PA Lookup
If you have questions about prior authorizations, please call:
Member and Recipient Service Line: 1-877-685-2415
Provider Support Service Line: 1-855-250-1539
Dental Services
Dental services are defined as diagnostic, preventive, or corrective procedures provided by or under the supervision of a dentist. This includes services to treat disease, maintain oral health, and treat injuries or impairments that may affect a beneficiary’s oral or general health. Such services must maintain a high standard of quality and must be within the reasonable limits of services customarily available and provided to most persons in the community with the limitations and exclusions specified in this policy. Only the procedure codes listed in this policy are covered under the North Carolina (NC) Medicaid (Title XIX) Dental Program.
Authorization Guidelines
Please submit any records and any other information that you believe support the member has met the applicable medical necessity criteria to Trillium.
Limits
∗ Treatment for primary prevention or remineralization ∗ Allowed for beneficiaries ages five through fourteen years of age ∗ Allowed for permanent first and second molars ∗ Valid tooth numbers (02, 03, 14, 15, 18, 19, 30, and 31) ∗ Allowed once per lifetime ∗ Reimbursement is at 100 percent for the first tooth and cutback to 50 percent for three additional teeth for a total of four teeth reimbursed per date of service (D1354 or D1355). If more than four teeth need treatment, all teeth should be treated (reimbursement of a total of four teeth constitutes payment of all affected teeth)
Age Group Details
Covered for permanent first and second molars for beneficiaries under 16 years of age.
Covered for primary molars for beneficiaries under eight years of age.
For children age 8 through 20 years with special needs, primary molar sealants require reference to special approval requirements. Allowed once in a lifetime per tooth.
How to Submit
N/A - No authorization is required
Resources
Dental Services
Dental services are defined as diagnostic, preventive, or corrective procedures provided by or under the supervision of a dentist. This includes services to treat disease, maintain oral health, and treat injuries or impairments that may affect a beneficiary’s oral or general health. Such services must maintain a high standard of quality and must be within the reasonable limits of services customarily available and provided to most persons in the community with the limitations and exclusions specified in this policy. Only the procedure codes listed in this policy are covered under the North Carolina (NC) Medicaid (Title XIX) Dental Program.
Authorization Guidelines
Please submit any records and any other information that you believe support the member has met the applicable medical necessity criteria to Trillium.
Limits
Includes band and loop, crown and loop, or distal shoe
- * Limited to replacement of primary molars and canines and permanent first
molars
- * Requires a quadrant indicator in the area of oral cavity field
- * Use delivery date as date of service when requesting payment
- * If the beneficiary’s Medicaid eligibility expires between the final impression
date and delivery date, the provider shall use the final impression date as the date of service
Exclusions
- • Limited to beneficiaries under 21 years of age for D1510 and D1516.
- • D1510 is limited to replacement of primary molars and canines and permanent first molars.
- • D1516 is limited to replacement of primary molars and canines and permanent first molars.
- • D1510 requires a quadrant indicator in the area of oral cavity field.
- • For D1510 and D1516, use the delivery date as the date of service when requesting payment.
- • If Medicaid eligibility expires between the final impression date and delivery date, use the final impression date as the date of service.Medicaid does not allow reimbursement for a non-deliverable space maintainer.
Age Group Details
- * Limited to beneficiaries under 21 years of age
How to Submit
N/A - No authorization is required
Resources
Dental Services
Dental services are defined as diagnostic, preventive, or corrective procedures provided by or under the supervision of a dentist. This includes services to treat disease, maintain oral health, and treat injuries or impairments that may affect a beneficiary’s oral or general health. Such services must maintain a high standard of quality and must be within the reasonable limits of services customarily available and provided to most persons in the community with the limitations and exclusions specified in this policy. Only the procedure codes listed in this policy are covered under the North Carolina (NC) Medicaid (Title XIX) Dental Program.
Authorization Guidelines
Please submit any records and any other information that you believe support the member has met the applicable medical necessity criteria to Trillium.
Limits
- * Limited to beneficiaries under 21 years of age
- * Limited to replacement of primary molars and canines and permanent first
molars
- * Bill D6985 when appliance is to serve as a fixed pediatric partial denture to
replace maxillary anterior teeth
- * Use the delivery date as date of service when requesting payment
- * If the beneficiary’s Medicaid eligibility expires between the final impression
date and delivery date, the provider shall use the final impression date as the date of service
Exclusions
- • Limited to beneficiaries under 21 years of age for D1510 and D1516.
- • D1510 is limited to replacement of primary molars and canines and permanent first molars.
- • D1516 is limited to replacement of primary molars and canines and permanent first molars.
- • D1510 requires a quadrant indicator in the area of oral cavity field.
- • For D1510 and D1516, use the delivery date as the date of service when requesting payment.
- • If Medicaid eligibility expires between the final impression date and delivery date, use the final impression date as the date of service.Medicaid does not allow reimbursement for a non-deliverable space maintainer.
Age Group Details
- * Limited to beneficiaries under 21 years of age
How to Submit
N/A - No authorization is required
Resources
Dental Services
Dental services are defined as diagnostic, preventive, or corrective procedures provided by or under the supervision of a dentist. This includes services to treat disease, maintain oral health, and treat injuries or impairments that may affect a beneficiary’s oral or general health. Such services must maintain a high standard of quality and must be within the reasonable limits of services customarily available and provided to most persons in the community with the limitations and exclusions specified in this policy. Only the procedure codes listed in this policy are covered under the North Carolina (NC) Medicaid (Title XIX) Dental Program.
Authorization Guidelines
Please submit any records and any other information that you believe support the member has met the applicable medical necessity criteria to Trillium.
Limits
- * Limited to replacement of primary molars and canines and permanent first
molars
- * Use the delivery date as date of service when requesting payment
- * If the beneficiary’s Medicaid eligibility expires between the final impression
date and delivery date, the provider shall use the final impression date as the date of service
Exclusions
- • Limited to beneficiaries under 21 years of age for D1510 and D1516.
- • D1510 is limited to replacement of primary molars and canines and permanent first molars.
- • D1516 is limited to replacement of primary molars and canines and permanent first molars.
- • D1510 requires a quadrant indicator in the area of oral cavity field.
- • For D1510 and D1516, use the delivery date as the date of service when requesting payment.
- • If Medicaid eligibility expires between the final impression date and delivery date, use the final impression date as the date of service.Medicaid does not allow reimbursement for a non-deliverable space maintainer.
Age Group Details
- * Limited to beneficiaries under 21 years of age
How to Submit
N/A - No authorization is required
Resources
Dental Services
Dental services are defined as diagnostic, preventive, or corrective procedures provided by or under the supervision of a dentist. This includes services to treat disease, maintain oral health, and treat injuries or impairments that may affect a beneficiary’s oral or general health. Such services must maintain a high standard of quality and must be within the reasonable limits of services customarily available and provided to most persons in the community with the limitations and exclusions specified in this policy. Only the procedure codes listed in this policy are covered under the North Carolina (NC) Medicaid (Title XIX) Dental Program.
Authorization Guidelines
Please submit any records and any other information that you believe support the member has met the applicable medical necessity criteria to Trillium.
Limits
Limited to replacement of primary molars and canines and permanent first molars ∗ Requires a quadrant indicator in the area of oral cavity field ∗ Use delivery date as date of service when requesting payment ∗ If the beneficiary’s Medicaid eligibility expires between the final impression date and delivery date, the provider shall use the final impression date as the date of service
Exclusions
- • Limited to beneficiaries under 21 years of age for D1510 and D1516.
- • D1510 is limited to replacement of primary molars and canines and permanent first molars.
- • D1516 is limited to replacement of primary molars and canines and permanent first molars.
- • D1510 requires a quadrant indicator in the area of oral cavity field.
- • For D1510 and D1516, use the delivery date as the date of service when requesting payment.
- • If Medicaid eligibility expires between the final impression date and delivery date, use the final impression date as the date of service.Medicaid does not allow reimbursement for a non-deliverable space maintainer.
Age Group Details
- * Limited to beneficiaries under 21 years of age
How to Submit
N/A - No authorization is required
Resources
Dental Services
Dental services are defined as diagnostic, preventive, or corrective procedures provided by or under the supervision of a dentist. This includes services to treat disease, maintain oral health, and treat injuries or impairments that may affect a beneficiary’s oral or general health. Such services must maintain a high standard of quality and must be within the reasonable limits of services customarily available and provided to most persons in the community with the limitations and exclusions specified in this policy. Only the procedure codes listed in this policy are covered under the North Carolina (NC) Medicaid (Title XIX) Dental Program.
Authorization Guidelines
Please submit any records and any other information that you believe support the member has met the applicable medical necessity criteria to Trillium.
Limits
Any combination of D2140, D2150, D2160, and D2161 rendered on a single posterior primary or permanent tooth on the same date of service that exceeds the maximum allowed fee for D2161 is reimbursed at the same fee as D2161. Each surface on the same tooth is covered only once per date of service.
Connecting or adjoining surfaces must be billed under one procedure code.
Exclusions
Primary tooth restorations are not allowed when normal exfoliation is imminent. Claims for services that fall outside the stated CDT service limitations are denied unless special approval is granted for medically necessary services for a Medicaid beneficiary under 21 years of age.
How to Submit
N/A - No authorization is required
Resources
Dental Services
Dental services are defined as diagnostic, preventive, or corrective procedures provided by or under the supervision of a dentist. This includes services to treat disease, maintain oral health, and treat injuries or impairments that may affect a beneficiary’s oral or general health. Such services must maintain a high standard of quality and must be within the reasonable limits of services customarily available and provided to most persons in the community with the limitations and exclusions specified in this policy. Only the procedure codes listed in this policy are covered under the North Carolina (NC) Medicaid (Title XIX) Dental Program.
Authorization Guidelines
Please submit any records and any other information that you believe support the member has met the applicable medical necessity criteria to Trillium.
Limits
Any combination of D2140, D2150, D2160, and D2161 rendered on a single posterior primary or permanent tooth on the same date of service that exceeds the maximum allowed fee for D2161 is reimbursed at the same fee as D2161. Each surface on the same tooth is covered only once per date of service.
Connecting or adjoining surfaces must be billed under one procedure code.
Exclusions
Primary tooth restorations are not allowed when normal exfoliation is imminent. Claims for services that fall outside the stated CDT service limitations are denied unless special approval is granted for medically necessary services for a Medicaid beneficiary under 21 years of age.
How to Submit
N/A - No authorization is required
Resources
Dental Services
Dental services are defined as diagnostic, preventive, or corrective procedures provided by or under the supervision of a dentist. This includes services to treat disease, maintain oral health, and treat injuries or impairments that may affect a beneficiary’s oral or general health. Such services must maintain a high standard of quality and must be within the reasonable limits of services customarily available and provided to most persons in the community with the limitations and exclusions specified in this policy. Only the procedure codes listed in this policy are covered under the North Carolina (NC) Medicaid (Title XIX) Dental Program.
Authorization Guidelines
Please submit any records and any other information that you believe support the member has met the applicable medical necessity criteria to Trillium.
Limits
Any combination of D2140, D2150, D2160, and D2161 rendered on a single posterior primary or permanent tooth on the same date of service that exceeds the maximum allowed fee for D2161 is reimbursed at the same fee as D2161. Each surface on the same tooth is covered only once per date of service.
Connecting or adjoining surfaces must be billed under one procedure code.
Exclusions
Primary tooth restorations are not allowed when normal exfoliation is imminent. Claims for services that fall outside the stated CDT service limitations are denied unless special approval is granted for medically necessary services for a Medicaid beneficiary under 21 years of age.
How to Submit
N/A - No authorization is required
Resources
Dental Services
Dental services are defined as diagnostic, preventive, or corrective procedures provided by or under the supervision of a dentist. This includes services to treat disease, maintain oral health, and treat injuries or impairments that may affect a beneficiary’s oral or general health. Such services must maintain a high standard of quality and must be within the reasonable limits of services customarily available and provided to most persons in the community with the limitations and exclusions specified in this policy. Only the procedure codes listed in this policy are covered under the North Carolina (NC) Medicaid (Title XIX) Dental Program.
Authorization Guidelines
Please submit any records and any other information that you believe support the member has met the applicable medical necessity criteria to Trillium.
Limits
Any combination of D2140, D2150, D2160, and D2161 rendered on a single posterior primary or permanent tooth on the same date of service that exceeds the maximum allowed fee for D2161 is reimbursed at the same fee as D2161. Each surface on the same tooth is covered only once per date of service.
Connecting or adjoining surfaces must be billed under one procedure code.
Exclusions
Primary tooth restorations are not allowed when normal exfoliation is imminent. Claims for services that fall outside the stated CDT service limitations are denied unless special approval is granted for medically necessary services for a Medicaid beneficiary under 21 years of age.
How to Submit
N/A - No authorization is required
Resources
Dental Services
Dental services are defined as diagnostic, preventive, or corrective procedures provided by or under the supervision of a dentist. This includes services to treat disease, maintain oral health, and treat injuries or impairments that may affect a beneficiary’s oral or general health. Such services must maintain a high standard of quality and must be within the reasonable limits of services customarily available and provided to most persons in the community with the limitations and exclusions specified in this policy. Only the procedure codes listed in this policy are covered under the North Carolina (NC) Medicaid (Title XIX) Dental Program. Resin-based composite restorations are allowed to restore a carious lesion into the dentin or a deeply eroded area into the dentin. Resin-based composite restorations are not covered as a preventive procedure and are not covered for treatment of cosmetic problems (such as diastemas, discolored teeth, developmental anomalies).
Authorization Guidelines
Please submit any records and any other information that you believe support the member has met the applicable medical necessity criteria to Trillium.
Limits
- • Each surface on the same tooth is covered only once per date of service.
- • Connecting or adjoining surfaces must be billed under one procedure code. Resin-based composite restorations are not covered when used as a preventive procedure. They are also not covered for cosmetic problems, including diastemas, discolored teeth, and developmental anomalies.
How to Submit
N/A - No authorization is required
Resources
Dental Services
Dental services are defined as diagnostic, preventive, or corrective procedures provided by or under the supervision of a dentist. This includes services to treat disease, maintain oral health, and treat injuries or impairments that may affect a beneficiary’s oral or general health. Such services must maintain a high standard of quality and must be within the reasonable limits of services customarily available and provided to most persons in the community with the limitations and exclusions specified in this policy. Only the procedure codes listed in this policy are covered under the North Carolina (NC) Medicaid (Title XIX) Dental Program. Resin-based composite restorations are allowed to restore a carious lesion into the dentin or a deeply eroded area into the dentin. Resin-based composite restorations are not covered as a preventive procedure and are not covered for treatment of cosmetic problems (such as diastemas, discolored teeth, developmental anomalies).
Authorization Guidelines
Please submit any records and any other information that you believe support the member has met the applicable medical necessity criteria to Trillium.
Limits
- • Each surface on the same tooth is covered only once per date of service.
- • Connecting or adjoining surfaces must be billed under one procedure code. Resin-based composite restorations are not covered when used as a preventive procedure. They are also not covered for cosmetic problems, including diastemas, discolored teeth, and developmental anomalies.
How to Submit
N/A - No authorization is required
Resources
Dental Services
Dental services are defined as diagnostic, preventive, or corrective procedures provided by or under the supervision of a dentist. This includes services to treat disease, maintain oral health, and treat injuries or impairments that may affect a beneficiary’s oral or general health. Such services must maintain a high standard of quality and must be within the reasonable limits of services customarily available and provided to most persons in the community with the limitations and exclusions specified in this policy. Only the procedure codes listed in this policy are covered under the North Carolina (NC) Medicaid (Title XIX) Dental Program. Resin-based composite restorations are allowed to restore a carious lesion into the dentin or a deeply eroded area into the dentin. Resin-based composite restorations are not covered as a preventive procedure and are not covered for treatment of cosmetic problems (such as diastemas, discolored teeth, developmental anomalies).
Authorization Guidelines
Please submit any records and any other information that you believe support the member has met the applicable medical necessity criteria to Trillium.
Limits
- • Each surface on the same tooth is covered only once per date of service.
- • Connecting or adjoining surfaces must be billed under one procedure code. Resin-based composite restorations are not covered when used as a preventive procedure. They are also not covered for cosmetic problems, including diastemas, discolored teeth, and developmental anomalies.
How to Submit
N/A - No authorization is required
Resources
Dental Services
Dental services are defined as diagnostic, preventive, or corrective procedures provided by or under the supervision of a dentist. This includes services to treat disease, maintain oral health, and treat injuries or impairments that may affect a beneficiary’s oral or general health. Such services must maintain a high standard of quality and must be within the reasonable limits of services customarily available and provided to most persons in the community with the limitations and exclusions specified in this policy. Only the procedure codes listed in this policy are covered under the North Carolina (NC) Medicaid (Title XIX) Dental Program. Resin-based composite restorations are allowed to restore a carious lesion into the dentin or a deeply eroded area into the dentin. Resin-based composite restorations are not covered as a preventive procedure and are not covered for treatment of cosmetic problems (such as diastemas, discolored teeth, developmental anomalies).
Authorization Guidelines
Please submit any records and any other information that you believe support the member has met the applicable medical necessity criteria to Trillium.
Limits
- • Each surface on the same tooth is covered only once per date of service.
- • Connecting or adjoining surfaces must be billed under one procedure code. Resin-based composite restorations are not covered when used as a preventive procedure. They are also not covered for cosmetic problems, including diastemas, discolored teeth, and developmental anomalies.
Exclusions
- * Not allowed on the same date of service as D2950 for the same tooth
How to Submit
N/A - No authorization is required
Resources
Dental Services
Dental services are defined as diagnostic, preventive, or corrective procedures provided by or under the supervision of a dentist. This includes services to treat disease, maintain oral health, and treat injuries or impairments that may affect a beneficiary’s oral or general health. Such services must maintain a high standard of quality and must be within the reasonable limits of services customarily available and provided to most persons in the community with the limitations and exclusions specified in this policy. Only the procedure codes listed in this policy are covered under the North Carolina (NC) Medicaid (Title XIX) Dental Program. Resin-based composite restorations are allowed to restore a carious lesion into the dentin or a deeply eroded area into the dentin. Resin-based composite restorations are not covered as a preventive procedure and are not covered for treatment of cosmetic problems (such as diastemas, discolored teeth, developmental anomalies).
Authorization Guidelines
Please submit any records and any other information that you believe support the member has met the applicable medical necessity criteria to Trillium.
Limits
- • Each surface on the same tooth is covered only once per date of service.
- • Connecting or adjoining surfaces must be billed under one procedure code. Resin-based composite restorations are not covered when used as a preventive procedure. They are also not covered for cosmetic problems, including diastemas, discolored teeth, and developmental anomalies.
Exclusions
- * Allowed for primary anterior teeth only
How to Submit
N/A - No authorization is required
Resources
Dental Services
Dental services are defined as diagnostic, preventive, or corrective procedures provided by or under the supervision of a dentist. This includes services to treat disease, maintain oral health, and treat injuries or impairments that may affect a beneficiary’s oral or general health. Such services must maintain a high standard of quality and must be within the reasonable limits of services customarily available and provided to most persons in the community with the limitations and exclusions specified in this policy. Only the procedure codes listed in this policy are covered under the North Carolina (NC) Medicaid (Title XIX) Dental Program. Resin-based composite restorations are allowed to restore a carious lesion into the dentin or a deeply eroded area into the dentin. Resin-based composite restorations are not covered as a preventive procedure and are not covered for treatment of cosmetic problems (such as diastemas, discolored teeth, developmental anomalies).
Authorization Guidelines
Please submit any records and any other information that you believe support the member has met the applicable medical necessity criteria to Trillium.
Limits
- • Each surface on the same tooth is covered only once per date of service.
- • Connecting or adjoining surfaces must be billed under one procedure code. Resin-based composite restorations are not covered when used as a preventive procedure. They are also not covered for cosmetic problems, including diastemas, discolored teeth, and developmental anomalies.
Exclusions
- * Any combination of D2391, D2392, and D2393 rendered on a single posterior primary tooth on the same date of service that exceeds the maximum allowed fee for D2393 is reimbursed at the same fee as D2393 * Any combination of D2391, D2392, D2393, and D2394 rendered on a single posterior permanent tooth on the same date of service that exceeds the maximum allowed fee for D2394 is reimbursed at the same fee as D2394
How to Submit
N/A - No authorization is required
Resources
Dental Services
Dental services are defined as diagnostic, preventive, or corrective procedures provided by or under the supervision of a dentist. This includes services to treat disease, maintain oral health, and treat injuries or impairments that may affect a beneficiary’s oral or general health. Such services must maintain a high standard of quality and must be within the reasonable limits of services customarily available and provided to most persons in the community with the limitations and exclusions specified in this policy. Only the procedure codes listed in this policy are covered under the North Carolina (NC) Medicaid (Title XIX) Dental Program. Resin-based composite restorations are allowed to restore a carious lesion into the dentin or a deeply eroded area into the dentin. Resin-based composite restorations are not covered as a preventive procedure and are not covered for treatment of cosmetic problems (such as diastemas, discolored teeth, developmental anomalies).
Authorization Guidelines
Please submit any records and any other information that you believe support the member has met the applicable medical necessity criteria to Trillium.
Limits
- • Each surface on the same tooth is covered only once per date of service.
- • Connecting or adjoining surfaces must be billed under one procedure code. Resin-based composite restorations are not covered when used as a preventive procedure. They are also not covered for cosmetic problems, including diastemas, discolored teeth, and developmental anomalies.
Exclusions
Any combination of D2391, D2392, and D2393 rendered on a single posterior primary tooth on the same date of service that exceeds the maximum allowed fee for D2393 is reimbursed at the same fee as D2393 * Any combination of D2391, D2392, D2393, and D2394 rendered on a single posterior permanent tooth on the same date of service that exceeds the maximum allowed fee for D2394 is reimbursed at the same fee as D2394
How to Submit
N/A - No authorization is required
Resources
Dental Services
Dental services are defined as diagnostic, preventive, or corrective procedures provided by or under the supervision of a dentist. This includes services to treat disease, maintain oral health, and treat injuries or impairments that may affect a beneficiary’s oral or general health. Such services must maintain a high standard of quality and must be within the reasonable limits of services customarily available and provided to most persons in the community with the limitations and exclusions specified in this policy. Only the procedure codes listed in this policy are covered under the North Carolina (NC) Medicaid (Title XIX) Dental Program. Resin-based composite restorations are allowed to restore a carious lesion into the dentin or a deeply eroded area into the dentin. Resin-based composite restorations are not covered as a preventive procedure and are not covered for treatment of cosmetic problems (such as diastemas, discolored teeth, developmental anomalies).
Authorization Guidelines
Please submit any records and any other information that you believe support the member has met the applicable medical necessity criteria to Trillium.
Limits
- • Each surface on the same tooth is covered only once per date of service.
- • Connecting or adjoining surfaces must be billed under one procedure code. Resin-based composite restorations are not covered when used as a preventive procedure. They are also not covered for cosmetic problems, including diastemas, discolored teeth, and developmental anomalies.
Exclusions
- * For primary teeth, providers should consider rendering other covered restorative services (amalgam or stainless-steel crown) when indicated due to extent of decay, behavior management concerns, inability to maintain a moisture-free field, high caries risk, etc. * Any combination of D2391, D2392, and D2393 rendered on a single posterior primary tooth on the same date of service that exceeds the maximum allowed fee for D2393 is reimbursed at the same fee as D2393 * Any combination of D2391, D2392, D2393, and D2394 rendered on a single posterior permanent tooth on the same date of service that exceeds the maximum allowed fee for D2394 is reimbursed at the same fee as D2394
How to Submit
N/A - No authorization is required
Resources
Dental Services
Dental services are defined as diagnostic, preventive, or corrective procedures provided by or under the supervision of a dentist. This includes services to treat disease, maintain oral health, and treat injuries or impairments that may affect a beneficiary’s oral or general health. Such services must maintain a high standard of quality and must be within the reasonable limits of services customarily available and provided to most persons in the community with the limitations and exclusions specified in this policy. Only the procedure codes listed in this policy are covered under the North Carolina (NC) Medicaid (Title XIX) Dental Program. Resin-based composite restorations are allowed to restore a carious lesion into the dentin or a deeply eroded area into the dentin. Resin-based composite restorations are not covered as a preventive procedure and are not covered for treatment of cosmetic problems (such as diastemas, discolored teeth, developmental anomalies).
Authorization Guidelines
Please submit any records and any other information that you believe support the member has met the applicable medical necessity criteria to Trillium.
Limits
- • Each surface on the same tooth is covered only once per date of service.
- • Connecting or adjoining surfaces must be billed under one procedure code. Resin-based composite restorations are not covered when used as a preventive procedure. They are also not covered for cosmetic problems, including diastemas, discolored teeth, and developmental anomalies.
Exclusions
- * Allowed for permanent posterior teeth only * Not allowed on the same date of service as D2950 for the same tooth * Any combination of D2391, D2392, D2393, and D2394 rendered on a single posterior permanent tooth on the same date of service that exceeds the maximum allowed fee for D2394 is reimbursed at the same fee as D2394
How to Submit
N/A - No authorization is required
Resources
Dental Services
Dental services are defined as diagnostic, preventive, or corrective procedures provided by or under the supervision of a dentist. This includes services to treat disease, maintain oral health, and treat injuries or impairments that may affect a beneficiary’s oral or general health. Such services must maintain a high standard of quality and must be within the reasonable limits of services customarily available and provided to most persons in the community with the limitations and exclusions specified in this policy. Only the procedure codes listed in this policy are covered under the North Carolina (NC) Medicaid (Title XIX) Dental Program.
Authorization Guidelines
Please submit any records and any other information that you believe support the member has met the applicable medical necessity criteria to Trillium.
Limits
Medicaid will pay for a maximum of six crowns per beneficiary for a single date of service.
- a. This limitation applies to procedure codes D2390, D2930, D2931, D2932, D2933, and D2934 or to any combination of these codes delivered on the same date of service.
- b. This limitation does not apply to beneficiaries treated under general anesthesia in a hospital or ambulatory surgical center.
- c. If a provider believes that medical necessity warrants delivery of more than six crowns for a beneficiary on a single date of service, the provider shall submit a prior approval request along with a letter describing the special circumstances of the case. D2931 is limited to permanent premolars and first and second molars.
Exclusions
Other Restorative Services are not covered when policy criteria are not met. General dental exclusions relevant to this category include cosmetic procedures and all crowns except resin-based composite crowns, prefabricated crowns, and temporary crowns. Within restorative services, primary tooth restorations are not allowed when normal exfoliation is imminent. For related restorative crown services, D2394 is allowed for permanent posterior teeth only and is not allowed on the same date of service as D2950 for the same tooth; D2335 is not allowed on the same date of service as D2950 for the same tooth.
How to Submit
N/A - No authorization is required
Resources
Dental Services
Dental services are defined as diagnostic, preventive, or corrective procedures provided by or under the supervision of a dentist. This includes services to treat disease, maintain oral health, and treat injuries or impairments that may affect a beneficiary’s oral or general health. Such services must maintain a high standard of quality and must be within the reasonable limits of services customarily available and provided to most persons in the community with the limitations and exclusions specified in this policy. Only the procedure codes listed in this policy are covered under the North Carolina (NC) Medicaid (Title XIX) Dental Program.
Authorization Guidelines
Please submit any records and any other information that you believe support the member has met the applicable medical necessity criteria to Trillium.
Limits
Medicaid will pay for a maximum of six crowns per beneficiary for a single date of service.
- a. This limitation applies to procedure codes D2390, D2930, D2931, D2932, D2933, and D2934 or to any combination of these codes delivered on the same date of service.
- b. This limitation does not apply to beneficiaries treated under general anesthesia in a hospital or ambulatory surgical center.
- c. If a provider believes that medical necessity warrants delivery of more than six crowns for a beneficiary on a single date of service, the provider shall submit a prior approval request along with a letter describing the special circumstances of the case. D2931 is limited to permanent premolars and first and second molars.
Exclusions
Other Restorative Services are not covered when policy criteria are not met. General dental exclusions relevant to this category include cosmetic procedures and all crowns except resin-based composite crowns, prefabricated crowns, and temporary crowns. Within restorative services, primary tooth restorations are not allowed when normal exfoliation is imminent. For related restorative crown services, D2394 is allowed for permanent posterior teeth only and is not allowed on the same date of service as D2950 for the same tooth; D2335 is not allowed on the same date of service as D2950 for the same tooth.
Additional Service Specifics
- * Limited to permanent premolars and first and second molars
How to Submit
N/A - No authorization is required
Resources
If you find any wrong or out of date information on our pages, we want to know. Please email info@TrilliumNC.org with any corrections.