Prior Authorization Chart

Mandatory Prior Authorization Chart
New Jersey Dental Pediatric EHB
As of January 1, 2017

Where Prior Authorization is required but not obtained, Delta Dental can apply a penalty of up to 50% of the charges that would otherwise be covered. Delta Dental will Disallow benefits for the dated claim services and the patient CANNOT BE BILLED FOR THE SERVICES FOR PENALIZED AMOUNT.

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Dental Services	Documentation Requirements
Sealant replacement.	Narrative
Porcelain fused to metal, cast and ceramic crowns (single restoration) – to restore form and function. Services will not be considered for cosmetic reasons, for teeth where other restorative materials will be adequate to restore form and function or for teeth that are not in occlusion or function and have a poor prognosis.	PA and/or FMX and/or Pano Complete missing tooth chart and photo if radiograph does not show need. Narrative if the procedure is performed due to attrition, erosion, abrasion (wear), abfraction, corrosion, or for periodontal, orthodontic, or other splinting.
Endodontic services other than Emergency Dental Services. Services will not be considered for teeth that are not in occlusion or function and have poor long term prognosis.	PA
Periodontal services. Requires submission of diagnostic materials and documentation. Periodontal root planing and scaling – with Prior Authorization, can be considered every six (6) months for individuals with special health care needs.	PA and periodontal charting as appropriate
All dentures, fixed prosthodontics (fixed bridges) and maxillofacial prosthetics require Prior Authorization.	Radiographs as appropriate, narrative
Denture rebase - following 12 months post denture insertion and subject to Prior Authorization, denture rebase is covered and includes adjustments for first six (6) months following service.	Narrative
Pediatric partial denture - for select cases to maintain function and space for anterior teeth with premature loss of primary anterior teeth, subject to Prior Authorization.	FMX and/or Pano Complete missing tooth chart Complete Treatment Plan Narrative if the procedure is performed due to attrition, erosion, abrasion (wear), abfraction, corrosion, or for periodontal, orthodontic, or other splinting.
Medically Necessary Orthodontic Services including continuation of transfer cases or cases started outside the program (otherwise Orthodontic Services are not covered). Removal can be requested by report as a separate service for Dentist that did not start case and requires Prior Authorization.	See orthodontic policies and procedures 20-X to 20-XX
Behavior management when exceeding the following thresholds based on place of service: One unit equals 15 minutes of additional time: Office or clinic – 2 units Inpatient/outpatient hospital – 4 units Skilled nursing/long term care – 2 units	Narrative
Dental Services to be rendered in a hospital or ambulatory surgical center (documentation must include the specific diagnosis and medical conditions that require admission to the hospital or ambulatory surgical center).	Narrative

New Jersey Pediatric Essential Health Benefit
Orthodontic Policy and Required Documentation Chart

Orthodontic treatment general policies

I. No benefits will be paid for orthodontic services unless they meet the following criteria:

They have received a Prior Authorization.
They are Medically Necessary Orthodontic Services.
Medical necessity must be met by demonstrating severe functional difficulties, developmental anomalies of facial bones and/or oral structures, facial trauma resulting in functional difficulties or documentation of a psychological/psychiatric diagnosis from a mental health provider that orthodontic treatment will improve the mental/psychological condition of the child.

Orthodontic treatment requires prior authorization and is not considered for cosmetic purposes.
Orthodontic consultation can be provided once annually as needed by the same provider.
Orthodontic cases that require extraction of permanent teeth must be approved for orthodontic treatment prior to extractions being provided. The orthodontic approval should be submitted with a referral to the oral surgeon or dentist providing the extractions and extractions should not be provided without proof of approval for orthodontic service.
Initiation of treatment should take into consideration time needed to treat the case to ensure treatment is completed prior to 19th birthday (when the child will no longer be covered under this plan).
Periodic oral evaluation, preventive services and needed dental treatment must be provided prior to the initiation of orthodontic treatment.
The placement of the appliance represents the treatment start date.
Reimbursement includes placement and removal of appliance. Removal can be requested by report as a separate service for a dentist that did not start the case and requires prior authorization.
Completion of treatment must be documented to include diagnostic photographs and panoramic radiograph/view of completed case and submitted when active treatment has ended and bands are removed. Date of service used is date of band removal.

II. Comprehensive treatment for handicapping malocclusions of the permanent dentition. Case must demonstrate medical necessity based on a score total equal to or greater than 26 on the HLD (NJ-Mod2) assessment form (accessible at [www.deltadentalnj.com]) with diagnostic tools substantiation or based on a total scores of less than 26 BUT with documented medical necessity.

III. Request for treatment must include diagnostic materials to demonstrate need, the form (accessible at [www.deltadentalnj.com]) and documentation that all needed dental preventive and restorative or other services have been completed.

IV. Approval for comprehensive treatment is for up to 12 visits at a time with request for continuation to include the previously mentioned documentation and most recent diagnostic tools to demonstrate progression of treatment.

Dental Services	Policies and Prior Authorization & Documentation Requirements
Orthodontic “workup” Submit with appropriate CDT diagnostic codes	Policy In addition to the services listed in Chapter 9 of this Participating Dentist Handbook, evaluation includes diagnostic workup, clinical evaluation, orthodontic treatment plan, consultation and completion of HLD (NJ-Mod2) assessment tool. Separate fees for these procedures are not chargeable to the Patient and will be non-billable. Must be provided by the same dentist/dental office that will be providing treatment. Limited to once per dentist/dental office annually.< /li> Should occur with the expectation that treatment must be completed by the time the patient reaches the age of 19. Should occur with expectation that patient will score 26 points or more on the HLD (NJ-Mod2) assessment or meets one of the other qualifying conditions (see Orthodontics – General Policy, page 20-5) Prior Authorization – Not Required Documentation Requirements Part of submission for prior authorization of specific orthodontic treatment plan.
Limited orthodontic treatment D8010 – D8040	Policy Includes the appliance, appliance insertion, all adjustments, repairs, removal, retention, and treatment visits. Separate fees for these services are non-billable. In many cases the total payment for limited orthodontic treatment is made at the start of treatment.If this is done you are responsible for completing treatment, even if eligibility has been terminated. Documentation supports one of the following qualifying conditions: Severe functional difficulties; Developmental anomalies of facial bones and/or oral structures; Facial trauma resulting in severe functional difficulties and/or, Demonstration that long term psychological health requires orthodontic correction. If service(s) is/are part of a comprehensive treatment plan, it/they will not be approved or reimbursed. Separate fees will be non-billable. The approved treatment must be started within six (6) months of receiving the approval Prior Authorization – Required Documentation Requirements Narrative of clinical findings, treatment plan and estimated treatment time; Diagnostic photographs; Diagnostic x-rays or digital films; Diagnostic study models bite registration, (will not be returned) ; If part of a comprehensive treatment plan – submit comprehensive plan that indicates the limited treatment phase The primary care dentist must provide on letterhead attestation that all needed preventive restorative or other dental treatment services have been completed. A copy must be submitted with the orthodontic treatment request. If applicable: Medical diagnosis and surgical treatment plan. Detailed documentation from a mental health professional indicating the psychological or psychiatric diagnosis, treatment history and prognosis and an attestation stating and substantiating that orthodontic correction will result in a favorable prognosis of the mental/psychological condition Upon completion of treatment, pre-treatment and post-treatment diagnostic photographs must be submitted
Interceptive orthodontic treatment D8050 – D8060	Policy Includes all appliances, injections, all adjustments, repairs, removal, retention, and treatment visits. Separate fees for these services will be non-billable. If service(s) is/are part of a comprehensive treatment plan, it/they will not be approved or reimbursed. Separate fees will be non-billable. Documentation supports one of the following conditions: Severe functional difficulties; Developmental anomalies of facial bones and/or oral structures; Facial trauma resulting in severe functional difficulties and/or, Demonstration that long term psychological health requires orthodontic correction. Prior Authorization – Required Documentation Requirements The documentation requirements are the same as stated below for comprehensive treatment. Upon completion of treatment, pre-treatment and post-treatment diagnostic photographs must be submitted.
Minor treatment to control harmful habits D8210 – D8220	Policy If service(s) is/are part of a comprehensive treatment plan, it/they will not be approved or reimbursed. Separate fees will be non-billable Includes removable or fixed appliances, insertion, all adjustments, repairs, removal, retention and treatment visits. Separate fees for these procedures by the same dentist/dental office are non-billable. Prior Authorization – Required Documentation Requirements Clinical findings Treatment plan including estimated treatment time and prognosis Diagnostic photographs and/or models
Comprehensive orthodontic treatment of the permanent dentition D8080 – D8090	Policy Includes all appliances, insertion, all adjustments, repairs, and retention. A separate fee for these procedures is non-billable. Eligibility should be verified prior to each visit. Documentation supports one of the following conditions: Reimbursement for orthodontic services includes the placement and removal of all appliances and brackets; therefore should it become necessary to remove the bands due to loss of eligibility, non-compliance or elective discontinuation of treatment by the parent, guardian or patient the appliance shall be removed at no additional charge because reimbursement for comprehensive orthodontics includes this service. Prior authorization for comprehensive orthodontic treatment will only be considered for the permanent dentition. As an exception, cases with late mixed dentition with treatment for permanent teeth will require documentation of the planned treatment for the existing primary teeth and the reason for starting treatment prior to their natural exfoliation for consideration of the request. The start date of treatment is considered to be the banding date which must occur within six (6) months of the Prior Authorization approval. NOTE: It is expected that twenty-four (24) months of active treatment will be adequate for the majority of cases. Prior Authorization – Required Documentation Requirements The completed HLD (NJ-Mod2) assessment form; Narrative of clinical findings for dysfunction and dental diagnosis; The comprehensive orthodontic treatment plan and estimated treatment time, including but not limited to: Class of malocclusion Type of appliance used / to be used Indication of Phase I or Phase II treatment Estimate of total months of treatment Date treatment began / will begin All fees Diagnostic services, which are charged separately Previous carrier payment information (if applicable) If invisalign is being used, indicate this on the claim form and if appropriate, provide the amount of the additional fee (if any) for invisalign over and above your usual fee for conventional treatment. Attestation from the primary care dentist that all needed preventive and restorative or other dental services have been completed; Diagnostic study models, bite registration (will not be returned) Diagnostic photographs; Diagnostic x-rays, digital x-rays or cephalometric film with tracing (when applicable), and, If applicable: Medical diagnosis and surgical treatment plan; Detailed documentation from a mental health professional indicating the psychological or psychiatric diagnosis, treatment history and prognosis and an attestation stating and substantiating that orthodontic correction will result in a favorable prognosis of the mental/psychological condition.
Continuation of treatment (after completing 12 treatment visits)	Policy After completing twelve (12) treatment visits or upon expiration of an approval, a new prior authorization request must be submitted for the additional visits with a maximum of twelve (12) additional monthly treatment visits being allowed. Prior Authorization – Required Documentation Requirements A copy of the treatment notes; Documentation of any problems with compliance; Attestation from primary care dentist that recall visits occurred and that all needed preventive and restorative or other dental services have been completed; Pre treatment and current treatment diagnostic photographs and/or diagnostic panoramic radiographs to show status and to demonstrate case progression; A copy of the initial approval if the case was started under a different NJ Pediatric Dental EHB Program.
Services transferred or started outside a dental pediatric EHB	Policy For continuation of care for transfer cases whether they were or were not started under the Delta Dental New Jersey Pediatric Dental EHB Program. Prior Authorization – Required Documentation Requirements A copy of the initial orthodontic case approval, if applicable The date when active treatment was started and the expected number of months for active treatment and retention with a maximum of 24 visits to be expected to treat a case; and, If applicable, a new treatment plan and documentation to support the treatment change if re-banding is planned. A copy of the orthodontic treatment notes, if available from the provider who started treatment Recent diagnostic photographs and/or panoramic radiographs, if available Attestation from the primary dentist that all needed preventive, restorative, and other treatment has been completed.
Orthognathic surgical cases with comprehensive orthodontic treatment	Policy For continuation of care for transfer cases whether they were or were not started under the Delta Dental New Jersey Pediatric Dental EHB Program. Prior Authorization – Required Documentation Requirements The surgical consultation report, treatment plan and approval for surgical case must be included with the request for prior authorization of the orthodontic services; Prior authorization and documentation requirements are the same as those stated above for comprehensive treatment and shall come from the treating dentist.
Completion of Comprehensive Treatment final records.	Policy If required documentation is not received, Delta Dental is entitled to recover all reimbursement provided until required documentation is submitted. Prior Authorization – Not Applicable Documentation Requirements Attestation of case completion must be submitted on the provider’s letterhead to document that active treatment had a favorable outcome and that the case is ready for retention. Procedure code D8680, orthodontic retention, and not D8670 shall be submitted for the date of service when the orthodontic treatment visit is to remove the bands and place the case in retention. The following must be submitted: Pretreatment and final diagnostic photographs and/or panoramic radiograph; and, Final diagnostic study models or diagnostic digital study models.
Continuation of treatment (after completing 12 treatment visits)	Policy After completing twelve (12) treatment visits or upon expiration of an approval, a new prior authorization request must be submitted for the additional visits with a maximum of twelve (12) additional monthly treatment visits being allowed. Prior Authorization – Required Documentation Requirements A copy of the treatment notes; Documentation of any problems with compliance; Attestation from primary care dentist that recall visits occurred and that all needed preventive and restorative or other dental services have been completed; Pre treatment and current treatment diagnostic photographs and/or diagnostic panoramic radiographs to show status and to demonstrate case progression; A copy of the initial approval if the case was started under a different NJ Pediatric Dental EHB Program.
Behavior not conductive to favorable outcomes	Policy It is the expectation that the case selection process for orthodontic treatment take into consideration the patient’s ability over the course of treatment to: Tolerate the treatment; Keep multiple appointments over several years; Maintain an oral hygiene regimen; Be cooperative and complete all needed preventive and treatment visits. Non-compliant behavior is defined as but not limited to: Continued poor oral hygiene; Keep multiple appointments over several years; Failure to maintain the appliances; Untreated dental disease. Prior Authorization – Not applicable unless removal of appliance is performed by a dentist/dental office that did not start the case Documentation Requirements A letter must be sent to the parent/guardian that documents the factors of concern and the corrective actions needed and that failure to comply can result in discontinuation of treatment with de-banding. A copy must be sent to Delta Dental of New Jersey. If the case is discontinued, the “Release from Treatment” form must be signed by the parent/guardian. The reimbursement for appliance placement includes their removal.
Replacement of appliance due to loss or damage beyond repair	Policy Delta Dental may provide benefits no more than once for each arch or unit without additional cost to the patient. Prior Authorization – Required Documentation Requirements Narrative describing specific circumstances.

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Prior Authorization Chart