Per the notice below, the New York State Department of Health (NYSDOH) has issued guidance on dental billing in Medicaid.

Fee-for-Service Dental Claim Submission Guidance When Third-Party Liability Payment Involved

New York State (NYS) Medicaid continues to work to increase provider compliance with properly reporting correct Coordination of Benefits (COB) information on claims submitted for beneficiaries who have primary insurance.  The COB claim to NYS Medicaid must accurately reflect the primary payers' adjudication of the claim as reported in the Explanation of Benefits (EOB).

When the primary insurance is a Medicare Advantage Plan / Medicare Part C with dental coverage:

• Claims for services involving a third-party payment by a Medicare Advantage Plan greater than zero dollars (>$0) must be submitted using the electronic claim format.  This also includes electronic submission of by-report procedure codes if a payment was made by a Medicare Pact C Plan.
• The payor code for Medicare Advantage Plans is the 16-health maintenance organization (HMO) and must be indicated on all electronic claims when Medicare Advantage is primary.
• It is the responsibility of the provider to submit the claim using the appropriate claim format with their usual or customary fee indicated along with reporting the Medicare Advantage Plan deductible amount, co-insurance amount, co-payment amount and paid amount.

Please note: A provider of a Medicare Part C benefit cannot attempt to recover any co-payment or co-insurance amount directly from Medicare and NYS Medicaid dually eligible individuals.  The provider is required to accept the Medicare Part C health plan payment and any NYS Medicaid payment as payment in full for the service.  The NYS Medicaid member may not be billed for any Medicare Part C co-payment/co-insurance amount that is not reimbursed by NYS Medicaid.

When the primary insurance is a private or commercial plan with dental coverage (not Medicare Advantage / Medicare Part C):

• Claims for services involving a third-party payment by private or commercial insurance plan (not Medicare Advantage), whether equal to or greater than zero dollars (= or > $0) may be submitted using either the electronic or paper claim format depending upon whether claim attachments are necessary (e.g., use paper claim format if the procedure code requires a report).
• It is the responsibility of the provider to submit the claim indicating their usual or customary fee along with reporting the amount paid by the private dental insurance plan in the "Other Insurance Paid" or "Other Payer Paid Amount" field.

Questions and Additional Information:

• Billing guidelines can be found on the eMedNY homepage.
• General billing questions should be directed to the eMedNY Call Center at (800) 343-9000.
• NYS Medicaid fee-for-service (FFS) questions regarding this guidance should be directed to dental@health.ny.gov.
• Questions regarding Medicaid Managed Care (MMC) reimbursement and/or documentation requirements should be directed to the MMC Plan of the enrollee.  For MMC Plan information, providers should refer to the eMedNY New York State Medicaid Program Information for All Providers - Managed Care Information document.