The Healthy Connections adult dental service benefit is administered by DentaQuest. DentaQuest is an independent company that administers dental benefits directly for Healthy Connections.
DentaQuest processes claims based on the South Carolina Department of Health and Human Services (SCDHHS) fee schedule and coverage policies, and SCDHHS, acting as its own fiscal agent, retains responsibility for claim payments to providers.
Adult dental services benefits include any covered diagnostic, preventive, therapeutic, rehabilitative or corrective procedure. Medical necessity or any referral information must be documented in the beneficiary’s medical record and must include a detailed description of services rendered. Healthy Connections does not cover services rendered for cosmetic purposes.
As of Dec. 1, 2014, SCDHHS has added preventive and restorative dental service coverage for eligible adults age 21 and older.
Filing Claims for the Provision of Adult Services
Adult preventive dental benefit — As of December 1, 2014, eligible Medicaid beneficiaries age 21 and older may receive up to $750 annually in covered dental treatment under an adult preventive dental benefit. The benefit’s first year concluded June 30, 2015, with the next year’s annual limitation beginning July 1, 2015, and continuing through June 30, 2016.
The $750 maximum benefit will be based on claim payments under the Healthy Connections adult dental fee schedule.
Sedation is not included within the standard benefit. Only when medically necessary, beneficiaries with special needs diagnoses or members receiving treatment by an oral surgeon may receive sedation services, which are excluded from the annual maximum benefit amount. Reimbursement for these services requires review for medical necessity.
Submission of a claim for treatment under the adult preventive benefit does not require any special indication or documentation unless the use of sedation as medically necessary needs to be determined.
Providers are able to view an adult beneficiary’s available benefit (the unused annual maximum benefit amount) on the DentaQuest Provider Web Portal at https://govservices.dentaquest.com/
This link leads to a third party website. That company is solely responsible for the privacy policies and content on its site.
Adult beneficiaries age 21 and older may also receive emergency medical services by an oral surgeon and dental services necessary to treat exceptional medical conditions. Neither treatment category will consume the $750 annual maximum under the adult preventive dental benefit as long as claims for treatment under these categories are appropriately submitted.