N.J. Admin. Code § 10:56-2.3 - Special dental services

(a) Dental services for which no specific procedure code and description are noted, or which are limited or prohibited by this chapter, may be considered on a case-by-case basis, upon request. Such a request shall be submitted on the two part Dental Prior Authorization Form (MC-10A), and the Dental Claim Form (MC-10) and forwarded to the Bureau of Dental Services, Mail Code 21, PO Box 713, Trenton, New Jersey 08625-0713. An unspecified procedure code appropriate for the requested service shall be used when submitting the prior authorization request for these dental services. The request shall be accompanied by all supporting documentation.

1. If such unspecified services are associated with a temporomandibular joint dysfunction diagnosis or therapy, the requesting provider shall comply with the New Jersey Board of Dentistry protocol for diagnosis and treatment planning as set forth in N.J.A.C. 13:30-8.22.

(b) If reimbursement for the dental service is "By Report," the requesting provider shall forward, in addition to all documentation required for any prior authorization request, a detailed written report, treatment plan and other documentation, such as charting, records, or radiographs, relevant to the requested dental service.

Notes

N.J. Admin. Code § 10:56-2.3

Amended by R.1986 d.385, effective 9/22/1986.
See: 18 N.J.R. 1337(a), 18 N.J.R. 1958(a).
Substantially amended.
Recodified from N.J.A.C. 10:56-1.6 by R.1996 d.428, effective 9/16/1996.
See: 28 N.J.R. 3069(a), 28 N.J.R. 4243(a).
Former section, "Dental Services Claim form (MC-10)", repealed.
Amended by R.1998 d.353, effective 7/20/1998.
See: 30 N.J.R. 514(a), 30 N.J.R. 2654(a).
Updated the address.
Amended by R.2007 d.36, effective 2/5/2007.
See: 38 N.J.R. 3419(a), 39 N.J.R. 479(a).
Rewrote the introductory paragraph of (a); and added new (a)1 and new (b).