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 - Orthodontic services
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. 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:
(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:
(d) Reimbursement for orthodontic services is limited to:
(e) The following limitations apply to orthodontic services:
(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