Or. Admin. Code § 410-123-1160

Current through Register Vol. 64, No. 1, January 1, 2025

Section 410-123-1160 - Prior Authorization

(1) The following services require Prior Authorization (PA)::

(a) Crowns: Porcelain fused to metal (D2751, D2752), Porcelain ceramic (D2740);

(b) Crown repair necessitated by restorative material failure, covered only for anterior teeth (D2980);

(c) Retreatment of previous root canal therapy, covered only for anterior teeth (D3346);

(d) Complete dentures (D5110, D5120);

(e) Immediate dentures (D5130, D5140);

(f) Partial dentures (D5211, D5212, D5221, D5222);

(g) Prefabricated post and core in addition to fixed partial denture retainer;

(h) Fixed partial denture repairs (D6980);

(i) Skin graft (D7920);

(j) Comprehensive Orthodontic treatment (D8070, D8080, D8090);

(k) Hospital dentistry (Refer to OAR 410-123-1490);

(l) Oral surgical services, when performed in an:

(A) Ambulatory surgical center (ASC); or

(B) Outpatient or inpatient hospital setting and related anesthesia (Refer to OAR 410-130-0200);

(m) Maxillofacial surgeries, in some instances (Refer to OAR 410-130-0200).

(2) PA for more frequent non-surgical periodontal scaling and root planing (D4341, D4342) may be requested when:

(a) Medically necessary and dentally appropriate due to periodontal disease found during pregnancy; and

(b) Documentation in the member's medical record supports the need for increased scaling and root planing.

(3) The Authority does not require PA for outpatient or inpatient services related to a "Dental Emergency Condition" as defined in OAR 410-123-1060.

(a) The member's clinical record must document any appropriate clinical information that supports the need for the hospitalization; and

(b) Refer to the Prioritized List of Health Services for funded emergency dental service codes.

(4) Periodontal maintenance is allowed once every six (6) months by PA when:

(a) Medically necessary and dentally appropriate (refer to EPSDT requirements in OAR chapter 410, division 151), such as due to presence of periodontal disease during pregnancy;

(b) Member's medical record documents the need;

(c) Records must clearly document the clinical indications for all periodontal procedures, including current pocket depth charting and radiographs.

(5) Denture replacement requires PA.

(6) Hospital dentistry always requires PA for the medical services provided by the facility:

(a) If a member is enrolled in an MCE with plan type CCOA:

(A) The dentist is responsible for:

(i) Contacting the MCE for PA requirements and arrangements; and

(ii) Submitting documentation to the MCE associated with the member record.

(B) The MCE must review the documentation and discuss any concerns they have, contacting the dentist as needed; and

(C) The total response time must not exceed fourteen (14) calendar days from the date of submission of all required documentation for routine dental care and must follow urgent or emergent dental care timelines.

(b) If a member is enrolled in an MCE with plan type CCOB:

(A) The dentist is responsible for:

(i) Contacting the MCE for PA requirements and arrangements; and

(ii) Submitting documentation to the MCE associated with the member record.

(B) The MCE shall review the documentation and discuss any concerns they have, contacting the dentist as needed. This allows for mutual plan (CCO and FFS) involvement and monitoring; and

(C) The MCE is responsible for payment of all facility and anesthesia services. The FFS program is responsible for payment of all dental services.

(c) If a member is enrolled in an MCE with plan type CCOF or CCOG and is enrolled in FFS for physical health, the:

(A) The Dentist is responsible for sending, by secure email or faxing, documentation and a completed American Dental Association (ADA) form to the Authority (Refer to the Dental Services Provider Guide);

(B) Member must have a referral from the PCM prior to any hospital service being approved by the Authority if assigned to a Primary Care Manager (PCM) through FFS medical, the;

(C) The Authority is responsible for payment of facility and anesthesia services;

(D) MCE is responsible for payment of all dental services; and

(E) The Authority shall issue a decision on PA requests within thirty (30) days of receipt of the request.

(d) If a member is FFS for both physical health and dental health or enrolled in MCE plan type CCOE, the:

(A) Dental provider is responsible for sending, by secure email or faxing, documentation, and a completed ADA form to the Authority (Refer to the Dental Services Provider Guide); and

(B) Authority is responsible for payment of all facility, anesthesia services and dental services.

(7) How to request PA:

(a) Submit the request to the Authority in writing. Refer to the Dental Services Provider Guide for specific instructions and forms to use. Telephone calls requesting PA shall not be accepted;

(b) Documentation submitted when requesting authorization must support the medical justification for the service. The authorization request must contain:

(A) A cover sheet detailing relevant provider and recipient Medicaid numbers;

(B) Requested dates of service;

(C) HCPCS or Current Dental Terminology (CDT) Procedure code requested;

(D) Amount of service or units requested;

(E) Any additional clinical information supporting medical justification for the services requested.

(c) Treatment justification: The Authority may request the treating dentist to submit appropriate radiographs or other clinical information that justifies the treatment:

(A) When radiographs are required, they must be:

(i) Readable copies and of photo quality;

(ii) Mounted or loose;

(iii) In an envelope, stapled to the PA form;

(iv) Clearly labeled with the dental provider's name and address and the member's name; and

(v) Of photo quality when it is a digital x-ray.

(B) Do not submit radiographs unless it is required by the Dental Services administrative rules, or they are requested during the PA process.

(8) The Authority shall issue a decision on PA requests within thirty (30) days of receipt of the request. The Authority shall provide PA for services when:

(a) The prognosis is favorable;

(b) The treatment is practical;

(c) The services are medically necessary and dentally appropriate; and

(d) A lesser-cost procedure may not achieve the same ultimate results.

(9) PA does not guarantee member eligibility or reimbursement. It is the responsibility of the provider to check the member's eligibility on each date of service.

(10) The Authority shall seek a general practice consultant or an oral surgery consultant for:

(a) Professional review to determine if a PA shall be approved; and

(b) Shall deny PA if the consultant decides that the clinical information furnished does not support the treatment of services.

Or. Admin. Code § 410-123-1160

HR 3-1994, f. & cert. ef. 2-1-94; HR 32-1994, f. & cert. ef. 11-1-94; OMAP 23-1999, f. & cert. ef. 4-30-99; OMAP 17-2000, f. 9-28-00, cert. ef. 10-1-00; OMAP 48-2002, f. & cert. ef. 10-1-02; DMAP 25-2007, f. 12-11-07, cert, ef. 1-1-08; DMAP 38-2008, f. 12-11-08, cert. ef. 1-1-09; DMAP 16-2009 f. 6-12-09, cert. ef. 7-1-09; DMAP 41-2009, f. 12-15-09, cert. ef. 1-1-10; DMAP 14-2010, f. 6-10-10, cert. ef. 7-1-10; DMAP 13-2013, f. 3-27-13, cert. ef. 4-1-13; DMAP 28-2013(Temp), f. 6-26-13, cert. ef. 7-1-13 thru 12-28-13; DMAP 61-2020, amend filed 12/11/2020, effective 1/1/2021; DMAP 50-2021, amend filed 12/24/2021, effective 1/1/2022; DMAP 8-2022, minor correction filed 02/04/2022, effective 2/4/2022; DMAP 60-2024, minor correction filed 02/21/2024, effective 2/21/2024; DMAP 139-2024, amend filed 12/06/2024, effective 1/1/2025

Statutory/Other Authority: ORS 413.042, ORS 414.065 & 414.707

Statutes/Other Implemented: ORS 414.065 & 414.707