MedicaidCoverageHigh impact
ForwardHealth Covers Dental Case Management for Members With Special Health Care Needs
Wisconsin Medicaid (ForwardHealth)·WI · Dentistry, Oral & Maxillofacial Surgery, Pediatrics·Medical Policy
Effective date
Oct 1, 2026
We identified it
Oct 3, 2026
Summary
Effective October 1, 2026, ForwardHealth (Wisconsin Medicaid) will cover dental case management services (CDT code D9997) for members with special health care needs at $100 per visit. Dental providers must obtain prior authorization for multiple visits within 180 days, billing with moderate-to-deep sedation, or when medical necessity cannot be documented with qualifying diagnoses. Claims require medical attestation from treating physicians and detailed clinical narratives.
Action Required
By October 1, 2026: (1) Billing team must update claim submission system to recognize CDT code D9997 and configure prior authorization requirements—PA is required for: multiple visits within 180 days per member per provider, D9997 billed with sedation codes D9222-D9225/D9239/D9243-D9247, non-qualifying diagnoses with medical necessity documentation, or POS code 15 (Mobile Unit). PA is NOT required for first visit per member per provider every 180 days or when D9997 is billed with D9230 (nitrous oxide only). (2) Verify billing software accepts ADA 2024 claim forms and ForwardHealth Portal electronic submission. (3) Dental providers and front desk must obtain signed medical attestations from treating physicians, nurse practitioners, or physician assistants dated within 12 months—attestations must confirm qualifying diagnosis and medical necessity. (4) Create encounter form template requiring clinical narrative documenting special accommodations/modifications and diagnosis justification. (5) Update charge capture to bill $100 flat rate per D9997 visit and coordinate correct POS codes (02, 05, 06, 07, 08, 10, 11, 31, 50, 54, 71 only—no other codes allowed). (6) Prepare Prior Authorization Dental Request Form (F-11035, 06/2024) and Prior Authorization/Dental Attachment 1 (F-11010, 01/2019) workflows for claims requiring PA. Consequence: Claims submitted without required PA, qualifying diagnosis documentation, or medical attestation will be denied; claims with D9997 billed with prohibited sedation codes without PA approval will be rejected.