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). Delta Dental Premier dentists may elect to opt out of only the HKD program and continue to participate with all other Delta Dental Premier groups.
To opt out, mail or fax a statement to Delta Dental declaring nonparticipation in program. Include the doctor’s name, tax identification number, license number and office address. Nonparticipating status for HKD will be effective 60 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 Delta Dental's Healthy Kids Dental 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 member or responsible party agrees to pay for a noncovered service, the HKD participating dentist will be held to the lesser of the submitted fee or Delta Dental's Healthy Kids Dental 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 Delta Dental HKD patient is essential as eligibility for these patients may change frequently. If you do not check eligibility on the date of service for a Delta Dental HKD patient before you begin treatment, and deliver services to an ineligible patient, you cannot receive reimbursement from Delta Dental and cannot bill the patient for the services. If you have not already done so, please set up a process where you check your Delta Dental HKD patients’ eligibility on their appointment days.
Third molar extraction criteria for HKD members
The HKD program administered by Delta Dental does not cover the prophylactic removal of asymptomatic teeth that exhibit no overt pathology or other qualifying conditions. To be a covered benefit, removal of asymptomatic third molars must be substantiated by evidence of pathology, disease or other local damage attributed to the third molar in question. Claims for extraction of one or more third molars, for patients enrolled in the HKD dental program administered by Delta Dental, must include a recent radiograph showing the entire length of the teeth involved and a short narrative in the remarks section of the claim that describes the pathology, disease, condition or symptoms specific to each tooth.
Examples of pathology, conditions or symptoms that would likely result in coverage of a third molar extraction include, but are not limited to:
- Unrestorable caries
- Fracture of the tooth
- 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 documented as particularly severe) that cannot be successfully treated through the use of antibiotics, irrigation or other local treatment
- Cellulitis, abscess or osteomyelitis
- Internal/external resorption of the third molar or adjacent teeth
- Follicular disease, including a cyst or 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, including those involving a reported symptom(s) of pain in the absence of overt pathology, disease or locally damaging effects. In such instances, as reflected in the patient treatment records, the provider attests that in their opinion, that extraction (of teeth without overt pathology, disease or evidence of local damage caused by the third molar), is the best treatment option to ameliorate the patient’s current condition. All such cases are subject to review by Delta Dental.
Examples of pathology, conditions or symptoms not likely to warrant benefit coverage include, but are not limited to:
- Orthodontia-related extraction(s)
- Non-symptomatic impaction - (prophylactic extraction of an impacted tooth)
- Pain and/or swelling related to the normal eruption process where observation and palliative therapy is appropriate
Please note that adjunctive services such as general anesthesia or deep sedation administered in conjunction with non-covered extractions would also not be covered.
Brush up on Healthy Kids Dental requirements
It’s important to remember the appointment access standards for your patients who have HKD administered by Delta Dental.
These standards are as follows:
Dental plan appointment and timely access to care standards
|Type of care
||Length of time
|Emergency dental services
||Within 48 hours
||Within 21 business days of request
||Within six weeks of request
||Within eight weeks of request
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.