LIBERTY Dental Plan
Dental Care Services Information Sheet
1-866-609-0418 Toll Free
www.libertydentalplan.com/NVMedicaid
The Nevada Medicaid Dental Program covers dental services for:
• Children who are newborns through age 20.
• Children who are under age 19 and qualify for Nevada Check Up.
• Pregnant women who are age 21 or older.
• Adults with special needs who are age 21 or older.
Age Group Dental Benefits Medicaid Provisions
Value-Added
Benefits
Children, newborns
through age 20
Children, under age
19 and qualify for
Nevada Check Up
The Nevada Medicaid Dental Program covers
most dental services for children.
Some of the covered dental services for children
include:
• Regular checkups
• Teeth cleanings
• Fluoride treatment
• Sealants
• X-rays
• Fillings
• Root canals
• Crowns/Dentures
• Extractions
• Anesthesia
• Space maintainers
• Emergency dental care
Nevada Medicaid provides dental services for
most Medicaid-eligible individuals under the
age of 21 as a mandated service, a required
component of the Early and Periodic
Screening, Diagnosis and Treatment (EPSDT)
benefit.
Through the EPSDT benefits, individuals under
the age of 21 receive comprehensive dental
care such as periodic and routine dental
services needed for restoration of teeth,
prevention of oral disease and maintenance of
dental health. The EPSDT program assures
children receive the full range of necessary
dental services, including orthodontia when
medically necessary and pre-approved by the
Nevada Medicaid QIO-like vendor. The EPSDT
screening provider may refer children for
dental services. However, such a referral is not
necessary if the parent otherwise elects to
contact a Medicaid dental provider. The local
Medicaid District Office can direct the
parent/guardian to local dental providers.
• Carries Risk Assessment
• Additional Fluoride Varnish
application at PCP office
(D1206)
• Screening of a patient (D0190)
• Assessment of a patient
(D0191)
Age Group Dental Benefits Medicaid Provisions
Value-Added
Benefits
Pregnant women
age 21 or older
Some of the covered dental services for pregnant
women include:
• Regular checkups
• Teeth cleanings
• Fluoride treatments
• X-rays
• Fillings
• Periodontal maintenance
• Periodontal scaling and root planning
• Crowns/Dentures
• Extractions
• Anesthesia
Nevada Medicaid offers expanded dental
services in addition to the adult dental services
for Medicaid-eligible pregnant women. These
expanded pregnancy-related services require
prior authorization.
Medical providers or Managed Care
Organizations should provide a dental referral
when it is discovered that a recipient is
pregnant. Dental providers should attach a
copy of the referral or provide a statement of
pregnancy in the comment section of the ADA
claim form to any Prior Authorization (PA)
requests for pregnancy-related dental
services. Pregnancy-related dental services are
discontinued on the date of delivery. Except
for services that were authorized but not
completed prior to the end of the pregnancy.
Eligible Pregnant Women:
• Third and Fourth Adult
Prophylaxis for Pregnant
Women (D1110)
Adults with special
needs age 21 or
older
Adult Benefits -
Eligible Medicaid
adults 21 and over
Some of the covered dental services for adults
include:
• Oral evaluations for emergency
extractions or palliative care
• X-rays for emergency extractions or
palliative care
• Full mouth debridement
• Prosthetic care, including fillings and
crowns
• Extractions
• Anesthesia
For Medicaid-eligible adults age 21 years and
older, dental services are an optional service.
Dental services for Medicaid-eligible adults
who qualify for full Medicaid benefits receive
emergency extractions, palliative care and may
also be eligible to receive prosthetic care
(dentures/partials) under certain guidelines
and limitations.
Nevada Medicaid authorizes payment for
services provided in Intermediate Care
Facilities for Individuals with Intellectual
Disabilities and nursing facilities to qualified
recipients eligible with full Medicaid benefits.
• Periodic Oral Evaluation
(D0120)
• Adult Prophylaxis (D1110)
• Dental Bitewing Four Films
(D0274)
• Intraoral Periapical First
Film (D0220), Each
additional Film (D0230)
Recipients enrolled in the Nevada Medicaid Dental Program and eligible for services, you may or may not owe any payment.
• If you see a dentist who is a member of the Nevada Medicaid Dental Program network, you don’t have to pay for dental services that are covered by the
program.
• If you see a dentist who is not part of the Nevada Medicaid Dental Program network, you may have to pay for all the services.
Your dentist may need to get approval in advance for some services.
