)  The terms ‘‘in writing’’ and ‘‘written’’ in §  1149.43(7) and (8) (relating to requirements for dental records) include prescriptions that are handwritten or transmitted by electronic means.

 (b)  Written prescriptions transmitted by electronic means must be electronically encrypted or transmitted by other technological means designed to protect and prevent access, alteration, manipulation or use by any unauthorized person.

 (c)  The term ‘‘signature’’ in §  1149.43(8)(vi) includes a handwritten or electronic signature that is made in accordance with the Electronic Transaction Act (73 P. S. § §  2260.101—2260.5101).

Source

   The provisions of this §  1149.43a adopted July 16, 2010, effective July 17, 2010, 40 Pa.B. 3963.

PAYMENT FOR DENTISTS’ SERVICES


§ 1149.51. General payment policy.

 Payment for dentists’ services is subject to the conditions and limitations set forth in this chapter and Chapters 1101 and 1150 (relating to general provisions; and MA Program payment policies) and the MA Program fee schedule. The following payment policies are applicable for dental services:

   (1)  The amount paid for dental services is the dentist’s usual charge to the general public or the fees listed in MA Program fee schedule, whichever is less.

   (2)  Payment is made for the services or items listed in the amounts specified in the MA Program fee schedule on behalf of a person no longer eligible for MA, provided the person was an eligible MA recipient at the time the ser-vice was initiated and the invoice for payment is submitted within 180 days after the service was initiated.

Source

   The provisions of this §  1149.51 adopted January 25, 1985, effective January 15, 1985, 15 Pa.B. 255; amended September 30, 1988, effective October 1, 1988, 18 Pa.B. 4418. Immediately preceding text appears at serial pages (96119) to (96120).

§ 1149.52. Payment conditions for various dental services.

 (a)  The fee paid by the Department for an inpatient surgical service includes pre-operative and postoperative visits as designated in the MA Program fee schedule.

 (b)  The Department pays only one dentist for performing a particular surgical service or procedure.

 (c)  Payment is made at reduced rates for space maintainers, crowns and dentures specified in MA Program fee schedule, if one of the following conditions are met:

   (1)  The person was an eligible MA recipient at the first visit after prior authorization was obtained as specified in subsection (j) but became ineligible for MA before the appliance was delivered.

   (2)  The dentist was unable to deliver the item to the recipient, and the following conditions were met:

     (i)   When the appliance is completed, the dentist shall notify the recipient and make an appointment. If the dentist is unable to contact the patient after 30 days, in spite of repeated attempts which must be documented in the recipient’s dental record, the dentist shall also send a letter to the recipient’s last known address and to the Executive Director of the appropriate County Assistance Office.

     (ii)   If neither the dentist nor the County Assistance Office can locate the recipient within the 60 days after the appliance is completed, the dentist shall submit an invoice for the service performed in accordance with the instructions in the provider handbook.

 (d)  Payment is made for dental procedures performed in the short procedure unit of a hospital only if:

   (1)  The short procedure unit has been approved for participation in the MA Program.

   (2)  The nature of the surgery or the condition of the patient precludes performing the procedure in the dentist’s office or other outpatient setting.

   (3)  A physician or dentist has documented in the patient’s medical record the medical justification for performing the procedure in a short procedure unit setting.

 (e)  Payment is made to dentists for inpatient hospital visits only if the conditions established in §  1150.54(a) (relating to surgical services) are met and daily dental care is provided by the dentist for a condition or diagnosis unrelated to daily medical care provided by a physician.

 (f)  Payment is made for an outpatient dental consultation only if:

   (1)  The consultation is requested by the dentist or physician in charge of the case.

   (2)  The consultation prepares a written report of the examination that includes the patient’s dental history and if applicable, the patient’s medical history.

   (3)  Except in an emergency situation, as described in §  1101.67(c) (relating to prior authorization), the Department has approved a request for the consultation prior to the service being rendered.

 (g)  Payment for an inpatient dental consultation is made only if:

   (1)  The consultation is requested by the dentist or physician in charge of the case.

   (2)  The consultant prepares a written report of the examination that also includes the patient’s dental history and if applicable, the patient’s medical history.

 (h)  Payment for diagnostic radiological services performed in the dentist’s office is made only if the dentist performs an oral examination of the patient prior to the radiological service.

 (i)  Payment is made to the dentist for general anesthesia provided in the office only if the recipient has a diagnosed medical problem, noted in the remarks section of the invoice, where use of local anesthesia is contraindicated as the sole agent in completion of the procedure. A surgical procedure by an oral surgeon or pedodontist need not be documented but it must be indicated in the remarks section of the invoice that the procedure was performed by the appropriate practitioner. However, the remarks section of the invoice does not have to be completed if general anesthesia was specifically included as part of a prior authorization requirement and that request was approved before the procedure was initiated.

 (j)  Payment is made only if the Department has prior authorized the following:

   (1)  Complete or partial dentures.

   (2)  Space maintainers.

   (3)  Orthodontic services.

   (4)  Crowns.

   (5)  When more than one tooth is extracted for insertion of a prosthetic device.

   (6)  Multiple extractions of six or more teeth extracted during one visit or one period of hospitalization.

   (7)  Surgical extractions.

   (8)  Outpatient dental consultations except as noted in subsection (f)(3).

 (k)  The fees for dentures include relining and adjustments made during a period of 180 days following insertion of the dentures.

 (l)  Payment is made for restorative services based on the number of surfaces restored, not on the number of restorations made per surface. For example, two restorations on the same surface of a tooth is considered to be a single restoration of one tooth surface. Fees for services include local anesthesia, polishing, cement bases and necessary medications, if applicable.

 (m)  The fees for crowns include buildup of the natural crown using either composite or amalgam. Payment for permanent crowns is made for fully developed permanent teeth and deciduous molars with no permanent successor. However, payment is made for stainless steel and temporary plastic crowns when made for primary or developing permanent teeth and not made in conjunction with the construction of a permanent crown.

 (n)  The fee for root canal therapy includes an apicoectomy if it is performed by the same dentist within 180 days of initial treatment. If an apicoectomy is performed by another dentist within 180 days of the initial treatment, the dentist will receive the fee for an apicoectomy as specified in Chapter 1150 (relating to MA Program payment policies).

 (o)  Payment for dental services performed on a hospital inpatient basis are compensable if the individual has a concomitant medical illness or handicapping condition and dental services need to be provided. This justification has to be written in the remarks section of the invoice in order for payment to be approved.

 (p)  Payment for removal of superficial root fragments not completely covered by bone will be considered as a simple extraction or surgical extraction of tooth, erupted.

Source

   The provisions of this §  1149.52 adopted January 25, 1985, effective January 15, 1985, 15 Pa.B. 255; amended September 30, 1988, effective October 1, 1988, 18 Pa.B. 4418. Immediately preceding text appears at serial pages (96120) to (96122).

Cross References

   This section cited in 55 Pa. Code §  1149.55 (relating to payment conditions for orthodontic services.)

§ 1149.54. Payment policies for orthodontic services.

 In addition to the payment policies established in this chapter, Chapters 1101 and 1150 (relating to the general provisions; and MA Program payment policies) and the MA Program fee schedule the following payment policies apply to orthodontic services:

   (1)  Payment for orthodontic services is made only if all of the conditions specified in §  1149.55 (relating to payment conditions for orthodontic services) are met.

   (2)  Payment for orthodontic services is subject to the limitations set forth in §  1149.56 (relating to payment limitations for orthodontic services).

   (3)  Payment is made only for those quarters during which the recipient is seen by the orthodontist and treatment is rendered.

   (4)  Payment for covered and approved orthodontic service is made on a quarterly basis as set forth in the MA Program fee schedule. The first quarter begins on the recipient’s first appointment day after the Department has authorized payment for the orthodontic services.

   (5)  The fees listed in the MA Program fee schedule include all appliances furnished by the orthodontist during the course of the orthodontic treatment.

   (6)  The fees listed in the MA Program fee schedule for the first quarter of treatment includes the cost of diagnostic aids such as models, photographs, radiographs and the like except as noted in paragraph (7).

   (7)  Payment for diagnostic aids is made only if the Department requests the diagnostic aids for review before the decision is made to approve orthodontic treatment and the treatment is denied by the Department.

   (8)  Payment will be discontinued for persons who become ineligible for MA benefits during the course of the orthodontic treatment. The last payment will be for the quarter in which the recipient becomes ineligible.

   (9)  Payment is made for orthodontic services for persons receiving orthodontic treatment at the time their eligibility for MA benefits begins in accordance with the policies set forth in this chapter subject to the conditions set forth in § §  1149.55 and 1149.56.

   (10)  Payment will not be made for recipients beginning orthodontic treatment through the Department of Health’s Cleft Palate Program, Division of Rehabilitation.

Source

   The provisions of this §  1149.54 adopted January 25, 1985, effective January 15, 1985, 15 Pa.B. 255; amended September 30, 1988, effective October 1, 1988, 18 Pa.B. 4418. Immediately preceding text appears at serial pages (96122) to (96123).

Cross References

   This section cited in 55 Pa. Code §  1149.56 (relating to payment limitations for orthodontic services).

§ 1149.55. Payment conditions for orthodontic services.

 Payment for orthodontic services is subject to the following conditions and requirements:

   (1)  The Department has authorized for the services prior to provision of the services as referenced in §  1149.52(j)(3) (relating to payment conditions for various dental services).

   (2)  The orthodontist is Board eligible or Board certified as defined in §  1149.2 (relating to definitions).

   (3)  They are necessary to prevent irreversible damage to the teeth or their supporting structures.

   (4)  They are necessary to treat acute dental problems as evidenced by the following factors:

     (i)   Dentofacial abnormalities that severely compromise the client’s physical health, as manifested by markedly protruding upper jaw and teeth, protruding lower jaw and teeth, the protrusion of upper and lower teeth so that the lips cannot be brought together, under-developed lower jaw and receding chin or marked asymmetry of the lower face.

     (ii)   Obvious difficulty in eating because of the malocclusion, so as to require liquid or semisoft diet, or cause pain in jaw joints during eating, or extreme grimacing or excessive motions of the orofacial muscles during eating because of necessary compensation for anatomic deviations.

     (iii)   Obvious severe breathing difficulties related to the malocclusion, such as unusually long lower face with downward rotation of the mandible and with lips that cannot be brought together, chronic mouth breathing and postural abnormalities relating to breathing difficulties—for example, head forward and extended, round shouldered.

     (iv)   Lisping or other speech articulation errors that are directly related to orofacial abnormalities.

   (5)  The recipient has a fully erupted set of permanent teeth.

   (6)  The recipient is 20 years of age or younger except as noted in paragraph (7).

   (7)  The recipient is 21 years of age or older but was receiving orthodontic services through the MA Program when the recipient turned 21 years of age.

   (8)  The recipient scored 25 or higher on the Salzmann Evaluation Index upon examination and evaluation by the orthodontist.

Source

   The provisions of this §  1149.55 adopted January 25, 1985, effective January 15, 1985, 15 Pa.B. 255; amended December 11, 1992, effective January 1, 1993, 22 Pa.B. 5995. Immediately preceding text appears at serial pages (130979) to (130980).

Cross References

   This section cited in 55 Pa. Code §  1149.54 (relating to payment policies for orthodontic services).

§ 1149.56. Payment limitations for orthodontic services.

 The following limits apply to payment for orthodontic services:

   (1)  Payment is made for only one Salzmann Index Evaluation per 12 month period per recipient.

   (2)  Payment for diagnostic aids requested by the Department under §  1149.54(7) (relating to payment policies for orthodontic services) will not exceed the fee for diagnostic aids which is listed under orthodontic exam in the MA Program fee schedule.

   (3)  Payment will not be made for quarters of orthodontia treatment initiated before March 1, 1980.

   (4)  Payment is made for only 8 quarters of treatment per lifetime except as noted in paragraph (5).

   (5)  For those persons who began orthodontic treatment prior to becoming eligible for MA, payment is made only for the difference between 8 quarters of care and quarters of care received prior to the person’s eligibility for MA.

   (6)  Payment for orthodontic services will not exceed $1,075. The fees paid for the initial orthodontic exam and treatment including the Salzmann Evaluation Index and the fees paid for the first quarter through the eighth quarter are listed in the Medical Assistance program fee schedule.

   (7)  Payment of the fee for each quarter as listed in the MA Program fee schedule is limited to one in each recipient’s lifetime.

   (8)  The amount of payment for each quarter of care is limited to the fee listed in the MA Program fee schedule.

Source

   The provisions of this §  1149.56 adopted January 25, 1985, effective January 15, 1985, 15 Pa.B. 255; amended September 30, 1988, effective October 1, 1988, 18 Pa.B. 4418. Immediately preceding text appears at serial pages (96124) to (96125).

Cross References

   This section cited in 55 Pa. Code §  1149.54 (relating to payment policies for orthodontic services).

§ 1149.57. Noncompensable services and items.

 No payment will be made to a dentist for the following services or items:

   (1)  Services or items not listed in the MA Program fee schedule.

   (2)  Silicate, acrylic or plastic restorations involving the occlusal surfaces of posterior teeth.

   (3)  Dental services for cosmetic purposes.

   (4)  Anesthesia services performed in a hospital short procedure unit, hospital emergency room or on an inpatient hospital basis.

   (5)  Diagnostic or pathological examinations of body fluids or tissues. Payment for these procedures is made only to hospital and independent laboratories approved for participation in the MA Program.

   (6)  Radiographs improperly identified as specified in §  1149.43(5) and (6) (relating to requirements for dental records) or not clearly readable or free from defects.

   (7)  Troches, lozenges, throat tablets, cough drops, chewing gum, mouth washes, and the like, prescribed for local treatment of disorders of the mouth and throat, even though the products are combined with antibiotic, antibacterial, analgesic, anesthetic or antitussive agents.

   (8)  Medications and supplies furnished by a dentist during the course of an examination or treatment.

   (9)  Initial oral examination or periodic oral examination when emergency treatment is provided.

   (10)  Fluoride treatment for persons 17 years of age or older.

   (11)  Self-curing dental materials.

   (12)  Crowns which are splinted for periodontal reasons.

   (13)  Crowns in conjunction with a bridge.

   (14)  Pontics in conjunction with a bridge.

   (15)  Fixed bridgework.

   (16)  Pulpotomy on fully developed permanent teeth.

   (17)  Root canal treatment, other than paste filling material, on primary teeth.

   (18)  Dental services other than those specified in §  1149.21 (relating to scope of benefits for the categorically needy), unless provided to MA recipients under 21 years of age.

Source

   The provisions of this §  1149.57 adopted January 25, 1985, effective January 15, 1985, 15 Pa.B. 255; amended September 30, 1988, effective October 1, 1988, 18 Pa.B. 4418; amended December 11, 1992, effective January 1, 1993, 22 Pa.B. 5995. Immediately preceding text appears at serial page (130981).

UTILIZATION


§ 1149.71. Scope of claims review procedures.

 Claims submitted for payment under the MA Program are subject to the utilization review procedures established in Chapter 1101 (relating to general provisions).

Source

   The provisions of this §  1149.71 adopted January 25, 1985, effective January 15, 1985, 15 Pa.B. 255.

ADMINISTRATIVE SANCTIONS


§ 1149.81. Provider misutilization.

 Providers determined to have billed for services inconsistent with MA Program regulations, to have provided services outside the scope of customary standards of dental practice, or to have otherwise violated the standards set forth in the provider agreement, are subject to the sanctions described in Chapter 1101 (relating to general provisions).

Source

   The provisions of this §  1149.81 adopted January 25, 1985, effective January 15, 1985, 15 Pa.B. 255.



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