New Jersey Administrative Code
Title 10 - HUMAN SERVICES
Chapter 56 - MANUAL FOR DENTAL SERVICES
Subchapter 2 - PROVISIONS FOR SERVICES
Section 10:56-2.13 - Prosthodontic services

i. Age, school status, employment status and rehabilitative potential of the beneficiary (for example, provision of dentures will enhance vocational placement);

ii. Medical status of beneficiary (nature and severity of disease or impairment) and psychological predisposition;

iii. Condition of the oral cavity, including abnormal soft tissue or osseous conditions;

iv. Condition of present dentures, if applicable.

i. Should the provider initiate the denture treatment (that is, take final impressions) prior to the expiration of the three month healing period, the dentist shall be responsible for all subsequent relines, rebases and/or remaking of the denture(s) if necessary for a six month period following insertion.

ii. When all services are to be performed by the same practitioner, the total treatment plan for the extractions, denture(s) and any other dental services shall be submitted and will be reviewed for prior authorization in toto. As soon as the extractions are completed, the claim should be submitted for payment for the diagnostic and/or surgical services. After the required period of time for healing has taken place and the denture provided, a second claim should be completed (for the dentures only) and submitted to the fiscal agent marked "continuation of previously authorized treatment plan."

i. The fee for immediate dentures shall include the necessary adjustments and relines for a six month period following insertion.

i. Dental history reveals that any or all dentures made in recent years have been unsatisfactory for reasons that are not remedial because of physiological or psychological reasons; or

ii. Dental history reveals that a denture was provided through any New Jersey State, county, or municipal agency in the seven and one-half year period prior to the date of the current request; or

iii. Repair, relining, or rebasing (jumping) of the beneficiary's present denture will make it serviceable.

i. Rebasing is the process of refitting a denture by the complete replacement of the denture base material without changing the occlusal relationship of the teeth.

ii. Relining is the process of resurfacing the tissue side of a denture with new base material to make it fit more accurately.

iii. The fee for relining and rebasing shall include all necessary adjustments for a six month period following insertion.

iv. Adjustments prior to and in conjunction with denture relining, rebasing (jumping) and repair shall not be reimbursable. Adjustments, repairs, relining, and rebasing shall not be reimbursable when new or replacement dentures have been prior authorized.

v. Rebases and relines shall not be reimbursable within 12 months of initial insertion of a denture without prior authorization, and shall thereafter be limited to once every 12 months without prior authorization.

vi. The beneficiary's name (first and last names or, where space is a limiting factor, first initial and last name) must be processed into all dentures during the original fabrication or where possible during any subsequent processing, such as repair, relining and rebasing. The social security number shall also be included if space permits. This requirement is consistent with the "Denture I.D. Law" (45:6-19.1 et seq.) and 13:30-8.11.