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Dental
14.1 Enrollment 14-3
14.2 Benefits and Limitations 14-3
14.2.1 Prior Authorization Requirements 14-3
14.2.2 Diagnostic Services 14-4
14.2.2.1 Prior Authorization Requirements 14-4
14.2.2.2 Clinical Oral Evaluations 14-4
14.2.2.3 First Dental Home 14-4
14.2.2.4 Radiographs or Diagnostic Imaging 14-5
14.2.2.5 Tests and Oral Pathology Procedures 14-6
14.2.3 Orthodontia Services 14-6
14.2.3.1 Prior Authorization Requirements 14-7
14.2.3.2 Required Documentation 14-7
14.2.3.3 Submitting Local Codes for Orthodontic Procedures 14-8
14.2.4 Preventive Services 14-11
14.2.4.1 Authorization Requirements 14-12
14.2.4.2 Oral Hygiene Instruction 14-12
14.2.4.3 Dental Prophylaxis and Topical Fluoride Treatment 14-12
14.2.4.4 Dental Sealants 14-12
14.2.4.5 Space Maintainers 14-12
14.2.4.6 Noncovered Counseling Services 14-13
14.2.5 Therapeutic Services 14-13
14.2.5.1 Prior Authorization Requirements 14-13
14.2.5.2 Interrupted Treatment Plan 14-14
14.2.5.3 Restorations 14-14
14.2.5.4 Endodontics 14-16
14.2.5.5 Pulp Caps and Pulpotomy 14-17
14.2.5.6 Root Canals 14-17
14.2.5.7 Periodontics 14-18
14.2.5.8 Prosthodontics (Removable) and Maxillofacial Prosthetics 14-20
14.2.5.9 Maxillofacial Prosthetics 14-21
14.2.5.11 Fixed Prosthodontics 14-23
14.2.5.12 Oral and Maxillofacial Surgery 14-25
14.2.5.13 Adjunctive General Services 14-27
14.2.5.15 Dental Anesthesia 14-28
14.2.5.16 Dental Behavior Management 14-29
14.2.5.17 Internal Bleaching of Discolored Tooth 14-30
14.2.5.18 Noncovered Services 14-30
14.2.6 Dental Treatment in Hospitals and Ambulatory Surgical Centers 14-30
14.2.6.1 Dental Hospital Calls 14-30
14.2.6.2 Authorization and Prior Authorization Requirements 14-30
14.2.6.3 Dental General Anesthesia Provided in the Inpatient or
Outpatient Setting (Medically Necessary Dental Rehabilitation or
Restoration Services) 14-31
14.2.7 Doctor of Dentistry Services as a Limited Physician 14-32
14.2.7.2 Cleft/Craniofacial Surgery by a Dentist Physician 14-34
14.2.7.3 Evaluation and Management or Consultation 14-35
14.2.7.4 X-Ray and Laboratory Procedures 14-35
14.2.7.5 Anesthesia by Dentist Physician 14-36
14.3 Claims Information 14-37
14.3.1 Dental Emergency Claims 14-37
14.3.2 Tooth Identification (TID) and Surface Identification (SID) Systems 14-38
14.3.3 Supernumerary Tooth Identification 14-38
14.4 Reimbursement 14-39
14.5 TMHP-CSHCN Services Program Contact Center 14-39
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