Benefit Changes for Texas Health Steps Orthodontic Dental Services Effective January 1, 2012 Information posted November 14, 2011 Effective for dates of service on or after January 1, 2012, the following Texas Health Steps (THSteps) orthodontic dental services benefits will change for Texas Medicaid. Comprehensive orthodontic services will be limited to once per lifetime by any provider and will be reimbursed at an all-inclusive rate. Procedure code D8080 must be billed with the appropriate modifier (U1 or U2). Procedure code D8692 will be a new benefit of Texas Medicaid when rendered by an orthodontist, federally qualified health center (FQHC), or THSteps-dental or dental group provider in the office setting. Procedure code D8660 will no longer be a benefit of Texas Medicaid. THSteps Dental Mandatory Prior Authorization Request Form has been revised. These changes will not affect prior authorization approvals for dates of service prior to January 1, 2012. Prior Authorization Requests From January 1, 2012, to February 29, 2012, prior authorizations for most orthodontic services will be suspended. During this time period, only the following exceptions will be processed through TMHP: Emergent conditions Intermediate care facilities for persons with intellectual disabilities (ICF-MR) Client s who have one of the following special medical conditions: o Cleft palate o Head-trauma injury involving the oral cavity o Skeletal anomalies involving the oral cavity On March 1, 2012, prior authorization requests for orthodontic services for Medicaid clients transitioning to managed care will be submitted to the client s dental plan instead of TMHP. Comprehensive Orthodontic Services Comprehensive orthodontic services are a benefit for clients who are 13 years of age and older who have permanent dentition and a severe handicapping malocclusion or one of the following special medical conditions: Cleft palate Head-trauma injury involving the oral cavity 1 of 9
Skeletal anomalies involving the oral cavity Exceptions to the age restriction may be considered for clients who have special medical conditions as listed above. A severe handicapping malocclusion is defined by Texas Medicaid as compromised masticatory (chewing) function as a result of the existing relationship between the maxillary (upper) and mandibular (lower) dental arches. Comprehensive orthodontic services include, but are not limited to, all of the following: Diagnostic work-ups Banding Brackets Monthly visits Initial retainers Special orthodontic treatment appliance(s) Reimbursement will be divided into four installments that are available for remittance as follows: First installment (procedure code D8080 with modifier U1) available at the initiation of comprehensive orthodontic services. Second installment (procedure code D8080 with modifier U1) available with information attached to the claim that shows one-third completion of comprehensive orthodontic services. Third installment (procedure code D8080 with modifier U1) available with information attached to the claim that shows two-thirds completion of comprehensive orthodontic services. Fourth installment (procedure code D8080 with modifier U2) available after the completion of the comprehensive orthodontic services has been approved by the TMHP Dental Director. Procedure code D8080 with modifier U1 is limited to once every 180 days, up to 3 per lifetime, by the same provider. Completion of comprehensive orthodontic services (procedure code D8080 with modifier U2) is limited to once per lifetime by any provider. Authorization Requirements Prior authorization is mandatory for all orthodontic services (procedure codes D8050, D8060, D8080 with U1, D8080 with U2, D8210, D8220, and D8680). Documentation must support medical necessity of any appliance requested. When requesting prior authorization, the provider must submit a completed THSteps Dental Mandatory Prior Authorization Request Form. 2 of 9
The TMHP Dental Director will review prior authorization requests for medical necessity including the following: Diagnostic models Permanent dentition not complete Special orthodontic appliance requested Client conditions not specified in the policy All prior authorization requests for orthodontic services must be accompanied by an attestation from the requesting provider that the provider is one of the following: A board-certified or board-eligible pediatric dentist. A board-certified or board-eligible orthodontist. A general dentist who must attest and maintain documentation of a minimum of 200 hours of continuing dental education specifically in orthodontics. Proof of the completion of continuing education hours is not required to be submitted with a request for prior authorization of orthodontic services, but documentation must be produced by the dentist during retrospective review. All attestations are subject to compliance review and recoupment. All required documents must be submitted together in one package per prior authorization request. A prior authorization request that is not submitted in one package per request will be considered an incomplete request. All documentation that is submitted with an incomplete request will be sent back to the provider with a letter that identifies the missing documentation. The provider will be allowed to resubmit a prior authorization request; however, the provider must wait until all diagnostic tools have been returned on an incomplete request before resubmitting the corrected documentation in a complete package with all required diagnostic tools. Prior authorizations requests containing only the missing or corrected documentation will not be processed. To avoid unnecessary denials, providers must submit correct and complete information, including documentation for medical necessity of the service(s) requested. Providers must maintain documentation of medical necessity in the client's dental record. A requesting provider may be asked for additional information to clarify or complete a request. All documentation that is submitted or maintained in the client s dental record will be subject to retrospective review. Treatment Plans Prior authorization requests will be approved only for services included in the comprehensive orthodontic services (procedure code D8080 with U1). The treatment plan must include all orthodontic services that will be rendered as part of the comprehensive orthodontic services. 3 of 9
Approved treatment plans must be initiated before the client s loss of Medicaid eligibility or before the client turns 21 and must be completed within 36 months of the authorization date. Services cannot be added or approved after Texas Medicaid eligibility has expired. No extensions on the allowed 36-month completion time frame will be approved. After obtaining prior authorization, the provider must advise the client that he or she will be able to receive the approved orthodontic service (including monthly orthodontic adjustment visits and retainers) even if he or she loses eligibility or reaches his or her 21 birthday. If a client reaches 21 years of age or loses Medicaid eligibility before the authorized comprehensive orthodontic services are completed, reimbursement is provided to complete the orthodontic treatment that was authorized and initiated while the client was 20 years of age or younger, eligible for Texas Medicaid, and completed within 36 months. To be reimbursed through Texas Medicaid, non-orthodontic services that are included as part of the treatment plan (extractions or surgeries) must be completed before the loss of client eligibility or the client s 21 birthday. Before Initial Comprehensive Orthodontic Services Begins When requesting prior authorization for procedure code D8080 with U1, providers must submit pretreatment diagnostic models, radiographs (X-rays), and other supporting documentation with the THSteps Dental Mandatory Prior Authorization Request Form. The provider must submit all of the following documentation with the request for prior authorization: An orthodontic treatment plan (The treatment plan must include all procedures required to complete full treatment, such as extractions, orthognathic surgery, upper and lower retainers, monthly adjustments, appliance removal if indicated, special orthodontic appliances. The treatment plan is limited to only the services that are required to properly treat the client.) A narrative that documents the medical necessity for orthodontic treatment A cephalometric radiograph with tracing (copies are preferred) Facial and intraoral photographs (copies are preferred) A full series of radiographs or a panoramic radiograph (copies are preferred) Pretreatment diagnostic models (E-models are accepted for pre-treatment records.) A completed and scored Handicapping Labio-Lingual Deviations (HLD) Index with the angle class documented in the diagnosis field (A minimum score of 26 points is required to request correction of a severe handicapping malocclusion.) Any additional pertinent information as determined by the dentist or requested by the TMHP Dental Director 4 of 9
Following Completion of Comprehensive Orthodontic Services When requesting prior authorization for procedure code D8080 with U2, providers must submit post-treatment diagnostic models, radiographs (X-rays), and other supporting documentation with the THSteps Dental Mandatory Prior Authorization Request Form. Prior authorization requests for procedure code D8080 with U2 will be reviewed by the TMHP Dental Director to verify services have been completed or all requirements for premature termination by the original provider have been met. The provider must submit final records with the request for prior authorization. Final records include all of the following documentation: Panoramic radiograph (copies are preferred) Cephalometric radiograph with tracing (copies are preferred) Six intraoral photographs (copies are preferred) Three extraoral photographs (copies are preferred) Post-treatment plaster diagnostic models (E-models will not be accepted for posttreatment records.) A narrative documenting completion of the treatment plan or termination of the comprehensive orthodontic services Documentation that the parent, legal guardian, or the client if he or she is 18 years of age or older or an emancipated minor understands that the provider has documented completion of the treatment plan, and the client is no longer eligible for comprehensive orthodontic services by Texas Medicaid The TMHP Dental Director will review the final record to determine whether the orthodontic treatment plan has been completed. Prior authorization for the final payment may be denied if the final records do not support the completion of the treatment plan. Premature Termination of Comprehensive Orthodontic Treatment Premature termination of comprehensive orthodontic treatment includes all the following: Removal of the brackets and arch wires Removal of appliances with the fabrication of retainers Delivery of orthodontic retainers Original Provider Premature termination of comprehensive orthodontic services by the original provider is included in procedure code D8080 with U2 and prior authorization approval. Different Provider Premature termination of comprehensive orthodontic services by a provider other than the original treating provider may be reimbursed for procedure code D8680 with prior authorization approval. 5 of 9
Documentation In addition to the final records described above, providers requesting premature termination of comprehensive orthodontic services must submit a release form that includes the following: A signature by either the parent, legal guardian, or client if he or she is 18 years of age or older or an emancipated minor. One of the following statements as appropriate: o The client is uncooperative or non-compliant with the treating dentist s directions and does not intend to complete orthodontic treatment. o The client requested the premature removal of orthodontic appliance(s) and does not intend to complete orthodontic treatment. o The client has requested the premature removal of orthodontic appliance(s) due to extenuating circumstances including, but not limited to, the following: Incarceration. Mental health complications with a recommendation from the treating physician. Foster care placement. Child of a migrant farm worker with the intent to complete orthodontic treatment at a later date if Medicaid eligibility for orthodontic services continues. A statement that the parent, legal guardian, or the client, if he or she is 18 years of age or older or an emancipated minor, understands that the provider has documented terminating the comprehensive orthodontic services, and the client is not eligible for comprehensive orthodontic services by Texas Medicaid/THSteps due to the client's request or uncooperative and/or non-compliance. If comprehensive orthodontic services are terminated due to extenuating circumstances, clients will be eligible for completion of their Medicaid orthodontic services if the services are re-initiated while the client is eligible for Medicaid. Transfer of Comprehensive Orthodontic Services Prior authorization for comprehensive orthodontic services is not transferable to another provider. The new provider must request a new authorization to complete the orthodontic treatment initiated by another provider. This request must be submitted on a completed THSteps Dental Mandatory Prior Authorization Request Form. The following supporting documentation must accompany the new request for transfer of comprehensive orthodontic services: All the documentation required for the original provider The reason the client left the previous provider An explanation of the treatment status 6 of 9
The authorization requests for clients who are undergoing comprehensive orthodontic services and subsequently become eligible for Medicaid are subject to the same requirements listed above. Prior authorization requests will be approved only for services included in the comprehensive orthodontic services (procedure code D8080). The treatment plan must include all orthodontic services that will be rendered as part of the comprehensive orthodontic services and are subject to the same requirements listed above. Diagnostic Tools Diagnostic models submitted to Texas Medicaid should be trimmed so they can be articulated easily. Radiographs (X-rays) that are submitted to Texas Medicaid must be diagnostic quality. X-rays do not have to be submitted on photographic quality paper. Diagnostic models are preferred in the form of plaster casts; however, providers may determine the positions in which these casts are made. E-models will only be accepted in the centric occlusion position,but not for posttreatment records for comprehensive orthodontic services. The prior authorization request must include the date of service the diagnostic tools were obtained (date the dental records were produced). All diagnostic tools must be properly labeled and protected when shipped by the provider. If any diagnostic tools are damaged during shipment, the provider may be required to reproduce the documentation for consideration of the prior authorization request. If medical necessity cannot be determined from the diagnostic tools submitted, the prior authorization request may be denied. Copies of diagnostic models, X-rays, and any other paper diagnostic tools will be accepted and are preferred. Copies will not be returned, but providers will be required to maintain the dental records for retrospective review. Originals will be returned to the submitting provider only when the document is clearly marked "original." TMHP will retain an image of each diagnostic tool that is submitted for every complete orthodontic prior authorization request. Handicapping Labio-Lingual Deviation (HLD) Index Providers must complete and sign the HLD Index including documentation of the client s presenting angle classification. The HLD index requires the use of a HLD score sheet and a Boley gauge for measuring. Scoring must be conservative. The client s occlusal relationship must be considered dysfunctional and have a minimum of 26 points on the HLD index to be considered for comprehensive orthodontic services. 7 of 9
Exception: Clients with one of the following situations do not have to meet the HLD 26- point minimum scoring requirement: The client is requesting the transfer of previously authorized comprehensive orthodontic services The client initiated comprehensive orthodontic services before becoming eligible for Medicaid. The client has a special medical condition, including one or more of the following: o Cleft palate o Post head trauma injury involving the oral cavity o Skeletal anomalies involving the oral cavity Providers must submit a sufficient narrative that describes the client s medical condition when requesting authorization for comprehensive orthodontic services when the HLD score is less than 26. With the client or models in the centric position, the HLD index is to be scored as follows: Cleft Palate: A cleft palate request for mixed dentition will be considered only if narrative justification supports treatment before the client reaches full permanent dentition. Severe Traumatic Deviations: Refers to facial accidents only. Points cannot be awarded for congenital deformity. It does not include traumatic occlusion for crossbite. Overjet in Millimeters: Score the client exactly as measured. The measurement must be recorded from the most protrusive incisor, then subtract 2 millimeters (mm) (a 2mm deviation is considered the norm) and enter the difference as the score. Overbite in Millimeters: Score the client exactly as measured. The measurement must be recorded from the labio-incisal edge of the overlapped anterior tooth or teeth to the point of maximum coverage, then subtract 3 mm (a 3 mm deviation is considered the norm) and enter the difference as the score. Mandibular Protrusion in Millimeters: Score the client exactly as measured. The measurement must be recorded from the line of occlusion of the permanent teeth, not from the ectopically erupted teeth in the anterior segment. Caution is advised in undertaking treatment of open bites in older teenagers because of the frequency of relapse. Ectopic Eruption: An unusual pattern of eruption, such as high labial cuspids or teeth that have erupted in a position that is grossly out of the long axis of the alveolar ridge. Ectopic eruption does not include teeth that are rotated or teeth that are leaning or slanted especially when the enamel-gingival junction is within the long axis of the alveolar ridge. Record the more serious condition. Do not include (score) teeth from an arch if that arch is to be counted in the following category of Anterior Crowding. For each arch, either the ectopic eruption or the anterior crowding may be scored, but not both. 8 of 9
Anterior Crowding: Arch length insufficiency must exceed 3.5 mm to be considered as crowding in either arch. Mild rotation that may react favorably to stripping or moderate expansion procedures are not to be scored as crowded. Excessive Anterior Spacing in Millimeters: The score for this category must be the total of the anterior spaces in millimeters. Providers must record all measurements rounded-off to the nearest millimeter. Enter a score of 0 if the condition is absent. Replacement Retainers Replacement retainer(s) (procedure code D8692) may be reimbursed as medically necessary. Retainer adjustments are not reimbursed separately. A THSteps Dental Mandatory Prior Authorization Form must be completed when requesting prior authorization for the replacement retainers. Procedure code D8692 is limited to once per lifetime, per arch due to loss or breakage. The initial upper and lower retainers are included in the reimbursement for procedure code D8080 and will not be reimbursed separately. Non-covered Services The following are not a benefit of Texas Medicaid: Orthodontic services for cosmetic purposes or primarily for self-worth.. Single arch comprehensive orthodontic treatment. Crossbite therapy (limited orthodontics) will not be considered for mixed dentition when there is a need for comprehensive orthodontic services of the adolescent dentition (procedure code D8080). An initial orthodontic/pre-orthodontic treatment visit (procedure code D8660) is considered part of an oral evaluation (procedure code D0120 or D0150). Consequently, procedure code D8660 is not considered a separate benefit of Texas Medicaid. Orthodontic services for a client who initiated orthodontic treatment through a private arrangement while Medicaid-eligible. 9 of 9