N.J. Admin. Code § 10:56-2.13

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

Section 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.

v. 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" (45:6-19.1 et seq.) and 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.

N.J. Admin. Code § 10:56-2.13

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.
Amended by R.1986 d.385, effective 9/22/1986.
See: 18 N.J.R. 1337(a), 18 N.J.R. 1958(a).
(b)9 "Denture" substituted for "Dental".
Recodified from 10:56-1.19 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.2000 d.426, effective 10/16/2000.
See: 32 N.J.R. 2411(a), 32 N.J.R. 3836(a).
In (c), increased the dollar amount of fees for repair of complete or partial dentures.
Amended by R.2001 d.268, effective 8/6/2001.
See: 33 N.J.R. 1554(a), 33 N.J.R. 2666(b).
Substituted references to beneficiaries for references to recipients throughout; in (b), inserted a reference to NJ Family Care.
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 "Prosthodontic treatment". Rewrote (a), (b) and (c); and deleted (d).