Dental Program

When completing and submitting a paper ADA Dental Claim form, dental providers should complete Field 23 with the participant’s MO HealthNet number exactly as shown on the participant's ID card. Anything other than the participant’s DCN, or leaving the field blank, will cause the claim to deny.

Correct Address for Mailing Paper Dental Claim Forms

MO HealthNet dental providers submitting paper dental claim forms for MO HealthNet fee-for-service participants, must mail claims to:

Wipro Infocrossing
P.O. Box 5600
Jefferson City, MO 65102

Paper claims sent to any other address will not be processed for payment. For additional information, reference Section 15.7 of the Dental Manual at http://manuals.momed.com/manuals/(link is external).

Fluoride Varnish During Well Child Check

Fluoride varnish is a covered service for participants age five and under, when the need is identified through an Early Periodic Screening, Diagnostic, and Treatment (EPSDT) visit. Fluoride varnish may be applied by physicians and nurse practitioners along with other medical professionals (RN, LPN, Physician Assistant) working in a physician’s office or clinic.Fluoride treatment is limited to 1 application of stannous fluoride, acid-phosphate fluoride or fluoride varnish per participant, 2 times per rolling year, per provider.

Dental Billing Tips

Dental Examination:

  • D0120 – Periodic Oral Evaluation
    • Not included in the Adult Dental Limited Package
    • Would require a letter of medical necessity from the patient’s primary care provider The medical necessity must meet MO HealthNet policy in Section 13 of the Dental Manual.
  • D0140 – Limited Oral Evaluation Problem Focused
    •  Code could be used with appropriate documentation of the problem.
  • D0150 - Compr
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