Clarification for Adults Enrolled in Dental Medicaid

Download PDF

Bulletin

September 5, 2024, 11:26AM

To:

Virginia Cardinal Care Smiles Participating Providers

From:

Cheryl J. Roberts, Director Department of Medical Assistance Services (DMAS)

The purpose of this bulletin is to provide a correction to a previously released memo from the Department of Medical Assistance Services (DMAS) on dental coverage for adults, age 21 years and over, who are receiving full Medicaid benefits. This coverage began on July 1, 2021. The previous memo indicated that bridges were a covered benefit for adults, age 21 years and over. Bridges are not a covered benefit for adults ages 21 years and over.

BACKGROUND

Dental coverage for adults enrolled in Medicaid focuses on overall oral health, prevention and restoration. Adult dental coverage is similar to the coverage currently available to pregnant women.

DENTAL BENEFITS ADMINISTRATOR – DENTAQUEST

DentaQuest is the Medicaid dental benefits administrator (DBA) for the Cardinal Care Smiles (CCS) program. DentaQuest administers the dental coverage and benefits for all Medicaid and FAMIS covered members including those enrolled in both managed care, FFS and members with special needs. Information regarding dental benefits for all members, including how dentists can enroll in the program is posted on DentaQuest’s website located at www.dentaquest.com or can be found on the DMAS website at https://www.dmas.virginia.gov. Information may also be obtained by calling the Cardinal Care Smiles program at 1-888-912-3456.

CONTACT INFORMATION:

How can I help adults enrolled in Medicaid find a dentist?

Option 1: Call the CCS program at 1-888-912-3456. A representative can even help the member make an appointment. The call center is available 8 a.m. – 6 p.m., Monday through Friday.

Option 2: Visit the website at https://www.dentaquest.com/en/members/virginia-medicaid-dental-coverage

CARDINAL CARE SMILES (CCS) SERVICES FOR ADULTS

Covered dental services for adults include the following:

Diagnostic (x-rays, exams)

Preventive (cleanings)

Restorative (fillings and crowns)

Endodontics (root canals, Pulpal Debridement)

Periodontics (gum related treatment)

Prosthodontics (dentures)

Oral surgery (extractions, alveoplasty and other oral surgeries)

Adjunctive general services (anesthesia).

*Braces and bridges are not covered for adult members.

Dental providers’ who wish to treat adults must be credentialed by DentaQuest and participate in Virginia’s Cardinal Care Smiles dental provider network.

Adults will be able to access non-emergency transportation services to participate in dental care.

Transportation for adults in fee-for-service (FFS) will be provided by ModivCare, formerly LogistiCare the DMAS FFS transportation broker. Transportation for adults enrolled in managed care will be handled by the Managed Care Organization’s (MCO) Non-Emergency Transportation (NEMT) vendor. FFS and MCO NEMT contact telephone numbers for reservations and ride assist can be found at: https://www.dmas.virginia.gov/for-members/benefits-and-services/transportation-services/.

Covered Services for Adults Enrolled In Medicaid as of July 1, 2021

Specialty Area

Description

Services Covered

Limitations

Diagnostic

and

Preventive

Care

Services that are used to

detect and recognize caries

and periodontal disease.

Up to three routine

cleanings may be

permissible

Exams, routine

cleanings,

X-rays

Non routine x-rays such

as imaging and cone

beam technology would

require prior

authorization

Restorative Care

Specialty allows dentists to restore teeth to proper function

Fillings and crowns

Crowns are a covered benefit for adults when the tooth has received root canal treatment.

*Bridges are not covered

Endodontics

Specialty allows dentists to

perform root canals on

teeth that have sound below

the gum structure (root) yet

the above gum structure is

compromised (decay or

trauma)

Root canals

Pulpal

Debridement

Endodontic retreatment

and surgical procedures

that have a questionable

success rate

Periodontics

Specialty focuses on keeping gums and the bone below the gums healthy.

Scaling and Root Planing Gingivectomies Periodontal maintenance procedures

Periodontal flap procedures, crown lengthening procedures, bone replacement grafts

Dentures and Partials

Specialty focuses on replacing teeth with removal appliances

Dentures, Partials, and Repair procedures

Partials are covered as a part of a definitive treatment plan

Oral Surgery

Specialty routinely extracts

teeth and performs

extractions requiring

surgical methods such as

removing bone

Extractions

Alveoplasty

Non-tooth extraction

procedures;

Surgery necessitated by

trauma; and

Implants

Adjunctive

General

Services

This area while not a

specialty is important in

that it allows coding for

anesthesia services and

many other dental

procedures not listed

elsewhere.

Anesthesia

Services

Non anesthesia services

may require prior

authorization

*Covered CDT codes and benefit limitations can be found in the Cardinal Care Smiles Office Reference Manual (ORM).

PROVIDER CONTACT INFORMATION & RESOURCES

Virginia Medicaid Web Portal Automated Response System (ARS)

Member eligibility, claims status, payment status, service limits, service authorization status, and remittance advice.

https://vamedicaid.dmas.virginia.gov/

Medicall (Audio Response System)

Member eligibility, claims status, payment status, service limits, service authorization status, and remittance advice.

1-800-884-9730 or 1-800-772-9996

Provider Appeals

DMAS launched an appeals portal in 2021. You can use this portal to file appeals and track the status of your appeals. Visit the website listed for appeal resources and to register for the portal.

https://www.dmas.virginia.gov/appeals/

Managed Care Programs

Cardinal Care Managed Care and Program of All-Inclusive Care for the Elderly (PACE). In order to be reimbursed for services provided to a managed care enrolled individual, providers must follow their respective contract with the managed care plan/PACE provider. The managed care plan may utilize different guidelines than those described for Medicaid fee-for-service individuals.

Cardinal Care Managed Care

https://www.dmas.virginia.gov/for-providers/managed-care/cardinal-care-…

PACE

Program of All-inclusive Care (virginia.gov)

Acentra Health

Behavioral Health Services

https://vamedicaid.dmas.virginia.gov/sa

Provider Enrollment

In-State: 804-270-5105

Out of State Toll Free: 888-829-5373

Email: VAMedicaidProviderEnrollment@gainwelltechnologies.com

Provider HELPLINE