N.J. Admin. Code § 10:56-2.10 - Restorative services

(a) Restorative treatment shall be limited to those services necessary to adequately restore and maintain the integrity and contours of the natural tooth, as follows:

1. Filling restorations shall be reimbursed as follows:

i. Reimbursement for restorations in primary teeth shall be limited to primary cuspids and molars of children up to and including age nine, or in primary incisors up to and including age five, but not where exfoliation is imminent, except when prior authorization by a Division dental consultant has been obtained by the provider.

ii. Amalgam and composite restorations may be provided on anterior and posterior teeth (numbers 1 through 16 and 17 through 32). The provider should select the restorative material most appropriate for the beneficiary's dental needs.

iii. Reimbursement for a restoration will include treatment of pulp exposure, lining or base, restoration, polishing of restoration, and local anesthesia.

iv. Plastic, acrylic, or unfilled resin restorative material shall be reimbursable.

v. A procedure code shall be selected on the basis of the number of surfaces restored per individual tooth (not on the basis of individual restorations); therefore, the fee for any surface shall include one or more restorations on that surface.

vi. Only one code is reimbursable per tooth except when amalgam and composite resin restorations are placed on the same tooth.

vii. Reimbursement for an occlusal restoration includes any extensions onto the occlusal one-third of the buccal or lingual surface(s) of the tooth.

viii. Extension of interproximal restorations into self cleansing areas will not be considered as additional surfaces. An additional surface will be reimbursable only when the buccal (facial) or lingual margin extends beyond the proximal one-third of the buccal (facial) and/or lingual surface(s).

2. Crown restorations shall be considered for reimbursement as follows:

i. Prior authorization is required for all crowns and shall be based on substantial loss of tooth structure and the condition of the remaining teeth and supporting tissue to justify this treatment. The Dental Prior Authorization Form (MC-10A) and the Dental Claim Form (MC-10) shall be submitted with recent radiographs for review by a Division dental consultant.

ii. Generally, temporary acrylic or plastic crowns shall be reimbursable only for badly broken down anterior teeth up to and including age 15. Likewise, preformed stainless steel crowns shall be reimbursable only for primary teeth and permanent posterior teeth up to and including age 17. If extenuating circumstances exist that require the use of stainless steel crowns for permanent teeth on beneficiaries beyond the age of 17, a request for prior authorization with documentation shall be submitted for review by a Division dental consultant.

iii. Porcelain jackets will not be reimbursed.

3. Post and core shall be reimbursable under the following conditions:

i. A post and core is reimbursable on an endodontically treated tooth only in conjunction with a crown as the final restoration.

ii. A post and core on an endodontically treated tooth shall extend into at least one-half, and preferably two-thirds, of the length of the endodontically treated canal. Failure of a post and core which results in the concurrent failure of a crown will be subjected to recovery of the reimbursement for both services based on this standard.

Notes

N.J. Admin. Code § 10:56-2.10

As amended, R.1975 d.262, eff. 9/1/1975.
See: 7 N.J.R. 318(a), 7 N.J.R. 466(a).
Recodified from N.J.A.C. 10:56-1.16 and amended by R.1996 d.428, effective 9/16/1996.
See: 28 N.J.R. 3069(a), 28 N.J.R. 4243(a).
Amended by R.2001 d.268, effective 8/6/2001.
See: 33 N.J.R. 1554(a), 33 N.J.R. 2666(b).
In (a)1i, inserted "/NJ Family Care" preceding "dental"; (a)1ii, substituted "beneficiary's" for "recipient's"; in (a)1v, inserted "fee-for-service" preceding "programs"; in (a)2i, substituted "beneficiaries" for "recipients".
Amended by R.2004 d.25, effective 1/20/2004.
See: 35 N.J.R. 4032(a), 36 N.J.R. 568(a).
In (a)2, rewrote i and substituted "reimbursed" for "authorized" in iv.
Amended by R.2007 d.36, effective 2/5/2007.
See: 38 N.J.R. 3419(a), 39 N.J.R. 479(a).
In (a)1i, substituted "Division" for "Medicaid/NJ Family Care"; in (a)2ii, substituted "Amalgam" for "Silver amalgam"; in (a)1iv, deleted "only when utilized for the six anterior teeth in each arch" following "reimbursable"; deleted former (a)1v; recodified former (a)1vi through (a)1ix as (a)1v through (a)1viii; in the introductory paragraph of (a)2, substituted "considered for reimbursement" for "reimbursed"; rewrote (a)2i and (a)2ii; deleted former (a)2iii; recodified former (a)2iv as (a)2iii; in (a)3, deleted "post and" preceding "core"; deleted former (a)3i; recodified former (a)3ii and (a)3iii as (a)3i and (a)3ii; and in (a)3ii, deleted "or post" preceding "and core" two times and substituted "shall" for "must".