10A N.C. Admin. Code 25H.0205

Current through Register Vol. 39, No. 9, November 1, 2024

Section 25H .0205 - RESTRICTIONS AND PRIOR APPROVAL

(a) The Division of Health Benefits shall have the right of prior approval for dental services except for routine and emergency services.

(b) All other dental services are subject to prior approval. Dental services categories requiring dental prior approval are as follows: Elective root canal treatment, periodontal services, orthodontic services, complex oral surgical and reconstructive procedures, complete and partial dentures, denture relines and analgesia (nitrous oxide). Each specific procedure under the American Dental Association (ADA) service category in this Paragraph will be listed in the provider dental manual and provider bulletins with the appropriate prior approval service restriction guidelines.

(c) The Division of Health Benefits may require prior approval for any services for individual providers who have been investigated by the Division under 10A NCAC 22F or by the Attorney General's Fraud Control Unit under 42 Code of Federal Regulations 455.300, and the investigation resulted in monetary recovery of payments made by Medicaid to the provider or criminal conviction of the provider.

10A N.C. Admin. Code 25H .0205

Authority G.S. 108A-25(b); 108A-54; S.L. 1985, c. 479, s. 86;
Eff. February 1, 1976;
Amended Eff. September 30, 1977;
Readopted Eff. October 31, 1977;
Amended Eff. October 1, 1992; February 29, 1980;
Transferred from 10A NCAC 22O .0205 Eff. May 1, 2012;
Pursuant to G.S. 150B-21.3A, rule is necessary without substantive public interest Eff. July 23, 2016;
Amended Eff. March 1, 2020.