Texas member benefit and billing updates (DentaQuest)
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Summarizes Texas-specific benefit limitation and billing/reimbursement changes for DentaQuest Dental (Texas Medicaid/CHIP) providers effective 9/1/2023 and related operational reminders for providers and members.
Procedure code D1354 (application of caries arresting medicament) becomes a benefit for Health Steps clients birth through six years of age and limited to once per lifetime per tooth ID.
Topical fluoride (D1206, D1208) limited to once every six months; D1110, D1120, D1206, D1208 denied when billed as emergency claims; certain preventive codes no longer reimbursed to orthodontists and OMFS.
Sealants (D1351, D1352) limited to once per lifetime per tooth ID; D1351 age range changed to 1 through 20 years; reimbursement is per-tooth and tooth ID and surface identification must be on claim.
Space maintainer codes have new lifetime and rolling-year limits and denial rules tied to prior reimbursements and provider/same-quadrant considerations.
Coverage and Billing Criteria
Coverage and billing criteria
Effective 9/1/2023, the following coverage limitations and billing rules apply for Texas Medicaid/CHIP under DentaQuest:
D1354: Caries arresting medicament
- D1354 (Caries arresting medicament) is covered for Texas Health Steps clients birth through 6 years of age.
- D1354 is limited to once per lifetime per Tooth ID (examples: A-T and 3, 14, 19, and 30) for services rendered in the office setting by any provider.
- D1354 will be denied if billed on the same date of service for the same Tooth ID as procedure code D1351 or D1352 by any provider.
- Silver diamine fluoride is the only material permitted for D1354.
D1351 / D1352: Dental sealants
- D1351 (sealant) age eligibility updated to clients 1 through 20 years of age.
- D1351 and D1352 are limited to once per lifetime per Tooth ID by any provider.
- Reimbursement for D1351 and D1352 is on a per-tooth basis regardless of number of surfaces; Tooth ID and Surface Identification (SID) must be indicated on the claim form.
- D1351 will be denied if billed on the same date of service for the same permanent Tooth ID as D1352 by any provider.
- D1351 and D1352 will be denied when billed as emergency claims.
- D1351 will no longer be reimbursed to orthodontists and oral maxillofacial surgeons.
Preventive: Prophylaxis and topical fluoride (D1110, D1120, D1206, D1208)
- Topical fluoride (D1206 and D1208) is limited to once every six months by any provider.
- Procedure codes D1110, D1120, D1206, and D1208 will be denied when billed as an emergency claim.
- D1110 and D1120 will no longer be reimbursed to orthodontist and oral maxillofacial surgeon providers.
- D1208 will no longer be reimbursed to orthodontist and oral maxillofacial surgeon providers for services rendered in the office setting, and D1208 will not be reimbursed to any provider type for services rendered in inpatient or outpatient hospital settings.
Space maintainers (D1510, D1520, D1553, D1556, D1575, D1516, D1517, D1526, D1527, D1551, D1552)
- Procedure codes D1510, D1520, D1553, D1556, and D1575 are limited to once per lifetime per quadrant by any provider.
- Procedure codes D1516, D1517, D1526, and D1527 are limited to once per lifetime, same procedure code, by any provider.
- Procedure code D1553 will be denied if procedure code D1510 was reimbursed within the previous rolling year in the same quadrant by the same provider.
- Procedure code D1551 will be denied if procedure code D1516 was reimbursed within the previous rolling year by the same provider.
- Procedure code D1552 will be denied if procedure code D1517 was reimbursed within the previous rolling year by the same provider.
- Procedure codes D1551 and D1552 are limited to once per lifetime when provided by the same provider.
Administrative reminders from the bulletin.
Procedure Codes and Frequency Limits
| D1354 | Caries arresting medicament — limited once per lifetime per Tooth ID; silver diamine fluoride only; benefit for Health Steps clients birth through 6 years of age; denied if billed same date for same Tooth ID as D1351 or D1352. |
| D1351 | Sealant — age 1 through 20 years; limited once per lifetime per Tooth ID; reimbursed per tooth (Tooth ID and SID required on claim); denied if billed same date for same permanent tooth as D1352; denied when billed as an emergency claim; no longer reimbursed to orthodontists and oral maxillofacial surgeons. |
| D1352 | Sealant for permanent tooth — limited once per lifetime per Tooth ID; reimbursed per tooth (Tooth ID and SID required on claim); denied when billed as an emergency claim. |
| D1206 | Topical fluoride — limited to once every six months by any provider; denied when billed as an emergency claim. |
| D1208 | Topical fluoride — limited to once every six months by any provider; denied when billed as an emergency claim; not reimbursed to orthodontists and oral maxillofacial surgeons in the office setting and not reimbursed to any provider in inpatient/outpatient hospital settings. |
| D1110 | Prophylaxis (adult) — will be denied when billed as an emergency claim; no longer reimbursed to orthodontists and oral maxillofacial surgeons. |
| D1120 | Prophylaxis (child) — will be denied when billed as an emergency claim; no longer reimbursed to orthodontists and oral maxillofacial surgeons. |
| D1510 | Space maintainer — limited once per lifetime, per quadrant; related rolling‑year denial interactions apply as specified. |
| D1520 | Space maintainer — limited once per lifetime, per quadrant. |
| D1553 | Space maintainer — limited once per lifetime, per quadrant; will be denied if D1510 was reimbursed within the previous rolling year in the same quadrant by the same provider. |
Billing, Claim Submission Rules, and Denial Risks
Billing/claim submission rules and denial risks (emergency claims, per‑tooth/SID, limits, provider restrictions)
Do not submit emergency claims for the listed preventive and sealant codes; follow per‑tooth/SID claim requirements, lifetime/rolling‑year limits, and provider‑type reimbursement restrictions to avoid denials.
- Do not bill D1110, D1120, D1206, or D1208 as emergency claims — these procedures will be denied when submitted as emergency claims. [6]
- Do not bill D1351 or D1352 as emergency claims — these sealant codes will be denied when submitted as emergency claims. [7]
- When billing sealants (D1351, D1352), report Tooth ID and Surface Identification (SID) on the claim; reimbursement is per tooth. Failure to include Tooth ID/SID may result in claim processing issues. [7]
- D1354 is limited to silver diamine fluoride and is restricted to once per lifetime per Tooth ID; D1354 will be denied if billed on the same date of service for the same Tooth ID as D1351 or D1352. [5]
- Topical fluoride (D1206, D1208) is limited to once every six months; D1208 and prophylaxis codes have provider‑type reimbursement restrictions — D1110/D1120 no longer reimbursed to orthodontists/OMFS, and D1208 not reimbursed to orthodontists/OMFS in office or to any providers in inpatient/outpatient hospital settings. [6]
- Space maintainer codes have lifetime and rolling‑year denial interactions tied to prior reimbursements by the same provider (e.g., D1553 denied if D1510 reimbursed within the previous rolling year in the same quadrant; similar rules apply for D1551/D1552 with D1516/D1517). [8]
Materials and Claim Identifiers
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