ModifiedHawaii Department of Human ServicesPolicy N/A

Medicaid Dental Program (Chapter 14) overview and operational policies

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Governs Medicaid dental benefits and program operations in Hawai‘i, describing the Children's and Adult Dental Programs, provider obligations, referrals, pre-authorization rules, and recent benefit updates; affects registered dental providers and Medicaid-enrolled patients.

Policy Summary

PayerHawaii Department of Human Services

PolicyMedicaid Dental Program (Chapter 14) overview and operational policies

Policy CodePolicy N/A

Change TypeBenefit additions and rate/coverage revisions (May 2025)

Effective DateMay 1, 2025

Last ReviewMay 1, 2025

Next Review DateN/A

Key ActionSubmit required pre-authorization documentation for general anesthesia and other listed services via the portal or forms, including the five GA components when applicable.

SourceLink

POLICY UPDATE CHANGES

Reimbursement for D1354 (Caries Arresting Agent) has been significantly increased and the benefit is now available for up to 6 carious teeth per day.

D1355 (Caries Prevention Agent) added as a new benefit in the Children's Dental Program for full-mouth application of selected topical preventive medicaments.

D9920 (Behavior management) added as a new benefit in the Children's Dental Program to reimburse for adaptations or additional time needed when treating patients with special medical considerations limiting cooperation.

Up to 6D1354 limit/day

New CDT benefitsMay 2025 additions

Required (select services)Pre-authorization

Children & AdultsChildren vs Adults

1 yearClaim deadline

Coverage Criteria and Limits

Coverage overview and criteria (partial — additional sections follow in later parts of document)

Program coverage is defined by population (children vs adults) and by specific benefit rules; certain services require pre-authorization and some services are excluded (e.g., extractions solely for orthodontic purposes).

ALL of the following

Program populations
- Children's Dental Program — beneficiaries younger than age 21; governed by EPSDT and offers broader services (including limited orthodontics for developmental defects).
- Adult Dental Program — beneficiaries age 21 and older; limited set of preventive, diagnostic, restorative, endodontic, periodontal, prosthodontic, and emergency services with specified frequency limits (examples: comprehensive oral evaluation once per five years; prophylaxis two per year; bitewings two per year; full series one per five years).
Benefits are paid only to registered dental providers at registered office locations using CDT codes in effect on the date of service.
A separate set of medically related oral surgery benefits may be available through Medicaid medical managed care plans (see section 14.11).
Pre-authorization is required for certain services (including any dental treatment under general anesthesia, orthodontics, and special benefit exceptions for severe developmental disability or medical fragility); emergency services do not require pre-authorization.

Providers should reference the most recent program version (e.g., May 2025) on the provider portal for updates and operational details.

General Anesthesia coverage criteria and authorization process

Criteria and process for Medicaid payment of dental services under general anesthesia and pre-authorization requirements.

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Alternatively, Medicaid will approve GA when ALL of the following four conditions are met:

The patient is extremely physically resistant/uncooperative.
Extensive oral treatment is necessary.
Postponement of treatment is likely to result in significant adverse effects to the patient's medical or dental condition.
Alternative dental treatments cannot be completed both safely and effectively in an office using adjunctive techniques or modalities (examples: behavioral management, protective stabilization, sedative medications, caries arrest with SDF, nitrous oxide or conscious sedation).

GA will not be approved to avoid anxiety, parental/dentist apprehension, scheduling convenience, to perform exams, or when alternatives could address the problem.

Pre-authorization process: Providers must submit five required components to the dental TPA (DHS Forms 1190, 1191, 1192; a dental authorization request that includes CPT 41899 via portal/ADA/HDS form; and chart notes/supporting documentation including tooth‑specific diagnoses, itemized treatment plan, narrative documenting necessity and attempted alternatives, and description of why office setting is unsafe). After dental pre-authorization is approved, separate submission to the beneficiary's Medicaid medical plan is required for hospital and anesthesia-related medical benefits; pre-approval does not guarantee coverage of all individual services and code‑specific limits still apply.

Payment criteria, clinical necessity, frequency, and provider limits

General coverage and payment criteria for dental services and provider limitations.

Eligibility: Patient must be enrolled in Medicaid on date of service and provider must be an approved Medicaid participant on date of service.

Clinical necessity: Procedures must provide reasonable clinical benefit; examples of nonpayment include restorations on near‑exfoliation teeth, unnecessary radiographs taken at short intervals, and unnecessary space maintainers.

Frequency: Procedures have frequency limitations measured by elapsed time (12‑month periods starting at last service date) with some exceptions (e.g., D4910 uses calendar year); intervals may be expressed as years, 2‑year renewal, or 'twice within any consecutive 12‑month period' where applicable.

Provider-based limits: Some benefits have provider‑specific limitations that follow the provider across service locations and limit total paid for a patient for specific codes or code ranges.

Self-pay options and billing restrictions

Rules for optional/self-pay services and restrictions on collecting payment from Medicaid patients.

Providers must inform patients of covered alternatives before recommending noncovered procedures and must obtain a signed financial acknowledgement before collecting any self‑pay fees; failure to obtain a signed agreement disqualifies collection.

Restrictions: Providers may not bill or collect for services that have an available/unused Medicaid benefit; may not collect General Excise Tax for Medicaid‑reimbursed services; FQHCs may not submit encounter claims for self‑pay‑only appointments.

Examples of allowable self‑pay situations (with signed agreement):

Teeth whitening (non‑benefit) — may be paid by patient with signed financial acknowledgment; no related Medicaid exam/x‑ray claims should be submitted.
Adult gold crowns (non‑benefit for adults) — patient may elect to pay up to UCR after being offered benefitted stainless‑steel alternative; signed agreement required; FQHCs may not submit encounter claims for these appointments.
Exceeding benefit frequency (e.g., prophylaxis/flouride more often than allowed) — after available benefits are used, patient may self‑pay with signed agreement; FQHCs may not submit encounter claims.

Claims, billing data, FQHC billing, and radiograph requirements

Claims submission, billing information, and radiograph rules.

Claims submission: Claims may be submitted electronically, via clearinghouse, Medicaid online portal, fax, or mail using the current ADA form; claims for completed multi‑visit procedures must use the completion date as the service date; submissions must be limited to procedures sharing the same service date.

Required billing information: Billing entity/dentist, mailing address, NPI (organizational NPI not required for sole providers using SSN as tax ID), Tax ID Number, and servicing provider name must be complete and accurate.

FQHC billing rules: PPS requires submission of D‑codes for eligible services; pediatric encounter first line D9999 with fee set to encounter rate, adult encounter first line D0140 with fee set to encounter rate; dentures are paid FFS (not PPS) and may require separate claim submission if other services are provided same day.

Radiograph requirements: Radiographs must be clinically necessary, individually prescribed per ADA/FDA guidance, of diagnostic quality, and may be requested by Med‑QUEST or Dental TPA; mid‑procedure and post‑operative radiographs are part of the primary procedure and are not billable separately.

Extracted coverage criteria

Coverage and limits for services in this segment:

D0210 (Full‑mouth series): Covered when clinically necessary; frequency limit 1 per 5 years; images must be diagnostic quality and may be requested to support claims.

D0270/D0272/D0274 (Bitewings): Covered; applied to the bitewing annual limit with a general frequency of 2 per year (D0274 no sooner than 4 months apart for some codes); individually prescribed and diagnostic quality required.

D1354 (Caries Arresting Medicament — SDF): Paid benefit available up to 6 teeth per day; if claimed for more than 6 teeth additional teeth will be denied; provider must retain photographic or radiographic images for each tooth claimed (images not required on claim in most situations).

D1355 (Caries Prevention Medicament — full‑mouth agents >=30% SDF or iodine‑based agents): Covered as a full‑mouth service; shares eligibility, combined frequency limitations, and payment availability with topical fluoride (D1206/D1208); same‑day topical prevention agents consolidated and paid as D1355 (only one paid benefit per day across D1206/D1208/D1355); if D1354 is claimed same day as D1355, Medicaid will consolidate and pay only D1355 and offices may not bill patients for D1354 on that date.

Space maintainer maintenance (re‑cementation, removal) performed by the office that placed the appliance is included in the original procedure and may not be billed separately.

Restorations: Covered when clinically necessary for caries or fracture; not covered solely for attrition/erosion/abrasion/occlusal wear; reimbursement determined by number of restored surfaces and noncontiguous restorations on same tooth should be submitted as a single restoration.

Crowns: Covered with frequency limits (e.g., D2740 limited to 1 per 5 years); temporary crowns are part of the crown procedure; additional documentation or photos may be requested if radiographs do not clearly justify a crown, especially for patients under age 12; some crowns limited to cases involving endodontic treatment, major cusp loss, or <50% sound tooth structure; pre‑authorization required for certain exceptions (e.g., third molar crowns, primary tooth posts/cores/pins when exception applies).

Crowns

Crown coverage and limitations

Temporary crowns are considered part of the definitive crown procedure and are not billed separately.

Posts, cores, and pins are not benefitted procedures for primary teeth unless there is a congenitally missing corresponding permanent tooth; pre‑authorization is required for such exceptions.

Some crowns (including porcelain/ceramic, PFM, full cast high noble) are limited to indications such as endodontic treatment, loss of one major cusp (posterior), or when less than 50% of sound tooth structure remains.

Frequency: Certain crowns and related post/core procedures have frequency limits (for example, many crown types and post/core codes are limited to 1 per 5 years per tooth); recementation is denied if within 6 months when performed by same dentist/office, allowed once within 6 months if performed by a different dentist/office, and subsequent recementations allowed every 12 months.

Root Canal Therapy (D3220-D3425)

Endodontic coverage rules

Pre-authorization: Root canal therapy codes D3220–D3425 do not require pre-authorization unless otherwise stated.

Clinical requirement: Tooth must be restorable with a favorable periodontal prognosis to qualify for endodontic therapy.

Claim timing: Claims 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 claim (dated on the initial treatment date) with the pre‑operative radiograph and narrative.

Documentation: Final post‑operative radiograph must demonstrate complete obturation; diagnostic radiograph allowances and angled films may be required to visualize all treated canals; additional working films are considered part of the root canal treatment and are not billable separately.

Retreatment: Retreatment is covered only for specific clinical circumstances reviewed by a dental consultant; retreatment by the same dentist/office within 24 months is considered part of the original procedure and not billed separately.

Periodontics

Periodontic coverage and documentation

Documentation: Periodontal charting must show patient name, date, six‑point pocket depth measurements on all teeth, areas of clinical attachment loss, and probing sites exhibiting bleeding.

Coverage: Periodontal scaling and root planing (SCRP) procedures do not require pre‑authorization (offices may elect to pre‑authorize).

Frequency: SCRP limited to 1 per 24 months; periodontal maintenance (D4910) limited to 2 per calendar year provided there is prior history of D4341/D4342 documented in the record.

Denial risk: D1110 and D4355 are denied when performed on the same day as D4341 or D4342.

Removable Prosthodontics

Removable prosthodontics coverage rules

Billable date: The insertion/delivery date is the billable date of service for dentures; related office visits, preparations, and adjustments are included in the denture procedure for six months post‑delivery and are not separately billable during that period.

Frequency and relines: Laboratory relines allowed one year after insertion; relines less than one year after insertion require pre‑authorization; subsequent relines limited to once every two years.

Coverage criteria: Partial denture fabrication requires specified missing‑tooth criteria (examples: at least one permanent anterior tooth missing; missing both first permanent molars in the same arch; missing three posterior permanent teeth in an arch; or missing two adjacent posterior permanent teeth). Complete dentures require missing all natural teeth in the arch (excluding unerupted third molars); fabrication is not covered if beneficiary has acceptable dentures that can be adjusted/relined.

Policy update: As of 2024, denture procedures no longer require pre‑authorization, although offices may elect to pre‑authorize to ensure documentation meets program criteria.

Repair/replacement limits: Examples include repair of broken denture base limits and replacement of missing/broken denture tooth limited to 1 per 6 months per tooth; some repairs limited to 1 per year as specified.

Coverage criteria and limitations (Oral & Maxillofacial Surgery)

Oral & Maxillofacial Surgery — coverage limitations

Extraction coverage: All tooth extraction benefits are limited to symptomatic teeth with clinical signs or radiographic pathology (acute/chronic pain, infection, inflammation, or radiographic evidence); elective extractions of asymptomatic teeth (including for orthodontic purposes or asymptomatic third molars) are not covered.

Postoperative care: Paid benefit for extractions/oral surgery includes postoperative care for 30 days by the same dentist/office; within this period additional D0140 or D9110 claims for post‑op visits related to the original procedure are not payable.

Biopsy requirement: Incisional biopsies require submission of a pathology report and are denied if one is not submitted.

Some oral surgery procedures that are medically related may be covered through Medicaid medical managed care plans rather than the dental program; referrals for such services should be to participating providers in the beneficiary's medical plan (see section 14.11).

Coverage criteria and administrative rules

Coverage and qualification criteria for specific dental services and distinctions between dental‑program and medical‑plan dental services.

D9239/D9243 (IV moderate/conscious sedation): Payable when used with a qualifying endodontic (D3220–D3425) or surgical dental (D7111–D7971) procedure included on the same claim; program benefit available to all ages only when the patient cannot cooperate without IV sedation and has a formal medical diagnosis involving emotional/behavioral dysregulation; pre‑authorization is optional but claims or pre‑auth must include narrative and a Hawaii‑licensed medical provider statement/chart note of formal diagnosis; maintain medical history, sedation record, diagnosis, and pre‑surgical radiographs.

D9230 (Nitrous oxide): Payable when used with qualifying endodontic or surgical dental procedure included on the same claim and when a formal medical diagnosis of emotional dysregulation or neurodivergent condition is documented; pre‑authorization optional with required narrative and medical provider statement/chart note.

D9920 (Behavior Management): New benefit payable when physical or behavioral challenges require significant modification to service delivery or when time‑only increases involve at least 15 additional minutes; must document process or time modifications, have evidence of medical necessity (qualifying diagnosis per HAR 11‑88.1.5 or equivalent), maintain at least 1 hour CE in past 24 months related to special needs care, is available up to 4 times per patient per year, and is denied if any pharmacologic sedation or nitrous oxide is used during the same appointment.

Teledentistry: Specific CDT exam and radiograph codes approved for teledentistry; only one claim submission allowed per patient visit with the service date equal to the originating site date; D9995 (synchronous) or D9996 (asynchronous) must be included (fee set to zero) and the originating site location must be documented on the claim.

Medical‑plan vs dental‑program services: Certain oral surgery and deep sedation/general anesthesia codes (listed in section 14.11/14.12) have benefits under Medicaid medical plans rather than the dental program; pre‑authorization and claims for those services are processed through the patient's managed care medical plan and coordinated with participating oral surgeons.

Dental prescriptions: Prescriptions written by dentists must be submitted to the State's Medicaid Pharmacy Benefit Manager (PBM) rather than to the beneficiary's QUEST Integration health plan.

Coverage criteria and guidance (excerpt)

Coverage notes, limits, and examples from this section:

Oral surgery codes with benefits in Medicaid medical plans (examples): D7982, D7983, D7990, D7995–D7999, and deep sedation/general anesthesia codes D9222/D9223 — these are processed through medical plans and not the dental program.

Dental prescription routing: Prescriptions written by dentists must be submitted to the State's Medicaid PBM (not the beneficiary's managed care plan); see Chapter 19 and PBM resources for details.

Topical prevention agents limit: Payments for topical fluoride, povidone iodine, and SDF are combined and treated as one payment with a limit of one paid benefit per day across D1206/D1208/D1355; when multiple agents are used at one appointment only one payment is allowed and D1355 may be submitted with or without a specific tooth assignment but multiple same‑day D1355 claims will be consolidated to a single paid benefit.

D9920 examples and exclusions: Examples where D9920 qualifies include significant physical/behavioral modifications (e.g., papoose board for combative ASD child; clinic modifications to treat a wheelchair patient; extended desensitization/orientation of ≥15 minutes). D9920 does not qualify for routine or minor behavioral issues (e.g., a crying child stabilized by a caregiver) where no significant process modification or ≥15 additional minutes is documented and medical need is not established.

Program focus: Adult Medicaid benefits prioritize prevention, therapeutic services, and establishing a dental home rather than esthetic or non‑critical restorative services.

Provider Requirements, Pre-Authorization, and Documentation

Prior Authorization

Pre-authorization required for GA, orthodontics, and special exceptions

Pre-authorization is required for any dental treatment performed under general anesthesia, orthodontics, and special benefit exceptions for patients with severe developmental disability, special medical need, or severe medical fragility. Providers must submit a Pre-Authorization Form with supporting documentation (including radiographs when applicable) via fax, mail, or the Medicaid online portal. If a properly submitted request is denied because the situation does not meet benefit criteria, the office may collect payment with a signed pre-agreement; if denial results from the office failing to request authorization or submit required information, the office may not collect payment from the patient.

Submission methods: fax, mail, or Medicaid online portal.
Include radiographs when applicable and an accepted clinical diagnosis.
Emergency services do not require pre-authorization.

Prior Authorization

Expedited ('Urgent') pre-authorization for <1 week procedures

Providers may request expedited (urgent) pre-authorization by writing 'Urgent' on the authorization form when the procedure requires performance within one week; this applies to procedures that otherwise require pre-authorization.

Mark 'Urgent' on top of the authorization form to request expedited review.

Prior Authorization

General anesthesia (GA) — five-component pre-authorization and medical-plan step

Pre-authorization for dental services under general anesthesia (GA) must be submitted to the Dental TPA with five required components: DHS Forms 1190, 1191, 1192; a dental authorization request that includes CPT 41899 (via portal, ADA form, or HDS form); and chart notes/narrative documenting diagnosis, tooth-specific treatment plan, necessity of GA, attempted alternatives, and why office setting is unsafe. After dental pre-authorization is approved, separate submission to the beneficiary's Medicaid medical plan is required for hospital and anesthesia-related medical benefits; pre-approval of GA does not guarantee coverage of all individual services or code-specific benefits.

Required five components: DHS 1190, DHS 1191, DHS 1192, dental authorization request including CPT 41899, and chart notes/narrative with diagnosis/treatment plan and evidence that alternatives were attempted.
Medicaid medical-plan authorization for hospital/anesthesia services must be requested separately after dental pre-authorization.

Documentation Required

Post-authorization: submit to Medicaid medical plan for hospital/anesthesia benefits

After dental GA pre-authorization is approved, the dentist must submit dental authorization forms to the appropriate Medicaid medical health plan for hospital and anesthesia-related services; approval of dental GA does not guarantee coverage of all individual services and code-specific limits still apply.

Dental pre-authorization is reviewed by Dental TPA; separate medical-plan approval is required for facility/anesthesia claims.
Code-specific benefit and frequency limits remain applicable despite GA pre-approval.

Documentation Required

Submit radiographs only when individually prescribed and clinically necessary

Radiographs must be individually prescribed, clinically necessary, and of diagnostic quality; Med-QUEST or the Dental TPA may request submission of any x-rays claimed. Midprocedure ('working') and post-operative radiographs are considered part of the procedure and are not separately billable.

Radiographs should follow ADA and FDA guidelines and be prescribed only when they provide additional diagnostic information.
TPA may request submission of x-rays to support claims.

Prior Authorization

Pre-authorize special crown cases and provide supporting images if requested

Certain crowns and related procedures require pre-authorization or additional documentation: special exceptions (e.g., third molar crowns for primary function) and posts/cores/pins for primary teeth (when a corresponding permanent tooth is congenitally missing) require pre-authorization. Additional photos or supporting documentation may be requested, especially for patients under age 12.

Pre-authorization required for special third molar crown exceptions and specified primary-tooth post/core exceptions.
If radiographs do not clearly justify a crown, the TPA may request photos or extra documentation.

Billing Rule

Do not bill separately for space maintainer maintenance by the placing office

Ongoing maintenance, re-cementation, and removal of a space maintainer performed by the office that placed the appliance are included in the original procedure and may not be billed separately.

Re-cement/re-bond frequency rules apply (see code-specific frequency limits).

Documentation Required

Provide photos/additional documentation for crown pre-authorization when radiographs are insufficient

If radiographs do not clearly justify a crown (especially for patients under age 12), the Dental TPA may request additional supporting documentation or photographs; pre-authorization is required for certain exceptions and for posts/cores/pins in primary teeth when indicated.

Provide photos or narrative documentation when requested to support clinical necessity for a crown.

Prior Authorization

RCT (D3220–D3425): generally no pre-authorization; submit claim after final obturation

Root canal therapy (RCT) codes D3220–D3425 do not require pre-authorization unless otherwise specified. Claims for RCT must be submitted only after final obturation is completed; if final obturation is not completed within four months, the office may submit a single D9110 claim dated on the initial treatment date with a pre-op radiograph and narrative.

Tooth must be restorable with favorable periodontal prognosis before RCT will be paid.
Final obturation radiograph must demonstrate complete obturation when submitting RCT claims.

Prior Authorization

Denture procedures: pre-authorization no longer required (offices may elect to pre-authorize)

As of 2024, denture fabrication procedures no longer require pre-authorization; offices may choose to pre-authorize to ensure documentation meets program criteria.

Insertion date is the billable date; adjustments and related visits are included for six months post-delivery and are not separately billable during that period.

Prior Authorization

Pre-authorization required for orthodontics; supporting documentation required for optional pre-auth items

Orthodontic benefits (limited and comprehensive) require pre-authorization with medical/dental diagnoses, treatment plan, anticipated treatment time and related information. Pre-authorization is optional for some denture rebases and for IV sedation (but claims or pre-auth must include supporting documentation).

Orthodontic pre-auth must include medical/dental diagnoses and treatment plan; orthodontist receives payment at treatment start and must maintain completion records.
IV sedation pre-authorization is optional, but claims/pre-auths must include a narrative and medical provider statement of formal diagnosis when used.

Billing Rule

Do not bill separate post-op D0140/D9110 for extraction/oral surgery within 30 days

Postoperative care for extractions and oral surgery is included in the paid benefit for 30 days by the same dentist/office; within that period, neither private offices nor FQHCs may submit D0140 or D9110 claims for post-op visits related to the original procedure.

Post-op issues (e.g., bleeding, dry socket) are included in the extraction/oral surgery payment for 30 days.

Documentation Required

Submit pathology report with incisional biopsy claims or expect denial

Incisional biopsies of oral tissue (soft or hard) require submission of a pathology report; claims are denied if a pathology report is not submitted.

Biopsy performed without a pathology report will be denied.
Biopsies are subject to dental review when performed with extractions in the same surgical area or date of service.

Prior Authorization

IV moderate sedation (D9239/D9243) — use only with qualifying procedures and required documentation

IV moderate (conscious) sedation codes D9239 and D9243 are payable only when used with a qualifying completed endodontic (D3220–D3425) or surgical dental (D7111–D7971) procedure included on the same claim, the patient displays inability to cooperate without IV sedation, and the patient has a formal medical diagnosis involving emotional/behavioral dysregulation; pre-authorization is optional but claims or pre-auths must include a narrative of inability to cooperate and a statement/chart note from a Hawaii-licensed medical provider with a formal diagnosis.

If nitrous oxide is used with IV sedation, D9230 is considered part of the D9239/D9243 service and not billable separately.
Maintain medical history, sedation record, diagnosis, and pre-surgical radiographs in clinical records.

Prior Authorization

Nitrous oxide (D9230) — payable only with qualifying procedure and documented formal diagnosis

Nitrous oxide (D9230) is a program benefit when used with a qualifying completed endodontic (D3220–D3425) or surgical dental (D7111–D7971) procedure included on the same claim, when the patient displays an inability to cooperate without nitrous oxide, and when medical need is confirmed by a formal medical diagnosis involving emotional dysregulation or a neurodivergent condition. Pre-authorization is optional; claims or pre-auths must include a narrative describing inability to cooperate and a statement/chart note from a Hawaii-licensed medical provider with a formal diagnosis.

D9230 is not billable separately if used together with IV sedation (it is then part of D9239/D9243).
Include narrative and medical provider statement with claim or pre-authorization submission when claiming D9230.

Documentation Required

Behavior Management (D9920) — document medical necessity, modifications, and CE; limited to 4/year

Behavior Management (D9920) is payable when medical necessity is documented (developmental/intellectual disability per HAR 11-88.1.5 or equivalent) and when the dental team significantly modifies the method/process of service delivery or extends appointment time by at least 15 minutes for time-only claims. The benefit is limited to four uses per year per patient, is denied if any pharmacologic sedation or nitrous oxide is used during the same appointment, and the provider must maintain at least one hour of continuing education related to care of individuals with special health care needs within the previous 24 months.

Process modifications must be documented; time-only increases must be ≥15 minutes.
Claim denied if pharmacologic sedation or nitrous oxide used during same appointment.
Maintain CE record (≥1 hour in past 24 months) to support claims.

Billing Rule

Include D9995/D9996 on all teledentistry claims and document patient location

All teledentistry claims must include D9995 (synchronous) or D9996 (asynchronous) as line items (fee set to zero). Clinics using FQHC PPS have specific submission guidance and may use D9999 or D0140 as first lines when using PPS; all claims must indicate the patient's treatment location in the claim remarks or the claim will be denied.

Set D9995/D9996 fee to zero and include as a claim line item.
For FQHC PPS: ensure patient and dentist were each physically located at separate eligible FQHC/RHC sites and use appropriate first-line codes (D9999 or D0140).
Include the specific patient location (name and address) in the 'Remarks' section to avoid denial.

Documentation Required

Submit dental prescription claims to the State PBM, not the beneficiary's managed care plan

Prescriptions written by dentists must be submitted to the State's Medicaid Pharmacy Benefit Manager (PBM) for claims processing, not to the beneficiary's QUEST Integration health plan.

Refer to Chapter 19 and the Med-QUEST pharmacy resources for PBM procedures and drug coverage details.

CDT / HCPCS Codes, Frequency, and Limits

Notable updated and new CDT codes in May 2025CDT | mixedCovered

D1354	Caries Arresting Agent — reimbursement increased; available for up to 6 carious teeth per day; providers must maintain photographic or radiographic images in the patient record (not required on claim).
D1355	Caries Prevention Agent — new Children's benefit for full‑mouth application of selected topical preventive medicaments (agents >=30% SDF or iodine-based agents); shares frequency/payment limits with topical fluoride and consolidates same‑day preventive agent claims.
D9920	Behavior management — new Children's benefit when provider must adapt procedures or use additional time for patients with special medical considerations limiting cooperation (documentation and CE requirements apply).

GA authorization codingCPT

41899

Dental authorization request code referenced for GA pre-authorization (included on dental authorization request per required documentation).

FQHC encounter codingCDT

D9999	FQHC pediatric encounter first-line code when setting fee to encounter rate; all program-eligible services listed subsequently with fees set to zero.
D0140	FQHC adult encounter first-line code when setting fee to encounter rate; program-eligible services listed subsequently with fees set to zero (use second D0140 with fee zero if appointment includes a limited problem-focused exam).

Full mouth seriesCPTCovered

D0210

Intraoral - Complete Series of Radiographic Images (12-22 images); frequency limitation: 1 per 5 years; submission may require chart/report per diagnostic need.

BitewingsCPTCovered

D0274

Bitewings - Four Radiographic Images (applies to bitewing annual limit along with D0270/D0272); frequency: 2 per year (no sooner than 4 months apart for some codes).

Preventive medicamentsCPTCovered

D1354	Caries Arresting Medicament (SDF) — paid benefit available for up to 6 teeth per day; providers must maintain photographic or radiographic images in patient records; when claimed same day as D1355, D1354 services are consolidated into D1355 with no additional payment.
D1355	Caries Prevention Medicament — full‑mouth application of agents with at least 30% SDF or iodine-based agents (including 10% povidone iodine); shares frequency/payment limits with topical fluoride (D1206/D1208); same-day topical preventive agents combined and paid as D1355 (one paid benefit per day).

Restorative (selected)CPTCovered

D2140	Amalgam - One Surface, Primary or Permanent.
D2330	Resin-based Composite - One Surface, Anterior.

CrownsCPTCovered

D2740	Crown - Porcelain/Ceramic (temporary crowns considered part of the crown; frequency limitation: 1 per 5 years).
D2790	Crown - Full Cast High Noble Metal (limited to specific indications such as endodontic treatment, loss of a major cusp, or <50% remaining tooth structure).

Selected crown codes and descriptionsCPTCovered

D2740	Crown - Porcelain/Ceramic.
D2750	Crown - Porcelain Fused to High Noble Metal.
D2790	Crown - Full Cast High Noble Metal.

Endodontic codes groupCPTCovered

D3220-D3425

Root Canal Therapy and related endodontic procedures (multiple specific codes described); final obturation must be completed before claim submission; retreatment covered only for specific clinical circumstances; 1 diagnostic radiographic image allowed per tooth; additional working films considered part of treatment.

Periodontics codesCPTCovered

D4341/D4342	Periodontal Scaling and Root Planing - D4341: four or more teeth per quadrant; D4342: one to three teeth per quadrant (frequency limitation: 1 per 24 months; peri charting and documentation required).
D4355	Full Mouth Debridement — to enable comprehensive periodontal evaluation (frequency limitations apply; age and prior service restrictions).
D4910	Periodontal Maintenance — frequency and calendar-year rules apply (see program for specifics).

Removable prosthodontics codesCPTCovered

D5110/D5120	Complete Denture - Maxillary/Mandibular.
D5130/D5140	Immediate Denture - Maxillary/Mandibular.
D5410/D5421/D5422	Adjustment codes for complete and partial dentures (adjustments and related office visits included for six months post-delivery).

Selected removable prosthodontics codes shown in this segmentCPT

D5410	Adjust Complete Denture - Maxillary.
D5411	Adjust Complete Denture - Mandibular.
D5421	Adjust Partial Denture - Maxillary.
D5422	Adjust Partial Denture - Mandibular.
D5511	Repair Broken Complete Denture Base, Mandibular.
D5520	Replace missing or broken teeth - complete denture (per tooth) — frequency: 1 per 6 months per tooth.
D5630	Repair or Replace Broken Retentive/Clasping Materials - Per Tooth — frequency: 1 per year per tooth.
D5640	Replace Missing or Broken Teeth - Partial Denture - Per Tooth — frequency: 1 per 6 months per tooth.
D5710	Rebase Complete Maxillary Denture — frequency: 1 per 2 years (pre-authorization optional).

Selected oral/maxillofacial surgery codesCPT

D7140	Extraction, erupted tooth or exposed root (elevation and/or forceps removal) — extraction benefits limited to symptomatic teeth with clinical/radiographic pathology; postoperative care included for 30 days.
D7210	Extraction of erupted tooth requiring removal of bone and/or sectioning of tooth.
D7220	Removal of Impacted Tooth - Soft Tissue.
D7230	Removal of Impacted Tooth - Partially Bony.
D7240	Removal of Impacted Tooth - Completely Bony.
D7285	Incisional biopsy of oral tissue — requires submission of a pathology report and is denied if not submitted.

Moderate/IV sedation codes and rulesCPT

D9239	Intravenous moderate (conscious) sedation - first 15 minutes — payable when criteria met and used with qualifying endodontic (D3220-D3425) or surgical dental (D7111-D7971) procedure included on same claim; pre-authorization optional; supporting documentation required.
D9243	Intravenous moderate (conscious) sedation - each subsequent 15 minutes — payable with same conditions as D9239; sedation records and supporting documentation required.

Teledentistry-eligible CDT exam and radiograph codesCDTCovered

D0120	Periodic oral evaluation - established patient.
D0140	Limited oral evaluation - problem focused.
D0145	Oral evaluation for patient under three years 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.

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Oral surgery and anesthesia CDT codes with benefits in Medicaid medical plansmixedCovered

D7982	Sialodochoplasty.
D7983	Closure of salivary fistula.
D7990	Emergency tracheotomy / Coronoidectomy (listed).
D7995	Synthetic graft - mandible or facial bones, by report.
D7996	Implant - mandible for augmentation purposes, by report.
D7997	Appliance removal (not by dentist who replaced appliance), includes removal of arch bar.
D7999	Unspecified oral surgery procedure, by report.
D9222	Deep sedation/general anesthesia - first 15 minutes (benefit in Medicaid medical plans).
D9223	Deep sedation/general anesthesia - each subsequent 15 minute increment (benefit in Medicaid medical plans).

D1354 per-day teeth limit

D1354 (Caries Arresting Medicament)Paid benefit available for up to 6 carious teeth per day; providers must retain photographic or radiographic images in the patient record but are not required to submit them with claims.

D2330 / D2140 (Restorative selected codes)Referenced as covered restorative codes (D2330 resin-based composite one surface anterior; D2140 amalgam one surface primary or permanent) and reimbursed when clinically necessary for caries or fracture.

D2790 / D2750 / D2740 (Crown codes)Selected crown codes described with coverage limits and documentation: D2740 (porcelain/ceramic), D2750 (porcelain fused to high noble), D2790 (full cast high noble); frequency limits (e.g., some crowns limited to 1 per 5 years) and pre-authorization/documentation may be required.

D5110/D5120, D5130/D5140, D5410/D5421/D5422, D5411, D5421, D5422, D5511, D5520, D5630, D5640, D5710Removable prosthodontics codes and rules: complete/immediate dentures, adjustments (D5410/D5411/D5421/D5422), repairs (D5511, D5630), replace missing/broken denture tooth per tooth (D5520/D5640), and rebase (D5710) with frequency and inclusion rules (insertion date billable; adjustments included for 6 months; rebases/relines limited by intervals and some require pre-auth).

frequency interval measured by elapsed time

Frequency measurement: elapsed timeProcedure frequency limitations are measured by elapsed time (a 12‑month period starting from the last date the service was performed); exceptions noted (e.g., D4910 uses calendar year).

Two-year interval exampleA procedure with a 2-year frequency interval renews 24 months after the initial procedure; 'twice a year' allows a maximum of two benefits in any consecutive 12-month period.

Minimum period between servicesSome procedures also have a required minimum period between service dates during which no benefit will be paid (specifics listed per code).

D0210 frequency

D0210 (Full‑mouth intraoral series)Intraoral complete series (12–22 images) covered when clinically necessary; frequency limit: 1 per 5 years.

Submission requirementsChart/report/other supporting documentation may be required when requested by the TPA or for claim support.

Diagnostic qualityImages must be diagnostic quality and individually prescribed per ADA/FDA guidelines to qualify.

Bitewing frequency

Bitewing radiographs (D0270/D0272/D0274)Bitewing images are covered and applied to a combined annual limit: generally up to 2 per year; for D0274 (four bitewings) frequency guidance includes 'no sooner than 4 months apart' in applying the annual limit.

Applied to annual limitD0270, D0272, and D0274 are applied to the bitewing annual limit; timing rules (minimum spacing) apply to specific codes.

Clinical necessityEach bitewing must be individually prescribed and of diagnostic quality; Med‑QUEST/Dental TPA may request submission of images for review.

D1354 per-day teeth limit (duplicate highlight)

D1354 per-day teeth limit (duplicate)Paid benefit available for up to 6 teeth per day; claims for more than 6 teeth will have additional teeth denied; provider must retain photographic or radiographic images in the patient record.

Interaction with D1355/D1206/D1208If D1354 is claimed the same day as D1355, Medicaid consolidates D1354 into D1355 with no additional payment; offices may not bill patient for D1354 on that date and any preserved D1354 benefit remains available for later use.

Documentation retention vs claim submissionProviders are not required to submit images with claims for D1354 in most situations but must maintain images in records if requested.

Final obturation claim submission

Final obturation claim submission (RCT)Claims for root canal therapy must be submitted only after final obturation is completed; if final obturation is not completed within 4 months, a single D9110 claim is permitted with a pre‑op radiograph and narrative.

Retreatment and diagnostic imagesRetreatment is covered only for specified clinical circumstances reviewed by dental consultant; 1 diagnostic radiographic image allowed per tooth—additional working films are considered part of treatment and not billable separately.

Documentation requirementThe narrative should include an endodontic diagnosis and reason for retreatment to support claims; final post‑op radiograph must demonstrate obturation.

Frequency limits examples

Repair and retentive material limitsRepair or replace broken retentive/clasping materials (D5630) limited to 1 per year per tooth.

Replace missing/broken denture toothReplacement of missing or broken teeth on partial/complete dentures (D5520/D5640) limited to 1 per 6 months per tooth.

Rebase/reline frequencyRebase of complete dentures (D5710) limited to once every 2 years; rebases/relines may be pre‑authorization optional and subject to specified intervals.

D9920 frequency limit

D9920 (Behavior Management) frequency limitD9920 is payable up to four times per year per patient when documented medical necessity and required process/time modifications are met.

Documentation and CE requirementProviders must document process modifications (or ≥15 minutes additional appointment time) and have at least 1 hour of CE in care of individuals with special needs within the previous 24 months to claim D9920.

Exclusions for D9920D9920 will be denied for any appointment that involved pharmacologic sedation or nitrous oxide and is not appropriate for routine minor behavior issues.

Teledentistry claim rule

Teledentistry claim submission ruleOnly one claim submission is allowed per patient visit; the service date on the claim must be the date the patient was at the originating site (regardless of asynchronous/synchronous workflow).

Claim contents and date consistencyWhen asynchronous technology causes a date mismatch between interpretation and visit, clinical records should note the discrepancy for auditing purposes.

Required teledentistry line itemsAll teledentistry claims must include D9995 (synchronous) or D9996 (asynchronous) with fee set to zero; FQHC PPS clinics have specific submission guidance and must include encounter code conventions.

Topical prevention agents payment limit

Topical prevention agents combined payment limitAt a single appointment, payment for topical fluoride (D1206/D1208), povidone iodine, and SDF (D1355) are combined and treated as one; limit of one paid benefit per day across D1206/D1208/D1355 (paid as D1355 when applicable).

D1355 full‑mouth scopeD1355 is a full‑mouth application benefit limited to agents with ≥30% SDF or iodine‑based agents (including 10% povidone iodine); D1355 may be submitted with or without an assigned tooth but only one D1355 paid per day.

Interaction with D1354If D1354 is claimed the same day as D1355, Medicaid consolidates D1354 into D1355 with no additional payment; offices may still submit both codes but only one payment will be made.

Program Definitions and Scope

inv-59: Children's Dental Program (under age 21) — governed by EPSDT; broader range of services including some orthodontic coverage for developmental defects.

Program (children)Children's Dental Program — covers enrollees under age 21 and is governed by EPSDT, offering a broader range of services including limited orthodontic benefits for developmental defects

ScopeIncludes preventive, diagnostic, restorative, endodontic, periodontal, prosthetic, orthodontic (select cases), and oral surgery services when criteria met

AdministrationDay-to-day operations and claims processing are conducted by a contracted third‑party administrator; benefits defined by DHS

inv-60: Adult Dental Program (age 21 and older) — limited set of preventive, diagnostic, restorative, endodontic, periodontal, prosthodontic, and emergency services with specified frequency limits.

Program (adults)Adult Dental Program — for enrollees aged 21 and older with a limited but specific set of covered services

Covered servicesIncludes preventive (oral evaluations, prophylaxis, topical agents), diagnostic/radiology, restorative, endodontic (per policy limits), periodontal, prosthodontic, and emergency services

Frequency limitsMany adult services have defined frequency limits (e.g., prophylaxis and periodic exams 2/year; comprehensive exam 1 per 5 years; full series x‑rays 1 per 5 years)

inv-61: Claim submission timing rule

DeadlineClaims for completed dental services must be submitted using CDT codes within one year of completion of the dental procedure

Multiple-visit proceduresSubmit with service date equal to the date of completion of the entire procedure (e.g., crowns on cementation date)

Supporting documentationMed-QUEST or Dental TPA may request additional materials (x‑rays, photos, narratives, perio charts, lab invoices) to support payment

inv-62: Elapsed time (frequency measurement)

MeasurementElapsed time = a 12‑month period starting from the last date the service was provided; used to determine frequency limits

Consecutive limitsA 'twice a year' allowance means a maximum of two paid benefits in any consecutive 12‑month period

Code exceptionD4910 periodontal maintenance is based on calendar year rather than elapsed time

inv-63: General anesthesia payment context (optional last-resort)

Role of GAGeneral anesthesia (GA) is an option of last resort and reserved for exceptional circumstances when safe treatment cannot be provided in office

Approval criteriaGA is approved only if one of three listed conditions is met or if all four alternative conditions are simultaneously met (see policy for details)

Not approved usesGA will not be approved for anxiety, scheduling convenience, routine exams, or when alternatives could address the problem

inv-64: Radiograph clinical necessity / billing

Clinical necessityRadiographs must be individually prescribed and clinically necessary per ADA/FDA guidelines; images must be diagnostic quality

SubmissionMed-QUEST or Dental TPA may request submission of any x‑rays claimed; midprocedure and post‑op radiographs are part of the procedure and not billable separately

RecordkeepingProviders should retain diagnostic images and be prepared to provide them if requested to support claims

inv-65: D1354 documentation note

RequirementFor D1354, providers must maintain photographic or radiographic images of caries for each tooth claimed in the patient record, though images need not be submitted with claims in most situations

Increased reimbursementD1354 reimbursement value has been significantly increased per the May 2025 update

Interaction with D1355If D1354 is claimed the same day as D1355, Medicaid consolidates payment under D1355 and preserves remaining D1354 benefit availability for other dates

inv-66: D1355 scope and interaction

ScopeD1355 is a new benefit for full‑mouth application of topical preventive medicaments (agents ≥30% SDF or iodine-based agents such as 10% povidone iodine)

Payment interactionD1355 shares eligibility and combined frequency/payment limits with topical fluoride codes (D1206/D1208); same‑day topical agent claims are consolidated and paid as D1355

Submission flexibilityD1355 can be submitted with or without an assigned tooth; if multiple same‑day D1355 claims are submitted only one will be paid

inv-67: Space maintainer billing inclusion

InclusionSpace maintainer ongoing maintenance, re‑cementation, and removal performed by the office that placed the appliance are considered part of the original procedure and may not be billed separately

Frequency examplesSpecific space maintainer codes have defined frequency limitations (see code criteria for exact intervals)

SubmissionClaims for re‑cement/rebond may have minimum intervals (e.g., no sooner than 6 months after placement for some codes)

inv-68: Final obturation requirement

Primary ruleFinal obturation must be completed before submitting a claim for root canal therapy (RCT) codes D3220–D3425

Late completion optionIf final obturation is not completed within 4 months of initiation, a single D9110 claim may be submitted dated to the initial treatment date with pre‑op radiograph and narrative

Retreatment noteRetreatment is covered only for specific clinical circumstances and retreatment by same dentist within 24 months may be considered part of original procedure

inv-69: Periodontal charting content requirements

Required elementsPeriodontal charting must include patient name, date, six‑point pocket depths, areas of clinical attachment loss, and bleeding sites

TimingPocket depth measurements must be within 6 months prior to date of service for scaling/root planing codes

DenialsProcedures may be denied if documentation does not support alveolar bone loss or attachment loss

inv-70: IV sedation definition

DefinitionIV moderate (conscious) sedation (D9239/D9243) — administration of intravenous sedation reported in 15‑minute increments

Use conditionsIV sedation is a benefit when patient cannot cooperate without it and is used with a qualifying completed endodontic or surgical dental procedure included on same claim

DocumentationClaims or pre‑auth must include narrative of inability to cooperate and medical provider statement/chart note with formal diagnosis

inv-71: Postoperative care period

Post-op periodPostoperative care following extractions/oral surgery is included in the paid benefit for 30 days by the same dentist/office; separate D0140 or D9110 claims for related post‑op visits within that period are not payable

Symptomatic requirementExtractions are limited to symptomatic teeth with clinical signs or radiographic pathology; elective extractions (including for orthodontics) are not covered

ScopeSome oral surgery procedures may instead have benefits under Medicaid medical managed care plans rather than the dental program

inv-72: Telehealth / Teledentistry definition

DefinitionTelehealth: use of telecommunication services to transmit patient health information when patient at an originating site and provider at a distant site; Teledentistry is a form of telehealth

PurposeIntended to facilitate access for patients who would otherwise face geographic barriers to care

Claiming implicationsSee teledentistry sections for service date and single‑claim rules that apply to telehealth encounters

inv-73: D9920 Behavior Management definition

DefinitionD9920 — Behavior Management: benefit for significant modifications to normal clinic processes or extended appointment time to safely provide dental care

ExamplesExamples include use of papoose board for combative ASD child, treating a patient in a wheelchair with clinic modifications, or extended orientation/desensitization requiring ≥15 minutes

RestrictionsD9920 will be denied for appointments involving pharmacologic sedation or nitrous oxide and requires provider CE documentation (≥1 hour in prior 24 months)

inv-74: D1355 Caries Preventive Medicament Application definition

Payment ruleD1355 — Caries Preventive Medicament Application is paid as a single full‑mouth application benefit and is combined with topical fluoride codes (D1206/D1208) for payment limits

Agent criteriaLimited to agents with ≥30% Silver Diamine Fluoride or iodine‑based agents (including 10% povidone iodine)

Submission noteIf D1355 is applied same day as D1354 or topical fluoride, claims are consolidated and only one payment will be made; D1355 may be submitted with or without an assigned tooth

Selected Notable Codes and Frequency Highlights

6D1354 teeth/day limit

1New D1355 benefit (Children)

1New D9920 benefit (Children)

0Image submission required on claim (no)

Policy Revision History

2025-05-01revisedLatest

D1354 (Caries Arresting Agent) reimbursement significantly increased and benefit updated to allow treatment of up to 6 carious teeth per day; providers no longer required to submit radiographic/photographic images with claims but must retain them in patient records.

2025-05added

D1355 (Caries Prevention Agent) added as a new Children’s Dental Program benefit for full-mouth application of selected topical preventive medicaments.

2025-05added

D9920 (Behavior Management) added as a new Children’s Dental Program benefit to reimburse adaptations or additional time when treating patients with special medical considerations limiting cooperation.

Policy Summary

PayerHawaii Department of Human Services

PolicyMedicaid Dental Program (Chapter 14) overview and operational policies

Policy CodePolicy N/A

Change TypeBenefit additions and rate/coverage revisions (May 2025)

Effective DateMay 1, 2025

Last ReviewMay 1, 2025

Next Review DateN/A

Key ActionSubmit required pre-authorization documentation for general anesthesia and other listed services via the portal or forms, including the five GA components when applicable.

SourceLink

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Medicaid Dental Program (Chapter 14) overview and operational policies

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Coverage Criteria and Limits

Coverage overview and criteria (partial — additional sections follow in later parts of document)

ALL of the following

Program populations
- Children's Dental Program — beneficiaries younger than age 21; governed by EPSDT and offers broader services (including limited orthodontics for developmental defects).
- Adult Dental Program — beneficiaries age 21 and older; limited set of preventive, diagnostic, restorative, endodontic, periodontal, prosthodontic, and emergency services with specified frequency limits (examples: comprehensive oral evaluation once per five years; prophylaxis two per year; bitewings two per year; full series one per five years).
Benefits are paid only to registered dental providers at registered office locations using CDT codes in effect on the date of service.
A separate set of medically related oral surgery benefits may be available through Medicaid medical managed care plans (see section 14.11).
Pre-authorization is required for certain services (including any dental treatment under general anesthesia, orthodontics, and special benefit exceptions for severe developmental disability or medical fragility); emergency services do not require pre-authorization.

Providers should reference the most recent program version (e.g., May 2025) on the provider portal for updates and operational details.

General Anesthesia coverage criteria and authorization process

Criteria and process for Medicaid payment of dental services under general anesthesia and pre-authorization requirements.

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Alternatively, Medicaid will approve GA when ALL of the following four conditions are met:

The patient is extremely physically resistant/uncooperative.
Extensive oral treatment is necessary.
Postponement of treatment is likely to result in significant adverse effects to the patient's medical or dental condition.
Alternative dental treatments cannot be completed both safely and effectively in an office using adjunctive techniques or modalities (examples: behavioral management, protective stabilization, sedative medications, caries arrest with SDF, nitrous oxide or conscious sedation).

GA will not be approved to avoid anxiety, parental/dentist apprehension, scheduling convenience, to perform exams, or when alternatives could address the problem.

Payment criteria, clinical necessity, frequency, and provider limits

General coverage and payment criteria for dental services and provider limitations.

Eligibility: Patient must be enrolled in Medicaid on date of service and provider must be an approved Medicaid participant on date of service.

Provider-based limits: Some benefits have provider‑specific limitations that follow the provider across service locations and limit total paid for a patient for specific codes or code ranges.

Self-pay options and billing restrictions

Rules for optional/self-pay services and restrictions on collecting payment from Medicaid patients.

Examples of allowable self‑pay situations (with signed agreement):

Teeth whitening (non‑benefit) — may be paid by patient with signed financial acknowledgment; no related Medicaid exam/x‑ray claims should be submitted.
Adult gold crowns (non‑benefit for adults) — patient may elect to pay up to UCR after being offered benefitted stainless‑steel alternative; signed agreement required; FQHCs may not submit encounter claims for these appointments.
Exceeding benefit frequency (e.g., prophylaxis/flouride more often than allowed) — after available benefits are used, patient may self‑pay with signed agreement; FQHCs may not submit encounter claims.

Claims, billing data, FQHC billing, and radiograph requirements

Claims submission, billing information, and radiograph rules.

Extracted coverage criteria

Coverage and limits for services in this segment:

D0210 (Full‑mouth series): Covered when clinically necessary; frequency limit 1 per 5 years; images must be diagnostic quality and may be requested to support claims.

Space maintainer maintenance (re‑cementation, removal) performed by the office that placed the appliance is included in the original procedure and may not be billed separately.

Crowns

Crown coverage and limitations

Temporary crowns are considered part of the definitive crown procedure and are not billed separately.

Posts, cores, and pins are not benefitted procedures for primary teeth unless there is a congenitally missing corresponding permanent tooth; pre‑authorization is required for such exceptions.

Root Canal Therapy (D3220-D3425)

Endodontic coverage rules

Pre-authorization: Root canal therapy codes D3220–D3425 do not require pre-authorization unless otherwise stated.

Clinical requirement: Tooth must be restorable with a favorable periodontal prognosis to qualify for endodontic therapy.

Periodontics

Periodontic coverage and documentation

Documentation: Periodontal charting must show patient name, date, six‑point pocket depth measurements on all teeth, areas of clinical attachment loss, and probing sites exhibiting bleeding.

Coverage: Periodontal scaling and root planing (SCRP) procedures do not require pre‑authorization (offices may elect to pre‑authorize).

Frequency: SCRP limited to 1 per 24 months; periodontal maintenance (D4910) limited to 2 per calendar year provided there is prior history of D4341/D4342 documented in the record.

Denial risk: D1110 and D4355 are denied when performed on the same day as D4341 or D4342.

Removable Prosthodontics

Removable prosthodontics coverage rules

Frequency and relines: Laboratory relines allowed one year after insertion; relines less than one year after insertion require pre‑authorization; subsequent relines limited to once every two years.

Policy update: As of 2024, denture procedures no longer require pre‑authorization, although offices may elect to pre‑authorize to ensure documentation meets program criteria.

Coverage criteria and limitations (Oral & Maxillofacial Surgery)

Oral & Maxillofacial Surgery — coverage limitations

Biopsy requirement: Incisional biopsies require submission of a pathology report and are denied if one is not submitted.

Coverage criteria and administrative rules

Coverage and qualification criteria for specific dental services and distinctions between dental‑program and medical‑plan dental services.

Dental prescriptions: Prescriptions written by dentists must be submitted to the State's Medicaid Pharmacy Benefit Manager (PBM) rather than to the beneficiary's QUEST Integration health plan.

Coverage criteria and guidance (excerpt)

Coverage notes, limits, and examples from this section:

Dental prescription routing: Prescriptions written by dentists must be submitted to the State's Medicaid PBM (not the beneficiary's managed care plan); see Chapter 19 and PBM resources for details.

Program focus: Adult Medicaid benefits prioritize prevention, therapeutic services, and establishing a dental home rather than esthetic or non‑critical restorative services.

Provider Requirements, Pre-Authorization, and Documentation

Prior Authorization

Pre-authorization required for GA, orthodontics, and special exceptions

Submission methods: fax, mail, or Medicaid online portal.
Include radiographs when applicable and an accepted clinical diagnosis.
Emergency services do not require pre-authorization.

Prior Authorization

Expedited ('Urgent') pre-authorization for <1 week procedures

Mark 'Urgent' on top of the authorization form to request expedited review.

Prior Authorization

General anesthesia (GA) — five-component pre-authorization and medical-plan step

Required five components: DHS 1190, DHS 1191, DHS 1192, dental authorization request including CPT 41899, and chart notes/narrative with diagnosis/treatment plan and evidence that alternatives were attempted.
Medicaid medical-plan authorization for hospital/anesthesia services must be requested separately after dental pre-authorization.

Documentation Required

Post-authorization: submit to Medicaid medical plan for hospital/anesthesia benefits

Dental pre-authorization is reviewed by Dental TPA; separate medical-plan approval is required for facility/anesthesia claims.
Code-specific benefit and frequency limits remain applicable despite GA pre-approval.

Documentation Required

Submit radiographs only when individually prescribed and clinically necessary

Radiographs should follow ADA and FDA guidelines and be prescribed only when they provide additional diagnostic information.
TPA may request submission of x-rays to support claims.

Prior Authorization

Pre-authorize special crown cases and provide supporting images if requested

Pre-authorization required for special third molar crown exceptions and specified primary-tooth post/core exceptions.
If radiographs do not clearly justify a crown, the TPA may request photos or extra documentation.

Billing Rule

Do not bill separately for space maintainer maintenance by the placing office

Ongoing maintenance, re-cementation, and removal of a space maintainer performed by the office that placed the appliance are included in the original procedure and may not be billed separately.

Re-cement/re-bond frequency rules apply (see code-specific frequency limits).

Documentation Required

Provide photos/additional documentation for crown pre-authorization when radiographs are insufficient

Provide photos or narrative documentation when requested to support clinical necessity for a crown.

Prior Authorization

RCT (D3220–D3425): generally no pre-authorization; submit claim after final obturation

Tooth must be restorable with favorable periodontal prognosis before RCT will be paid.
Final obturation radiograph must demonstrate complete obturation when submitting RCT claims.

Prior Authorization

Denture procedures: pre-authorization no longer required (offices may elect to pre-authorize)

As of 2024, denture fabrication procedures no longer require pre-authorization; offices may choose to pre-authorize to ensure documentation meets program criteria.

Insertion date is the billable date; adjustments and related visits are included for six months post-delivery and are not separately billable during that period.

Prior Authorization

Pre-authorization required for orthodontics; supporting documentation required for optional pre-auth items

Orthodontic pre-auth must include medical/dental diagnoses and treatment plan; orthodontist receives payment at treatment start and must maintain completion records.
IV sedation pre-authorization is optional, but claims/pre-auths must include a narrative and medical provider statement of formal diagnosis when used.

Billing Rule

Do not bill separate post-op D0140/D9110 for extraction/oral surgery within 30 days

Post-op issues (e.g., bleeding, dry socket) are included in the extraction/oral surgery payment for 30 days.

Documentation Required

Submit pathology report with incisional biopsy claims or expect denial

Incisional biopsies of oral tissue (soft or hard) require submission of a pathology report; claims are denied if a pathology report is not submitted.

Biopsy performed without a pathology report will be denied.
Biopsies are subject to dental review when performed with extractions in the same surgical area or date of service.

Prior Authorization

IV moderate sedation (D9239/D9243) — use only with qualifying procedures and required documentation

If nitrous oxide is used with IV sedation, D9230 is considered part of the D9239/D9243 service and not billable separately.
Maintain medical history, sedation record, diagnosis, and pre-surgical radiographs in clinical records.

Prior Authorization

Nitrous oxide (D9230) — payable only with qualifying procedure and documented formal diagnosis

D9230 is not billable separately if used together with IV sedation (it is then part of D9239/D9243).
Include narrative and medical provider statement with claim or pre-authorization submission when claiming D9230.

Documentation Required

Behavior Management (D9920) — document medical necessity, modifications, and CE; limited to 4/year

Process modifications must be documented; time-only increases must be ≥15 minutes.
Claim denied if pharmacologic sedation or nitrous oxide used during same appointment.
Maintain CE record (≥1 hour in past 24 months) to support claims.

Billing Rule

Include D9995/D9996 on all teledentistry claims and document patient location

Set D9995/D9996 fee to zero and include as a claim line item.
For FQHC PPS: ensure patient and dentist were each physically located at separate eligible FQHC/RHC sites and use appropriate first-line codes (D9999 or D0140).
Include the specific patient location (name and address) in the 'Remarks' section to avoid denial.

Documentation Required

Submit dental prescription claims to the State PBM, not the beneficiary's managed care plan

Prescriptions written by dentists must be submitted to the State's Medicaid Pharmacy Benefit Manager (PBM) for claims processing, not to the beneficiary's QUEST Integration health plan.

Refer to Chapter 19 and the Med-QUEST pharmacy resources for PBM procedures and drug coverage details.

CDT / HCPCS Codes, Frequency, and Limits

Notable updated and new CDT codes in May 2025CDT | mixedCovered

D1354	Caries Arresting Agent — reimbursement increased; available for up to 6 carious teeth per day; providers must maintain photographic or radiographic images in the patient record (not required on claim).
D1355	Caries Prevention Agent — new Children's benefit for full‑mouth application of selected topical preventive medicaments (agents >=30% SDF or iodine-based agents); shares frequency/payment limits with topical fluoride and consolidates same‑day preventive agent claims.
D9920	Behavior management — new Children's benefit when provider must adapt procedures or use additional time for patients with special medical considerations limiting cooperation (documentation and CE requirements apply).

GA authorization codingCPT

41899

Dental authorization request code referenced for GA pre-authorization (included on dental authorization request per required documentation).

FQHC encounter codingCDT

D9999	FQHC pediatric encounter first-line code when setting fee to encounter rate; all program-eligible services listed subsequently with fees set to zero.
D0140	FQHC adult encounter first-line code when setting fee to encounter rate; program-eligible services listed subsequently with fees set to zero (use second D0140 with fee zero if appointment includes a limited problem-focused exam).

Full mouth seriesCPTCovered

D0210

Intraoral - Complete Series of Radiographic Images (12-22 images); frequency limitation: 1 per 5 years; submission may require chart/report per diagnostic need.

BitewingsCPTCovered

D0274

Bitewings - Four Radiographic Images (applies to bitewing annual limit along with D0270/D0272); frequency: 2 per year (no sooner than 4 months apart for some codes).

Preventive medicamentsCPTCovered

D1354	Caries Arresting Medicament (SDF) — paid benefit available for up to 6 teeth per day; providers must maintain photographic or radiographic images in patient records; when claimed same day as D1355, D1354 services are consolidated into D1355 with no additional payment.
D1355	Caries Prevention Medicament — full‑mouth application of agents with at least 30% SDF or iodine-based agents (including 10% povidone iodine); shares frequency/payment limits with topical fluoride (D1206/D1208); same-day topical preventive agents combined and paid as D1355 (one paid benefit per day).

Restorative (selected)CPTCovered

D2140	Amalgam - One Surface, Primary or Permanent.
D2330	Resin-based Composite - One Surface, Anterior.

CrownsCPTCovered

D2740	Crown - Porcelain/Ceramic (temporary crowns considered part of the crown; frequency limitation: 1 per 5 years).
D2790	Crown - Full Cast High Noble Metal (limited to specific indications such as endodontic treatment, loss of a major cusp, or <50% remaining tooth structure).

Selected crown codes and descriptionsCPTCovered

D2740	Crown - Porcelain/Ceramic.
D2750	Crown - Porcelain Fused to High Noble Metal.
D2790	Crown - Full Cast High Noble Metal.

Endodontic codes groupCPTCovered

D3220-D3425

Periodontics codesCPTCovered

D4341/D4342	Periodontal Scaling and Root Planing - D4341: four or more teeth per quadrant; D4342: one to three teeth per quadrant (frequency limitation: 1 per 24 months; peri charting and documentation required).
D4355	Full Mouth Debridement — to enable comprehensive periodontal evaluation (frequency limitations apply; age and prior service restrictions).
D4910	Periodontal Maintenance — frequency and calendar-year rules apply (see program for specifics).

Removable prosthodontics codesCPTCovered

D5110/D5120	Complete Denture - Maxillary/Mandibular.
D5130/D5140	Immediate Denture - Maxillary/Mandibular.
D5410/D5421/D5422	Adjustment codes for complete and partial dentures (adjustments and related office visits included for six months post-delivery).

Selected removable prosthodontics codes shown in this segmentCPT

D5410	Adjust Complete Denture - Maxillary.
D5411	Adjust Complete Denture - Mandibular.
D5421	Adjust Partial Denture - Maxillary.
D5422	Adjust Partial Denture - Mandibular.
D5511	Repair Broken Complete Denture Base, Mandibular.
D5520	Replace missing or broken teeth - complete denture (per tooth) — frequency: 1 per 6 months per tooth.
D5630	Repair or Replace Broken Retentive/Clasping Materials - Per Tooth — frequency: 1 per year per tooth.
D5640	Replace Missing or Broken Teeth - Partial Denture - Per Tooth — frequency: 1 per 6 months per tooth.
D5710	Rebase Complete Maxillary Denture — frequency: 1 per 2 years (pre-authorization optional).

Selected oral/maxillofacial surgery codesCPT

D7140	Extraction, erupted tooth or exposed root (elevation and/or forceps removal) — extraction benefits limited to symptomatic teeth with clinical/radiographic pathology; postoperative care included for 30 days.
D7210	Extraction of erupted tooth requiring removal of bone and/or sectioning of tooth.
D7220	Removal of Impacted Tooth - Soft Tissue.
D7230	Removal of Impacted Tooth - Partially Bony.
D7240	Removal of Impacted Tooth - Completely Bony.
D7285	Incisional biopsy of oral tissue — requires submission of a pathology report and is denied if not submitted.

Moderate/IV sedation codes and rulesCPT

D9239	Intravenous moderate (conscious) sedation - first 15 minutes — payable when criteria met and used with qualifying endodontic (D3220-D3425) or surgical dental (D7111-D7971) procedure included on same claim; pre-authorization optional; supporting documentation required.
D9243	Intravenous moderate (conscious) sedation - each subsequent 15 minutes — payable with same conditions as D9239; sedation records and supporting documentation required.

Teledentistry-eligible CDT exam and radiograph codesCDTCovered

D0120	Periodic oral evaluation - established patient.
D0140	Limited oral evaluation - problem focused.
D0145	Oral evaluation for patient under three years 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.

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Oral surgery and anesthesia CDT codes with benefits in Medicaid medical plansmixedCovered

D7982	Sialodochoplasty.
D7983	Closure of salivary fistula.
D7990	Emergency tracheotomy / Coronoidectomy (listed).
D7995	Synthetic graft - mandible or facial bones, by report.
D7996	Implant - mandible for augmentation purposes, by report.
D7997	Appliance removal (not by dentist who replaced appliance), includes removal of arch bar.
D7999	Unspecified oral surgery procedure, by report.
D9222	Deep sedation/general anesthesia - first 15 minutes (benefit in Medicaid medical plans).
D9223	Deep sedation/general anesthesia - each subsequent 15 minute increment (benefit in Medicaid medical plans).

D1354 per-day teeth limit

frequency interval measured by elapsed time

Two-year interval exampleA procedure with a 2-year frequency interval renews 24 months after the initial procedure; 'twice a year' allows a maximum of two benefits in any consecutive 12-month period.

Minimum period between servicesSome procedures also have a required minimum period between service dates during which no benefit will be paid (specifics listed per code).

D0210 frequency

D0210 (Full‑mouth intraoral series)Intraoral complete series (12–22 images) covered when clinically necessary; frequency limit: 1 per 5 years.

Submission requirementsChart/report/other supporting documentation may be required when requested by the TPA or for claim support.

Diagnostic qualityImages must be diagnostic quality and individually prescribed per ADA/FDA guidelines to qualify.

Bitewing frequency

Applied to annual limitD0270, D0272, and D0274 are applied to the bitewing annual limit; timing rules (minimum spacing) apply to specific codes.

Clinical necessityEach bitewing must be individually prescribed and of diagnostic quality; Med‑QUEST/Dental TPA may request submission of images for review.

D1354 per-day teeth limit (duplicate highlight)

Documentation retention vs claim submissionProviders are not required to submit images with claims for D1354 in most situations but must maintain images in records if requested.

Final obturation claim submission

Documentation requirementThe narrative should include an endodontic diagnosis and reason for retreatment to support claims; final post‑op radiograph must demonstrate obturation.

Frequency limits examples

Repair and retentive material limitsRepair or replace broken retentive/clasping materials (D5630) limited to 1 per year per tooth.

Replace missing/broken denture toothReplacement of missing or broken teeth on partial/complete dentures (D5520/D5640) limited to 1 per 6 months per tooth.

Rebase/reline frequencyRebase of complete dentures (D5710) limited to once every 2 years; rebases/relines may be pre‑authorization optional and subject to specified intervals.

D9920 frequency limit

D9920 (Behavior Management) frequency limitD9920 is payable up to four times per year per patient when documented medical necessity and required process/time modifications are met.

Exclusions for D9920D9920 will be denied for any appointment that involved pharmacologic sedation or nitrous oxide and is not appropriate for routine minor behavior issues.

Teledentistry claim rule

Claim contents and date consistencyWhen asynchronous technology causes a date mismatch between interpretation and visit, clinical records should note the discrepancy for auditing purposes.

Topical prevention agents payment limit

Program Definitions and Scope

inv-59: Children's Dental Program (under age 21) — governed by EPSDT; broader range of services including some orthodontic coverage for developmental defects.

ScopeIncludes preventive, diagnostic, restorative, endodontic, periodontal, prosthetic, orthodontic (select cases), and oral surgery services when criteria met

AdministrationDay-to-day operations and claims processing are conducted by a contracted third‑party administrator; benefits defined by DHS

inv-60: Adult Dental Program (age 21 and older) — limited set of preventive, diagnostic, restorative, endodontic, periodontal, prosthodontic, and emergency services with specified frequency limits.

Program (adults)Adult Dental Program — for enrollees aged 21 and older with a limited but specific set of covered services

Frequency limitsMany adult services have defined frequency limits (e.g., prophylaxis and periodic exams 2/year; comprehensive exam 1 per 5 years; full series x‑rays 1 per 5 years)

inv-61: Claim submission timing rule

DeadlineClaims for completed dental services must be submitted using CDT codes within one year of completion of the dental procedure

Multiple-visit proceduresSubmit with service date equal to the date of completion of the entire procedure (e.g., crowns on cementation date)

Supporting documentationMed-QUEST or Dental TPA may request additional materials (x‑rays, photos, narratives, perio charts, lab invoices) to support payment

inv-62: Elapsed time (frequency measurement)

MeasurementElapsed time = a 12‑month period starting from the last date the service was provided; used to determine frequency limits

Consecutive limitsA 'twice a year' allowance means a maximum of two paid benefits in any consecutive 12‑month period

Code exceptionD4910 periodontal maintenance is based on calendar year rather than elapsed time

inv-63: General anesthesia payment context (optional last-resort)

Role of GAGeneral anesthesia (GA) is an option of last resort and reserved for exceptional circumstances when safe treatment cannot be provided in office

Approval criteriaGA is approved only if one of three listed conditions is met or if all four alternative conditions are simultaneously met (see policy for details)

Not approved usesGA will not be approved for anxiety, scheduling convenience, routine exams, or when alternatives could address the problem

inv-64: Radiograph clinical necessity / billing

Clinical necessityRadiographs must be individually prescribed and clinically necessary per ADA/FDA guidelines; images must be diagnostic quality

SubmissionMed-QUEST or Dental TPA may request submission of any x‑rays claimed; midprocedure and post‑op radiographs are part of the procedure and not billable separately

RecordkeepingProviders should retain diagnostic images and be prepared to provide them if requested to support claims

inv-65: D1354 documentation note

Increased reimbursementD1354 reimbursement value has been significantly increased per the May 2025 update

Interaction with D1355If D1354 is claimed the same day as D1355, Medicaid consolidates payment under D1355 and preserves remaining D1354 benefit availability for other dates

inv-66: D1355 scope and interaction

ScopeD1355 is a new benefit for full‑mouth application of topical preventive medicaments (agents ≥30% SDF or iodine-based agents such as 10% povidone iodine)

Payment interactionD1355 shares eligibility and combined frequency/payment limits with topical fluoride codes (D1206/D1208); same‑day topical agent claims are consolidated and paid as D1355

Submission flexibilityD1355 can be submitted with or without an assigned tooth; if multiple same‑day D1355 claims are submitted only one will be paid

inv-67: Space maintainer billing inclusion

Frequency examplesSpecific space maintainer codes have defined frequency limitations (see code criteria for exact intervals)

SubmissionClaims for re‑cement/rebond may have minimum intervals (e.g., no sooner than 6 months after placement for some codes)

inv-68: Final obturation requirement

Primary ruleFinal obturation must be completed before submitting a claim for root canal therapy (RCT) codes D3220–D3425

Retreatment noteRetreatment is covered only for specific clinical circumstances and retreatment by same dentist within 24 months may be considered part of original procedure

inv-69: Periodontal charting content requirements

Required elementsPeriodontal charting must include patient name, date, six‑point pocket depths, areas of clinical attachment loss, and bleeding sites

TimingPocket depth measurements must be within 6 months prior to date of service for scaling/root planing codes

DenialsProcedures may be denied if documentation does not support alveolar bone loss or attachment loss

inv-70: IV sedation definition

DefinitionIV moderate (conscious) sedation (D9239/D9243) — administration of intravenous sedation reported in 15‑minute increments

Use conditionsIV sedation is a benefit when patient cannot cooperate without it and is used with a qualifying completed endodontic or surgical dental procedure included on same claim

DocumentationClaims or pre‑auth must include narrative of inability to cooperate and medical provider statement/chart note with formal diagnosis

inv-71: Postoperative care period

Symptomatic requirementExtractions are limited to symptomatic teeth with clinical signs or radiographic pathology; elective extractions (including for orthodontics) are not covered

ScopeSome oral surgery procedures may instead have benefits under Medicaid medical managed care plans rather than the dental program

inv-72: Telehealth / Teledentistry definition

PurposeIntended to facilitate access for patients who would otherwise face geographic barriers to care

Claiming implicationsSee teledentistry sections for service date and single‑claim rules that apply to telehealth encounters

inv-73: D9920 Behavior Management definition

DefinitionD9920 — Behavior Management: benefit for significant modifications to normal clinic processes or extended appointment time to safely provide dental care

ExamplesExamples include use of papoose board for combative ASD child, treating a patient in a wheelchair with clinic modifications, or extended orientation/desensitization requiring ≥15 minutes

RestrictionsD9920 will be denied for appointments involving pharmacologic sedation or nitrous oxide and requires provider CE documentation (≥1 hour in prior 24 months)

inv-74: D1355 Caries Preventive Medicament Application definition

Payment ruleD1355 — Caries Preventive Medicament Application is paid as a single full‑mouth application benefit and is combined with topical fluoride codes (D1206/D1208) for payment limits

Agent criteriaLimited to agents with ≥30% Silver Diamine Fluoride or iodine‑based agents (including 10% povidone iodine)

Submission noteIf D1355 is applied same day as D1354 or topical fluoride, claims are consolidated and only one payment will be made; D1355 may be submitted with or without an assigned tooth

Policy Revision History

2025-05-01revisedLatest

2025-05added

D1355 (Caries Prevention Agent) added as a new Children’s Dental Program benefit for full-mouth application of selected topical preventive medicaments.

2025-05added