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
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 primary and permanent anterior teeth
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 primary anterior teeth
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 primary anterior teeth
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
- * Use for placement of restorative material to protect the tooth, relieve pain,
promote healing, or prevent further deterioration
- * Not allowed for billing of a temporary filling while awaiting completion of
endodontic therapy
- * Not allowed as a base or liner under a restoration
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
The provider(s) shall submit to the following:
- a. the prior approval request; and
- b. all health records and any other records that support the beneficiary has met
the specific criteria in Subsection 3.2 of this policy.
As indicated in Subsection 5.3, the provider shall submit a request for prior approval before rendering certain dental services. Prior approval applies only to procedures, not to reimbursement amounts and does not guarantee payment. The beneficiary’s eligibility for the date of service must be verified before rendering treatment. Failure to obtain required prior approval before rendering a service shall result in denial of payment for that service. The Medicaid program has the right to require prior approval for any services by providers who have been or are under investigation by NC Medicaid.
A prior approval request consists of the following:
- a. Electronic entry into the NCTracks Prior Approval Portal or a completed
2019 American Dental Association (ADA) Dental Claim Form submitted by mail;
- b. Properly arranged radiographic images that are clearly labeled with the date
taken, the provider’s name, and the beneficiary’s name;
- c. Documentation as specified in Subsection 5.3 Limitations or
Requirements; and
- d. Any additional information to clarify unusual circumstances or explain the
complexity of the treatment plan such as a pre-treatment narrative, periodontal charting, photographic images, and etc.
When radiographic images cannot be obtained, the provider shall include a written explanation and shall complete the tooth chart in field 33 on the ADA Dental Claim Form. Panoramic radiographic images must be labeled clearly to indicate the beneficiary’s left and right. All radiographic images must be of diagnostic quality suitable for interpretation and must be retained in the beneficiary’s record for a minimum of six years for the purpose of Medicaid post-payment review (minimum of 10 years per NC State Dental Board of Examiners rules). Prior approval requests must be entered in the NCTracks Prior Approval Portal or mailed to the address listed below.
Limits
- * Limited to teeth prepared for a crown that has been approved as a noncovered service
- * Placement of restorative material to yield a more ideal form, including the
elimination of undercuts
Age Group Details
- * Limited to recipients age 16 and older
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
- * Not allowed on the same date of service as D2161, D2335, D2394, or D2951 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
- * 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
- * Not allowed for the same tooth on the same date of service as D3222,
D3230, D3240, D3310, D3320, or D3330
- * Not to be construed as the first stage of root canal therapy
Exclusions
Medicaid will pay for a maximum of six pulpotomies per beneficiary for a single date of service.
- a. This limitation applies to procedure code D3220.
- b. This limitation does not apply to a beneficiary 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 pulpotomies 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.
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
- * Not allowed for the same tooth on the same date of service as D3220, D3230, D3240, D3310, D3320, or D3330 * Not to be construed as the first stage of root canal therapy
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
- * Not allowed for the same tooth on the same date of service as D3220 or D3222
Age Group Details
- * Limited to beneficiaries under six 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
- * Allowed for primary second molars only * Not allowed for the same tooth on the same date of service as D3220 or D3222
Age Group Details
Limited to beneficiaries under nine 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
- * Permanent anterior teeth only
- * Not allowed for the same tooth on the same date of service as D3220 or
D3222
- * Request reimbursement using the date of completion as the service date
Exclusions
Diagnostic radiographic images may be billed separately as needed.
Progress radiographic images taken during root canal therapy and all appointments needed to complete treatment are included in the procedure and must not be billed separately.
All radiographic images must be maintained in the beneficiary record.
D3310 is limited to permanent anterior teeth only.
D3320 is limited to beneficiaries under 21 years of age. For this endodontic therapy subsection, progress radiographic images taken during root canal therapy and all appointments necessary to complete treatment are not separately billable because they are included in the procedure.
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
- * Permanent anterior teeth only
- * Not allowed for the same tooth on the same date of service as D3220 or
D3222
- * Request reimbursement using the date of completion as the service date
Exclusions
Diagnostic radiographic images may be billed separately as needed.
Progress radiographic images taken during root canal therapy and all appointments needed to complete treatment are included in the procedure and must not be billed separately.
All radiographic images must be maintained in the beneficiary record.
D3310 is limited to permanent anterior teeth only.
D3320 is limited to beneficiaries under 21 years of age. For this endodontic therapy subsection, progress radiographic images taken during root canal therapy and all appointments necessary to complete treatment are not separately billable because they are included in the procedure.
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
- * Permanent anterior teeth only
- * Not allowed for the same tooth on the same date of service as D3220 or
D3222
- * Request reimbursement using the date of completion as the service date
Exclusions
Diagnostic radiographic images may be billed separately as needed.
Progress radiographic images taken during root canal therapy and all appointments needed to complete treatment are included in the procedure and must not be billed separately.
All radiographic images must be maintained in the beneficiary record.
D3310 is limited to permanent anterior teeth only.
D3320 is limited to beneficiaries under 21 years of age. For this endodontic therapy subsection, progress radiographic images taken during root canal therapy and all appointments necessary to complete treatment are not separately billable because they are included in the procedure.
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
Not allowed for the same tooth on the same date of service as D3220, D3222, D3230, D3240, D3310, D3320, or D3330. D3351, D3352, and D3353: for beneficiaries under 21 years of age, covered for permanent teeth.
D3351, D3352, and D3353: for beneficiaries 21 years of age and older, limited to permanent anterior teeth only.
Exclusions
Diagnostic radiographic images may be billed separately as needed.
Progress radiographic images taken during root canal therapy and all appointments needed to complete treatment are included in the procedure and must not be billed separately.
All radiographic images must be maintained in the beneficiary record.
D3310 is limited to permanent anterior teeth only.
D3320 is limited to beneficiaries under 21 years of age. For this endodontic therapy subsection, progress radiographic images taken during root canal therapy and all appointments necessary to complete treatment are not separately billable because they are included in the procedure.
Age Group Details
- * For beneficiaries under 21 years of age, covered for permanent teeth * For beneficiaries 21 years of age and older, limited to permanent 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.
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
Not allowed for the same tooth on the same date of service as D3220, D3222, D3230, D3240, D3310, D3320, or D3330. D3351, D3352, and D3353: for beneficiaries under 21 years of age, covered for permanent teeth.
D3351, D3352, and D3353: for beneficiaries 21 years of age and older, limited to permanent anterior teeth only.
D3352 is allowed four times per year.
Exclusions
Diagnostic radiographic images may be billed separately as needed.
Progress radiographic images taken during root canal therapy and all appointments needed to complete treatment are included in the procedure and must not be billed separately.
All radiographic images must be maintained in the beneficiary record.
D3310 is limited to permanent anterior teeth only.
D3320 is limited to beneficiaries under 21 years of age. For this endodontic therapy subsection, progress radiographic images taken during root canal therapy and all appointments necessary to complete treatment are not separately billable because they are included in the procedure.
Age Group Details
- * For beneficiaries under 21 years of age, covered for permanent teeth * For beneficiaries 21 years of age and older, limited to permanent 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.
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
Not allowed for the same tooth on the same date of service as D3220, D3222, D3230, D3240, D3310, D3320, or D3330. D3351, D3352, and D3353: for beneficiaries under 21 years of age, covered for permanent teeth.
D3351, D3352, and D3353: for beneficiaries 21 years of age and older, limited to permanent anterior teeth only.
D3352 is allowed four times per year.
Exclusions
Diagnostic radiographic images may be billed separately as needed.
Progress radiographic images taken during root canal therapy and all appointments needed to complete treatment are included in the procedure and must not be billed separately.
All radiographic images must be maintained in the beneficiary record.
D3310 is limited to permanent anterior teeth only.
D3320 is limited to beneficiaries under 21 years of age. For this endodontic therapy subsection, progress radiographic images taken during root canal therapy and all appointments necessary to complete treatment are not separately billable because they are included in the procedure.
Age Group Details
- * For beneficiaries under 21 years of age, covered for permanent teeth * For beneficiaries 21 years of age and older, limited to permanent 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.
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 permanent teeth only
- * Includes opening tooth, preparation of canal spaces, and placement of medication
Exclusions
Pulpal regeneration is not covered when the beneficiary does not meet the policy's coverage criteria and limitations, including when the service is outside the service-specific age or tooth-type restrictions. Medicaid also does not cover services that are experimental, investigational, or part of a clinical trial.
Age Group Details
- * For beneficiaries under 21 years of age, covered for permanent teeth * For beneficiaries 21 years of age and older, limited to permanent 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.
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 permanent teeth only
Age Group Details
- * For beneficiaries under 21 years of age, covered for permanent teeth * For beneficiaries 21 years of age and older, limited to permanent 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.
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 permanent teeth only
- * Does not include final restoration
Age Group Details
- * For beneficiaries under 21 years of age, covered for permanent teeth * For beneficiaries 21 years of age and older, limited to permanent anterior teeth only
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.