CurrentNeighborhood Health Plan of Rhode IslandPolicy N/A

Oral surgery services reimbursement

Defines coverage, coding, documentation, and reimbursement requirements for oral surgery procedures for Neighborhood Health Plan of Rhode Island members under the Rhode Island EOHHS contract; applies to Medicaid (excluding EFP) and INTEGRITY programs.

Policy Summary

PayerNeighborhood Health Plan of Rhode Island

PolicyOral surgery services reimbursement

Policy CodePolicy N/A

Change TypeMaterial removalcode additions

Effective DateJun 1, 2010

Next Review DateN/A

Key ActionVerify eligibility, coverage and authorization criteria prior to rendering services.

SourceLink

POLICY UPDATE CHANGES

Removed exclusion for anesthesia services related to dental treatment rendered in an inpatient or outpatient hospital setting.

Added codes effective 1/1/24 as noted in the document history.

Medicaid & INTEGRITYPrograms this policy applies to

1+Codes added 1/1/24

Lifetime = 1Mandibular prosthesis/occlusal orthotic devices

Subject to auditDocumentation audits

Coverage Criteria and Rules

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Coverage criteria and rules

Coverage is contingent on medical necessity, appropriate provider type, documentation, and coding standards.

ALL of the following

ALL of the following
- All services must be medically necessary to qualify for reimbursement; Neighborhood may use the following to determine medical necessity: National Coverage Determination (NCD), Local Coverage Determination (LCD), industry-accepted criteria such as InterQual, Rhode Island EOHHS recommendations, and Clinical Medical Policies.
ALL of the following
- Services must be billed by an Oral Surgeon.
- Dental clinic services (room and anesthesia charges billed by a hospital when non-covered dental services are rendered to a Neighborhood member in an institutional outpatient setting) follow the same billing requirement.
ALL of the following
- Neighborhood reserves the right to request medical records for any service billed; documentation must support the service(s) billed and the medical necessity of the service(s); Neighborhood follows CMS standards for documentation.
ALL of the following
- Submit complete claims for payment within contractually determined timely filing guidelines.
- Coding must meet CPT, ICD-10-CM, and HCPCS standards as defined by the respective code sets and guidelines.
ALL of the following
- Mandibular prosthesis and occlusal orthotic devices are limited to once in a lifetime per member.

ALL of the following

Inclusion of a code in the policy does not guarantee coverage or reimbursement; payments remain subject to member benefits, eligibility, claim edits, and contractual terms.

ALL of the following

It is the provider's responsibility to verify eligibility, coverage, and authorization criteria prior to rendering services; refer to Neighborhood's plan-specific Prior Authorization Reference page and Clinical Medical Policies; contact Provider Services for questions.

Oral Surgery and Related Procedure Codes

Oral surgery and related dental procedure codesmixedCovered

41899	Unlisted procedure, dentoalveolar structures
D7260	Oroantral fistula closure
D7261	Primary closure of sinus perforation
D7270	Tooth reimplantation and/or stabilization of accidentally or avulsed displaced tooth and/or alveolus
D7284	Excisional biopsy of minor salivary glands
D7285	Incisional biopsy of oral tissue - hard (bone, tooth)
D7286	Incisional biopsy of oral tissue - soft
D7287	Exfoliative cytological sample collection
D7288	Brush biopsy - transepithelial sample collection
D7295	Harvest of bone for use in autogenous grafting procedure

1–10 of 114

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Inclusion caveat — coverage not guaranteed

Policy inclusion caveatInclusion of a code in this policy does not guarantee coverage or reimbursement; payment remains subject to member benefits, eligibility, coding edits, and contract terms.

Coding list statusCodes listed are provided for reference and do not by themselves establish coverage; clinical and billing rules still apply.

Claim adjudication driversCoverage and reimbursement decisions are based on medical necessity, documentation, and applicable contractual and coding rules.

Prior Authorization and Verification Responsibilities

Prior Authorization

Verify eligibility, coverage, and prior authorization before services

It is the provider’s responsibility to verify member eligibility, coverage, and any required authorizations before delivering services. Providers must consult Neighborhood’s plan-specific Prior Authorization Reference page and Neighborhood’s Clinical Medical Policies for details.

Verify member eligibility and benefits prior to service.
Confirm if prior authorization is required and obtain authorization when applicable using Neighborhood’s Prior Authorization Reference page.
Refer to Neighborhood’s Clinical Medical Policies for clinical authorization criteria.

Key Definitions

Oral surgery — definition and scope

DefinitionOral surgery: diagnosis and surgical treatment of diseases, injuries and defects of the hard and soft tissues of the mouth and jaw.

Billing requirementOral surgery services must be billed by an Oral Surgeon.

ScopeIncludes procedures addressing both hard (bone, tooth) and soft tissues of the mouth and jaw.

Dental clinic services — hospital room and anesthesia charges

DefinitionDental clinic services: room and anesthesia charges billed by a hospital when non-covered dental services are rendered to a Neighborhood member in an institutional outpatient setting.

When billedApplied when dental services provided in a hospital outpatient/institutional setting are non-covered but ancillary facility/anesthesia charges are billed.

Billing providerThese charges are hospital-billed (facility) charges distinct from the oral surgeon’s professional claim.