Chapter 15 — Alabama Medicaid Dental Program
Customize your policy alerts
Sign up for all Alabama Medicaid policy alerts
Know when Alabama Medicaid releases new policies or updates existing guidance.
Monitor payer policy activity
Governs Medicaid-covered dental services, provider participation, limitations, prior authorization, billing rules, and mobile dental clinic requirements for Alabama Medicaid recipients (including EPSDT for individuals under 21 and pregnant individuals). Affects enrolled/licensed dental providers and mobile dental clinic operators serving Alabama Medicaid beneficiaries.
No material clinical or coverage changes in this revision.
Coverage, Eligibility, and Operational Rules
Coverage criteria and operational rules
Coverage is provided under EPSDT for individuals under 21 and to pregnant Medicaid-eligible individuals over 21; providers must follow enrollment and operational rules and certain services require prior authorization or specific limits as described below.
ALL of the following
- Recipient is eligible for Alabama Medicaidapplies to all ages where Medicaid eligibility criteria met
EPSDT and pregnancy rules
- EPSDT applies: availability of certain dental services is required for eligible children under age 21
- Pregnant individuals over 21: certain dental services are provided to pregnant Medicaid-eligible individuals
ALL of the following
- Dental providers must be licensed to practice in the State where services are provided
- Dentists must enroll with the fiscal agent and be assigned a provider number for each office location; each claim constitutes a contract with the Alabama Medicaid Agency and represents services/fees are usual and customary by community standards
- Providers must verify recipient eligibility through the fiscal agent; claims on ineligible persons cannot be paid
ALL of the following
- Periodic oral examination: limited to once every 6 months for eligible Medicaid recipients under age 21
- Dental sealants: limited to one application per tooth in a recipient's lifetime
- Radiology: limited to radiographs required to make a diagnosis; films must be properly mounted and identified with patient name, date, dentist name, and left/right
ALL of the following
- Orthodontia is covered only when medically necessary
- Treatment must be continuation of care initiated through multidisciplinary clinics administered by Alabama Children's Rehabilitation Service or other qualified clinics enrolled as contract vendors
- All medically necessary orthodontic treatment must be prior authorized by Medicaid
ALL of the following
- Certain dental services require prior authorization; providers must follow Chapter 13 of the Alabama Medicaid Provider Manual for listings of covered procedures and prior authorization requirements
ALL of the following
- Each claim filed constitutes a contract with the Alabama Medicaid Agency; providers represent that services provided and fees charged are usual and customary by community standards
- Providers must accept Medicaid payment as payment in full for covered services unless benefits are exhausted or the service is not covered (see Provider Manual for details)
ALL of the following
- Mobile dental clinics must be registered with the Board and enroll with Medicaid as required
- Obtain parental consent for minors and maintain location/session records; provide patient information at visit conclusion
- Arrange emergency follow-up within a 50-mile radius or provide follow-up themselves; notify Board and Medicaid upon sale or cessation of operation
Covered Procedures, Limits, and Orthodontia
| No codes listed |
Prior Authorization and Provider Requirements
Prior authorization required for specified dental services
Certain dental services require prior authorization. Providers must obtain prior authorization for services identified in the Alabama Medicaid Provider Manual, Chapter 13, which lists covered procedures and prior authorization requirements.
- Obtain prior authorization for any service listed in Chapter 13 when required.
- Refer to the Alabama Medicaid Provider Manual, Chapter 13 (provided by the fiscal agent) for the specific list of covered procedures and the applicable prior authorization rules.
Key Definitions
OpenPayer is powered by Trek Health's payer performance platform. Trek continuously ingests, validates, and normalizes Transparency in Coverage data alongside payer policies and other commercial payer data to create a structured payer intelligence foundation. OpenPayer uses this foundation to deliver personalized search results, dynamically generated policy pages, and tailored policy monitoring based on each user's payers, specialties, billing codes, and areas of interest. The same intelligence powers broader payer performance workflows, including reimbursement benchmarking, contract evaluation, payer negotiations, and financial decision-making.