Current through Vol. 42, No. 1, September 16, 2024
(a) Orthodontic
services are available for members who are SoonerCare-eligible and under
eighteen (18) years of age at the time the request for prior authorization for
treatment is received. In order to be eligible for SoonerCare orthodontic
services, members must be referred through an OHCA contracted primary care
dentist using the DEN-2 form found on the Oklahoma Health Care Authority (OHCA)
website; a member can receive a referral from a primary care dentist to the
orthodontist only after meeting the following:
(1) The member has had a caries free initial
visit; or
(2) Has all decayed areas
restored and has remained caries free for twelve 12 months; and
(3) Has demonstrated competency in
maintaining an appropriate level of oral hygiene.
(b) Member with cleft palate can be referred
directly by their treating physician without a dental referral and are exempt
from above requirements.
(c) The
SoonerCare Orthodontic Program limits orthodontic services to handicapping
malocclusions determined to be severe enough to warrant medically necessary
treatment. The orthodontic provider has the ability to determine if members may
qualify with a visual screening. Diagnostic record accumulation and/or
submission should only occur for members with high potential for acceptance.
These orthodontic services include the following:
(1) A handicapping malocclusion, as measured
on the Oklahoma Health Care Authority (OHCA) Handicapping Labio-Lingual
Deviation Index of Malocclusion (DEN-6) form, with a minimum score of thirty
(30);
(2) Any classification
secondary to cleft palate or other maxillofacial deformity;
(3) If a single tooth or anterior crossbite
is the only medical need finding, service will be limited to interceptive
treatment;
(4) Fixed appliances
only; and
(5) Permanent dentition
with the exception of cleft defects.
(d) Reimbursement for orthodontic services is
limited to:
(1) Orthodontists, or
(2) General or Pediatric dental practitioners
who have completed at least two-hundred (200) certified hours of continuing
education in the field of orthodontics practice and submit for review at least
twenty-five successfully completed comprehensive cases. Of these twenty-five
comprehensive cases, ten or more must be extraction cases. An applicant for
this certification must practice in an OHCA deemed under-served area. The
comprehensive cases submitted must be of a complexity consistent with type of
handicapping malocclusion likely to be treated in the SoonerCare program.
(A) Cases submitted must include at least one
(1) of each of the following types:
(i) Deep
overbite where multiple teeth are impinging upon the soft tissue of the
palate;
(ii) Impacted canine or
molar requiring surgical exposure;
(iii) Bilateral posterior crossbite requiring
fixed rapid palatal expansion; and
(iv) Skeletal class II or III requiring
orthognathic surgery.
(B)
As with all dental or orthodontia treatment performed and reimbursed by
SoonerCare, all pre and post orthodontic records must be available for
review.
(C) The OHCA requires all
general dentists providing comprehensive orthodontic care to submit a copy of
the Oklahoma Board of Dentistry continuing education report and verification
that at least twenty (20) continuing education hours in the field of
orthodontics has been completed per reporting period. All verification reports
must be submitted to OHCA Dental Unit every three (3) years, no later than
August 30. In addition, verification of adequate progress for all active
orthodontic cases will be reviewed by the OHCA Dental Unit upon completion of
twenty-four (24) months of therapy.
(e) The following limitations apply to
orthodontic services:
(1) Cosmetic
orthodontic services are not a covered benefit of the SoonerCare program and no
requests should be submitted;
(2)
All orthodontic procedures require prior authorization for payment;
(3) Prior authorization for orthodontic
treatment is not a notification of the member's eligibility and does not
guarantee payment. Payment for authorized services depends on the member's
eligibility at the beginning of each treatment year. Treatment year is
determined by date of banding; and
(4) The member must be SoonerCare-eligible
and under eighteen (18) years of age at the time the request for prior
authorization for treatment is received by the OHCA. Services cannot be added
or approved after eligibility has expired. It is the orthodontist's
responsibility to verify that the member has current SoonerCare eligibility and
the date of birth indicates the member is under age eighteen (18).
(f) Orthodontic services are an
elective procedure. The orthodontist must interview the prospective member as
to his/her understanding of and willingness to cooperate fully in a lengthy
treatment program.
(g) The
interview information is unavailable to OHCA except through the provider's
recommendation of treatment. The interview process for OHCA members is
equivalent to that of private pay patients.
(h) Providers are not obligated to accept a
member when it appears that the member will not cooperate in the orthodontic
hygiene treatment program, does not return to the general dentist for
preventive visits or is not willing to keep eligibility for SoonerCare
current.
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 601,
eff 11-21-95 (emergency); Amended at 13 Ok Reg 1645, eff 5-27-96 ; Amended at
16 Ok Reg 692, eff 12-31-98 (emergency); Amended at 16 Ok Reg 1429, eff
5-27-99 ; Amended at 18 Ok Reg 262, eff 11-21-00 (emergency); Amended at 18 Ok
Reg 1130, eff 5-11-01 ; Amended at 19 Ok Reg 334, eff 11-14-01 (emergency);
Amended at 19 Ok Reg 1067, eff 5-13-02 ; Amended at 22 Ok Reg 104, eff 7-6-04
(emergency); Amended at 21 Ok Reg 2492, eff 7-11-05 ; Amended at 23 Ok Reg
2489, eff 6-25-06 ; Amended at 27 Ok Reg 2765, eff 7-20-10 (emergency);
Amended at 28 Ok Reg 1419, eff 6-25-11 ; Amended at 30 Ok Reg 1177, eff
7-1-13
