Information for Medicaid Dental Providers

Welcome to the New York State Medicaid Dental Provider Page. New York State offers an extensive dental services benefit to all Medicaid members.

Centers for Medicare and Medicaid (CMS) New Interoperability and Prior Authorization Final Rule (CMS-0057-F):

• On January 17, 2024, the Centers for Medicare and Medicaid Services (CMS) released the CMS Interoperability and Prior Authorization Final Rule (CMS-0057-F). The rule requires state Medicaid programs to implement a change to determination timelines. NYS was granted an extension to implement the new timelines, and it will be effective January 1, 2027, to align with federal guidelines.
• For more information see CMS Interoperability and How the New Rule Will Change Prior Approval, Effective January 1, 2027 (External Link)

Dental Benefit Highlights:

• Effective January 31, 2024 the clinical criteria for coverage of root canals, crowns, replacement dentures and dental implant were changed to allow for expanded coverage. The aim of these revisions is to maintain a member’s natural dentition whenever clinically appropriate. Please refer to the following resources for additional information:
  • Benefit Criteria Guidance and Clinical Criteria Guidance
  • New NYS Medicaid Dental Policies Webinar - January 2, 2024
    • Recording (YouTube) | Slide Deck (PDF) | FAQ Document (PDF)
  • Justification of Replacement Dentures and Evaluation of Dental Implant Patient forms are required forms that must accompany all Fee-for Service (FFS) and Medicaid Managed Care (MMC) pre-authorization requests for these services. These forms are located on eMedNY.
• Dental Services for members of the Intellectual and Developmental Disability (I/DD) population:
  • Additional frequency limits for certain dental services are available to individuals who receive ongoing services from community programs operated or certified the New York State Office for People with Developmental Disabilities (OPWDD) with a Restriction Exception code RE 81 (“TBI Eligible”) or RE 95 ((OPWDD/Managed Care Exemption”). See Appendix I in the New York State Medicaid Dental Policy and Procedure Code Manual for a list of eligible dental services.
  • NYS Medicaid FFS private practitioners will be reimbursed 20 percent over the base fee schedule for all dental services provided to the I/DD population (identified with an RE code of "81" or "95") who are enrolled in FFS. This enhanced payment rate is intended to incentivize practices to increase access to care for NYS Medicaid FFS members with I/DD and compensate for the additional time necessary to care for these members. See the July 2023 New York State Medicaid Update.
  • Provider Resources:
    • Considerations for Patients with Special Needs | American Dental Association
    • AAPD Dental Practice Support for Treating Patients with Disabilities (PDF)

---

Contact Information:

• GDIT
  Billing Questions, Remittance Clarification, Request for Claim Forms, ePACES Enrollment, Electronic Claim Submission Support (eXchange, FTP), Provider Enrollment
  (800) 343-9000
• Dental Prior Approval and Claims:
  Bureau of Dental Review
  (800) 342-3005, Option 2
  dental@health.ny.gov
• General Questions about the NYS Medicaid Fee for Service Dental Program:
  Division of Program Development and Management
  (518) 473-2160
  dentalpolicy@health.ny.gov
• Questions related to New York State Medicaid Managed Care should be directed to the enrollee's Managed Care Plan. If you disagree with a Managed Care determination, follow the Managed Care Plan’s appeal process. Once you have followed this process, if the issue remains unresolved, send details of the disagreement, along with any documentation of your efforts to resolve, to: managedcarecomplaint@health.ny.gov