Current through Register Vol. 51, No. 19, September 20, 2024
A.
Preauthorization is issued when:
(1) Program
procedures are met;
(2) Program
limitations are met;
(3) The
provider submits to the Department, adequate documentation demonstrating that
the service to be preauthorized is medically necessary; and
(4) The participant is eligible for the
service.
B.
Preauthorization is required for the following:
(1) Resin fused to metal crown;
(2) Porcelain fused to metal crown;
(3) Nonprecious metal crown (full
cast);
(4) Apicoectomies and
periradicular services;
(5) Certain
periodontal services;
(6) Complete
upper/lower denture;
(7) Partial
upper/lower denture (including clasps and teeth);
(8) Any elective clinical or surgical
procedure not listed on the current dental fee schedule;
(9) Surgery normally considered cosmetic but
qualified by traumatic or pathological causation;
(10) Laboratory rebasing of
dentures;
(11) Addition of teeth or
clasps to an existing, functional complete or partial denture;
(12) General restorative treatment to be
rendered in a hospital;
(13)
Special periodontal appliances;
(14) Apexification and recalcification
procedures;
(15) Hemisection,
including any root removal, including endodontic therapy;
(16) Overdenture complete;
(17) Overdenture partial;
(18) Condylectomy;
(19) Meniscectomy;
(20) Arthrotomy; and
(21) All orthodontic procedures.
C. At a minimum, the documentation
required when requesting preauthorization for the following services is:
(1) A complete radiographic survey of the
mouth for:
(a) Complete or partial dentures;
or
(b) Except in the case of
special needs children, where sedation would be required for a complete
radiograph of the mouth, special periodontal appliances and periodontal
therapies;
(2)
Individual periapical radiographs for:
(a)
Except in the case of special needs children, where sedation would be required
for an individual periapical radiograph or bitewing, endodontic therapy
(periapicals and bitewings shall be submitted when the request is for posterior
teeth);
(b) Apicoectomy;
(c) Except in the case of special needs
children, where sedation would be required for an individual periapical
radiograph, periradicular and apexification or recalcification services;
and
(d) Full coverage permanent
crown restorations (excludes stainless steel and provisional resin crowns);
and
(3) Full mouth
radiographs and a periodontal chart, identifying the depths and locations of
the pockets, when periodontal services are requested.
D. Except as described in §F of this
regulation, preauthorization is valid for dental services when the services are
approved and completed within 6 months after the date of the receipt of the
preauthorization number from the Program.
E. Preauthorization normally required by the
Program is waived when the services are covered and approved by Medicare.
However, if the entire or any part of a claim is rejected by Medicare, and the
claim is referred to the Program for payment, payment will be made for services
covered by the Program only if authorization for those services has been
obtained before billing. Non-Medicare claims require preauthorization according
to §§A-D of this regulation.
F. Preauthorization for Orthodontic
Treatment.
(1) Preauthorization is required
for traditional comprehensive orthodontic services treatment and for
self-ligating braces for the correction of medically necessary conditions,
which cause dysfunction due to a handicapping malocclusion. At a minimum the
following comprehensive pretreatment documentation shall be submitted:
(a) Cephalometric head film with
analysis;
(b) Panoramic or full
series of periapical radiographs;
(c) 6-8 diagnostic quality extra-oral and intra-oral
photographs;
(d) Clinical summary
with diagnosis;
(e) HLD score
sheets from attending orthodontist; and
(f) Treatment plan.
(2) Preauthorization for periodic orthodontic
treatment is valid for:
(a) 24 months for
traditional comprehensive orthodontic treatment; or
(b) 12 months for self-ligating
braces.
