These services include, but are not limited to, sedation, general anesthesia and utilization of surgical facilities. Recognize that although these services are covered, your treatment may be difficult to provide if you are unable to find a provider such as an anesthesiologist willing to accept the MA rate. MNC must take into account the patient’s age, developmental status and psychosocial well-being, in addition to the setting appropriate to the needs of the child and family.
Dental care is medically necessary to prevent and eliminate orofacial disease, infection and pain, to restore the form and function of the dentition and to correct facial disfiguration or dysfunction. If your patient is under age 21 and requires care that satisfies the definition of “medically necessary,” the services should be paid for under the MA system.
DPW developed a defined benefits package with a fee schedule to cover most of the procedures that children may need. However, this fee schedule is not all-inclusive. There are some frequency limitations. An example of this would be “one dental prophylaxis every 180 days.” If it is medically necessary for a child to need more than one dental prophylaxis within 180 days, that prophylaxis should be covered by DPW.
Any MNC care not listed under the defined benefits package fee schedule must also be covered. Fees for services which are not listed on the DPW fee schedule are negotiable. If you cannot reach an acceptable level of reimbursement, DPW (Access, Access Plus or Health Choices) programs have the right to refer your patient to another dental provider. Also, be aware that co-pays or deductibles cannot be charged for any patient under age 21.
For dentists in family or general practice, treatment of healthy children between the ages of approximately nine and 21 will generally allow for the completion of all necessary care paid for by DPW. Parents should readily accept most treatment plans for their children because these services require no out-of-pocket expense from them. Payments will be based on the fee schedule you have agreed upon. This should prevent any misunderstandings regarding levels of compensation.