DentaQuest Notices

Claims Reminders – Billing / Rendering

DentaQuest would like to remind all providers that claims adjudication for payment requires that accurate claims information is submitted. This includes, but is not limited to the Billing Dentist / Dental Entity and Treating Dentist / Treatment Location fields.  Please refer to the information below to ensure you are submitting the correct information in the correct fields.  Submitting incorrect Billing and Treating information will cause claims to deny.

 

Billing Dentist or Dental Entity

• Box 48 – This should match what is submitted on the W-9. The address must be the billing location address and not treatment location address
• Box 49 – This must be the Billing NPI
• Group – If the group has a service office / subpart NPI, that is the NPI that should be used
• If no service office / subpart, the business NPI must be used
• Non-Group – Depending on business set-up, this may be a Business NPI or Provider NPI
• Box 51 – This must be the SSN or TIN as reported on the W-9 for tax purposes

 

Treating Dentist and Treatment Location Information

• Box 53 – Information is for the provider that renders service(s) (treating provider)
• Box 54 – The reported NPI must be for the provider who renders service(s)
• Box 55 – The reported license number must be for the provider who renders service(s)
• Box 56 – The provider specialty code is the taxonomy code for the provider who render(s) services. If the provider has multiple taxonomy codes, the one reported must be appropriate for the services that are rendered

As we’ve previously communicated, effective for dates of service on or after July 1, 2017, the benefit criteria for anesthesia has changed for Texas Medicaid. The following information will provide clarity on the process to follow for prior authorization and claim submission to DentaQuest.

• A completed Criteria for Dental Therapy Under General Anesthesia form
• A completed Prior Authorization Claim Form. This must include CDT code(s) for all procedures to be performed and D9223 or D9500 (a DentaQuest specific code that indicates Medical Anesthesia Services) based on place of service and anesthesiologist type
• Location where the procedure(s) will be performed (office or outpatient)
  Tentative date of service if outpatient request or in office using a medical anesthesiologist
• Narrative unique to the client, detailing reasons for the proposed level of anesthesia (indicate procedure code D9223 or D9500). The narrative must include history of prior treatment, failed attempts at other levels of sedation, behavior in the dental chair, proposed restorative treatment (tooth ID and surfaces), urgent need to provide comprehensive dental treatment based on extent of diagnosed dental caries, and any relevant medical condition(s).
• Diagnostic quality radiographs or photographs)
  When appropriate radiographs or photographs cannot be taken prior to general anesthesia, the narrative must support the reasons for an inability to perform diagnostic services. For these special cases that receive authorization, diagnostic quality radiographs or photographs will be required for payment and will be reviewed by the DentaQuest Dental Director.

The current process of scoring 22 points on the Criteria for Dental Therapy Under General Anesthesia form does not guarantee authorization or reimbursement for clients who are six years of age and younger.

Note: In cases of an emergency medical condition, accident, or trauma, prior authorization is not necessary. However, a narrative and appropriate pre- and post-treatment radiographs or photographs must be submitted with the claim, which will be reviewed by the DentaQuest Dental Director.

A copy of the Criteria for Dental Therapy under General Anesthesia form must be maintained in the client’s dental record. The client’s dental record must be available for review by representatives of the Health and Human Services Commission (HHSC) or its designee. The following outlines the process based on place of service (in office / outpatient) and anesthesiologist type (dental / medical).

 

Dental Therapy under General Anesthesia - In Office

Treating Dentist using Dental Anesthesiologist

• Is responsible for obtaining prior authorization from DentaQuest and is responsible for providing the anesthesia prior authorization information to the dental anesthesiologist
• Submits one D9223 and CDT code(s) that will be performed under general anesthesia for prior authorization DentaQuest will determine medical necessity of the general anesthesia based on the submitted treatment plan and required documentation
• DentaQuest will notify the treating dentist of the determination via a Provider Determination Letter (PDL). For services that are approved, the treating dentist would then provide a copy of the PDL to the dental anesthesiologist. Code D9223 will indicate the DentaQuest determination and will be either approved or denied. While we are reviewing the necessity of the general anesthesia on the overall treatment plan, certain services on the PDL will indicate Service Not Reviewed if they do not typically require authorization under DentaQuest policy. Failure to submit per Prior Authorization Criteria as outlined above will result in a denial. See example below, indicating the anesthesia service (D9223) has been approved.
  

Dental Anesthesiologist

• Upon completion of the approved services, the dental anesthesiologist will submit claims to DentaQuest
• The DentaQuest approved authorization number from treating dentist must be in “Box 35” of the claims form or in the notes section of the portal
• Must submit appropriate units of D9223 with supporting documentation
• Must have a current level 4 permit

Treating Dentist

• Upon completion of the approved services, the treating dentist will submit therapeutic services rendered to DentaQuest

Treating Dentist using Medical Anesthesiologist

• Is responsible for obtaining prior authorization from DentaQuest and is responsible for providing the anesthesia prior authorization information to the medical anesthesiologist
• Submits D9500 and CDT code(s) that will be performed under general anesthesia for prior authorization
• DentaQuest will determine medical necessity of the general anesthesia based on the submitted treatment plan and required documentation.
• DentaQuest will notify the treating dentist of the determination via a Provider Determination Letter (PDL). For anesthesia that is approved, the treating dentist would then provide a copy of the PDL to the medical anesthesiologist. Code D9500 will indicate the DentaQuest determination and will be either approved or denied. While we are reviewing the necessity of the general anesthesia on the overall treatment plan, certain services on the PDL will indicate Service Not Reviewed if they do not typically require authorization under DentaQuest policy. Failure to submit per Prior Authorization Criteria as outlined above will result in a denial. See example below, indicating the medical anesthesia service (D9500) has been approved.

Medical Anesthesiologist

• Is responsible for submitting a separate prior authorization request to the member’s MCO along with the approved DentaQuest PDL
• The MCO reviews submitted documentation from DentaQuest to determine whether medical anesthesia is approved or denied
• Upon completion of the approved services, the medical anesthesiologist will submit claims to the member’s MCO using the appropriate CPT code(s)

Treating Dentist

• Upon completion of the approved services, the treating dentist will submit therapeutic services rendered to DentaQuest

 

Dental Therapy under General Anesthesia – Outpatient

Treating Dentist

• Is responsible for obtaining prior authorization from DentaQuest and is responsible for providing the anesthesia prior authorization information to the medical anesthesiologist and/or facility
• Submits code D9500 and CDT code(s) that will be performed under general anesthesia for prior authorization
• The prior authorization request must indicate tentative procedure date(s) of service and facility name in “Box 35” (remarks) of the ADA claim form Place of service must also be indicated in “Box 38” of the ADA claim form
• DentaQuest will determine medical necessity of the general anesthesia based on the submitted treatment plan and required documentation
• DentaQuest will notify the treating dentist of the determination via a Provider Determination Letter (PDL). For anesthesia that is approved, the treating dentist would then provide a copy of the PDL to the medical anesthesiologist and/or facility. Code D9500 will indicate the DentaQuest determination for Medical Anesthesia Services

Medical Anesthesiologist and/or Facility

• Is responsible for submitting a separate prior authorization request to the member’s MCO along with the approved DentaQuest PDL
• The MCO reviews submitted documentation from DentaQuest to determine whether medical anesthesia and/or facility is approved or denied
• Upon completion of the approved services, the medical anesthesiologist and/or facility will submit claims to the member’s MCO using the appropriate CPT code(s)

Treating Dentist

• Upon completion of the approved services, the treating dentist will submit therapeutic services rendered to DentaQuest

Please remember that the provider who submits the authorization for the dental therapeutic services must be the provider that performs the services. If the authorized provider does not perform the service, claims will deny. In the event the authorized provider is unable to perform the services, DentaQuest must be notified to update the authorization prior to the services being performed. This is not applicable to the anesthesiologist.

Treating Dentist using Dental Anesthesiologist

• Is responsible for obtaining prior authorization from DentaQuest and is responsible for providing the anesthesia prior authorization information to the dental anesthesiologist
• Submits one D9223 and CDT code(s) that will be performed under general anesthesia for prior authorization DentaQuest will determine medical necessity of the general anesthesia based on the submitted treatment plan and required documentation
• DentaQuest will notify the treating dentist of the determination via a Provider Determination Letter (PDL). For services that are approved, the treating dentist would then provide a copy of the PDL to the dental anesthesiologist. Code D9223 will indicate the DentaQuest determination and will be either approved or denied. While we are reviewing the necessity of the general anesthesia on the overall treatment plan, certain services on the PDL will indicate Service Not Reviewed if they do not typically require authorization under DentaQuest policy. Failure to submit per Prior Authorization Criteria as outlined above will result in a denial. See example below, indicating the anesthesia service (D9223) has been approved.
• The prior authorization request must indicate tentative procedure date(s) of service and facility name in “Box 35” (remarks) of the ADA claim form Place of service must also be indicated in “Box 38” of the ADA claim form

Dental Anesthesiologist

• Upon completion of the approved services, the dental anesthesiologist will submit claims to DentaQuest
• The DentaQuest approved authorization number from treating dentist must be in “Box 35” of the claims form or in the notes section of the portal
• Must submit appropriate units of D9223 with supporting documentation
• Must have a current level 4 permit

Treating Dentist

• Upon completion of the approved services, the treating dentist will submit therapeutic services rendered to DentaQuest

 

Texas Administrative Code (TAC) – Records and Sedation Requirements

The Texas Administrative Code provides specific rules that apply to dental record documentation requirements and required sedation information. Please refer to the following:

• 22 Tex. Admin. Code $108.8 Records of the Dentist
• 22 Tex. Admin Codes $110.2 Sedation / Anesthesia Permit
• 22 Tex. Admin Codes $110.6 Deep Sedation and Anesthesia
• 22 Tex. Admin Codes $110.7 Portability
• 22 Tex. Admin Codes $110.10 Use of General Anesthetic Agents