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  • Wilson

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    cmbucholtz
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    The document outlines dental coverage and procedures for CareSource Ohio Medicaid plans including Unison and Buckeye. It lists covered preventative services like exams, cleanings, and fluoride treatments for both children and adults. It also provides information on coverage for procedures like sealants, space maintainers, root canals, crowns, extractions, partials, dentures, and orthodontics noting prior authorization requirements and lifetime limits for some services.

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    The document outlines dental coverage and procedures for CareSource Ohio Medicaid plans including Unison and Buckeye. It lists covered preventative services like exams, cleanings, and fluoride treatments for both children and adults. It also provides information on coverage for procedures like sealants, space maintainers, root canals, crowns, extractions, partials, dentures, and orthodontics noting prior authorization requirements and lifetime limits for some services.

    Copyright:

    Attribution Non-Commercial (BY-NC)
    Download as DOCX, PDF, TXT or read online from Scribd
    Flag for inappropriate content
    6 views2 pages

    Wilson

    Uploaded by

    cmbucholtz
    The document outlines dental coverage and procedures for CareSource Ohio Medicaid plans including Unison and Buckeye. It lists covered preventative services like exams, cleanings, and fluoride treatments for both children and adults. It also provides information on coverage for procedures like sealants, space maintainers, root canals, crowns, extractions, partials, dentures, and orthodontics noting prior authorization requirements and lifetime limits for some services.

    Copyright:

    Attribution Non-Commercial (BY-NC)
    Download as DOCX, PDF, TXT or read online from Scribd
    Flag for inappropriate content
    of 2

    CARESOURCE OHIO MEDICAID UNISON & BUCKE

    Adult (14+) Exam, prophy


    2 X per year(14-20 = fluoride)
    Children (13-) Exam, prophy,
    fluoride 2 X per year
    Adult (14+) Exam, prophy
    1 X per year(14-20=fluoride)
    Periodontal Treatment,
    Debridements, SRP’s, 4910’s REFERRAL REFERRAL REFERRAL
    st nd
    Sealants 1 & 2 molars
    Age 5-17, once per lifetime
    Space maintainers, once per
    lifetime, age 1-20 years old
    Pre-crown bonding Will pay for one or t
    other, not both
    Root canals ANTERIOR

    Root canals POSTERIOR

    Crowns, P&C, ANTERIOR


    MUST PRIOR MUST PRIOR MUST PRIOR
    Extractions
    PART BONY
    Extractions
    FULL BONY MUST PRIOR MUST PRIOR MUST PRIOR
    Partials - 8 YEAR LIFE. Must be
    missing 3 or more teeth, not 3rds, MUST PRIOR MUST PRIOR MUST PRIOR
    OR 1 anterior tooth.
    Dentures
    8 YEAR LIFE MUST PRIOR MUST PRIOR MUST PRIOR
    Reline/Adding teeth or clasps,
    after 4 years from seat date
    Orthodontics/TMD or TMJ
    REFERRAL REFERRAL REFERRAL
    *Submit with proper clinical
    notes & radiographs

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