1 of 46 documents new jersey administrative code



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§ 10:56-2.6 Diagnostic services: general
(a) A complete evaluation of the oral cavity shall be a comprehensive and thorough inspection of the oral cavity to include diagnosis, an oral cancer screening, charting of all abnormalities, and development and recording of a complete treatment plan. It should permit a Division dental consultant (with accompanying radiographs) to determine the appropriateness of the treatment plan.

1. This dental evaluation is reimbursable only when part of a total treatment plan, unless the evaluation discloses no need for treatment, in which case this must be indicated by placing the statement "No Other Treatment Necessary (N.O.T.N.)" under Remarks (Item 20) on the Dental Claim Form (MC-10).

2. Except as provided in N.J.A.C. 10:78-7.1, for reimbursement purposes, a comprehensive dental evaluation shall be limited to once every six months for those beneficiaries through age 20 and once every 12 months for those beneficiaries 21 years of age or older except as prior authorized by a Division dental consultant.

(b) An emergency oral evaluation is distinguished from a complete evaluation of the oral cavity in that it is applicable only for diagnosis and/or observation of a specific complaint in an emergency situation.

(c) The dentist who examines a nursing facility beneficiary shall provide the treatment necessary unless the evaluation indicates that a specialist is needed.

(d) A Handicapping Malocclusion Assessment Examination (refer to N.J.A.C. 10:56-2.15) shall not be reimbursed for individuals age 21 or older.

1. For reimbursement purposes, a Handicapping Malocclusion Assessment Examination shall be limited to once every 12 months unless authorized. In addition, reimbursement shall be limited to the provider or provider group who does such an examination with the intention of personally providing any orthodontic treatment necessary.

2. Orthodontic evaluation, including the Handicapping Malocclusion Assessment Examination, shall be conducted before a child reaches age 18 to ensure that all orthodontic treatment proposed can be completed prior to the child's reaching age 21. Unless extenuating circumstances exist and the Division dental consultant has previously reviewed and approved the treatment, any and all orthodontic treatment not completed prior to the child's reaching age 21 shall be the sole responsibility of the provider.



18 of 46 DOCUMENTS


NEW JERSEY ADMINISTRATIVE CODE

Copyright © 2014 by the New Jersey Office of Administrative Law


*** This file includes all Regulations adopted and published through the ***

*** New Jersey Register, Vol. 46 No. 11, June 2, 2014 ***


TITLE 10. HUMAN SERVICES

CHAPTER 56. MANUAL FOR DENTAL SERVICES

SUBCHAPTER 2. PROVISIONS FOR SERVICES
N.J.A.C. 10:56-2.7 (2014)
§ 10:56-2.7 Diagnostic services: radiography
(a) Radiological procedures shall be limited to those normally required to make a diagnosis and shall show all areas where treatment is anticipated with the exception of soft tissue lesions.

(b) All radiographs should be examined carefully by the provider to assure quality care and to make certain that all necessary treatment has been diagnosed, planned for and/or completed.

(c) Radiographs may be reviewed by dental consultants of the Medicaid/NJ Family Care fee-for-service programs and/or a dentist in private practice not employed by New Jersey Medicaid/NJ Family Care fee-for-service programs, if appropriate. It is recommended that the two film packet be used or a copy may be made by those dentists who wish to retain a set of radiographs in their office at all times.

(d) The originals of all radiographic films shall be available to authorized representatives of the New Jersey Medicaid/NJ Family Care fee-for-service programs. Radiographs shall be forwarded to the Division of Medical Assistance and Health Services in the following situations:

1. When prior authorization is requested; or

2. Upon request by the Medicaid/NJ Family Care fee-for-service programs for utilization review or adjudication purposes.

(e) All radiographic films shall be suitable for interpretation and when submitted to the New Jersey Medicaid/NJ Family Care fee-for-service programs or their agents shall be properly mounted, marked "Right" and "Left" and identified with the beneficiary's name, the date, and the name of the dentist. Films that are technically unacceptable for proper interpretation will be returned to the provider for replacement at no additional cost to the Medicaid/NJ Family Care fee-for-service programs. No reimbursement shall be made for the new set of radiographs that the dentist is required to provide. When already reimbursed, recoupment will be made, unless a replacement set of radiographs is sent to the Division for review.

(f) Reimbursement for dental radiographs shall be limited according to the following standards:

1. A complete series radiographic study is defined and limited by age. The maximum number of diagnostic radiographs that may be reimbursed as a single radiographic study every three years without prior authorization shall be as follows:

i. Up to and including age six: eight films (six periapical plus two bitewing films);

ii. Age seven, up to and including age 14: 12 films (10 periapical films, plus two bitewing films) or a panorex and two posterior bite wing films;

iii. For those beneficiaries 15 years of age or older: 16 radiographs (at least 14 periapical plus two posterior bitewing films) or a panorex plus four posterior bite wing films;

iv. A complete series radiographic study, which may include two or more bitewing radiographs with a panorex radiograph. Any additional films over and above that number, as limited by age, are considered to be part of that complete series and no additional reimbursement can be made. If, however, extenuating circumstances exist, the need for additional films in (f)1i through iii above must be substantiated and a specific authorization obtained from the Division dental consultant;

v. The three year limitation in (b)4i(1), (2), and (4) above will continue to apply even though an age change transfers the beneficiary from one age category to another. For example, a beneficiary who has eight radiographs at age six is not eligible for the 12 film series until he or she has reached age nine and three years have passed;

vi. The maximum amount reimbursable for radiographs billed individually or in groups in conjunction with an initial evaluation, and/or one treatment plan and/or within a six month period is that amount paid for a complete series as outlined in (b)4 above. During any 12 month period subsequent to a complete radiography series study within the three year period, the maximum number of radiographs permitted shall be as follows:

(1) Up to and including age six -- four films;

(2) Age seven and up to and including age 14 -- four films; and

(3) Age 15 years of age or older -- six films;

vii. If the provider requires additional films, he or she shall first secure prior authorization from the Division dental consultant;

viii. If a beneficiary patient transfers to a new dental provider's office, that new dental provider's office shall request a copy of the beneficiary's radiographs from the previous dental provider, in accordance with N.J.A.C. 13:30-8.7. The previous dental provider may request approval through the prior authorization process for duplication of the films. That prior authorization request shall be directed to the Division dental consultant and shall indicate the type and number of films to be duplicated; or

ix. If the films or their copies cannot be provided by the previous dental provider, the new dental provider shall document this fact in the beneficiary's patient record and proceed to take the needed films that are required to diagnose, develop a treatment plan and provide treatment. It is not the intention of the Medicaid/NJ FamilyCare program to impede timely treatment while waiting for the previous dentist to provide the requested radiographs and records.

(g) In an emergency situation, in order to establish a diagnosis which must be recorded under Remarks (Item 20) of the Dental Claim Form (MC-10) a radiograph may be taken at any time, as dentally necessary.

(h) Postoperative radiographs normally taken at the conclusion of dental treatment by a dental provider shall be maintained as part of the beneficiary's dental records (for example, final radiographs at completion of endodontic treatment, or certain surgical procedures).

(i) Radiological services other than those ordinarily provided by a practitioner in his or her own office may be referred to a dental specialist who will provide radiological services limited to his or her own special field. Radiological services may also be requested from a physician who is a specialist in radiology or a qualified hospital facility.

1. Services provided by another dentist, physician, or hospital facility shall be billed directly to the Medicaid/NJ Family Care fee-for-service programs by that provider and not by the referring dentist.


19 of 46 DOCUMENTS


NEW JERSEY ADMINISTRATIVE CODE

Copyright © 2014 by the New Jersey Office of Administrative Law


*** This file includes all Regulations adopted and published through the ***

*** New Jersey Register, Vol. 46 No. 11, June 2, 2014 ***


TITLE 10. HUMAN SERVICES

CHAPTER 56. MANUAL FOR DENTAL SERVICES

SUBCHAPTER 2. PROVISIONS FOR SERVICES
N.J.A.C. 10:56-2.8 (2014)
§ 10:56-2.8 Diagnostic services: Clinical laboratory services
(a) "Clinical laboratory services" includes services provided by:

1. Independent clinical laboratories, including physician/dentist operated, out of hospital laboratories which perform primarily diagnostic work referred by other practitioners; and

2. Hospital laboratories and laboratories of educational institutions which provide laboratory services to ambulatory beneficiaries as requested by a licensed practitioner.

(b) Services provided by any of the above laboratories shall be billed directly to the Medicaid/NJ FamilyCare program by the laboratory, and not by the dentist.

(c) All facilities or entities that perform clinical laboratory testing shall have certification for the services they are performing (see N.J.A.C 10:61). Reimbursement for laboratory testing performed shall not be made to any facility without such CLIA certification. It shall be the initiating entity's responsibility to refer tests to laboratories which are New Jersey Medicaid/NJ Family Care fee-for-service providers and have a valid CLIA identification number.


20 of 46 DOCUMENTS


NEW JERSEY ADMINISTRATIVE CODE

Copyright © 2014 by the New Jersey Office of Administrative Law


*** This file includes all Regulations adopted and published through the ***

*** New Jersey Register, Vol. 46 No. 11, June 2, 2014 ***


TITLE 10. HUMAN SERVICES

CHAPTER 56. MANUAL FOR DENTAL SERVICES

SUBCHAPTER 2. PROVISIONS FOR SERVICES
N.J.A.C. 10:56-2.9 (2014)
§ 10:56-2.9 Preventive dental care
(a) In addition to an oral evaluation every six months for beneficiaries through age 20 and once every 12 months for beneficiaries 21 years of age or older, preventive dental care encompasses the following recommended services:

1. Prophylaxis, as follows:

i. Dental prophylaxis means the complete removal of calculus and stains from the exposed and unexposed areas of the teeth by scaling and polishing.

ii. For reimbursement purposes, dental prophylaxis shall be limited to once every six months for beneficiaries through age 20 and once every 12 months for beneficiaries 21 years of age or older, except as otherwise prior authorized by a Division dental consultant, and except as provided (a)1ii(1) below.

(1) Beneficiaries with developmental disabilities, neurological impairments, or other disabilities, regardless of age, shall be eligible for evaluation, radiographs as appropriate, prophylaxis, extra-scaling and topical application of fluoride including prophylaxis, as often as every three months. Claims may be submitted directly to the fiscal agent for payment, without prior authorization. In the event that any of the services listed in (A) below are required more often than every three months, a prior authorization request shall be submitted to the Division dental consultant. The nature of the beneficiary's disability shall be recorded under Remarks (Item 20) on the Dental Claim Form.

(A) The following procedure codes shall be used only if a beneficiary is developmentally disabled, neurologically impaired or medically compromised:



Comprehensive Oral Evaluation

D0150-76

Prophylaxis-Adult

D1110-76

Prophylaxis-Child

D1120-76

Topical Application of Fluoride with prophylaxis, Child

D1201-76

Topical Application of Fluoride with prophylaxis, Adult

D1205-76

Full Mouth Debridement

D4355-76

Non-intravenous Conscious Sedation

D9248-76

NOTE: Non-Intravenous Conscious Sedation shall be prior authorized after four times in a 12-month period.

2. Fluoride Treatment, as follows:

i. Topical fluoride treatment should be administered in accordance with appropriate standards. This consists of topical application of stannous fluoride or acid fluoride phosphate as a liquid or gel.

ii. A complete prophylaxis shall be performed prior to and in conjunction with the topical fluoride treatment.

iii. Reimbursement for topical fluoride treatment shall be limited to once every six months without need for prior authorization for those beneficiaries through age 20.

iv. This is not a covered service for persons 21 years of age and over, except as noted in (a)1ii(1) above.

v. Oral fluoride medication may be prescribed (see: N.J.A.C. 10:56-2.17).

vi. Use of a prophylaxis paste containing fluoride shall not be billed as "topical fluoride treatment." For reimbursement purposes, this is considered to be only a prophylaxis.

3. To encourage the maintenance of dental health, the same type of recall procedure as used in dental practice in the community shall be extended to eligible Medicaid/NJ Family Care fee-for-service beneficiaries.

4. Beneficiary education for Medicaid/NJ Family Care fee-for-service beneficiaries should consist of dental health orientation identical to that given all patients.

5. Sealants shall be a covered service of the Medicaid/NJ Family Care fee-for-service programs, subject to the following limitations:

i. Application of sealants shall be limited to a one time application to all occlusal surfaces that are unfilled and caries free, in premolars and permanent molars.

ii. Application of sealants shall be limited to beneficiaries up to and including 16 years of age.

iii. Sealants applied, other than as outlined above, are not reimbursable unless authorized by a Division dental consultant. A complete explanation of the request shall be attached to the prior authorization request.

iv. Since sealants may be reimbursed only once for each tooth, the provider should make certain that sealants have not been applied previously.


21 of 46 DOCUMENTS


NEW JERSEY ADMINISTRATIVE CODE

Copyright © 2014 by the New Jersey Office of Administrative Law


*** This file includes all Regulations adopted and published through the ***

*** New Jersey Register, Vol. 46 No. 11, June 2, 2014 ***


TITLE 10. HUMAN SERVICES

CHAPTER 56. MANUAL FOR DENTAL SERVICES

SUBCHAPTER 2. PROVISIONS FOR SERVICES
N.J.A.C. 10:56-2.10 (2014)
§ 10:56-2.10 Restorative services
(a) Restorative treatment shall be limited to those services necessary to adequately restore and maintain the integrity and contours of the natural tooth, as follows:

1. Filling restorations shall be reimbursed as follows:

i. Reimbursement for restorations in primary teeth shall be limited to primary cuspids and molars of children up to and including age nine, or in primary incisors up to and including age five, but not where exfoliation is imminent, except when prior authorization by a Division dental consultant has been obtained by the provider.

ii. Amalgam and composite restorations may be provided on anterior and posterior teeth (numbers 1 through 16 and 17 through 32). The provider should select the restorative material most appropriate for the beneficiary's dental needs.

iii. Reimbursement for a restoration will include treatment of pulp exposure, lining or base, restoration, polishing of restoration, and local anesthesia.

iv. Plastic, acrylic, or unfilled resin restorative material shall be reimbursable.

v. A procedure code shall be selected on the basis of the number of surfaces restored per individual tooth (not on the basis of individual restorations); therefore, the fee for any surface shall include one or more restorations on that surface.

vi. Only one code is reimbursable per tooth except when amalgam and composite resin restorations are placed on the same tooth.

vii. Reimbursement for an occlusal restoration includes any extensions onto the occlusal one-third of the buccal or lingual surface(s) of the tooth.

viii. Extension of interproximal restorations into self cleansing areas will not be considered as additional surfaces. An additional surface will be reimbursable only when the buccal (facial) or lingual margin extends beyond the proximal one-third of the buccal (facial) and/or lingual surface(s).

2. Crown restorations shall be considered for reimbursement as follows:

i. Prior authorization is required for all crowns and shall be based on substantial loss of tooth structure and the condition of the remaining teeth and supporting tissue to justify this treatment. The Dental Prior Authorization Form (MC-10A) and the Dental Claim Form (MC-10) shall be submitted with recent radiographs for review by a Division dental consultant.

ii. Generally, temporary acrylic or plastic crowns shall be reimbursable only for badly broken down anterior teeth up to and including age 15. Likewise, preformed stainless steel crowns shall be reimbursable only for primary teeth and permanent posterior teeth up to and including age 17. If extenuating circumstances exist that require the use of stainless steel crowns for permanent teeth on beneficiaries beyond the age of 17, a request for prior authorization with documentation shall be submitted for review by a Division dental consultant.

iii. Porcelain jackets will not be reimbursed.

3. Post and core shall be reimbursable under the following conditions:

i. A post and core is reimbursable on an endodontically treated tooth only in conjunction with a crown as the final restoration.

ii. A post and core on an endodontically treated tooth shall extend into at least one-half, and preferably two-thirds, of the length of the endodontically treated canal. Failure of a post and core which results in the concurrent failure of a crown will be subjected to recovery of the reimbursement for both services based on this standard.


22 of 46 DOCUMENTS


NEW JERSEY ADMINISTRATIVE CODE

Copyright © 2014 by the New Jersey Office of Administrative Law


*** This file includes all Regulations adopted and published through the ***

*** New Jersey Register, Vol. 46 No. 11, June 2, 2014 ***


TITLE 10. HUMAN SERVICES

CHAPTER 56. MANUAL FOR DENTAL SERVICES

SUBCHAPTER 2. PROVISIONS FOR SERVICES
N.J.A.C. 10:56-2.11 (2014)
§ 10:56-2.11 Endodontic services
(a) Reimbursement for root canal therapy for all teeth shall include pulpal extirpation, endodontic treatment to include complete filling of the root canal(s) with permanent material, all necessary radiographs during treatment, a radiograph demonstrating proper completion, and follow-up care.

1. Silver points shall not be reimbursed when used as the "permanent material" for filling the root canal.

2. Complete filling of the root canal is defined as filling of the canal to within 0.5 millimeters of the apex.

(b) Root canal treatment for beneficiaries with permanent teeth will not be reimbursed without prior authorization by a Division dental consultant. When the beneficiary is in pain, the dentist should institute emergency measures to extirpate the pulp and/or relieve the pain only until authorization is requested and received. The Dental Prior Authorization Form (MC-10A), and the Dental Claim Form (MC-10) shall be submitted with diagnostic periapical radiograph(s) of the involved teeth.

1. The pulpotomy code is also reimbursable as an emergency endodontic procedure.

(c) Root canal therapy for primary teeth (with permanent successors only) shall include pulpal extirpation, and endodontic treatment to include complete filling of the root canal(s) with resorbable filling material. A radiograph(s) demonstrating proper completion shall be available for review by Division staff.

(d) Pulp capping (direct) is defined as an obtundent or regenerative dressing over the directly exposed vital pulp. This is differentiated from the routine placement of a medicated base or lining under a restoration. Pulp capping is not a separate reimbursable procedure.

(e) Apicoectomy will be considered for prior authorization and/or reimbursement only if one or more of the following conditions exist:

1. Overfilled canal (previously treated tooth);

2. Canal cannot be filled properly because of excessive root curvature or calcification;

3. Fractured root tip that cannot be reached endodontically;

4. Broken instrument in canal;

5. Perforation of the apical third of canal;

6. Displaced root canal filling lying free in periapical tissues and acting as an irritant;

7. Periapical pathology not resolved by previous endodontic therapy;

8. Periapical pathology which in the practitioner's judgment will not be resolved by endodontic therapy alone;

9. A post, post and core, or post-crown which cannot be removed.

(f) Apicoectomy should not be performed for convenience. If endodontic treatment is necessary, but none of the above conditions exist, reimbursement for the apicoectomy will not be made.

(g) Retrograde filling(s) will be inserted when necessary in conjunction with appropriate endodontic treatment, to include apicoectomy, but not in lieu of a properly filled canal.

(h) Reimbursement includes those post-treatment radiographs determined necessary by the practitioner. Such radiographs shall be available to the Medicaid/NJ FamilyCare fee-for-service programs upon request.



23 of 46 DOCUMENTS


NEW JERSEY ADMINISTRATIVE CODE

Copyright © 2014 by the New Jersey Office of Administrative Law


*** This file includes all Regulations adopted and published through the ***

*** New Jersey Register, Vol. 46 No. 11, June 2, 2014 ***


TITLE 10. HUMAN SERVICES

CHAPTER 56. MANUAL FOR DENTAL SERVICES

SUBCHAPTER 2. PROVISIONS FOR SERVICES
N.J.A.C. 10:56-2.12 (2014)

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