Severe Malocclusion Program Billing

Criteria

Referral

Prior Authorization

• D8080 or D8090 – should be billed once the child has been banded

– D8080 is only allowed for patients under 15

• Client’s under 12 - <12 referral form required

– D8090 is allowed for patients aged 15-18.

• D8670 - the quarterly payments will be billed by dates of service within the quarter

(please continue to list each date of service the child was seen in the office for

adjustments repairs or any others services)

• D8690 - If client loses eligibility a prior authorization should be requested and the

remaining charges billed once PA is approved.

• No other codes are allowed for full treatment under the SMP program

Billing – Full Treatment

• D8060 – Interceptive Treatment

– Only allowed for clients under 12.

– Each arch is 1 unit.

• D8660 - Initial Consultation

– A PA is only required if the client is under 12.

– A $75.00 fee is only to be billed if clients other than Medicaid paid this amount also.

– 1-per lifetime benefit. If this has been billed before the child is not eligible for another consultation.

The SMP Referral form for patient’s under 12 is required for all PA requests for these

services.

Billing – Client’s under 12

• D8670 – Periodic Treatment

– Only request and bill for as many quarters as will be required to complete treatment

• D8680 – Retention and Removal

– Only allowed for transfer cases when treatment will not be continued.

Note: These codes can be billed together or separately.

• D8692 – Replace Lost or Broken Retain

• D8060 – Interceptive Treatment

Billing - Transfers

Please only submit requests to Wyoming Medicaid for clients that meet the criteria.

Cleft Palate Deformities – Cleft palate deformities with a recommendation from the

Cleft Palate Team

AND/OR

Impacted Anterior Teeth – Teeth that are impacted will be evaluated and approved

based on necessity.

AND/OR

Criteria

Deep Impinging Overbite – Deep Impinging Overbite will only be considered if the

teeth are destroying palate soft and/or tissue laceration and/or loss of gingival

attachment. There MUST be photographic documentation of the damage, laceration, or

loss of attachment.

– Note: This has been approved in the past with only palatal irritations, inflammation, and/or indentations.

In order to consistently meet the set criteria, this cannot be approved without sufficient documentation

of destruction.

AND/OR

Criteria

Anterior Crossbite – Anterior Crossbite will only be considered if the teeth are causing

tissue laceration and/or loss of gingival attachment. There MUST be photographic

documentation of attachment loss and recession of the gingival margin

– Note: This condition has been approved in the past with only palatal irritations, inflammation, and/or

indentations. In order to consistently meet the set criteria, this cannot be approved without sufficient

documentation of destruction.

AND/OR

Criteria

Severe Traumatic Deviation – Traumatic deviations are, for example, loss of premaxilla

segment by burns or by accident; the result of osteomyelitis; or other gross pathology

– Congenitally missing teeth are not considered Severe Traumatic Deviation. Missing teeth should be

indicated on Part 2 of the SMP request form.

– A narrative should be written on Part 2 explaining what the deviation is.

– This should also be indicated as part of the HLD score

AND/OR

A minimum HLD index score of 30

Note: A lower score may be approved if special circumstances apply

Criteria

SMP Referral is only needed if client is under 12 years old.

• Dentists –

– Refer clients to an enrolled Wyoming Medicaid Orthodontist.

– Use the Parent Handout to educate parents on if their child is eligible or not.

• Orthodontists –

– Please do not submit request for patient’s who do not meet criteria.

– If you are receiving referrals for clients that don’t meet the basic criteria please contact Dental

Services.

Consideration for Oral Surgery Referral is only required if the client will need Maxillo-

Facial Surgery.

– Refer clients to an enrolled Wyoming Medicaid Oral Surgeon.

Referrals

• Fill out and send the Prior Authorization Request Form to Medical Policy.

• Include:

– The completed Severe Malocclusion Treatment Request Form

– Color Photos

– X-rays

– Any referral forms required

– Any supplemental documentation of your choice

• Do not include:

– The PA Form instruction sheet

– Claim Forms

Please note that incomplete forms, or forms that require correction will be pended for 30 days awaiting

updates.

Requesting Prior Authorization

Patient Information (Boxes 1-4)

• Boxes 1 & 2 - The client’s date of birth is required.

– Listing DOB helps to confirm patient information is correct.

– Age helps to confirm codes are correct.

• Box 3 - Wyoming Medicaid Client ID must contain all 10 digits, including all leading

zeros, as it appears on their card.

• Box 4 - The client’s name should be their legal name as it appears on their card.

Instructions for the Prior Authorization

Request Form

Provider Information (Boxes 5-11)

• Box 5 - Pay-To Provider NPI is the10 digit NPI of the clinic or group that bills for

the services.

• Box 6 - Taxonomy is a 10 alpha-numeric digit code used to identify the pay-to

provider type.

– Example: 122300000X (the orthodontist taxonomy)

• Box 7 - Pay-To Provider Name should be listed as the Clinic or Group Name as

it is listed on your enrollment welcome packet.

– The treating provider name can be included secondary to the clinic but it is NOT required on

this form.

Provider Information (Boxes 5-11)

• Boxes 8 & 9 - The address helps to confirm we are providing the request for the

correct provider.

• Boxes 10 & 11 - Please include a contact telephone number and name for

Medical Policy to use should they need to discuss any questions or concerns

about your PA.

Service Information (Boxes 12-18)

• Box 12a – “From Date” is the date you would like to start treatment.

– It must include month, day, and year (i.e. MM/DD/YYYY or Nov 18, 2019).

– Dates of service that are prior to when Medical Policy RECEIVES a request are considered

retro and will require an explanation as to why the procedure was done without an approved

PA

• Box 12b – “To date” is the date you believe treatment will end.

– This can be an estimate but must include month, day, and year (i.e. MM/DD/YYYY or Dec 5,

2021.

Service Information (Boxes 12-18)

• Box 13 - Service Description can be an abbreviation or summary of the code

description

• Box 14 - Proc Code(s) must be the complete 5 digit Dental code, including the

leading “D”.

– Must be age appropriate

– Must be only SMP codes

– Only list one (1) code per line

Service Information (Boxes 12-18)

• Box 15 - Modifiers are not required unless billed

– If used, list all in box 15 with commas or dashes to separate

– If not used, leave the box blank OR fill with “N/A”

• Box 16 - Units are the number of times a service will be billed, not a number of

items

– D8670 units should be listed as the number of quarters treatment will take, not months.

Service Information (Boxes 12-18)

• Box 17 - Cost should always be the usual and customary charge to each service

– Cost must be per code

– Cost should be the total for ALL units

– IF cost is listed as an “each” it must be indicated. E.G “$300.00 each” for D8670

• Box 18 - Treating provider NPI must be for the Dentist or Orthodontist providing

the service

– Just the NPI needs listed, not the provider’s name

Miscellaneous

• Box 20 should only be used for Modifications of an already approved PA

– This box should not be used to indicate any medical necessity or notes for Medical Policy

– Example: there is an approved PA but the treating provider NPI and date of service do not

match the claim.

– The information should be corrected in the corresponding boxes and then noted in box 20

– E.G – Please modify the dates of service and treating NPI on PA 9000850001

Miscellaneous

• Box 21 – A DATED signature is required but it does not have to be

– It can be a stamp or electronic

– It CANNOT be typed

– The signature must be in this box not box 22

• Box 22 is only for emergency authorizations made over the phone.

• All boxes under 22 are for fiscal agent (Medical Policy) use only. Do not use.

Please fill in each blank.

Header

• Client’s name, client ID, and date of birth should match boxes 1-4 of the PA form.

• Exam date must be within 6 months prior to the request being date (box 12a of the PA

form).

• Location – if the clinic/group has multiple offices, indicate which location services will

take place at.

• Provider Group Name and NPI should match boxes 5 & 7 of the PA form.

• Treating provider name is the name of the dentist or orthodontist performing services.

• Treating NPI should match box 18 of the PA form.

• Fee – the total usual and customary charge for all services

Instructions for the SMP Treatment

Request Form

Part 1. Treatment Requested

• Indicate if Full, Interceptive, or Transfer Case treatment is being requested.

– Only indicate the # of months for transfer cases

• Indicate if MAXILLO-FACIAL Surgery is required.

– If yes:

o Provide an explanation

o An Oral Surgery Referral form is required

If not included the request will be pended and not sent to the consultant until it is

received.

Part 2. Diagnostic Information

Fill out all applicable information.

This is the section in which to provide a narrative explaining a Severe Traumatic

Deviation, if applicable.

Part 3. Brief Initial Opinions

• Oral Hygiene must be indicated

– If poor hygiene is indicated the request will be administratively denied by the fiscal agent.

• If restorations are NOT complete an explanation is required.

– If it is not included the request will be pended until a corrected SMP request form is received.

Part 4.HLD Index

• The HLD score must be completed on all requests, including transfer cases.

– Total points must be filled out.

• A treatment narrative is not required but highly recommended by the consultant.

Signature

This form must be signed and dated by the dentist/orthodontist requesting

services

• Electronic and stamped signatures are allowed

• Typed signatures are NOT allowed

Requests should be emailed to Medical Policy at:

WYMEDPOL@conduent.com

Or mailed to:

Wyoming Medicaid

ATTN: Medical Policy

Po Box 667

Cheyenne, Wyoming 82003

Requests that do not include color photos (i.e. updates or non SMP)

can be sent via fax to:

307-772-8405

Submitting Requests

• When records are received, the prior authorization number will be issued with an

APPROVED, PENDING, OR DENIED status.

• At this time a physical letter will be sent to the correspondence address listed on the

pay-to provider’s account

• The status of your prior authorization can also be checked on the secure web portal,

under prior authorization inquiry

Submitted Requests

• Approved - If the PA is approved a notification that includes the amount of approved

units and cost will be sent.

– Treatment can begin once you have your approved prior authorization number.

• Pending - If your PA is listed as pending, the fiscal agent is waiting for documentation

either from the provider or a determination from the state consultant.

– Starting 1/1/20 a PA will only be pended for 30 days. If the missing information is not received, it

will be denied.

– Comments will be included to detail what the request is pending for.

– Hygiene and growths holds will be in a pending status for 13 months unless otherwise stated.

• Denied - If it is denied a notification that includes the reasons for the denial will be

sent.

Statuses

Dental Services - For policy questions:

1-888-863-5806

Client Services - For client benefits:

1-800-251-1269

Customer Service Center (CSC) - For eligibility:

1-855-294-2127

Medical Policy – For PA status and submission questions:

1-800-251-1268 options 1-1-4-3

Contact Information