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Serving Wyoming Medicaid Providers



Dental General Manual, Covered Services and Bulletins


Dental Manuals

Dental Manual
Dental Fee Schedule

To search for specific information within the PDF document, select Ctrl F on your keyboard and type your keyword in the find box.


Important Dental Information

12/17/14 - Updated Section on page 10-18 to include additional information regarding D8660
11/17/14 - Updated all claim form information to reflect the new 2012 ADA Claim Form
10/14/14 -  Updated Section 10.2.2 Information on code D0376
9/1/14 - Updated Section 6.7 (LOA), updated Section 10..2.21 to reflect the new Malocclusion Program Changes, added new forms (Referral Under 12 and Malocclusion Treat ment Request) Section and
7/1/14 - Added D0367 to Section 10.2.2, added D0191 to Section 11.2.1, Added D4355 Section 11.2.5
4/1/14 - Removed Note in Section 10.1.14
3/17/14 - Added sentance regarding D4910 in Section 10.2.9
3/1/14 - Added FQHC Section 10.1.7, Added codes to section 10.2.11
2/14/14 - Added Code D7941 to Section 10.2.13
2/4/14 - Added wording to Section 10.2.9

July 1, 2014 Changes

Effective July 1, 2014 and foward, Wyoming Medicaid will be accepting new dental codes.  Information regarding these new codes, billing for deliverable items, Letter of Agreements (LOAs) was sent out in a provider bulletin via email.




The Wyoming Medicaid Dental Program will be implementing the following changes October 1,2013.

* D1110 - Adult Prophylaxis - Pregnant clients and developmentally disabled clients over the age of 21 may now have 2 cleanings per year.
* D6010-D6199, D6205-D6985 - Implant services and fixed prosthesis - The criteria for these services has been revised.

For complete details on these changes review the "Dental Program Changes 10.1.13" Document link below or contact Dental Services at 1-888-863-5806.

Dental Program Changes 10.1.13


Providers billing D9230, Nitrous Oxide, will experience a slight delay in reimbursement. This delay is due to system updates that are in process to ensure claims are processed and paid according to the revised policy. Providers may submit claims for payment and these claims will be held and released for payment when the system is approved, the anticipated completion is the first week of September. Providers may also elect to submit their claims after the system is approved.


Nitrous Oxide is a covered benefit for all clients 0-9, and then for those clients that are eligible for the DDCW, DDAW, or ABIW benefit plan when the client exhibits behaviors that require additional support to complete extractions or restorative treatment safely for any age (0-999).

Dental Program Changes 8.1.2013

The Wyoming Medicaid Dental program will be implementing changes to the program effective August 1, 2013.
* Medicaid is introducing the 1+1 baby and toddler dental program to encourage parents and dentists to begin dental visits at age 1. Providers will be reimbursed for additional codes for these younger clients.
* Nitrous Oxide could be a covered benefit for clients who are receiving restorative services and/or extractions. Nitrous Oxide is for any clients under 10 years old OR disabled clients of any age who are on either the DDAW or DDCW benefit plan.
* Endodontics will no longer be a covered services for adults (ages 21 older).
* Panoramic or Full Mouth Series xrays will be allowed once per 5 years.
For complete details regarding these changes review the above link Dental Program Changes 8.1.13 or contact Dental Services at 1-888-863-5806.

Dental Bulletins and Forms

2012 ADA Dental Claim Form Mandate 11.26.14
Re-Enrollment Reminder Email 10.10.14
Policy Change for Root Canal/Crowns 9.16.14
Orthodontic Parent Handout-Spanish Version
Web Portal Billing for Dentists 8.26.14
Severe Malocclusion 8.26.14
Orthodontic Referral Updates for all Dentists 8.15.14
Othodontic Updates for Orthodontic Providers 8.15.14
Malocclusion Treatment Request Form
Malocclusion Referral Form for Clients under 12
July 1, 2014 Dental Program Changes
Client Acceptance Form Reminder
On-line/Web Re-enrollment 5.1.14
Wyoming Medicaid ICD-10 Information
2nd Qtr 2014 Health Check Newsletter
Sample ADA Dental Claim Form
Tooth Replacement Request Form 10.1.13
Medicaid and Kid Care Application Changes 9.10.13
Dental Program Changes 10.1.13
Dental Nitrous Oxide Update 8.7.13
1+1 Dental Program
PDAP Oxygen Termination 7.1.13
Dental Program Changes Email
Dental Program Changes 8.1.2013
Revised Dental Client Accpetance Notice
Recovery Audit Contractor Information and Training Opportunities 5.10.13
Important Dental Enrollment Policy 2.19.13
Dental CDT Code Changes 1.7.13
Wyoming Medicaid Fraud/Program Integrity Information
Orthodontic Parent Handout - Updated 8.19.14
Wyoming Medicaid Dental Training Presentation
Crippling Malocclusion Program Criteria Presentation
Dental Provider Client Acceptance FormUpdated
Letter of Agreement
Revised Medicaid Policies

Additional Links

Medicaid and State Healthcare Benefit Plans: Provides client benefit plan names, descriptions, eligibility limitations, coverage types and coverage limitations. This information is useful when determining if a client is eligible for services.
Carrier Code List: List of Insurance Carrier Codes and Names