Medicaid and Medicare Dental Billing: What Dental Offices Need to Know

Medicaid dental billing is run by each state, which must cover dental care for children through the EPSDT benefit but decides for itself what adult dental care to cover. Medicare dental billing is far narrower: Original Medicare generally excludes dental care, paying only in limited cases tied to other covered treatment. Many Medicare Advantage plans add their own dental benefits.

Because the two programs work so differently, dental offices that see Medicaid or Medicare patients need separate rules, separate verification steps and often separate enrollment. This guide explains the basics. Program details change, so confirm current rules with your state Medicaid agency and with CMS at cms.gov before you rely on them.

How does Medicaid dental billing work?

Medicaid is jointly funded by the federal government and the states, and each state runs its own program within federal rules. For dental offices, that means the rules you follow depend on where you practice. Key questions to answer for your state:

• Who administers dental benefits? Some states pay dental claims directly through the state Medicaid agency or its fiscal agent. Many contract with dental managed care organizations or dental benefit administrators, each with its own enrollment, portal and claim rules.
• What is covered for adults? Adult dental coverage is optional for states. Some cover only emergency care, some cover a limited set of services, and some offer more extensive benefits.
• What needs prior authorization? Many programs require authorization for services such as crowns, dentures, periodontal treatment, orthodontics and treatment under general anesthesia.
• What are the frequency limits and fee schedules? Medicaid fee schedules are set by the state or the plan, and providers generally must accept the Medicaid payment as payment in full for covered services.

Providers must enroll with the state Medicaid program, and often separately with each managed care plan, before they can be paid. If you are adding Medicaid plans, our dental credentialing team can help organize those applications.

What is EPSDT dental coverage for children?

The Early and Periodic Screening, Diagnostic, and Treatment (EPSDT) benefit is Medicaid’s comprehensive benefit for enrollees under age 21. Under federal rules, Medicaid must cover dental services for children, including at a minimum relief of pain and infections, restoration of teeth and maintenance of dental health. States set periodicity schedules for dental visits, and necessary treatment found during a screening must be covered even if it is not otherwise listed in the state plan.

The Children’s Health Insurance Program (CHIP) also includes dental coverage. States that run CHIP as part of Medicaid follow EPSDT rules, while separate CHIP programs must still cover dental services that prevent disease, promote oral health, restore oral structures and treat emergencies. For pediatric offices, verifying which program and which plan a child belongs to is the first step on every visit. Our page on pediatric dental billing covers more of this workflow.

What makes Medicaid dental claims get denied?

• Eligibility that lapsed or changed plans between the appointment and the date of service.
• Missing or expired prior authorization.
• Services over the program’s frequency limits.
• Rendering providers who are not individually enrolled.
• Missing attachments such as radiographs or charting.
• Claims sent to the state when the patient is in a managed care plan, or the reverse.

Checking eligibility on the day of service, not only when the appointment is booked, prevents many of these. Medicaid eligibility can change month to month.

Does Medicare cover dental care?

Generally no. The Medicare statute excludes most dental services, such as routine cleanings, fillings, extractions and dentures. CMS does pay for dental services in a limited number of situations where the dental care is inextricably linked to, and clinically necessary for, another Medicare-covered service. Examples CMS lists include dental exams and treatment needed before an organ transplant, cardiac valve replacement or valvuloplasty, certain cancer treatments, and dialysis for end-stage renal disease, as well as some services related to jaw fractures and reconstruction after tumor removal.

CMS has added to this list through its recent annual payment rules, so it is worth checking the CMS Medicare dental coverage page each year.

How are Medicare-covered dental services billed?

When a dental service qualifies, CMS expects the dental claim to show that link to the other covered service. As of July 1, 2025, CMS requires the KX modifier on claims for dental services that the clinician believes are inextricably linked to other covered services, and requires a diagnosis code on the dental claim (the 837D or the ADA claim form) for these services. The dentist must be enrolled in Medicare to bill, and the dental record should clearly explain why the dental work was needed for the related treatment.

What about Medicare Advantage dental benefits?

Medicare Advantage (Part C) plans are offered by private insurers and many include supplemental dental benefits that go beyond Original Medicare. These benefits vary widely: some cover only preventive care, others cover basic and major services, and many have annual maximums. The benefit may be administered by a separate dental carrier with its own network, claim address and payer ID.

For billing, treat Medicare Advantage dental benefits like a commercial dental plan whose rules you must verify individually. Confirm the dental administrator, network status, covered services, frequencies and maximum at each visit. Our dental insurance verification service is designed to capture these details before the appointment.

What about patients who have both Medicare and Medicaid?

Some patients are dually eligible. Medicaid is generally the payer of last resort, so when Medicare or a Medicare Advantage plan covers a service, it pays first. Some states cover dental services for dually eligible people through Medicaid or through integrated plans. These cases need careful verification of which plan is primary for each service.

How do government program claims differ from commercial dental claims?

The claim form is usually the same, but the surrounding rules are stricter. Medicaid programs and their managed care plans often require that every rendering dentist, not only the practice, is enrolled and linked to the billing entity. Many require authorization numbers on the claim itself, and some will not pay for a service at all if the authorization was obtained after treatment began. Filing limits can be shorter than commercial plans, and corrected claims often follow a specific replacement or void process.

Patient financial rules also differ. When a patient has Medicaid and the service is covered, the office generally cannot bill the patient for the difference between its fee and the Medicaid payment. If a service is not covered, many states have rules about informing the patient in advance and documenting their agreement to pay. Medicare dental services that are not inextricably linked to covered care are simply not Medicare benefits, but documenting that clearly for the patient still prevents confusion. Train front desk staff on these differences, because the patient conversation usually happens before the billing team sees the claim.

How should a dental office organize government program billing?

• Keep a short reference sheet for each program and plan you accept: enrollment status, claim address or payer ID, authorization rules and frequency limits.
• Verify eligibility at scheduling and again on the day of service.
• Track authorizations with their expiration dates.
• Review denials by program each month to spot repeated problems.
• Watch for program bulletins and fee schedule updates from your state and from CMS.

Government program claims tend to have strict filing limits and detailed attachment rules. A consistent dental claims processing routine and timely follow-up on dental accounts receivable help keep them from aging out.

Want a second look at your Medicaid or Medicare dental claims?

If government program claims are a growing share of your dental practice, set up a free consultation. We can go over your current programs, authorization tracking and recent denials with you and talk about how a steadier verification and follow-up routine could work in your office.