Early and Periodic Screening Diagnosis and Treatment - Medical Vendor Payments (Reissue)

    Early and Periodic Screening, MEDICAL VENDOR PAYMENTS Diagnosis and Treatment 
  

At any age before seven - a child should receive two cavity-detecting 
(bitewing) radiographs and at least six periapical radiographs or the 
equivalent such as a panographic survey. 

Between seven and thirteen years - a new patient should receive two 

cavity-detecting (bitewing) and ten periapical radiographs or the 
equivalent such as a panographic survey. 

Above the age of 13 ~ the radiographic survey should include cavity- 
detecting (bitewing) and fourteen periapical radiographs or the 
equivalent such as a panographic survey, 

Preventive Services 
  

Prophylaxis 
  

This service should include a scaling of the teeth, removal of 
acquired stains, and polishing of the teeth. 

Topical Flouride Treatment (including prophylaxis) 
  

This item refers to a single treatment consisting of an application 

of stannous flouride solution or gel or acidulated phosphate solution 
or gel immediately preceded by a prophylaxis, 

Restorative Services 
  

Amn lgam Restorations 
  

Cavity preparation must have an outline adequate for retention and 
extended to conform with the principles of mrevention., A pit 
restoration will not be classified as a one surface restoration. 
Payment will be made for only one restoration per surface. No 
reimbursement will be made for permanent restorations attempted 
cn primary teeth where early exfoliation (more than two-thirds of 
the root structure is resorbed) is expected. 

Attention is drawn to the notation "three or more surfaces" as 
contained in procedure 2160 of the Maximm Fee Schedule. This is 
construed to mean that no combination of services on a single tooth 
in a current period of treatment should be billed in excess of the 
fee for procedure 2160, 

  

Page 11 of 19-6l4  



  
    

    

  

2i ENT Early and Periodic Screening, 
¢ YEDICAL VENDOR PA 8 Diagnosis and Treatment 
  

Ping 

Reinforcing pins may be added to amalgam £i11ing or composite resin 
anterior £illings (limit of 3 pins). 

  

Silicate, Plastic and Composite Restorations 

This type of restoration is authorized for deciduous cuspids, permanent 
anterior teeth and first bicuspids only. Attention is drawn to the 
notation "maximum on same tooth not to exceed" as contained in 
procedure 2300 of the Maximm Fee Schedule, This is construed to 

mean that no combination of treatment on a single tooth in a current 
Period of treatment should be billed in excess of the allowable fee. 

Crowns 

Plastic, gold, and porcelain crowns are considered to be beyond the 

scope of the EFSDT Medicaid program and may be approved only under 

unusual circumstances. Crowns will not be approved solely for 
esthetic reasons. Polycarbonate and stainless steel crowns are 

intended for use on teeth with significant loss of crown structure. 

Bridgework (Fixed) 
  

This service is considered to be beyond the scope of the EPSDT Medicaid 
Program and may be apvroved only under umusual circumstances. 

Endodontic Services 
  

Pulpotomy 
  

This service is defined as the complete removal of the corcnal 
portion of the pulp. It is limited to instances where the prognosis 
is favorable and should not be applied to primary teeth where roots 
show signs ‘of advanced resporption (more than two-thirds of the root 

structure is resorbed). 

Root Canal 
  

Request for approval must be justified by submitting a total diagnosis 
and treatment plan supported by sufficient radiographs of good _ 

diagnostic quality, dated and suitably mounted to judge the general 

dental health status. If a subsequent crown will be needed it should 

be so stated on the request for approval of root canal treatment. 

  

trausd MIGE 11976 Ties TT  



  

    

  

  

MEDICAL VENDOR PAYMENTS 
Early and Periodic Screening, 

Diagnosis and Treatment 
  

Pulp Capping 

Calcium Hydroxide - must be actual pulp exposure (radiographs if 
requested), Capping exposed pulps in primary teeth is contraindicated 
and not a benefit of the program, In these instances treatment of 

choice would be a pulpotomy with formocresol treatment. 

  

Protective Base 
  

Protective base is considered incidental and integral to the filling 
and is not reimbursable. 

Periodontal Services 
  

Subgingival Cuxrrettage and Root Planning 

Indication for approval is clinical and radiographic evidence of 
large amounts of supra and/or subgingival calculus and deep pocket 

formation. 

  

Fees for fewer than five teeth per quadrant may be pro-rated. 

Removeable Prosthetic Services 
  

Full Dentures 
  

Only one denture per recipient is allowable in a five-year pericd. 
Radiographs are required to be submitted with the treatment plan. 
If immediate prothesis is part of the treatment plan, so state. 
Immediate dentures are not considered temporary dentures. Good 
Judgment is expected in the extraction of multiple posterior teeth 
far in advance of the expected application of immediate prosthesis, 

Partial Dentures 
  

Provision of removable prosthesis will be considered only when 
masticatory function is impaired, or when existing prosthesis 
is unservicable, or in instances when esthetic considerations 
interfere with employment or social develorment. Only one removable 
prosthesis per recipient is allowable in a five-year pericd. 

The participating dentist must submit a current full mouth series 

of radiographs of good diagnostic quality, dated and suitably mounted. 

A certification of the health of the coral cavity must be provided 
(all carious teeth functionally restored and supporting structures 
in good health). The certification must be signed by the responsible 

dentist. 

  

Fesued AG 11976 Page 13 of 19-614 

 



  
  

  

  

  

Early and Periodic Screening, 

( JCAL R24 § Diagnosis and Treatment 

  

The design of the denture must be outlined including the teeth to be 

replaced and the teeth to be clasped. Design of the prosthesis and 

material used should be ag simple as possible consistent with basic 
principles of prosthodontics. 

Please do not request a partial denture unless the patient has missing 
anterior teeth or less than eight occluding posterior teeth. 

Denture Reline 
  

Only one denture reline per recipient is allowable in a five-year 

period. > 

Orthodontic Services 
  

This service can be provided only to those children suffering from a 
physically handicapping malocclusion, such as cleft palate and approved 
by the cleft pelate team of the Division of Health's Handicapped Children's 
program, Such children should be brought to the attention of the EPSDT 
Program Director. 

Oral Surgery Services fi 
  

2 These services are applicable to both primary and permanent dentitions 
( although an unusually heavy use in the primary dentition will be questioned 
Gif by reviewing authorities to assure that a significant health service has 

been provided, 

Hospitalization 
  

Hospitalization for the convenience of the patient or the dentist 
should be avoided unless justified by the physical condition of the. 

5 patient or the severity of the procedure to be performed. Surgery 
in hospital will be approved when need has been established. Permission 

for hospitalization is obtained from the EPSDT Program Director. 

Surgical Extraction 
  

These are defined as extractions which are preceded by an incision, 
flap and removal of bone, Pre- or post-treatment radiograph(s) 
may be requested for surgical removals, 

Anesthesia 
  

The administration of general anesthesia will be approved for procedures 

only when performed by a qualified person with special training in 

general anesthesia and when Justification is furnished for its use. 

  

Issued AUG 1 1976 Page 14 of 19-614 

 



    

    nt a —— et 4 i th ——— tee ee eee 

  

VENDOR PAYMENTS Early and Periodic Screening, 
Diagnosis and Treatment 

  

  

Premedication 
  

Premedication and nitrous oxide analgesia are reimbursable only 
when prior approval has been granted. 

Services Not Covered 
  

"Cosmetic procedures 

Fixed bridges 

Occlusal correction 

Plaque control 

Premedications and/or nitrous oxide analgesia except for patients who 

manifest a physical or behavioral problem that would otherwise preclude 

treatment. Prior approval required. 

Payment for more than one restoration on a single tooth surface. 

Separate allowance for tooth preparation or placement of temporary 

restoration except when the temporary filling is used medicinally in 

the treatment of a hyperemic pulp. 

Routine post-operative services . 

Treatment of incipient or non-carious lesions 

Restoration of deciduous centrals and laterals 

Recording Forms 
  

Rev.* The combination pre-authorization and provider billing form, 

EDS Form 392-106, will be supplied to the provider for use in the 
EPSDT Program. The referring agency will complete the referral section 

of the form. The patient or the parent will present the form to the 

provider on the initial visit. This form must be completely filled 

out as indicated, including ADA service codes, and submitted for prior 

approval to the EPSDT Dental Program, Office of Family Security, P.O. 

Box 44065, Baton Rouge, Louisiana 70804. 

This form is for the provider's use in recording all proposed 

services for an individual patient. The provider is to list each 

service on a separate line. List the screening package on the first 

line. The proper ADA service code for each proposed service must be 

entered in the appropriate column. X-rays need not be submitted unless 

** a service from category B is included. (See page of 19-614). 

  

Reissued June 1, 1979 Page 15 of 19-614 

Replacing August 1, 1978 issue 

 



    

  

  

MEDICAL VENDOR PAYMENTS Early and Periodic Screening, 
Diagnosis and Treatment 

  

This form will be returned to the provider with or without 

  

  

Rev.* authorization to proceed with the treatment as indicated. The 

same EDS Form 392-106 showing the initial of the OFS approving 
authority shall be used by the provider for billing purposes at 

the conclusion of the pre-authorized service. This is accomplished 

by the completion of the dates of service column for the specific 

procedures rendered. Single billing is to be accomplished at the 

** conclusion of the treatment. 

EPSDT DENTAL PROGRAM 
MAXTMUM FEE SCHEDULE OF AUTHORIZED SERVICES 

Category A 

Services contained in this category are the services generally 

allowable under the program and require no justification when listed 

in the claim for payment or treatment plan submitted for prior 

authorization. : 

DIAGNOSTIC AND PREVENTIVE 

00120 Basic screening package (child or adult) consists $ 26.00 

of examination, prophylaxis, flouride treatment, 

bite wing X-rays, oral hygiene instruction 

00130 Re~examination (referral) 10.00 

00210 Full mouth X-ray series 20.00 

00240 Occlusal X-ray 5.00 

00220 Periapical X-ray (lst film) 3.00 

00230 Periapical X-ray (each additional £ilm) 1.00 

Reissued June 1, 1979 Page 16 of 19-614 

Replacing November 1, 1977 issue 

 



   
  

MEDICAL VENDOR PAYMENTS Early and Periodic Screening, 
Diagnosis and Treatment 

  

‘RESTORATIVE 
  

FEES FOR RESTORATIVE FILLINGS ARE THE SAME FOR DECIDUOUS AND 
PERMANENT TEETH AND INCLUDE SEDATIVE BASES WHEN REQUIRED. 

  

02139 Amalgam Restoration - pit $ 3.00 

02140 Amalgam Restoration - one surface 15.00 

02150 Amalgam Restoration - two surfaces 20.00 

02160 Amalgam Restoration - three or more surfaces 25.00 

FEE FOR PROCEDURE 02160 REPRESENTS THE MAXIMUM FEE ALLOWED 
FOR ANY COMBINATION OF AMALGAM RESTORATIONS FOR A SINGLE 
TOOTH COVERED BY. A PROPOSED PLAN OF TREATMENT. 

02300 Esthetic Restoration - Class III or V (Silicate, 
plastic composite) not to exceed three individual 
restorations on a single tooth $ 13.00 

02335 Esthetic Restoration - Class IV (mesial or distal 20.00 
with angle) 

02340 Acid Etch Restoration of fractured anterior 40.00 
restoring entire incisal edge (with report) 

Rev. ¥ 

02711 Polycarbonate Crown (limited to permanent anteriors $ 30.00 
and deciduous cuspids) 

02190 Retentive Pin - per pin (not to exceed three) 4.00 ° 

3 SURGERY 

00450 BIOPSY (including pathology report) 25.00 

07110 Routine extraction (permanent or deciduous) to 12.00 
include routine postoperative care 

07210 Surgical extraction (permanent or deciduous) to 20.00 
include incision, surgical flap, suturing and routine 
postoperative care. (include X-ray with report) 

07510 Incision and drainage of abscess 10.00 

Reissued July 1, 1983 Page 17 of 19-614 
Replacing July 1, 1980 issue 

 



  

Early and Periodic Screening 
Dizgnosis and Treatment 

  

  

MISCELLANEQUS SERVICES 

09360 Nitrous Oxide Analgesia per visit 3.00 

03110 Pulp Cap - direct (permanent tooth only) 5.00 

03200 Vital Pulpotomy 15.00 

05600 Denture Repair (with report) ; ¥.C. 

09340 Emergency Visit (no definitive treatment, 7.00 
example: consultation, prescription) 

09110 Emergency Palliative Treatment (emergency treatment S 10.00 
; of pain (minor procedure), example: sedative 

restoration) 

FEE FOR ONLY ONE OF THE PRECEDING (09340 or 09110) IS AUTHORIZED 
FOR A SINGLE EMERGENCY SERVICE. IF, HOWEVER, A DEFINITIVE 
SERVICE IS PROVIDED AT THE EMERGENCY VISIT THEN THE FEE WOULD 
BE THE FEE ALLOWED FOR THAT SERVICE (example: extraction, filling), 
AND NO CHARGE IS TO BE MADE FOR THE EMERGENCY VISIT. : 

Category B 
  

Services in this category require special and individual consideration 
tefore preauthorization can be granted. Requests for these services must 
we accampanied by a brief report of circumstances including appropriate 

  

1 x-rays ard clinical findings that justify the requested treatment. 

i ENDQOGNTICS 

03310 Extirpaticn of pulp and Tilling one root canail $ ..80.00 
(excluding restoraticn) : 

03320 tirpaticn of pulp and £i1ling two root canals 120.00 
(excluding restoration) 

03330 Extirpation of pulp and filling three or more 130.00 
root canals (excluding restoration) 

03350 Apexification (root canal fees apply) 

03400 Apicoectomy 45.00 

** 03220 Puipectomy 40.00 

Reissued November 1, 1977 Page 18 of 19-614 
Replacing August 1, 1976 issue 

 



  
  

  

  

MEDICAL VENDOR PAYMENTS : Early and Periodic Screening, 

  

& Diagnosis and Treatment 

: SURGERY Wt 

07220 Surgical removal of impacted tooth (soft tissue $ 30.00 

impaction) ) 

07230 Surgical removal of impacted tooth (partially soft 50.00 

: tissue, partially bony impaction) 

07240 Surgical removal of impacted tooth (complete bony 75.00 
impaction) 

07400 Surgical Excision of pericoronal gingiva 20.00 

07960 Frenulectomy 25.00 

07300 Alveolectomy/Alveaplasty (surgical preparation of 33.C0 

ridge for dentures ) - per quadrant 

PERIODONTICS ah 

2 043810 Periodontal Prophylaxis (full mouth, subgingival- 25.00 

( scaling) 

04220 Subgingival Curettage, Root Planing, Complete 30.00 
Periodontal Scaling (per quadrant) 

. Incipient bane loss must be evident radiographically 

04210 Gingivectomy/Gingivoplasty (per quadrant) 40.00 

04330 Equilibration - by special request 1.L. 

REMOVABLE PRCSTHESIS 

05210 Partial Denture (acrylic base - without clasps) 100.00 

35220 Partial Denture (acrylic base - rests - wire clasps) 165.00 

05230 Partial Denture (cast framework - acrylic saddles) 300.00 

05100 Complete Denture (per unit) 225.00 

05730 Relining Upper or Lower Denture (chairside) 25.00 

05750 Relining Upper or Lower Denture (laboratory) 70.00 

  Issued November 1, 1977 Page 18a of 19-614 

 



   . 
Le | 

  

  

~ MEDICAL VENDOR PAYMENTS ; : Early and Periodic Screening 
- Diagnosis and Treatment 

  

2 CROWN AND BRIDGE 

02830 Stainless Steel Crown 
02950 Crown Buildups - pin retained : 

(pins to be listed individually with appropriate fee) 

02890 Post and Core 

02790 Cast Gold Crown 

02740 Porcelain Jacket Crown 

02750 Porcelain Fused to Gold Crown (per unit) 

: MISCELLANEOUS SERVICES 

3 01510 Fixed Space Maintainer (unilateral) 

01525 Removable Bilateral Space Maintainer (lingual arch) 

09420 Hospital fee (total fee, pre and postoperative) 
Special Request for hospitalization required 

Orthodontia - considered only by special request 

: : A11 other services not shown 

1.C 
Mn Ghia 

Dental procedures designated "I.C." are individual consideration items 
and will be given individual consideration by the dental advisors of the 

. EPSDT Program. Determination of appropriate payments for these procedures 
The provider's 

usual charge and a brief report including X-rays must accompany the bill. 

will be made with consideration of the provider's report. 

35.00 

145.00 

125.00 

185.00 

35.00 

70.00 

75.00 

I.C 

I.C 

  Reissued July 1, 1983 
Replacing November 1, 1977 issue 

  

Page 18b of 19-614



  
ht th kh + + ate re am ae SS = 0 FS a | bo 

o> 

  

  

MEDICAL VENDOR PAYMENTS Early and Periodic Screening, 
Diagnosis and Treatment 

  

GUIDELINES FOR PRESCRIBING DRUGS 
UNDER THE EPSDT_ PROGRAM 
  

All persons eligible for dental care are eligible for certain medications 
without prior approval. Those medications for which they are eligible and 
which would interest the dentist are Legend Drugs (those drugs which bear the 
legend: “Caution Federal law prohibits the dispensing without a prescription"). 

A prescription for these drugs may be written when necessary; and the 
patient, -upon presentation to the pharmacist, will receive the medication free 
of charge. 

The written prescription must contain the prescribing dentist's vendor 
number which has been assigned to him under the EPSDT Program. 

Rev.* E. EPSDT Eyeglass Program 
  

The OFS is responsible for administering the EPSDT Eyeglass Program. 

(1) The following procedures will be followed to purchase eyeglasses 
for eligible persons: 

(a) When a child is seen in the initial EPSDT screening clinic 
at the health unit, he will routinely be given eye testing. 
Children who fail these tests will be referred to the 
professional practitioner of his choice for definitive diagnosis 
and treatment. The client's medical eligibility card will 
entitle him to an eye examination and ‘treatment other than 
glasses. 

(b) In order to assure payment for the service, when a client is seen 
by either an ophthalmologist or an optometrist without referral 

. by the EPSDT screening clinic, it will be necessary for that 
provider to check the client's medical card for EPSDT 
eligibility to determine that the visit for which he will be 
billing is within the twelve (12) visit limitation. : 

(c) If eyeglasses are prescribed the following policy will apply: 

(i) Claims for prescriptions or prescription components meeting 

the standards and maximum fee schedule shall be forwarded 

to the fiscal agent by the dispensing provider 

(ophthalmologist, optometrist or optical company) for 
payment. 

(ii) Claims for all prescriptions or prescription components 

for professional services which exceed the standards and 

the maximum fee schedule (see 19-614-E (2)) must be forwarded 
by the dispensing provider (ophthalmologist, optometrist 
or optical company) to the Eye Anomalies Section of the 

Office of Health Services and Environmental Quality, P. O. 

  

Reissued October 1, 1983 Page 19 of 19-614 

Replacing June 1, 1979 issue 

 



  

  

  
  

 —— — —— —— iat + Sen aly 

  

MEDICAL VENDOR PAYMENTS Early and Periodic Screening, 
Diagnosis and Treatment 

  

Box 60630, New Orleans, Louisiana 70160, for professional 
review and approval. 

The Committee on Standards Review recommends a $60.00 
ceiling (not including the professional examination fee) 
on eyeglasses. The Committee and the Office of Family 
Security reserve the right to weigh each individual request 
on its own merits and to alter the scope of the fee 
schedule. The Office of Family Security recommends that eye- 

glasses which cost in excess of the schedule not be prepared 
until approval is received from the Eye Anomalies Program. 

(d) Payment is made for contact lenses within the allowed prescription 
range in lieu of eyeglasses only if approved by the Eye 
Anomalies Section. 

(e) When an eye condition impairs the client's vision to 20/200 or 
less, even with correction with glasses, referral should be 
made to the Blind Services Program, Office of Human Development. 

(2) Reimbursement 
  

- 

Reimbursement will be made for eyeglasses according to the following 
standards and maximum fee schedules: 

(a) Spectacles: 
  

(i) 

(11) 

(iii) 

(iv) 

Lenses to be first quality, untinted, conforming to the 
Z 80.1 Standards of the American National Standards 
Institute for hardened glass or plastic lenses, to 
Federal Food and Drug Administration regulations and 
Louisiana Law; 

Frames are to be non-metal, sturdy, non-flammable plastic 
frames; 

No lenses shall be prescribed unless at least one lens 
exceeds +1.00 sphere, -0.50 sphere or plus or minus 0.50 
plano cylinder; 

Spheres or compounds : SINGLE VISION 
plus or minus cyl series, : Glass or plastic 
properly transposed to find 
price bracket 

0.50S to 4.00< $37.25% 
0.25C to 4.00C ; 

4.12S to 7.00S< $40.50* 
0.25C to 4.00C =". 

7.12S to 12.00S = $45. 35% 
0.25C to 4.00C Tn 

*Includes allowance for frame. 
  

‘Reissued October 1, 1983 
Replacing June 1, 1979 issue 

  

Page 20 of 19-614



  

MEDICAL VENDOR PAYMENTS Early and Periodic Screening, 
: ; Diagnosis. and. Treatment 

  

(b) Replacement of lenses: \ 

One pair of lenses (without frames) 
0.50S to 4.00S 

0.25C to 4.00C 

One pair of lenses (without frames) 
4.125 to 7.00S 

0.25C to 4.00C 

One pair of lenses (without frames) 
7.12S to 12.00S 

0.25C to 4.00C 

Half pair of lenses (without Frames) 
0.50S to 4.00S 

0.25C to 4.00C 

Half pair of lenses (without frames) 
4.12S to 7.00S 

0.25C to 4.00C 

Half pair of lenses (without frames) 
7.125 to 12.00S ° 

0.25C to 4.00C 

(c) Replacement of broken frames or parts: 

Complete frame ..... AE SOL PING a TN 
Front only 
Pair Of 2emplas., cove cvivsssnronsrnanevs .: $6. 
Half pAIr OF LomDIeS.cce svrvseransevress $4. 

  

Reissued October 1, 1983 Page 21 of 19-614 
Replacing June 1, 1979 issue  



  

  ee et ee eee en ce 

  

MEDICAL VENDOR PAYMENTS 
Early and Periodic Screening, 

Diagnosis and Treatment 
  

19-615 DENTAL PROGRAM AND EYEGLASSING PROGRAM FOR FOSTER CHILDREN 
  

For dental and eyeglassing services provided foster children, 

the forms described in 19-614 must be used and the amount of payment 
made under the dental and eyeglassing components of the EPSDT program 

shall be applicable for foster children. 

  

  

Rev.* A. Dental Program for Foster Children 

The health unit (and the local Office of Human Development and 

the School Nurses in Orleans and Jefferson Parishes) provides referrals 

only to dentists who are registered providers in the EPSDT program. 

The EPSDT dental quota does not apply to the foster child. Should a 
dentist who is not a registered provider wish to participate, you may 

refer him/her to Dr. Robert McNamee, Dental Program Consultant in 
State Office. This should be done prior to securing screening or any 

treatment. This also means that registered providers can be utilized 

for emergency treatment. 

Before proceeding with any further dental work the dentist will 

complete the EDS Form 392-106 listing all dental services required by 

the patient and submit same to the Program Director for authorization. 

Providers shall bill for all dental services by EDS Form 392-106. 

Dental procedures for a Foster Care child shall follow the EPSDT 

guidelines. Eowever, upon special request, certain dental services 

(1.e., orthodontics, gold bridgework, etc.) not customarily provided 
under the EPSDT guidelines can be authorized for the foster care child. 

When requesting approval and payment for orthodontic services, 
the foster care worker shall be aware of the following considerations: 

(1) Orthodontia must be purchased with foster care funds. 
Budgetary constraints will limit the number of approvals 

for this service. : 

(2) The assessment of the need for referral for orthodontic con- 

sultation shall be made by the general dentist selected to 
provide the EPSDT dental screening and basic dental care for 

the child. If the foster parent or the foster care worker 

feels the child needs orthodontic treatment, they should seek 

the advice of the treating dentist and seek orthodontic 

consultation only with his positive recormendation. 

(3) The child's total emotional and health situation should be 
assessed in evaluating whether a request will be made for 

aporoval. The child's interest in and willingness to partici- 

pate in ongoing treatment shall be evaluated. 

(4) The projected length of placement in foster care should be 

a consideration since generally provision of orthodontic 

services is a lengthy process. 

Reissued June 1, 1979 Page 1 of 13-615 

Replacing larch 1, 1977 issue 

 



rg
 

  

  

MEDICAL VENDOR PAYMENTS 
Early and Periodic Screening, 

Diagnosis and Treatment 
  

** 

(5) The orthodontist providing the services shall be a registered 

Title XIX provider. 

When the decision is made to request approval for orthodontic 

treatment, the foster care worker shall contact the orthodontist to 

arrange an appointment for the child. FADS Form 112 - VENDOR REIMBURSEMENT 

shall be initiated to pay for the examination. The orthodontist shall be 

requested to submit to the worker a resume of his findings including th 

following: . 

(a) Nature of the dental services needed by the child 

(b) Recommended dental treatment plan 

(ec) Approximate length of time needed to complete the treat- 

ment plan 

(d) Total charge for the dental services 

The orthodontist will forward the recommended dental treatment 

plan to the foster care worker. FADS Form 112 - VENDOR REIMBURSEMENT 

will also.be submitted to the worker for payment of the initial examina- 

tion. In order to individualize the foster child and his needs, the 

worker shall attach to the recommended dental treatment plan a brief 

but pertinent social summary regarding the child's placement in foster 

care, including reason for placement, adjustment, general health of 

child, etc. These materials shall be directed to the Medical Assistance 

Program in State Office, Attention: Dr. Robert McNamee, Dental Program 

Consultant, for professional evaluation of the child's needs. After 

evaluating the dental treatment plan, the Dental Program Consultant 

will route all materials to the Social Services Program for approval of 

funding. g 

For an approved dental treatment plan, the Social Services Program 

will authorize the orthodontic services on FADS Form 102 - STATE OFFICE 

AUTHORIZATION. The foster care worker will receive an approval memorandum 

and copy of FADS 102 - STATE OFFICE AUTHORIZATION. The Dental Program 

Consultant will also receive a copy of the approval memorandum. 

After receiving notification of the approved orthodontic services, 

the foster care worker shall advise the orthodontist of -approval and - 

explain the FADS billing procedure. Utilizing his usual billing system, 

the orthodontist will submit billings for services to the foster care 

worker who will initiate FADS 112 - VENDOR REDTMBURSEMENT. The orthodontist 

may bill for services on a monthly or quarterly basis or at the completion 

of the services. 

. When requested orthodontic treatment for a child is not approved, 

the foster care worker will be notified by memorandum for the Social 

Services Program. : 

  

Reissued June 1, 1979 Page 2 of 19-615 

Replacing March 1, 1977 issue 

 



  

  

MEDICAL VENDOR PAYMENTS Early and Periodic Screening, 
: , ped Diagnosis and Treatment 
  

B. Eyeglass Program for ‘Foster Children 
  

Rev.* Procedures are the same as those stated in 19-614(1). Should the 
request be denied by the Eye Anomalies Review Section, the Foster Care 
Worker may request approval for purchase of the eyeglasses with Foster 

** Care funds. 

  

Reissued October 1, 1983 | Page 3 of 19-615 
Replacing dune 1, 1979 issue