|
19.18.2 Mandatory Prior Authorization
Prior authorization is required for all THSteps orthodontic services except for procedure code D8660. The prior authorization request must contain the date of service that the orthodontic records were produced. If the request is approved, the date that the records were produced is considered to be the date on which orthodontic treatment begins.
If orthodontic treatment is medically indicated, providers are responsible for obtaining prior authorization for a complete orthodontic treatment plan while the client is eligible for Medicaid and THSteps and younger than 21 years of age.
Prior authorization is a condition for reimbursement; it is not a guarantee of payment.
Upon receipt of prior authorization of complete treatment plans, providers are to advise clients that they will be able to receive the approved treatment services (e.g. orthodontic adjustments, bracket replacements and retainers), even if they lose Medicaid eligibility or reach 21 years of age. Approved orthodontic treatment must be initiated before the loss of Medicaid eligibility and completed within 36 months of the authorization date.
Note: Providers must submit all orthodontic services for Medicaid Managed Care clients following these guidelines. STAR and STAR+PLUS are not responsible for orthodontic services.
Requests for orthodontic services must be accompanied by all the following documentation:
• An orthodontic treatment plan. The treatment plan must include all procedures required to complete full treatment (such as, extractions, orthognathic surgery, upper and lower appliance, monthly adjustments, anticipated bracket replacements, appliance removal if indicated, special orthodontic appliances, etc.). The treatment plan should incorporate only the minimal number of appliances required to properly treat the case. Requests for multiple appliances to treat an individual arch are reviewed for duplication of purpose.
•Cephalometric radiograph with tracing models
•Completed and scored HLD sheet with diagnosis of Angle class (26 points required for approval of non-cleft palate cases).
•Facial photographs.
•Full series of radiographs or a panoramic radiograph; diagnostic-quality films are required (copies are accepted and radiographs will not be returned to the provider).
•Any additional pertinent information as determined by the dentist or requested by TMHP's Dental Director Requests for crossbite therapy require properly trimmed models to be retained in the office and must demonstrate the following criteria:
•Posterior teeth. Not end to end, but buccal cusp of upper teeth should be lingual to buccal cusp of lower teeth.
•Anterior teeth. The incisal edge of upper should be lingual to the incisal of the opposing arch.
The dentist should be certain that radiographs, photographs, and other information are properly packaged to avoid damage. TMHP is not responsible for lost or damaged materials.
|
