The following orthodontic services are covered under the dental care program subject to the specified limitations.
(A) Surgical access of an unerupted tooth. Coverage is limited to situations whereby an orthodontic attachment is placed on the crown to facilitate eruption. Prior authorization is required. Complete radiographs must be submitted with each request.
(B) Minor treatments to control harmful habits.
(1) Fixed appliance therapy.
(2) Removable appliance therapy.
(3) Prior authorization is required on all tooth guidance appliances to control harmful habits including, but not limited to, thumb- and finger-sucking, tongue-thrusting, and bruxism. Complete radiographs and study models of the mouth must be submitted with each request.
(C) Comprehensive orthodontics.
(1) Coverage of comprehensive orthodontics is limited to the most severe handicapping orthodontic conditions. Coverage is further limited to consumers under age twenty-one. Only one course of orthodontic treatment per consumer, per lifetime is covered.
(2) Prior authorization is required for all comprehensive orthodontic treatment. Effective December 7, 2010, all prior authorization requests must be submitted through the Ohio department of job and family services (ODJFS) web portal. Paper prior authorization requests will be returned to the provider unprocessed.
Documentation necessary to complete the prior authorization request that cannot be uploaded and submitted through the ODJFS web portal, such as x-rays and dental molds, must be submitted separately.
The following must be included with the prior authorization request:
(a) A completed prior authorization request.
(b) Lateral and frontal photographs of consumer with lips together.
(c) Cephalometric film with lips together, including a tracing.
(d) A complete series of radiographs or a panoramic radiograph.
(e) Diagnostic models.
(f) Treatment plan, including projected length and cost of treatment.
(g) A completed referral evaluation criteria form (JFS 03630/appendix to this rule ). A consumer must demonstrate a minimum of five symptoms, with at least two of the symptoms appearing under dentofacial abnormality before the provider submits a request for consideration.
(3) Upon evaluation of all the documentation which includes study models, cephalometric film and tracing, radiographs, photographs, and the referral evaluation criteria form, the department will determine if the condition will be considered a severely handicapping orthodontic condition and covered by medicaid. If the case is denied, the prior authorization will be returned to the provider indicating that the orthodontic treatment will not be reimbursed by Ohio medicaid. However, an authorization will be issued for the payment of the photographs, cephalometric radiograph and tracing, and the diagnostic models. Full mouth radiographs and panoramic films do not require prior authorization and can be billed separately on a dental invoice by the dentist who provided the radiographs.
(4) The original prior authorization will cover the entire course of treatment as long as the consumer remains eligible for medicaid services. For those cases approved for treatment, the department will issue a prior authorization that approves payment for the records and the first quarter of treatment. Payment for subsequent quarters of orthodontic treatment will be made at the beginning of each quarter of active treatment through a maximum of eight quarters. Also, payment will be made for retention services after the active treatment is completed. The dentist, using the original prior authorization number, should bill the department every ninety days at the beginning of the quarter to receive payment for that quarter. At the end of the active treatment, the department can be billed one time per arch for retention service. Payment will not be made for active treatment after retention is begun.
(5) If the consumer becomes ineligible during the time that comprehensive orthodontic treatment is being rendered, the quarter payment will permit coverage to continue through the end of the authorized quarter of treatment. For example, if the prior authorized treatment quarter begins February first, and the consumer becomes ineligible as of March first, treatment is to continue through the remainder of the quarter for which payment has been made, (February first - April thirtieth). It will be the responsibility of the consumer and the dentist to determine a payment mechanism for subsequent quarters of treatment provided when the consumer is ineligible for medicaid.
(6) Payment for active treatment will be made for a maximum of eight quarters. In some cases more than eight quarters may be necessary to complete treatment. However, the fee associated with eight quarters of treatment is the maximum amount reimbursable and is considered payment-in-full. No additional reimbursement can be sought from the department, consumer, or other source if the treatment requires additional quarters.
R.C. 119.032 review dates: 09/20/2010 and 08/01/2016
Promulgated Under: 119.03
Statutory Authority: 5111.02
Rule Amplifies: 5111.01 , 5111.02 , 5111.021
Prior Effective Dates: 4/7/77, 12/21/77, 5/9/86, 2/1/88, 11/15/93, 8/1/95, 12/29/99 (Emer), 10/1/03, 1/1/06, 7/1/08