N.J. Admin. Code § 10:56-2.6

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

Section 10:56-2.6 - Diagnostic services: general

(a) A complete evaluation of the oral cavity shall be a comprehensive and thorough inspection of the oral cavity to include diagnosis, an oral cancer screening, charting of all abnormalities, and development and recording of a complete treatment plan. It should permit a Division dental consultant (with accompanying radiographs) to determine the appropriateness of the treatment plan.

1. This dental evaluation is reimbursable only when part of a total treatment plan, unless the evaluation discloses no need for treatment, in which case this must be indicated by placing the statement "No Other Treatment Necessary (N.O.T.N.)" under Remarks (Item 20) on the Dental Claim Form (MC-10).

2. Except as provided in 10:78-7.1, for reimbursement purposes, a comprehensive dental evaluation shall be limited to once every six months for those beneficiaries through age 20 and once every 12 months for those beneficiaries 21 years of age or older except as prior authorized by a Division dental consultant.

(b) An emergency oral evaluation is distinguished from a complete evaluation of the oral cavity in that it is applicable only for diagnosis and/or observation of a specific complaint in an emergency situation.

(c) The dentist who examines a nursing facility beneficiary shall provide the treatment necessary unless the evaluation indicates that a specialist is needed.

(d) A Handicapping Malocclusion Assessment Examination (refer to 10:56-2.15 ) shall not be reimbursed for individuals age 21 or older.

1. For reimbursement purposes, a Handicapping Malocclusion Assessment Examination shall be limited to once every 12 months unless authorized. In addition, reimbursement shall be limited to the provider or provider group who does such an examination with the intention of personally providing any orthodontic treatment necessary.

2. Orthodontic evaluation, including the Handicapping Malocclusion Assessment Examination, shall be conducted before a child reaches age 18 to ensure that all orthodontic treatment proposed can be completed prior to the child's reaching age 21. Unless extenuating circumstances exist and the Division dental consultant has previously reviewed and approved the treatment, any and all orthodontic treatment not completed prior to the child's reaching age 21 shall be the sole responsibility of the provider.

N.J. Admin. Code § 10:56-2.6

As amended, R.1982 d.403, effective 11/15/1982. (Operative date: February 1, 1983.)
See: 13 N.J.R. 875(a), 14 N.J.R. 1301(a).
Section substantially amended.
As amended, R.1983 d.584, eff. 1/1/1984.
See: 15 N.J.R. 1160(a), 15 N.J.R. 2170(a).
Amended by R.1986 d.385, effective 9/22/1986.
See: 18 N.J.R. 1337(a), 18 N.J.R. 1958(a).
Section renumbered and (b)4 new.
Recodified from 10:56-1.14 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 (a)2, substituted "Except as provided in N.J.A.C. 10:78-7.1, for" for "For", inserted "/NJ Family Care fee-for-service" preceding "programs", and substituted "beneficiaries" for "recipients"; in (c), substituted "beneficiary" for "recipient".
Amended by R.2007 d.36, effective 2/5/2007.
See: 38 N.J.R. 3419(a), 39 N.J.R. 479(a).
Substituted "evaluation" for "examination" throughout; in the introductory paragraph of (a), substituted "Division dental consultant" for "Dental Consultant"; in (a)1, deleted "Services" following "Dental"; in (a)2, substituted "20" for "17", "21" for "18" and "Division dental consultant" for "Dental Consultant of the Medicaid/NJ Family Care fee-for-service programs"; rewrote the introductory paragraph of (d); deleted (d)1; recodified former (d)2 as (d)1; in (d)1, substituted "shall be" for "is" two times; and added new (d)2.