1.2 Provider Eligibility and Training
Primary Medical Care Providers
In 2009, the Ohio Director of Health’s Task Force on Oral Health
and Access to Dental Care recommended an increase in the number of primary
care providers and other non-oral-health providers who offer appropriate
preventive services (e.g., fluoride varnish) to individuals who are at
increased risk for oral disease.
In Ohio, fluoride varnish may be applied to children’s teeth
by dentists, dental hygienists, and dental assistants within their
scope of practice, as well as by physicians and designated staff
within their scope of practice. Medicaid participants have been
a major focus of state’s efforts because they are at increased
risk for dental caries. In Ohio, Medicaid services are primarily
administered through managed
care plans (MCPs). Almost all children
eligible for Medicaid receive services through MCPs.
The Smiles for Ohio—Fluoride Varnish program was established
on July 1, 2006, when ODJFS authorized Medicaid
coverage and reimbursement for primary medical
care providers for the application of fluoride varnish during a
well or sick child visit for children from first tooth eruption
up to age 3 when medically appropriate. (Note: The original ruling used a CDT code which has been replaced with D1208.)
To be eligible for reimbursement for fluoride application, a provider
must meet the following criteria:
Who
- Physicians or advanced practice nurses licensed to practice
in Ohio who provide Medicaid services in accordance with the
rules and regulations of the program.
The following letters from the ODJFS provide documentation about
- It is understood that physicians may delegate procedures
to staff within their scope of practice (e.g., nurses, physician
assistants, medical assistants).
What
- Coverage of fluoride varnish application is limited
to one application every 180 days (every 6 months).
- Fluoride varnish application is billable in addition
to a well or sick child visit but should not be the sole reason
for the visit.
- Reimbursement for a fluoride varnish application is $14.70.
How
- Fluoride varnish application has three components:
oral assessment, varnish application, and referral.
- The purpose of the oral assessment is to identify
obvious oral health problems; if an oral assessment is combined
with a Healthchek visit, the assessment does not need to be
repeated before applying fluoride varnish.
- If the child has obvious oral health problems and
does not have an oral health care provider, the physician must
provide referral to a dentist or to the ODJFS agency.
- Providers must give parents or other primary caregivers
information about the fluoride varnish application procedure
and about proper oral health care (anticipatory guidance).
- Providers should follow standard billing procedures and submit CDT
code D1208 [topical application of fluoride (prophylaxis not included)—child]. This is a new CDT code effective January 1, 2013.
- There are special considerations for cost-based
clinics.
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