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Home > Parents' Corner > How to pay for the Visit

How to pay for the Visit

BILLING DENTI-CAL FOR FLUORIDE VARNISH (DENTAL PROVIDERS)

BILLING MEDI-CAL/HEALTHY FAMILIES/PRIVATE MEDICAL INSURANCE FOR FLUORIDE VARNISH (MEDICAL PROVIDERS)

 

How do I bill Denti-Cal for a fluoride varnish application?

There are two different ways to bill Denti-Cal for a fluoride varnish application:

1. The usual way

Currently there is no Denti-Cal procedure code for a fluoride varnish application, per se. However, fluoride varnish is a form of topical fluoride application, so you may submit a Denti-Cal claim for a fluoride varnish application using Procedure Code 061 (Prophylaxis, Including Topical Application of Fluoride, Beneficiaries Age 5 and Under). If the child is age 6 through 17, use Procedure Code 062 (Prophylaxis, Including Topical Application of Fluoride, Beneficiaries age 6 through 17). Note that, as with any claim for a topical fluoride application, a prophylaxis must be provided in conjunction with the fluoride varnish application in order to claim reimbursement. If no calculus is present, a "toothbrush prophylaxis" may be substituted for a rubber cup prophylaxis. See the example of a properly completed Denti-Cal claim for a fluoride varnish application and initial examination on page xx.

A fluoride varnish application may be claimed once in a six-month period without prior authorization, and more frequently than once in a six-month period if a physical limitation or oral condition (e.g., drug hyperplasia) exists, and provided that the service is prior authorized and the request for prior authorization includes documentation of the physical limitation or oral condition justifying the need.


2. EPSDT Supplemental Services

The Early and Periodic Screening, Diagnosis, and Treatment (EPSDT) program is Medicaid's joint federal/state comprehensive and preventive health program for individuals under the age of 21. Federal law requires states to provide any medically necessary health care service (including dental services) to an an EPSDT beneficiary (i.e., any full-scope Medi-Cal beneficiary under age 21), even if the service is not available under a State's Medicaid plan to the rest of the Medicaid population, and regardless of whether it is specifically listed in the Medicaid plan as a covered service. When such services are claimed, they are called EPSDT Supplemental Services (EPSDT-SS).

What services can be claimed as EPSDT Supplemental Services?

As noted above, any medically necessary dental procedure, regardless of whether it is listed in the Denti-Cal Provider Manual, can be claimed as an EPSDT Supplemental Service (EPSDT-SS). Thus, a fluoride varnish application can be claimed more frequently than once every six months under EPSDT-SS. Claiming a procedure as EPSDT-SS is not an assurance that the claim will be approved and paid. All EPSDT-SS claims require prior authorization and will be reviewed on a case-by-case basis by a Department of Health Services Dental Consultant. Requests for prior authorization are made using the Denti-Cal Treatment Authorization Request (TAR) form. In addition, a detailed narrative documenting the need for the procedure must accompany the TAR.

How do I submit a claim for EPSDT Supplemental Services?

Please read the Denti-Cal Bulletin excerpt on pages xx-xx carefully and be sure to follow its instructions explicitly. For your convenience, a form (EPSDT-Supplemental Services Narrative Documentation) can be found on page xx. This form may help you "cover all the bases" with respect to the documentation requirements. This is not an official Denti-Cal form, and is provided only to help speed the documentation process. Feel free to reproduce it.

CLAIM FORM FOR USUAL DENTI-CAL BILLING

NOTE: The following language is from the Denti-Cal Bulletin, Volume 18, Number 1, January 2002.

EARLY AND PERIODIC SCREENING, DIAGNOSIS, AND TREATMENT (EPSDT) SERVICES
The Early and Periodic Screening, Diagnosis, and Treatment (EPSDT) service is Medicaid's comprehensive and preventive child health program for individuals under the age of 21 (such individuals are called "EPSDT beneficiaries"). EPSDT was further defined by federal law as part of the Omnibus Budget Reconciliation Act of 1989 (OBRA 89) legislation and includes dental services. In addition, section 1905(r)(5) of the Social Security Act requires that any medically necessary health care service listed in section 1905(a) be provided to an EPSDT beneficiary even if the service is not available under a State's Medicaid plan to the rest of the Medicaid population.The California Department of Health Services established regulations, effective on April 4, 1994, and amended effective April 27, 1995, to clarify the Department's implementation of the EPSDT program within Medi-Cal. The applicable regulations, contained within Title 22 of the California Code of Regulations, are sections 51184, 51242, 51304, 51340, 51340.1, and 51532.
Whenever a Medi-Cal dental provider completes an oral examination on a beneficiary under the age of 21, an EPSDT screening service (and diagnostic service) has occurred. Any further treatment resulting from that examination is considered to be an EPSDT dental service - provided that the dental procedure is contained within the Medi-Cal dental program's scope of benefits.

EPSDT Supplemental Services (EPSDT-SS)
EPSDT beneficiaries may require dental services that are not part of the current Medi-Cal dental scope of benefits. Conversely, the dental service may be part of the Medi-Cal dental scope of benefits for adults but not for children; or the dental provider may want to provide the service at a frequency or periodicity greater than currently allowed by the Medi-Cal dental program. In these cases, such dental services are called EPSDT Supplemental Services (EPSDT-SS).


Prior Authorization Required
All EPSDT Supplemental Services must be prior authorized. Requests for prior authorization are made using the Denti-Cal Treatment Authorization Request (TAR) form(s) DC001B, DC001D, DC002B, DC009B, and DC017B as applicable. Whenever possible, use current Medi-Cal dental program procedure codes to request authorization for EPSDT-SS. If the requested dental service is beyond the scope of the Medi-Cal dental program (where no Denti-Cal procedure code exists), use procedure code 999 and fully describe the service (including any applicable CDT code).


Specific Narrative Documentation Required

EPSDT-SS TARs must explicitly state in the "Comments" section (Block 34) that the request is for EPSDT Supplemental Services. In addition, the EPSDT-SS TAR must be accompanied by the following patient case information:

  1. Principal diagnosis and any significant associated diagnoses.
  2. Prognosis of the patient's case, both with and without the requested treatment.
  3. Etiology of the patient's dental disease(s) or condition(s), with date of onset (if known).
  4. Clinical significance of the patient's dental disease(s) or condition(s) or the functional impairment caused by the patient's dental disease(s) or condition(s).
  5. If the services of other dental providers (including dental specialists) will be required, then a complete case management plan (including coordination of care) must be presented - this plan must explain the therapeutic goals to be achieved by each dental provider, and the anticipated time for achievement of goals.
  6. If the requested dental services are necessary in order to correct or ameliorate a non-dental disease or condition, then supporting documentation from the appropriate health care provider is required. For example: a child's speech therapist determines that a diagnosed speech pathosis cannot be resolved without dental treatment. The dentist who is requesting authorization for EPSDT-SS dental services would need to obtain supporting documentation from the child's speech therapist, and include this documentation in the EPSDT-SS TAR.
  7. The extent to which dental services have been previously provided to address the dental disease(s) or condition(s) and the past clinical outcomes.

The dental provider should attach any additional documentation (e.g., narrative, radiographic, photographic) that is needed to fully justify the medical necessity and appropriateness of the requested services to the EPSDT-SS TAR. Medi-Cal dental program consultants will review each EPSDT-SS TAR and determine the medical necessity and appropriateness of the requested dental services using the following guidelines:

  1. The requested dental services must be necessary to correct or ameliorate diseases, defects and conditions.
  2. The services are not requested solely for the convenience of the beneficiary, family, dental provider or another provider of services.
  3. The services are not unsafe for the individual patient and are not experimental.
  4. The services are neither primarily cosmetic in nature nor primarily for the purpose of improving the patient's appearance. The correction of severe or disabling disfigurement shall not be considered to be primarily cosmetic nor primarily for the purpose of improving the patient's appearance.
  5. Where alternative dental treatment is available and such alternative treatment lies within the professional standard of care, the requested services must be the most cost-effective.
  6. The requested services must be generally accepted by the professional dental community as effective and proven treatments for the conditions for which they are proposed to be used. Such acceptance shall be demonstrated by scientific evidence, consisting of well designed and well conducted investigations published in peer reviewed journals and, when available, opinions and evaluations published by national dental organizations, consensus panels and other technology evaluation bodies. Such evidence shall demonstrate that the services can correct or ameliorate the conditions for which they are prescribed.
  7. The requested services must be within the authorized scope of practice of the dental provider and are an appropriate mode of treatment for the dental condition of the beneficiary.
  8. The predicted beneficial outcome of the services outweighs potential harmful effects.

EPSDT-SS Requests for Orthodontic Services
All EPSDT-SS requests for orthodontic services must include a completed Handicapping Labio-Lingual Deviation (HLD) Index Scoresheet (DC0016) in addition to the aforementioned documentation requirements. The review of active orthodontic services also requires the submission of study models.
For detailed instructions on how to complete the HLD Index, refer to Section 4 "Orthodontic Services for Handicapping Malocclusion."



EPSDT-Supplemental Services
Narrative Documentation

  • This form must accompany the Denti-Cal Treatment Authorization Request (TAR).
  • Print "EPSDT-SS-See attached narrative" in Box 34 of the TAR.
  • Whenever possible, use current Denti-Cal procedure codes to request authorization for EPSDT-SS. Where no Denti-Cal procedure code exists, use any applicable CDT code and/or fully describe the procedure.
  1. Description of requested procedure(s) and applicable procedure code(s), if known
  2. Principal diagnosis and any significant associated diagnoses
  3. Prognosis of the patient's case with requested treatment
  4. Prognosis of the patient's case without requested treatment
  5. Etiology of patient's dental disease(s) or condition(s), and date of onset (if known)
  6. Clinical significance of patient's dental disease(s) or condition(s), or the functional impairment caused by patient's dental disease(s) or condition(s)
  7. If the services of other dental providers (including dental specialists) will be required, then a complete case management plan (including coordination of all care) must be presented. This plan must explain the therapeutic goals to be achieved by each dental provider, and the anticipated time for achievement of goals. Attach as a separate document.

If the requested dental services are necessary in order to correct or ameliorate a non-dental disease or condition, then supporting documentation from the appropriate health care provider is required. For example, a child's speech therapist determines that a diagnosed speech pathosis cannot be resolved without dental treatment. The dentist who is requesting authorization for EPSDT-SS dental services would need to obtain supporting documentation from the child's speech therapist, and include this documentation. Attach as a separate document.


 

BILLING MEDI-CAL/HEALTHY FAMILIES/PRIVATE MEDICAL INSURANCE FOR FLUORIDE VARNISH (MEDICAL PROVIDERS)


How do I bill Medi-Cal for a fluoride varnish application?

Currently, Medi-Cal will reimburse for an office visit at which a fluoride varnish application is provided, but not for the varnish application itself. An attempt to remedy this situation is underway.

Submit a claim to EDS using the UB92 claim form.
Under description of service (Box 43), enter "Medical Visit."
Under HCPCS/Rates (Box 44), enter "01."
Under Principal Diagnosis Code (Box 67), enter "V0731" (this represents the ICD9 Code V07.31: Prophylactic Fluoride Administration, entered on this form without the decimal). Other ICD9 Codes can also be used, as appropriate, e.g., 521.00 (Unspecified caries), 521.01 (Caries limited to enamel), or 521.09 (Other dental caries).

How do I bill Healthy Families for a fluoride varnish application?

Example: Blue Cross
Submit a claim using the CMS-1500 claim form.
Under Diagnosis (Box 21), enter "V07.31" (this is ICD9 Code V07.31: Prophylactic Fluoride Administration, entered on this form with the decimal). Other ICD9 Codes can also be used, as appropriate, e.g., 521.00 (Unspecified caries), 521.01 (Caries limited to enamel), or 521.09 (Other dental caries).
Under Procedures, Services, or Supplies--CPT/HCPCS (Box 24D), enter "99212" (this is the CPT-4 code for Office outpatient visit, established patient, Straightforward). For a new patient, you would use "99202" (Office outpatient visit, new patient, Straightforward).

How do I bill private medical insurance for a fluoride varnish application?

Private medical insurers may vary in their willingness to reimburse for a fluoride varnish application. Our only experience to date is with Blue Shield. The claims process is identical to that used for Healthy Families, as described above.



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