This document pertains to services provided on or after January 1, 2020. Copyright Notice: Current Dental Terminology © 2020 American Dental Association. All rights reserved. Applicable FARS/DFARS apply. "Not covered" codes are not part of the OHP Plus benefit package, or are for services that are incidental to another service and not reimbursed separately. Where applicable, please refer to Prioritized List placement, Guideline Notes and OARs listed for each code for complete information regarding benefit coverage and limitations. For services billed as medical, use the CMS-1500 claim format, CPT/HCPCS codes and ICD-10-CM diagnosis codes. (This list may not note every dental code that has a corresponding medical code.) To find fee-for-service reimbursement rates, view the OHP Fee-for-Service Fee Schedule at http://www.oregon.gov/oha/hsd/ohp/pages/fee-schedule.aspx. This schedule represents a given point in time and may not include payable codes that were added to MMIS after the posted fee schedule date.
This dataset has the following 11 columns:
| Column Name | API Column Name | Data Type | Description | Sample Values |
|---|---|---|---|---|
| Code | code | text | Procedure code | D1206 D1515 D1516 D1355 D1550 view top 100 |
| Description | description | text | Brief description of the service covered by the procedure code | topical fluoride varnish application of topical fluoride varnish by a physician or other qualified health care professional counseling for the control and prevention of adverse oral, behavioral, and systemic health effects associated with high-risk substance use space maintainer - removable, bilateral, maxillary Re-cement or re-bond unilateral space maintainer – per quadrant view top 100 |
| OHP Plus Benefit Coverage | ohp_plus_benefit_coverage | text | Indicates whether the code is covered for all members, specific benefit groups (e.g., under age 21), or not covered under the OHP Plus benefit package | Covered for under age 21 only All members Not covered Covered for under age 19 only view top 100 |
| Prioritized List Placement | prioritized_list_placement | url | If applicable, provides the procedure's line placement on the Prioritized List of Health Services, with a link to guidance for that line | view top 100 |
| Guideline Note 1 | guideline_note_1 | url | If applicable, provides the Guideline Note associated with the code's Prioritized List placement, with a link to guidance for that line | view top 100 |
| Guideline Note 2 | guideline_note_2 | url | If applicable, provides additional Guideline Note associated with the code's Prioritized List placement, with a link to guidance for that line | view top 100 |
| Guideline Note 3 | guideline_note_3 | url | If applicable, provides additional Guideline Note associated with the code's Prioritized List placement, with a link to guidance for that line | view top 100 |
| OAR 1 | oar | url | If applicable, provides a link to Dental Services OAR that lists specific limitations for the code | view top 100 |
| Limitations | limitations | text | Coverage limitations for this code (such as age or annual benefit limits) | For adults 19 years of age and older — Limited to once every 12 months; For children under 19 years of age — Limited to twice every 12 months Covered only for clients under 19 years of age The Division shal cover fixed and removable space maintainers only for clients under 19 years of age. Use for clients 14 years of age and older Are covered only for children under 16 years of age. The Division limits coverage to: Permanent molars; and Only one sealant treatment per molar every five years, except for visible evidence of clinical failure. view top 100 |
| Notes | notes | text | Lists additional notes regarding billing, documentation and deletions | Excluded file (e.g., travel vaccines) For children under 19 years of age, topical fluoride varnish may be applied by a licensed medical practitioner during a medical visit. Topical fluoride treatment from a medical practitioner counts toward the overall maximum number of fluoride treatments. Additional topical fluoride treatments may be available, up to a total of four treatments per client within a 12-month period, when high-risk conditions or oral health factors are clearly documented in chart notes. The Division may not reimburse if performed on the same date of service as the following codes: D1120 (Prophylaxis — child); D4210 (Gingivectomy or gingivoplasty — four or more contiguous teeth or bounded teeth spaces per quadrant) D4211 (Gingivectomy or gingivoplasty — one to three contiguous teeth or bounded teeth spaces per quadrant); D4341 (Periodontal scaling and root planning — four or more teeth per quadrant); D4342 (Periodontal scaling and root planning — one to three teeth per quadrant); D4346 (Scaling in presence of generalized moderate to severe inflammation, full mouth after oral evaluation); D4355 (Full mouth debridement to enable comprehensive evaluation and diagnosis); and D4910 (Periodontal maintenance). Additional prophylaxis benefit provisions may be available for persons with high risk oral conditions due to disease process, pregnancy, medications, or other medical treatments or conditions, severe periodontal disease, rampant caries and for persons with disabilities who cannot perform adequate daily oral health care. The Division may not reimburse if performed on the same date of service as the following codes: D1110 (Prophylaxis — adult); D4210 (Gingivectomy or gingivoplasty — four or more contiguous teeth or bounded teeth spaces per quadrant); D4211 (Gingivectomy or gingivoplasty — one to three contiguous teeth or bounded teeth spaces per quadrant); D4341 (Periodontal scaling and root planning — four or more teeth per quadrant); D4342 (Periodontal scaling and root planning — one to three teeth per quadrant); D4346 (Scaling in presence of generalized moderate to severe inflammation, full mouth after oral evaluation); D4355 (Full mouth debridement to enable comprehensive evaluation and diagnosis); and D4910 (Periodontal maintenance). Additional prophylaxis benefit provisions may be available for persons with high risk oral conditions due to disease process, pregnancy, medications, or other medical treatments or conditions, severe periodontal disease, rampant caries and for persons with disabilities who cannot perform adequate daily oral health care. view top 100 |
| File Date | file_date | calendar_date | The effective date of the file | 2022-01-01T00:00:00.000 2021-01-01T00:00:00.000 view top 100 |