(1) For dental services listed in the RVD scale, the department shall pay the lowest of the following for dental services covered by the Medicaid program:

(a) the provider's usual and customary charge for the service;

(b) the amount determined using the methodology described in ARM 37.86.1004.

(2) For dental services that are not listed in the RVD scale, the department shall pay the lowest of the following for dental services covered by the Medicaid program:

(a) the provider's usual and customary charge;

(b) the amount determined using the by-report method as follows:

(i) for covered dental services provided to persons age 18 and over, 65.2% of the provider's usual and customary charge for the service;

(ii) for covered dental services provided to persons age 17 and under, 80% of the provider's usual and customary charge for the service.

(3) Reimbursement for services delivered to adults is the fee specified in the fee schedule or, if reimbursement is based on the "by report" method, 65.2% of the provider's usual and customary charge for the service. Services delivered to adults are services provided while the recipient is age 21 and over.

(4) Reimbursement for services delivered to a child is the fee specified in the fee schedule or, if reimbursement is based on the "by report" method, 80% of the provider's usual and customary charge for the service. Services delivered to children are services provided while the recipient is up to and including age 17.

(5) Reimbursement for services delivered to individuals age 18 through 20 is the fee specified in the fee schedule for adults, or if reimbursement is based on the "by report" method 80% of the provider's usual and customary charge for the service.

(6) No extra fee for pulp capping or bases is reimbursable.

(7) Payment for denture adjustments during the first year after delivery of the dentures is available only to a dentist or denturist who did not make the dentures.

(8) Medical procedures, within the scope of practice for licensed dentists, that are not listed in the dental services provider manual are reimbursed in accordance with the methodologies provided in ARM 37.85.212 and 37.86.105.

(9) A dentist examining more than one Medicaid recipient in a long term care facility on the same day is allowed payment for one nursing home call in addition to the examination fees. Examination is considered a recorded evaluation.

(10) Payment for orthodontia will be as follows:

(a) Full band orthodontia for Medicaid recipients who have cleft lip/palate, craniofacial anomalies or malocclusions caused by traumatic injury and interceptive orthodontia for Medicaid recipients who have posterior crossbite with shift, anterior crossbite and/or anterior deep bite at 80% or greater vertical incisor overbite, will be reimbursed at 85% of the provider's usual and customary charge, subject to the maximum allowable charge as published in the department's Orthodontic Coverage and Reimbursement Guidelines, December 1999.

(b) Payment will be based upon a treatment plan submitted by the provider which will include at a minimum, a description of the plan of treatment, estimated usual and customary charge and time line for treatment. The department will reimburse 40% of the Medicaid allowed amount up front for application of appliances, the remainder being paid in monthly installments as determined by the time line defined in the provider's treatment plan for completing orthodontic care.

(c) Recipients are limited to an overall lifetime cap of $7000.00 for interceptive and full band orthodontia phases unless otherwise provided by these rules. Services included in the separate phases including monthly visits, are as listed in the department's orthodontic coverage and reimbursement guidelines. Surgeries are not included in this lifetime cap.

(d) Maximum allowable charges for each phase of orthodontic treatment, time lines for orthodontic phases of care, and the services included in each phase of orthodontic care are listed in the department's Orthodontic Coverage and Reimbursement Guidelines. The department hereby adopts and incorporates herein by reference the department's Orthodontic Coverage and Reimbursement Guidelines updated through December 1999. The guidelines, issued by the department to all providers of orthodontic services, inform providers of the requirements applicable to the delivery of services. A copy of the department's Orthodontic Coverage and Reimbursement Guidelines is available from the Department of Public Health and Human Services, Health Resources Division, Acute Services Bureau, 1400 Broadway, P.O. Box 202951, Helena, MT 59620-2951.