All dental providers practicing within the scope of practice for their licensure are eligible to provide services to PrimeWest Health members as long as they are willing to accept PrimeWest Health reimbursement as "payment in full" and agree not to balance bill our members.
Dental providers may also find the following resources helpful:
- The current PrimeWest Health Dental Covered Services chart explains what dental codes are covered for the following member groups:
- Children under age 21 and pregnant adults
- Non-pregnant adults age 21 and over
- The Quick Reference Guide for Dental Providers is a resource for dental billing, claims submission, Service Authorizations, covered services, and Provider Updates.
- Our Dental Services Handout offers more information on PrimeWest Health dental services
- Our Early Dental Care booklet provides parents of young children with a dental activity book
- Recent information about Critical Access Dental Payment from the Minnesota Department of Human Services (DHS)
- Dental Services (Overview) from DHS
- Allied Oral Health Professional (Overview) from DHS
- Dental C&TC Standards from DHS
- PrimeWest Health-developed Dental Handouts with helpful dental information for members
Adult Prophylaxis D1110
Adult prophylaxis D1110 is now covered twice per calendar year for non-pregnant adults age 21 and over.
Claims for D1110 submitted and denied with a date of service January 1 – April 10, 2014 will be reprocessed and paid if the denial was due to the previous 365-day rolling year guideline that was in place effective July 1, 2013.
Adult prophylaxis D1110 authorization requirements for non-pregnant adults
Authorization is required for prophylaxis in addition to the two prophylaxes allowed and performed in accordance with an appropriate individualized treatment plan, up to a maximum of two additional prophylaxes within a calendar year. Service Authorization approval does not guarantee that two additional cleanings will be approved. There may be cases where only one additional cleaning is approved.
If you have additional questions, please review Chapter 19, Dental Services, of the Provider Manual or call the Provider Contact Center at 1-866-431-0802 (toll free).
Dental benefits change, effective July 1, 2013
The dental benefits for non-pregnant adults as well as children and pregnant adults have changed.
The 2013 Minnesota Legislature expanded coverage for certain dental services for the fee-for-service (FFS), non-pregnant adult, benefit set. Based on these changes, PrimeWest Health has made dental benefit changes effective for services provided on or after July 1, 2013.
The following services will be covered when medical necessity criteria are met for non-pregnant adult dental services:
- D9410: House calls or extended care facility calls for on-site delivery of covered Medical Assistance services (no Service Authorization required)
- D9920: Behavioral management when additional staff time is required to accommodate behavioral challenges and sedation is not used
- D9241 – D9242; D9248: Oral or intravenous (IV) sedation if the covered dental service cannot be performed safely without it or would otherwise require the service to be performed under general anesthesia in a hospital or surgical center
- D1110: Prophylaxis according to an appropriate individualized treatment plan that meets criteria for covering the additional prophylaxis service(s), but no more than four times per a 365-day span. Criteria includes patients who are physically disabled or reside in a facility (including nursing homes) or group home setting and rely on others to provide daily oral care. Please provide the date of the last prophylaxis when requesting a Service Authorization.
Please see Chapter 19, Dental Services, of the PrimeWest Health Provider Manual for detailed Service Authorization criteria and guidelines for the additional non-pregnant adult covered dental codes.
Authorization Requirement Changes for Non-Pregnant Adults, Children, and Pregnant Adults
- Partial denture Service Authorization requests should include copies (not originals) of current radiographs
- Oral surgery Service Authorization requests: A referring provider must release the patient’s health record to another provider regardless of the status of the patient’s account. Rendering providers are responsible for working with the referring provider to obtain all needed documentation to request an authorization for a PrimeWest Health-covered service.
- Dental providers billing for sleep apnea appliances: 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 (DME). Dentists assure the proper fit of the appliance. Most appliances require that a dentist take necessary impressions and a bite registration. See the Dental Providers Billing for Sleep Apnea Appliance section in Chapter 19, Dental Services, of the PrimeWest Health Provider Manual for correct coding for oral appliances for the treatment of obstructive sleep apnea.
- Multiple surgeries: Modifier 51 is no longer required on multiple surgeries performed on the member on the same day by the same provider