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.
Provider Resources:
The 2025 Program Manual and updated Fee Schedule are now available on eMedNY.
The revised documents are effective January 1, 2025.
The following additional provider resources can also be found on eMedNY.
- Information on Provider Enrollment
- New York State Dental Policy and Procedure Code Manual and Dental Fee Schedule
- New York State Department of Health Medicaid Updates
- Dental Provider Communications
- eMedNY Listserv sign up
- Provider Outreach and Training information
- Billing Guidance
- Prior Approval Guidelines
- Justification of Need for Replacement Prosthesis Form
- Evaluation of Dental Implant Patient Form
Dental Benefit Highlights 2024-2025:
- Effective January 31, 2024 the clinical criteria for coverage of root canals, crowns, replacement dentures and dental implant was 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
- 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.
- Guidance for Fee for Service (FFS) dental claim submission when there is third party liability payment greater than $0 was issued in the May 2024 Medicaid Update. Coordination of Benefits (COB) information on claims submitted for beneficiaries who have primary insurance must accurately reflect the primary payor's adjudication of the claim as reported on the Explanation of Benefits (EOB). Please refer to the Medicaid update for further billing guidance.
- Effective August 1, 2024 for Fee for Service (FFS) and October 1, 2024 for Medicaid Managed Care members (MMC) the treating dental specialist can be reimbursed for a panoramic radiograph (panorex) even if one has been taken within three years, to render the necessary dental care when the panorex provided from the referring dentist is not diagnostic or cannot be obtained. Claims for payment should be accompanied by a narrative explaining the patient-specific medical necessity. Please refer to the July 2024 Medicaid Update for further information.
- Effective January 1, 2025 for Medicaid fee-for-service (FFS) members and Medicaid Managed Care members (MMC), providers can be reimbursed for eConsult's in the dental setting. eConsult's, also known as electronic consultations or interprofessional consultations between a dentist and another medical health care professional [physician, physician assistant (PA), nurse practitioner (NP), midwife (MW)], are intended to improve access to specialty expertise by assisting the treating/requesting provider with the care of the patient, without patient contact, with the consultative provider on medical issues that may affect the planned dental treatment of the patient. Please refer to the October 2024 Medicaid Update for further information.
- Effective January 1, 2025 "D1354" application of caries arresting medicament has been expanded to all NYS Medicaid members, for conservative treatment of an active, non-symptomatic carious lesion in the dental setting. "D1354" is reimbursable for topical application of silver diamine fluoride, without mechanical removal of sound tooth structure, regardless of the age of the NYS Medicaid member. Please refer to the November 2024 Medicaid Update for further information.
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