20509 Dental Services Reimbursement Methodology

A. Services covered in the LaCHIP Affordable Plan Dental Program shall be reimbursed at the lower of either:

1. the dentist’s billed charges minus any third party coverage; or

2. the state’s established schedule of fees, which is developed in consultation with the Louisiana Dental Association and the Medicaid dental consultants, minus any third party coverage.

B. Effective for dates of service on or after July 1, 2012, the reimbursement fees for LaCHIP Affordable Plan dental services shall be reduced to the following percentages of the 2009 National Dental Advisory Service comprehensive fee report 70th percentile, unless otherwise stated in this Chapter:

1. 65 percent for the following oral evaluation services:

a. periodic oral examination;

b. oral examination-patients under 3 years of age; and

c. comprehensive oral examination-new patients;

2. 62 percent for the following annual and periodic diagnostic and preventive services:

a. radiographs-periapical, first film;

b. radiographs-periapical, each additional film;

c. radiographs-panoramic film;

d. diagnostic casts;

e. prophylaxis-adult and child;

f. topical application of fluoride, adult and child (prophylaxis not included); and

g. topical fluoride varnish, therapeutic application for moderate to high caries risk patients (under 6 years of age);

3. 45 percent for the following diagnostic and adjunctive general services:

a. oral/facial image;

b. non-intravenous conscious sedation; and

c. hospital call; and

4. 56 percent for the remainder of the dental services.

C. Removable prosthodontics and orthodontic services are excluded from the July 1, 2012 rate reduction.

D. Effective for dates of service on or after August 1, 2013, the reimbursement fees for LaCHIP Affordable Plan dental services shall be reduced by 1.5 percent of the rate on file July 31, 2013, unless otherwise stated in this Chapter.

1. The following services shall be excluded from the August 1, 2013 rate reduction:

a. removable prosthodontics; and

b. orthodontic services.

AUTHORITY NOTE: Promulgated in accordance with R.S. 36:254 and Title XXI of the Social Security Act.

HISTORICAL NOTE: Promulgated by the Department of Health and Hospitals, Bureau of Health Services Financing, LR 39:1285 (May 2013), amended LR 40:1008 (May 2014).

20509 Dental Services Reimbursement Methodology

Official source

A. Services covered in the LaCHIP Affordable Plan Dental Program shall be reimbursed at the lower of either:

1. the dentist’s billed charges minus any third party coverage; or

2. the state’s established schedule of fees, which is developed in consultation with the Louisiana Dental Association and the Medicaid dental consultants, minus any third party coverage.

1. 65 percent for the following oral evaluation services:

a. periodic oral examination;

b. oral examination-patients under 3 years of age; and

c. comprehensive oral examination-new patients;

2. 62 percent for the following annual and periodic diagnostic and preventive services:

a. radiographs-periapical, first film;

b. radiographs-periapical, each additional film;

c. radiographs-panoramic film;

d. diagnostic casts;

e. prophylaxis-adult and child;

f. topical application of fluoride, adult and child (prophylaxis not included); and

g. topical fluoride varnish, therapeutic application for moderate to high caries risk patients (under 6 years of age);

3. 45 percent for the following diagnostic and adjunctive general services:

a. oral/facial image;

b. non-intravenous conscious sedation; and

c. hospital call; and

4. 56 percent for the remainder of the dental services.

C. Removable prosthodontics and orthodontic services are excluded from the July 1, 2012 rate reduction.

1. The following services shall be excluded from the August 1, 2013 rate reduction:

a. removable prosthodontics; and

b. orthodontic services.

AUTHORITY NOTE: Promulgated in accordance with R.S. 36:254 and Title XXI of the Social Security Act.

HISTORICAL NOTE: Promulgated by the Department of Health and Hospitals, Bureau of Health Services Financing, LR 39:1285 (May 2013), amended LR 40:1008 (May 2014).