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Healthy Kids Dental Dentist Information

Dentist participation with Healthy Kids Dental

Delta Dental Premier participating dentists in Michigan are automatically eligible to treat children enrolled in Healthy Kids Dental (HKD) and MIChild. Delta Dental Premier dentists may elect to opt out of only the HKD and MIChild programs and continue to participate with all other Delta Dental Premier groups. To opt out, mail or fax a statement to Delta Dental declaring nonparticipation with only these two programs. Include the doctor’s name, tax identification number, license number and office address. Nonparticipating status for HKD and MIChild will be effective 30 days from the date Delta Dental receives the statement. Address your request to Provider Records, Delta Dental, PO Box 30416, Lansing, MI 48909-7916, or fax to (517) 706-3618.



Reimbursement for services rendered to HKD members

Reimbursement to all Michigan participating dentists for covered services rendered to HKD members is based on the Delta Dental PPO fee schedule. Eligible HKD members can receive treatment from any Delta Dental Premier participating Michigan dentist who agrees to accept the lesser of the submitted fee or the amount in the HKD fee schedule as full payment for services. The dentist cannot balance bill the member for any difference between his or her regular fees and the amount in the current fee schedule. This schedule is, on average, 66–89 percent higher than traditional Medicaid reimbursement.

All covered services for eligible HKD members are reimbursed at 100 percent of the dentist’s submitted fee or the amount in the HKD fee schedule, whichever is less. Aside from a few exceptions noted in the fee schedule, all of Delta Dental’s standard time limitations and policies apply to the covered services. Additionally, because HKD is a public program designed to deliver medically necessary treatment, the removal of asymptomatic third molars is not a covered benefit.

For any services not covered by HKD, the cost will be the responsibility of the member or responsible party. However, such cost must be discussed with these individuals in advance, and non-covered (or alternate) services should only be done with their agreement to pay for those services.

IMPORTANT: Please check the eligibility of every HKD patient on the day of treatment.

 

Third molar extraction criteria for HKD members

The Healthy Kids Dental (HKD) program does not cover prophylactic removal of pathology-free (asymptomatic) third molars. Surgical removal of third molars must be substantiated by evidence of pathology. Claims for extraction of one or more third molars for a HKD member must include a radiograph and a short narrative in the “Remarks” section of the claim form that describes the specific pathology that indicated extraction.

Evidence of pathology includes the following conditions:

  • Unrestorable caries
  • Fracture
  • Caries in the adjacent second molar that cannot satisfactorily be treated without the removal of the third molar
  • Non-treatable pulpal and/or periapical pathology
  • Unmanageable periodontal disease in a second molar that was caused or exacerbated by the position of the adjacent third molar
  • Second or subsequent episodes of pericoronitis (unless the first episode is particularly severe) that cannot be safely controlled through the use of antibiotics, irrigation, or other topical treatment
  • Cellulitis, abscess, or osteomyelitis
  • Internal/external resorption of the third molar or adjacent teeth
  • Follicular disease, including cyst/tumor
  • Tooth/teeth impeding orthognathic surgery, reconstructive surgery, trauma surgery or other jaw surgery
  • Involvement in a tumor or within the field of tumor resection
  • Medical condition(s) in which the risks associated with third molar retention outweigh the potential complications associated with extraction, such as prior to radiotherapy, cardiac surgery or organ transplant

Other conditions will be evaluated on a case-by-case basis

The following conditions do not indicate medical necessity:

(Note: Prophylactic removal of pathology-free (asymptomatic) third molars is not a covered benefit. Adjunctive service, such as general anesthesia or deep sedation, administered in conjunction with non-covered extractions is not covered.)

  • Orthodontia-related extraction(s)
  • Non-symptomatic impaction
  • Pain and/or swelling unless supported by documentation of qualifying pathology

 

HKD claims address

Delta Dental
PO Box 9085
Farmington Hills, MI 48333-9085



NOTE: Delta Dental will not prohibit a Healthy Kids Dental provider from advocating on behalf of the member in any grievance or utilization review process, or in the pre-treatment estimate process to obtain a benefits estimate.