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 PPOSM 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 to 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.
If a procedure does not appear on your fee schedule, it is not a covered benefit. Payment for noncovered services is the responsibility of the member or responsible party; however, the fee must be discussed with the individual in advance and treatment should only be rendered if they agree to pay for noncovered (or alternate) procedures.
The member’s or responsible party’s approval to proceed with treatment, knowing they will be financially responsible, should be noted in the patient record. If an HKD/MIChild member or responsible party agrees to pay for a noncovered service, the HKD/MIChild participating dentist will be held to the lesser of the submitted fee or the Delta Dental PPO fee schedule for any charges to the member or responsible party. Due to federal Medicaid requirements, covered services that are denied by Delta Dental (example: a procedure that exceeds a frequency limitation) cannot be charged to the member or responsible party unless the member or responsible party has agreed to pay for it.
IMPORTANT ELIGIBILITY INFORMATION
Verification of eligibility on the date of service of each Healthy Kids Dental and MIChild (HKD/MIChild) patient is essential as eligibility for HKD/MIChild patients may change frequently. If an HKD/MIChild provider’s office fails to check eligibility on the date of service for an HKD/MIChild patient and delivers services to an ineligible patient, the provider will not receive reimbursement from Delta Dental and cannot bill the patient for the services.
Third molar extraction criteria for HKD members
The 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 an 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
- Caries in the adjacent second molar that cannot satisfactorily be treated without the removal of the third molar
- Nontreatable 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)
- Nonsymptomatic impaction
- Pain and/or swelling unless supported by documentation of qualifying pathology
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.