N.J. Admin. Code § 10:56-2.12

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

Section 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 10:56-3.1(d)6 vi.

N.J. Admin. Code § 10:56-2.12

Recodified from 10:56-1.18 and amended by R.1996 d.428, effective 9/16/1996.
See: 28 N.J.R. 3069(a), 28 N.J.R. 4243(a).
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), substituted "beneficiary" for "recipient"; in (d), inserted a reference to NJ Family Care.
Amended by R.2004 d.25, effective 1/20/2004.
See: 35 N.J.R. 4032(a), 36 N.J.R. 568(a).
Added a new (a); recodified former (a) as (b) and substituted "Additional periodontal" for "Periodontal"; recodified former (b) through (d) as (c) through (e).
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 "Periodontal treatment". In (a), substituted "scaling and root planing" for "services" and "four" for "up to eight", and added last two sentences; in (b), substituted "services" for "treatment", inserted "periodontal charting," and "Division", and deleted "or slides" following "Photographs"; in (c), substituted "surgery" for "treatment"; in (d), deleted "of the code" following "authorization" and "(s)" following "quandrant", substituted "services" for "scaling and root planing" and inserted "charting, indicating"; and in (e), substituted "a site in a quadrant" for "a portion thereof," and "the Division" for "Medicaid/NJ Family Care".