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19.18.5 Transfer of Orthodontic Services
Prior authorization issued to a dental provider for orthodontic services is not transferable to another dental provider. The new provider must submit to TMHP a new prior authorization request in order to be approved to complete the orthodontic treatment initiated by the original provider.
The following supporting documentation must accompany the new request for orthodontia services and must include the date of service the orthodontic records were produced:
• All of the documentation as required for the original provider.
•The reason the client left the previous provider, if known.
•An explanation of the treatment status.
•A compete treatment plan addressing all procedures for which authorization is being requested (such as the number of monthly adjustments or retainers required to complete the case).
•A full diagnostic work-up (D8080) with an HLD Index. The score of 26 points will be modified according to any progress achieved.
Exception: The prior authorization requests for clients who initiate orthodontic services before becoming eligible for Medicaid do not require models or the HLD score sheet, nor does the client have to meet the HLD Index of 26 points. However, a complete plan of treatment is required. Note: Medicaid clients who initiate orthodontic services privately (e.g. pay out of pocket for the orthodontic workup and/or initial banding, etc.) while Medicaid eligible due to not meeting the HLD index 26-points, are not eligible to have their orthodontic services transferred to and reimbursed by Medicaid.
To request prior authorization to complete the orthodontic treatment initiated by another provider, complete a THSteps Dental Mandatory Prior Authorization Request Form and send it with the complete plan of treatment and appropriate documentation for orthodontic services and/or crossbite therapy to the TMHP Dental Director at the following address:
Texas Medicaid & Healthcare Partnership
THSteps and ICF-MR Dental Authorization and Information
PO Box 202917
Austin, TX 78720-2917
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