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
- * Limited to permanent anterior teeth only
Exclusions
Apicoectomy/periradicular service D3410 is not covered for teeth outside the stated code limitation, because the procedure is limited to permanent anterior 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
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
- * Includes scaling and root planing
- * Allowed once in a lifetime
- * Requires pretreatment narrative documenting underlying medical condition
- * Requires periodontal charting (pocket depth measurements must be
abnormal)
- * Requires current diagnostic radiographic images of the proposed surgical
site
- * Requires current diagnostic photographic images of the proposed surgical
site
- * Requires a quadrant indicator in the area of oral cavity
- * Not allowed for the same quadrant as D4211, D4240, D4241, D4341, or
D4342 on the same date of servic
Exclusions
D4210 is allowed once in a lifetime.
D4211 is allowed once in a lifetime.
A quadrant indicator in the area of oral cavity is required for D4210 and D4211.
Not allowed for the same quadrant as D4211, D4240, D4241, D4341, or D4342 on the same date of service for D4210.
Not allowed for the same quadrant as D4210, D4240, D4241, D4341, or D4342 on the same date of service for D4211.
Dental prophylaxis and periodontal procedures, including D4210, D4211, D4240, and D4241, are not allowed on the same date of service for the same beneficiary. Dental prophylaxis and periodontal procedures are not allowed in any combination on the same date of service for the same beneficiary.
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
- * Includes scaling and root planing
- * Allowed once in a lifetime
- * Requires pretreatment narrative documenting underlying medical condition
- * Requires periodontal charting (pocket depth measurements must be
abnormal)
- * Requires current diagnostic radiographic images of the proposed surgical
site
- * Requires current diagnostic photographic images of the proposed surgical
site
- * Requires a quadrant indicator in the area of oral cavity
- * Not allowed for the same quadrant as D4211, D4240, D4241, D4341, or
D4342 on the same date of servic
Exclusions
D4210 is allowed once in a lifetime.
D4211 is allowed once in a lifetime.
A quadrant indicator in the area of oral cavity is required for D4210 and D4211.
Not allowed for the same quadrant as D4211, D4240, D4241, D4341, or D4342 on the same date of service for D4210.
Not allowed for the same quadrant as D4210, D4240, D4241, D4341, or D4342 on the same date of service for D4211.
Dental prophylaxis and periodontal procedures, including D4210, D4211, D4240, and D4241, are not allowed on the same date of service for the same beneficiary. Dental prophylaxis and periodontal procedures are not allowed in any combination on the same date of service for the same beneficiary.
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
- * Includes scaling and root planing
- * Allowed once in a lifetime
- * Requires pretreatment narrative documenting underlying medical condition
- * Requires periodontal charting (pocket depth measurements must be
abnormal)
- * Requires current diagnostic radiographic images of the proposed surgical
site
- * Requires current diagnostic photographic images of the proposed surgical
site
- * Requires a quadrant indicator in the area of oral cavity
- * Not allowed for the same quadrant as D4211, D4240, D4241, D4341, or
D4342 on the same date of servic
Exclusions
D4210 is allowed once in a lifetime.
D4211 is allowed once in a lifetime.
A quadrant indicator in the area of oral cavity is required for D4210 and D4211.
Not allowed for the same quadrant as D4211, D4240, D4241, D4341, or D4342 on the same date of service for D4210.
Not allowed for the same quadrant as D4210, D4240, D4241, D4341, or D4342 on the same date of service for D4211.
Dental prophylaxis and periodontal procedures, including D4210, D4211, D4240, and D4241, are not allowed on the same date of service for the same beneficiary. Dental prophylaxis and periodontal procedures are not allowed in any combination on the same date of service for the same beneficiary.
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
- * Includes scaling and root planing
- * Allowed once in a lifetime
- * Requires pretreatment narrative documenting underlying medical condition
- * Requires periodontal charting (pocket depth measurements must be
abnormal)
- * Requires current diagnostic radiographic images of the proposed surgical
site
- * Requires current diagnostic photographic images of the proposed surgical
site
- * Requires a quadrant indicator in the area of oral cavity
- * Not allowed for the same quadrant as D4211, D4240, D4241, D4341, or
D4342 on the same date of servic
Exclusions
D4210 is allowed once in a lifetime.
D4211 is allowed once in a lifetime.
A quadrant indicator in the area of oral cavity is required for D4210 and D4211.
Not allowed for the same quadrant as D4211, D4240, D4241, D4341, or D4342 on the same date of service for D4210.
Not allowed for the same quadrant as D4210, D4240, D4241, D4341, or D4342 on the same date of service for D4211.
Dental prophylaxis and periodontal procedures, including D4210, D4211, D4240, and D4241, are not allowed on the same date of service for the same beneficiary. Dental prophylaxis and periodontal procedures are not allowed in any combination on the same date of service for the same beneficiary.
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
- * Each quadrant is allowed one time per 24-month interval
- * Requires periodontal charting (probing depth measurements must be
abnormal in multiple sites) or radiographic evidence of bone loss
- * Limited to no more than two quadrants of scaling and root planing on the
same date of service. This limitation does not apply to beneficiaries treated under general anesthesia in a hospital or ambulatory surgical center
- * Requires a quadrant indicator in the area of oral cavity
- * Not allowed for the same quadrant as D4210, D4211, D4240, D4241, or
D4342 on the same date of service
- * Allowed once in a lifetime
- * Requires pretreatment narrative documenting underlying medical condition
- * Requires periodontal charting (pocket depth measurements must be
abnormal)
- * Requires current diagnostic radiographic images of the proposed surgical
site
- * Requires current diagnostic photographic images of the proposed surgical
site
- * Requires a quadrant indicator in the area of oral cavity
- * Not allowed for the same quadrant as D4211, D4240, D4241, D4341, or
D4342 on the same date of servic
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
- * Each quadrant is allowed one time per 24-month interval
- * Requires periodontal charting (probing depth measurements must be
abnormal in multiple sites) or radiographic evidence of bone loss
- * Limited to no more than two quadrants of scaling and root planing on the
same date of service. This limitation does not apply to beneficiaries treated under general anesthesia in a hospital or ambulatory surgical center
- * Requires a quadrant indicator in the area of oral cavity
- * Not allowed for the same quadrant as D4210, D4211, D4240, D4241, or
D4342 on the same date of service
- * Allowed once in a lifetime
- * Requires pretreatment narrative documenting underlying medical condition
- * Requires periodontal charting (pocket depth measurements must be
abnormal)
- * Requires current diagnostic radiographic images of the proposed surgical
site
- * Requires current diagnostic photographic images of the proposed surgical
site
- * Requires a quadrant indicator in the area of oral cavity
- * Not allowed for the same quadrant as D4210, D4211, D4240, D4241, or
D4341 on the same date of service
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
∗ Reported instead of an adult prophylaxis for beneficiaries who have swollen, inflamed gingiva, generalized suprabony pockets and moderate to severe bleeding upon probing ∗ One procedure of D1110, D4346 or D4910 is allowed once per beneficiary per six calendar month period for the same provider ∗ Not allowed for an individual beneficiary on the same date of service as a prophylaxis (D1110) or periodontal procedures (D4210, D4211, D4240, D4241, D4341, D4342, D4355 or D4910)
Age Group Details
∗ Limited to beneficiaries age 13 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
- * Allowed one time per 12-month interval
- * Requires documentation in the beneficiary’s chart of extenuating
circumstances that warrant the comprehensive oral evaluation (D0150) or detailed and extensive oral evaluation (D0160) to be rendered on the same date of service following the full mouth debridement (for example, hardship due to issues regarding transportation, health, work, school, childcare, etc.)
- * Not allowed on the same date of service as D1110, D1120, D4210, D4211,
D4240, D4241, D4341, D4342, D4346, or D4910
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 only if D4210, D4211, D4240, or D4241 precedes this treatment
- * Allowed two (2) times per year
- * Procedure may be alternated with D1110
- * Not allowed on same date of service as D1110, D1120, D4210, D4211,
D4240, D4241, D4341, D4342, or D4355
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
Only one denture, complete or immediate, is allowed per arch every 10 years.
Providers must use the date of delivery as the date of service when requesting payment for a denture.
Payment for complete dentures includes any adjustments or relines necessary for six months after the date of delivery, regardless of Medicaid eligibility status.
In nursing facilities or adult care homes, prior approval for fabrication of a complete denture is granted only if accompanied by the completed DHB 6022 supplement.
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
Only one denture, complete or immediate, is allowed per arch every 10 years.
Providers must use the date of delivery as the date of service when requesting payment for a denture.
Payment for complete dentures includes any adjustments or relines necessary for six months after the date of delivery, regardless of Medicaid eligibility status.
In nursing facilities or adult care homes, prior approval for fabrication of a complete denture is granted only if accompanied by the completed DHB 6022 supplement.
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
Only one denture, complete or immediate, is allowed per arch every 10 years.
Providers must use the date of delivery as the date of service when requesting payment for a denture.
Payment for complete dentures includes any adjustments or relines necessary for six months after the date of delivery, regardless of Medicaid eligibility status.
In nursing facilities or adult care homes, prior approval for fabrication of a complete denture is granted only if accompanied by the completed DHB 6022 supplement.
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
Only one denture, complete or immediate, is allowed per arch every 10 years.
Providers must use the date of delivery as the date of service when requesting payment for a denture.
Payment for complete dentures includes any adjustments or relines necessary for six months after the date of delivery, regardless of Medicaid eligibility status.
In nursing facilities or adult care homes, prior approval for fabrication of a complete denture is granted only if accompanied by the completed DHB 6022 supplement.
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
Only one denture, complete or immediate, is allowed per arch every 10 years.
Providers must use the date of delivery as the date of service when requesting payment for a denture.
Payment for complete dentures includes any adjustments or relines necessary for six months after the date of delivery, regardless of Medicaid eligibility status.
In nursing facilities or adult care homes, prior approval for fabrication of a complete denture is granted only if accompanied by the completed DHB 6022 supplement.
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
Only one partial denture is allowed per arch every eight years. Medicaid does not cover temporary or interim dentures, cast metal partial dentures, or unilateral partial dentures. All necessary preparation of the oral cavity must be complete prior to denture delivery. Hand delivery of an appliance to a beneficiary does not constitute delivery of an appliance. Partial dentures delivered by another provider (for example, an immediate partial denture) shall be forwarded directly to that provider. Providers must use date of delivery as the date of service when requesting payment for a denture. Payment includes any adjustments or relines necessary for six months after the date of delivery regardless of Medicaid eligibility status.
Exclusions
In a nursing facility or adult care home, prior approval for fabrication of a partial denture is granted only with DHB 6022.Medicaid does not cover temporary or interim partial dentures, cast metal partial dentures, or unilateral partial dentures.
Age Group Details
For beneficiaries under 21 years of age
- • Any missing anterior teeth (incisors or
canines)
- • Two missing first molars in an arch
- • Three missing posterior permanent teeth in
an arch
- • Two adjacent missing posterior permanent
teeth in an arch For beneficiaries age 21 and older
- • Any missing anterior teeth (incisors or canines)
- • Four missing posterior permanent teeth in an
arch
- • Three adjacent missing posterior permanent teeth
in an arch
Additional Service Specifics
Missing third molars do not count when determining Medicaid coverage for a partial denture. Appliances shall not be authorized when radiographic images show substantial space closure after tooth loss due to tooth migration preventing replacement of the missing tooth. The provider must document mobility, pocket depth, presence of inflammation, and prognosis for periodontally compromised abutment teeth. The provider must also indicate whether it would be possible to add teeth to the partial or convert it to a complete denture if the compromised abutment teeth are lost.
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
Only one partial denture is allowed per arch every eight years. Medicaid does not cover temporary or interim dentures, cast metal partial dentures, or unilateral partial dentures. All necessary preparation of the oral cavity must be complete prior to denture delivery. Hand delivery of an appliance to a beneficiary does not constitute delivery of an appliance. Partial dentures delivered by another provider (for example, an immediate partial denture) shall be forwarded directly to that provider. Providers must use date of delivery as the date of service when requesting payment for a denture. Payment includes any adjustments or relines necessary for six months after the date of delivery regardless of Medicaid eligibility status.
Exclusions
In a nursing facility or adult care home, prior approval for fabrication of a partial denture is granted only with DHB 6022.Medicaid does not cover temporary or interim partial dentures, cast metal partial dentures, or unilateral partial dentures.
Age Group Details
For beneficiaries under 21 years of age
- • Any missing anterior teeth (incisors or
canines)
- • Two missing first molars in an arch
- • Three missing posterior permanent teeth in
an arch
- • Two adjacent missing posterior permanent
teeth in an arch For beneficiaries age 21 and older
- • Any missing anterior teeth (incisors or canines)
- • Four missing posterior permanent teeth in an
arch
- • Three adjacent missing posterior permanent teeth
in an arch
Additional Service Specifics
Missing third molars do not count when determining Medicaid coverage for a partial denture. Appliances shall not be authorized when radiographic images show substantial space closure after tooth loss due to tooth migration preventing replacement of the missing tooth. The provider must document mobility, pocket depth, presence of inflammation, and prognosis for periodontally compromised abutment teeth. The provider must also indicate whether it would be possible to add teeth to the partial or convert it to a complete denture if the compromised abutment teeth are lost.
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
For denture replacement override requests based on significant medical condition, the dentist must state that the existing denture cannot be made functional by adjusting or relining it and that a new denture is likely to be functional.
Exclusions
In a nursing facility or adult care home, prior approval for fabrication of a partial denture is granted only with DHB 6022.Medicaid does not cover temporary or interim partial dentures, cast metal partial dentures, or unilateral partial dentures.
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
For denture replacement override requests based on significant medical condition, the dentist must state that the existing denture cannot be made functional by adjusting or relining it and that a new denture is likely to be functional.
Exclusions
In a nursing facility or adult care home, prior approval for fabrication of a partial denture is granted only with DHB 6022.Medicaid does not cover temporary or interim partial dentures, cast metal partial dentures, or unilateral partial dentures.
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
For denture replacement override requests based on significant medical condition, the dentist must state that the existing denture cannot be made functional by adjusting or relining it and that a new denture is likely to be functional.
Exclusions
In a nursing facility or adult care home, prior approval for fabrication of a partial denture is granted only with DHB 6022.Medicaid does not cover temporary or interim partial dentures, cast metal partial dentures, or unilateral partial dentures.
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.