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2012 Texas Medicaid Provider Procedures Manual

Children’s Services Handbook : 4. Texas Health Steps (THSteps) Dental : 4.2 Services, Benefits, Limitations, and Prior Authorization : 4.2.24 Orthodontic Services (THSteps) : 4.2.24.4 Transfer of Orthodontic Services

4.2.24.4
Transfer of Orthodontic Services
Prior authorization that has been 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 to get approval to complete the orthodontic treatment that was initiated by the original provider.
To complete the treatment plan, the client must be eligible for Medicaid. It is the provider's responsibility to verify the client's eligibility through www.YourTexasBenefitsCard.com, TexMedConnect, or the TMHP Contact Center.
If the client does not return for the completion of services and there is documented failure to keep appointments by the client, the dental provider who initiated the services may submit a claim for reimbursement. The claim must be received by TMHP within the 95-day filing deadline from the last DOS.
The following supporting documentation must accompany the new request for orthodontia services and must include the DOS the orthodontic diagnostic tools were completed and include:
Note:
A complete 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).
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:
If Medicaid clients initiate orthodontic services outside of Medicaid because they do not score 26 points on the HLD, they are not eligible to have their orthodontic services transferred to or reimbursed by Medicaid.
Providers who want to request prior authorization to complete orthodontic treatment that was initiated by another provider must complete a THSteps Dental Mandatory Prior Authorization Request Form and send it with the complete plan of treatment, and the appropriate documentation for orthodontic services or crossbite therapy to the TMHP Dental Director at the following address:
Texas Medicaid & Healthcare Partnership
Fee-for-Service and IFC-MR Dental Authorizations
PO Box 204206
Austin, TX 78720-4206

Texas Medicaid & Healthcare Partnership
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