Or. Admin. Code § 410-123-1160

Current through Register Vol. 63, No. 12, December 1, 2024

Section 410-123-1160 - Prior Authorization

(1) Health Services Division (Division) prior authorization (PA) requirements. For fee-for-service (FFS) dental members, the following services require PA:

(a) Crowns (porcelain fused to metal/porcelain ceramic);

(b) Crown repair;

(c) Retreatment of previous root canal therapy - anterior;

(d) Complete dentures;

(e) Immediate dentures;

(f) Partial dentures;

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

(h) Fixed partial denture repairs;

(i) Skin graft;

(j) Orthodontics (when covered pursuant to OAR 410-123-1260).

(k) Hospital dentistry always requires PA, regardless of the member's enrollment status. Refer to OAR 410-123-1490 for more information;

(l) Oral surgical services require PA when performed in an ambulatory surgical center (ASC) or an outpatient or inpatient hospital setting and related anesthesia, and the current Medical Surgical Services administrative rule OAR 410-130-0200 for information;

(m) Maxillofacial surgeries may require PA in some instances. Refer to the current Medical Surgical Services OAR 410-130-0200, for information.

(2) The Division does not require PA for outpatient or inpatient services related to a "Dental Emergency Condition" which means determination based on the presenting symptoms (not the final diagnosis) as perceived by a prudent layperson (rather than a Health Care Professional) and includes cases in which the absence of immediate medical attention would not in fact have had the adverse results. The member's clinical record shall document any appropriate clinical information that supports the need for the hospitalization. Refer to Line 54 of the Prioritized List of Health Services for funded emergency dental service codes.

(3) How to request PA:

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

(b) Documentation submitted when requesting authorization shall support the medical justification for the service. The authorization request shall 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 Division may request the treating dentist to submit appropriate radiographs or other clinical information that justifies the treatment:

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

(i) Readable copies;

(ii) Mounted or loose;

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

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

(v) If digital x-ray, they shall be of photo quality.

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

(4) The Division will issue a decision on PA requests within 30 days of receipt of the request. The Division will provide PA for services when:

(a) The prognosis is favorable;

(b) The treatment is practical;

(c) The services are Dentally Appropriate; and

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

(5) 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.

(6) For certain services and billings, the Division will seek a general practice consultant or an oral surgery consultant for professional review to determine if a PA will be approved. The Division will deny PA if the consultant decides that the clinical information furnished does not support the treatment of services.

(7) For hospital dentistry, refer to OAR 410-123-1490 for details regarding PA requirements.

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

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

Statutes/Other Implemented: ORS 414.065 & 414.707