N.J. Admin. Code § 10:56-2.9 - Preventive dental care

(a) In addition to an oral evaluation every six months for beneficiaries through age 20 and once every 12 months for beneficiaries 21 years of age or older, preventive dental care encompasses the following recommended services:

1. Prophylaxis, as follows:

i. Dental prophylaxis means the complete removal of calculus and stains from the exposed and unexposed areas of the teeth by scaling and polishing.

ii. For reimbursement purposes, dental prophylaxis shall be limited to once every six months for beneficiaries through age 20 and once every 12 months for beneficiaries 21 years of age or older, except as otherwise prior authorized by a Division dental consultant, and except as provided (a)1ii(1) below.

(1) Beneficiaries with developmental disabilities, neurological impairments, or other disabilities, regardless of age, shall be eligible for evaluation, radiographs as appropriate, prophylaxis, extra-scaling and topical application of fluoride including prophylaxis, as often as every three months. Claims may be submitted directly to the fiscal agent for payment, without prior authorization. In the event that any of the services listed in (A) below are required more often than every three months, a prior authorization request shall be submitted to the Division dental consultant. The nature of the beneficiary's disability shall be recorded under Remarks (Item 20) on the Dental Claim Form.

(A) The following procedure codes shall be used only if a beneficiary is developmentally disabled, neurologically impaired or medically compromised:

Comprehensive Oral Evaluation	D0150-76
Prophylaxis-Adult	D1110-76
Prophylaxis-Child	D1120-76
Topical Application of Fluoride with prophylaxis, Child	D1201-76
Topical Application of Fluoride with prophylaxis, Adult	D1205-76
Full Mouth Debridement	D4355-76
Non-intravenous Conscious Sedation	D9248-76

NOTE: Non-Intravenous Conscious Sedation shall be prior authorized after four times in a 12-month period.

2. Fluoride Treatment, as follows:

i. Topical fluoride treatment should be administered in accordance with appropriate standards. This consists of topical application of stannous fluoride or acid fluoride phosphate as a liquid or gel.

ii. A complete prophylaxis shall be performed prior to and in conjunction with the topical fluoride treatment.

iii. Reimbursement for topical fluoride treatment shall be limited to once every six months without need for prior authorization for those beneficiaries through age 20.

iv. This is not a covered service for persons 21 years of age and over, except as noted in (a)1ii(1) above.

v. Oral fluoride medication may be prescribed (see: N.J.A.C. 10:56-2.17).

vi. Use of a prophylaxis paste containing fluoride shall not be billed as "topical fluoride treatment." For reimbursement purposes, this is considered to be only a prophylaxis.

3. To encourage the maintenance of dental health, the same type of recall procedure as used in dental practice in the community shall be extended to eligible Medicaid/NJ Family Care fee-for-service beneficiaries.

4. Beneficiary education for Medicaid/NJ Family Care fee-for-service beneficiaries should consist of dental health orientation identical to that given all patients.

5. Sealants shall be a covered service of the Medicaid/NJ Family Care fee-for-service programs, subject to the following limitations:

i. Application of sealants shall be limited to a one time application to all occlusal surfaces that are unfilled and caries free, in premolars and permanent molars.

ii. Application of sealants shall be limited to beneficiaries up to and including 16 years of age.

iii. Sealants applied, other than as outlined above, are not reimbursable unless authorized by a Division dental consultant. A complete explanation of the request shall be attached to the prior authorization request.

iv. Since sealants may be reimbursed only once for each tooth, the provider should make certain that sealants have not been applied previously.

Notes

N.J. Admin. Code § 10:56-2.9

As amended, R.1982 d.403, eff. 11/16/1982. (Operative date: February 1, 1983.)
See: 13 N.J.R. 875(a), 14 N.J.R. 1301(a).
Section substantially amended.
Amended, R.1986 d.385, effective 9/22/1986.
See: 18 N.J.R. 1337(a), 18 N.J.R. 1958(a).
Old (a)1i deleted and new text substituted.
Recodified from N.J.A.C. 10:56-1.15 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).
Rewrote the section.
Amended by R.2003 d.16, effective 1/16/2003.
See: 34 N.J.R. 2681(a), 35 N.J.R. 232(a).
Rewrote the section.
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 (a)1ii, (a)1ii(1) and (a)2iii; added (a)1ii(1)(A); in (a)2iv, inserted ", except as noted in (a)1ii(1) above"; and in (a)5iii, substituted "Division" for "Medicaid/NJ Family Care" and "shall" for "must".