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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 : 4.2.27 Orthodontic Services (THSteps) : 4.2.27.4 Premature Termination of Comprehensive Orthodontic Treatment

4.2.27.4
Premature termination of comprehensive orthodontic treatment includes the following:
Documentation of one of the following must be retained for premature termination of comprehensive orthodontic treatment:
Documentation that the client requested premature removal and a release of liability form has been signed by the parent, guardian, or client if he or she is at least 18 years of age.
Premature termination of comprehensive orthodontic treatment must be submitted with procedure code D8680.
Removal of the appliance (procedure code D8680) will be denied if the claim is submitted by any provider on the same date of service as orthodontic treatment (procedure codes D8050, D8060, and D8080).
Providers must keep a copy of the release of liability form on file and are responsible for this documentation during a review process.
If premature removal of the appliances is requested before completion of treatment, future orthodontic services may not be considered. The provider must document why the premature removal was necessary.

Texas Medicaid & Healthcare Partnership
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