For Federally Qualified Health Centers (FQHCs) and Rural Health Centers, dental HCPCS should be included on the 837I electronic claim form with the well child visit HCPC and ICD 10 code. Use appropriate revenue code.

The DentaQuest Office Reference manual provides definitions of high risk for billing purposes. Exact language must be used in documentation to qualify a child ages 0 – 4 as eligible for reimbursement of screening/fluoride varnish 4 times/year. Otherwise, the standard is 2 times/year. Child members ages 5 through 20 years may receive fluoride varnish 3 times/year regardless of risk. Refer to Medicaid guidelines for most recent information.

High Risk of Caries is indicated if a member has one or more of the following four criteria:

• Presents with demonstrable caries, has a history of restorative treatment, or has a history of dental plaque AND has a history of enamel demineralization, OR
• Is a child member (age 0 through 20 years old) of mothers with a high caries rate, especially with untreated caries, OR
• Is a child member (age 0 through 20 years old) who sleeps with a bottle containing anything other than water, or who is breastfeed throughout the night (at-will nursing), OR\Is a child member (age 0 through 20 years old) who has special health needs.

To submit “High Risk” claim the word “HIGH RISK” must be written in box 35 (the comments section of the current ADA Claim form). In addition, the criteria qualifying this member as “High Risk” needs to be documented in the Remarks section of the Claims form. Alternatively, the “Pediatric Oral Health Screening” form can be submitted in place of the narrative in the Remarks section.