How to Submit to Medicaid for Dental Work

Medicaid is a federally-funded health insurance program that offers low- or no-cost assistance to low-income households. While Medicaid predominantly covers emergency care, sick care and preventative care, eligible participants can seek partial or total reimbursement for other medical expenses not covered by the program. Dental care is one area not explicitly covered under Medicaid insurance, but participants may be able to recover some out-of-pocket expenses related to medically-necessary dental care by claiming it as an "Incurred Medical Expense." Note, however, that submitting a claim for dental work does not necessarily mean Medicaid will cover the expenses or even partially reimburse you.

Things You'll Need

• Form 1263 (Claim for Incurred Medical Expense)

Instructions

1. Obtain a new Form 1263 (Claim for Incurred Medical Expense) from your regional Medicaid agency, of ask your dental office for assistance if you are unsure of where to go. If your state Medicaid agency maintains online versions of claim forms through its website, you may be able to download and print the form, as well. Note that some state agencies may assign a different name and/or claim form number to the form.

2. Complete Form 1263 by providing your full name, physical address, Social Security number and Medicaid Participant Identification Number (MPIN, or "m-pin"). Enter the name, telephone number and address of the dentist's office where the work will be performed, along with the full name of the dentist who will be performing your treatment.

3. Provide the full amount of anticipated expenses you expect to incur as a result of receiving the treatment. Your dentist can provide you with this information. If you and/or your dentist are unsure of the exact amount, provide an approximation. Remember, you may be personally responsible for any amount exceeding Medicaid's approval, so it is imperative to provide the most accurate information.

4. Sign your completed Form 1263 when you are finished, then have your dentist (and, if applicable, your parent or guardian) sign in the appropriate spaces. Make a copy of the signed form and retain the copy for your personal records.

5. Contact the regional nurse at the Medicaid agency for your county or region to request the IME prior to having the dental work performed. Mail or personally deliver your original signed Form 1263, along with any other documents your Medicaid regional nurse requests. The sooner you submit all requisite documents, the faster Medicaid will be able to process your claim.

6. Undergo your planned dental treatment only after receiving written authorization from Medicaid. If your claim was denied or sent back requesting additional information, you must resubmit your Form 1263 and obtain authorization again before undergoing any planned treatments.

7. Contact both the dental office and your local Medicaid agency after 30 days to ensure Medicaid has remitted full payment for the treatment. If not, continue following up once a week and provide any additional documents or information Medicaid may request to finish processing the claim. Remember, you are responsible for any expenses Medicaid does not pay, so it is in your best interest to follow up and ensure you are not held liable for the bill.

Tips & Warnings

• Medicaid requires prior authorization on planned treatment care, which means you must obtain prior authorization before you undergo any uncovered medical or dental procedure for a condition that is not life-threatening.

References

• Center for Medicare & Medicaid Service
• Center for Medicare & Medicaid Service: Medicaid Dental Coverage Overview
• Center for Medicare & Medicaid Service: Medicaid Dental Policies
• Center for Medicare & Medicaid Service: CMS Forms
• Center for Medicare & Medicaid Service: Medicaid National Dental Contacts