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 | D5984 D5933 D5928 D5915 D5991 view top 100 |
Description | description | text | Brief description of the service covered by the procedure code | radiation shield orbital prosthesis precision attachment orbital prosthesis-replacement obturator prosthesis-modification 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 | Not covered Members age 16 years and older Members age 21 years of age and older All members 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 clients through age 20, the Division limits payment for reline of complete or partial dentures to once every three years. For clients age 21 and older, the Division limits payment for reline of complete or partial dentures to once every five years. Allowed for clients 21 years of age and older a maximum of two times per year The Division shall cover rebases only if a reline may not adequately solve the problem. For clients through age 20, the Division limits payment for rebase to once every three years. For clients age 21 and older, the Division limits payment for rebase to once every five years. Allowed for clients 21 years of age and older a maximum of four times per year, per arch Allowed for clients age 16 years and older view top 100 |
Notes | notes | text | Lists additional notes regarding billing, documentation and deletions | Medical service. Refer to OAR 410-123-1220 Third molars are not a consideration when counting missing teeth. Replacement of removable partial or full dentures, when it cannot be made clinically serviceable by a less costly procedure (e.g., reline, rebase, repair, tooth replacement), is limited to full dentures once every ten years and partial dentures once every five years, only if dentally appropriate. Replacement of partial dentures with full dentures is payable five years after the partial denture placement. The Division may make exceptions to this limitation in cases of acute trauma or catastrophic illness that directly or indirectly affects the oral condition and results in additional tooth loss. This pertains to, but is not limited to, cancer and periodontal disease resulting from pharmacological, surgical, and medical treatment for aforementioned conditions. Severe periodontal disease due to neglect of daily oral hygiene may not warrant rebasing. 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 |