Current through Register Vol. 63, No. 9, September 1, 2024
(1)
Health Services Division (Division) prior authorization (PA) requirements. For
fee-for-service (FFS) dental members, the following services require PA:
(a) Crowns (porcelain fused to
metal/porcelain ceramic);
(b) Crown
repair;
(c) Retreatment of previous
root canal therapy - anterior;
(d)
Complete dentures;
(e) Immediate
dentures;
(f) Partial
dentures;
(g) Prefabricated post
and core in addition to fixed partial denture retainer;
(h) Fixed partial denture repairs;
(i) Skin graft;
(j) Orthodontics (when covered pursuant to
OAR 410-123-1260).
(k) Hospital dentistry always requires PA,
regardless of the member's enrollment status. Refer to OAR
410-123-1490 for more
information;
(l) Oral surgical
services require PA when performed in an ambulatory surgical center (ASC) or an
outpatient or inpatient hospital setting and related anesthesia, and the
current Medical Surgical Services administrative rule OAR
410-130-0200 for
information;
(m) Maxillofacial
surgeries may require PA in some instances. Refer to the current Medical
Surgical Services OAR
410-130-0200, for
information.
(2) The
Division does not require PA for outpatient or inpatient services related to a
"Dental Emergency Condition" which means determination based on the presenting
symptoms (not the final diagnosis) as perceived by a prudent layperson (rather
than a Health Care Professional) and includes cases in which the absence of
immediate medical attention would not in fact have had the adverse results. The
member's clinical record shall document any appropriate clinical information
that supports the need for the hospitalization. Refer to Line 54 of the
Prioritized List of Health Services for funded emergency dental service
codes.
(3) How to request PA:
(a) Submit the request to the Division in
writing. Refer to the Dental Services Provider Guide for specific instructions
and forms to use. Telephone calls requesting PA will not be accepted;
(b) Documentation submitted when requesting
authorization shall support the medical justification for the service. The
authorization request shall contain:
(A) A
cover sheet detailing relevant provider and recipient Medicaid
numbers;
(B) Requested dates of
service;
(C) HCPCS or Current
Dental Terminology (CDT) Procedure code requested;
(D) Amount of service or units
requested;
(E) Any additional
clinical information supporting medical justification for the services
requested.
(c) Treatment
justification: The Division may request the treating dentist to submit
appropriate radiographs or other clinical information that justifies the
treatment:
(A) When radiographs are required,
they shall be:
(i) Readable copies;
(ii) Mounted or loose;
(iii) In an envelope, stapled to the PA
form;
(iv) Clearly labeled with the
dentist's name and address and the member's name; and
(v) If digital x-ray, they shall be of photo
quality.
(B) Do not
submit radiographs unless it is required by the Dental Services administrative
rules or they are requested during the PA process.
(4) The Division will issue a
decision on PA requests within 30 days of receipt of the request. The Division
will provide PA for services when:
(a) The
prognosis is favorable;
(b) The
treatment is practical;
(c) The
services are Dentally Appropriate; and
(d) A lesser-cost procedure would not achieve
the same ultimate results.
(5) PA does not guarantee member eligibility
or reimbursement. It is the responsibility of the provider to check the
member's eligibility on each date of service.
(6) For certain services and billings, the
Division will seek a general practice consultant or an oral surgery consultant
for professional review to determine if a PA will be approved. The Division
will deny PA if the consultant decides that the clinical information furnished
does not support the treatment of services.
(7) For hospital dentistry, refer to OAR
410-123-1490 for details
regarding PA requirements.
Statutory/Other Authority: ORS
413.042, ORS
414.065 &
414.707
Statutes/Other Implemented: ORS
414.065 &
414.707
