Covered and Noncovered Services : Covered Services and Requirements

Dental Sealants

ForwardHealth reimburses HealthCheck nursing agencies enrolled in Wisconsin Medicaid for providing dental sealants to BadgerCare Plus and Medicaid members under age 21 when they are provided by a dentist or a dental hygienist as a HealthCheck service. Medicaid coverage for sealants in HealthCheck nursing agencies is limited to tooth numbers 02, 03, 14, 15, 18, 19, 30, and 31. Sealants for other teeth require PA.

The dentist or dental hygienist providing sealants is not required to be Medicaid-enrolled since the HealthCheck nursing agency is Medicaid-enrolled. Dental hygienists may provide sealants at a HealthCheck nursing agency under one of the following:

• A dentist's order
• A physician's order
• An agency protocol

Submitting Claims

HealthCheck nursing agencies are required to submit claims for dental sealants using either the ADA 2006 Claim Form or the ADA 2012 Claim Form with CDT procedure code D1351 and the appropriate tooth number(s). Providers should submit claims fee-for-service, even if the member is enrolled in an HMO, including HMOs that cover dental services. Providers should use the appropriate claim form instructions for the ADA 2006 or 2012 claim forms when submitting these claims for dental sealants provided by HealthCheck nursing agencies.

There is a once-per-three-year limitation on sealants for permanent first and second molars. To exceed the once-per-three-year limitation, a narrative must be attached to the claim explaining why the limitation was exceeded. The narrative must be signed by a licensed dentist.

Prior Authorization

PA is required for tooth numbers/letters 01, 04-13, 16, 17, 20-29, 32, A-T, and supernumerary teeth (AS-TS, 51-82). For these teeth, HealthCheck providers are required to refer the member to a Medicaid-enrolled dentist to request PA and provide these services. If the PA request is approved, Wisconsin Medicaid will reimburse the dentist for the service.