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
Surgery of the Lingual Frenulum
Surgery of the lingual frenulum includes incision, excision, or surgical alteration of a short frenum to free the tongue and allow greater range of motion of the tongue.
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
Prior approval is required for beneficiaries 2 years of age and older. Surgery of the lingual frenulum is limited to once per lifetime.
Place of Service
Inpatient, Outpatient, Physician’s Office or Dental Office.
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.
Conditional Requirements
Labial - Yes Lingual –Yes (age 1 and older) Lingual - No (under 1 year of age)
Limits
- * Document necessity (for example, impairing speech, hindering mastication, preventing seating of a denture)
- * Requires current diagnostic photographic images of the proposed surgical site * Limited to once per lifetime for lingual frenuloplasty
How to Submit
Please submit your request to Trillium Health Resources
Resources
Surgery of the Lingual Frenulum
Surgery of the lingual frenulum includes incision, excision, or surgical alteration of a short frenum to free the tongue and allow greater range of motion of the tongue.
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
Prior approval is required for beneficiaries 2 years of age and older. Surgery of the lingual frenulum is limited to once per lifetime.
Place of Service
Inpatient, Outpatient, Physician’s Office or Dental Office.
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 operculectomy
- * Not allowed on the same date of service as an extraction for the same tooth
- * Not allowed for crown lengthening or gingivectomy
- * 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.
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
- * Not allowed on the same date of service as D7980
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
- * Not allowed on the same date of service as D7979
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.
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.
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.
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
Orthodontic Services
Orthodontics is defined as a corrective procedure for functionally impairing occlusal conditions (including craniofacial abnormalities and traumatic or pathologic anatomical deviations) that cause pain or suffering, physical deformity, significant malfunction, aggravates a condition, or results in further injury or infirmity. 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 include any records and any other information that you believe support the member has met the applicable medical necessity criteria.
Limits
- * Limited to functionally impairing malocclusions caused by an occlusal
condition that exhibits a profound impact from a congenital or developmental disorder (craniofacial anomaly such as cleft lip and palate or other conditions caused by a syndrome), severe trauma, or pathology which effect the function of speech, chewing, or swallowing
- * Includes placement and monitoring of fixed or removable appliances such
as a functional appliance necessary to initiate active treatment
- * Use for full banding including the placement of bands, brackets, and
appliances necessary to initiate active treatment of the upper and lower arches
- * Once in a lifetime service
- * Prior approval of orthodontic services is granted for 36 months
- * Essential to confirm on each date of service that the beneficiary is still
eligible under the same health plan (Medicaid) in which the approval was granted in NCTracks. If the beneficiary is not eligible and the health plan is not the same as approved, no payment will be issued
- * Once the banding has been paid, use for the maintenance visits for
comprehensive orthodontic treatment of the transitional dentition
- * Allowed once per calendar month (for example, a patient seen for a
comprehensive orthodontic treatment of the transitional dentition visit on any date in January would be eligible for the next visit on any date in February)
- * Not allowed for repair or replacement of broken or missing brackets,
bands, or wires when no other maintenance treatment is rendered
- * Limited to 23 reimbursable maintenance visits
- * The banding and 23 maintenance visits constitute the total reimbursement
for comprehensive orthodontic treatment and the provider is expected to complete any additional maintenance visits necessary to achieve an acceptable treatment outcome without further reimbursement
Exclusions
Not covered:
- a. Interceptive or Phase I treatment cases of the primary and transitional
dentition except for cases involving functionally impairing malocclusions caused by cleft lip and palate or other severe craniofacial developmental anomalies or severe traumatic injuries;
- b. Minor tooth movement cases requiring a relatively short treatment period
(less than 12 months);
- c. Cuspid impactions with a poor prognosis of being brought down into
occlusion in the presence of no other significant problems;
- d. Bilateral or unilateral posterior crossbites of moderate severity without a
significant mandibular shift or history of temporomandibular dysfunction and a lack of other significant problems;
- e. Class I malocclusions with moderate crowding, no crossbites, overbite and
overjet within normal limits;
- f. Simple space closure of mild to moderate anterior spacing;
- g. Simple one arch treatment;
- h. Localized tooth alignment problems requiring a relatively short period of
treatment (such as simple anterior or posterior crossbites, diastema closure, rotations);
- i. Orthodontic treatment begun prior to the patient becoming eligible for
Medicaid;
- j. Habit appliance therapy;
- k. Occlusal guard (including splint therapy for the treatment of
temporomandibular dysfunction); and
- l. Orthodontic treatment started as a private pay arrangement before Medicaid
approval is requested.
Age Group Details
- * Limited to beneficiaries under 21 years of age
Additional Service Specifics
Pregnant Medicaid eligible beneficiaries covered under the Medicaid for Pregnant Women program class “MPW” and beneficiaries covered under the Family Planning Waiver program class “MAFD” are not eligible for orthodontic services as described in this policy. Beneficiaries covered under the Medicare Qualified Beneficiaries program class “MQB” do not receive a Medicaid card and the only benefit that the beneficiary receives from Medicaid is the payment of the Medicare premium. The beneficiary is not eligible for any orthodontic services as described in this policy. Beneficiaries enrolled with the Program of All-Inclusive Care for the Elderly (PACE) are not covered for orthodontic services as described in this policy.
How to Submit
N/A - No authorization is required
Resources
Orthodontic Services
Orthodontics is defined as a corrective procedure for functionally impairing occlusal conditions (including craniofacial abnormalities and traumatic or pathologic anatomical deviations) that cause pain or suffering, physical deformity, significant malfunction, aggravates a condition, or results in further injury or infirmity. 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 include any records and any other information that you believe support the member has met the applicable medical necessity criteria.
Limits
- * Limited to functionally impairing malocclusions for Medicaid
beneficiaries
- * Includes placement and monitoring of fixed or removable appliances such
as a functional appliance necessary to initiate active treatment
- * Use for full banding including the placement of bands, brackets, and
appliances necessary to initiate active treatment of the upper and lower arches
- * Once in a lifetime service * Prior approval of orthodontic services is granted for 36 months
- * Essential to confirm on the date of banding that the beneficiary is still
eligible under the same health plan (Medicaid) in which the approval was granted in NCTracks. If the beneficiary is not eligible and the health plan is not the same as approved, no payment will be issued
Exclusions
Not covered:
- a. Interceptive or Phase I treatment cases of the primary and transitional
dentition except for cases involving functionally impairing malocclusions caused by cleft lip and palate or other severe craniofacial developmental anomalies or severe traumatic injuries;
- b. Minor tooth movement cases requiring a relatively short treatment period
(less than 12 months);
- c. Cuspid impactions with a poor prognosis of being brought down into
occlusion in the presence of no other significant problems;
- d. Bilateral or unilateral posterior crossbites of moderate severity without a
significant mandibular shift or history of temporomandibular dysfunction and a lack of other significant problems;
- e. Class I malocclusions with moderate crowding, no crossbites, overbite and
overjet within normal limits;
- f. Simple space closure of mild to moderate anterior spacing;
- g. Simple one arch treatment;
- h. Localized tooth alignment problems requiring a relatively short period of
treatment (such as simple anterior or posterior crossbites, diastema closure, rotations);
- i. Orthodontic treatment begun prior to the patient becoming eligible for
Medicaid;
- j. Habit appliance therapy;
- k. Occlusal guard (including splint therapy for the treatment of
temporomandibular dysfunction); and
- l. Orthodontic treatment started as a private pay arrangement before Medicaid
approval is requested.
Age Group Details
- * Limited to beneficiaries under 21 years of age
Additional Service Specifics
Pregnant Medicaid eligible beneficiaries covered under the Medicaid for Pregnant Women program class “MPW” and beneficiaries covered under the Family Planning Waiver program class “MAFD” are not eligible for orthodontic services as described in this policy. Beneficiaries covered under the Medicare Qualified Beneficiaries program class “MQB” do not receive a Medicaid card and the only benefit that the beneficiary receives from Medicaid is the payment of the Medicare premium. The beneficiary is not eligible for any orthodontic services as described in this policy. Beneficiaries enrolled with the Program of All-Inclusive Care for the Elderly (PACE) are not covered for orthodontic services as described in this policy.
How to Submit
N/A - No authorization is required
Resources
Orthodontic Services
Orthodontics is defined as a corrective procedure for functionally impairing occlusal conditions (including craniofacial abnormalities and traumatic or pathologic anatomical deviations) that cause pain or suffering, physical deformity, significant malfunction, aggravates a condition, or results in further injury or infirmity. 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 include any records and any other information that you believe support the member has met the applicable medical necessity criteria.
Limits
- * Use for the maintenance visits for comprehensive orthodontic treatment of the adolescent dentition
- * Limited to functionally impairing malocclusions for Medicaid beneficiaries
- * Prior approval of orthodontic services is granted for 36 months
- * Allowed once per calendar month (for example, a patient seen for a periodic orthodontic treatment visit on any date in January would be eligible for the next visit on any date in February)
- * Not allowed for repair or replacement of broken or missing brackets, bands, or wires when no other maintenance treatment is rendered
- * Limited to 23 reimbursable maintenance visits
- * The banding and 23 maintenance visits constitute the total reimbursement for comprehensive orthodontic treatment and the provider is expected to complete any additional maintenance visits necessary to achieve an acceptable treatment outcome without further reimbursement
- * If the case is approved and the banding is paid, Medicaid will continue to pay for monthly maintenance visits regardless of eligibility
Exclusions
Not covered:
- a. Interceptive or Phase I treatment cases of the primary and transitional
dentition except for cases involving functionally impairing malocclusions caused by cleft lip and palate or other severe craniofacial developmental anomalies or severe traumatic injuries;
- b. Minor tooth movement cases requiring a relatively short treatment period
(less than 12 months);
- c. Cuspid impactions with a poor prognosis of being brought down into
occlusion in the presence of no other significant problems;
- d. Bilateral or unilateral posterior crossbites of moderate severity without a
significant mandibular shift or history of temporomandibular dysfunction and a lack of other significant problems;
- e. Class I malocclusions with moderate crowding, no crossbites, overbite and
overjet within normal limits;
- f. Simple space closure of mild to moderate anterior spacing;
- g. Simple one arch treatment;
- h. Localized tooth alignment problems requiring a relatively short period of
treatment (such as simple anterior or posterior crossbites, diastema closure, rotations);
- i. Orthodontic treatment begun prior to the patient becoming eligible for
Medicaid;
- j. Habit appliance therapy;
- k. Occlusal guard (including splint therapy for the treatment of
temporomandibular dysfunction); and
- l. Orthodontic treatment started as a private pay arrangement before Medicaid
approval is requested.
Age Group Details
- * Limited to beneficiaries under 21 years of age
Additional Service Specifics
Pregnant Medicaid eligible beneficiaries covered under the Medicaid for Pregnant Women program class “MPW” and beneficiaries covered under the Family Planning Waiver program class “MAFD” are not eligible for orthodontic services as described in this policy. Beneficiaries covered under the Medicare Qualified Beneficiaries program class “MQB” do not receive a Medicaid card and the only benefit that the beneficiary receives from Medicaid is the payment of the Medicare premium. The beneficiary is not eligible for any orthodontic services as described in this policy. Beneficiaries enrolled with the Program of All-Inclusive Care for the Elderly (PACE) are not covered for orthodontic services as described in this policy.
How to Submit
N/A - No authorization is required
Resources
Orthodontic Services
Orthodontics is defined as a corrective procedure for functionally impairing occlusal conditions (including craniofacial abnormalities and traumatic or pathologic anatomical deviations) that cause pain or suffering, physical deformity, significant malfunction, aggravates a condition, or results in further injury or infirmity. 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 include any records and any other information that you believe support the member has met the applicable medical necessity criteria.
Limits
- * Once in a lifetime service
Exclusions
Not covered:
- a. Interceptive or Phase I treatment cases of the primary and transitional
dentition except for cases involving functionally impairing malocclusions caused by cleft lip and palate or other severe craniofacial developmental anomalies or severe traumatic injuries;
- b. Minor tooth movement cases requiring a relatively short treatment period
(less than 12 months);
- c. Cuspid impactions with a poor prognosis of being brought down into
occlusion in the presence of no other significant problems;
- d. Bilateral or unilateral posterior crossbites of moderate severity without a
significant mandibular shift or history of temporomandibular dysfunction and a lack of other significant problems;
- e. Class I malocclusions with moderate crowding, no crossbites, overbite and
overjet within normal limits;
- f. Simple space closure of mild to moderate anterior spacing;
- g. Simple one arch treatment;
- h. Localized tooth alignment problems requiring a relatively short period of
treatment (such as simple anterior or posterior crossbites, diastema closure, rotations);
- i. Orthodontic treatment begun prior to the patient becoming eligible for
Medicaid;
- j. Habit appliance therapy;
- k. Occlusal guard (including splint therapy for the treatment of
temporomandibular dysfunction); and
- l. Orthodontic treatment started as a private pay arrangement before Medicaid
approval is requested.
Age Group Details
- * Limited to beneficiaries under 21 years of age
Additional Service Specifics
Pregnant Medicaid eligible beneficiaries covered under the Medicaid for Pregnant Women program class “MPW” and beneficiaries covered under the Family Planning Waiver program class “MAFD” are not eligible for orthodontic services as described in this policy. Beneficiaries covered under the Medicare Qualified Beneficiaries program class “MQB” do not receive a Medicaid card and the only benefit that the beneficiary receives from Medicaid is the payment of the Medicare premium. The beneficiary is not eligible for any orthodontic services as described in this policy. Beneficiaries enrolled with the Program of All-Inclusive Care for the Elderly (PACE) are not covered for orthodontic services as described in this policy.
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 minor dental procedures to relieve oral pain
- * Document in the beneficiary’s chart the nature of the emergency and the specific treatment provided
- * Not allowed for writing prescriptions, dispensing drugs or medicaments through the office, or administering drugs orally
How to Submit
N/A - No authorization is required
Resources
DEEP SEDATION/GENERAL ANESTHESIA-1ST 30 MINUTES
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.
Reauthorization Guidelines
See the Carolina Complete Health site for specific requirements
How to Submit
Please submit your request to Carolina Complete Health through Availity
DEEP SEDATION/GENERAL ANESTHESIA-EA ADD 15 MIN
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.
Reauthorization Guidelines
See the Carolina Complete Health site for specific requirements
How to Submit
Please submit your request to Carolina Complete Health through Availity
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 once per date of service
- * Allowed only in an office setting
- * Deep sedation/general anesthesia performed in the dental office must include documentation in the record of pharmacologic agents, monitoring of vital signs, and complete anesthesia time
- * Reimbursement includes all drugs and/or medicaments necessary for adequate anesthesia
- * Reimbursement includes monitoring and management
Exclusions
Medicaid does not cover acupuncture, hypnosis, or other non-pharmacologic methods. The policy also states that non-intravenous conscious sedation is not covered. Local anesthesia is not separately reimbursable because it is considered part of the underlying procedure.
Additional Service Specifics
In ambulatory surgical centers, anesthesia services are billed based on total anesthesia time; time begins when the anesthesiology provider prepares the beneficiary for induction and ends when the beneficiary can be placed under postoperative supervision and the provider is no longer in personal attendance.
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.