Billing for Dental Services to Prepaid Dental Health Plan Enrollees
Due to a provision in Florida law, Medicaid recipients are no longer allowed to “opt out” of the Statewide Prepaid Dental Health Plan (PDHP) program and receive dental services through Medicaid Fee-for-Service (also called straight Medicaid). Effective July 1, 2013, all Medicaid children eligible for the PDHP program were enrolled in one of the two PDHPs: DentaQuest or MCNA Dental.
Medicaid Fee-for-Service dental providers should not cancel appointments in July for recipients newly assigned to a PDHP. Each PDHP is required to cover previously scheduled or ongoing treatments for a minimum of the first 30 days of a recipient’s enrollment. Providers must check eligibility and bill the recipient’s PDHP for services rendered during the month of July 2013. Providers who are not participating in one or both PDHP networks should contact the PDHP’s provider relations department(s) for information on how to submit claims. Fee-for-Service claims submitted for PDHP-enrolled recipients beginning with a July 1, 2013 date of service will automatically deny.
For recipients in active orthodontia care prior authorized by Florida Medicaid, each PDHP is required to cover the completion of the treatment whether or not the orthodontist participates in the PDHP’s provider network. Providers must check eligibility to determine the recipient’s enrollment and contact the PDHP’s provider relations department to obtain a continuity of care form. A continuity of care form and Medicaid prior authorization approval must be submitted for each recipient in active orthodontic treatment. Claims submitted to the PDHP without the continuity of care form and/or Medicaid prior authorization approval will automatically deny.
Continuity of care forms are available from the DentaQuest and MCNA Dental provider relations departments. See below for contact information.
(800) 494-6262, Option 6
If you have any questions, please send an email to statewide.PDHP@ahca.myflorida.com.
Upcoming Florida Dental Managed Care Steering Committee Meeting
MCNA and DentaQuest will host the Florida Dental Managed Care Steering Committee Meeting to discuss Statewide Prepaid Dental Health Plan (PDHP).
The Florida Dental Managed Care Steering Committee Meeting will be
Friday, November 8, 2013,
9:30 a.m. – 2:30 p.m. E.S.T.
at the DoubleTree by Hilton Orlando Downtown,
60 South Ivanhoe Boulevard, Orlando, FL 32804.
Please note that there will be no conference call capability for this meeting. Your attendance is encouraged. For additional information contact MCNA Provider Hotline at 1-855-698-6262, or DentaQuest Provider Relations Supervisor Carol Schoneke at 800-417-7140 ext. 82317.
Due to a provision in Florida law, Medicaid recipients will no longer be allowed to “opt out” of the Statewide Prepaid Dental Health Plan (PDHP) program and instead receive dental services through Medicaid Fee-for-Service (also called straight Medicaid). Effective July 1, 2013, all Medicaid children eligible for the PDHP program will be enrolled in one of the two PDHPs: DentaQuest or MCNA Dental.
Recipients who have opted out of the PDHP program up to this point will be notified of this change by mail and offered a choice between the two PDHPs. Recipients who do not choose a PDHP will be assigned to one by the state effective July 1, but may change plans at any time thereafter.
For updates on the Statewide PDHP program as they become available, visit this website and watch for forthcoming Provider Alerts. Please direct questions to the Statewide PDHP mailbox at statewide.PDHP@ahca.myflorida.com.
The Statewide Prepaid Dental Health Plan (PDHP) program is operational in the counties shown below on the color-coded map.
In the 2010 proviso language (Specific Appropriation 204 of HB 5001), the Agency was directed to implement a statewide Prepaid Dental Health Plan (PDHP). As a result, Florida Medicaid has contracted with two PDHPs, DentaQuest and MCNA Dental Plans, to provide children’s dental services in all Florida counties except Miami-Dade and the Reform counties, which are Baker, Broward, Clay, Duval, and Nassau.
View the Reference Information tab above to download a PDF version of this map or to contact an area office.
The PDHPs must cover all Medicaid State Plan dental services covered by Medicaid for children under 21 years of age. Except for children enrolled in Medicaid managed care plans offering optional dental services, and a few special services excluded groups, most Medicaid children are required to enroll in one of the two PDHPs. The amount, duration, and scope of covered dental services will remain the same.
Providers who are interested in becoming part of one or both of the Prepaid Dental Health Plan (PDHP) networks should contact the provider service toll-free number or visit their website.
1 (855) 698-6262
1 (877) 468-5581
June 26, 2013 Webinar for Medicaid Dental Providers Presentation [1.04 MB PDF] 6/27/2013
Prepaid Dental Health Plans (PDHPs) are Medicaid managed dental care options available to Medicaid recipients who are 20 years of age or younger and not enrolled in a health plan that provides dental services.
Based on legislative mandate, the Agency will expand the PDHP program statewide in fiscal year 2011-2012.
The following services are managed by the PDHP:
- Adjunctive general services
- Dentures, full and partial
- Diagnostic examinations
- Endodontics/periodontal treatment
- Injectable medications
- Oral and maxillofacial surgery
- Orthodontic treatment, if medically necessary
- Preventive services
- Surgical procedures and extractions
Services included must be provided up to the limits specified by Medicaid and cannot be more restrictive.
If a recipient is enrolled in a PDHP, the provider must bill the PDHP instead of billing straight fee-for-service Medicaid. How the PDHP reimburses the providers depends on the terms of the provider’s agreement with the PDHP.
The following Medicaid recipients are NOT eligible to enroll in a PDHP:
- Recipients 21 years of age or older.
- Recipients who reside in an intermediate care facility for the developmentally disabled or state hospitals.
- Recipients whose Medicaid eligibility is determined monthly through the Medically Needy Program.
- Recipients who are members of a Medicaid-funded health plan that provides dental services.
- Recipients who are in the Statewide Inpatient Psychiatric Program.
The Statewide PDHP program is available in Medicaid Areas 1, 2, 3, 4, 5, 6, 7, 8, 9 and 11 (Monroe County only).
Who can participate?
Children through Age 20 who have Medicaid or MediKids through age four.
What are the names of the Dental Plans?
- MCNA Dental
What if my child has special needs?
The dental plans are able to handle children who have special needs.
Both plans offer the same services that you had under Medicaid fee-for-service.
Some examples are:
- Fluoride treatments
- Pulling teeth
- Braces if medically necessary
The plan will send you a member ID and a handbook with all the details.
What if my child has braces?
The dental plan will continue to pay the same orthodontist for the braces. Call the new dental plan about continuing care until treatment is completed.
What if we moved?
Please report the new address to DCF or the Social Security Administration, or if your child is enrolled in MediKids, to the MediKids Helpline.
Optional Dental Services
Non-Reform Health Plans that Cover State Plan Dental
Please remember that Non-Reform health plans may choose to cover State Plan dental services. We refer to this as "optional dental." If they choose to cover State Plan dental, then they receive extra capitation and are responsible for all State Plan dental services detailed in the Medicaid Provider Dental Services Coverage and Limitations Handbook.
The following health plans will continue to cover optional dental services effective January 1, 2013:
- Healthy Palm Beaches
- First Coast Advantage, LLC
- Care Access
- FL Healthcare Plus
Please be careful to request service authorization and to bill accordingly.
Verifying Medicaid PDHP Eligibility [301KB PDF] Updated 8/19/2013
Map of Counties and Rollout Schedule [112KB PDF]
Recipient Welcome Letter [193KB PDF]
Model Statewide Prepaid Dental Health Plan (SPDHP) Contract
The Agency has received lots of questions concerning the Statewide Prepaid Dental Health Plan program. If you have a question, please send it to the PDHP Mailbox at statewide.PDHP@ahca.myflorida.com.
Provider FAQs Updated 5/20/2103
Recipient FAQs Updated 5/20/2103
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