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 a quadrant indicator in the area of oral cavity. For D7311, there must be three edentulous units in a quadrant to qualify for payment.
Exclusions
- * Must be three edentulous units in a quadrant to qualify for payment for alveoloplasty
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
- * Requires a quadrant indicator in the area of oral cavity * Requires current diagnostic photographic images of the proposed surgical site
Exclusions
- * Must be three edentulous units in a quadrant to qualify for payment for alveoloplasty
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
- * Must be three edentulous units in a quadrant to qualify for payment for alveoloplasty
- * Requires a quadrant
indicator in the area of oral cavity
- * Requires current diagnostic photographic images of the proposed surgical site
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
Requires an arch indicator (UP, LO) in the area of oral cavity
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
- * Document the exact procedure to be performed and the estimated fee
- * Requires an arch indicator (UP, LO) in the area of oral cavity
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
Certain second surgeries, such as bilateral procedures, performed on the same date of service may be reimbursed at 50 percent of the maximum allowed rate
Additional Service Specifics
The Surgical Excision of Intra-osseous Lesions subsection specifically applies to excision of malignant tumor and removal of benign odontogenic cyst or tumor, with code selection based on lesion diameter up to 1.25 cm or greater than 1.25 cm. A pathology report is required as an attachment to the claim for payment to receive reimbursement of any excision of lesion, cyst, or tumor.
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
Certain second surgeries, such as bilateral procedures, performed on the same date of service may be reimbursed at 50 percent of the maximum allowed rate
Additional Service Specifics
The Surgical Excision of Intra-osseous Lesions subsection specifically applies to excision of malignant tumor and removal of benign odontogenic cyst or tumor, with code selection based on lesion diameter up to 1.25 cm or greater than 1.25 cm. A pathology report is required as an attachment to the claim for payment to receive reimbursement of any excision of lesion, cyst, or tumor.
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
Certain second surgeries, such as bilateral procedures, performed on the same date of service may be reimbursed at 50 percent of the maximum allowed rate
Additional Service Specifics
The Surgical Excision of Intra-osseous Lesions subsection specifically applies to excision of malignant tumor and removal of benign odontogenic cyst or tumor, with code selection based on lesion diameter up to 1.25 cm or greater than 1.25 cm. A pathology report is required as an attachment to the claim for payment to receive reimbursement of any excision of lesion, cyst, or tumor.
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
Certain second surgeries, such as bilateral procedures, performed on the same date of service may be reimbursed at 50 percent of the maximum allowed rate
Additional Service Specifics
The Surgical Excision of Intra-osseous Lesions subsection specifically applies to excision of malignant tumor and removal of benign odontogenic cyst or tumor, with code selection based on lesion diameter up to 1.25 cm or greater than 1.25 cm. A pathology report is required as an attachment to the claim for payment to receive reimbursement of any excision of lesion, cyst, or tumor.
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
Certain second surgeries, such as bilateral procedures, performed on the same date of service may be reimbursed at 50 percent of the maximum allowed rate
Additional Service Specifics
The Surgical Excision of Intra-osseous Lesions subsection specifically applies to excision of malignant tumor and removal of benign odontogenic cyst or tumor, with code selection based on lesion diameter up to 1.25 cm or greater than 1.25 cm. A pathology report is required as an attachment to the claim for payment to receive reimbursement of any excision of lesion, cyst, or tumor.
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
Certain second surgeries, such as bilateral procedures, performed on the same date of service may be reimbursed at 50 percent of the maximum allowed rate
Additional Service Specifics
The Surgical Excision of Intra-osseous Lesions subsection specifically applies to excision of malignant tumor and removal of benign odontogenic cyst or tumor, with code selection based on lesion diameter up to 1.25 cm or greater than 1.25 cm. A pathology report is required as an attachment to the claim for payment to receive reimbursement of any excision of lesion, cyst, or tumor.
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 as an arch procedure * Requires an arch indicator (UP, LO) in the area of oral cavity
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 as an arch procedure
How to Submit
N/A - No authorization is required
Resources
Dental Services
Dental services are defined as diagnostic, preventive, or corrective procedures provided by or under the supervision of a dentist. This includes services to treat disease, maintain oral health, and treat injuries or impairments that may affect a beneficiary’s oral or general health. Such services must maintain a high standard of quality and must be within the reasonable limits of services customarily available and provided to most persons in the community with the limitations and exclusions specified in this policy. Only the procedure codes listed in this policy are covered under the North Carolina (NC) Medicaid (Title XIX) Dental Program.
Authorization Guidelines
Please submit any records and any other information that you believe support the member has met the applicable medical necessity criteria to Trillium.
Limits
- * Allowed as a lower arch procedure
How to Submit
N/A - No authorization is required
Resources
Dental Services
Dental services are defined as diagnostic, preventive, or corrective procedures provided by or under the supervision of a dentist. This includes services to treat disease, maintain oral health, and treat injuries or impairments that may affect a beneficiary’s oral or general health. Such services must maintain a high standard of quality and must be within the reasonable limits of services customarily available and provided to most persons in the community with the limitations and exclusions specified in this policy. Only the procedure codes listed in this policy are covered under the North Carolina (NC) Medicaid (Title XIX) Dental Program.
Authorization Guidelines
Please submit any records and any other information that you believe support the member has met the applicable medical necessity criteria to Trillium.
Limits
- * Requires documentation of medical necessity * Requires a pathology report to be submitted as an attachment to the claim for payment
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
Certain second surgeries (for example, bilateral procedures) performed on the same date of service may be reimbursed at 50 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
- * Involves incision through mucosa; document area of incision * Not allowed in the same site as a surgical tooth extraction
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
- * Document the area of the incision
How to Submit
N/A - No authorization is required
Resources
Dental Services
Dental services are defined as diagnostic, preventive, or corrective procedures provided by or under the supervision of a dentist. This includes services to treat disease, maintain oral health, and treat injuries or impairments that may affect a beneficiary’s oral or general health. Such services must maintain a high standard of quality and must be within the reasonable limits of services customarily available and provided to most persons in the community with the limitations and exclusions specified in this policy. Only the procedure codes listed in this policy are covered under the North Carolina (NC) Medicaid (Title XIX) Dental Program.
Authorization Guidelines
Please submit any records and any other information that you believe support the member has met the applicable medical necessity criteria to Trillium.
Limits
- * Use for removal of bony spicules
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.