Dental Services Rendered in an Outpatient Facility or Ambulatory Surgery Center

REIMBURSEMENT POLICY STATEMENTIndiana Medicaid Policy Name & Number Date Effective Dental Services Rendered in an Outpatient Facility or Ambulatory Surgery Center-IN MCD-PY-1304 11/01/2024 Policy Type REIMBURSEMENT Reimbursement Policies prepared by CareSource and its affiliates are intended to provide a general reference regarding billin g, coding and documentation guidelines. Coding methodology, regulatory requirements, industry-standard claims editing logic, benefi ts design and other factors are considered in developing Reimbursement Policies. In addition to this Policy, Reimbursement of services is subject to member benefits and eligibility on the date of service, m edical necessity, adherence to plan policies and procedures, claims editing logic, provider contractual agreement, and applicable referral, authorization, notification and utilization management guidelines. Medically necessary services include, but are not limited to, those health care services or supplies that are proper and necessary for the diagnosis or treatment of disease, i llnes s, or injury and without which the patient can be expected to suffer prolonged, increased or new morbidity, impairment of functi on, dysfunction of a body organ or part, or significant pain and discomfort. These services meet the standards of good medical practice in the local area, are the lowest cost alternative, and are not provided mainly for the convenience of the member or provider. Medically necessary services also include those services defined in any federal or state coverage mandate, Evidence of Coverage documents, Medical Policy Statements, Provider Manuals, Member Handbooks, and/or other policies and procedures. This Policy does not ensure an authorization or Reimbursement of services. Please refer to the plan contract (often referred to as the Evidence of Coverage) for the service(s) referenced herein. If there is a conflict between this Policy and the plan contract (i.e., Evidence of Coverage), then the plan contract (i.e., Evidence of Coverage) will be the controlling document used to ma ke the determination. CareSource and its affiliates may use reasonable discretion in interpreting and applying this Policy to services provided in a particular case and may modify this Policy at any time. According to the rules of Mental Health Parity Addiction Equity Act (MHPAEA), coverage for the diagnosis and treatment of a behavioral health disorder will not be subject to any limitations that are less favorable than the limitations that apply to medical conditions as covered under this policy.Table of ContentsA. Subject ………………………….. ………………………….. ………………………….. …………………………. 2 B. Background ………………………….. ………………………….. ………………………….. …………………… 2 C. Definitions ………………………….. ………………………….. ………………………….. ……………………… 2 D. Policy ………………………….. ………………………….. ………………………….. ………………………….. .. 3 E. Conditions of Coverage ………………………….. ………………………….. ………………………….. …… 5 F. Related Policies/Rules ………………………….. ………………………….. ………………………….. …….. 6 G. Review/Revision History ………………………….. ………………………….. ………………………….. ….. 6 H. References ………………………….. ………………………….. ………………………….. ……………………. 6 Dental Services Rendered in an Outpatient Facility or Ambulatory Surgery Center-IN MCD-PY-1304Effective Dat e: 11/01/2024The REIMBURSEMENT Policy Statement detailed above has recei ved due consideration as defined inthe REIMBURSEMENT Policy Statement Policy and is approved.5 3. The facility request should include the facility services requested (ie, operating room charges, anesthesia) , the Dental Authorization Approval Letter, and the dental authorization number. 4. CareSource Medical Utilization Management team will complete ALL of the following: a. Verify that facility is in network . b. Review the dental pre-determination letter (PDL) or authorization . c. Complete the administrative approval for facility fee and anesthesia. Determine medical necessity for any other facility-related CPT/HCPCS codes submitted . HCPCS code G0330 only requires administrative review . d. Fax a Facility Approval to the hospital/ASC which can also be viewed in the CareSource Provider Portal . E. Conditions of CoverageFacility Reimbursement is dependent on, but not limited to, submitting approved HCPCS and CPT codes along with appropriate modifiers, if applicable. Please refer to the individual fee schedule for appropriate codes. The following list(s) of codes is provided as a reference. This list may not be all inclusive and is subject to updates : 0078 Outpatient Hospital Facility (SPU) POS (19, 22); Ambulatory Surgical Center POS (24) o Use HCPCS code G0330 as facility fee code 0083 Will be paid according to CareSource contract and IHCP fee schedule. For a list of revenue codes reimbursed, as well as outpatient payment information for relevant codes, see the Revenue Codes tab of the Outpatient Fee Schedule accessible from the IHCP Fee Schedules page at in.gov/Medicaid/providers . 0083 Dental-related facility charges must be billed on an institutional claim (UB-04 claim form, Portal institutional claim, 837I transaction). o Use CPT 00170 for anesthesia for intraoral treatments, including biopsy 0083 Will be paid according to CareSource contract and IHCP fee schedule . 0083 All associated professional services, such as radiology and anesthesia, as well as ancillary services related to the dental services, must be billed on a professional claim (CMS-1500 claim form or electronic equivalent). 0078 Inpatient Hospital Facility POS (21) o All services as well as any additional room and board fees would have to be pre – certified and receive medical necessity review. Services are subject to benefit provisions , and criteria for dental hospital admissions for both adult and pediatric members is i n accordance with 405 IND . ADMIN . CODE 5-33 . 0078 Dental/Oral Surgery Professional Services o The scope of this policy is limited to medical plan coverage of the facility and/or general anesthesia services provided in conjunction with dental treatment, not the dental or oral surgery services. For i nformation on dental benefits, please consult the CareSource Office Reference Manual for clinical guidelines, policies , and procedures , and the provider contracted fee schedule .