Page 152

State Children’s Health Insurance Program

Phase 1 Effective Date: April 1, 1998 151 Revised: 1/26/98, 2/19/98, 3/3/98, 3/6/98 Phase 2 Effective Date: July 1, 1998

Revised: 8/20/98, 8/24/98, 10/1/99, 7/28/00, 1/31/01, 7/02/02, 7/22/02, 1/3/03, 2/13/04, 9/27/04, 11/15/05, 8/11/05, 10/1/06, 7/1/09, 7/1/10, 7/1/11, 7/1/12 7510, 7511

incision & drainage of abscess

Hospital Case Management All non-emergency hospital cases require a preauthorization. Only cases with the following conditions will be considered: • Medically compromised patients • Severe behavior management cases • Complex restorative cases

Criteria for Medical Immobilization including Papoose Boards (ADA code 9920) Written and signed informed consent from a legal guardian is required and needs to be documented in the patient record prior to this procedure. The specific nature of the recipient management problem and the technique utilized must be documented in writing in the recipient’s dental record.

Techniques acceptable for 9920 include: 1. Papoose or Pedi-wrap 2. Two or more personnel to assure safety of child and staff.

Techniques not acceptable for 9920 include: 1. Tell-show-do 2. Positive reinforcement or abnormal amount of time consumed.

Routine use of restraining devices to immobilize young children in order to complete their dental care is not acceptable practice, violates the standard of care, and will result in termination of the provider from the network.

The plan will not reimburse for behavior management if: 1. Billed routinely every time the recipient visits the office; or 2. Billed with either sedation or analgesia on the same date of service.

Indications for behavior management include patients who require immediate diagnosis and/or limited treatment and cannot cooperate due to a mental or physical disability.

Please note the following: • Dentist must not restrain children without formal training in medical immobilization. • Dentist auxiliaries must not use restraining devices to immobilize children. Appendix E Dependents of State Employee Coverage Maintenance of Agency Contribution