| (a) Emergency dental services. The Texas Department
of Human Services (DHS) will reimburse nursing facilities the cost
of emergency dental services provided to eligible Medicaid residents
residing in Medicaid-contracted facilities or distinct parts.
(1) Recipients must be 21 years of age or older.
(2) Dental care for recipients under the age of 21
is covered under the Early and Periodic Screening, Diagnosis, and
Treatment (EPSDT) program.
(3) Services reimbursed are subject to the limitations
specified in §19.1401(b) of this title (relating to Dental Services).
(4) Emergency dental services may be provided only
if the attending physician orders a dental consultation. See §19.1201
of this title (relating to Physician Services).
(b) Dental providers. Emergency dental services must
be provided by a dentist licensed by the Texas State Board of Dental
Examiners who, if not employed by the facility, contracts with the
facility according to the specifications outlined in §19.1906
of this title (relating to Use of Outside Resources).
(c) Reimbursement for Emergency Dental Services. The
cost of emergency dental services provided to eligible Medicaid residents
residing in nursing facilities will be reimbursed to facilities, provided
that the services are not reimbursable by the Medicaid claims processor
or the EPSDT program.
(d) Payment of Claims.
(1) The facility must accept payment by DHS as payment
in full for services. Neither the dentist nor the facility may charge
an additional fee to the recipient, his family, or his trust fund,
except that the dentist may charge the recipient for services that:
(A) the recipient requests; and
(B) are not reimbursable by the Texas Medical Assistance
Program.
(2) Payments for emergency dental services are the
lower of the:
(A) dentist's usual fee; or
(B) maximum fee as determined by the Texas Health and
Human Services Commission (HHSC).
(3) DHS reimburses facilities for services properly
rendered in accordance with applicable laws, regulations, and operational
instructions. DHS may withhold or suspend payment for services that
are not properly rendered.
(4) Nursing Facility Emergency Dental Services makes
no payment for services that are available under any other Texas Medical
Assistance Program.
(5) Complete and accurate claims for services must
be received within 12 months from the date of service.
(6) Claims for services delivered before the effective
date of this section must be submitted within 12 months of the effective
date of this section.
(7) Adjustments to claims must be received by DHS's
claims processor during the applicable 12-month period. Claims and
adjustments rejected or denied during the 12-month period through
no fault of the dentist may be paid upon approval by DHS.
|
| Source Note: The provisions of this §554.1402 adopted to be effective May 1, 1995, 20 TexReg 2393; amended to be effective November 1, 2002, 27 TexReg 9387; transferred effective January 15, 2021, as published in the Texas Register December 11, 2020, 45 TexReg 8871 |
