N.J. Admin. Code § 10:56-2.15

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

Section 10:56-2.15 - Orthodontic services

(a) The procedures in this section shall be followed for orthodontic referral, evaluation, and treatment.

(b) Comprehensive orthodontic treatment shall be limited to handicapping malocclusions. Cases with 24 or more points on the New Jersey Handicapping Malocclusion Assessment System shall be considered as having a handicapping malocclusion. Prior authorization shall be obtained in accordance with (e) below before any orthodontic treatment is initiated.

1. Orthodontic treatment shall not be reimbursed for the following:

i. For cosmetic purposes only;

ii. For individuals age 21 or older; and

iii. Except as specified at (d) below, for individuals with less than 24 points on the New Jersey Handicapping Malocclusion Assessment System (see (c) below).

2. The following factors shall be considered by a dentist before making any referral and also by the practitioner who may render orthodontic treatment before assessing the beneficiary and performing the diagnostic work-up:

i. The assessment system is a modification of the work of Dr. J.A. Salzmann who has consented to allow the New Jersey Medicaid/NJ FamilyCare program to modify and utilize it.

ii. The difference from Dr. Salzmann's original work is that the New Jersey Medicaid/NJ FamilyCare program does not allow the eight additional points to denote aesthetic handicap for the anterior segment.

iii. Referrals for orthodontics and initiation of orthodontic treatment should be delayed until the beneficiary has all permanent teeth, unless prior authorized by a Division dental consultant.

iv. The beneficiary, together with the parent or guardian, should have the desire and ability to complete an extended treatment plan.

v. The rehabilitative potential of the beneficiary should be considered.

vi. The practitioner should be aware of the following:

(1) The Medicaid/NJ FamilyCare Eligibility Identification card should be examined on the first visit of each month. Make certain that the beneficiary being treated is listed as eligible and that the Medicaid/NJ FamilyCare number has not changed. If possible, a photocopy should be retained as part of the beneficiary's records on a monthly basis.

(c) The New Jersey Medicaid/NJ FamilyCare Program Handicapping Malocclusion Assessment System shall be utilized to determine if the case fulfills the requirements for a diagnostic workshop and subsequent orthodontic treatment.

1. A reprint from the American Journal for Orthodontics (10/68) entitled "Handicapping Malocclusion Assessment to Establish Treatment Priority" provides comprehensive instructions for completion of the Handicapping Malocclusion Assessment Record Form (FD-10). A copy of the reprint can be ordered from the Medicaid/NJ FamilyCare fiscal agent:

Unisys

PO Box 4752

Trenton, New Jersey 08650-4752

(d) The practitioner shall evaluate the beneficiary as follows:

1. The practitioner, considering the factors in this section, shall perform a visual/oral evaluation of the beneficiary, and complete the Handicapping Malocclusion Assessment Record Form (FD-10) to determine if the severity of the malocclusion will qualify (24 points or more) for diagnostic work-up and initiation of treatment.

2. If the malocclusion does not meet the minimum number of assessment points (24), the practitioner should not proceed with the diagnostic workup since the case does not qualify and reimbursement will be denied.

i. Exception: If the malocclusion does not meet the minimum number of Assessment points (24), but there are other extenuating circumstances that should be considered, the practitioner should proceed with the diagnostic workup; however, the extenuating factors shall be recorded and substantiated and submitted with the diagnostic workup and treatment plan to the Bureau of Dental Services for prior authorization. Examples of possible extenuating circumstances are:

(1) Facial or oral clefts;

(2) Extreme antero-posterior relationships;

(3) Extreme mandibular prognathism;

(4) A deep overbite where incisor teeth contact palatal tissue;

(5) Extreme bi-maxillary protrusion.

ii. For reimbursement of the Handicapping Malocclusion Assessment Examination only, the practitioner shall submit the Dental Claim Form (MC-10) directly to the Medicaid/NJ FamilyCare fiscal agent, identifying, by procedure code D8660, the service that has been rendered. A copy of the Handicapping Malocclusion Assessment Record Form (FD-10) shall be retained in the provider's record for the patient. The provider shall submit the claim to:

Unisys

PO Box 4811

Trenton, New Jersey 08650-4811

iii. Requests for treatment which are submitted with assessments below the minimum number of points required (see (d)2 above) shall be denied for reimbursement for the diagnostic materials submitted, or shall be subject to recovery, if payment has already been made.

3. If the malocclusion meets or exceeds the minimum number of assessment points (24), the practitioner may proceed with the diagnostic workup.

(e) Prior authorization requirements for special orthodontic services are:

1. Upon completion of the diagnostic work-up, the provider shall submit the following to the Division of Medical Assistance and Health Services, Bureau of Dental Services, PO Box 713, Trenton, New Jersey 08625-0713.

i. The Dental Prior Authorization Form (MC-10A) part 1 of 2 and the Dental Claim Form MC-10 part 2 of 2 utilizing the proper code number(s) with requested fees for:

(1) Assessment examination;

(2) Diagnostic aids utilized;

(3) Treatment necessary to carry the case to completion.

ii. A brief description of the proposed plan of treatment on provider's personal letterhead;

iii. A copy of the Handicapping Malocclusion Assessment Record Form (FD-10);

iv. Diagnostic aids shall include and reimbursement will be limited to:

(1) Photographs of the diagnostic models with the correct inter-arch relationship indicated and/or photographs of the beneficiary which demonstrate the malocclusion and/or extenuating circumstance(s). The maximum number of photographs which is reimbursable is eight;

(A) The actual diagnostic models should only be submitted if it is impossible to demonstrate the orthodontic problem and extenuating circumstances by photographs, or if requested;

(2) A cephalometric radiograph with a detailed tracing;

(3) A series of intra-oral radiographs consistent with 10:56-2.7 (or a diagnostic panoramic radiograph);

(4) Extra-oral lateral plate radiographs (but not if diagnostic panoramic radiograph has been submitted);

(5) Photographs (minimum size two inches by two inches)--maximum reimbursable--eight.

(6) All the diagnostic aids will be returned to the practitioner, but shall continue to be available upon request of the Division of Medical Assistance and Health Services. It is suggested that models, radiographs, and photographs be duplicated before submission to enable the practitioner to retain a set in the office should there be breakage or loss in mailing.

2. A Division dental consultant will review the plan of requested treatment utilizing the diagnostic aids submitted and render a decision.

3. The practitioner will be notified by the Medicaid/NJ FamilyCare program of the action taken on the treatment request following review by the Division dental consultants.

(f) Periodically, the Division of Medical Assistance and Health Services, Bureau of Dental Services, may request a progress report from the provider, and, as necessary, progress photographs and other appropriate records to determine whether authorization should be continued. Failure to respond to this request in writing, personally signed by the provider, may result in suspension of authorization and reimbursement to the provider.

1. Reimbursement for periodic orthodontic treatment visits shall be based on the orthodontic treatment services provided. Reimbursement shall not be requested for any period in which there is no visit.

2. Reimbursement for periodic orthodontic treatment visits shall be provided for a total of 36 visits per beneficiary; however, the provider shall request and obtain authorization for any visits needed in excess of 28 visits prior to such visits.

(g) If the beneficiary's eligibility continues through completion of treatment, final records similar to the diagnostic aids described in (e)1iv above, shall be taken at termination of treatment and shall be submitted upon the Division's request, to:

Division of Medical Assistance and Health Services

Bureau of Dental Services

PO Box 713

Trenton, New Jersey 08625-0713

(h) An itemized Dental Claim Form (MC-10) should be sent to the Medicaid/NJ FamilyCare fee-for-service fiscal agent for reimbursement of the cost of the final records immediately upon completion of the treatment and preparation of the records.

(i) Reimbursement for comprehensive orthodontic evaluations and/or orthodontic assessment evaluations shall be made under the following conditions:

1. Reimbursement shall be limited to the provider or provider group who does such an evaluation with the intention of personally providing any orthodontic treatment necessary.

2. Reimbursement shall be limited to once every 12 months, unless prior authorized.

3. Comprehensive orthodontic evaluations shall not be reimbursable for beneficiaries age 21 or older.

(j) All orthodontic cases shall be subject to Post-Utilization Review by the Division. Therefore, all providers shall maintain all pre and post-treatment records for at least seven years following completion.

(k) The following orthodontic cases shall undergo prepayment review by the Division before reimbursement will be remitted to the provider:

1. Orthodontic cases below 24 points on the Salzmann Assessment;

2. All limited orthodontic treatment cases;

3. All transfer orthodontic cases; and

4. All orthodontic cases in which the beneficiary has discontinued treatment for a period of six months or more and then returns for treatment.

N.J. Admin. Code § 10:56-2.15

As amended, R.1983 d.584, eff. 1/1/1984.
See: 15 N.J.R. 1160(a), 15 N.J.R. 2170(a).
Deletion of references to orthodontists and replacement by references to general practitioners.
Amended by R.1986 d.385, effective 9/22/1986.
See: 18 N.J.R. 1337(a), 18 N.J.R. 1958(a).
Note recodified to (e)1iv(6).
Recodified from 10:56-1.21 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.1998 d.353, effective 7/20/1998.
See: 30 N.J.R. 514(a), 30 N.J.R. 2654(a).
Updated addresses throughout the section.
Amended by R.2000 d.426, effective 10/16/2000.
See: 32 N.J.R. 2411(a), 32 N.J.R. 3836(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)2vi(1), inserted references to NJ FamilyCare; in (e)1iv(1), rewrote the last sentence; rewrote (g) as (g) and (h); recodified former (h) through (j) as (i) through (k); and substituted "beneficiary" for "recipient" and "beneficiary's" for "recipient's", throughout.
Amended by R.2003 d.16, effective 1/6/2003.
See: 34 N.J.R. 2681(a), 35 N.J.R. 232(a).
Rewrote the section.
Amended by R.2004 d.25, effective 1/20/2004.
See: 35 N.J.R. 4032(a), 36 N.J.R. 568(a).
Inserted references to NJ FamilyCare throughout.
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 "Orthodontic treatment". Rewrote the section.