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Reimbursement Information

Medicaid programs cover preventive oral health services in the primary care setting. Other health plans also may cover services.

Periodicity and Billing of Oral Health Prevention in Primary Care- FINAL Updated 2.22.24

Fluoride Varnish Application
MaineCare
Billing codes: CPT 99188 or alternatively D1206
Reimbursement rate: CPT 99188 & D1206- $26.58/ application

  • Application of topical fluoride varnish is covered up to four (4) times per calendar year for
    members under the age of 21. These limitations apply across qualified providers, including
    dental providers. Qualified providers shall bill using CPT code 99188.
  • Federally Qualified Health Centers, Rural Health Centers, and Indian Health Services are to use
    these codes for encounter purposes; reimbursement for the visit will continue to be paid at the
    core rate for the practice

Private Medical Insurers

Billing Code: CPT 99188 with a modifier of 33
Reimbursement Rate: Amount will vary based on insurer.

  • Private insurers have to cover all level A and B recommendations of the US Preventive Service
    Task Force (UPPSTF)
  • Fluoride varnish by medical providers for children ages 6 months through 5 years (to the 6th
    birthday) is a Level B recommendation
  • If the provider is out of network the claim could be denied

Oral Evaluation
MaineCare
Billing codes: Children under 3 years of age D0145; MaineCare members over age 3 D0191
Reimbursement rate: D0145- $50.21; D0191- $14.55

  • MaineCare covers oral health risk assessments for members who do not have a dental home
    and/or have not seen a dentist in the past year.
  • The provider must:
    • Question about the existence of a current primary dentist/dental home;
    • Include risk screening questions based on oral health history;
    • Include assessment of mouth and teeth; and
    • Develop an oral health plan which, if needed, includes parent, legal guardian, and/or
      primary caregiver education about importance of establishing a primary dentist/dental
      home for the child, and provide a referral to a dentist (when possible
  • MaineCare will cover two (2) evaluations per calendar year across all qualified providers, but no
    more than once every 150 days. Additional information is available in MBM, Chapter III, Section
    25, Dental Services.

Private Medical Insurers

  • Currently there are no commercial insurers that reimburse for oral evaluation

Silver Diamine Fluoride (SDF)
MaineCare
Billing code: D1354
Reimbursement rate: D01354- $27.82/tooth

  • Medicament application is covered twice per tooth per year for members with a documented
    history of high caries. Medicament applications are not covered on teeth that have received
    restoration service in the last twelve (12) months.

Private Medical Insurers
Billing code: CPT 0792T
Reimbursement rate: Unknown if commercial insurers will reimburse for SDF

Updated February 2024