Md. Code Regs. 10.09.05.06

Current through Register Vol. 51, No. 25, December 13, 2024

Section 10.09.05.06 - Preauthorization Requirements

A. Preauthorization is issued when:

(1) Program procedures are met;

(2) Program limitations are met;

(3) The provider submits to the Department, adequate documentation demonstrating that the service to be preauthorized is medically necessary; and

(4) The participant is eligible for the service.

B. Preauthorization is required for the following:

(1) Resin fused to metal crown;

(2) Porcelain fused to metal crown;

(3) Nonprecious metal crown (full cast);

(4) Apicoectomies and periradicular services;

(5) Certain periodontal services;

(6) Complete upper/lower denture;

(7) Partial upper/lower denture (including clasps and teeth);

(8) Any elective clinical or surgical procedure not listed on the current dental fee schedule;

(9) Surgery normally considered cosmetic but qualified by traumatic or pathological causation;

(10) Laboratory rebasing of dentures;

(11) Addition of teeth or clasps to an existing, functional complete or partial denture;

(12) General restorative treatment to be rendered in a hospital;

(13) Special periodontal appliances;

(14) Apexification and recalcification procedures;

(15) Hemisection, including any root removal, including endodontic therapy;

(16) Overdenture complete;

(17) Overdenture partial;

(18) Condylectomy;

(19) Meniscectomy;

(20) Arthrotomy; and

(21) All orthodontic procedures.

C. At a minimum, the documentation required when requesting preauthorization for the following services is:

(1) A complete radiographic survey of the mouth for:

(a) Complete or partial dentures; or

(b) Except in the case of special needs children, where sedation would be required for a complete radiograph of the mouth, special periodontal appliances and periodontal therapies;

(2) Individual periapical radiographs for:

(a) Except in the case of special needs children, where sedation would be required for an individual periapical radiograph or bitewing, endodontic therapy (periapicals and bitewings shall be submitted when the request is for posterior teeth);

(b) Apicoectomy;

(c) Except in the case of special needs children, where sedation would be required for an individual periapical radiograph, periradicular and apexification or recalcification services; and

(d) Full coverage permanent crown restorations (excludes stainless steel and provisional resin crowns); and

(3) Full mouth radiographs and a periodontal chart, identifying the depths and locations of the pockets, when periodontal services are requested.

D. Except as described in §F of this regulation, preauthorization is valid for dental services when the services are approved and completed within 6 months after the date of the receipt of the preauthorization number from the Program.

E. Preauthorization normally required by the Program is waived when the services are covered and approved by Medicare. However, if the entire or any part of a claim is rejected by Medicare, and the claim is referred to the Program for payment, payment will be made for services covered by the Program only if authorization for those services has been obtained before billing. Non-Medicare claims require preauthorization according to §§A-D of this regulation.

F. Preauthorization for Orthodontic Treatment.

(1) Preauthorization is required for traditional comprehensive orthodontic services treatment and for self-ligating braces for the correction of medically necessary conditions, which cause dysfunction due to a handicapping malocclusion. At a minimum the following comprehensive pretreatment documentation shall be submitted:

(a) Cephalometric head film with analysis;

(b) Panoramic or full series of periapical radiographs;

(c) 6-8 diagnostic quality extra-oral and intra-oral photographs;

(d) Clinical summary with diagnosis;

(e) HLD score sheets from attending orthodontist; and

(f) Treatment plan.

(2) Preauthorization for periodic orthodontic treatment is valid for:

(a) 24 months for traditional comprehensive orthodontic treatment; or

(b) 12 months for self-ligating braces.

Md. Code Regs. 10.09.05.06

Regulations .06 amended effective October 13, 1976 (3:21 Md. R. 1206)
Regulations .06B amended as an emergency provision effective February 1, 1982 (9:2 Md. R. 110); emergency status extended at 9:11 Md. R. 1122 and 9:17 Md. R. 1697 (Emergency provisions are temporary and are not printed in COMAR)
Regulation .06C adopted effective April 4, 1980 (7:7 Md. R. 708)
Regulation .06 amended effective May 19, 2008 (35:10 Md. R. 972)
Regulation .06 amended as an emergency provision effective July 16, 2009 (36:17 Md. R. 1310); amended permanently effective November 30, 2009 (36:24 Md. R. 1858)
Regulation .06A amended effective August 27, 2007 (34:17 Md. R. 1507)
Regulation .06B amended effective October 1, 1985 (12:19 Md. R. 1848); December 24, 1990 (17:25 Md. R. 2907)
Regulation .06F amended effective December 27, 2010 (37:26 Md. R. 1787); amended effective 43:5 Md. R. 385, eff.3/14/2016; amended effective 44:16 Md. R. 808, eff. 8/14/2017; amended effective 48:22 Md. R. 938, eff. 11/1/2021; amended effective 48:23 Md. R. 979, eff. 11/15/2021; amended effective 50:13 Md. R. 512, eff. 7/10/2023