NCTracks
New NCTracks Edits to Limit Dental and Orthodontic Services on MPW Recipients
Effective August 2, 2015, NCTracks will deny/recoup payment of dental and orthodontic services for recipients covered under the Medicaid for Pregnant Women (MPW) program if the date of service is after delivery of the baby and outside of Medicaid policies. This is a longstanding Medicaid policy that was previously accomplished through post-payment review.
According to Clinical Coverage Policy 4A, Dental Services:
“For pregnant Medicaid-eligible beneficiaries covered under the Medicaid for Pregnant Women program class ‘MPW,’ dental services as described in this policy are covered through the day of delivery.” Therefore, claims for dental services rendered for recipients under “MPW” eligibility after the date of delivery are outside the policy limitation and are subject to denial/recoupment.
According to Clinical Coverage Policy 4B, Orthodontic Services:
“Pregnant Medicaid-eligible beneficiaries covered under the Medicaid for Pregnant Women program class ‘MPW’ are not eligible for orthodontic services as described in this policy.” Therefore, claims for orthodontic records (D0150, D0330, D0340, and D0470) or orthodontic banding (D8070 or D8080) rendered for recipients under “MPW” eligibility are outside of policy limitation and are subject to denial/recoupment.
Periodic orthodontic treatment visits (D8670) and orthodontic retention (D8680) will continue to be reimbursed regardless of the recipient’s eligibility status at that visit as long as the recipient was eligible on the date of banding.
New Explanation of Benefits (EOB) Codes effective August 2, 2015
· EOB 57710: Recipients covered under the Medicaid for Pregnant Women program (MPW) are not eligible for dental services after the delivery date. Refer to DMA Clinical Coverage Dental Policy 4A.
· EOB 57700: Recipients covered under the Medicaid for Pregnant Women program (MPW) are not eligible for dental services after the delivery date. Dental claims paid in history are recouped. Refer to DMA Clinical Coverage Dental Policy 4A.
· EOB 01832: Recipients covered under the Medicaid for Pregnant Women program (MPW) are not eligible for orthodontic services as described in DMA Clinical Coverage Policy 4B.
Medicaid providers are required to verify Medicaid recipient eligibility each time a service is rendered. Please refer to the NCMMIS Provider Claims and Billing Assistance Guide for eligibility verification methods.
Links to the NC Division of Medical Assistance Clinical Coverage Policies: