23 Miss. Code. R. 204-1.6 - Prior Authorization
A. The Division of
Medicaid requires prior authorization, except for emergencies, from the
Utilization Management/Quality Improvement Organization (UM/QIO) of the
following dental services:
1. Surgical access
of an unerupted tooth,
2. Radical
resection of mandible with tooth bone graft,
3. Arthrotomy,
4. Complicated suture greater than five (5)
cm,
5. Osteoplasty - for
orthognathic deformities,
6.
Osteotomy - mandibular rami,
7.
Osteotomy - mandibular rami with bone graft, includes obtaining the
graft,
8. Osteotomy - segmented or
subapical - per sextant or quadrant,
9. Osteotomy - body of mandible,
10. Lefort I (maxilla - total),
11. Lefort I (maxilla - segmented),
12. Lefort II or Lefort III (osteoplasty of
facial bones for midface hypoplasia),
13. Repair of maxillofacial soft and hard
tissue defect,
14. Closure of
salivary fistula,
15.
Coronoidectomy,
16. All procedures
billed under unspecified dental procedure codes, and
17. The following types of analgesia and
sedation for dental office-based procedures:
a. Analgesia, anxiolysis, inhalation of
nitrous oxide,
b. Non-Intravenous
conscious sedation,
c. Deep
sedation/general anesthesia, and
d.
Intravenous conscious sedation/analgesia.
B. In the case of an emergency, documentation
justifying the medical necessity for the urgent or emergency procedure must be
provided to the UM/QIO to receive a Treatment Authorization Number (TAN) for
billing purposes.
C. The prior
authorization will apply only to those procedures on the treatment plan which
were approved.
Notes
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No prior version found.