CSHCN 2009 > Physician > Benefits, Limitations, and Authorization Requirements

29.2.35.12 Cleft/Craniofacial Procedures

The CSHCN Services Program may reimburse providers for the repair and reconstruction of cleft lip, cleft palate, and craniofacial anomalies.

Repair and reconstruction of cleft lip/palate and craniofacial anomalies may be considered for reimbursement only if the procedures are performed by approved cleft/craniofacial (C/C) teams (comprehensive or affiliated) and only if the services are prior authorized.

Individual providers enrolled in the CSHCN Services Program who perform C/C procedures must also be members of a designated C/C specialty team.

A cleft/craniofacial team must include at least the following participants:

•A plastic surgeon or oral surgeon

•An otolaryngologist

•A primary care physician

•An orthodontist and/or a pediatric dentist

•A master's level licensed speech language pathologist

•A client educator

•A designated C/C team care coordinator who may also be one of the previously listed participants

•An administrator

C/C teams must ensure that each client has a C/C team care coordinator to assure that the focus of the service is client- and family-oriented, and that the client, family, and C/C team jointly develop a comprehensive treatment plan for the client, which is recorded in the client's medical record and provided to the client and family.

The administrator is responsible for coordinating and maintaining C/C team records and assuring that the C/C team adheres to CSHCN Services Program rules and regulations.

If the specialty team requirements are not met, all services related to the cleft/craniofacial procedure are denied. To facilitate statewide coverage, the CSHCN Services Program also may approve affiliated providers. CSHCN Services Program-approved affiliated providers must be linked with a CSHCN Services Program-approved comprehensive team and must ensure coordination of client management as needed. The affiliated providers must specify the comprehensive C/C team with which they are affiliated at the time of application.

Note: Anesthesiologists are not required to be members of a C/C specialty team. An anesthesiologist may be reimbursed if the claim is resubmitted on appeal and filing deadlines are met.

Refer to: Section 2.1.6, "Cleft/Craniofacial (C/C) Specialty Teams," on page 2-6 for information about requirements.

The following procedure codes must be prior authorized and performed by a CSHCN Services Program provider that is a member of or affiliated with an approved cleft/craniofacial team:

The procedure codes noted above are restricted to clients from birth through 20 years of age.

Verification of approved C/C team membership is determined during the prior authorization process.