Page 2351

Official source

services identified in the Fee Schedule: Enhanced Adult Dental Services, adopted by reference in 7 AAC 160.900 and provided to a recipient 21 years of age or older, as follows:

(1) periodic or comprehensive oral evaluation not more than one time per fiscal year, panoramic radiographs not more than one time per fiscal year and other dental radio graphs necessary for dental care;

(2) preventive care, including

(A) prophylaxis, including necessary scaling, polishing, and instructions on oral hygiene and diet, not more than two times per fiscal year; and

(B) topical application of fluoride not more than four times per fiscal year, or topical fluoride varnish not more than four times per fiscal year, or a combination of topical application of fluoride and fluoride varnish not more than four times per fiscal year;

(3) restorative care for the treatment of decayed or fractured teeth, including amalgams and resins, and crowns if the tooth cannot be restored with amalgams or resin; under this paragraph,

(A) a claim submitted for up to two crowns in a single day must be accompanied by medical justification;

(B) a provider must obtain prior authorization from the department for three or more crowns in a single day or four or more crowns in a 12-month period;

(C) all surfaces restored on a single tooth on the same day are considered connected; therefore, payment is limited to one single or multi-surface restoration code per tooth per day;

(D) final restorations are limited to not more than five surfaces per tooth; tooth preparation, temporary restorations, sedative and cement bases, and local anesthesia are considered components of a complete restorative procedure and may not be billed separately; and

(E) the department will provide payment for a crown only upon seatment of the permanent crown, and for a partial or denture only upon seatment of the appliance; the department will not provide partial payment for incomplete or in-progress dental services;

(4) endodontics, with the following limitations:

(A) palliative and sedative treatments may not exceed two times per tooth before a definitive treatment;

(B) with respect to root canal therapy, tooth preparation, temporary filling of the root canal, and follow-up care are considered components of a complete root canal and may not be billed separately;

Page 2351

Official source

services identified in the Fee Schedule: Enhanced Adult Dental Services, adopted by reference in 7 AAC 160.900 and provided to a recipient 21 years of age or older, as follows:

(2) preventive care, including

(A) prophylaxis, including necessary scaling, polishing, and instructions on oral hygiene and diet, not more than two times per fiscal year; and

(3) restorative care for the treatment of decayed or fractured teeth, including amalgams and resins, and crowns if the tooth cannot be restored with amalgams or resin; under this paragraph,

(A) a claim submitted for up to two crowns in a single day must be accompanied by medical justification;

(B) a provider must obtain prior authorization from the department for three or more crowns in a single day or four or more crowns in a 12-month period;

(C) all surfaces restored on a single tooth on the same day are considered connected; therefore, payment is limited to one single or multi-surface restoration code per tooth per day;

(4) endodontics, with the following limitations:

(A) palliative and sedative treatments may not exceed two times per tooth before a definitive treatment;

(B) with respect to root canal therapy, tooth preparation, temporary filling of the root canal, and follow-up care are considered components of a complete root canal and may not be billed separately;