Oklahoma Administrative Code
Title 317 - Oklahoma Health Care Authority
Chapter 30 - Medical Providers-Fee for Service
Subchapter 5 - Individual Providers and Specialties
Part 79 - DENTISTS
Section 317:30-5-700.1 - Orthodontic prior authorization
Current through Vol. 41, No. 20, July 1, 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, per Oklahoma Administrative Code 317:30-5-700. The following records and documentation, plainly labeled with the member's full name, recipient identification number (RID), and the orthodontist's name are required for prior authorization of orthodontic services and must be submitted to the Dental Unit of the Oklahoma Health Care Authority (OHCA) Dental Program when the member has a total score of not less than thirty (30) points or meets other eligibility criteria in paragraph (d).
(b) All images and required documentation must be submitted in one (1) package. OHCA is not responsible for lost or damaged materials.
(c) All records and documentation submitted in a request for prior authorization for orthodontic treatment are reviewed by the OHCA orthodontic consultant for compensability and length of treatment. Any documentation on which a decision is made will not be returned.
(d) Some children not receiving a minimum score of thirty (30) on the HDL Index may have other conditions to be considered. In the event an orthodontist believes there are other medical, social, or emotional conditions impacting the general health of the child, he/she refers to the conditions listed on the Early and Periodic Screening, Diagnostic and Treatment (EPSDT) exception section found on the HLD. The following guidelines and restrictions apply to other conditions:
(e) If it is determined that the malocclusion is not severe enough to warrant medically necessary orthodontic services or the member's age precludes approval, a computer generated notice is issued to the provider and member with notice of the denial, the reason for the denial, and appeal rights [see Oklahoma Administrative Code (OAC) 317:2-1 for grievance procedures and processes].
(f) Orthodontic treatment and payment for the services are approved within the scope of the SoonerCare program. If orthodontic treatment is approved, a computer generated notice is issued authorizing the first year of treatment.
(g) If the member moves from the geographic area or shows a need to change their provider, then the provider who received the yearly payment is financially responsible until completion of that member's orthodontic treatment for the current year.
(h) If the provider who received yearly payment does not agree to be financially responsible, then the OHCA may recoup funds paid for the member's orthodontic treatment.
(i) All orthodontic services are subject to post-utilization review. This review may include a request by the OHCA to submit medical documentation necessary to complete the review. After review is completed, these materials are returned to the orthodontist.
(j) Electronic images of casts and/or oral/facial images may be requested by OHCA or representatives of OHCA. Providers will be reimbursed for either the study model or images when obtained for orthodontic evaluation and/or therapy.
Added at 13 Ok Reg 1645, eff 5-27-96; Amended at 13 Ok Reg 3585, eff 7-16-96 (emergency); Amended at 14 Ok Reg 1780, eff 5-27-97; Amended at 15 Ok Reg 542, eff 11-5-97 (emergency); Amended at 15 Ok Reg 1528, eff 5-11-98; Amended at 15 Ok Reg 3822, eff 6-24-98 (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 20 Ok Reg 521, eff 1-6-03 (emergency); Amended at 20 Ok Reg 1216, eff 5-27-03; 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