ModifiedHawaii Department of Human ServicesPolicy N/A
Medicaid Dental Program — Coverage, Billing and Authorization Rules (Chapter 14)
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Governs Hawaii Medicaid dental benefits, provider obligations, referral and pre-authorization rules, and program structure for children's (under 21) and adult (21+) dental programs; affects registered dental providers and Medicaid-enrolled patients in Hawaii.
Policy Summary
PayerHawaii Department of Human Services
PolicyMedicaid Dental Program — Coverage, Billing and Authorization Rules (Chapter 14)
Policy CodePolicy N/A
Change TypeBenefit additions and billing rule revisions
Effective DateApr 1, 2026
Next Review DateN/A
Key ActionSubmit pre-authorization (with supporting documentation and radiographs) for general anesthesia, orthodontics, and special benefit exceptions as required.
SourceLink
POLICY UPDATE CHANGES
D4346 (scaling for moderate or severe gingival inflammation) is a new benefit available for ages 14 and older.
D9920 (behavior management) is now available for all ages.
Claims processing for multiple restorations on the same tooth: providers may submit multiple codes for distinct fillings on the same tooth starting May 1, 2026.
D4346New dental benefit code added (ages 14+)
D9920Behavior management benefit expanded to all ages
May 1, 2026Multiple restorations claim option effective
Pre-authPre-authorization required for select services
1 yearClaim submission deadline
Coverage Criteria and Limits
Coverage and billing criteria (partial)
Coverage updates and key program rules extracted from the provided excerpts.
ALL of the following
- D4346 (Scaling in the presence of moderate or severe gingival inflammation) is covered for ages 14 and older for removal of plaque, calculus and stains from supra- and sub-gingival surfaces when generalized moderate or severe gingival inflammation exists in the absence of periodontitis.ages 14+
Clinical status must show at least 30% of teeth with calculus and moderate or severe inflammation as defined in policy.
- D9920 (Behavior Management) is covered for all ages when the provider must adapt clinical procedure or use additional time due to selected intellectual or developmental disability (I/DD) considerations that limit physical cooperation.
Process modifications must be documented; see behavior management rules for limits and documentation.
- Starting May 1, 2026 providers may submit multiple CDT codes for distinct restorations on the same tooth; reimbursement will remain limited to the value of a single multi-surface restoration.
Submission option only effective May 1, 2026; payment consolidated as single multi-surface value.
- Pre-authorization is required for any dental treatment performed under general anesthesia, for orthodontics, and for special benefit exceptions related to severe developmental disability, special medical need, or severe medical fragility; emergency services are exempt.
Delivering these services before approval will result in denial of payment to the dentist.
- Program scope: Children's Dental Program governed by EPSDT provides broader benefits for enrollees under 21; Adult Dental Program (21+) includes preventive, diagnostic, restorative, endodontic (root canals on permanent molars), periodontal, prosthodontic, and emergency services with defined frequency limits (examples: scaling/root planing 1 per 24 months; periodontal maintenance two per year; dentures 1 per 5 years).
Providers must be enrolled and eligible on date of service and follow frequency constraints.
Coverage and billing items must be submitted using CDT codes and claims filed within one year of completion of the dental procedure; multiple-visit procedures must be claimed with service date set to date of completion (e.g., crown seat/cementation).
Additional documentation (x-rays, photos, perio charts, narratives, lab invoices, pathology reports, models) may be requested to support payment.
General Anesthesia (GA) benefit criteria
Covered under general anesthesia only when criteria demonstrate GA is a last-resort necessity.
ONE of the following must be met
- Patient has intellectual or developmental disability that prevents cooperation necessary to safely complete the needed and specific procedure.
- A medical condition exists where necessary local anesthesia is ineffective or contraindicated for the needed procedure.
- Patient has sustained extensive orofacial or dental trauma for which treatment under local anesthesia would be ineffective or compromised.
OR when ALL of the following are met
- Patient is extremely physically resistant or uncooperative.
- Extensive oral treatment is necessary.
- Postponement of treatment is likely to result in significant adverse effects on the patient's medical or dental condition.
- Alternative dental treatments cannot be completed safely and effectively in an office using adjunctive techniques (examples: behavioral management, protective stabilization, sedative medications, caries arrest/SDF, nitrous oxide).
Payment and clinical necessity criteria
General payment and clinical necessity rules for Medicaid dental claims.
Procedures must be of reasonable clinical benefit to the patient; examples of non-covered or reviewable situations include long-term restoration on a near-exfoliation tooth, unnecessary radiographs or radiographs at short intervals without pathology, and placement of space maintainers that provide no benefit.
Benefits require the patient be enrolled in Medicaid and the provider be approved for Medicaid participation on the date of service.
Claims must use CDT codes and be submitted within one year of completion of the dental procedure; multiple-visit procedures must be submitted only upon completion, with the service date set to the completion/seat/cementation date.
Self-pay and optional service rules
Rules governing optional (non-covered) services and self-pay arrangements.
Providers must inform patients of covered alternatives that reasonably address the situation before offering non-covered/self-pay services, and must obtain a signed financial acknowledgement in advance; failure to create a signed agreement disqualifies the dentist from collecting payment.
Providers may not collect payment for services with an available/unused Medicaid benefit; General Excise Tax rules apply as stated.
Examples of allowable self-pay scenarios
- Teeth whitening requested by patient (not a Medicaid benefit) — provider may collect payment up to UCR with signed financial understanding; FQHCs may not submit encounter claims for these appointments.
- Adult requests a non‑benefit restorative material (e.g., gold crown instead of benefitted stainless-steel crown) — patient may self-pay up to UCR after signed acknowledgement; provider must inform patient of benefitted alternative and may not submit Medicaid claim to offset cost.
- Requests exceeding benefit frequency (e.g., prophylaxis every 3 months) — after available benefits are exhausted, office may charge family up to UCR with pre-agreement; FQHCs may not submit encounter claim for self-pay appointment.
Providers may not impose missed-appointment fees for Medicaid-covered procedures; offices are encouraged to submit administrative tracking codes (D9986/D9987) for monitoring rather than charging patients.
FQHC / PPS coverage stance
FQHC/RHC PPS billing and encounter submission rules.
FQHCs/RHCs submitting PPS encounter claims must include D-codes for all eligible dental services completed at the encounter; PPS payments are limited to the clinical, submission, and frequency limitations described in the manual.
For pediatric PPS encounter claims (patients <21), the first line must be D9999 with the fee set to the center's encounter rate; all program-eligible services provided are listed on subsequent lines with fees set to zero.
For adult PPS encounter claims (patients 21+), the first line must be D0140 with the fee set to the center's encounter rate; subsequent services listed with zero fees. Denture fabrication is paid fee-for-service and should not be submitted under the D9999/D0140 encounter lines.
Multiple-visit procedures must be submitted only upon completion (service date = completion/seat/cementation); an appointment that did not complete a benefitted procedure does not qualify for encounter-rate payment.
Coverage criteria and operational rules (excerpt)
Selected operational rules, frequency limits, documentation and billing instructions from the excerpt.
Oral examinations of infants and children must include age‑appropriate anticipatory guidance (dietary counseling, oral hygiene instruction, counseling for oral habits, injury prevention, substance abuse, etc.) documented in the patient record.
Periodic and evaluation codes (D0120, D0145, D0150) share an annual oral evaluation limit; certain evaluation codes have a minimum interval (no sooner than 4 months apart for some codes) and specified submission requirements (e.g., radiographs, perio chart) as applicable.
Radiographs must be individually prescribed, clinically necessary, and of diagnostic quality per ADA/FDA guidance; Med-QUEST or Dental TPA may request submission of any x-rays claimed. Midprocedure and post-operative radiographs are part of the procedure and are not separately billable.
D0210 (complete series) is limited to 1 per 5 years with specified exceptions; bitewing limits and panoramic frequency constraints apply as described in the manual.
D1354 (Caries Arresting Medicament/SDF) is a paid benefit up to 6 teeth per day and requires photographic or radiographic images in records; D1355 (full‑mouth caries prevention medicament) is limited to agents meeting the listed concentrations and is combined with topical fluoride codes such that only one paid prevention benefit is allowed per day when combined.
When a space maintainer's ongoing maintenance, re-cementation, and final removal are performed by the original placing office, those services are considered part of the original procedure and may not be billed separately.
From May 1, 2026 providers may submit individual service codes per distinct restored surface; reimbursement will be consolidated and paid as if a single multi-surface restoration was performed.
For crowns, additional documentation or photos may be requested if radiographs do not clearly justify a crown (especially patients under age 12); special exceptions (e.g., third molar crowns, primary tooth with congenitally missing permanent tooth) require pre-authorization.
Crowns
Coverage rules, required documentation, and limits for crowns and related procedures.
Providers may be requested to submit additional supporting documentation or photographs when radiographs do not clearly justify a crown, with special attention for patients under age 12.
Posts, cores, and pins are not benefitted for primary teeth unless there is a congenitally missing corresponding permanent tooth; such exceptions require pre-authorization.
Certain crown-related services (including post and core) are subject to frequency limitations (e.g., 1 per 5 years per tooth as specified) and require pre-op radiographs and supporting documentation as listed in the crown criteria.
D2920 (re-cement crown) is limited: denied if within 6 months of initial placement by the same dentist/office; allowed once within 6 months if performed by a different dentist/office; subsequent recements allowed every 12 months (see recement policy).
Endodontics (RCT)
Endodontic therapy coverage, clinical prerequisites, and claim submission rules.
Pre-authorization is not required for Root Canal Therapy codes D3220-D3425 unless otherwise stated in specific circumstances.
To qualify for endodontic coverage, the tooth must be restorable with a favorable periodontal prognosis.
Claims for RCT must be submitted only after final obturation is completed. If final obturation is not completed within 4 months of initiation, the office may submit a single D9110 appointment claim dated to the initiation with a pre-operative radiograph and narrative.
Retreatment of previous RCT is covered only for specific clinical circumstances after dental consultant review; retreatment by the same dentist/dental office within 24 months of initial treatment is considered part of the original procedure and not separately billable.
Final post‑operative radiograph must demonstrate final and complete obturation; one diagnostic radiographic image is allowed per tooth; additional working films are part of the RCT and not separately billable.
Periodontics
Periodontal coverage criteria, documentation requirements, and frequency limits.
Periodontal charting must include patient name, date, six‑point pocket depth measurements on all teeth, areas of clinical attachment loss, and bleeding sites; these charts are expected in the record for perio services.
Scaling and root planing (SCRP) procedures do not require pre-authorization (offices may pre-authorize); periodontal pocket depth measurements must be within 6 months prior to the date of service and clinical attachment loss >= 4 mm for SCRP eligibility.
D4346 (scaling in presence of moderate or severe gingival inflammation) is indicated ages 14+ when at least 30% of teeth show calculus buildup and moderate or severe inflammation; D4346 should not be reported with prophylaxis, SCRP, or debridement procedures.
Frequency limits: certain periodontal procedures have shared frequency constraints (e.g., some codes limited to once per 24 months); periodontal maintenance (D4910) allowed up to two times per calendar year when prior history is documented.
Provider must maintain photographs of inflammation at 30% of teeth for certain services (e.g., D4346/D4355) as part of documentation.
Removable Prosthodontics
Coverage, frequency limits, and billing rules for removable prosthodontics (dentures and partials).
Insertion/delivery date is the billable date of service for dentures; office visits related to denture fabrication, including preparation and all adjustment visits for six months after delivery, are part of the same procedure and are not separately billable to Medicaid or the patient.
Laboratory relines are allowed one year after insertion; relines less than one year after insertion require pre-authorization; subsequent relines limited to once every two years as specified.
Coverage criteria for partial dentures require specified patterns of missing permanent teeth (e.g., at least one permanent anterior tooth, or specified posterior combinations); complete dentures require missing all natural teeth in the arch (excluding unerupted third molars). A new denture is not covered if acceptable existing dentures can be adjusted or relined.
As of 2024, denture procedures no longer require pre-authorization though offices may choose to pre-authorize to ensure documentation meets program criteria; denture claims for health centers are paid FFS, not PPS, and should be submitted accordingly.
Extractions and oral surgery coverage
Coverage stance and limits for extractions and oral surgery.
Extraction benefits are limited to symptomatic teeth with clinical signs or symptoms of pathology (acute/chronic pain, inflammation, infection, or radiographic pathology). Elective extractions of asymptomatic teeth (including for orthodontic reasons or asymptomatic third molars) are not covered and may be billed to the patient following self-pay rules.
Paid benefit for extractions includes postoperative care by the same dentist/dental office for 30 days following surgery; during this period related post‑op visit codes (e.g., D0140, D9110) cannot be submitted separately for the same procedure.
ANY of the following
- Some oral surgery procedures have no benefit in the Medicaid dental program but may be covered under Medicaid managed care medical plans; providers should refer to the medical-plan benefit list and pre-authorization pathways for those services.
- Incisional biopsies require submission of a pathology report and will be denied if a pathology report is not submitted; when performed with extractions in the same area/date, claims are subject to dental review.
Refer to section 14.11 for medically necessary dental needs covered under Medicaid medical plans.
Coverage stance for described services
Coverage stance and specific criteria for orthodontics, sedation, behavior management, teledentistry, and medically-related oral surgery.
Orthodontics: All Medicaid orthodontic benefits require pre-authorization that includes diagnoses, treatment plan, anticipated treatment time and related documentation; D8660 (pre-orthodontic exam) is covered when narrative indicates treatment not started and provider has not been previously reimbursed for listed orthodontic codes (frequency limitation: 1 per lifetime for pre-orthodontic exam).
IV Moderate/Conscious Sedation (D9239/D9243) is a program benefit for all ages only when ALL three criteria are met: (1) patient displays inability to perform procedures without IV sedation; (2) IV sedation is used in conjunction with a completed endodontic (D3220-D3425) or surgical dental procedure (D7111-D7971) included on the same claim; (3) patient has a formal medical diagnosis involving emotional or behavioral dysregulation or a neurodivergent condition. Pre-authorization is optional; claims or pre-auth must include a narrative and a statement/chart note from a Hawaii licensed medical provider confirming diagnosis.
Nitrous Oxide (D9230) is covered when ALL three criteria are met: (1) patient displays inability to perform procedures without nitrous; (2) nitrous is used with a qualifying endodontic or surgical dental procedure on the same claim; (3) medical need confirmed by formal diagnosis involving emotional dysregulation or neurodivergent condition. Pre-authorization is optional; claims require narrative and licensed medical provider note.
Behavior Management (D9920) is payable when medical need (diagnosis of developmental or intellectual disability) requires significant modification of service delivery or at least a 15‑minute increase in appointment time; D9920 may be used standalone or with other procedures, is limited to four uses per year, denied if any pharmacologic sedation or nitrous oxide is used, and requires documentation and CE evidence.
Teledentistry: Claims for teledentistry must include D9995 (synchronous) or D9996 (asynchronous) (fee set to zero), include eligible CDT exam/radiograph codes (see approved list), use the originating site date as the service date, and include the patient's physical location (name/address) in the claim 'Remarks' section; missing location will result in denial. FQHC PPS rules may apply when both patient and dentist are at eligible separate FQHC/RHC sites.
Oral surgery procedures listed as benefits in Medicaid medical plans (not dental plans) are identified by CDT codes in the manual; such services should be processed through the patient's managed care medical plan and may require medical-plan pre-authorization.
Coverage criteria and billing guidance (partial)
Additional coverage and billing guidance drawn from the provided excerpts.
Oral surgery CDT codes listed in the manual identify procedures that may have benefits under Medicaid medical plans (not dental plans); review the code list and route claims through the appropriate medical-plan authorization process when applicable.
Dentist‑written prescriptions must be submitted to the State's Medicaid Pharmacy Benefit Manager (PBM), not the beneficiary's QUEST Integration health plan; see Chapter 19 and PBM resources for pharmacy claim procedures.
Topical preventive agents (D1206/D1208/D1355) used at a single appointment are combined for payment and limited to one paid benefit per day; if D1354 is claimed the same day as D1355, D1354 will be consolidated into D1355 and no additional payment made for D1354 on that date.
Behavior management (D9920) qualifies when significant process modification or at least 15 additional minutes is required for medical need with qualifying I/DD diagnosis; examples of qualifying and non-qualifying scenarios are provided in the manual; D9920 is limited to four times per 12 months and will be denied if pharmacologic sedation or nitrous oxide is used.
If a service is not included in benefits, offices may collect patient payment following the self-pay rules in Section 14.7 (signed financial understanding required); providers must comply with state practice rules for administration of preventive agents and staffing scope of practice.
Codes, Frequencies, and Billing Rules
Notable code changesCDTCovered
| D4346 | Scaling in presence of moderate or severe gingival inflammation; new benefit for ages 14+. |
| D9920 | Behavior management; now available for all ages; payment when provider must adapt procedure or use additional time for selected I/DD-related cooperation limitations. |
FQHC/PPS encounter codesCDT
| D9999 | FQHC pediatric encounter first line when submitting PPS pediatric encounter claims; fee set to center's encounter rate; other services listed on subsequent lines with zero fees. |
| D0140 | FQHC adult encounter first line when submitting PPS encounter claims; fee set to center's encounter rate; additional D0140 zero-fee line for limited exams. |
Oral evaluation diagnostic codes and rulesCDTCovered
| D0120 | Periodic Oral Evaluation - Established Patient (applies to oral evaluation annual limit). |
| D0140 | Limited Oral Evaluation - Problem Focused (criteria and exclusions listed). |
| D0145 | Oral Evaluation for a patient under 3 years with counseling of primary caregiver (applies to oral evaluation annual limit). |
Representative procedure codes and descriptions from excerptCPTCovered
| D0120 | Periodic Oral Evaluation - Established Patient |
| D0145 | Oral Evaluation for a patient under 3 years of age |
| D0150 | Comprehensive Oral Evaluation - New or Established Patient |
| D0210 | Intraoral - Complete Series of Radiographic Images |
| D0274 | Bitewings - Four Radiographic Images |
| D1354 | Caries Arresting Medicament (SDF) - per tooth |
| D1355 | Caries Prevention Medicament - full mouth |
| D1110 | Prophylaxis - Adult |
| D1206 | Topical Application of Fluoride Varnish |
| D2140 | Amalgam - One Surface, Primary or Permanent |
Representative dental procedure codes referencedCPT | mixed
| D2740 | Crown - Porcelain/Ceramic |
| D2750 | Crown - Porcelain Fused to High Noble Metal |
| D2910 | Core buildup / diagnostic note re crowns: indications (e.g., loss of cusp, <50% tooth structure) |
| D2920 | Re-cement or re-bond crown |
| D2930 | Prefabricated stainless-steel crown - primary tooth |
| D3220-D3425 | Root Canal Therapy codes |
| D4346 | Scaling in presence of moderate or severe inflammation |
| D5110 | Complete Denture - Maxillary |
| D5120 | Complete Denture - Mandibular |
Listed prosthodontic, oral surgery and orthodontic procedure codesCPTCovered
| D5410 | Adjust Complete Denture - Maxillary / Mandibular |
| D5421 | Adjust Partial Denture - Maxillary |
| D5422 | Adjust Partial Denture - Mandibular |
| D5630 | Repair or Replace Broken Retentive/Clasping Materials - Per Tooth |
| D5710 | Rebase Complete Maxillary Denture |
| D5730 | Reline Complete Maxillary Denture (Chairside) |
| D5740 | Reline Maxillary Partial Denture (Chairside) |
| D5820 | Interim partial denture - maxillary |
| D7111 | Extraction, coronal remnants - primary tooth |
| D7140 | Extraction, erupted tooth or exposed root |
1–10 of 19
1/2
CDT codes approved for TeledentistryCPT | CDTCovered
| D0120 | Periodic oral evaluation - established patient |
| D0140 | Limited oral evaluation - problem focused |
| D0145 | Oral evaluation for a patient under three years of age and counseling with primary caregiver |
| D0150 | Comprehensive oral evaluation - new or established patient |
| D0210 | Intraoral - complete series of radiographic images |
| D0220 | Intraoral - periapical first radiographic image |
| D0230 | Intraoral - periapical each additional radiographic image |
| D0240 | Intraoral - occlusal radiographic image |
| D0270 | Bitewing - single radiographic image |
| D0272 | Bitewing - two radiographic images |
1–10 of 12
1/2
Miscellaneous and oral surgery procedures (medical-plan benefits)CDTCovered
| D9110 | Palliative treatment of dental pain |
| D9920 | Behavior Management, By Report |
| D9420 | Hospital or Ambulatory Center Call |
| D7340 | Vestibuloplasty and related oral surgery procedures |
| D7440 | Excision of malignant tumor - small lesion |
| D7460 | Removal of benign non-odontogenic cyst or tumor up to 1.25 cm |
| D7471 | Removal of lateral exostosis |
| D7710 | Maxilla - open reduction (fracture) |
| D7940 | Osteoplasty for orthognathic deformities |
Oral surgery and anesthesia CDT codes (partial list)CDTCovered
| D7820 | Closed reduction of dislocation |
| D7830 | Manipulation under anesthesia |
| D7840 | Condylectomy |
| D7850 | Surgical discectomy, with/without implant |
| D7852 | Disc repair |
| D7872 | Arthroscopy - diagnosis, with or without biopsy |
| D9222 | Deep sedation/general anesthesia - first 15 minutes |
| D9223 | Deep sedation/general anesthesia - each subsequent 15 minute increment |
Preventive agent and behavior management codesCPTCovered
| D1355 | Caries preventive medicament application (full-mouth single payment) |
| D1354 | Application of Caries Arresting Medicament (SDF) - per tooth; policy combines payment considerations with D1355 |
| D1206 | Topical fluoride varnish |
| D1208 | Topical fluoride - excluding varnish |
Multiple restorations on same tooth (inv-24)
Policy change effective dateProviders may submit multiple CDT codes for distinct restorations on the same tooth starting May 1, 2026.
Reimbursement ruleReimbursement will remain limited to the value of a single multi-surface restoration (payment consolidated regardless of multiple codes).
Claiming optionDentists may either submit a single multi-surface code or submit separate codes for each distinct restored surface; payment outcome is the same.
Elapsed time frequency measurement (inv-25)
Measurement unitFrequency limitations are measured in years, defined as 12-month periods starting from the last service date.
Example intervalA 2-year frequency interval means the benefit renews 24 months after the initial procedure date.
Twice-per-year ruleA procedure allowed 'twice a year' pays a benefit a maximum of twice within any consecutive 12-month period.
Claim submission deadline (inv-26)
Claim submission deadlineDental claims must be submitted using CDT codes within one year of completion of the dental procedure.
Multiple-visit proceduresClaims for multiple-visit procedures must be submitted with the service date set to the date of completion of the entire procedure (e.g., crown seat/cementation date).
Submission methodsClaims may be submitted electronically via clearinghouse, Medicaid online portal, fax, or mail using the current ADA form.
D1354 paid teeth limit (inv-27)
Daily teeth limitD1354 (Caries Arresting Medicament - SDF) paid benefit available for up to 6 teeth per day; additional teeth on same date will be denied.
Documentation requirementProviders must maintain photographic or radiographic images of caries for each D1354 tooth claimed (images generally not required to be submitted with claim).
Interaction with D1355If D1354 is claimed the same day as D1355, Medicaid will consolidate into D1355 and no additional payment for D1354 will be made; D1354 benefits preserved for later use.
D0210 frequency (inv-28)
Frequency limitD0210 (Intraoral - Complete Series) is limited to 1 per 5 years.
Related radiograph limitsPanoramic (D0330) generally limited to 1 per 2 years with exceptions for oral surgeons.
Application to adults/childrenRadiograph frequency and submission requirements vary by code and patient age; radiographs must be individually prescribed and clinically necessary.
Bitewing frequency (inv-29)
Bitewing limitBitewing radiographs (D0270/D0272/D0274) are limited to 2 per year (applied to the bitewing annual limit).
Minimum spacingBitewing images have a minimum interval of no sooner than 4 months apart when applicable.
Annual limit applicationBitewing codes share the same annual limit across single/two/four image codes.
D0150 frequency per dentist/office (inv-30)
D0150 frequency per dentist/officeD0150 (Comprehensive Oral Evaluation) limited to 1 per 5 years when performed by the same dentist or dental office.
Shared annual limitD0150, D0120, and D0145 are applied to the oral evaluation annual limit.
No-duplicate submissionsWhen performed by the same dentist/office less than 5 years apart, D0150 allowances are limited consistent with D0120 rules.
RCT submission timing (inv-31)
Submission timingRoot canal therapy claims must be submitted only after final obturation; final post-operative radiograph must demonstrate complete obturation.
Exception when not completed within 4 monthsIf final obturation is not completed within 4 months, the office may submit a single D9110 (palliative) claim dated to initiation with a pre-op radiograph and narrative.
Pre-authorizationPre-authorization generally not required for RCT codes D3220-D3425 unless otherwise stated.
Re-cement limitation (inv-32)
6-month recement rule (same office)D2920 (Re-cement crown) will be denied if performed within 6 months of initial placement by the same dentist/dental office.
6-month allowance (different dentist)D2920 may be allowed once within 6 months when performed by a different dentist/dental office.
Subsequent recement frequencySubsequent recements after the initial allowance are subject to further frequency limits (e.g., allowed every 12 months thereafter).
Frequency limits for impacted tooth removal (inv-33)
Lifetime per-tooth limitSome impacted tooth removal codes (e.g., certain D7240/D7241 listings) are limited to 1 per tooth per lifetime.
Surgical complexity notesCompletely bony impacted tooth removal requires mucoperiosteal flap elevation and bone removal; documentation of complexity may be requested.
Operative report requirementFor unusually difficult/comlicated impacted removals, an operative report documenting specific complications may be required for payment consideration.
Repair/Replacement limits (inv-34)
D5630 repair limitD5630 (Repair or Replace Broken Retentive/Clasping Materials - Per Tooth) limited to 1 per year per tooth.
D5640 replacement limitD5640 (Replace Missing or Broken Teeth - Partial Denture - Per Tooth) limited to 1 per 6 months per tooth.
General prosthodontic frequencyRepairs and replacements have per-tooth and per-period frequency constraints; offices should consult the specific code entries for exact intervals.
D9920 frequency limit (inv-35)
Annual frequency capD9920 (Behavior Management) is payable up to 4 times per 12 months per patient.
Eligibility criteriaD9920 is paid when medical need (I/DD diagnosis) requires significant modification of service delivery or at least a 15-minute increase in appointment time; process modifications must be documented.
ExclusionsD9920 will be denied if any pharmacologic sedation or nitrous oxide is used during the appointment; providers must maintain CE documentation.
Topical prevention agents per-day payment limit (inv-36)
One-per-day combined paymentAt a single appointment, combined topical prevention agents (D1206, D1208, D1355) are combined and limited to one paid benefit per day (paid as D1355 when combined with D1355).
D1355 full-mouth treatmentD1355 is a full-mouth caries prevention medicament application for agents ≥30% SDF or iodine-based agents and is treated as a single full‑mouth benefit.
Claim submission guidanceOffices may submit both topical fluoride and D1355 codes on a claim but only one will receive payment; D1355 may be submitted with or without an assigned tooth.
Prior Authorization, Documentation, and Submission Requirements
Prior Authorization
Pre-Authorization Requirements
Pre-authorization is required for dental treatment performed under general anesthesia, orthodontics, and special benefit exceptions for patients with severe developmental disability, special medical need, or severe medical fragility. Emergency services do not require pre-authorization; delivering these services before approval will result in denial of payment to the dentist.
Prior Authorization
Pre-Authorization overview — which benefits require prior approval
Certain dental benefits (general anesthesia, orthodontics, and special benefit exceptions) require pre-authorization; emergency services are exempt from pre-authorization requirements.
Documentation Required
Requesting Pre-Authorization — required submission and attachments
Providers must submit a Pre-Authorization Form with supporting documentation, including radiographic image(s) when applicable and an accepted clinical diagnosis. Submission may be done by fax, mail, or through the Medicaid online portal.
Prior Authorization
Expedited Pre-Authorization for urgent cases
For urgent pre-authorization needs that require the procedure within a week, providers may request expedited approval by writing 'Urgent' on the top of the authorization form when submitting the request.
Prior Authorization
Pre-authorization for General Anesthesia (GA) — five required components
Pre-authorization for general anesthesia requires submission of five components to the dental TPA: Forms DHS 1190, 1191, and 1192; a dental authorization request that includes CPT code 41899 (submitted via portal, ADA claim form, or Med-QUEST form); and chart notes/supporting documentation with tooth‑specific diagnosis and a narrative justifying the need for GA and alternatives attempted. After dental pre-authorization is approved, the dentist must submit authorization to the appropriate Medicaid medical health plan for hospital/anesthesia services.
- Required documents: DHS 1190, DHS 1191, DHS 1192
- Dental authorization request that includes CPT 41899 (portal, ADA claim form, or Med-QUEST request form)
- Chart notes with tooth‑specific diagnosis, itemized treatment plan, and narrative documenting alternatives attempted and why office care is unsafe
Denial Risk
Denied Pre-authorization — when patient billing is permitted
If a properly submitted pre-authorization is denied because the case does not meet benefit criteria, the office may collect payment from the patient only with a signed pre-agreement to specific charges; if denial is due to the office failing to submit required pre-authorization or information, the office may not collect payment from the patient.
Prior Authorization
Crowns — pre-authorization required for special exceptions
Pre-authorization is required for special crown exceptions such as third molar crowns and some primary tooth crowns; posts, cores, and pins for primary teeth are not benefitted unless there is a congenitally missing corresponding permanent tooth, in which case pre-authorization is required.
- Additional supporting documentation or photos may be requested when radiographs do not clearly justify a crown, especially for patients under age 12
- Special exceptions (third molar crowns; primary tooth with congenitally missing permanent tooth) require pre-authorization
Documentation Required
Radiograph documentation requests — submission and clinical necessity
Med-QUEST or the Dental TPA may request submission of any x-rays claimed. Radiographs must be clinically necessary, individually prescribed in accordance with ADA and FDA guidelines, and of diagnostic quality.
- Midprocedure ('working') and post‑operative radiographs are considered part of the procedure and are not separately billable
Billing Rule
Space maintainer billing restriction — maintenance included in original benefit
When performed by the office that originally placed the appliance, ongoing maintenance, re-cementation, and final removal of a space maintainer are considered part of the original procedure and may not be billed or claimed separately.
Prior Authorization
Root Canal Therapy (D3220–D3425) — pre-auth and submission timing
Pre-authorization is not required for Root Canal Therapy codes D3220–D3425 unless otherwise stated. Claims must be submitted only after final obturation is completed; if final obturation is not completed within 4 months, the office may submit a single D9110 claim dated to the initiation with the pre‑operative radiograph and narrative.
- Tooth must be restorable with favorable periodontal prognosis
- If final obturation not completed within 4 months, submit single D9110 appointment claim with pre-op radiograph and narrative
Prior Authorization
Crowns & Dentures — pre-auth guidance and exceptions
Providers may request pre-authorization for crowns in patients under age 12 when radiographs do not clearly justify a crown. Denture procedures no longer require pre-authorization as of 2024, though offices may choose to pre-authorize; certain crown/post/core exceptions for primary teeth require pre-authorization.
- Denture insertion date is billable date; denture adjustments within 6 months are part of original procedure
- Laboratory reline less than 1 year after insertion requires pre-authorization
Prior Authorization
Pre-authorization for denture rebasing (D5710, D5711) — when required
Rebase complete dentures and some rebasing services (e.g., D5710, D5711) are indicated as Pre-Auth or Pre-Auth optional in the policy and may require pre-authorization per the listed rules.
- Some rebase codes are labeled 'Pre-Auth' or 'Pre-Auth optional' and have timing/frequency limits
Prior Authorization
Orthodontics — pre-authorization and pre-orthodontic exam (D8660) requirements
All Medicaid orthodontic benefits require pre-authorization that includes dental and/or medical diagnoses, the treatment plan, anticipated treatment time, and related documentation; pre-orthodontic exam (D8660) requires a narrative confirming treatment not started and that the provider has not previously been reimbursed for listed orthodontic codes.
- Pre-authorization required for limited (D8010, D8020) and comprehensive (D8070, D8080, D8090) orthodontic treatment
- Pre-orthodontic exam (D8660) frequency limitation: 1 per lifetime
Documentation Required
Dental prescription claims routing — submit dentist prescriptions to State PBM
Prescriptions written by dentists must be submitted to the State's Medicaid Pharmacy Benefit Manager (PBM), not through the beneficiary's QUEST Integration health plan; see Chapter 19 for pharmacy procedures.
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Program Definitions and Scope
Children's Dental Program (EPSDT) (inv-56)
EPSDT coverage for childrenChildren's Dental Program (under age 21) is governed by federal EPSDT guidelines and offers a broader set of dental services, including some orthodontic therapy limited to developmental defects.
Program intent for childrenEPSDT emphasizes prevention and early detection/management to reduce disease and provide basic preventive and therapeutic care.
Orthodontic scopeComprehensive orthodontic therapy for children is offered only for developmental defects such as orofacial clefts; extractions solely for orthodontic purposes are not covered.
Adult Dental Program (inv-57)
Adult program age thresholdAdult Dental Program covers enrollees aged 21 and older and includes preventive, diagnostic, restorative, endodontic, periodontal, prosthodontic, and emergency services.
Key adult benefits and limitsExamples: scaling/root planing limited to 1 per 24 months; periodontal maintenance allowed two per year; complete dentures one every five years; denture relines one every two years.
Enrollment requirementBenefits require that the patient be enrolled in Medicaid and the provider be approved for Medicaid participation on the date of service.
Date of Service enrollment requirement (inv-58)
Enrollment on date of serviceBenefits require the patient to be enrolled in Medicaid and the provider approved for Medicaid participation on the date of service.
Claiming upon completionMultiple-visit procedures must be submitted only upon completion with the service date set to the completion date (e.g., crown seat/cementation).
Use of CDT codesClaims must use current CDT codes in effect on the date of service and be submitted within program time limits (one year).
General Anesthesia (GA) coverage (inv-59)
GA as last-resort benefitGeneral Anesthesia (GA) for dental services is an option of last resort and payments are limited to situations where necessary dental services cannot be safely performed in a normal office setting.
Qualifying criteria (OR set)GA is covered when ONE of: (1) I/DD prevents cooperation, (2) local anesthesia ineffective/contraindicated, or (3) sustained extensive orofacial/dental trauma where local anesthesia is ineffective.
Qualifying criteria (AND set)GA is also covered when ALL four conditions are met: extreme resistance/uncooperativeness; extensive oral treatment needed; postponement likely to cause significant adverse effects; and alternatives cannot safely/effectively complete care in-office (behavioral management, protective stabilization, sedatives, SDF, nitrous oxide).
Self-pay / Optional services (inv-60)
Self-pay optionProviders may offer non-covered services on a self-pay basis after informing patients of covered alternatives and obtaining a signed financial acknowledgement; failure to obtain signed agreement disqualifies collection.
Restrictions on collectionsProviders may not bill or collect for services that have an available/unused Medicaid benefit and may not collect GET for Medicaid-reimbursed services.
Examples of self-pay servicesExamples include cosmetic teeth whitening, adult-requested gold crowns, or services after frequency limits have been met; fees may not exceed provider UCR.
Radiographs (inv-61)
Clinical necessityRadiographic images must be clinically necessary, individually prescribed per ADA and FDA guidelines, and of diagnostic quality to qualify for payment.
Documentation & requestsMed-QUEST or the Dental TPA may request submission of any x-rays claimed; midprocedure and post-op radiographs are considered part of a procedure and are not separately billable.
Frequency constraintsSpecific radiograph codes have frequency limits (e.g., bitewings 2 per year; complete series D0210 1 per 5 years; panoramic D0330 typically 1 per 2 years).
Caries Arresting & Prevention Medicaments (inv-62)
D1354 specificityD1354 is limited to silver diamine fluoride (SDF) per tooth; the paid benefit is available for up to 6 teeth per day and requires office records (photos/x-rays) for each tooth claimed.
D1355 full-mouth ruleD1355 is a full-mouth caries prevention medicament application for agents ≥30% SDF or iodine-based agents and is billed as a single full‑mouth benefit.
Combined daily paymentWhen D1354 and D1355 or topical fluoride codes are performed the same day, benefits are combined and limited to one paid benefit per day (paid as D1355 when combined).
Restorative billing option (effective May 1, 2026) (inv-63)
Option start dateEffective May 1, 2026, dentists may submit individual service codes for each distinct filling on a tooth.
Payment consolidationReimbursement will be consolidated and calculated as if a single multi-surface filling was performed (total payment limited to that single multi-surface value).
Claiming examplesExample: a tooth with mesial, buccal, and occlusal restorations may be claimed as a single MOB or as separate MO and B codes; either submission results in the same single payment.
D4346 (inv-64)
Code and indicationD4346: Scaling in the presence of moderate or severe gingival inflammation — removal of plaque, calculus and stains when generalized moderate or severe gingival inflammation exists without periodontitis.
Age eligibilityD4346 is available only for patients aged 14 and older.
Clinical threshold (actionable)Clinical status must show at least 30% of teeth with calculus buildup and moderate or severe inflammation (e.g., bleeding on probing); provider must maintain photos of inflammation for certain services.
Elective extraction & post-op rules (inv-65 / inv-66 / inv-67)
Elective extraction exclusionExtraction of asymptomatic teeth (including for orthodontic purposes or asymptomatic third molars) is not covered by Medicaid; payment for non-covered elective services may be collected following self-pay rules.
Postoperative care periodExtraction benefits include postoperative care by the same dentist/dental office for 30 days following surgery; related post-op visit codes cannot be submitted separately during this period for the same procedure.
Pathology requirement for biopsiesIncisional biopsies (D7285/D7286) require submission of a pathology report and will be denied if not submitted; subject to dental review when performed with extractions in same area/date of service.
RCT submission timing & related coverage (inv-31 / inv-51 / inv-52)
Post-op RCT radiograph requirementFinal post-operative radiograph must demonstrate final and complete obturation of the root canal system for RCT claims.
Claim timing and exceptionRCT claim submitted only after final obturation; if not completed within 4 months, a single D9110 claim (dated to initiation) with pre-op radiograph and narrative is allowed.
Sedation linkIV sedation (D9239/D9243) and nitrous oxide (D9230) coverage require use with a completed qualifying endodontic or surgical dental procedure included on the same claim and formal medical diagnosis; pre-authorization optional.
Pathology report requirement (inv-67)
Pathology report requirementIncisional biopsies of hard (D7285) and soft tissue (D7286) require submission of a pathology report and will be denied if one is not submitted.
Dental review on concurrent proceduresBiopsies performed with extractions in the same surgical area or date of service are subject to dental review; documentation must support the combined services.
Claim support itemsProviders should submit pathology reports and any required narratives with the claim to avoid denials.
Teledentistry / Telehealth (inv-68)
DefinitionTelehealth is use of telecommunication services to transmit patient health information while patient is at an originating site and provider at a distant site; teledentistry is a form of telehealth to facilitate access.
Claiming requirementTeledentistry claims must include eligible CDT exam/radiograph codes and use originating site date as service date; missing patient location/remarks may result in denial.
Approved teledentistry codesCertain CDT codes (e.g., D0120, D0140, D0145, D0150, D0210, D0220-D0274, D0330) are approved for teledentistry billing as specified in code list.
Behavior Management (D9920) (inv-69 / inv-35 / inv-72)
Behavior Management (D9920) by-report rulesD9920 is a by-report benefit payable when medical need (I/DD diagnosis) requires significant modification of method/process or ≥15 minutes additional appointment time; providers must document modifications and maintain CE.
Age availabilityD9920 is now available for all ages (expanded benefit).
Limitations and exclusionsD9920 is denied if any pharmacologic sedation or nitrous oxide is used during the appointment; limit is up to 4 times per 12 months.
Sedation / Nitrous Oxide eligibility (inv-70)
Eligibility criteriaIV sedation (D9239/D9243) and nitrous oxide (D9230) are available when: (1) patient cannot cooperate without sedation/NO; (2) used with a qualifying endodontic or surgical dental procedure included on same claim; and (3) formal medical diagnosis of emotional/behavioral dysregulation or neurodivergent condition is provided.
Documentation requiredClaims or pre-authorization should include a narrative describing inability to cooperate and a statement/chart note from a Hawaii licensed medical provider confirming diagnosis; pre-authorization is optional.
Billing interactionIf nitrous is used with IV sedation, nitrous is considered part of D9239/D9243 and not billable separately to Medicaid or the patient.
D1355 (inv-71)
D1355 payment ruleD1355 (Caries Preventive Medicament) is paid as a single full‑mouth benefit (treated as whole‑mouth rather than per‑tooth).
Daily combined limitWhen D1355 is performed with topical fluoride (D1206/D1208) or SDF (D1354) on same day, payments are combined and limited to one paid benefit per day across these codes.
Claiming guidanceOffices may submit both D1355 and other topical agent codes on the claim but only one will receive payment; D1355 may be assigned to a tooth or not—either will be paid once.
D9920 (Behavior Management) guidance (inv-72)
D9920 usageD9920 Behavior Management billed by report for significant modifications or extended time (examples: protective stabilization, wheelchair accommodations, extended desensitization sessions).
Documentation & CEProviders must document process/time modifications and maintain at least one hour of CE related to care of individuals with I/DD within the previous 24 months for claims.
Non-qualifying scenariosRoutine crying, brief calming, or <15-minute additional time without qualifying diagnosis do not qualify for D9920 (examples provided).
PBM routing for dentist prescriptions (inv-73)
Prescription claims routingPharmacy claims for prescriptions written by dentists must be submitted to the State's Medicaid Pharmacy Benefit Manager (PBM), not the beneficiary's QUEST Integration health plan.
Reference to ChapterSee Chapter 19 for detailed procedures and policies on pharmacy services and claims submittal.
Provider actionDentists should bill dentist-written prescriptions through the State PBM to ensure correct processing and payment.
Policy Summary
PayerHawaii Department of Human Services
PolicyMedicaid Dental Program — Coverage, Billing and Authorization Rules (Chapter 14)
Policy CodePolicy N/A
Change TypeBenefit additions and billing rule revisions
Effective DateApr 1, 2026
Next Review DateN/A
Key ActionSubmit pre-authorization (with supporting documentation and radiographs) for general anesthesia, orthodontics, and special benefit exceptions as required.
SourceLink
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