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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 : 4.2.29 Mandatory Prior Authorization : Orthodontic Services
Orthodontic Services
Prior authorization is required for all THSteps orthodontic services except for procedure code D8660. The prior authorization request must contain the DOS that the orthodontic diagnostic tools 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.
For group providers, if the provider requested authorization using their group provider identifier on the THSteps Dental Mandatory Prior Authorization Form, any performing provider within the group who is skilled in the authorized service can provide services to the client. If a provider uses their individual performing provider identifier, only that provider may provide services to the client.
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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 who is 20 years of age or younger.
A diagnostic model, radiographs (X-rays), and other supporting documentation must be submitted with the THSteps Dental Mandatory Prior Authorization Request Form when requesting prior authorization for comprehensive orthodontic treatment or crossbite therapy. A prior authorization request for comprehensive orthodontic treatment or crossbite therapy submitted without the THSteps Dental Mandatory Prior Authorization Request Form, diagnostic model, radiographs (X-rays), and any other necessary supporting documentation will not be considered and will be returned to the provider.
Prior authorization is a condition of 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, unless the client is incarcerated. Medicaid does not pay for any dental services, including orthodontic, while the client is incarcerated.
Providers must submit all orthodontic services for Medicaid managed care clients following these guidelines. Claims for dental services provided to children in foster care must be filed with Delta Dental, the claims processor for Superior Health Plan. STAR and STAR+PLUS are not responsible for orthodontic services.

Texas Medicaid & Healthcare Partnership
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