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Dental Managed Care Differential Payment for IHS-MOA Facilities

September 24, 2018

Effective for dates of service on or after January 1, 2018, Indian Health Services – Memorandum of Agreement (IHS-MOA) 638, Clinics facilities that submit all-inclusive, per-visit code 03 (dental services) claims for Medi-Cal recipients enrolled in a Dental Managed Care Plan (Sacramento and Los Angeles counties only) must list the Dental Managed Care Plan as a payer in Boxes 50 – 55 on the UB-04 claim form.

Updated manual pages reflecting this policy will be released in a future Medi-Cal Update.