The Evidence-Based Decision Support Unit handles quality issues.
Fax: (573) 526-4650
Crystal.L.McNail@dss.mo.gov (573) 751-7179
Fax: (573) 526-4650
Questions concerning file layouts and transactions/processing rules, file transactions in the Health Plan Record Layout Manual, encounter voids, encounter rejections, Provider Demographic File, cycle dates, RA processes and hard copy fee schedules should be directed to:
Policy questions related to system issues such as billing codes, how to bill a service, written requests for changing codes to Pl-W and carve out services should be directed to:
COMPREHENSIVE DAY REHABILITATION
MO HealthNet Managed Care health plans are required to provide comprehensive day rehabilitation services to child members under the age of 21 and adult pregnant women with ME codes 18, 43, 44, 45, 61, 95, 96, and 98. Services must be sufficient in amount, duration, and scope to reasonably achieve their purpose and may only be limited by medical necessity. Comprehensive day rehabilitation services are for certain members with disabling impairments as the result of a traumatic head injury. Comprehensive day rehabilitation services begin early post trauma as part of the coordinated system of care. Rehabilitation services must be based on an individualized, goal-oriented, comprehensive, and coordinated treatment plan. The treatment plan must be developed, implemented, and monitored through an interdisciplinary assessment designed to restore a member to optimal level of physical, cognitive, and behavioral function. (See RSMo 208.152)
MO HealthNet Managed Care health plans are responsible for providing rehabilitation services to survivors of a Traumatic Brain Injury (TBI) as follows:
Service Plan Development
Description of Services
Half-day rehabilitation service;
Full-day rehabilitation service.
The evaluation/assessment should identify the specific functional outcomes for the member to achieve with regard to the degree of personal and independent living level of work productivity, and psychological adjustment. The evaluation is one of the chief basis for determining the member’s program eligibility according to disability and need for rehabilitation.
Comprehensive day rehabilitation services cover a combination of goal oriented rehabilitation services provided according to a multiple hour schedule over a week’s time. Services are designed to maintain and improve the member’s ability to function as independently as possible in the community.
Members age 21 and over (except for pregnant women) are not eligible for comprehensive day rehabilitation services.
The Comprehensive Day Rehabilitation Program Manual can be referenced online at the MO HealthNet Division website www.dss.mo.gov/mhd for additional information. Special bulletins may also be referred online for additional information.
MO HEALTHNET MANAGED CARE CHILD MEMBERS (under the age of 21)
MO HealthNet Managed Care health plans are required to provide dental services
for child members under the age of 21. Services must be sufficient in amount,
duration, and scope to reasonably achieve their purpose and may only be limited
by medical necessity. Dental services include, but are not limited to, diagnostic,
preventive, and restorative procedures, post orthodontic services, and medically
necessary oral and maxillofacial surgeries. Expanded services, such as
comprehensive orthodontics, are covered.
The MO HealthNet Managed Care health plans must conduct early periodic
screening, diagnosis, and treatment (EPSDT) screens to identify health and
developmental problems. In Missouri, this program is known as the Healthy
Children and Youth (HCY) Program. It is recommended that preventive dental
services and oral treatment for children begin at age 6-12 months and be
repeated every six (6) months or as medically indicated. Although an oral
screening may be part of a physical examination, the Department of Health and
Human Services, Centers for Medicare and Medicaid Services (CMS), states that it
does not substitute for examination through direct referral to a dentist.
Orthodontic procedures are covered as expanded EPSDT/HCY services.
Orthodontics will only be approved for the most severe malocclusions and in cases of medical necessity as determined by the state orthodontic consultant when the treating orthodontist/dentist submits documentation supporting medical necessity.
When an eligible participant is believed to have a condition that may require orthodontic treatment, the attending dentist should refer the participant to a qualified dentist or orthodontist for preliminary examination to determine if the treatment will be approved. The fact that the participant has moderate or even severe orthodontic problems, or has been advised by a dentist or orthodontist to have treatment is not, by itself, a guarantee that the participant will qualify for orthodontia services through MO HealthNet. Coverage is determined solely by meeting the criteria listed below in subsections A and B, or in C.
Requirements for Orthodontic Care
A. General Requirements
To be eligible for orthodontia services, the participant must meet all of the following general requirements:
1. Be under twenty-one (21) years of age; and
2. Have good oral hygiene documented in the child’s treatment plan; and
3. Have all dental work complete; and
4. Have permanent dentition. Exceptions to having permanent dentition
are as follows:
a. Participant has a primary tooth retained due to ectopic or missing permanent tooth; or
b. Participant may have primary teeth present if they have cleft palate, severe traumatic deviations, or an impacted maxillary central incisor; or
c. Participant may have primary teeth if they are thirteen (13) years of age or older; or
d. The orthodontia provider has provided to the state written documentation which proves that orthodontic treatment is medically necessary under one of the criteria in subsection C.
B. Handicapping Labio-Lingual Deviation (HLD) Index
The determination whether or not a participant will be approved for orthodontic services shall be initially screened using the Handicapping Labio-Lingual Deviation (HLD) Index. The HLD Index must be fully completed in accordance with the instructions in Section 14.3 of the MO HealthNet Dental Provider Manual and must be submitted with the Prior Authorization (PA) form. MO HealthNet will approve orthodontic services when the participant meets all the criteria in subsection A above and one (1) of the criteria listed in paragraphs 1 to 7 below:
Has a cleft palate;
Has a deep impinging overbite when the lower incisors are damaging the soft tissue of the palate (lower incisor contact only on the palate is not sufficient);
Has a cross-bite of individual anterior teeth when damage of soft tissue is present;
Has severe traumatic deviations;
Has an over-jet greater than nine millimeter (9mm) or reverse over-jet of greater than three and one-half millimeters (3.5mm);
Has an impacted maxillary central incisor; or
Scores twenty-eight (28) points or greater on the HLD Index.
C. Medical Necessity
If the participant meets the criteria in subsection A above but does not meet any of the criteria in subsection B, MO HealthNet will consider whether orthodontic services should be provided based upon other evidence that orthodontic services are medically necessary.
MO HealthNet Managed Care health plans shall consider additional information of a substantial nature about the presence of severe deviations affecting craniofacial health. Other deviations shall be considered to be severe if, left untreated, they would cause irreversible damage to the teeth and underlying structures, resulting in disease related bone and tooth loss, or craniofacial deformities associated with developmental disabilities in chewing or speaking.
Other evidence shall include information of a substantial nature about the presence of a medical condition which is directly affected by the condition of the mouth or underlying structures. Orthodontic treatment shall be considered to be medically necessary if, without the orthodontic treatment, the medical condition would be adversely affected and would result in pain, infection, illness or significant and immediate impact on the normal function of the body and the individual’s ability to function. In addition, such orthodontic treatment must be demonstrated to be 1) of clear clinical benefit to the eligible participant; 2) appropriate for the injury or illness in question; and 3) conform to the standards of generally accepted orthodontic practice as supported by applicable medical and scientific literature. In addition to documentation from an orthodontist or dentist, a recommendation for orthodontic treatment in relation to a medical condition must also be supported by documented evidence of the medical condition from a licensed medical doctor, board certified to diagnose the medical condition.
In addition, MO HealthNet Managed Care health plans may consider information of a substantial nature about the presence of mental, emotional, and/or behavioral problems, disturbances or dysfunctions, as defined in the most current edition of the Diagnostic Statistical Manual of the American Psychiatric Association, and which may be caused by the participant’s daily functioning as it related to a dent facial deformity. The MO HealthNet Division will only consider cases where a diagnostic evaluation has been performed by a licensed psychiatrist or a licensed psychologist who has accordingly limited his or her practice to child psychiatry or child psychology. The evaluation must clearly and substantially document how the dent facial deformity is related to the child’s mental, emotional, and/or behavioral problems and must clearly and substantially document that orthodontic treatment is medically necessary and will significantly ameliorate the problems.
Orthodontic treatment shall not be considered to be medically necessary when:
a. The orthodontic treatment is for aesthetic or cosmetic reasons only; or
b. The orthodontic treatment is to correct crowded teeth only, if the child can adequately protect the periodontium with reasonable oral hygiene measures; or
c. The child has demonstrated a lack of motivation to maintain reasonable standards of oral hygiene and oral hygiene is deficient.
Medical Necessity Documentation
If the participant does not meet the HLD Index requirements and the treating orthodontist/dentist feels the orthodontia services are medically necessary, as indicated in Section 13.42.C. of the MO HealthNet Dental Provider Manual a written, detailed explanation of the medical necessity of the orthodontia services must be submitted along with the complete HLD Index, study models and the prior authorization request form. All documentation must be completed, signed and dated by the treating orthodontist/dentist. If medical necessity is based on a medical condition, which left untreated, the medical condition would be adversely affected and would result in pain, infection, illness or significant and immediate impact on the normal function of the body and the individual’s ability to function. Additional documentation from a licensed medical doctor, board certified to diagnose the medical condition, justifying the need for the orthodontia services must be submitted along with documentation from the treating orthodontist/dentist. Likewise, if medical necessity is based on the presence of mental, emotional, and/or behavioral problems, disturbances or dysfunctions additional documentation from a licensed psychiatrist or a licensed psychologist who has limited his or her practice to child psychiatry or child psychology justifying the need for orthodontia services must be submitted along with the required documentation from the treating orthodontist/dentist. The evaluation must clearly and substantially document how the dent facial deformity is related to the child’s mental, emotional and/or behavioral problems and must clearly and substantially document that orthodontic treatment is medically necessary and will significantly ameliorate the problems.
Comprehensive orthodontic treatment includes, but is not limited to:
complete diagnostic records and a written treatment plan;
placement of all necessary appliances to properly treat the member (both removable and fixed appliances);
all necessary adjustments;
removal of appliances at the completion of the active phase of treatment;
placement of retainers or necessary retention techniques;
adjustment of the retainers and observation of the member for a proper period of time (approximately 18 to 24 months).
For severe skeletal cases, extended treatment times should be considered.
Regular Dental Care/Oral Hygiene For Orthodontic Patients
The member should be a good candidate for comprehensive orthodontic
treatment in that he/she has exhibited a history of good oral hygiene. The MO
HealthNet Managed Care health plan may provide care management if necessary.
The member should also be under the care of a dentist for routine care and all
necessary dentistry; for example, prophylaxis, fillings, etc., should be completed.
Extractions in the Fee-For-Service Program are not included in the fee for the
orthodontic treatment but are separately covered under the Dental Program.
In some situations, orthodontics alone may not correct the malocclusion and
orthognathic surgery is required. Orthognathic surgery is a medical service and
is the MO HealthNet Managed Care health plan’s responsibility.
A dental hygienist who has been in practice at least three years and who is
practicing in a public health setting may provide fluoride treatments, teeth
cleaning, and sealants, if appropriate, to MO HealthNet eligible children without
the supervision of a dentist.
In accordance with 19 CSR 10-4.040, a public health setting is defined as a location where dental services authorized by Section 332.311 RSMo are performed so long as the delivery of services are sponsored by a governmental health entity which includes:
Department of Health and Senior Services
A county health department
A city health department operating under a city charter
A combined city/county health department
A nonprofit community health center qualified as exempt from a federal taxation under section 501 (c) (3) of the Internal Revenue Code including a community health center that received funding authorization by section 329, 330, and 340 of the United States Public Health Services Act.
The procedures covered under the dental hygienist program are:
Prophylaxis-adult-both arches ages 13-20
Prophylaxis-child-both arches ages 0-12
Topical application of fluoride-prophylaxis not included-child
Topical fluoride varnish ages 0-20
Unspecified adjunctive procedure. (Office notes, invoice of costs or operative report are required with claim. For prophylaxis more often than every six months, or panorex more than 24 months, office notes are required with claim explaining medical necessity or emergency nature of the service).