OAR 410-123-1260
OHP Dental Benefits

(1)

This administrative rule aligns with and reflects changes to the Prioritized List of Health Services and the American Dental Association’s (ADA) Code on Dental Procedures and Nomenclature (CDT Codes), as well as a restoration of benefits resulting from legislative action in 2015. Effective January 1, 2017, the Health Evidence Review Commission (HERC) added and deleted oral health procedure codes. This rule provides information on how the Oregon Health Plan covers newly opened CDT codes and restored benefits as of October 1, 2016. Incorporated by reference the “Covered and Non-Covered Dental Services” database dated January 1, 2021, is located on the Health Systems Division (Division) website at: https://data.oregon.gov/Health-Human-Services/Oregon-Medicaid-Covered-and-Non-Covered-Dental-Cod/5t6q-5tkx/data. All CDT codes, OHP coverage or non-coverage statuses, prioritized list lines, guideline note references and benefit limitations are found in the above referenced database. Instructions for database use can be found in the Dental Services Provider Guide: https:/­/­www.oregon.gov/­oha/­HSD/­OHP/­Pages/­Policy-Dental.aspx.
(2) GENERAL:
(a) Early and Periodic Screening, Diagnosis and Treatment (EPSDT):
(A) Refer to Code of Federal Regulations (42 CFR 441, Subpart B) and OAR chapter 410, division 120 for definitions of the EPSDT program, eligible clients, and related services. EPSDT dental services include but are not limited to:
(i) Dental screening services for eligible EPSDT individuals; and
(ii) Dental diagnosis and treatment that is indicated by screening at as early an age as necessary, needed for relief of pain and infections, restoration of teeth, and maintenance of dental health.
(B) Providers shall provide EPSDT services for eligible Division clients according to the following documents:
(i) The Dental Services program administrative rules (OAR chapter 410, division 123), for dentally appropriate services funded on the Oregon Health Evidence Review Commission’s Prioritized List of Health Services (Prioritized List); and
(ii) The “Oregon Health Plan (OHP) - Recommended Dental Periodicity Schedule,” dated April 1, 2018, incorporated in rule by reference and posted on the Division website in the Dental Services Provider Guide document at: https:/­/­www.oregon.gov/­OHA/­HSD/­OHP/­Pages/­Policy-Dental.aspx.
(b) Restorative, periodontal, and prosthetic treatments:
(A) Documentation shall be included in the client’s charts to support the treatment. Treatments shall be consistent with the prevailing standard of care and may be limited as follows:
(i) When prognosis is unfavorable;
(ii) When treatment is impractical;
(iii) A lesser-cost procedure achieves the same ultimate result; or
(iv) The treatment has specific limitations outlined in this rule.
(B) Prosthetic treatment, including porcelain fused to metal crowns, are limited until rampant progression of caries is arrested and a period of adequate oral hygiene and periodontal stability is demonstrated; periodontal health needs to be stable and supportive of a prosthetic.
(c) Full and/or partial denture replacement: For indications and limitations of coverage and dental appropriateness, the Division may cover reasonable and necessary replacement of dentally appropriate, covered full and/or partial dentures, including those items purchased or in use before the client enrolled with the Division.
(A) Replacement of full and/or partial dentures because of loss due to circumstances beyond the member’s control, accident or natural disaster/ Situations involving the provision of dentally appropriate items when:
(i) There is a change in the client’s condition that warrants a new device;
(ii) The item is not repairable; and
(iii) There is coverage for the specific item as identified in chapter 410, division 123.
(iv) Full and partial dentures that the client owns may be replaced in cases of loss due to circumstances beyond the member’s control or irreparable damage. Irreparable damage refers to a specific accident or to a natural disaster.

(B)

Cases suggesting malicious damage, culpable neglect, or wrongful disposition of full and/or partial dentures may not be covered. All other dental services are represented in the above referenced Dental Benefits Database.

Source: Rule 410-123-1260 — OHP Dental Benefits, https://secure.­sos.­state.­or.­us/oard/view.­action?ruleNumber=410-123-1260.

Last Updated

Jun. 8, 2021

Rule 410-123-1260’s source at or​.us