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
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
If multiple repairs are made to one appliance on the same date of service, the first repair is reimbursed at 100 percent of the maximum allowed rate and subsequent repairs at 35 percent of the maximum allowed rate
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
If multiple repairs are made to one appliance on the same date of service, the first repair is reimbursed at 100 percent of the maximum allowed rate and subsequent repairs at 35 percent of the maximum allowed rate
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
If multiple repairs are made to one appliance on the same date of service, the first repair is reimbursed at 100 percent of the maximum allowed rate and subsequent repairs at 35 percent of the maximum allowed rate
Other Information
- * Requires a tooth number in the tooth number field
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
If multiple repairs are made to one appliance on the same date of service, the first repair is reimbursed at 100 percent of the maximum allowed rate and subsequent repairs at 35 percent of the maximum allowed rate
Exclusions
Appliances are not authorized when repair or reline would make existing appliances serviceable. Appliances are also not authorized when lost by the beneficiary, hospital, or nursing home. More generally for removable prosthodontics, appliances are not authorized when extractions are not medically necessary, or when the beneficiary's dental history indicates negligence in appliance care or physiological or psychological problems that have caused previous dentures to be unsatisfactory.
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
If multiple repairs are made to one appliance on the same date of service, the first repair is reimbursed at 100 percent of the maximum allowed rate and subsequent repairs at 35 percent of the maximum allowed rate
Exclusions
Appliances are not authorized when repair or reline would make existing appliances serviceable. Appliances are also not authorized when lost by the beneficiary, hospital, or nursing home. More generally for removable prosthodontics, appliances are not authorized when extractions are not medically necessary, or when the beneficiary's dental history indicates negligence in appliance care or physiological or psychological problems that have caused previous dentures to be unsatisfactory.
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
If multiple repairs are made to one appliance on the same date of service, the first repair is reimbursed at 100 percent of the maximum allowed rate and subsequent repairs at 35 percent of the maximum allowed rate
Exclusions
Appliances are not authorized when repair or reline would make existing appliances serviceable. Appliances are also not authorized when lost by the beneficiary, hospital, or nursing home. More generally for removable prosthodontics, appliances are not authorized when extractions are not medically necessary, or when the beneficiary's dental history indicates negligence in appliance care or physiological or psychological problems that have caused previous dentures to be unsatisfactory.
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
If multiple repairs are made to one appliance on the same date of service, the first repair is reimbursed at 100 percent of the maximum allowed rate and subsequent repairs at 35 percent of the maximum allowed rate
Exclusions
Appliances are not authorized when repair or reline would make existing appliances serviceable. Appliances are also not authorized when lost by the beneficiary, hospital, or nursing home. More generally for removable prosthodontics, appliances are not authorized when extractions are not medically necessary, or when the beneficiary's dental history indicates negligence in appliance care or physiological or psychological problems that have caused previous dentures to be unsatisfactory.
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
If multiple repairs are made to one appliance on the same date of service, the first repair is reimbursed at 100 percent of the maximum allowed rate and subsequent repairs at 35 percent of the maximum allowed rate
Exclusions
Appliances are not authorized when repair or reline would make existing appliances serviceable. Appliances are also not authorized when lost by the beneficiary, hospital, or nursing home. More generally for removable prosthodontics, appliances are not authorized when extractions are not medically necessary, or when the beneficiary's dental history indicates negligence in appliance care or physiological or psychological problems that have caused previous dentures to be unsatisfactory.
Additional Service Specifics
- * Requires a tooth number in the tooth number field
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
If multiple repairs are made to one appliance on the same date of service, the first repair is reimbursed at 100 percent of the maximum allowed rate and subsequent repairs at 35 percent of the maximum allowed rate
Exclusions
Appliances are not authorized when repair or reline would make existing appliances serviceable. Appliances are also not authorized when lost by the beneficiary, hospital, or nursing home. More generally for removable prosthodontics, appliances are not authorized when extractions are not medically necessary, or when the beneficiary's dental history indicates negligence in appliance care or physiological or psychological problems that have caused previous dentures to be unsatisfactory.
Additional Service Specifics
- * Requires a tooth number in the tooth number field
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
If multiple repairs are made to one appliance on the same date of service, the first repair is reimbursed at 100 percent of the maximum allowed rate and subsequent repairs at 35 percent of the maximum allowed rate
Exclusions
Appliances are not authorized when repair or reline would make existing appliances serviceable. Appliances are also not authorized when lost by the beneficiary, hospital, or nursing home. More generally for removable prosthodontics, appliances are not authorized when extractions are not medically necessary, or when the beneficiary's dental history indicates negligence in appliance care or physiological or psychological problems that have caused previous dentures to be unsatisfactory.
Additional Service Specifics
- * Requires a tooth number in the tooth number field
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
If multiple repairs are made to one appliance on the same date of service, the first repair is reimbursed at 100 percent of the maximum allowed rate and subsequent repairs at 35 percent of the maximum allowed rate
Exclusions
Appliances are not authorized when repair or reline would make existing appliances serviceable. Appliances are also not authorized when lost by the beneficiary, hospital, or nursing home. More generally for removable prosthodontics, appliances are not authorized when extractions are not medically necessary, or when the beneficiary's dental history indicates negligence in appliance care or physiological or psychological problems that have caused previous dentures to be unsatisfactory.
Additional Service Specifics
- * Requires a tooth number in the tooth number field
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
Allowed for a laboratory reline. The provider may request prior approval for the initial reline of a complete or partial denture beginning six months after the date of delivery of the denture. Subsequent relines are allowed once every five years. Medicaid does not cover tissue conditioning, soft relines, or rebase procedures.
Note: For an immediate denture (D5130 or D5140), the initial reline may be approved and rendered earlier than six months from denture delivery if the provider determines that healing of extraction sites is essentially complete and a reline is necessary to ensure proper fit and function of the denture. Subsequent relines are allowed once every five years
Exclusions
Complete denture payment includes any adjustments or relines needed for 6 months after delivery.
Immediate denture payment includes all adjustments needed for 6 months after delivery.
Partial denture payment includes any adjustments or relines needed for 6 months after delivery. Medicaid does not cover tissue conditioning, soft relines, or rebase procedures. In addition, removable prosthodontic appliances are not authorized when repair or reline would make existing appliances serviceable, and appliances are not authorized when lost by the beneficiary, hospital, or nursing home.
Additional Service Specifics
- * Requires a tooth number in the tooth number field
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
Allowed for a laboratory reline. The provider may request prior approval for the initial reline of a complete or partial denture beginning six months after the date of delivery of the denture. Subsequent relines are allowed once every five years. Medicaid does not cover tissue conditioning, soft relines, or rebase procedures.
Note: For an immediate denture (D5130 or D5140), the initial reline may be approved and rendered earlier than six months from denture delivery if the provider determines that healing of extraction sites is essentially complete and a reline is necessary to ensure proper fit and function of the denture. Subsequent relines are allowed once every five years
Exclusions
Complete denture payment includes any adjustments or relines needed for 6 months after delivery.
Immediate denture payment includes all adjustments needed for 6 months after delivery.
Partial denture payment includes any adjustments or relines needed for 6 months after delivery. Medicaid does not cover tissue conditioning, soft relines, or rebase procedures. In addition, removable prosthodontic appliances are not authorized when repair or reline would make existing appliances serviceable, and appliances are not authorized when lost by the beneficiary, hospital, or nursing home.
Additional Service Specifics
- * Requires a tooth number in the tooth number field
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
Allowed for a laboratory reline. The provider may request prior approval for the initial reline of a complete or partial denture beginning six months after the date of delivery of the denture. Subsequent relines are allowed once every five years. Medicaid does not cover tissue conditioning, soft relines, or rebase procedures.
Note: For an immediate denture (D5130 or D5140), the initial reline may be approved and rendered earlier than six months from denture delivery if the provider determines that healing of extraction sites is essentially complete and a reline is necessary to ensure proper fit and function of the denture. Subsequent relines are allowed once every five years
Exclusions
Complete denture payment includes any adjustments or relines needed for 6 months after delivery.
Immediate denture payment includes all adjustments needed for 6 months after delivery.
Partial denture payment includes any adjustments or relines needed for 6 months after delivery. Medicaid does not cover tissue conditioning, soft relines, or rebase procedures. In addition, removable prosthodontic appliances are not authorized when repair or reline would make existing appliances serviceable, and appliances are not authorized when lost by the beneficiary, hospital, or nursing home.
Additional Service Specifics
- * Requires a tooth number in the tooth number field
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
Allowed for a laboratory reline. The provider may request prior approval for the initial reline of a complete or partial denture beginning six months after the date of delivery of the denture. Subsequent relines are allowed once every five years. Medicaid does not cover tissue conditioning, soft relines, or rebase procedures.
Note: For an immediate denture (D5130 or D5140), the initial reline may be approved and rendered earlier than six months from denture delivery if the provider determines that healing of extraction sites is essentially complete and a reline is necessary to ensure proper fit and function of the denture. Subsequent relines are allowed once every five years
Exclusions
Complete denture payment includes any adjustments or relines needed for 6 months after delivery.
Immediate denture payment includes all adjustments needed for 6 months after delivery.
Partial denture payment includes any adjustments or relines needed for 6 months after delivery. Medicaid does not cover tissue conditioning, soft relines, or rebase procedures. In addition, removable prosthodontic appliances are not authorized when repair or reline would make existing appliances serviceable, and appliances are not authorized when lost by the beneficiary, hospital, or nursing home.
Additional Service Specifics
- * Requires a tooth number in the tooth number field
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
Allowed for a laboratory reline. The provider may request prior approval for the initial reline of a complete or partial denture beginning six months after the date of delivery of the denture. Subsequent relines are allowed once every five years. Medicaid does not cover tissue conditioning, soft relines, or rebase procedures.
Note: For an immediate denture (D5130 or D5140), the initial reline may be approved and rendered earlier than six months from denture delivery if the provider determines that healing of extraction sites is essentially complete and a reline is necessary to ensure proper fit and function of the denture. Subsequent relines are allowed once every five years
Exclusions
Complete denture payment includes any adjustments or relines needed for 6 months after delivery.
Immediate denture payment includes all adjustments needed for 6 months after delivery.
Partial denture payment includes any adjustments or relines needed for 6 months after delivery. Medicaid does not cover tissue conditioning, soft relines, or rebase procedures. In addition, removable prosthodontic appliances are not authorized when repair or reline would make existing appliances serviceable, and appliances are not authorized when lost by the beneficiary, hospital, or nursing home.
Additional Service Specifics
- * Requires a tooth number in the tooth number field
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
Allowed for a laboratory reline. The provider may request prior approval for the initial reline of a complete or partial denture beginning six months after the date of delivery of the denture. Subsequent relines are allowed once every five years. Medicaid does not cover tissue conditioning, soft relines, or rebase procedures.
Note: For an immediate denture (D5130 or D5140), the initial reline may be approved and rendered earlier than six months from denture delivery if the provider determines that healing of extraction sites is essentially complete and a reline is necessary to ensure proper fit and function of the denture. Subsequent relines are allowed once every five years
Exclusions
Complete denture payment includes any adjustments or relines needed for 6 months after delivery.
Immediate denture payment includes all adjustments needed for 6 months after delivery.
Partial denture payment includes any adjustments or relines needed for 6 months after delivery. Medicaid does not cover tissue conditioning, soft relines, or rebase procedures. In addition, removable prosthodontic appliances are not authorized when repair or reline would make existing appliances serviceable, and appliances are not authorized when lost by the beneficiary, hospital, or nursing home.
Additional Service Specifics
- * Requires a tooth number in the tooth number field
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
Allowed for a laboratory reline. The provider may request prior approval for the initial reline of a complete or partial denture beginning six months after the date of delivery of the denture. Subsequent relines are allowed once every five years. Medicaid does not cover tissue conditioning, soft relines, or rebase procedures.
Note: For an immediate denture (D5130 or D5140), the initial reline may be approved and rendered earlier than six months from denture delivery if the provider determines that healing of extraction sites is essentially complete and a reline is necessary to ensure proper fit and function of the denture. Subsequent relines are allowed once every five years
Exclusions
Complete denture payment includes any adjustments or relines needed for 6 months after delivery.
Immediate denture payment includes all adjustments needed for 6 months after delivery.
Partial denture payment includes any adjustments or relines needed for 6 months after delivery. Medicaid does not cover tissue conditioning, soft relines, or rebase procedures. In addition, removable prosthodontic appliances are not authorized when repair or reline would make existing appliances serviceable, and appliances are not authorized when lost by the beneficiary, hospital, or nursing home.
Additional Service Specifics
- * Requires a tooth number in the tooth number field
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
Allowed for a laboratory reline. The provider may request prior approval for the initial reline of a complete or partial denture beginning six months after the date of delivery of the denture. Subsequent relines are allowed once every five years. Medicaid does not cover tissue conditioning, soft relines, or rebase procedures.
Note: For an immediate denture (D5130 or D5140), the initial reline may be approved and rendered earlier than six months from denture delivery if the provider determines that healing of extraction sites is essentially complete and a reline is necessary to ensure proper fit and function of the denture. Subsequent relines are allowed once every five years
Exclusions
Complete denture payment includes any adjustments or relines needed for 6 months after delivery.
Immediate denture payment includes all adjustments needed for 6 months after delivery.
Partial denture payment includes any adjustments or relines needed for 6 months after delivery. Medicaid does not cover tissue conditioning, soft relines, or rebase procedures. In addition, removable prosthodontic appliances are not authorized when repair or reline would make existing appliances serviceable, and appliances are not authorized when lost by the beneficiary, hospital, or nursing home.
Additional Service Specifics
- * Requires a tooth number in the tooth number field
How to Submit
N/A - No authorization is required
Resources
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