The following topics are featured in the October Special Provider Bulletin:
- Oral Health Community Health Worker (CHW) Services Billable by Medi-Cal Dental Providers with CDT Code D9994 Effective December 1, 2024
To visit the Provider Bulletin please visit the following link:
The Department of Health Care Services (DHCS) is establishing a new Community Health Worker (CHW) benefit, as a billable Medi-Cal Dental benefit to allow CHWs to provide oral health services and receive reimbursement through Medi-Cal Dental. The added CHW services benefit integrates CHWs into the oral healthcare system to enhance preventive care and provide support services to Medi-Cal members. The CHW benefit will be billed under the Current Dental Terminology code D9994 (Dental Case Management, Patient Education to Improve Oral Health Literacy).
Effective December 1, 2024, dental providers who bill Medi-Cal Dental may bill the CDT D9994. For the purposes of this bulletin, dental providers include licensed dentists, registered dental hygienists, registered dental hygienists in alternative practice, and registered dental hygienists in extended functions. This regulatory bulletin does not authorize dental assistants, registered dental assistants, or registered dental assistants in extended functions to enroll in or bill Medi-Cal directly.
In accordance with Welfare & Institutions Code (W&I Code) Section 14043.75(b), DHCS is establishing specific billing criteria for dental providers to bill CDT D9994. These requirements implement and make specific CDT Code D9994 as a payable benefit when billed by an enrolled Medi-Cal Dental dentist or hygienist, and as such have the full force and effect of law. Under the covered CHW benefit, members will receive oral health literacy and support for dental care and be provided with information consistent with established or recognized oral health care standards from eligible CHWs. A Medi-Cal Dental enrolled provider, who is a supervising provider, oversees a CHW and their services delivered to Medi-Cal members. CHW services are preventive health services to prevent disease, disability, and other health conditions or their progression; to prolong life; and promote physical and mental health. Covered CHW Services Medi-Cal Dental offers Oral Health Education and Oral Health Navigation as covered CHW services: CHWs provide Oral Health Education to promote members’ oral health or address barriers to dental health care. This includes delivering information consistent with established or recognized oral health care standards. CHWs have an important role in Oral Health Navigation by helping members access dental services and overcome barriers to care. CHWs provide information, training, and support to help individuals navigate the oral health care system, understand how it works, and become active participants in their own care. In addition, CHWs connect members with community resources that promote oral health and address specific barriers. This includes connecting members to translation or interpretation services for dental appointments, arranging transportation for dental visits, or helping to address other health-related social needs. CHW Services Via Teledentistry There are no place of service restrictions for CHW services. Currently, Medi-Cal CHWs may render services via synchronous teledentistry within their scope of practice. Please refer to the Teledentistry section in Section 4 of the Medi-Cal Dental Provider Manual for guidance regarding providing services via teledentistry.
Billing Criteria
Criteria for D9994: Dental Case Management – Patient Education to Improve Oral Health Literacy is as follows:
1. Prior Authorization is not required.
2. Written documentation for payment – shall include the name of the CHW that provided the training, the number of patients present at the training, and the time of the training session (i.e. 12:30 PM – 1:00 PM).
3. A benefit:
a. For Members:
i. With one or more chronic health conditions (including behavioral health) or exposure to violence or trauma which has an impact on the Member’s oral health.
ii. Who are at risk for a chronic health condition or environmental health exposure which has an impact on the Member’s oral health.
iii. Who face barriers meeting their oral health or oral health-related social needs and/or would benefit from preventive oral health services.
iv. See Provider Handbook (Section 4 Pages 22-28) for a detailed list of medical necessity eligibility criteria.
b. Up to 4 units (two hours) daily per Member, subject to the yearly maximum.
i. Additional units per day may be requested on a TAR with documentation supporting the medical necessity. If the additional units have already been provided, then a claim may be submitted along with documentation supporting the medical necessity.
c. Up to 12 units of care (six hours) per Member per year.
i. Additional units per year may be requested on a TAR. Documentation shall include a written plan of care.
4. Refer to Provider Handbook (Section 4, Treating Members) for additional information.
Reimbursement Schedule
Effective for dates of service on or after December 1, 2024, the Schedule of Maximum Allowances (SMA) for CDT procedure code D9994 (DENTAL CASE MANAGEMENT – PATIENT EDUCATION TO IMPROVE ORAL HEALTH LITERACY) will be updated.
|
CDT Code |
Description |
Units |
SMA (each 30-minutes = 1 unit) |
|||
|
Rate per unit |
1 unit |
2 units |
3 units |
4 units |
||
|
D9994 |
Dental Case Management – Patient Education to Improve Oral Health Literacy, each 30 minutes: 1 Patient |
$26.66 |
$26.66 |
$53.32 |
$79.98 |
$106.64 |
|
D9994 |
Dental Case Management – Patient Education to Improve Oral Health Literacy, each 30 minutes: 2-4 Patients |
$12.66 |
$12.66 |
$25.32 |
$37.98 |
$50.64 |
|
D9994 |
Dental Case Management – Patient Education to Improve Oral Health Literacy, each 30 minutes: 5-8 Patients |
$9.46 |
$9.46 |
$18.92 |
$28.38 |
$37.84 |
Section 5 of the Medi-Cal Dental Provider Handbook Schedule of Maximum Allowances will reflect the changes on that date.
DHCS invites and encourages dental providers to attend a public comment meeting to learn more about billing for Community Health Workers. The meeting is scheduled for [October 31, 2024 from 10:00 AM to 11:00 AM].
For more information, you can call the Telephone Service Center (TSC) at (800) 423-0507, available Monday through Friday from 8:00 AM through 5:00 PM.
W&I Code Section 14043.75(b) Meeting Notice
In accordance with W&I Code Section 14043.75(b), the Department of Health Care Services (DHCS), Medi-Cal Dental Services Division (MDSD) will host a virtual dental CHW informational webinar on October 31, 2024. The purpose of this meeting is for DHCS to share updates and information on the new dental CHW benefit and to provide dental stakeholders with a forum to provide input on Medi-Cal Dental to help improve the delivery of Oral Health Care Services.
The meeting information is as follows:
Date: October 31, 2024
Time: 10:00 AM to 11:00 AM
Webinar Meeting Information: Meeting link to join Meeting ID: 275 865 716 05
Passcode: CJfRQB
Dial in by phone
+1 279-895-6425,,134897732# United States, Sacramento
Phone conference ID: 134 897 732#
ADDITIONAL BACKGROUND
On July 1, 2022, CHW services became a covered benefit under the Medi-Cal Program per SPA 22-0001. DHCS released a CHW policy that included the minimum qualifications for CHWs to provide services eligible for reimbursement through Medi-Cal. The policy, when initially released, did not allow D9994 to be billed for CHW Services.
Effective December 1, 2024, pursuant to SPA 24-0016, DHCS is adding CHW services as a billable Medi-Cal benefit to allow CHWs to provide oral health services and receive reimbursement through Medi-Cal Dental. The added CHW services benefit integrates CHWs into the oral healthcare system to enhance preventive care and provide support services to Medi-Cal members. The CHW benefit will be billed under the Current Dental
Terminology code D9994 (Dental Case Management, Patient Education to Improve Oral Health Literacy).
