Mandatory Prior Authorization Chart
New Jersey Dental Pediatric EHB
As of January 1, 2014
go to www.deltadentalnj.com for the current Mandatory Prior Authorization Chart
Dental Services / Documentation Requirements /Diagnostic and Preventive Services
1. Evaluations and/or prophylaxes and/or topical fluoride treatments for a Child with Special Health Care Needs if the service is being performed more often than once (1) per 6 months. Prior Authorization for these services is not required if the Patient has been recognized as a Child with Special Health Care Needs by a previous Prior Authorization during the preceding twelve (12) months. Delta Dental must be notified if there is a change in the Patient’s health that would no longer qualify them as a Child with Special Health Care Needs. Fluoride varnish for Patients under six (6) years of age will be paid no more than once (1) per 3-month period and is exempt from this Prior Authorization requirement.
/ Narrative2. Space maintainers if being requested for anterior teeth and/or permanent teeth.
/ Narrative3. Sealant replacement.
/ Narrative4. Radiographs exceeding the following limitations:
a. During any 12-month period for three years subsequent to a complete radiography series study more than four (4) intraoral films for a child up to age fourteen (14) and more than six (6) for a child fifteen (15) years or older.b. Complete radiograph series within three (3) years of a prior complete radiograph series. / Narrative
Restorative Services
5. Restorations and extractions involving primary cuspids and molars if the Patient is 10 years of age or older.
/ PA and/or PBW6. Restorations and extractions involving primary incisors if the Patient is 6 years of age or older.
/ PA and/or PBW7. Gold foils, inlays, onlays, crowns, post and cores, pins, copings, additional procedures to construct new crown under existing partial denture framework.
/ PA and/or FMX and/or PanoComplete missing tooth chart and photo if radiograph does not show need
8. Prefabricated resin crowns if the Patient is sixteen (16) years of age or older.
/ PA and/or FMX and/or PanoComplete missing tooth chart and photo if radiograph does not show need
9. Temporary crowns (for immediate protection of a fractured tooth) if the Patient is 16 years of age or older, and interim or provisional procedures of any type.
/ PA and/or FMX and/or PanoComplete missing tooth chart and photo if radiograph does not show need
Endodontic Services for other Than Emergency Dental Services
10. Pulpotomy, partial pulpotomy for apexogenesis
/ PA11. Treatment of Root Canal Obstruction, incomplete endodontic therapy (inoperable, unrestorable, or fractured tooth), internal repair of perforation
/ PA and Narrative12. Endodontic Therapy on primary and permanent teeth, endodontic retreatment, apexification, apicoectomy/periradicular services, hemisection, canal preparation and fitting of preformed dowel or post. / PA
13. Surgical procedure for isolation of tooth with rubber dam, unspecified endodontic procedure
/ NarrativePeriodontal Services
14. Gingivectomy, gingival flap procedure, osseous surgery,
/ PA and/or FMX and/or Pano Periodontal chartingNarrative (if more than two quadrants are to be performed on the same day)
15. Clinical crown lengthening – hard tissue,
/ PA16. Apically positioned flap, soft tissue grafts, distal or proximal wedge
/ Periodontal charting17. Bone replacement grafts, biologic materials to aid in soft and osseous tissue generation, guided tissue regeneration, surgical revision
/ PAPeriodontal charting
18. Periodontal scaling and root planning
/ Periodontal charting,Narrative (if more than two quadrants are to be performed on the same day)
19. Localized delivery of chemotherapeutic agents via a controlled release vehicle
/ PAPeriodontal charting post scaling and root planning and prior to D4381 placement
20. Full mouth debridment, unspecified periodontal procedure
/ NarrativeFixed and Removable Prosthodontics
21. Removable complete dentures
/ Radiographs as appropriateNarrative
22. Fixed and removable partial dentures, overdentures, precision attachments, pediatric fixed partial dentures, connector bars
/ FMX and/or PanoComplete missing tooth chart
Complete Treatment Plan
23. Repairs of any type (including crowns and fixed bridges), rebases and relines if being performed more than once (1) per twelve (12) month period, tissue conditioning, modification of a partial denture following implant surgery
/ NarrativeImplant Services
24. Surgical placement, abutment, crown, or prosthesis
/ PA and/or FMX and/or PanoComplete missing tooth chart
Complete Treatment Plan
Narrative
25. Implant Repairs
/ NarrativeOral Surgery Services
26. Extraction of an erupted tooth if:
· The tooth is restorable
· The tooth has no carious lesions, or
· The extraction would necessitate the insertion of a prosthesis
/ PA27. Surgical removal of erupted teeth and residual tooth roots (cutting procedure).
/ PA and/or Pano28. Removal of impacted teeth.
/ PA and/or PanoNarrative stating reasons for proposed removal
29. Removal of teeth and other oral surgical services for orthodontic purposes.
/ Approved prior authorization for orthodontic treatment plan30. Alveoloplasty, vestibulolasty
/ PA and/or FMX and/or Pano (if in conjunction with extractions)Narrative
31. Tori removal, removal of lateral exostosis, surgical reduction of osseous tuberosity frenulectomy, frenuloplasty, excision of hyperplastic tissue, and pericoronal gingiva
/ NarrativeMedically Necessary Orthodontic Services including continuation of transfer cases or cases started outside the program
/ See orthodontic policies and procedures (see pages 4 through 9)Adjunctive General Services
32. Anesthesia services, therapeutic drug injections, and other drugs.
/ Narrative33. Behavior management when exceeding the following thresholds based on place of service:
1. One unit equals 15 minutes of additional time:· Office or clinic - 2 units
· Inpatient/outpatient hospital - 4 units
· Skilled nursing/long term care - 2 units
/ Narrative34. Dental services to be rendered in a hospital or ambulatory surgical center (documentation must include the specific diagnosis and medical conditions that require admission to the hospital or ambulatory surgical center).
/ Narrative35. Occlusal guards, athletic mouthguards, application of desensitizing medicaments and resins, occlusal adjustment, odontoplasty, and internal bleaching.
/ Narrative36. Emergency services for other than treatment of chronic or acute pain.
/ Narrative37. Unspecified procedures.
/ NarrativeAdditional documentation requirements for New Jersey Dental Pediatric EHB
The following services are Not Covered under this Dental Benefits Program UNLESS they are not covered by the patient’s Medical Coverage (which must be substantiated by an explanation of benefits from medical plan stating that the service is not covered.
Extraoral, posterior-anterior or lateral skull and facial bone survey, cephalometric, and oral facial photographic (unless performed for orthodontic purposes), cone beam CT, maxillofacial MRI, maxillofacial ultrasound, sialography and sialoendoscopy images (capture, interpretation and post processing as applicable), tests and examinations, and oral pathology laboratory procedures.
Maxillofacial prosthetics, implant services, any oral surgical procedure not listed as requiring prior authorization, deep sedation/general anesthesia, intravenous conscious sedation/analgesia, non intravenous conscious sedation, behavior management, professional visits (other than house visits and office visits for observation during regular hours), drugs
New Jersey Pediatric Essential Health Benefit
Orthodontic Policy and Required Documentation Chart
Orthodontic treatment general policies
I. No benefits will be paid for orthodontic services unless they meet the following criteria:
1. They have received a Prior Authorization.
2. They are Medically Necessary Orthodontic Services.
3. Medical necessity must be met by demonstrating severe functional difficulties, developmental anomalies of facial bones and/or oral structures, facial trauma resulting in functional difficulties or documentation of a psychological/psychiatric diagnosis from a mental health provider that orthodontic treatment will improve the mental/psychological condition of the child.
o Orthodontic treatment requires prior authorization and is not considered for cosmetic purposes.
o Orthodontic consultation can be provided once annually as needed by the same provider.
o Orthodontic cases that require extraction of permanent teeth must be approved for orthodontic treatment prior to extractions being provided. The orthodontic approval should be submitted with a referral to the oral surgeon or dentist providing the extractions and extractions should not be provided without proof of approval for orthodontic service.
o Initiation of treatment should take into consideration time needed to treat the case to ensure treatment is completed prior to 19th birthday (when the child will no longer be covered under this plan).
o Periodic oral evaluation, preventive services and needed dental treatment must be provided prior to the initiation of orthodontic treatment.
o The placement of the appliance represents the treatment start date.
o Reimbursement includes placement and removal of appliance. Removal can be requested by report as a separate service for a dentist that did not start the case and requires prior authorization.
o Completion of treatment must be documented to include diagnostic photographs and panoramic radiograph/view of completed case and submitted when active treatment has ended and bands are removed. Date of service used is date of band removal.
II. Comprehensive treatment for handicapping malocclusions of the permanent dentition. Case must demonstrate medical necessity based on a score total equal to or greater than 26 on the HLD (NJ-Mod2) assessment form (accessible at [www.deltadentalnj.com]) with diagnostic tools substantiation or based on a total scores of less than 26 BUT with documented medical necessity.
III. Request for treatment must include diagnostic materials to demonstrate need; the form (accessible at [www.deltadentalnj.com]) and documentation that all needed dental preventive and restorative or other services have been completed.
IV. Approval for comprehensive treatment is for up to 12 visits at a time with request for continuation to include the previously mentioned documentation and most recent diagnostic tools to demonstrate progression of treatment.
DENTAL SERVICES / POLICIES AND PRIOR AUTHORIZATION & DOCUMENTATION REQUIREMENTS /Orthodontic “workup”
Submit with appropriate CDT diagnostic codes / Policy
· In addition to the services listed in Chapter 9 of this Participating Dentist Handbook, evaluation includes diagnostic workup, clinical evaluation, orthodontic treatment plan, consultation and completion of HLD (NJ-Mod2) assessment tool. Separate fees for these procedures are not chargeable to the Patient and will be DISALLOWED.
· Must be provided by the same dentist/dental office that will be providing treatment.
· Limited to once per dentist/dental office annually.
· Should occur with the expectation that treatment must be completed by the time the patient reaches the age of 19.
· Should occur with expectation that patient will score 26 points or more on the HLD (NJ-Mod2) assessment or meets one of the other qualifying conditions (see Orthodontics – General Policy, page 4)
Prior Authorization – Not Required
Documentation Requirements
· Part of submission for prior authorization of specific orthodontic treatment plan.
Limited orthodontic treatment
D8010 – D8040 / Policy
· Includes the appliance, appliance insertion, all adjustments, repairs, removal, retention, and treatment visits. Separate fees for these services are DISALLOWED.
· In many cases the total payment for limited orthodontic treatment is made at the start of treatment. If this is done you are responsible for completing treatment, even if eligibility has been terminated.
· Documentation supports one of the following qualifying conditions:
1. Severe functional difficulties;
2. Developmental anomalies of facial bones and/or oral structures;
3. Facial trauma resulting in severe functional difficulties and/or,
4. Demonstration that long term psychological health requires orthodontic correction.
· If service(s) is/are part of a comprehensive treatment plan, it/they will not be approved or reimbursed. Separate fees will be DISALLOWED.
· The approved treatment must be started within six (6) months of receiving the approval
Prior Authorization – Required
Documentation Requirements
1. Narrative of clinical findings, treatment plan and estimated treatment time;
2. Diagnostic x-rays or digital films;
3. Diagnostic photographs are required, including three facial photographs (profile, frontal, and smiling), and five intraoral photographs (frontal, right lateral, left lateral, and maxillary and mandibular occlusal);
4. In lieu of photographs, diagnostic study models, bite registration (will not be returned);
5. If part of a comprehensive treatment plan – submit comprehensive plan that indicates the limited treatment phase;
6. The primary care dentist must provide on letterhead attestation that all needed preventive restorative or other dental treatment services have been completed. A copy must be submitted with the orthodontic treatment request;
7. If applicable:
A. Medical diagnosis and surgical treatment plan.
B. Detailed documentation from a mental health professional indicating the psychological or psychiatric diagnosis, treatment history and prognosis and an attestation stating and substantiating that orthodontic correction will result in a favorable prognosis of the mental/psychological condition.
8. Upon completion of treatment pre-treatment and post-treatment diagnostic photographs must be submitted.
Interceptive orthodontic treatment
D8050 – D8060 / Policy
· Includes all appliances, injections, all adjustments, repairs, removal, retention, and treatment visits. Separate fees for these services will be DISALLOWED.
· If service(s) is/are part of a comprehensive treatment plan, it/they will not be approved or reimbursed. Separate fees will be DISALLOWED.
· Documentation supports one of the following conditions:
1. Severe functional difficulties;
2. Developmental anomalies of facial bones and/or oral structures;
3. Facial trauma resulting in severe functional difficulties and/or,
4. Demonstration that long term psychological health requires orthodontic correction.
Prior Authorization – Required
Documentation Requirements
· The documentation requirements are the same as stated below for comprehensive treatment.
· Upon completion of treatment pre-treatment and post-treatment diagnostic photographs must be submitted.
Minor treatment to control harmful habits
D8210 – D8220 / Policy
· If service(s) is/are part of a comprehensive treatment plan, it/they will not be approved or reimbursed. Separate fees will be DISALLOWED.
· Includes removable or fixed appliances, insertion, all adjustments, repairs, removal, retention and treatment visits. Separate fees for these procedures by the same dentist/dental office are DISALLOWED.
Prior Authorization – Required
Documentation Requirements
· Clinical findings
· Treatment plan including estimated treatment time and prognosis