What Are the Dental Medicaid Reimbursement Rates for My Patient?
Jul 06, 2023Medicaid participants are categorized into Medical Eligibility (ME) groups based on their unique situation.
The ME code tells you which procedures are covered for that patient.
As a reminder, eligibility must be verified on each date of service because it can fluctuate.
To check eligibility, visit MO HealthNet’s eMOMed Portal.
Once you’ve pulled up your patient’s profile, you’ll want to check several things:
- Do They Have Active Coverage?
- Do They Have Another Form of Insurance?
- Are They a MO HealthNet or a Managed Care Plan Participant?
- What is Their ‘Plan Code’ also known as their ‘ME Code’
Look under the “Eligibility/Benefit Code” header to determine the status of their coverage.
Here you’ll see one of two things: ‘1 – Active’ or ‘6 – Inactive’.
If their status is ‘Inactive’ on the date of service - no Medicaid coverage is available.
The patient is responsible for any costs associated with care, unless they have another form of insurance. Their costs would need to be detailed in writing before care is provided.
If their status is ‘Inactive’ with ‘Y-Spend Down’ - they will pay a portion of the costs.
The patient will have a specified dollar amount listed for which they are responsible. Refer to the Eligibility and Spend Down Overview for additional details.
If their status is ‘Active’ - find their ME Code and Insurance Type.
First look under the ‘Plan Code’ header to find the numeric code that is associated with their coverage level. Then refer to the ‘Insurance Type’ to see which care plan is active for billing.
You’ll see one of the following under insurance type:
- MC-MO HealthNet
- MC-UHC
- MC-HealthyBlue
- MC-Home State Health
- MC-Show Me Healthy Kids
- OT- Other Insurance.
The options above tell you which payor will be billed for the care provided.
If ‘OT’ appears in addition to one of the MC or Managed Care plans, the other insurance listed must be billed first as primary payor.
Then use their Plan Code to determine their coverage level in the Provider Resource Guide.
Now, refer to Section 5 of the Dental Provider Manual to see their associated procedure codes, requirements, and fees for billing.
If your patient has limited coverage, look in the column titled “Limited Adult Coverage”. Codes that have this box marked are also available to participants with limited coverage.
You can also use this section to see if their needed service has age limits, additional requirements for billing, or requires Prior Authorization (PA).
Now check the Dental Fee Schedule to find the reimbursement fee for each procedure code.
Once you’ve opened this page, select ‘Dental Services’ in the column on the left. Then scroll down to the purple ‘Search Options’ box and select the ‘Proc Code’ radial button.
Put your patient’s procedure code in the box and choose ‘Go’. This search will return the fee that you can bill for that procedure.
With this information, you’ll know exactly what reimbursement you can expect for each patient.
Still Unsure About Finding Dental Medicaid Reimbursement Rates?
Check out our Medicaid Mini – Decoding the Codes for additional support.
Need More?
Your Medicaid Mentor – Jessica Emmerich, is here to offer you support. Email, call, or text her at 573-536-2474.