Current through Vol. 42, No. 1, September 16, 2024
(a)
Prior authorizations.
Providers must have prior authorization for certain specified services before
delivery of that service, unless the service is provided on an emergency basis
[See Oklahoma Administrative Code (OAC)
317:30-5-695(d)(2)]
. Requests for dental services requiring prior authorization must be
accompanied by sufficient documentation.
(b)
Requests for prior
authorization. Requests for prior authorization, and any related
documents, must be submitted electronically through the OHCA secure provider
portal. Prior authorized services must be billed exactly as they appear on the
prior authorization. Payment is not made for any services provided prior to
receiving authorization except for the relief of pain.
(c)
Prosthodontic services.
Prosthodontic services provided to members who have become ineligible
mid-treatment are covered if the member was eligible for SoonerCare on the date
the final impressions were made.
(d)
Adults. Listed below are
examples of services requiring prior authorization for members twenty-one (21)
years of age and over/older. Minimum required records to be submitted with each
request are right and left mounted bitewings and periapical films or images of
tooth/teeth involved or the edentulous areas if not visible in the bitewings.
Images must be of diagnostic quality. Images must be identified by the tooth
number and include date of exposure, member name, member ID, provider name, and
provider ID. All images, regardless of the media, must be submitted together
with a completed and signed comprehensive treatment plan that details all
needed treatment at the time of examination, with the prior authorization
requesting all needed treatment. The images, digital media, and photographs
must be of sufficient type and quality to clearly demonstrate for the reviewer,
the pathology which is the basis for the authorization request. Documentation
of a periodontal evaluation with six (6) point measurements for teeth to remain
must be included with requests.
(1)
Removable prosthetics.(A) This
includes full and partial dentures.
(i) One
(1) per every five (5) years is available for adults under twenty-five (25)
years of age.
(ii) One (1) per
every seven (7) years is available for adults twenty-five (25) years of age and
over.
(iii) Provider is responsible
for any needed follow up for a period of two (2) years post
insertion.
(B) Partial
dentures are allowed for replacement of missing anterior permanent teeth or two
(2) or more missing posterior teeth in the same arch. Provider must indicate
which teeth will be replaced.
(2)
Periodontal scaling and root
planing. Procedure involves instrumentation of the crown and root
surfaces of the teeth to remove plaque and calculus from these surfaces. This
procedure requires that each tooth involved have three (3) or more of the
six-point measurements (probing pocket depths) equivalent to four (4)
millimeters or greater, and image supported alveolar bone loss. Image supported
subgingival calculus, and bleeding on probing, must be demonstrated on multiple
teeth for consideration of scaling and root planing. A minimum of two (2) teeth
per quadrant must be involved, with the appropriate CDT code usage for fewer
than four (4) teeth per quadrant. This procedure is not allowed in conjunction
with any other periodontal surgery. Four quadrants of scaling and root planing
will not be approved in conjunction with recent oral prophylaxis.
(3)
Scaling in the presence of
generalized moderate or severe gingival inflammation. Procedure is
designed for removal of plaque, calculus and stain from supra- and sub-gingival
tooth surfaces when there is generalized moderate or severe gingival
inflammation as indicated by generalized suprabony pockets and bleeding on
probing, in the absence of periodontitis (alveolar bone loss). Generalized
supra- and sub-gingival calculus, and moderate to severe inflammation must be
demonstrated, with probing pocket depths of five (5) mm or greater. This
procedure is intended for scaling of the entire mouth in lieu of oral
prophylaxis, and is only performed after a comprehensive evaluation has been
completed.
(e)
Children. Listed below are examples of services requiring prior
authorization for members under twenty-one (21)years of age. Minimum required
records to be submitted with each request are right and left mounted bitewings
and periapical films or images of tooth/teeth involved or the edentulous areas
if not visible in the bitewings. Images must be of diagnostic quality. Images
must be identified by the tooth number and include date of exposure, member
name, member ID, provider name, and provider ID. All images, regardless of the
media, must be submitted together with a completed and signed comprehensive
treatment plan that details all needed treatment at the time of examination,
and a completed prior authorization requesting all needed treatments. The
images, digital media, and photographs must be of sufficient quality to clearly
demonstrate for the reviewer, the pathology which is the basis for the
authorization request.
(1)
Endodontics. Root canal therapy is not considered an emergency
procedure unless due to trauma to an anterior tooth. The provider must document
the member's improved oral hygiene and flossing ability and submit it with the
prior authorization request to be considered when requesting endodontic therapy
for multiple teeth. Pulpal debridement may be performed for the relief of pain
while waiting for the decision from the Oklahoma Health Care Authority (OHCA)
on request for endodontics.
(A) Payment is
made for services provided in accordance with the following guidelines:
(i) Permanent teeth only;
(ii) Only ADA accepted materials are
acceptable under the OHCA policy;
(iii) Pre and post-operative periapical
images must be available for review;
(iv) Providers are responsible for any
follow-up treatment required by a failed endodontically treated tooth within
twenty-four (24) months post completion;
(v) A tooth will not be approved if it
appears there is not adequate natural tooth structure remaining to establish
good tooth/restorative margins or if crown to root ratio is poor. Approval of
second molars is contingent upon proof of medical necessity; and
(vi) An endodontic procedure may not be
approved if the tooth requires a post and core to retain a crown due to lack of
tooth structure.
(B)
Endodontics will not be considered if:
(i) An
opposing tooth has super erupted;
(ii) The tooth impinges upon space of
adjacent tooth space by one third or greater;
(iii) Fully restored tooth will not be in
functional occlusion with opposing tooth;
(iv) Opposing second molars are involved
unless prior authorized;
(v) The
member has multiple teeth failing due to previous inadequate root canal therapy
or follow-up.
(C) All
rampant, active caries must be removed prior to requesting
endodontics.
(D) Endodontically
treated teeth must be restored to limited occlusal function and all contours
must be replaced. Core build-up code is only available for use if other
restorative codes are not sufficient. These teeth will not be approved for a
crown if it appears the apex is not adequately sealed.
(2)
Crowns for permanent teeth.
Crowns are compensable for restoration of natural teeth for members who are
sixteen (16) through twenty (20) years of age. Certain criteria and limitations
apply.
(A) The following conditions must exist
for approval of this procedure:
(i) All
rampant, active caries must be removed prior to requesting any type of
crown;
(ii) The tooth must be
decayed to such an extent to prevent proper cuspal or incisal
function;
(iii) The clinical crown
is fractured or destroyed by one-half or more; and
(iv) Endodontically treated teeth must have
three (3) or more surfaces restored or lost due to carious activity to be
considered for a crown.
(B) The conditions listed above in (A)(i)
through (iv) must be clearly visible on the submitted images when a request is
made for any type of crown.
(C)
Routine build-up(s) for authorized crowns are included in the fee for the
crown.
(D) A crown will not be
approved if adequate tooth structure does not remain to establish cleanable
margins, there is invasion of the biologic width, poor crown to root ratio, or
the tooth appears to retain insufficient amounts of natural tooth structure.
Cast dowel cores are not allowed for molar or pre-molar teeth.
(E) Preformed post(s) and core build-up(s)
are not routinely provided with crowns for endodontically treated
teeth.
(F) Chart documentation must
include the OHCA caries risk assessment form demonstrating member is at a low
to moderate risk and be submitted with the prior authorization request for
crowns for permanent teeth.
(G)
Provider is responsible for replacement or repair of all crowns if failure is
caused by poor laboratory processes or procedure by provider for forty-eight
(48) months post insertion.
(3)
Partial dentures.
(A) This appliance is the treatment of choice
for replacement of missing anterior permanent teeth or two (2) or more missing
posterior teeth in the same arch for members sixteen (16) years of age and
older.
(B) Interim partial dentures
are available for children five (5) years of age and older.
(C) Provider must indicate which teeth will
be replaced.
(D) Members must have
improved oral hygiene documented for at least twelve (12) months in the
provider's records and submitted with prior authorization request to be
considered.
(E) Provider is
responsible for any needed follow up for a period of two (2) years post
insertion.
(F) This appliance
includes all necessary clasps and rests.
(4)
Occlusal guard. Narrative of
medical necessity must be sent with prior authorization.
(5)
Fixed cast non-precious metal or
porcelain/metal bridges. Only members seventeen (17) through twenty (20)
years of age will be considered for this treatment. Destruction of healthy
teeth to replace a single missing tooth is not considered medically necessary.
Members must have excellent oral hygiene documented for at least eighteen (18)
months in the requesting provider's records and submitted with prior
authorization request to be considered. Provider is responsible for any needed
follow up until member loses eligibility.
(6)
Periodontal scaling and root
planing. Procedure involves instrumentation of the crown and root
surfaces of the teeth to remove plaque and calculus from these surfaces. This
procedure requires that each tooth involved have three (3) or more of the
six-point measurements (probing pocket depths) equivalent to four (4)
millimeters or greater, and image supported alveolar bone loss. Image supported
subgingival calculus, and bleeding on probing, must be demonstrated on multiple
teeth for consideration of scaling and root planing. A minimum of two (2) teeth
per quadrant must be involved, with the appropriate CDT code usage for fewer
than four (4) teeth per quadrant. This procedure is not allowed in conjunction
with any other periodontal surgery. Four quadrants of scaling and root planing
will not be approved in conjunction with recent oral prophylaxis.
(7)
Scaling in the presence of
generalized moderate or severe gingival inflammation. Procedure is
designed for removal of plaque, calculus and stain from supra- and sub-gingival
tooth surfaces when there is generalized moderate or severe gingival
inflammation as indicated by generalized suprabony pockets and bleeding on
probing, in the absence of periodontitis (alveolar bone loss). Generalized
supra- and sub-gingival calculus, and moderate to severe inflammation must be
demonstrated, with probing pocket depths of five (5) mm or greater. This
procedure is intended for scaling of the entire mouth in lieu of oral
prophylaxis, and is only performed after a comprehensive evaluation has been
completed.
Added at 12 Ok Reg
751, eff 1-5-95 through 7-14-95 (emergency); Added at 12 Ok Reg 3131, eff
7-27-95; Amended at 13 Ok Reg 899, eff 8-1-95 (emergency); Amended at 13 Ok Reg
1645, eff 5-27-96; Amended at 15 Ok Reg 3822, eff 6-24-98 (emergency); Amended
at 16 Ok Reg 692, eff 12-31-98 (emergency); Amended at 16 Ok Reg 1429, eff
5-27-99; Amended at 23 Ok Reg 2489, eff 6-25-06; Amended at 24 Ok Reg 660, eff
2-1-07 (emergency); Amended at 24 Ok Reg 2088, eff 6-25-07; Amended at 25 Ok
Reg 2759, eff 5-1-08 (emergency); Amended at 26 Ok Reg 530, eff 2-1-09
(emergency); Amended at 26 Ok Reg 2121, eff 6-25-09; Amended at 28 Ok Reg 1419,
eff 6-25-11; Amended at 29 Ok Reg 1107, eff
6-25-12
