Provider Type 22 Billing Guide
Updated: 03/27/2023 Provider Type 22 Billing Guide
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Dentist
Dental Services Program Overview
Recipients age 21 and older may receive emergency extractions, palliative care, and dentures/prosthetic care under
certain guidelines and limitations.
Recipients age 21 and older on the Waiver for Individuals with Intellectual and Developmental Disabilities (ID Waiver)
are eligible to receive expanded dental services to include restorations, root canals and preventive care. The expanded
dental services for the ID Waiver recipients have a maximum limit of $2,500 annually.
Recipients under age 21 may receive a larger range of dental services including orthodontia, certain restorative services
and routine maintenance to promote dental health. For more information on services provided under the Healthy Kids
Program - (Early Periodic Screening, Diagnostic, and Treatment - EPSDT), see Chapter 1500 of the Medicaid Services
Manual.
Recipients who are pregnant may receive some periodontal services (see the Fee-for-Service Coverage, Limitations and
Prior Authorization Requirements for the Nevada Medicaid and Nevada Check Up Dental Program), diagnostic, restorative
and preventative care. Services for recipients who are pregnant require prior authorization.
Recipients in rural Nevada: Dental services provided in rural areas of Nevada are billed under the Fee for Service (FFS)
benefit plan. Orthodontic services are billed under the FFS benefit plan for both rural and urban areas. Submit prior
authorization requests and claims to Gainwell Technologies, Nevada Medicaid’s fiscal agent. Gainwell Technologies is
referred to as Nevada Medicaid throughout this document.
Recipients in Urban Clark and Urban Washoe counties:
LIBERTY Dental Plan (LIBERTY) became the Dental Benefits Administrator for Nevada Medicaid effective January 1, 2018.
Effective January 1, 2023, dental providers that are partnered with Liberty Dental Plan can now provide the expanded
dental services to ID Waiver recipients. Any Liberty dental provider who renders expanded dental services to an ID
Waiver recipient must bill the claims through Medicaid Fee-For-Service.
Policy
Please see the following documents on the Division of Health Care Financing and Policy (DHCFP) website at:
http://dhcfp.nv.gov
• MSM Chapter 100 contains important information applicable to all provider types.
• MSM Chapter 1000 covers dental program policy and requirements.
• MSM Chapter 1500 covers policy and requirements for the Healthy Kids Program.
• MSM Chapter 2100 covers policy and requirements for individuals on the ID Waiver for expanded dental services.
• Provider Type 22 Dental Fee Schedules webpage provides Nevada Medicaid rates for dental services and ID
Waiver dental services.
Recipient Eligibility
Verify a recipient’s eligibility each time before submitting a prior authorization request and before providing services. It is
recommended that providers check eligibility monthly.
Options available to providers for verifying recipient eligibility are:
• Electronic Verification System (EVS): To access EVS, visit the Nevada Medicaid website at www.medicaid.nv.gov.
Select the “EVS” tab to review the User Manual and to register or login to EVS. EVS is available 24 hours a day, 7
days a week, except during maintenance periods.
• Automated Response System (ARS): To access ARS, call (800) 942-6511. The ARS provides eligibility information
via the phone. Your National Provider Identifier (NPI) is required to log on.
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Dentist
• Swipe Card System: To implement a swipe card system, please contact a swipe card vendor directly.
Billing Instructions
The following document contains a reference table to determine Fee-for-Service coverage, limitations and prior
authorization requirements for the Nevada Medicaid and Nevada Check Up Dental Program.
• Attachment A: Fee-for-Service Coverage, Limitations and Prior Authorization Requirements for the
Nevada Medicaid and Nevada Check Up Dental Program
For the expanded dental services for ID Waiver recipients, the following Attachment B of the PT 22 Dental Billing Guide
contains a reference table with the procedure codes and service limitations specific to expanded dental services.
• Attachment B: Fee-for-Service Coverage, Limitations and Prior Authorization Requirements for Dental Services
for the Waiver for Individuals with Intellectual and Developmental Disabilities
Submit claims using Direct Data Entry (DDE) through the Electronic Verification System (EVS) secure Provider Web Portal
or use an approved Trading Partner to submit your claims. See EVS User Manual Chapter 3 Claims and the Dental 837D
Companion Guide for claim submission instructions.
Note: Provider type 22 (Dentist) providers are instructed to submit dental claims with tooth surface codes indicated in
alphabetical order.
Prior Authorization (PA)
Except for services for ID Waiver recipients, before submitting a prior authorization request:
• It is the provider’s responsibility to verify that the recipient is covered under the Nevada Medicaid program and
is eligible to receive the service you are requesting.
• Providers are advised to use the Fee-for-Service Coverage, Limitations and Prior Authorization Requirements for
the Nevada Medicaid and Nevada Check Up Dental Program document to verify a service is covered and if that
service requires prior authorization.
Submitting Prior Authorization Requests
Submit prior authorization requests 1-2 weeks before the recipient’s appointment.
The Provider Web Portal, at www.medicaid.nv.gov, must be used to request authorization for all services. See the
Electronic Verification System (EVS) Chapter 4 Prior Authorization for instructions.
Providers will need to submit the request(s) for authorization on the Provider Web Portal and upload the forms and
clinical documentation. Providers must attach a document in the Provider Web Portal to move the prior authorization
request to the review status.
Dental Requests
• Use the ADA Claim Form and list all dental procedures to be performed.
• X-rays are recommended and can save time with the review process when submitted for services including but
not limited to:
o Anchors for partial dentures.
o Restorative services provided under pregnancy-related services.
• Dental History Requests: The Provider Web Portal allows dental providers, or their delegates, the ability to
search recipient treatment history online through the secured areas of the Provider Web Portal.
o Log in to the Provider Web Portal and click on “Treatment History” under the “Claims” tab.
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o Instructions are available in the Electronic Verification System (EVS) User Manual Chapter 9: Treatment
History.
o Please note that the code history search is completed by individual code. For example, if you do a search
using procedure code D0330, the search results will only return a history of paid claims for D0330 for the
recipient. If a related code would also impose a limit on the procedure code you are proposing to use, you
must do a separate search for that code. For history checks regarding dentures/partials, please check any
and all related codes.
Outpatient Requests
• Prior authorization for dental procedures performed in an outpatient/surgical center setting may require prior
authorization.
• Use the ADA Claim Form and list all dental procedures to be performed.
• The request must include a narrative signed by the provider stating the clinical rationale for the dental
procedures to be completed in an “outpatient” setting. Include the outpatient facility name and your NPI.
• Outpatient services must be requested at least eight business days prior to the date of service and must follow
the age specific requirements below:
Recipients of All Ages: For Medicaid recipients of all ages: If PA is required for the dental procedure (CDT code), the
dentist rendering the service must obtain prior authorization. Reference Nevada Medicaid’s Fee-for-Service Coverage,
Limitations and Prior Authorization Requirements (Attachment A of the PT 22 Billing Guide) document located on the
provider website at www.medicaid.nv.gov for a list of covered CDT codes, prior authorization requirements and service
limitations.
Recipients Ages Five and Below: For Medicaid recipients ages five and below, prior authorization is required for the
outpatient facility. The authorization request must include a narrative signed by the provider with the clinical rationale for
the dental procedure to be completed in an outpatient setting. The narrative must detail the clinical reason, including
medical necessity, that the recipient is unable to have the services completed in the office.
Recipients Ages Six to 20: For Medicaid recipients ages six to 20, specific authorization is not required for the
anesthesiologist and/or outpatient facility. Procedures done as outpatient services for recipients less than 21 years of
age in a hospital or surgical center must be identified. The provider must enter “Outpatient Facility Services” at the top
of the Examination and Treatment Plan box of the claim form.
Recipients 21 Years of Age and Older: For Medicaid recipients 21 years of age and older, the outpatient facility
services must be prior authorized. The authorization request must include a narrative signed by the provider with the
clinical rationale for the dental procedure to be completed in an outpatient setting. The narrative must detail the clinical
reason that the recipient is unable to have the services completed in the office.
Inpatient Requests
• Use the ADA Claim Form and list all dental procedures to be performed.
• The request must include a narrative signed by the provider stating the clinical rationale for the dental
procedures to be completed in an “inpatient” setting. Include the inpatient facility name and your NPI.
• Inpatient services must be requested at least eight business days prior to the date of service.
Orthodontia
• In all areas of Nevada, orthodontia is provided through the FFS benefit plan and requires a dentist’s referral. Prior
authorization requests and claims for orthodontia must be submitted to the Nevada Medicaid fiscal agent.
Please see the Dental PA Instructions and the Orthodontic Medical Necessity (OMN) Form (FA-25) for specific
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information required for requesting review for medical necessity and prior authorization for orthodontia. It
should be noted orthodontia is not included under the ID Waiver expanded dental benefits.
Providers are instructed to create the request for authorization and provide the required documentation through the
Provider Web Portal. The request must include the following:
• The ADA Claim Form.
• Documentation explaining the medical necessity for the service.
• A Treatment Plan signed by the orthodontist including the diagnosis, treatment and prognosis.
• Diagnostic photographs demonstrating measurements. Diagnostic photographs means photographs that are
clear enough to confirm a diagnosis. Photos of mounted models must be accompanied by photos and x-rays of
the patient. Measurements must be documented in photos with a Boley gauge, probe or disposable ruler.
Panoramic x-rays (Attach a clear copy.)
• Client Treatment History Form (FA-26)
• Orthodontic Medical Necessity (OMN) Form (FA-25)
All documentation must be submitted through the Provider Web Portal.
Authorizations for orthodontia services are effective for one year (e.g., May 26, 2020, through May 25, 2021) and are not
to exceed the date immediately prior to the recipient’s 21st birthday as long as the recipient is Medicaid eligible.
Retrospective Authorization
A retrospective authorization is an authorization that is granted after a dental service is provided. Retrospective
authorization may be granted only when:
• The recipient is determined Medicaid eligible for past dates and you provided services within those dates. You
must request retrospective authorization within 90 days of the date of the eligibility decision. (This does not
apply to Nevada Check Up recipients as Nevada Check Up does not offer retroactive eligibility.)
• Services are provided under life-threatening circumstances or serious health complication circumstances (e.g.,
from conditions such as HIV, AIDS, cancer or bone marrow or organ transplants).
To request retrospective authorization:
• Complete the ADA claim form as you would for a prior authorization request. Include dates of service in the
appropriate fields.
• Write “Retrospective” in the top margin of the claim form. Do not write over bar coding or in claim form fields.
• If a service was provided under life threatening circumstances, include documentation certifying the services
were necessary due to health complicating conditions such as HIV, AIDS, cancer, bone marrow transplantation or
post organ transplant.
Concurrent Authorization
If additional dates of service are required, you must request continued (concurrent) authorization by submitting another
authorization request to Nevada Medicaid prior to the end of the already authorized service dates. On your request,
include the reason for requesting extended treatment.
Prior Authorization for Medications
The Nevada Medicaid Preferred Drug List (PDL) is available online at www.medicaid.nv.gov (select “Preferred Drug List”
from the “Pharmacy” menu). This list contains Nevada Medicaid preferred drugs for over 20 drug classes. Prior
authorization is required for non-listed drugs within listed classes and as otherwise noted on the PDL.
If you have questions regarding medications, please contact our Pharmacy Technical Call Center at (866) 244-8554.
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Dentist
After Submitting Your Request
The Nevada Medicaid fiscal agent uses state and federal guidelines to review and determine whether services meet the
established requirements for payment. The Provider Web Portal will have the determination, dates of service and code(s)
requested for review.
Authorization does not guarantee payment of a claim. Payment is contingent upon eligibility, available benefits,
contractual terms, limitations, exclusions, coordination of benefits and other terms and conditions set forth by the
benefit program.
Incomplete Requests and Requests for Additional Information
When requests for prior authorization are pended for additional information, Nevada Medicaid generates a notice
requesting additional information. This notice is mailed to the “Mail To” address that providers have chosen on the
enrollment or revalidation applications. In addition, a note is placed in the Provider Web Portal with notification that the
request is in a pending status awaiting receipt of additional information. The note in the portal and the letter specify the
additional information that is needed and when the information is due in order to complete the request for review. If the
information is not received within the specified time frame, the request for review will be denied.
Denied Requests
If your request is denied, both the provider and the recipient receive written notification from Nevada Medicaid and the
recipient may then submit a Fair Hearing request to the DHCFP. Fair Hearing instructions are included in the written
notification sent to the recipient. Providers can submit a Fair Hearing request to the DHCFP after exhausting the appeals
process available through the Nevada Medicaid fiscal agent. For more information on requesting a State Fair Hearing, see
MSM Chapter 3100.
A peer-to-peer review or reconsideration can be requested by providers for prior authorizations that are denied or
modified. If you request a peer-to-peer review and afterward determine a reconsideration is appropriate, the
reconsideration may be requested if it meets the timelines identified below. Once a reconsideration is requested, you no
longer have the option of requesting a peer-to-peer review of the prior authorization.
Peer-to-Peer Review
A provider may request a peer-to-peer review by emailing nvpeer_to_peer@gainwelltechologies.com or calling (800) 525-
2395 within 10 business days of the adverse determination. A peer-to-peer review does not extend the 30-day deadline
for reconsideration.
Peer-to-peer reviews are a physician-to-physician discussion or in some cases between the Nevada Medicaid second level
clinical review specialist and a licensed clinical professional operating within the scope of their practice. The provider is
responsible for having a licensed clinician who is knowledgeable about the case participate in the peer-to-peer review.
Reconsideration
A reconsideration is a written request from the provider asking Nevada Medicaid to re-review a denied or reduced
authorization request. Use form FA-29B to submit your request through the Provider Web Portal.
A reconsideration is not available for technical denials.
The provider must request reconsideration within 30 calendar days from the date of the original determination.
For a reconsideration request, the provider is also responsible to provide additional medical information (e.g., intensity of
service, severity of illness, risk factors) that might not have been submitted with the original/initial request that supports
the level of care/services requested.
Nevada Medicaid or the DHCFP will notify the provider of the outcome of the reconsideration within 30 calendar days.
The 30-day provider deadline for a reconsideration is independent of the 10-day deadline for a peer-to-peer review.
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Dentist
If proper medical justification is not provided to Nevada Medicaid in an initial/continued stay request, a peer-to-peer
review, and/or a reconsideration review, Nevada Medicaid considers the lack of proper medical justification a failure of
the provider to comply with proper documentation requirements.
Documentation for Authorization Reconsideration:
• Provide a synopsis of the medical necessity not presented in the initial authorization request that you wish to
have considered.
• Include only the medical records that support the medical necessity issues identified in the synopsis.
Voluminous documentation will not be reviewed to determine medical necessity of requested services. It is the provider’s
responsibility to identify the pertinent information in the synopsis.
Forms and Information
• Forms FA-25 and FA-26 are available online at www.medicaid.nv.gov (select “Forms” from the “Providers”
menu).
• The Nevada Medicaid Prior Authorization Department is available to answer providers’ questions on dental and
orthodontia prior authorization requests. This department can be reached by calling (800) 525-2395.
Smoking/Tobacco Cessation Counseling
Current Procedural Terminology (CPT) codes 99406 (Smoking and tobacco use cessation counseling visit, intermediate, 3-
10 minutes) and 99407 (Smoking and tobacco use cessation counseling visit, intensive, greater than 10 minutes) may be
used to bill smoking cessation counseling for all Nevada Medicaid recipients. Procedure codes 99406 and 99407 are no
longer restricted to counseling for pregnant women only. The limitation for both codes is a maximum of 24 encounters
per year. These limitations can be exceeded if determined medically necessary by Nevada Medicaid.
