Texas Register, Volume 28, Number 14, Pages 2821-2988, April 4, 2003 Page: 2,866
2821-2988 p. ; 28 cm.View a full description of this periodical.
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younger than 12 months also can be seen for emergency dental ser-
vices by the dentist for trauma or baby bottle tooth decay. Recipients
up to age 21 may also self-refer for dental services.
33.311. Requirements for Provider Enrollment and Continuing Par-
ticipation.
(a) Dentists providing THSteps dental services must:
(1) be licensed by the SBDE;
(2) operate in accordance with the laws relating to the prac-
tice of dentistry and the rules and regulations of the SBDE;
(3) document the dental necessity of a stainless steel crown
before the crown is applied by radiographs or other documentation
methods established by the SBDE;
(4) comply with a minimum standard of documentation
and record keeping for each of the dentist's patients, pursuant to 22
T.A.C. 108.7-108.8, concerning SBDE minimum standards of care
and documentation requirements, whether the patient's costs are paid
privately or through the Texas Medicaid program;
(5) practice in the United States of America; and
(6) be enrolled as THSteps dental provider.
(b) Dentists who deliver emergency dental services as defined
in 33.308 of this title (relating to Emergency Dental Services) to Med-
icaid and THSteps-eligible Texas recipients while the recipients are out
of state are not required to be licensed by the SBDE, but must be au-
thorized to provide Title XIX services in the state in which the services
are delivered.
(c) Enrollment and continuing participation as a THSteps den-
tal provider are voluntary. An application for enrollment may be denied
and/or continuing participation may be terminated for any of the fol-
lowing reasons:
(1) disciplinary action(s) taken against the provider by the
SBDE or the licensing entity of any other state;
(2) previous or current Medicaid or other federally funded
health care program violation(s);
(3) prior imposition of sanctions by a regulatory entity of
the State of Texas or any other state;
(4) failure of the provider to comply with THSteps program
rules;
(5) a judgment in civil litigation or a criminal conviction
based on fraud or abuse in Medicaid or any other federally funded
health care program in any state. This includes a plea into a first of-
fender program, misdemeanor, or felony;
(6) failure to comply with Family Code, 231.006, regard-
ing payment of child support;
(7) notification from the HHSC OIE of adverse action
taken against the provider; or
(8) any other reason authorized by rules, regulations,
statute, or contract.
(d) A provider shall cease providing THSteps services and no-
tify TDH, HHSC or its designee if the SBDE suspends or revokes the
provider's license, unless the suspension or revocation is probated in
its entirety and without conditions or limitations.
33.314. Charges to Recipients.
(a) A provider shall not require a down payment before pro-
viding Medicaid-allowable services to eligible recipients.(b) A provider shall not charge recipients for missed appoint-
ments.
(c) If the denial or reduction of a dental claim is the result of
any of the following errors that are attributed to the provider, a provider
shall neither bill, nor take recourse against an eligible recipient for ser-
vices that are within the amount, duration, and scope of benefits of
THSteps:
(1) failure to submit a claim, including claims not received
by the HHSC or its designee;
(2) failure to submit a claim within the filing deadlines;
(3) filing of an incorrect paper or electronic claim;
(4) failure to resubmit a corrected paper or electronic claim
within the appropriate time period;
(5) failure to appeal a claim denial within the appropriate
time period; or
(6) errors made in claims preparation, appeal submission,
or the appeal process.
(d) A provider may bill a recipient for a dental service or item
only if:
(1) a request for prior authorization or a claim for payment
for the service or item did not establish dental necessity, the service or
item is not a benefit of the Medicaid program, or the service or item is
not allowable according to program rules and policy requirements; and
(2) the service or item was provided at the request of the
recipient and the provider obtained a written client acknowledgment
statement, as described in the manual, which was signed and dated by
the recipient or the recipient's parent/guardian prior to the initiation
of the specified dental service, and is retained in the recipient's dental
record.
33.315. Payment of Claims.
(a) The provider must accept payment by HHSC or its de-
signee as payment in full for services.
(b) Providers will be reimbursed for allowable services de-
livered in accordance with applicable laws, regulations, operational
instructions, and the provider agreement. Payment may be withheld
or suspended for services not delivered in accordance with applicable
rules and regulations. Medicaid payments will not be made for services
that are allowable and payable by any other third-party insurer or as-
sistance program.
(c) In the event of the provider's death, a completed claim will
be considered for payment only if the executor of the estate signs the
claim and the services were performed by the provider in accordance
with the THSteps program requirements.
33.317. Change to Another Provider
(a) A provider may refer a recipient to another provider or dis-
continue treatment for any of the following reasons:
(1) treatment by a dental specialist, such as a pediatric den-
tist, periodontist, endodontist, orthodontist, or oral surgeon, is indi-
cated;
(2) services needed are outside the skills or scope of prac-
tice of the initial provider; or
(3) documented failure by the recipient or the recipient's
caretaker or guardian to keep appointments, documented noncompli-
ance with the treatment plan, or documented conflicts with the recipi-
ent or recipient's family member(s).28 TexReg 2866 April 4, 2003 Texas Register
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Texas. Secretary of State. Texas Register, Volume 28, Number 14, Pages 2821-2988, April 4, 2003, periodical, April 4, 2003; Austin, Texas. (https://texashistory.unt.edu/ark:/67531/metapth101027/m1/45/: accessed May 26, 2024), University of North Texas Libraries, The Portal to Texas History, https://texashistory.unt.edu; crediting UNT Libraries Government Documents Department.