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Pennsylvania Medicaid (DHS)Medicaid · Prior Auth · Provider Bulletin · PA · Dentistry, Oral & Maxillofacial SurgeryMedium impact

MAB2022090701

Effective date
Aug 29, 2022
Identified
Jun 20, 2026

Summary

Effective for dates of service on and after August 29, 2022, the Pennsylvania Medical Assistance dental fee schedule added procedure codes D3921, D9947, D9948 and D9949, and added D4346 for scaling in the presence of generalized moderate or severe gingival inflammation. The age limit for D1208 was revised to include beneficiaries under the age of 21. Prior authorization is now required for D3310, D3320 and D3330, and tooth numbers must now be reported for D1354, D5630 and D5660.

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What to do

Action · 7 steps
01Already effective August 29, 2022: Dentists bill Medical Assistance fee-for-service claims using the MA Program Dental Fee Schedule.
02Bill D3921, D9947, D9948 and D9949 under the fee schedule, and bill D4346 only in combination with routine prophylaxis and/or periodontal maintenance (D1110, D1120, D4910, D4346) totaling 3 per year.
03Before billing D3310, D3320 or D3330, get prior authorization, and submit it with a full mouth periapical or a panorex and current radiograph(s) of the affected area(s).
04For D4355, secure post-operative review approval through the prior authorization program, and make sure the procedure name and procedure code match and accurately describe the requested service.
05Report tooth numbers on claims for D1354, D5630 and D5660.
06Do not report tooth numbers for D7450 and D7451.
07Check current applicability of these requirements before acting, because the source is dated 2022.

Codes mentioned

D1208D1354D3310D3320D3330D3921D4346D4355D5630D5660D7450D7451D9947D9948D9949

Original notice

MAB2022090701
pa.gov · Always check the source before changing claims.
View original ↗

Related changes

See all Pennsylvania Medicaid (DHS) changes →
mab2025091101HighEffective Aug 1, 2025 · Provider BulletinMAB2022082602MediumEffective Aug 29, 2022 · Provider BulletinMedical Assistance Program Dental Fee Schedule and Dental Provider Handbook Update MAB 27-19-17MediumEffective Aug 19, 2019 · ReimbursementMAB2023083101MediumEffective Sep 5, 2023 · Provider BulletinBrowse every Pennsylvania Medicaid (DHS) change in the policy list

Related policy hubs

Pennsylvania Medicaid (DHS) policiesPA policy changesDentistryOral & Maxillofacial SurgeryCode D1208Code D1354Code D3310Code D3320Code D3330Code D3921Code D4346Code D4355Code D5630Code D5660Code D7450Code D7451Code D9947Code D9948Code D9949

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