Ala. Admin. Code r. 560-X-15-.01

Current through Register Vol. 43, No. 1, October 31, 2024

Section 560-X-15-.01 - Dental Program - General

(1)

(a) The availability of certain dental health care services for eligible children under age 21 is required through the Alabama Medicaid Program as part of the Early and Periodic Screening, Diagnosis, and Treatment (EPSDT) Program.

(b) Certain dental services are provided to pregnant Medicaid eligible individuals over 21.

(2) Dental providers must be licensed to practice in the state in which the service is provided. Dentists are exempt from a contract requirement at the present time, but must enroll with the fiscal agent and be assigned a provider number for each office location. Each claim filed constitutes a contract with the Alabama Medicaid Agency, and represents that the services provided and fees charged are usual and customary by community standards and payment.

(3) Dental Services are defined as any diagnostic, preventive, or corrective procedures administered by or under the direct supervision of a dentist licensed to practice in the state the service is provided. Such services include treatment of the teeth and the associated structures of the oral cavity, and of disease, injury, or impairment which may affect the oral or general health of the individual. Such services shall maintain a high standard of quality and shall be within the reasonable limits of those services which are customarily available and provided to most persons in the community.

(4) Patient Identification

(a) The Alabama Medicaid Agency issues a plastic Medicaid Eligibility Card to persons when they are first eligible for benefits.

(b) The provider must verify eligibility through the fiscal agent office. The recipient or responsible adult is required to present this card with some form of identification when requesting services.

(c) It is most important that a provider's staff verify a Medicaid recipient's eligibility, since claims submitted on ineligible persons cannot be paid by Medicaid.

(d) Chapter One, General, Alabama Medicaid Agency Administrative Code, contains information about the identification of Medicaid recipients.

(5) Providers who agree to accept Medicaid payment must agree to do so for all covered services rendered during a particular visit. The dentist agrees when billing Medicaid for a covered service that the dentist will accept as payment in full the amount paid by Medicaid for that service and that no additional charge will be made. Providers may not bill Medicaid recipients they have accepted as patients for covered services. The dentist shall not charge or bill the recipient for cancelled or missed appointments. Conditional collections from patients made before Medicaid pays, which are to be refunded after Medicaid pays, are not permissible. The dentist may bill the patient for services rendered in the following circumstances:

(a) when benefits are exhausted for the set limit or

(b) when the service is a Medicaid non-covered benefit.

Refer to Chapter One, General Alabama Medicaid Agency Administrative Code, for further information regarding Providers Rights and Responsibilities.

Ala. Admin. Code r. 560-X-15-.01

Rule effective October 1, 1982. Amended effective April 12, 1984; June 8, 1985. Emergency rule effective December 1, 1986. Amended effective March 12, 1987. Emergency rule effective April 1, 1991. Amended effective June 12, 1991; January 13, 1993. Amended: Filed September 6, 2000; effective October 11, 2000. Amended: Filed May 12, 2004; effective June 16, 2004.

Amended by Alabama Administrative Monthly Volume XLI, Issue No. 06, March 31, 2023, eff. 5/15/2023.

Author: Tina Edwards, Dental Program

Statutory Authority: State Plan, Attachment 3.1-A, page 1.2, 4.b(4); Title XIX, Social Security Act; 42 C.F.R. §§ 441.57.