1 of 46 documents new jersey administrative code


§ 10:56-2.12 Periodontal services



Download 1.73 Mb.
Page4/14
Date27.11.2016
Size1.73 Mb.
1   2   3   4   5   6   7   8   9   ...   14
§ 10:56-2.12 Periodontal services
(a) Reimbursement shall be provided for periodontal scaling and root planing for four quadrants annually without prior authorization. Prior authorization shall be obtained for additional quadrants of periodontal scaling and root planing, and all other periodontal services. Such requests for prior authorization shall be submitted using the Dental Prior Authorization Form (MC-10A) and the Dental Claim Form (MC-10).

(b) Additional periodontal services may be prior authorized by the Division on a very selective basis. Such prior authorization shall be based on the requirements of this section and on the professional judgment of the Division dental consultant. A detailed description of the condition, including periodontal charting, radiographs, and photographs where appropriate, shall be submitted to the Division dental consultant. Photographs are an excellent means of presenting the condition of the oral tissues to the consultant and shall be reimbursable.

(c) When requesting periodontal surgery, consideration should be given to the age and health of the beneficiary, the amount of bone loss, the condition of the remaining dentition, the desire, ability, and motivation of the beneficiary to follow through with necessary home and follow-up care, and the prognosis for the remaining teeth.

(d) When requesting prior authorization for periodontal services, the provider should submit, in addition to radiographs and photographs, a narrative, to include periodontal charting, indicating pocket depth for each tooth in the quadrant requested.

(e) Reimbursement will be based upon quadrants, a site in a quadrant or the equivalent thereof, as determined by the Division dental consultant in accordance with N.J.A.C. 10:56-3.1(d)6vi.

24 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. 10:56-2.13 (2014)
§ 10:56-2.13 Prosthodontic services
(a) Removable prosthodontic services shall be provided as follows:

1. Dentures, both partial and complete, may be prior authorized when submitted evidence indicates masticatory deficiencies likely to impair the general health of the beneficiary. Prefabricated dentures or dentures that are temporary in nature shall not be reimbursable. When submitting a Dental Claim Form (MC-10) for reimbursement of approved complete or partial dentures, the date of service used shall be the date of insertion of the denture(s).

2. The following factors should also be considered when requesting prior authorization for dentures (including immediate dentures);

i. Age, school status, employment status and rehabilitative potential of the beneficiary (for example, provision of dentures will enhance vocational placement);

ii. Medical status of beneficiary (nature and severity of disease or impairment) and psychological predisposition;

iii. Condition of the oral cavity, including abnormal soft tissue or osseous conditions;

iv. Condition of present dentures, if applicable.

3. Generally, prior authorization for partial dentures to replace posterior teeth will not be granted if there are at least eight posterior teeth which in the opinion of a dental consultant are in reasonably good periodontal condition, occlusion and position, or where a prosthesis in one arch will produce equivalent dentition.

4. With the exception of immediate complete dentures, there shall be a three month wait for healing between the date of the last extraction and the initiation of the denture(s), partial or complete.

i. Should the provider initiate the denture treatment (that is, take final impressions) prior to the expiration of the three month healing period, the dentist shall be responsible for all subsequent relines, rebases and/or remaking of the denture(s) if necessary for a six month period following insertion.

ii. When all services are to be performed by the same practitioner, the total treatment plan for the extractions, denture(s) and any other dental services shall be submitted and will be reviewed for prior authorization in toto. As soon as the extractions are completed, the claim should be submitted for payment for the diagnostic and/or surgical services. After the required period of time for healing has taken place and the denture provided, a second claim should be completed (for the dentures only) and submitted to the fiscal agent marked "continuation of previously authorized treatment plan."

5. The fee for a partial denture shall include payment for all necessary clasps and rests. A minimum of two clasps and rests shall be provided.

6. The fee for complete maxillary and/or mandibular dentures shall include necessary adjustments for a six month period following insertion.

i. The fee for immediate dentures shall include the necessary adjustments and relines for a six month period following insertion.

7. Partial dentures shall be described on the Prior Authorization Form (MC-10A), indicating material used, position of clasps and teeth to be replaced. Fee includes necessary adjustments for a six month period following insertion.

8. Payment for dentures will be denied or recovered unless all dental procedures are completed in both arches before impressions are taken.

9. Dentures shall not be prior authorized when:

i. Dental history reveals that any or all dentures made in recent years have been unsatisfactory for reasons that are not remedial because of physiological or psychological reasons; or

ii. Dental history reveals that a denture was provided through any New Jersey State, county, or municipal agency in the seven and one-half year period prior to the date of the current request; or

iii. Repair, relining, or rebasing (jumping) of the beneficiary's present denture will make it serviceable.

10. Reimbursement for repairs to complete or partial dentures shall include adjustments for three months. Prior authorization shall be required when the repair exceeds $ 165.00 for a specialist or $ 150.00 for a non-specialist.

11. Denture relining, rebasing (jumping) or repairing services, except as noted in this section, are reimbursable.

i. Rebasing is the process of refitting a denture by the complete replacement of the denture base material without changing the occlusal relationship of the teeth.

ii. Relining is the process of resurfacing the tissue side of a denture with new base material to make it fit more accurately.

iii. The fee for relining and rebasing shall include all necessary adjustments for a six month period following insertion.

iv. Adjustments prior to and in conjunction with denture relining, rebasing (jumping) and repair shall not be reimbursable. Adjustments, repairs, relining, and rebasing shall not be reimbursable when new or replacement dentures have been prior authorized.

iv. Rebases and relines shall not be reimbursable within 12 months of initial insertion of a denture without prior authorization, and shall thereafter be limited to once every 12 months without prior authorization.

vi. The beneficiary's name (first and last names or, where space is a limiting factor, first initial and last name) must be processed into all dentures during the original fabrication or where possible during any subsequent processing, such as repair, relining and rebasing. The social security number shall also be included if space permits. This requirement is consistent with the "Denture I.D. Law" (N.J.S.A. 45:6-19.1 et seq.) and N.J.A.C. 13:30-8.11.

(b) Fixed prosthodontic services shall be provided as follows:

1. Fixed bridges will not normally be reimbursed. If extenuating circumstances exist, a prior authorization request shall be submitted to the Division dental consultant with recent diagnostic full mouth radiographs and written documentation of the circumstances.

2. In extenuating circumstances, if a patient is mentally or physically compromised to the extent that a removable prosthesis cannot be tolerated, a request accompanied by documentation from the physician should be submitted.

3. Replacement of an existing defective fixed bridge will only be considered for reimbursement if there are no other missing teeth in that arch, there is no radiographic evidence of a periodontal pathology present on recent radiographs and the abutment teeth have a favorable long term prognosis.

4. If there are fewer than eight posterior teeth in reasonably good occlusion and periodontal condition, a partial denture will be recommended by the Division dental consultant.

(c) Implant services shall be provided as follows:

1. Implants will not normally be considered for reimbursement. Prior authorization for implants will be limited to requests that demonstrate that a beneficiary has a facial anomaly, deformity or has been unable to function with a complete denture for at least two years and other oral surgical corrections have been unsuccessful in improving the retention of the denture.

2. If extenuating circumstances exist, a prior authorization request shall be submitted to a Division dental consultant with all supporting documentation and a complete restorative treatment plan, including denture services.

3. If other dentists are or will be involved in providing the needed comprehensive dental services, a team approach between the providers should be used to develop a treatment plan. The restorative dentist shall take the lead, collect the prior authorization requests from all involved providers and submit the requests to the Division dental consultant for review.

4. The Division dental consultant may forward an evaluation form requesting additional information.

5. The Dental Claim Form (MC-10) and diagnostics will be returned to the lead dentist by the Division dental consultant for forwarding to the appropriate team member.


25 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. 10:56-2.14 (2014)
§ 10:56-2.14 Oral and maxillofacial surgical services
(a) Dental extraction services shall be provided as follows:

1. Extraction of teeth other than those classified as non-restorable shall require prior authorization.

i. If a provider is considering any extraction which will necessitate the insertion of a dental prosthesis, the provider shall request prior authorization. Reimbursement for such an extraction rendered without prior authorization will be denied, or if already paid, reimbursement will be recovered. Due to the rule limiting the authorization of dentures, N.J.A.C. 10:56-2.13, it may be impossible to replace a denture following such extraction(s). Therefore, careful consideration should be given to the condition of teeth prior to a request for dentures initially; and prior to any extraction which would jeopardize an existing denture.

ii. When any extraction is to be performed in conjunction with or during orthodontic treatment, the dentist shall determine:

(1) That such orthodontic treatment has met the Salzmann Handicapping Malocclusion Guidelines established by the New Jersey Medicaid/NJ FamilyCare Program or has been prior authorized by a Division dental consultant.

(2) That such extraction has the express consent of the practitioner to whom orthodontic treatment has been authorized. Reimbursement will be denied (or if already paid, reimbursement will be recovered) for any extraction performed:

(A) In conjunction with orthodontic care, if such orthodontic treatment has not met the New Jersey Medicaid/NJ FamilyCare guidelines or has not been prior authorized by the Division dental consultant; or

(B) On a prior authorized orthodontic case without the consent of the practitioner to whom orthodontic treatment has been authorized, or without the approval of the Division dental consultant.

2. Reimbursement for dental extraction(s) includes local anesthesia, required suturing and routine post-operative care, including removal of the sutures. Alveoloplasty is reimbursable in conjunction with the extraction of teeth or the roots of teeth in the same quadrant during the same treatment visit. The alveoloplasty and the extractions shall be submitted on the same Dental Claim Form (MC-10) and have the same date of service.

3. Alveoloplasty, not related to current dental extraction(s), is reimbursable based on demonstrated dental necessity. Prior authorization shall not be required.

(b) Prior authorization shall not be required for the extraction of impacted teeth for beneficiaries age 18 and older. Prior authorization shall be required for such an extraction for beneficiaries under the age of 18. Extraction of impacted teeth should be undertaken only when conditions arising from such impactions warrant their removal. The extraction of asymptomatic impacted teeth or those teeth where dental/medical necessity cannot be demonstrated will not be accepted for reimbursement and shall be subject to recovery if payment has already been made.

1. In order to qualify for surgical removal of a tooth with partial or complete bony impaction, the following shall be required:

i. Incision of overlying soft tissue;

ii. Removal of bone; and/or

iii. Sectioning of the tooth.

(c) Other oral and maxillofacial surgery services shall be provided as follows:

1. Requests for prior authorization of oral surgical procedures, when such authorization is necessary, shall include a detailed description giving dates, diagnosis, site, and size of the operative area (number of lesions, and/or number and size of lacerations). For prior authorization, preoperative and any radiographs taken postoperatively, radiological, operative, and laboratory reports should be submitted directly to the Division dental consultant with the Dental Claim Form (MC-10). The dentist shall also make available all other reports, including hospital radiographs, upon request.

2. In the event that the oral surgery service to be performed is of an emergency nature and prior authorization is normally required but not feasible, then the Dental Prior Authorization Form (MC-10A) and the Dental Claim Form (MC-10) with all necessary information as mentioned in paragraph (c)1 above should be forwarded to the Division dental consultant for authorization prior to submission for payment.

3. The dentist performing a biopsy will receive reimbursement for the surgical portion only.

i. The laboratory performing the diagnostic service (and not the dentist) shall bill the program directly for the diagnostic service.

ii. The dentist will be reimbursed when the biopsy is performed as an independent procedure separate and apart, and on a different date from, the excision of the total lesion.

(d) Extractions to be performed for orthodontic purposes only shall be submitted to the Division dental consultant for prior authorization. Referrals for prior authorization shall be noted in section 14 of the Dental Claim Form, MC-10.



26 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. 10:56-2.15 (2014)
§ 10:56-2.15 Orthodontic services
(a) The procedures in this section shall be followed for orthodontic referral, evaluation, and treatment.

(b) Comprehensive orthodontic treatment shall be limited to handicapping malocclusions. Cases with 24 or more points on the New Jersey Handicapping Malocclusion Assessment System shall be considered as having a handicapping malocclusion. Prior authorization shall be obtained in accordance with (e) below before any orthodontic treatment is initiated.

1. Orthodontic treatment shall not be reimbursed for the following:

i. For cosmetic purposes only;

ii. For individuals age 21 or older; and

iii. Except as specified at (d) below, for individuals with less than 24 points on the New Jersey Handicapping Malocclusion Assessment System (see (c) below).

2. The following factors shall be considered by a dentist before making any referral and also by the practitioner who may render orthodontic treatment before assessing the beneficiary and performing the diagnostic work-up:

i. The assessment system is a modification of the work of Dr. J.A. Salzmann who has consented to allow the New Jersey Medicaid/NJ FamilyCare program to modify and utilize it.

ii. The difference from Dr. Salzmann's original work is that the New Jersey Medicaid/NJ FamilyCare program does not allow the eight additional points to denote aesthetic handicap for the anterior segment.

iii. Referrals for orthodontics and initiation of orthodontic treatment should be delayed until the beneficiary has all permanent teeth, unless prior authorized by a Division dental consultant.

iv. The beneficiary, together with the parent or guardian, should have the desire and ability to complete an extended treatment plan.

v. The rehabilitative potential of the beneficiary should be considered.

vi. The practitioner should be aware of the following:

(1) The Medicaid/NJ FamilyCare Eligibility Identification card should be examined on the first visit of each month. Make certain that the beneficiary being treated is listed as eligible and that the Medicaid/NJ FamilyCare number has not changed. If possible, a photocopy should be retained as part of the beneficiary's records on a monthly basis.

(c) The New Jersey Medicaid/NJ FamilyCare Program Handicapping Malocclusion Assessment System shall be utilized to determine if the case fulfills the requirements for a diagnostic workshop and subsequent orthodontic treatment.

1. A reprint from the American Journal for Orthodontics (10/68) entitled "Handicapping Malocclusion Assessment to Establish Treatment Priority" provides comprehensive instructions for completion of the Handicapping Malocclusion Assessment Record Form (FD-10). A copy of the reprint can be ordered from the Medicaid/NJ FamilyCare fiscal agent:


Unisys


PO Box 4752

Trenton, New Jersey 08650-4752

(d) The practitioner shall evaluate the beneficiary as follows:

1. The practitioner, considering the factors in this section, shall perform a visual/oral evaluation of the beneficiary, and complete the Handicapping Malocclusion Assessment Record Form (FD-10) to determine if the severity of the malocclusion will qualify (24 points or more) for diagnostic work-up and initiation of treatment.

2. If the malocclusion does not meet the minimum number of assessment points (24), the practitioner should not proceed with the diagnostic workup since the case does not qualify and reimbursement will be denied.

i. Exception: If the malocclusion does not meet the minimum number of Assessment points (24), but there are other extenuating circumstances that should be considered, the practitioner should proceed with the diagnostic workup; however, the extenuating factors shall be recorded and substantiated and submitted with the diagnostic workup and treatment plan to the Bureau of Dental Services for prior authorization. Examples of possible extenuating circumstances are:

(1) Facial or oral clefts;

(2) Extreme antero-posterior relationships;

(3) Extreme mandibular prognathism;

(4) A deep overbite where incisor teeth contact palatal tissue;

(5) Extreme bi-maxillary protrusion.

ii. For reimbursement of the Handicapping Malocclusion Assessment Examination only, the practitioner shall submit the Dental Claim Form (MC-10) directly to the Medicaid/NJ FamilyCare fiscal agent, identifying, by procedure code D8660, the service that has been rendered. A copy of the Handicapping Malocclusion Assessment Record Form (FD-10) shall be retained in the provider's record for the patient. The provider shall submit the claim to:


Unisys


PO Box 4811

Trenton, New Jersey 08650-4811

iii. Requests for treatment which are submitted with assessments below the minimum number of points required (see (d)2 above) shall be denied for reimbursement for the diagnostic materials submitted, or shall be subject to recovery, if payment has already been made.

3. If the malocclusion meets or exceeds the minimum number of assessment points (24), the practitioner may proceed with the diagnostic workup.

(e) Prior authorization requirements for special orthodontic services are:

1. Upon completion of the diagnostic work-up, the provider shall submit the following to the Division of Medical Assistance and Health Services, Bureau of Dental Services, PO Box 713, Trenton, New Jersey 08625-0713.

i. The Dental Prior Authorization Form (MC-10A) part 1 of 2 and the Dental Claim Form MC-10 part 2 of 2 utilizing the proper code number(s) with requested fees for:

(1) Assessment examination;

(2) Diagnostic aids utilized;

(3) Treatment necessary to carry the case to completion.

ii. A brief description of the proposed plan of treatment on provider's personal letterhead;

iii. A copy of the Handicapping Malocclusion Assessment Record Form (FD-10);

iv. Diagnostic aids shall include and reimbursement will be limited to:

(1) Photographs of the diagnostic models with the correct inter-arch relationship indicated and/or photographs of the beneficiary which demonstrate the malocclusion and/or extenuating circumstance(s). The maximum number of photographs which is reimbursable is eight;

(A) The actual diagnostic models should only be submitted if it is impossible to demonstrate the orthodontic problem and extenuating circumstances by photographs, or if requested;

(2) A cephalometric radiograph with a detailed tracing;

(3) A series of intra-oral radiographs consistent with N.J.A.C. 10:56-2.7 (or a diagnostic panoramic radiograph);

(4) Extra-oral lateral plate radiographs (but not if diagnostic panoramic radiograph has been submitted);

(5) Photographs (minimum size two inches by two inches)--maximum reimbursable--eight.

(6) All the diagnostic aids will be returned to the practitioner, but shall continue to be available upon request of the Division of Medical Assistance and Health Services. It is suggested that models, radiographs, and photographs be duplicated before submission to enable the practitioner to retain a set in the office should there be breakage or loss in mailing.

2. A Division dental consultant will review the plan of requested treatment utilizing the diagnostic aids submitted and render a decision.

3. The practitioner will be notified by the Medicaid/NJ FamilyCare program of the action taken on the treatment request following review by the Division dental consultants.

(f) Periodically, the Division of Medical Assistance and Health Services, Bureau of Dental Services, may request a progress report from the provider, and, as necessary, progress photographs and other appropriate records to determine whether authorization should be continued. Failure to respond to this request in writing, personally signed by the provider, may result in suspension of authorization and reimbursement to the provider.

1. Reimbursement for periodic orthodontic treatment visits shall be based on the orthodontic treatment services provided. Reimbursement shall not be requested for any period in which there is no visit.

2. Reimbursement for periodic orthodontic treatment visits shall be provided for a total of 36 visits per beneficiary; however, the provider shall request and obtain authorization for any visits needed in excess of 28 visits prior to such visits.

(g) If the beneficiary's eligibility continues through completion of treatment, final records similar to the diagnostic aids described in (e)1iv above, shall be taken at termination of treatment and shall be submitted upon the Division's request, to:


Division of Medical Assistance and Health Services

Bureau of Dental Services

PO Box 713

Trenton, New Jersey 08625-0713

(h) An itemized Dental Claim Form (MC-10) should be sent to the Medicaid/NJ FamilyCare fee-for-service fiscal agent for reimbursement of the cost of the final records immediately upon completion of the treatment and preparation of the records.

(i) Reimbursement for comprehensive orthodontic evaluations and/or orthodontic assessment evaluations shall be made under the following conditions:

1. Reimbursement shall be limited to the provider or provider group who does such an evaluation with the intention of personally providing any orthodontic treatment necessary.

2. Reimbursement shall be limited to once every 12 months, unless prior authorized.

3. Comprehensive orthodontic evaluations shall not be reimbursable for beneficiaries age 21 or older.

(j) All orthodontic cases shall be subject to Post-Utilization Review by the Division. Therefore, all providers shall maintain all pre and post-treatment records for at least seven years following completion.

(k) The following orthodontic cases shall undergo prepayment review by the Division before reimbursement will be remitted to the provider:

1. Orthodontic cases below 24 points on the Salzmann Assessment;

2. All limited orthodontic treatment cases;

3. All transfer orthodontic cases; and

4. All orthodontic cases in which the beneficiary has discontinued treatment for a period of six months or more and then returns for treatment.



1   2   3   4   5   6   7   8   9   ...   14


The database is protected by copyright ©dentisty.org 2019
send message

    Main page