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 | D0191 D0483 D0220 D0382 D0418 view top 100 |
Description | description | text | Brief description of the service covered by the procedure code | accession of tissue assessment of a patient diagnostic casts 3-D photographic image – image capture only 3D photographic image 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 All members Covered for under age 21 only Deleted by the ADA effective 01/01/2017 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) | Providers shall perform HbA1c testing on the same patient no more frequently than annually unless the dentist determines it medically/dentally necessary to test more frequently due to unexplained progression of periodontal disease, delayed wound healing or recurrent oral candida infection. HbA1c should not be tested more frequently than every 3 months. For clients under age six, radiographs may be billed separately a maximum of once every 12 months. Once every five years, unless D0210 has been billed within the five-year period For children under 19 years of age, a maximum of once every 12 months when performed by the same practitioner and twice every 12 months only when performed by different practitioners For adults 19 years of age and older, once every 12 months For clients under age six, radiographs may be billed separately once every 12 months. view top 100 |
Notes | notes | text | Lists additional notes regarding billing, documentation and deletions | Excluded file (e.g., travel vaccines) The Division only covers oral exams performed by medical practitioners when the medical practitioner is an oral surgeon. The Division may not reimburse dental exams when performed by a dental hygienist (with or without an expanded practice permit). The Division only covers oral exams performed by medical practitioners when the medical practitioner is an oral surgeon When D0191 is reported in conjunction with an oral evaluation (D0120-D0180) using teledentistry, D0191 shall be disallowed even if done by a different provider The minimum standards for reimbursement of intra-oral complete series are: For clients age six through 11 — a minimum of ten periapicals and two bitewings for a total of 12 films; For clients ages 12 and older — a minimum of ten periapicals and four bitewings for a total of 14 films. If fees for multiple single radiographs exceed the allowable reimbursement for a full mouth complete series (D0210), the Division shall reimburse for the complete series. 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 |