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
∗ Requires an arch indicator (UP, LO) in the area of oral cavity field
Exclusions
Removable prosthodontic appliances generally shall not be authorized when extractions are not medically necessary; when the beneficiary's dental history indicates negligence in proper appliance care or physiological or psychological problems made previous dentures unsatisfactory; when repair or reline would make existing appliances serviceable; or when the appliances are lost by the beneficiary, hospital, or nursing home.
How to Submit
N/A - No authorization is required
Resources
Dental Services
Dental services are defined as diagnostic, preventive, or corrective procedures provided by or under the supervision of a dentist. This includes services to treat disease, maintain oral health, and treat injuries or impairments that may affect a beneficiary’s oral or general health. Such services must maintain a high standard of quality and must be within the reasonable limits of services customarily available and provided to most persons in the community with the limitations and exclusions specified in this policy. Only the procedure codes listed in this policy are covered under the North Carolina (NC) Medicaid (Title XIX) Dental Program.
Authorization Guidelines
Please submit any records and any other information that you believe support the member has met the applicable medical necessity criteria to Trillium.
Limits
- * Use the delivery date as date of service when requesting payment
- * If the beneficiary’s Medicaid eligibility expires between the final impression
date and delivery date, the provider shall use the final impression date as the date of service
Age Group Details
- * Limited to beneficiaries under six years of age
How to Submit
N/A - No authorization is required
Resources
Dental Services
Dental services are defined as diagnostic, preventive, or corrective procedures provided by or under the supervision of a dentist. This includes services to treat disease, maintain oral health, and treat injuries or impairments that may affect a beneficiary’s oral or general health. Such services must maintain a high standard of quality and must be within the reasonable limits of services customarily available and provided to most persons in the community with the limitations and exclusions specified in this policy. Only the procedure codes listed in this policy are covered under the North Carolina (NC) Medicaid (Title XIX) Dental Program.
Authorization Guidelines
Please submit any records and any other information that you believe support the member has met the applicable medical necessity criteria to Trillium.
Limits
Payment for an extraction includes local anesthesia, any necessary sutures, and routine postoperative care. Primary tooth extractions are not allowed when normal exfoliation is imminent.
Exclusions
Primary tooth extractions are not allowed when normal exfoliation is imminent. Tooth number is required on the claim for D7140, using a valid tooth number from A-T, 1-32, AS-TS, or 51-82.
In ambulatory surgical center settings, dental providers use place of treatment 24 for dental treatment.
Additional Service Specifics
The broader prosthodontic section also indicates that appliances shall not be authorized when extractions are not medically necessary, reinforcing that extractions must be medically necessary when part of denture-related treatment planning.
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
Payment for an extraction includes local anesthesia, any necessary sutures, and routine postoperative care. Primary tooth extractions are not allowed when normal exfoliation is imminent.
Exclusions
Primary tooth extractions are not allowed when normal exfoliation is imminent. Tooth number is required on the claim for D7140, using a valid tooth number from A-T, 1-32, AS-TS, or 51-82.
In ambulatory surgical center settings, dental providers use place of treatment 24 for dental treatment.
Additional Service Specifics
The broader prosthodontic section also indicates that appliances shall not be authorized when extractions are not medically necessary, reinforcing that extractions must be medically necessary when part of denture-related treatment planning.
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
Payment for an extraction includes local anesthesia, any necessary sutures, and routine postoperative care. Primary tooth extractions are not allowed when normal exfoliation is imminent.
Exclusions
Primary tooth extractions are not allowed when normal exfoliation is imminent. Tooth number is required on the claim for D7140, using a valid tooth number from A-T, 1-32, AS-TS, or 51-82.
In ambulatory surgical center settings, dental providers use place of treatment 24 for dental treatment.
Additional Service Specifics
The broader prosthodontic section also indicates that appliances shall not be authorized when extractions are not medically necessary, reinforcing that extractions must be medically necessary when part of denture-related treatment planning.
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
Payment for an extraction includes local anesthesia, any necessary sutures, and routine postoperative care. Primary tooth extractions are not allowed when normal exfoliation is imminent.
Exclusions
Primary tooth extractions are not allowed when normal exfoliation is imminent. Tooth number is required on the claim for D7140, using a valid tooth number from A-T, 1-32, AS-TS, or 51-82.
In ambulatory surgical center settings, dental providers use place of treatment 24 for dental treatment.
Additional Service Specifics
The broader prosthodontic section also indicates that appliances shall not be authorized when extractions are not medically necessary, reinforcing that extractions must be medically necessary when part of denture-related treatment planning.
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
Payment for an extraction includes local anesthesia, any necessary sutures, and routine postoperative care. Primary tooth extractions are not allowed when normal exfoliation is imminent.
Exclusions
Primary tooth extractions are not allowed when normal exfoliation is imminent. Tooth number is required on the claim for D7140, using a valid tooth number from A-T, 1-32, AS-TS, or 51-82.
In ambulatory surgical center settings, dental providers use place of treatment 24 for dental treatment.
Additional Service Specifics
The broader prosthodontic section also indicates that appliances shall not be authorized when extractions are not medically necessary, reinforcing that extractions must be medically necessary when part of denture-related treatment planning.
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
Payment for an extraction includes local anesthesia, any necessary sutures, and routine postoperative care. Primary tooth extractions are not allowed when normal exfoliation is imminent.
Exclusions
Primary tooth extractions are not allowed when normal exfoliation is imminent. Tooth number is required on the claim for D7140, using a valid tooth number from A-T, 1-32, AS-TS, or 51-82.
In ambulatory surgical center settings, dental providers use place of treatment 24 for dental treatment.
Additional Service Specifics
The broader prosthodontic section also indicates that appliances shall not be authorized when extractions are not medically necessary, reinforcing that extractions must be medically necessary when part of denture-related treatment planning.
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
Payment for an extraction includes local anesthesia, any necessary sutures, and routine postoperative care. Primary tooth extractions are not allowed when normal exfoliation is imminent.
Exclusions
Primary tooth extractions are not allowed when normal exfoliation is imminent. Tooth number is required on the claim for D7140, using a valid tooth number from A-T, 1-32, AS-TS, or 51-82.
In ambulatory surgical center settings, dental providers use place of treatment 24 for dental treatment.
Additional Service Specifics
The broader prosthodontic section also indicates that appliances shall not be authorized when extractions are not medically necessary, reinforcing that extractions must be medically necessary when part of denture-related treatment planning.
Other Information
- * Requires documentation of clinical or radiographic conditions that qualify the extraction as unusually complicated (for example, full impaction requiring multisectioning of the tooth, full impaction high in the maxillary sinus area or low in the mandibular canal area, full vertical or horizontal impaction)
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
Payment for an extraction includes local anesthesia, any necessary sutures, and routine postoperative care. Primary tooth extractions are not allowed when normal exfoliation is imminent.
Exclusions
Primary tooth extractions are not allowed when normal exfoliation is imminent. Tooth number is required on the claim for D7140, using a valid tooth number from A-T, 1-32, AS-TS, or 51-82.
In ambulatory surgical center settings, dental providers use place of treatment 24 for dental treatment.
Additional Service Specifics
The broader prosthodontic section also indicates that appliances shall not be authorized when extractions are not medically necessary, reinforcing that extractions must be medically necessary when part of denture-related treatment planning.
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
Payment for an extraction includes local anesthesia, any necessary sutures, and routine postoperative care. Primary tooth extractions are not allowed when normal exfoliation is imminent.
Exclusions
Primary tooth extractions are not allowed when normal exfoliation is imminent. Tooth number is required on the claim for D7140, using a valid tooth number from A-T, 1-32, AS-TS, or 51-82.
In ambulatory surgical center settings, dental providers use place of treatment 24 for dental treatment.
Additional Service Specifics
The broader prosthodontic section also indicates that appliances shall not be authorized when extractions are not medically necessary, reinforcing that extractions must be medically necessary when part of denture-related treatment planning.
Other Information
- * Requires documentation of medical necessity * Requires documentation that the beneficiary was informed that a portion of the tooth remains
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.
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.
How to Submit
N/A - No authorization is required
Resources
Dental Services
Dental services are defined as diagnostic, preventive, or corrective procedures provided by or under the supervision of a dentist. This includes services to treat disease, maintain oral health, and treat injuries or impairments that may affect a beneficiary’s oral or general health. Such services must maintain a high standard of quality and must be within the reasonable limits of services customarily available and provided to most persons in the community with the limitations and exclusions specified in this policy. Only the procedure codes listed in this policy are covered under the North Carolina (NC) Medicaid (Title XIX) Dental Program.
Authorization Guidelines
Please submit any records and any other information that you believe support the member has met the applicable medical necessity criteria to Trillium.
Limits
- * Not allowed on the same date of service as an extraction for the same tooth
How to Submit
N/A - No authorization is required
Resources
Dental Services
Dental services are defined as diagnostic, preventive, or corrective procedures provided by or under the supervision of a dentist. This includes services to treat disease, maintain oral health, and treat injuries or impairments that may affect a beneficiary’s oral or general health. Such services must maintain a high standard of quality and must be within the reasonable limits of services customarily available and provided to most persons in the community with the limitations and exclusions specified in this policy. Only the procedure codes listed in this policy are covered under the North Carolina (NC) Medicaid (Title XIX) Dental Program.
Authorization Guidelines
Please submit any records and any other information that you believe support the member has met the applicable medical necessity criteria to Trillium.
Limits
- * Report the surgical exposure separately using D7280
- * Not allowed on the same date of service as an extraction for the same tooth
How to Submit
N/A - No authorization is required
Resources
Dental Services
Dental services are defined as diagnostic, preventive, or corrective procedures provided by or under the supervision of a dentist. This includes services to treat disease, maintain oral health, and treat injuries or impairments that may affect a beneficiary’s oral or general health. Such services must maintain a high standard of quality and must be within the reasonable limits of services customarily available and provided to most persons in the community with the limitations and exclusions specified in this policy. Only the procedure codes listed in this policy are covered under the North Carolina (NC) Medicaid (Title XIX) Dental Program.
Authorization Guidelines
Please submit any records and any other information that you believe support the member has met the applicable medical necessity criteria to Trillium.
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.
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.
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
- * Report in addition to those autogenous graft procedures that do not include harvesting of bone
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
- * Requires a quadrant indicator in the area of oral cavity. For D7311, there must be three edentulous units in a quadrant to qualify for payment.
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.