Ala. Admin. Code r. 480-5-5-.28
Current through Register Vol. 43, No. 1, October 31, 2024
Section 480-5-5-.28 - Dental Services(1) Basic Information - The Rules set out in this chapter apply to providers rendering dental and maxillofacial surgery services. Providers of these services shall also, when applicable, follow the rules and policies in these Rules pertaining to pre-certification, utilization review, bill screening, and claims payment.(2) Dental Services (a) Dental codes and descriptors published in the American Dental Associations' (ADA) Current Dental Terminology Manual (CAT-2) shall be used for billing dental services.(b) Dental procedures shall be identified by the ADA's five-digit code.(c) Dental services may include professional consultations or visits in the office or hospital.(d) Dental services shall be billed using the J510 (ADS85) form.(e) Reimbursement for services rendered shall be limited to the provider's charge, the Maximum Fee Schedule for Dentists, or any mutually agreed upon reimbursement pursuant to Code of Ala. 1975, § 25-5-314, whichever is less.(f) For dental procedures not listed in the Maximum Fee Schedule for Dentists, reimbursement shall be based on usual and customary charges in the area where the service is provided and based on documentation submitted by the provider.(3) Oral and Maxillofacial Surgery Services (a) Oral and maxillofacial surgical services may be reimbursed if the services are medically necessary for the treatment of work related injuries or diseases to the jaw, structure contiguous to the jaw, and reduction of any fracture to the jaw or facial bone.(b) Oral and maxillofacial surgery services shall be billed using the CPT-4 procedure codes, if appropriate, used by medical surgeons and found in the Maximum Fee Schedule for Physicians.(4) Oral and Maxillofacial surgeons are subject to the billing and reimbursement rules and guidelines for medical surgeons.(a) The reimbursement for surgical services shall include the procedure itself and the global period of six weeks.(b) Multiple surgical procedures performed in the course of an operative session shall be reimbursed according to the rules pertaining to medical surgeons set out in Rule 480-5-5-.15. Removal of internal fixation devices are included in the global fee regardless of the period of time between their placement and removal.(c) Starred (*) surgical procedures performed shall be reimbursed according to the rules pertaining to medical surgeons set out in Rule 480-5-5-.15.(d) Any and all supplies, equipment, and devices used in the treatment of a compensable injury are included in the maximum fee amount for the procedure.(5) Plan of Care (a) Except in an emergency or urgent situation, a plan of care shall be provided to the RUE or employer/agent prior to the commencement of services.(b) In regards to emergency situations, a plan of care shall be provided to the RUE or employer/agent after the initial stabilizing service has been provided, but prior to any extensive follow up treatment. Author: Workers' Compensation Division
Ala. Admin. Code r. 480-5-5-.28
New Rule: Filed August 9, 1996; effective September 13, 1996.Statutory Authority:Code of Ala. 1975, § 25-5-293