R414-49-4. Program Access Requirements

(1) A Medicaid-enrolled provider who is also affiliated with the University of Utah School of Dentistry Medicaid Associated Provider Program shall perform each dental service. (2) A provider shall verify a member's eligibility for dental services through the Medicaid eligibility system on each date of service before the rendering of a dental or surgical procedure. (3) A provider shall determine the coverage, limitations, quantity limits, and prior authorization (PA) requirements for each service before delivery. (4) Any service requiring PA must obtain approval before the service is provided. Medicaid does not cover services provided without an approved PA. (5) A provider may verify the coverage of a particular service based on a member's enrollment eligibility status by using the PRISM Coverage and Reimbursement Code Look-up Tool found on the Utah Medicaid website. (6) Further details, clinical criteria, and guidance for the coverage of dental services are outlined in the Dental, Oral Maxillofacial, and Orthodontia Services Utah Medicaid Provider Manual. (7) To ensure member access, a provider must maintain accurate directory information in the PRISM portal, including specialty and linguistic capabilities. (8) Any dental service, including a medical necessity exception, is provided through a fee-for-service delivery system.