Dental services covered by Program HH

• Bitewing x-rays once a year, unless already covered by Medicaid
• Comprehensive exam once every three years, but not within three years of a comprehensive exam covered by Medicaid
• Full mouth series once every four years
• Panoramic x-ray once every three years but not within three years of a panoramic x-ray covered by Medicaid, except if provided in conjunction with a scheduled outpatient facility procedure or as medically necessary for the diagnosis and follow-up of oral and maxillofacial pathology and trauma.
• Panoramic x-ray once every two years for patients who cannot cooperate for intra-oral film due to a developmental disability or medical condition that does not allow for intra-oral film placement
• Periapical x-rays
• Periodic exam once every six months, but not within six months of a periodic exam covered by Medicaid.

• Anterior and premolars only
• Molars with prior authorization

• Treatment that meets the specifications of utilization criteria

• Biopsies
• Extractions
• Incise and drain
• Splinting for repositioning a traumatized tooth or stabilizing an alveolar fracture

Limited to children through age 20

Prior authorization is required for all of the following:

• Bone replacement graft for ridge preservation per site
• Placement of device to facilitate eruption of impacted tooth
• Radical resection of maxilla or mandible
• Surgical repositioning of teeth
• Tooth transplantation
• Transseptal fiberotomy

• MA coverage - once every six months
  
• Program HH coverage only - once every six months
• Previous history of documented periodontal therapy
  • May be alternated with a periodontal maintenance appointment
• Fluoride varnish
  • Once a year
• Sealants - recipients through age 18
  • Only first and second permanent molars

• Full mouth debridement once every five years
• Periodontal maintenance once per six months, but not within three months of a prophylaxis covered by Medical Assistance or Program HH
• Scaling and root planing once every 3 years

• Palliative treatment
• Sedative fillings

• Removable appliances - once per arch every three years but not within three years of a removable appliance provided by MA. Partial dentures must meet utilization criteria and be prior authorized
• Reline, rebase and repair of removable appliance - may not exceed the cost of new appliance.

Limited to children through age 20

Must meet utilization criteria and be prior authorized:

• Fixed partial denture (crowns and pontics)

• Anterior fillings
• Crowns - made of prefabricated stainless steel, prefabricated resin or laboratory resin
• Posterior fillings - paid at the amalgam rate regardless of the material used

The following must meet utilization criteria and be prior authorized:

• All TMJ splints
• Occlusal orthotic appliance
• Unspecified TMD therapy, by report