N.J. Admin. Code § 10:56-1.4

Current through Register Vol. 56, No. 12, June 17, 2024

Section 10:56-1.4 - Prior authorization

(a) For dental services that require prior authorization, a Prior Authorization Form, (MC-10A), and the Dental Claim Form (MC-10), shall be submitted to:

Division of Medical Assistance and Health Services

Office of Utilization Management

Bureau of Dental Services, Mail Code 21

PO Box 713

Trenton, New Jersey 08625-0713

Telephone: (609) 588-7136

1. Requests for prior authorization should include recent diagnostic radiographs. When appropriate for the service requested, documentation to substantiate or demonstrate the need for the requested dental services shall also be included.

(b) Oral hygiene devices require prior authorization, regardless of cost.

(c) Consideration for prior authorization shall be based on the least costly appliance fulfilling the requirements of the specific situation or the extenuating circumstances.

(d) Dental services which require prior authorization and are defined as "non-routine services" are specified at N.J.A.C. 10:56-3 and are designated by one of the following indicators:

1. A single asterisk (*); or

2. A double asterisk (**); and/or

3. A crosshatch (#).

(i) The crosshatch denotes that a special authorization requirement(s) exists. The requirements are listed adjacent to the procedure codes involved.

4. Those services which do not require prior authorization have no asterisk or crosshatch indicators and are those basic services defined by Medicaid/NJ FamilyCare as "routine services."

(e) Prior authorization requests cannot be transferred from one dentist to another.

(f) Situations which require prior authorization for services which would otherwise be considered routine services include:

1. Services involving more than one supernumerary tooth;

2. The extraction of restorable teeth or teeth with no carious lesions;

3. Extractions in conjunction with orthodontic treatment not being reimbursed by the Medicaid/NJ FamilyCare program; and

4. Services to teeth that were denied as having been previously extracted.

(g) Prior authorization for additional and/or amended services that are found to be necessary after the original dental treatment plan has been prior authorized may be requested by recording such need on the Dental Prior Authorization Form (MC-10A). Providers shall submit a copy of the Dental Claim Form (MC-10) for the approved services and a second prior authorization request for the new services, indicating that a change in treatment plan has occurred. Providers shall include recent radiographs and any pertinent documentation to assist in consideration of the new services.

(h) Providers shall complete all dental procedures in both arches before impressions are taken for dentures. Payment for prior authorized dentures will be denied unless all dental procedures are completed in both arches before impressions are taken.

(i) Prior authorizations shall be effective for one year from the date of authorization and for the three months immediately preceding the date of authorization. Prior authorized ("non-routine") services shall be completed within one year of the date of the original authorization by the Division dental consultant.

1. If providers are unable to complete the services within the prior authorized period, providers may contact the Division dental consultant and request an extension of the authorized effective period, in accordance with (g) above.

2. All requirements of 10:49-7.2, regarding timeliness of claim submission and inquiry requirements shall apply to all prior authorized services. Dental providers shall direct all questions regarding the status of a prior authorization request and denials of prior authorization requests to the Bureau of Dental Services, Mail Code 21, PO Box 713, Trenton, New Jersey 08625-0713, Telephone: (609) 588-7136.

N.J. Admin. Code § 10:56-1.4

As amended, R.1974 d.53, eff. 3/15/1974.
See: 6 N.J.R. 13(a), 6 N.J.R. 150(b).
As amended, R.1984 d.270, eff. 7/2/1984.
See: 15 N.J.R. 813(a), 16 N.J.R. 1788(b).
Section substantially amended.
Recodified from 10:56-1.3 and amended by R.1996 d.428, effective 9/16/1996.
See: 28 N.J.R. 3069(a), 28 N.J.R. 4243(a).
Former N.J.A.C. 10:56-1.4, "Non-covered services", recodified to 10:56-1.7.
Amended by R.1998 d.353, effective 7/20/1998.
See: 30 N.J.R. 514(a), 30 N.J.R. 2654(a).
In (a), updated the address in the introductory paragraph.
Amended by R.2000 d.426, effective 10/16/2000.
See: 32 N.J.R. 2411(a), 32 N.J.R. 3836(a).
In (b)1, increased the dollar amount of a diagnostic examination with radiography; in (b)3, increased the dollar amounts of specialist and nonspecialist fees for denture adjustment and repair, and amended the date of the increases.
Amended by R.2001 d.268, effective 8/6/2001.
See: 33 N.J.R. 1554(a), 33 N.J.R. 2666(b).
In (b)3, inserted a reference to NJ FamilyCare fee for service preceding "reimbursement".
Amended by R.2004 d.25, effective 1/20/2004.
See: 35 N.J.R. 4032(a), 36 N.J.R. 568(a).
In (a), inserted ", with the Dental Claim Form (MC-10) attached," preceding "shall be submitted to:" in the introductory paragraph, amended the address, and inserted a reference to NJ FamilyCare in 3; in (d), inserted references to NJ FamilyCare in the introductory paragraph and 1.
Amended by R.2007 d.36, effective 2/5/2007.
See: 38 N.J.R. 3419(a), 39 N.J.R. 479(a).
Rewrote the section.