N.J. Admin. Code § 10:56-2.1

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

Section 10:56-2.1 - Dental treatment or services plan

(a) In accordance with good dental practice, a plan of treatment or services shall be developed and described for each Medicaid/NJ FamilyCare patient on the Dental Claim Form (MC-10) following a comprehensive evaluation. If no treatment is necessary, this fact shall be entered on the Dental Claim Form (MC-10) under Remarks (Item 20). (No Other Treatment Necessary or NOTN).

(b) Any dental treatment plan, including those not requiring prior authorization, may be reviewed by dental consultants of the New Jersey Medicaid/NJ FamilyCare program.

(c) In those instances where prior authorization is necessary, the two page prior authorization documents, that is, the Dental Prior Authorization Form MC-10(A) and the Dental Claim Form MC-10, shall be submitted along with the treatment plan and any additional documentation or radiographs appropriate to the request. A Division dental consultant may modify or deny the provider's treatment plan in accordance with the requirements of the New Jersey Medicaid/NJ FamilyCare fee-for-service programs, as specified in this chapter. Such modifications or denials are designed to provide dental treatment to the beneficiary that is adequate for the correction of the problem, that can be expected to last for the longest period of time, and represents, in the opinion of the dental consultant(s), the most judicious application of Medicaid/NJ FamilyCare fee-for-service reimbursement. If in the professional judgment of the provider such modification is not appropriate, the dentist may request another review by the Division dental consultant. A further review in the Bureau of Dental Services may be requested through the Division dental consultant.

(d) In any dental treatment or services plan, the dentist shall discuss the proposed treatment plan and receive approval from the beneficiary and/or family member/guardian before submission for authorization and again after authorization is received and prior to initiation of treatment. It is suggested that the provider have the beneficiary sign the office records or a separate statement that the treatment plan meets with their approval, since no alteration of the treatment plan will be reimbursed based on the subsequent rejection of all or part of that treatment plan by the beneficiary or family member/guardian.

(e) Consideration for development of a dental treatment plan shall be based upon the least costly treatment fulfilling the requirements of the specific situation. On the basis of post-utilization review, any dental treatment plan, including those not requiring prior authorization, may be reviewed by Division dental consultants to determine appropriateness of treatment. If the treatment is not appropriate, the payment shall be recovered.

(f) If, in the opinion of a dentist, the beneficiary requires the services of a specialist, the dentist shall note the name of the practitioner to whom the beneficiary is being referred on the Dental Claim Form (MC-10) under remarks (Item 20). The specialist shall note the name and Medicaid/NJ FamilyCare Provider Service Number of the referring dentist on the Dental Claim Form (MC-10) in section 14, which is designated as Referring Practitioner.

N.J. Admin. Code § 10:56-2.1

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 10:56-1.2 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 section, "General billing procedures", repealed.
Amended by R.2001 d.268, effective 8/6/2001.
See: 33 N.J.R. 1554(a), 33 N.J.R. 2666(b).
In (c) and (f), inserted references to NJ FamilyCare and NJ FamilyCare fee-for-service; in (g), inserted a reference to NJ FamilyCare; in (c), (f) and (g), substituted references to beneficiaries for references to recipients.
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) and (b), inserted references to NJ FamilyCare.
Amended by R.2007 d.36, effective 2/5/2007.
See: 38 N.J.R. 3419(a), 39 N.J.R. 479(a).
Section was "Dental treatment plan". In (a), inserted "or services", deleted "Services" following "Dental" two times and substituted "evaluation" for "examination" and "shall" for "must; rewrote (c); in (d), inserted "or services", substituted "shall" for "must" and inserted a comma following "their approval"; in (e), inserted "Division" and deleted "of the New Jersey Medicaid program" following "consultants"; deleted former (f); recodified former (g) as new (f); and in (f), deleted "Services" following "Dental" two times.