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RULE §354.1221Authorized Dentists' Services

(a) Dentists' services provided by a doctor of dentistry (DDS, DMD, or DDM), as defined in §354.1121 of this subchapter (relating to Definitions), are covered by the Texas Medicaid Program if the services:

  (1) are within the dentist's scope of practice, as defined by state law; and

  (2) would be covered by the Texas Medicaid Program when they are provided by a licensed physician (MD or DO).

(b) Substitute dentist. A dentist may act as a billing agent, pursuant to 42 CFR 447.10, to submit claims. To qualify for reimbursement, the billing agent dentist and substitute dentist must comply with the following requirements:

  (1) The substitute dentist must be licensed to practice in the state of Texas.

  (2) Consistent with the requirements of §371.1605 and §371.1705 of this title (relating to Provider Responsibility and Mandatory Exclusion, respectively), the substitute dentist must be enrolled in Medicaid and not be on the Medicaid or Title XX provider exclusion list.

  (3) The substitute dentist's National Provider Identifier (NPI) must be entered on the dental claim form.

  (4) The billing agent dentist must submit the claims on behalf of the substitute dentist and may recover no more than the actual administrative cost of submitting the claim on behalf of the substitute dentist. This cost is not reimbursable by Medicaid.

  (5) The billing agent dentist may only bill for services furnished by a substitute dentist on a temporary basis, for no longer than a 90-day consecutive period. Except as provided in paragraph (6) of this subsection, the billing agent dentist may not submit a claim for services furnished by a substitute dentist to address long-term absences or vacancies in a dental practice.

  (6) A billing agent dentist may submit claims for the services of a substitute dentist for longer than 90 consecutive days, if the billing agent dentist has been called or ordered to active duty as a member of a reserve component of the Armed Forces. Medicaid accepts claims from the billing agent dentist for services provided by the substitute dentist for the duration of the billing agent dentist's active duty as a member of a reserve component of the Armed Forces.

Source Note: The provisions of this §354.1221 adopted to be effective October 8, 1984, 9 TexReg 4975; amended to be effective January 1, 1988, 13 TexReg 1593; transferred effective September 1, 1993, as published in the Texas Register September 7, 1993, 18 TexReg 5978; transferred effective September 1, 2001, as published in the Texas Register May 24, 2002, 27 TexReg 4561; amended to be effective December 31, 2017, 42 TexReg 7381

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