Medicaid Orthodontic Services Overview in New York

Medicaid orthodontic services in New York are provided for members with severe physically handicapping malocclusion. Orthodontic treatment must meet medical necessity criteria, including demonstrating functional difficulties, developmental anomalies, facial trauma, or psychological health needs. Services require prior authorization and must be rendered by a licensed Orthodontist within specified timeframes. Child Health Plus covers orthodontics for serious medical conditions only. Pre-orthodontic visits are essential for monitoring growth and development before active treatment begins.

• Medicaid Orthodontics
• New York
• Orthodontic Services
• Prior Authorization
• Pre-Orthodontic Visit

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1. LIBERTY Dental Plan of New York Orientation for Medicaid Orthodontists Making members shine, one smile at a time www.libertydentalplan.com Revised March 2022

2. Contents 2021 Orthodontic Training Agenda Overview Pre-orthodontic treatment visits HLD Assessment Tool Minor Treatment to Control Harmful Habits Limited Orthodontic Treatment Comprehensive Orthodontic Treatment Orthodontic Retention Comprehensive Orthodontic Billing Process Continuation of Orthodontic Care Conclusion of Active Treatment Unfavorable Treatment Outcomes Right to Appeal Links for Orthodontic Use 2 Making members shine, one smile at a time www.libertydentalplan.com

3. Overview 2021 Orthodontic Training In New York, orthodontia is only covered for Medicaid members who have a severe physically handicapping malocclusion. In order for NY Medicaid members to qualify for orthodontic services, medical necessity must be met by demonstrating one or more of the following pathologies: Severe functional difficulties Developmental anomalies of facial bones and/or oral structures Facial trauma resulting in severe functional difficulties Demonstration that long-term psychological health requires orthodontic correction Limited and Comprehensive orthodontic services must be prior authorized and rendered by a licensed Orthodontist: Approved cases must be started within six (6) months of receiving the approval *Please note: Child Health Plus does not routinely cover orthodontics. It is only covered in the treatment of serious medical conditions such as cleft palate and cleft lip; maxillary/mandibular micrognathia (underdeveloped upper or lower jaw); extreme mandibular prognathism; severe asymmetry (craniofacial anomalies); ankylosis of the temporomandibular joint; and other significant skeletal dysplasia. 3 Making members shine, one smile at a time www.libertydentalplan.com

4. Pre-Orthodontic Treatment Visit 2021 Orthodontic Training Pre-orthodontic treatment examination to monitor growth and development (D8660) Periodic observation of patient dentition, at intervals established by the dentist, to determine when orthodontic treatment should begin. Diagnostic procedures are documented separately. May not be reimbursed in conjunction with other examination codes Cannot be reimbursed after active orthodontic treatment has begun Minimum age of 5 and maximum age 20 Can be billed 3 times per calendar year prior to starting active treatment. *Orthodontist should ONLY use procedure code D8660 for examinations prior to starting active care 4 Making members shine, one smile at a time www.libertydentalplan.com

5. HLD Assessment Tool 2021 Orthodontic Training The intent of the HLD Index To measure the presence or absence and the degree of the handicap caused by the components to be scored with the Index. It is NOT intended to diagnose malocclusion. The HLD is completed by the dentist that will be rendering the orthodontic treatment Automatic qualifiers are listed on the top section of page 1 on the HLD form. If automatic qualifiers are not met, then there must be a total score equal to or greater than 26 (when scored correctly) to qualify for treatment. Total scores of less than 26 with extenuating circumstances (i.e., functional difficulties and/or medical anomaly) may qualify for medical necessity exception. The pre-authorization must include all medical evidence and supporting documentation. Form and Instructions may be found on LIBERTY Dental Plan s Provider Resource Library NY HLD Index Form 5 Making members shine, one smile at a time www.libertydentalplan.com

6. Minor Treatment to Control Harmful Habits 2021 Orthodontic Training D8210 and D8220 include appliances for habits such as thumb sucking and tongue thrusting. D8210 can be billed once every 12 months Documentation must be submitted supporting a harmful habit. Age 5 and over D8220 can be billed once in a lifetime Documentation must be submitted supporting a harmful habit. Age 5 and over Procedures can be reviewed for appropriateness before treatment is initiated by submitting a prior approval request. Procedures can also be submitted after treatment without prior approval as a By Report based on documentation submitted with the claim substantiating a qualifying physically handicapping malocclusion. 6 Making members shine, one smile at a time www.libertydentalplan.com

7. Limited Orthodontic Treatment 2021 Orthodontic Training Limited Orthodontic Treatment The submitted records must demonstrate a physically handicapping malocclusion indicating the need for limited orthodontic treatment. Reimbursement is determined based on supporting documentation submitted and is payable once per lifetime. D8010 Limited orthodontic treatment of the primary dentition D8020 Limited orthodontic treatment of the transitional dentition D8030 Limited orthodontic treatment of the adolescent dentition D8040 Limited orthodontic treatment of the adult dentition Procedure codes D8030 and D8040 cannot be substituted for procedure codes D8070, D8080, and D8090 if a member does not qualify for comprehensive orthodontic treatment as per NYS Medicaid criteria. 7 Making members shine, one smile at a time www.libertydentalplan.com

8. Comprehensive Orthodontic Treatment 2021 Orthodontic Training Comprehensive Orthodontic Treatment With the exception of cleft palate and other surgical cases, only members with late mixed dentition or permanent dentition will be considered for the initiation of comprehensive orthodontic treatment. The following documentation must be submitted along with the prior approval request: Panoramic and/or mounted full mouth series of intra-oral radiographic images A cephalometric radiographic image with teeth in centric occlusion and cephalometric analysis / tracing Photographs of frontal and profile views Intra-oral photographs depicting right and left occlusal relationships as well as an anterior view Maxillary and mandibular occlusal photographs Completed and signed HLD Index Form Narrative if necessary 8 www.libertydentalplan.com Making members shine, one smile at a time

9. Comprehensive Orthodontic Treatment 2021 Orthodontic Training Comprehensive Orthodontic Treatment (continued) The reimbursement for a pre-authorized comprehensive treatment requires a claim submission using code D8070, D8080, D8090 with the date the appliances were placed. Services reimbursed through these codes will include all appliances, theirinsertions, adjustments, repairs and removal as well as the retention phase of treatment to the provider of placement Reimbursement for comprehensive orthodontic treatment is all inclusive and covers all orthodontic services, both fixed and removable that needs to be provided to correct the orthodontic condition Majority of cases are expected to be completed within 8 units of D8670. However, an additional 4 units may be approved if medically necessary 9 www.libertydentalplan.com Making members shine, one smile at a time

10. Comprehensive Orthodontic Billing Process 2021 Orthodontic Training First Year Step 1: Submit Prior Authorization for D8070, D8080, D8090 Approval authorizes 4 units of D8670 Documents required: Completed HLD Form demonstrating medical necessity, diagnostic quality photographs, cephalometric and panoramic images. Step 2: Upon approval, complete initial banding and submit claim for D8070, D8080, D8090 (Must be within 6 months of approval). Step 3: Submit claim for each quarterly periodic visit with code D8670 (Units 1-4). Code D8670 can only be billed a maximum of (4) times in a twelve-month period beginning 90 days after the date of service on which orthodontic appliances have been placed and active treatment has begun and at the end of each subsequent quarter. Second Year Step 4: Upon completion of (4) units of D8670 or 1 year (whichever comes first), submit prior authorization for second year of treatment. Required documentation: treatment notes, documentation of any compliance issues Diagnostic quality pre- and current photographs demonstrating case progression Approval authorizes additional (4) units of D8670 Step 5: Upon approval, submit claims with code D8670 for each quarterly periodic visit (Units 5-8). * Please note Liberty Dental does not pay remaining quarters when treatment is completed early 10 www.libertydentalplan.com Making members shine, one smile at a time

11. Comprehensive Orthodontic Billing Process 2021 Orthodontic Training Third Year It is the expectation of LIBERTY that the majority of orthodontic cases are completed within a two-year period. Should a case extend beyond the two-year period, a prior approval request for additional units (D8670) must be submitted. The request must include progress report and photographs of the current conditions to assess the progress of treatment and determine if additional treatment time (up to a maximum of three (3) years) is warranted. Retention Code D8680 is payable once per lifetime and prior authorization is required The request must include progress report and photographs of the current conditions to assess the progress of treatment. 11 www.libertydentalplan.com Making members shine, one smile at a time

12. Continuation of Orthodontic Care 2021 Orthodontic Training Requests to RESTART comprehensive orthodontic treatment on a member for which Medicaid FFS paid the original comprehensive code (D8070, D8080, or D8090), but who now has LIBERTY coverage, should be submitted to LIBERTY for consideration For consideration and approval of payment by LIBERTY for orthodontic care in progress, the treating orthodontist must send a claim with the following required information: A copy of the authorization for treatment and the Explanation of Payment (EOP) and/or Explanation of Benefits (EOB) statements from the previous carrier Documentation of the number of orthodontic treatment visits that have been rendered to date. This can be done by providing EOB/EOPs for all payments received for all treatment visits, or printout from the previous carrier showing all the visits for which payment has been received The total fee-for service reimbursement amount for active treatment will not exceed the maximum fees listed in the contracted LIBERTY Fee Schedule 12 www.libertydentalplan.com Making members shine, one smile at a time

13. Conclusion of Active Treatment 2020 Orthodontic Training D8680 Orthodontic retention (removal of appliances, construction and placement of retainer(s) Pre-authorization is required The following documentation must be submitted along with the prior approval request: Photographs of frontal and profile views Intra-oral photographs depicting right and left occlusal relationships as well as an anterior view Maxillary and mandibular occlusal photographs Photos of articulated models can be submitted optionally (Do NOT send stone casts) Upon Approval, submit claim for the day the bands are removed Requests must be submitted, and approval obtained PRIOR to the removal of appliances. Any request denied or otherwise returned for insufficient results will require the re-application of all appliances, if necessary, and continuation of care without additional compensation. Payment will not be made for retention for a case that had been de-banded without prior authorization. Replacement of retainers or removable appliances due to loss or damage beyond repair is allowed once using code D8703 or D8704 within one year of payment for D8680 and must include documentation of the incident and medical necessity. D8695 Removal of fixed orthodontic appliances for reasons other than completion of treatment (REPORT NEEDED) Services provided by an orthodontist other than the originating orthodontist. 13 www.libertydentalplan.com Making members shine, one smile at a time

14. Unfavorable Treatment Outcomes 2021 Orthodontic Training If it is determined that treatment is not progressing because the patient is exhibiting non-compliant behavior, then discontinuation of treatment can be considered due to, but not limited to the following: Multiple missed orthodontic and general dental appointments Continued poor oral hygiene Failure to maintain the appliances Untreated dental disease A letter must be sent to the parent/guardian that documents the factors of concern and the corrective actions needed and that failure to comply can result in discontinuation of treatment. If orthodontic treatment is discontinued for cause, the parent/guardian and/or member must sign a statement indicating they understand treatment is being discontinued prior to completion; the reason(s) for discontinuation of treatment; and, that it will jeopardize their ability to have further orthodontic treatment provided through the NYS Medicaid Program. The treating orthodontist must make reasonable provisions to provide necessary treatment during the transition of care to another provider or for de-banding. 14 Making members shine, one smile at a time www.libertydentalplan.com

15. Right to Appeal 2021Orthodontic Training Automatic qualifiers are listed on the top section of page 1 on the HLD form. If automatic qualifiers are not met, then there must be a total score equal to or greater than 26 (when scored correctly) to be eligible for orthodontic care. If the member qualifies for medical necessity exception, the pre-authorization may be submitted with other supporting documents. If you disagree with a decision, please view the appeal language provided on the Explanation of Payment or referenced in the applicable Provider Reference Guide Should a prior authorization request be denied by LIBERTY, members can enter into a private pay arrangement with your office. The following steps must be taken: Member to exhaust their appeal rights Enter into a private pay agreement that is mutual, voluntary and in writing Consent should detail specific codes and the dollar amount agreed upon Consent must be saved in the patient record. 15 www.libertydentalplan.com Making members shine, one smile at a time

16. Links for Orthodontic Use 2021 Orthodontic Training Liberty Web Portal Informed Consent Form Attestation Form NY HLD Index Form 16 Making members shine, one smile at a time www.libertydentalplan.com

17. 2021Claims Training Questions? 17 www.libertydentalplan.com Making members shine, one smile at a time