Mississippi Administrative Code
Title 23 - Division of Medicaid
Part 204 - Dental Services
Chapter 1 - General
Rule 23-204-1.6 - Prior Authorization
Universal Citation: MS Code of Rules 23-204-1.6
Current through September 24, 2024
A. The Division of Medicaid requires prior authorization, except for emergencies, from the Utilization Management/Quality Improvement Organization (UM/QIO) of the following dental services:
1. Surgical access
of an unerupted tooth,
2. Radical
resection of mandible with tooth bone graft,
3. Arthrotomy,
4. Complicated suture greater than five (5)
cm,
5. Osteoplasty - for
orthognathic deformities,
6.
Osteotomy - mandibular rami,
7.
Osteotomy - mandibular rami with bone graft, includes obtaining the
graft,
8. Osteotomy - segmented or
subapical - per sextant or quadrant,
9. Osteotomy - body of mandible,
10. Lefort I (maxilla - total),
11. Lefort I (maxilla - segmented),
12. Lefort II or Lefort III (osteoplasty of
facial bones for midface hypoplasia),
13. Repair of maxillofacial soft and hard
tissue defect,
14. Closure of
salivary fistula,
15.
Coronoidectomy,
16. All procedures
billed under unspecified dental procedure codes, and
17. The following types of analgesia and
sedation for dental office-based procedures:
a. Analgesia, anxiolysis, inhalation of
nitrous oxide,
b. Non-Intravenous
conscious sedation,
c. Deep
sedation/general anesthesia, and
d.
Intravenous conscious sedation/analgesia.
B. In the case of an emergency, documentation justifying the medical necessity for the urgent or emergency procedure must be provided to the UM/QIO to receive a Treatment Authorization Number (TAN) for billing purposes.
C. The prior authorization will apply only to those procedures on the treatment plan which were approved.
Miss. Code Ann. §§ 43-13-117, 43-13-121.
Disclaimer: These regulations may not be the most recent version. Mississippi may have more current or accurate information. We make no warranties or guarantees about the accuracy, completeness, or adequacy of the information contained on this site or the information linked to on the state site. Please check official sources.
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