CurrentArizona Health Care Cost Containment SystemPolicy 431

Oral Health Care for Early and Periodic Screening, Diagnostic, and Treatment Aged Members

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Establishes oral health screening, referral, dental home, covered service, provider, and contractor requirements for EPSDT-eligible members in AHCCCS contractor and fee-for-service programs, excluding the Federal Emergency Services Program.

Policy Summary

PayerArizona Health Care Cost Containment System

PolicyOral Health Care for Early and Periodic Screening, Diagnostic, and Treatment Aged Members

Policy CodePolicy 431

Change TypeNo material change

Effective DateOct 23, 2026

Next Review DateN/A

Key ActionProviders serving fee-for-service members should refer to AMPM Policy 820 for applicable prior authorization requirements.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

6 monthsContractor dental-home assignment

1 yearFFS PCP dental referral

2/yearOral exams and prophylaxis

4/yearRoutine fluoride varnish

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CurrentArizona Health Care Cost Containment SystemPolicy 431

Oral Health Care for Early and Periodic Screening, Diagnostic, and Treatment Aged Members

Customize your policy alerts

Sign up for Arizona Health Care Cost Containment System Policy 431 alerts

Get alerted when Policy 431 changes without checking for updates manually.

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Policy Summary

PayerArizona Health Care Cost Containment System

PolicyOral Health Care for Early and Periodic Screening, Diagnostic, and Treatment Aged Members

Policy CodePolicy 431

Change TypeNo material change

Effective DateOct 23, 2026

Next Review DateN/A

Key ActionProviders serving fee-for-service members should refer to AMPM Policy 820 for applicable prior authorization requirements.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

6 monthsContractor dental-home assignment

1 yearFFS PCP dental referral

2/yearOral exams and prophylaxis

4/yearRoutine fluoride varnish

ExcludedCosmetic-only services

Covered Dental Services and Eligibility Requirements

PCP screening and referral

Covered when all PCP screening, referral, and documentation requirements are met.

PCP screening and referral: At each EPSDT preventive well visit, the PCP must perform an oral-health screening; refer the member for appropriate services based on needs identified through screening and for routine dental care according to the AHCCCS EPSDT Periodicity Schedule; and document evidence of the referral on the EPSDT Clinical Sample Templates or specified electronic equivalent and in the member's medical record.Screening during every preventive well visit; referral timing follows the member's condition and ACOM Policy 417 appointment standards

The screening identifies gross dental or oral lesions and does not replace a thorough dental examination or direct referral to a dental provider.

Dental home requirements

Dental home assignment, enrollment, and access requirements include all of the following.

Dental home access: The dental home must provide comprehensive acute and preventive oral health care, assessment of oral diseases and conditions, individualized caries- and periodontal-risk prevention, anticipatory guidance, acute trauma planning, oral hygiene and dietary counseling, and referral to dental specialists when necessary.

Required initial dental-home access

Fee-for-service members: The PCP refers the member to a dental provider by one year of age.By age 1 year
Contractor-enrolled members: The member is assigned to a dental home by six months of age or upon enrollment.By age 6 months or upon enrollment

Ongoing access: The member receives routine preventive care from a dental provider and is referred for oral-health concerns requiring additional evaluation or treatment. Members may self-refer to a network dental provider when enrolled with a Contractor or to any AHCCCS-registered dental provider when receiving fee-for-service coverage.

Earlier referral is permitted when screening identifies potential caries or another condition requiring dental assessment or treatment.

Emergency and preventive services

Covered emergency and preventive services are subject to applicable age, frequency, provider, and medical-necessity limits.

Emergency dental services: Treatment is for pain, infection, swelling, or injury; extraction is limited to symptomatic teeth, including symptomatic, infected, non-restorable, or retained primary teeth; and general anesthesia, conscious sedation, or minimal anxiolysis is used when local anesthesia is contraindicated or member management requires it.

Extractions are limited to symptomatic teeth. Minimal sedation applies when members respond normally to verbal commands.

Preventive dental services: Services include comprehensive and periodic examinations, oral prophylaxis with self-care oral-hygiene instruction, medically necessary radiology following AAPD recommendations, topical fluoride and fluoride varnish, qualifying dental sealants, and medically necessary space maintainers when posterior primary teeth are lost.Two oral examinations and two oral prophylaxis services per member per year through age 20; fluoride varnish up to four times per year through age 5; Panorex films up to three times per provider for children ages 3 through 20 unless additional films are medically necessary

Fluoride prophylaxis paste or fluoride mouth rinse alone does not meet the AHCCCS standard for fluoride treatment. First and second molar sealants are covered twice per molar, per provider/location, with three years between applications through age 15; additional applications require medical necessity.

Therapeutic dental services

Therapeutic dental services are covered when all applicable medical-necessity and utilization requirements are met.

Therapeutic services: The service is medically necessary and cost effective and may be subject to prior authorization by the Contractor or, for fee-for-service members, the AHCCCS Division of Fee-For-Service Management.Medical necessity and cost effectiveness; prior authorization may apply

Covered therapeutic service category

Periodontal procedures, including scaling, root planing, curettage, gingivectomy, or osseous surgery.
Qualifying crowns, including stainless-steel crowns for primary and permanent posterior teeth; specified esthetic crowns for anterior primary teeth; or qualifying precious or cast semi-precious crowns for functional permanent endodontically treated teeth, excluding third molars, for members ages 18 through 20.
Endodontic services, including pulp therapy for permanent and primary teeth, excluding third molars unless a third molar functions in place of a missing molar.

Orthodontic and orthognathic services

Orthodontic services and orthognathic surgery are covered only when all of the following criteria are met.

Qualifying orthodontic or orthognathic treatment: The service is medically necessary; it is the primary treatment of choice or an essential part of an overall treatment plan; and the treatment plan is developed by the PCP and dental provider in consultation with each other.Medical necessity plus primary treatment of choice or essential treatment-plan component

Examples of qualifying conditions include congenital craniofacial or dentofacial malformation requiring reconstructive surgery, trauma requiring surgical treatment, or skeletal discrepancy involving the maxillary or mandibular structures. Treatment whose primary purpose is cosmetic is not covered.

Affiliated practice dental hygienist reimbursement

Affiliated practice dental hygienist services are reimbursable only when all applicable requirements are met.

Eligibility and reimbursement requirements

Both the dental hygienist and the affiliated dental provider are registered AHCCCS providers.
The dental hygienist is registered with AHCCCS and identified as the treating provider under the hygienist's individual AHCCCS provider identification number or NPI.
When services are billed to an AHCCCS Contractor, both the dental hygienist and affiliated dental provider are credentialed network providers of that Contractor.
Services are provided in accordance with applicable state statutes and regulations, AHCCCS policy, the provider agreement, and the affiliated practice agreement.
The hygienist provides documentation of an affiliated practice agreement with an AHCCCS-registered dentist that is recognized by the dental board and confirms the affiliation.

Dental radiographs

Dental radiographs are reimbursable only when the provider meets the qualification requirement.

Dental radiograph qualification: The provider is qualified to perform both the exposure and the interpretation of dental radiographs.Both exposure and interpretation

AHCCCS reimbursement is restricted to providers meeting both qualifications.

Services or items furnished solely for cosmetic purposes are excluded from AHCCCS coverage.

Orthodontic services are not covered when their primary purpose is cosmetic. Coverage requires medical necessity and that the service be the primary treatment of choice or an essential part of an overall treatment plan developed by the PCP and dental provider in consultation with each other.

The CHP is excluded from the requirement to follow the Dental Uniform Prior Authorization List.

Therapeutic dental services, including orthodontic services and orthognathic surgery, are not supported under this policy when they are not medically necessary and cost effective. Orthodontic services and orthognathic surgery must also be the primary treatment of choice or an essential part of an overall treatment plan developed by the PCP and dental provider in consultation with each other.

Frequency, Utilization, and Service Limits

Oral examinations and prophylaxis

Oral examinationsTwo oral examinations per member per year through age 20

Oral prophylaxisTwo oral prophylaxis per member per year through age 20

Additional servicesAdditional examinations or treatments require medical necessity

Fluoride varnish

Annual limitUp to four fluoride varnish applications per year

Application intervalOne application every three months

Age limitAvailable through age 5

Prior Authorization, Documentation, and Billing Requirements

Prior Authorization

Therapeutic Services May Require Prior Authorization

Therapeutic dental services are covered only when medically necessary and cost effective. Services may require prior authorization (PA) by the Contractor or, for fee-for-service (FFS) members, the AHCCCS Division of Fee-For-Service Management (DFSM).

Therapeutic services include periodontal procedures, crowns, endodontic services, restorations, removable dental prosthetics, orthodontic services, orthognathic surgery, and dental appliances.
Verify the applicable Contractor or DFSM PA requirement before providing services.

Prior Authorization

Follow the Dental Uniform Prior Authorization List

Contractors must follow the Dental Uniform Prior Authorization List posted on the AHCCCS website. Requests to change the List must use the designated change-request process and include supporting documentation and rationale; the CHP is excluded from the List requirement.

Submit requests through the Requests for Changes to Dental Prior Authorization Requirements process in Contract Section F, Attachment F3, Contractor Chart of Deliverables.

EPSDT Oral Health Program Context

EPSDT oral-health screening is part of the preventive well visit and is intended to identify gross dental or oral lesions. The screening is not a thorough clinical examination, does not establish a clinical diagnosis or treatment plan, and does not replace examination by a dental provider. Identified needs should be referred for appropriate dental services and routine dental care.

Key Dental Program Terms

Oral health screening

PurposeA screening performed during a PCP preventive well visit to identify gross dental or oral lesions

Clinical scopeIt is not a thorough clinical examination and does not involve making a clinical diagnosis or treatment plan

LimitationIt does not substitute for examination through direct referral to a dental provider

Dental home

Primary functionThe source of comprehensive oral health care

ServicesIncludes acute and preventive services and comprehensive assessment of oral diseases and conditions

Additional support

Policy Summary

PayerArizona Health Care Cost Containment System

PolicyOral Health Care for Early and Periodic Screening, Diagnostic, and Treatment Aged Members

Policy CodePolicy 431

Change TypeNo material change

Effective DateOct 23, 2026

Next Review DateN/A

Key ActionProviders serving fee-for-service members should refer to AMPM Policy 820 for applicable prior authorization requirements.

SourceLink

On This Page

Restoration of carious permanent or primary teeth with accepted dental materials, subject to the stated restrictions on cast or porcelain restorations.

Medically necessary restorations of anterior teeth for children under age 5.

Removable dental prosthetics, including complete and removable partial dentures.

Orthodontic services, orthognathic surgery, or dental appliances when the applicable coverage criteria are met.

The hygienist maintains individual patient records in accordance with the Arizona State Dental Practice Act, including member identification, HCDM identification, DR identification when applicable, signed HCDM authorization for consent of services, member medical history, and documentation of services rendered.

Panorex films

Age rangeChildren ages 3 through 20

Provider limitUp to three Panorex films maximum per provider

ExceptionAdditional Panorex films require medical necessity

Dental sealants

Teeth coveredFirst and second molars

ApplicationsCovered twice per first or second molar

Provider and locationLimit applies per provider/location

IntervalThree years of intervention are required between applications

Age limitCovered through age 15; additional applications require medical necessity

PCP fluoride varnish eligibility

Eligible ageMembers as early as 6 months of age

Erupted tooth requirementAt least one tooth must have erupted

Visit and frequency limitAdditional applications may occur every three months during EPSDT well visits through the fifth birthday

Maintain adherence to the current AHCCCS Dental Uniform Prior Authorization List.

Unsupported block type: prior_auth

Documentation Required

Document Oral-Health Screening Referrals

PCPs must refer EPSDT members to a dental provider when the oral-health screening identifies a need and for routine dental care according to the AHCCCS EPSDT Periodicity Schedule. Evidence of the referral must be documented on the EPSDT Clinical Sample Templates or an electronic equivalent and in the member’s medical record.

An oral-health screening does not replace a comprehensive examination by a dental provider.
Schedule referrals according to the applicable appointment standards: urgent care no later than three business days and routine care within 45 calendar days, or within 30 calendar days for CHP routine care.

Documentation Required

Submit Fluoride-Varnish Training Certificate

PCPs may be reimbursed for fluoride-varnish applications at EPSDT well visits only after completing AHCCCS-required training and submitting the training certificate to each participating Contractor before payment is issued.

Applications may begin at six months of age after at least one tooth has erupted.
Additional applications may occur every three months during an EPSDT well visit through the member’s fifth birthday, according to AHCCCS-approved fee schedules.
PCP-applied fluoride varnish does not replace an oral-health visit.

Documentation Required

Obtain Preventive-Treatment Consent

Obtain written consent for the examination and any preventive treatment that does not involve an irreversible procedure. Complete the consent at the initial examination and update it at each subsequent six-month follow-up appointment.

Explain the diagnosis, proposed treatment, alternatives, and the risks and benefits of treatment and of declining treatment.
Consents must be signed and dated by the provider and the member, HCDM, or DR as applicable, and retained in the member’s chart.

Documentation Required

Document Invasive Treatment and Plan

Obtain a separate written consent before any irreversible or invasive procedure, including fillings and pulpotomy. A written treatment plan must also be reviewed and signed by both parties, and the member, HCDM, or DR must receive a copy of the complete plan.

Document the informed-consent discussion and associated risks and benefits.
Maintain the signed consent and treatment plan in the member’s chart for audit.

Documentation Required

Maintain Required Provider Records

Dental services must be provided by AHCCCS-registered dental providers. Affiliated-practice dental hygienists must maintain complete individual patient records under the Arizona State Dental Practice Act and AHCCCS requirements.

Records must include member identification; HCDM and, when applicable, DR identification; signed HCDM authorization for consent; medical history; and services rendered.
The affiliated-practice dental hygienist must be registered with AHCCCS, identified as the treating provider under the individual AHCCCS provider identification/NPI, and meet applicable Contractor credentialing requirements.
Provide services and maintain records consistent with State statutes and regulations, AHCCCS policy and provider agreements, and the affiliated-practice agreement.

Documentation Required

Document the Affiliation Agreement

Affiliated-practice dental hygienists must document the affiliated-practice relationship with an AHCCCS-registered dentist. The agreement must be recognized by the dental board and available to confirm the affiliation.

Both the dental hygienist and affiliated dental provider must be AHCCCS-registered providers.
Submit or retain documentation of the affiliated-practice agreement as required for reimbursement and compliance.

Documentation Required

Maintain Contractor Dental-Program Processes

Contractors must operate documented dental-program processes that support timely dental-home enrollment and ongoing care. Processes must address outreach, missed appointments, due-date notifications, provider engagement, and no-show reduction.

Enroll members in a dental home by six months of age or upon assignment to a Contractor, allow member choice within the network, and automatically assign a provider when the member does not select one.
Monitor dental-home participation, conduct targeted outreach, and follow up with members who miss appointments or have not completed required visits.
Notify members, HCDM, and DR of dental-visit due dates every six months; send a second notice when a visit has not occurred. Non-mailing processes require AHCCCS MCH/EPSDT Team preapproval.
Require contracted providers to use the AHCCCS Dental Periodicity Schedule and encourage scheduling the next dental screening during the current visit.

Denial Risk

Cosmetic-Only Treatment Is Not Covered

Services or items furnished solely for cosmetic purposes are excluded from AHCCCS coverage. Orthodontic services are not covered when their primary purpose is cosmetic, including cosmetic orthodontics.

Do not bill AHCCCS for treatment provided solely for cosmetic purposes.
Orthodontic and orthognathic services must meet the applicable medical-necessity and treatment-plan requirements.

Prior Authorization

Support Medical Necessity and Treatment Plans

Therapeutic dental services, including orthodontic services and orthognathic surgery, must be medically necessary and cost effective. Orthodontic or orthognathic treatment must be the primary treatment of choice or an essential part of an overall treatment plan developed by the PCP and dental provider in consultation with one another.

Orthodontic treatment may address congenital craniofacial or dentofacial malformations requiring reconstructive surgery, trauma requiring surgery, or skeletal discrepancies involving the maxillary or mandibular structures.
Confirm Contractor or DFSM PA requirements before treatment when applicable.
Cosmetic purpose alone does not establish medical necessity or coverage.

Documentation Required

Meet Provider and Record Requirements

Use AHCCCS-registered providers and complete all required written consents and treatment plans before providing covered dental treatment. Consents and plans must be signed and dated as applicable and maintained in the member’s chart for audit.

Written consent is required for examination and non-irreversible preventive treatment and must be updated at six-month follow-ups.
A separate written consent and signed treatment plan are required for irreversible or invasive procedures; provide the member, HCDM, or DR a copy of the complete plan.
Document the diagnosis, proposed treatment, alternatives, risks, benefits, and risks of not receiving treatment.

Billing Rule

Apply Frequency and Utilization Limits

Apply the EPSDT dental frequency, age, provider/location, and medical-necessity limits when scheduling and billing services. Additional examinations, treatments, sealants, and radiographs require medical-necessity support when they exceed stated limits.

Allow up to two oral examinations and two oral prophylaxis services per member per year through age 20; additional services must be medically necessary.
For members up to age five, fluoride varnish may be applied up to four times per year, generally once every three months.
Cover panorex films up to three times per provider for children ages three through 20; additional films require medical necessity and must follow AAPD recommendations.
Cover dental sealants on first and second molars up to twice per molar, per provider/location, with three years between applications and through age 15; additional applications require medical necessity.
Radiology services, including panoramic, full-mouth, bitewing, occlusal, and periapical films, must be medically necessary and follow AAPD recommendations.

Billing Rule

Confirm Radiograph Qualification

AHCCCS reimbursement for dental radiographs is limited to providers qualified to perform both radiograph exposure and interpretation.

Confirm the rendering provider’s qualifications for both exposure and interpretation before billing radiograph services.

Includes individualized risk-based prevention, anticipatory guidance, trauma planning, oral hygiene and dietary counseling, and specialist referral when necessary

HCDM/DR

MeaningThe member's health care decision maker or designated representative, as applicable

Consent roleParticipates in informed consent

Treatment planning roleParticipates in treatment-plan review

Dental home

DefinitionAn ongoing relationship with a dental provider that provides comprehensive oral health care

Member choiceMembers may select a provider within the Contractor's provider network and receive instructions on how to select or change a dental home provider

AssignmentMembers who do not select a dental home provider are automatically assigned one by the Contractor

Affiliated practice dental hygienist

DefinitionA dental hygienist practicing under an affiliated practice agreement with an AHCCCS-registered dentist

Provider registrationBoth the dental hygienist and the affiliated dental provider must be registered AHCCCS providers

Practice relationshipThe hygienist practices under an affiliated practice agreement and is subject to applicable registration, credentialing, documentation, reimbursement, and statutory requirements