The MHCP dental program provides medically necessary, cost-effective oral health care to MHCP recipients. This care meets specific limits outlined in Statute and Rule and have been adopted by DHS and explained in this manual. Services provided must be medically necessary and meet dental community standards of care.
MHCP covered dental services and limits are identified in the corresponding areas of this manual through the links below.
Before beginning a dental service or procedure, verify recipient eligibility and available services. The MN–ITS eligibility response identifies some of the dental benefit limits to the extent that fee-for-service (FFS) claims have been processed for payment. Providers must contact the Provider Call Center to verify if claims have been processed for payment for other limited services not displayed. This is not a guarantee that your service will be covered as this information is based on claims that have completed the adjudication process.
Refer to the appropriate Covered Services sections below to review current coverage.
For recipients enrolled in a managed care organization (MCO), contact the MCO for information about dental coverage limitations.
For MHCP Program HH, review the covered services listed under Major Programs to verify dental coverage is available.
MHCP considers dental services provided beyond those identified under Covered Services and in excess of the frequencies noted as non-covered services and the recipient’s responsibility. Providers must inform the recipient before providing a non-covered service for which the recipient is financially responsible using the Advance Recipient Notice of Non-covered service/Item (DHS-3640) (PDF).
Do not submit authorization requests for services that do not require authorization or are non-covered services;they incur unnecessary costs and will not be approved.
Providers eligible to deliver limited dental services include:
Advanced Dental Therapist
Limited authorization dental hygienists
Non-dental health providers
Community Health Workers (CHW)
Head Start agencies
Public health nurses
Women, Infant, & Children (WIC) programs
MHCP Recipients (MA and Minnesota Care)
Verify eligibility before providing services. Programs and coverage may change and not all programs cover dental services. Determine eligibility for dental services using the recipient’s major program code and the dental coverage information on the MHCP Benefits At-a-glance. For recipients with major program HH refer to Program HH Covers Services.
Please refer to these subsections for service details:
As required by the Centers for Medicare & Medicaid Services (CMS), the Minnesota Child and Teen Checkups (C&TC) Schedule of Age-Related Dental Standards (DHS-5544) (PDF) was developed. Both primary care and dental providers must use this schedule, which is in keeping with recommendations of the American Academy of Pediatric Dentistry..
Primary care providers should perform an oral exam as part of the physical exam at every C&TC screening. Early access to high risk children provides opportunities for primary care providers to partner with dental providers to ensure that children receive dental care. A collaborative effort between primary care and dental providers is essential.
Primary care providers should complete caries risk assessments, anticipatory guidance, and referrals to dentists. Other components of the Schedule of Age Related Dental Standards are elements that should be completed as part of C&TC screenings and as part of a dental visit. A child’s first oral evaluation by a dentist should be completed at the time of the eruption of the first tooth in the mouth or no later than 12 months of age.
Dental Providers Billing for Sleep Apnea Appliance
For patients who cannot tolerate a continuous positive airway pressure (CPAP) machine, a physician may prescribe an oral appliance. The oral appliance is considered Durable Medical Equipment. Dentists assure the proper fit of the appliance. Most appliances require that a dentist take necessary impressions and a bite registration.
Correct coding for oral appliances for the treatment of obstructive sleep apnea:
E0485 Oral device or appliance used to reduce upper airway collapsibility, adjustable or non-adjustable, prefabricated, includes fitting and adjustment.
E0486 Oral device or appliance used to reduce upper airway collapsibility, adjustable or non-adjustable, custom fabricated, includes fitting and adjustment.
For a custom fabricated appliance to be covered, criteria A-D must be met:
A face-to-face evaluation by a physician prior to a sleep test to assess the client for obstructive sleep apnea testing
The sleep test must meet one of the following three criteria
The apnea-hypoxia index (AHI) or Respiratory Disturbance Index (RDI) is greater than or equal to 15 events per hour with a minimum of 30 events
The AHI or RDI is greater than or equal to 5 and less than or equal to 14 events per hour with a minimum of 10 events and documentation of:
Hypertension, ischemic heart disease, or history of stroke.
The AHI is greater than 30 or the RDI is greater than 30 and meets either of the following (a or b):
The enrollee is not able to tolerate a positive airway pressure device; or
The treating physician determines that the use of a positive airway pressure device is contraindicated
The device must be ordered by a physician following review of the report of the sleep test (the physician who provides the order for the oral appliance could be different from the one who performed the clinical evaluation in criterion A.)
The device is provided and billed for by a dentist
A custom fabricated oral appliance (E0486) is one that is individually and uniquely made for a specific patient. It involves taking an impression of the patient's teeth and making a positive model of plaster or equivalent material. Basic materials are used with the positive model to produce the final product. Custom fabrication requires more than trimming, bending, or making other modifications to a substantially prefabricated item. A custom fabricated oral appliance may include a prefabricated component (for example, the joint mechanism).
Use Code E0486 only for custom fabricated mandibular advancement devices. To be coded as E0486, custom fabricated mandibular advancement devices must meet all of the criteria below:
Have a fixed mechanical hinge (see below) at the sides, front or palate
Be able to protrude the individual beneficiary’s mandible beyond the front teeth when adjusted to maximum protrusion
Incorporate a mechanism that allows the mandible to be easily advanced by the beneficiary in increments of one millimeter or less
Retain the adjustment setting when removed from the mouth
Maintain the adjusted mouth position during sleep
Remain fixed in place during sleep so as to prevent dislodging the device
Require no return dental visits beyond the initial 90-day fitting and adjustment period to perform ongoing modification and adjustments to maintain effectiveness (see below)
A fixed hinge is defined as a mechanical joint containing an inseparable pivot point. Interlocking flanges, tongue and groove mechanisms, hook and loop or hook and eye clasps, elastic straps or bands, etc. do not meet this requirement.
Items that require repeated adjustments and modification beyond the initial 90-day fitting and adjustment period to maintain fit or effectiveness are not eligible for classification as DME. These items are considered dental therapies, which are not eligible for reimbursement.
Submit a medical authorization request in MN–ITS
Use the appropriate ICD diagnosis code
Indicate the appropriate HCPCS code (E0485 or E0486) for the appliance
Fax the supporting documentation to the Authorization Medical Review Agent and include:
Copy of the sleep study results and interpretation by a physician.
Documentation of a trial of a CPAP machine.
Billing and Documentation:
Use the Professional 837P claim.
Complete and Fax the AUC claims attachment cover sheet
Include the following with the AUC cover sheet (Word doc):
Copy of the lab slip with fee included
Cost of materials including those used to fabricate the impression and bite registration
Dental Procedures Reported with CPT Coding
Dentists and board eligible and board certified oral and maxillofacial surgeons must use the Physician’s Current Procedural Terminology (CPT) procedure codes when billing complex oral surgery to MHCP. To receive reimbursement for CPT procedure codes, you must be individually enrolled with MHCP.
Dentists using CPT procedure codes and coding must select the code for the procedure or service that most accurately identifies the service performed. You must also list any additional procedures performed, or pertinent special services. When necessary, list any modifying or extenuating circumstances.
Adequately document any service or procedure in the recipient’s medical record. Bill medical services provided by a dentist using current CPT procedure codes on the 837P.
Modifiers Modifying medical procedure codes indicates that a service or procedure has been altered by some specific circumstance, but has not changed in its definition or code. The use of modifiers eliminates the need for separate procedure billings. Use modifiers when applicable. Refer to the CPT manual for specific information on modifiers.
Bilateral Procedures – Modifier 50
Use modifier 50 only when the exact same service or code is reported for each bilateral anatomical site.
Report bilateral surgical procedure codes on one line appended with modifier 50
Enter 1 unit on a line reported with modifier 50 (Example: 49500 – 50 – 1 unit)
Do not use modifier 50 with procedure codes that are identified as bilateral or for codes that use the words one or both within the code description
Multiple surgeries Service dates on or after Oct. 1, 2011:
MHCP follows Medicare guidelines (highest valued procedure at 100%; subsequent procedures at 50%)
Subsequent claims for the same recipient, on the same day, by the same provider will deny. Replace the original claim with a claim that includes all surgeries performed.
Assistant Surgeon Assistant surgeon must use the authorization number given to the primary surgeon when billing.
Alveoloplasty or Gingivectomy Report medical procedure codes 41820, 41828, 41872, and 41874 with the appropriate oral cavity designation code as required by the Minnesota Administrative Uniformity Committee (AUC).
Alveoloplasty services do not require a denial from Medicare before billing MHCP. Use Physician’s Current Procedural Terminology (CPT) procedure codes when billing complex oral surgery, including alveloplasty. To receive reimbursement for CPT procedure codes, you must be individually enrolled with MHCP.
Temporomandibular Joint Disorder (TMD) Treatment for temporomandibular disorders (TMD) is considered a medical service when the underlying pain and dysfunction is caused by 1) pain related TMD including myalgia, myofascial pain, arthralgia, arthritis or headache attributed to TMD or 2) temporomandibular joint (TMJ) intra-articular disorders, including disk displacement with and without reduction, degenerative joint disease, osteoarthritis or subluxation. Document that the history and physical exam support the diagnosis.
Medical authorizations must be submitted on the 278 authorization transaction. The ICD diagnosis code and the associated CPT code for the occlusal orthotic device (41899 unlisted procedure, dentoalveolar structures) must be included on the authorization request. Print the response, attach the required documentation and mail it to the Authorization Medical Review Agent. Write the 11-digit number assigned on each page of your documentation, including the TMD information request form (DHS-6119) (PDF).
Dental Procedures Billed on An Institutional Claim
Dental CDT procedure codes allow reimbursement for a unit count of one. Report each individual dental service on a separate service line. Refer to the General Billing Guidelines below.
Community Health Worker – Patient Education
Community Health Worker employed and supervised by a dentist can perform patient education as described in the MHCP Provider Manual Community Health Worker section.
Refer to MHCP Provider Manual Provider Requirements section for covered services that enable a recipient to obtain health care services.
The following services are not covered. Separate billing, to either MHCP or the recipient, is prohibited for these services. This is not an all-inclusive list.
Disposable equipment or supplies
Fluoride trays or rinses
Infection control procedures
Periodontal charting (separate from codes D0150 or D0180)
Treatment deemed to be cosmetic or for aesthetic reasons
Additional noncovered services may be listed in the Dental Services subsections above.
The Authorization Medical Review Agent must receive all required documentation to complete their review. Verify the recipient is eligible for FFS and that the service requires authorization before submitting the authorization request to the Medical Review Agent. Refer to MHCP fee-for-service (FFS) dental authorization charts below for procedure-specific documentation requirements:
Report dental codes that require tooth numbers or oral cavity designations with supporting clinical documentation including tooth numbers or oral cavity designations for the service(s) provided
Include an Electronic Claim Attachment number and type on your claim
Fax the AUC Uniform Cover Sheet for Health Care Claim Attachments with supporting documentations
Crown: A restoration covering or replacing the major part of the whole portion of the tooth not covered by supporting tissues.
Dental Service: A diagnostic, preventive, or restorative procedure furnished by or under the supervision of a dentist.
Dental Surgery: Services performed by a dentist are defined as surgery when related to the jaw or any structure contiguous to the jaw. “Structures contiguous to the jaw” include structures of the facial area and below the eyes (for example, mandible, teeth, gums, tongue, palate, salivary glands, or sinuses). This includes reduction of any fracture of the jaw or any facial bone, including dental splints or other applications used for this purpose.
Emergency Services: A medical condition manifesting itself by acute symptoms of sufficient severity (including severe pain) such that a prudent layperson, who possesses an average knowledge of health and medicine, could reasonably expect the absence of immediate medical attention to result in placing the health of the individual (or, with respect to a pregnant woman, the health of the woman or her unborn child) in serious jeopardy, serious impairment to bodily functions, or serious dysfunction of any bodily organ or part. MHCP guidelines provide that the recipient must require immediate dental attention and is seen at the next available or the earliest opportunity.
Fixed Partial Denture, Fixed Cast Metal Restoration or Fixed Bridge: A prosthetic replacement of one or more missing teeth that is cemented or attached to the abutment adjacent to the space filled by the prosthetic replacement and that cannot be removed by the patient.
Implant: Material inserted or grafted into tissue or bone; or a device specially designed to be placed surgically within or on the mandibular or maxillary bone as a means of providing for dental replacement.
Medical and Surgical Services: Medical and surgical services furnished by a doctor of dental medicine or dental surgery if the services:
If furnished by a physician, would be considered physician’s services;
Under the law of the state where they are furnished, may be furnished either by a physician or doctor of dental medicine or dental surgery; and
Are furnished by a doctor of dental medicine or dental surgery who is authorized to furnish those services in the state in which he or she furnished the services.
Oral Hygiene Instruction: An organized education program by or under the supervision of a dentist to instruct a patient about the care of the patient’s teeth.
Rebase: The process of refitting a denture by replacing the base material.
Reline: The process of resurfacing the tissue side of the denture with a new base material.
Removable Prosthesis or Removable Dental Prosthesis: Includes dentures and removable partial dentures. Any dental device or appliance replacing one or more missing teeth, including associated structures, if required, that is designed to be removed and reinserted by the patient.