(a) Dental treatment consists of the following:
(1) emergency dental treatments, which are procedures
necessary to control bleeding, relieve pain, and eliminate acute infection;
operative procedures that are required to prevent the imminent loss
of teeth; and treatment of injuries to the teeth or supporting structures;
(2) routine preventative dental treatments, which are
examinations, x-rays, cleanings, sealants, oral prophylaxes, and topical
fluoride applications;
(3) therapeutic dental treatments, which include fillings,
scaling, extractions, crowns, and pulp therapy for permanent and primary
teeth; restoration of carious permanent and primary teeth; maintenance
of space; and limited provision of removable prostheses when masticatory
function is impaired, when an existing prosthesis is unserviceable,
or when aesthetic considerations interfere with employment or social
development;
(4) orthodontic dental treatments, which are procedures
that include treatment of retained deciduous teeth; cross-bite therapy;
facial accidents involving severe traumatic deviations; cleft palates
with gross malocclusion that will benefit from early treatment; and
severe, handicapping malocclusions affecting permanent dentition with
a minimum score of 26 as measured on the Handicapping Labio-lingual
Deviation Index; and
(5) dental sedation, which is sedation necessary to
perform dental treatment including non-routine anesthesia, (for example,
intravenous sedation, general anesthesia, or sedative therapy prior
to routine procedures) but does not include the administration of
routine local anesthesia only.
(b) Dental treatment does not include cosmetic orthodontia.
(c) HHSC approves the following amounts as the maximum
for an individual's dental treatment:
(1) $2,500 per IPC period for services described in
subsection (a)(1) - (4) of this section; and
(2) $2,000 per IPC period for sedation, other than
the administration of routine local anesthesia, as described in subsection
(a)(5) of this section.
(d) For an initial dental exam, a program provider
may include up to $200 on the IPC without submitting a completed HHSC
Prior Authorization for Dental Services form signed by the individual's
dentist to HHSC for approval. For all other dental treatments, a program
provider must submit a completed HHSC Prior Authorization for Dental
Services form that has been signed by the individual's dentist to
HHSC with the IPC for authorization.
(e) If a program provider determines emergency dental
treatment is necessary to ensure an individual's health and welfare
and the necessary service is not included on the individual's IPC
and IPP or exceeds the amount included in the IPC for dental treatment,
a program provider must submit a revised IPC and revised IPP to HHSC
in accordance with §260.77(c) of this chapter (relating to Renewal
and Revision of an IPP and IPC ).
(f) For an individual under 21 years of age, a program
provider must first access dental treatment benefits through the Texas
Health Steps--Comprehensive Care Program before dental treatment may
be provided under the DBMD Program.
(g) A program provider must maintain, in the individual's
record, a copy of the dentist's invoice for dental treatment.
(h) HHSC does not reimburse a program provider for
cosmetic orthodontia.
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