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Dental services reimbursement and billing (DHAT, emergent adults, children)
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Defines reimbursement rates, coverage, and billing notes for dental services (children under 21, emergent adults, DHAT providers) for Alaska Medicaid; includes CDT code listings, authorization and documentation requirements, and fee schedule references.
No material clinical or coverage changes in this revision.
Coverage and Billing Criteria
Dental coverage and billing criteria — general reimbursement and key authorization/documentation rules
General reimbursement rules and key authorization/documentation requirements for covered dental services.
Coverage and billing criteria for listed adult dental CDT codes — Emergent/Enhanced rules, tooth/surface coding, and written medical justification
Coverage and billing rules specific to listed adult CDT codes (Emergent and Enhanced benefits), including tooth/surface coding and count‑based authorization/justification requirements.
ALL of the following
- Examples of codes subject to this rule include D2931, D2932, D2920 (crowns) and D7140, D7111 (extractions).
CDT Codes and Code Groups
| D0120 | PERIODIC ORAL EVALUATION |
| D0140 | LIMIT ORAL EVAL PROBLM FOCUS |
| D0145 | ORAL EVALUATION, PT < 3YRS |
| D0150 | COMPREHENSVE ORAL EVALUATION |
| D1120 | Dental prophylaxis - child |
| D1206 | TOPICAL FLUORIDE VARNISH |
| D1351 | DENTAL SEALANT PER TOOTH |
| D2150 | Amalgam two surfaces - permanent |
| D2330 | RESIN ONE SURFACE-ANTERIOR |
| D7140 | EXTRACTION ERUPTED TOOTH/EXR |
| D9110 | PALLIATIVE TX DENTAL PAIN |
| D9930 | TREATMENT OF COMPLICATIONS |
| D0120 | PERIODIC ORAL EVALUATION |
| D0150 | COMPREHENSVE ORAL EVALUATION |
| D0210 | INTRAOR COMPREHENSIVE SERIES |
| D0330 | PANORAMIC IMAGE |
| D1110 | DENTAL PROPHYLAXIS ADULT |
| D1206 | TOPICAL FLUORIDE VARNISH |
| D2140 | AMALGAM ONE SURFACE PERMANEN |
| D2330 | RESIN ONE SURFACE-ANTERIOR |
| D2391 | POST 1 SRFC RESINBASED CMPST |
| D4341 | PERIODONTAL SCALING & ROOT |
| D4355 | FULL MOUTH DEBRIDEMENT |
| D4910 | PERIODONTAL MAINT PROCEDURES |
| D0220 | INTRAORAL PERIAPICAL FIRST |
| D7140 | EXTRACTION ERUPTED TOOTH/EXR |
| D2931 | PREFAB STNLSS STEEL CROWN PE |
| D2932 | PREFABRICATED RESIN CROWN |
Prior Authorization & Documentation Requirements
Crown prior authorization and written justification
Attach written medical justification to the claim when attaching 1–2 crowns on the date of service; 3 crowns on the date of service or 4 or more in 12 months must be prior authorized for consideration. If a prior authorization is submitted on the claim, written medical justification is not required.
- Applies to prefabricated and other crowns (e.g., D2931, D2932, D2920 as noted).
- If prior authorization is included on the claim, do not also attach separate written justification.
Extraction prior authorization and written justification
Attach written medical justification to the claim when 1–2 extractions are performed on the date of service; 3 extractions on the date of service or 4 or more in 12 months must be prior authorized for consideration. Written medical justification is not required if prior authorization is submitted on the claim.
- Applies to extraction codes such as D7111 and D7140 as indicated in the billing notes.
- Follow prior authorization thresholds (3 same-day or 4+ in 12 months) to determine when authorization is required.
Periodontal scaling — service authorization required
Certain periodontal scaling codes are flagged as requiring service authorization. Verify Service Authorization Required status and obtain authorization when indicated before billing.
- Codes with Service Authorization Required = X include D4341, D4342, and D4346.
- Ensure authorization is obtained per the code listing prior to claim submission when required.
Extractions — prior authorization and written justification
Attach written medical justification to the claim when 1–2 extractions are performed on the date of service; 3 extractions on the date of service or 4 or more in 12 months must be prior authorized for consideration. Written medical justification is not required if prior authorization is submitted on the claim.
- Specifically called out for D7140 and D7111 in the emergent and children sections.
- Follow the 3-on-same-day or 4+ in 12 months threshold to trigger prior authorization.
Prefabricated crown — prior authorization and written justification
Attach written medical justification to the claim when 1–2 prefabricated or other crowns are performed on the date of service; 3 crowns on the date of service or 4 or more in 12 months must be prior authorized for consideration. Written medical justification is not required if prior authorization is submitted on the claim.
- Applies to prefabricated crown codes D2931 and D2932 (and related crown codes such as D2920 where billing notes reference authorization thresholds).
- If prior authorization is submitted on the claim, separate written justification need not be attached.
Medical justification required for selected emergent services
Medical justification must be attached to the claim for selected emergent treatment codes. Palliative and treatment-of-complications codes specifically require medical justification when billed.
- Codes requiring medical justification include D9110 (Palliative treatment of dental pain) and D9930 (Treatment of complications).
- Ensure justification documentation is attached to the claim when submitting these emergent service codes.
Provider Types & Reimbursement Definitions
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