OAR 410-123-1490
Hospital Dentistry

(1) The purpose of hospital dentistry is to provide safe, efficient dental care when providing routine (non-emergency) dental services for Division of Medical Assistance Programs (Division) clients who present special challenges that require the use of general anesthesia or IV conscious sedation services in an Ambulatory Surgical Center (ASC), inpatient or outpatient hospital setting. Refer to OAR 410-1231060 for definitions.
(2) Division reimbursement for hospital dentistry is limited to covered services and may be prorated if non-covered dental services are performed during the same hospital visit:
(a) See OAR 410-123-1060 (Definition of Terms) for a definition of Division hospital dentistry services;
(b) Refer to OAR 410-123-1220 (Coverage According to the Prioritized List of Health Services) and the “Covered and Non-Covered Dental Services” document.
(3) Hospital dentistry is intended for the following Division clients:
(a) Children (18 or younger) who:
(A) Through age 3 -- Have extensive dental needs;
(B) 4 years of age or older -- Have unsuccessfully attempted treatment in the office setting with some type of sedation or nitrous oxide;
(C) Have acute situational anxiety, fearfulness, extreme uncooperative behavior, uncommunicative such as a client with developmental or mental disability, a client that is pre-verbal or extreme age where dental needs are deemed sufficiently important that dental care cannot be deferred;
(D) Need the use of general anesthesia (or IV conscious sedation) to protect the developing psyche;
(E) Have sustained extensive orofacial or dental trauma;
(F) Have physical, mental or medically compromising conditions; or
(G) Have a developmental disability or other severe cognitive impairment and one or more of the following characteristics that prevent routine dental care in an office setting:
(i) Acute situational anxiety and extreme uncooperative behavior;
(ii) A physically compromising condition;
(b) Adults (19 or older) who:
(A) Have a developmental disability or other severe cognitive impairment, and one or more of the following characteristics that prevent routine dental care in an office setting:
(i) Acute situational anxiety and extreme uncooperative behavior;
(ii) A physically compromising condition;
(B) Have sustained extensive orofacial or dental trauma; or
(C) Are medically fragile, have complex medical needs, contractures or other significant medical conditions potentially making the dental office setting unsafe for the client.
(4) Hospital dentistry is not intended for:
(a) Client convenience. Refer to OAR 410-120-1200 (Excluded Services and Limitations);
(b) A healthy, cooperative client with minimal dental needs; or
(c) Medical contraindication to general anesthesia or IV conscious sedation.
(5) Required documentation: The following information must be included in the client’s dental record:
(a) Informed consent: client, parental or guardian written consent must be obtained prior to the use of general anesthesia or IV conscious sedation;
(b) Justification for the use of general anesthesia or IV conscious sedation. The decision to use general anesthesia or IV conscious sedation must take into consideration:
(A) Alternative behavior management modalities;
(B) Client’s dental needs;
(C) Quality of dental care;
(D) Quantity of dental care;
(E) Client’s emotional development;
(F) Client’s physical considerations;
(c) If treatment in an office setting is not possible, documentation in the client’s dental record must explain why, in the estimation of the dentist, the client will not be responsive to office treatment;
(d) The Division, Coordinated Care Organization (CCO) or Prepaid Health Plan (PHP) may require additional documentation when reviewing requests for prior authorization (PA) of hospital dentistry services. See OAR 410-123-1160 (Prior Authorization) and section (6) of this rule for additional information;
(e) If the dentist did not proceed with a previous hospital dentistry plan approved by the Division for the same client, the Division will also require clinical documentation explaining why the dentist did not complete the previous treatment plan.
(6) Hospital dentistry always requires prior authorization (PA) for the medical services provided by the facility:
(a) If a client is enrolled in a CCO or PHP and a Dental Care Organization (DCO):
(A) The dentist is responsible for:
(i) Contacting the CCO or PHP for PA requirements and arrangements; and
(ii) Submitting documentation to both the CCO or PHP and DCO;
(B) The CCO or PHP and DCO should review the documentation and discuss any concerns they have, contacting the dentist as needed. This allows for mutual plan involvement and monitoring;
(C) The total response time should not exceed 14 calendar days from the date of submission of all required documentation for routine dental care and should follow urgent/emergent dental care timelines;
(D) The CCO or PHP is responsible for payment of all facility and anesthesia services. The DCO is responsible for payment of all dental professional services;
(b) If a client is enrolled in a Physician Care Organization (PCO) and a Dental Care Organization (DCO):
(A) The PCO is responsible for payment of all facility and anesthesia services provided in an outpatient hospital setting or an ASC. The Division is responsible for payment of all facility and anesthesia services provided in an inpatient hospital setting. The DCO is responsible for payment of all dental professional services;
(B) The dentist is responsible for:
(i) Contacting the PCO, if services are to be provided in an outpatient setting or an ASC, for PA requirements and arrangements; or
(ii) Contacting the Division, if services are to be provided in an inpatient setting; and
(iii) Submitting documentation to both the PCO (or the Division) and the DCO;
(B) The PCO or the Division and the DCO should review the documentation and discuss any concerns they have, contacting the dentist as needed. This allows for mutual plan involvement and monitoring;
(C) The total response time should not exceed 14 calendar days from the date of submission of all required documentation for routine dental care and should follow urgent/emergent dental care timelines;
(b) If a client is fee-for-service (FFS) for medical services and enrolled in a DCO:
(A) The dentist is responsible for faxing documentation and a completed American Dental Association (ADA) form to the Division. Refer to the Dental Services Provider Guide;
(B) If the client is assigned to a Primary Care Manager (PCM) through FFS medical, the client must have a referral from the PCM prior to any hospital service being approved by the Division;
(C) The Division is responsible for payment of facility and anesthesia services. The DCO is responsible for payment of all dental professional services;
(D) The Division will issue a decision on PA requests within 30 days of receipt of the request;
(c) If a client is enrolled in an CCO or PHP and is FFS dental:
(A) The dentist is responsible for contacting the CCO or PHP to obtain the PA and arrange for the hospital dentistry;
(B) The dentist is responsible for submitting required documentation to the CCO or PHP;
(C) The CCO or PHP is responsible for all facility and anesthesia services. The Division is responsible for payment of all dental professional services;
(d) If a client is FFS for both medical and dental:
(A) The dentist is responsible for faxing documentation and a completed ADA form to the Division. Refer to the Dental Services Provider Guide;
(B) The Division is responsible for payment of all facility, anesthesia services and dental professional charges.

Source: Rule 410-123-1490 — Hospital Dentistry, https://secure.­sos.­state.­or.­us/oard/view.­action?ruleNumber=410-123-1490.

Last Updated

Jun. 8, 2021

Rule 410-123-1490’s source at or​.us