5.4 Use of Public Funding

Reimbursement

ODH-funded programs may submit claims for Medicaid beneficiaries for sealants, using diagnostic and preventive code D1351 (sealant). ODH does not approve ODH-funded programs routine billing for examinations, X-rays, or topical fluoride applications for Medicaid beneficiaries. ODH believes that examinations and X-rays should be conducted by dentists who provide all needed care. If programs were reimbursed for those services, dental offices (where children enrolled in Medicaid eventually receive care) would not be reimbursed.

Health Professional Enrollment

Dentists participating in sealant programs must be credentialed by Ohio Medicaid and each of the Medicaid MCPs or the TPA serving their region. Health professional enrollment information for Ohio Medicaid is available from Ohio Medicaid Job and Family Services. Health professionals may also call the provider enrollment unit at (800) 686-1516. Information about the credentialing process for MCPs that administer oral health programs or TPAs must be obtained directly from the appropriate company by phone or via their Web site.

Filing Claims

All health professionals must obtain a National Provider Identifier (NPI) for filing and processing of claims. NPI applications are available from the National Plan and Provider Enumeration System at (800) 465-3203 or (800) 692-2326 (TTY) or via their Web site.

Dental sealant programs may submit claim forms electronically or via paper. Electronic submission results in faster claims processing, reduced administrative costs, reduced probability of errors, faster feedback on claims status, and minimal staff training or cost. The School-Based Dental Sealant Program Manual has information about available options for claim submissions to the respective MCPs that administer oral health programs or TPAs, but local sealant programs may wish to check with those payers directly.

Ohio Medicaid and each Medicaid MCP or TPA that administers claims has systems to provide health professionals with information that they need. The table Accessing Medicaid Systems summarizes how to access those systems.

Table 1. Accessing Medicaid Systems

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