Prior Authorization Chart

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

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:

1. Severe functional difficulties;
2. Developmental anomalies of facial bones and/or oral structures;
3. Facial trauma resulting in severe functional difficulties and/or,
4. 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:
  
  1. Medical diagnosis and surgical treatment plan.
  2. 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

• 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:
1. Severe functional difficulties;
2. Developmental anomalies of facial bones and/or oral structures;
3. Facial trauma resulting in severe functional difficulties and/or,
4. 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

• 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

1. The completed HLD (NJ-Mod2) assessment form;
2. Narrative of clinical findings for dysfunction and dental diagnosis;
3. 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.

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.

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.

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.

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:
1. Pretreatment and final diagnostic photographs and/or panoramic radiograph; and,
2. Final diagnostic study models or diagnostic digital study models.

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.

• 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:
1. Tolerate the treatment;
2. Keep multiple appointments over several years;
3. Maintain an oral hygiene regimen;
4. Be cooperative and complete all needed preventive and treatment visits.
• Non-compliant behavior is defined as but not limited to:
1. Continued poor oral hygiene;
2. Keep multiple appointments over several years;
3. Failure to maintain the appliances;
4. 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.

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.