DHS 107.07(2)(a)
(a) All of the following dental services require prior authorization in order to be reimbursed under MA:
DHS 107.07(2)(a)4.a.
a. Surgical extractions of teeth and tooth roots for orthodontia, or for asymptomatic impacted teeth.
DHS 107.07(2)(a)4.d.
d. Other repair procedures including osteoplasty, alveoloplasty, and sialolithotomy.
DHS 107.07(2)(a)6.
6. General anesthesia, intravenous conscious sedation, nitrous oxide, and non-intravenous conscious sedation for recipients age 21 and over, where the treatment is not provided in a hospital or in an emergency situation.
DHS 107.07(2)(a)7.
7. Surgical or other dental services, including fixed prosthodontics in order to correct conditions that may reasonably be assumed to significantly interfere with a recipient's personal or social adjustment or employability.
DHS 107.07(2)(b)
(b) A provider who submits a request for prior authorization of dental services to the department shall identify the recipient's birth date and the items enumerated in s.
DHS 107.02 (3) (d).
DHS 107.07(3)
(3)
Other limitations. All of the following limitations apply to the coverage of dental services under this section:
DHS 107.07(3)(a)
(a)
General limitations. The MA program may impose reasonable limitations on reimbursement of the services listed in subs.
(1) and
(1m) regarding any of the following:
DHS 107.07(3)(a)1.
1. Frequency of service per time period, including coverage of services in emergency situations only.
DHS 107.07(3)(a)3.
3. Required documentation, including pathology report or operative report.
DHS 107.07(3)(b)1.1. Reimbursement for dentures and partial dentures includes 6 months postdelivery care. If a prior authorization request for these services is approved, the recipient shall be eligible on the date the authorized treatment is started, which is the date the final impressions were taken. Once started, the service shall be reimbursed to completion, regardless of the recipient's eligibility.
DHS 107.07(3)(b)2.
2. Temporomandibular joint surgery is a covered service only when performed after all professionally accepted non-surgical medical or dental treatment has been provided, and the necessary non-surgical medical or dental treatment has been determined unsuccessful by the department's dental consultant.
DHS 107.07(3)(b)3.
3. The diagnostic work-up for orthodontic services shall be performed and submitted with the prior authorization request. If the request is approved, the recipient is required to be eligible on the date the authorized orthodontic treatment is started as demonstrated by the placement of bands for comprehensive orthodontia. Once started, the service shall be reimbursed to completion, regardless of the recipient's eligibility.
DHS 107.07(3)(b)4.
4. A non-covered service specified under sub.
(4) or
(4m) may be reimbursed if the department's dental consultant requests that the service be performed in order to review the request for prior authorization.
DHS 107.07(4)
(4)
Non-covered services; dentists and physicians. The following dental services are not covered under MA whether or not the service is performed by a dentist; physician; or a person under the supervision of a dentist or physician:
DHS 107.07(4)(a)
(a) General services for purely aesthetic or cosmetic purposes.
DHS 107.07(4)(d)
(d) Tests and laboratory examinations, other than for diagnostic casts when required by the department.
DHS 107.07(4)(e)
(e) Oral hygiene instruction or training in preventive dental care as a separate procedure, including tooth brushing technique, flossing or use of special oral hygiene aids, tobacco cessation counseling, or nutritional counseling.
DHS 107.07(4)(f)4.
4. Endodontic filling materials that are not approved for use by the American Dental Association.
DHS 107.07(4)(L)
(L) Professional visits, other than for the oral evaluation of a nursing home resident, or hospital calls as noted in sub.
(1) (j) 4. DHS 107.07(4m)
(4m)
Non-covered services; dental hygienists. The following services are not covered by MA whether or not the service is performed by a person under the supervision of a dentist or physician or by a dental hygienist who is individually certified under ch.
DHS 105:
DHS 107.07(4m)(b)
(b) Oral hygiene instruction or training in preventive dental care as a separate procedure, including tooth brushing technique, flossing or use of special oral hygiene aids, tobacco cessation counseling, or nutritional counseling.
DHS 107.07(5)
(5)
Unusual circumstances. In certain unusual circumstances the department may request that a non-covered service be performed, including but not limited to diagnostic casts, in order to substantiate a prior authorization request. In these cases the service shall be reimbursed.
DHS 107.07 History
History: Cr.
Register, February, 1986, No. 362, eff. 3-1-86; am. (1) (c) 10. and (2) (c) 9. e. and f., cr. (2) (c) 9. g. and (3) (8), r. and recr. (4) (q),
Register, February, 1988, No. 386, eff. 3-1-88; r. and recr. (1) (g) and (4) (j), renum. (2) (c) 9. to 12. and (4) (k) to (t) to be (2) (c) 10. to 13. and (4) (m) to (v), cr. (2) (c) 9., (4) (k) and (L),
Register, December, 1989, No. 408, eff. 1-1-90; correction in (4) (j) made under s. 13.93 (2m) (b) 7., Stats.,
Register, December, 1989, No. 408;
CR 05-033: r. and recr. (1), (3) and (4) cr. (1m), (2) (a) 5. to 7. and (4m), am. (2) (a) (intro.) and 1. to 4. and (2) (b), r. (2) (c)
Register August 2006 No. 608, eff. 9-1-06; emerg. r. (1) (k) and (2) (a) 5., am. (2) (a) (intro.), (3) (intro.), (a) 3., (4) (intro.), (j) and (4m) eff. 4-30-07;
CR 07-041: r. (1) (i), (k) and (2) (a) 5., am. (2) (a) (intro.), (3) (intro.), (a) 3., (4) (intro.), (j) and (4m)
Register December 2007 No. 624, eff. 1-1-08; corrections in (1m) (intro.) and (4m) (intro.) made under s. 13.92 (4) (b) 7., Stats.,
Register December 2008 No. 636;
CR 22-043: r. (4) (b), am. (4) (c), r. (4) (k) 1.
Register May 2023 No. 809, eff. 6-1-23.
DHS 107.08(1)(a)(a) Inpatient services. Covered hospital inpatient services are those medically necessary services which require an inpatient stay ordinarily furnished by a hospital for the care and treatment of inpatients, and which are provided under the direction of a physician or dentist in an institution certified under s.
DHS 105.07 or
105.21.
DHS 107.08(1)(b)
(b) Outpatient services. Covered hospital outpatient services are those medically necessary preventive, diagnostic, rehabilitative or palliative items or services provided by a hospital certified under s.
DHS 105.07 or
105.21 and performed by or under the direction of a physician or dentist for a recipient who is not a hospital inpatient.
DHS 107.08(2)
(2)
Services requiring prior authorization. The following covered services require prior authorization:
DHS 107.08(2)(a)
(a) Covered hospital services if provided out-of-state under non-emergency circumstances by non-border status providers;
DHS 107.08 Note
Note: For more information on prior authorization, see s.
DHS 107.02 (3).
DHS 107.08(3)(a)(a) Inpatient limitations. The following limitations apply to hospital inpatient services:
DHS 107.08(3)(a)1.
1. Inpatient admission for non-therapeutic sterilization is a covered service only if the procedures specified in s.
DHS 107.06 (3) are followed; and
DHS 107.08(3)(a)2.
2. A recipient's attending physician shall determine if private room accommodations are medically necessary. Charges for private room accommodations shall be denied unless the private room is medically necessary and prescribed by the recipient's attending physician. When a private room is not medically necessary, neither MA nor the recipient may be held responsible for the cost of the private room charge. If, however, a recipient requests a private room and the hospital informs the recipient at the time of admission of the cost differential, and if the recipient understands and agrees to pay the differential, then the recipient may be charged for the differential.
DHS 107.08(3)(b)
(b) Outpatient limitations. The following limitations apply to hospital outpatient services:
DHS 107.08(3)(b)1.
1. For services provided by a hospital on an outpatient basis, the same requirements shall apply to the hospital as apply to MA-certified non-hospital providers performing the same services;
DHS 107.08(3)(b)2.
2. Outpatient services performed outside the hospital facility may not be reimbursed as hospital outpatient services; and
DHS 107.08(3)(b)3.
3. All covered outpatient services provided during a calendar day shall be included as one outpatient visit.
