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OHCA Policies and Rules

317:30-5-695. Eligible dental providers and definitions

[Revised 09-14-2020]

(a) Eligible dental providers in Oklahoma's SoonerCare program are:

(1) Individuals licensed as dentists under Title 59 of Oklahoma Statutes (O.S.), Sections 328.21, 328.22, and 328.23 (licensed dentists, specialty dentists and out of state dentists);

(2) Individuals issued permits as dental interns under 59 O.S. 328.26;

(3) Individuals who are third and fourth year dental students at an accredited Oklahoma dental college; and

(4) Any individual issued a license in another state as a dentist.

(b) All eligible providers must be in good standing with regard to their license. Any revocation or suspension status of a provider referenced in subsection (a) above renders the provider ineligible for payment or subject to recoupment under SoonerCare.

(c) Eligible providers must document and sign records of services rendered in accordance with guidelines found at Oklahoma Administrative Code (OAC) 317:30-3-15.

(d) The American Dental Association's version of Code on Dental Procedures and Nomenclature (CDT) is used by the Oklahoma Health Care Authority (OHCA) to communicate information related to codes, and procedures for administration. Definitions, nomenclature, and descriptors as listed in the CDT will apply, with the exception of more specific definitions or limitations set forth.

(1) "Decay" means carious lesions in a tooth; decomposition and/or dissolution of the calcified and organic components of the tooth structure.

(2) "Images" means radiographs and diagnostic imaging that are part of the clinical record. Images should only be taken for clinical reasons as determined by the dentist and must be of diagnostic quality, properly identified, and dated.

(3) "Medically necessary extractions" means, but is not limited to, an extraction of a tooth that has met medically necessary criteria due to the presence of pathology, trauma, severe periodontal involvement, significant caries, pain or infection.

(4) "Medically necessary oral healthcare" means treatment deemed necessary by a physician or dentist when a patient's medical condition or treatment is or will be likely complicated by an untreated oral health problem.

(5) "Palliative treatment" means action that relieves pain but is not curative. Palliative treatment is an all-inclusive service. No other codes are reimbursable on the same date of service.

(6) "Radiographic caries" means dissolution of the calcified and organic components of tooth tissue that has penetrated the enamel and is approaching the dentinoenamel junction.

(7) "Unbundling" means billing separately for several individual procedures that are included within one (1) CDT or Current Procedural Terminology (CPT) code.

(8) "Upcoding" means reporting a more complex and/or higher cost procedure than actually performed.

Disclaimer. The OHCA rules found on this Web site are unofficial. The official rules are published by the Oklahoma Secretary of State Office of Administrative Rules as Title 317 of the Oklahoma Administrative Code. To order an official copy of these rules, contact the Office of Administrative Rules at (405) 521-4911.