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December 2016 Texas Medicaid Provider Procedures Manual

Children’s Services Handbook : 4 Texas Health Steps (THSteps) Dental : 4.2 Services, Benefits, Limitations, and Prior Authorization : 4.2.21 Prosthodontic (Fixed) Services

4.2.21
Prosthodontic procedure codes require prior authorization.
Refer to:
Subsection 4.2.32, “Mandatory Prior Authorization” in this handbook for documentation requirements.
Periapical radiographs are required for each tooth involved in the authorization request. The criteria used by the TMHP Dental Director are:
 
A 16–20, PPXR, MTID, CCP
A 16–20, PPXR, MTID, CCP
A 16–20, PPXR, MTID, CCP
A 16–20, PPXR, MTID, CCP
A 16–20, PPXR, MTID, CCP
A 16–20, PPXR, MTID, CCP
A 16–20, PPXR, MTID, CCP
A 16–20, PPXR, MTID, CCP
A 16–20, PPXR, MTID, CCP
A 16–20, PPXR, MTID, CCP
A 16–20, PPXR, CCP
A 16–20, PPXR, CCP
A 16–20, PPXR, CCP
A 16–20, PPXR, CCP
A 16–20, PPXR, CCP
A 16–20, PPXR, CCP
A 16–20, PPXR, CCP
A 16–20, PPXR, CCP
A 16–20, PPXR, CCP
A 16–20, PPXR, CCP
A 16–20, PPXR, CCP
A 16–20, PPXR, CCP
A 16–20, PPXR, CCP
A 16–20, PXR, CCP
A 16–20, PXR, CCP
A 16–20, N, PXR, CCP
A 16–20, N, PXR, CCP
A 16–20, N, PXR, CCP
A 16–20, N, PXR, CCP
A=Age range limitations, N=Narrative required, FMX=Full–mouth radiographs (nonpanoramic), MTID=Missing tooth ID(s), PPXR=Preoperative and postoperative radiographs required, PXR=Preoperative radiographs required, PHO=Preoperative and postoperative photographs required, PC=Periodontal charting required, PATH=Pathology report required and must be retained in the client’s record, CCP=Comprehensive Care Program, NC=No charge to Medicaid and may not bill the client, and *= Services payable to an FQHC for a client encounter

Texas Medicaid & Healthcare Partnership
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