OAR 410-123-1160: Prior Authorization

(1) The Authority covers the following services only with Prior Authorization (PA) approval: (a) Crowns: (A) Porcelain fused to metal (D2751, D2752); and (B) Porcelain ceramic (D2740); (b) Crown repair necessitated by restorative material failure (D2980), covered only for anterior teeth; (c) Retreatment of previous root canal therapy (D3346), covered only for anterior teeth; (d) Complete dentures; (e) Immediate dentures; (f) Partial dentures; (g) Immediate partial dentures; (h) Prefabricated post and core (D2954); (i) Fixed partial denture repairs (D6980); (j) Skin graft (D7920); (k) Comprehensive Orthodontic treatment (D8070, D8080, D8090, D8091); (l) Hospital dentistry (Refer to OAR 410-123-1490); (m) Oral surgical services, when performed in an: (A) Ambulatory surgical center (ASC); or (B) Outpatient or inpatient hospital setting and related anesthesia (Refer to OAR 410-130-0200); and (n) Maxillofacial surgeries, in some instances (Refer to OAR 410-130-0200). (2) The Authority does not require PA for outpatient or inpatient services related to a “Dental Emergency Condition” as defined in OAR 410-123-1060: (a) The member’s medical record must document any appropriate clinical information that supports the need for the hospitalization; and (b) Refer to the Prioritized List of Health Services for funded emergency dental service codes. (3) The frequency allowed for the following services may be increased with approved PA . (a) Frequencies of Periodontal scaling and root planing (D4341, D4342), and scaling in the presence of generalized moderate to severe inflammation (D4346) may be increased from the once (1) every two (2) years limitation when: (A) Medically necessary and dentally appropriate due to periodontal disease found during pregnancy or 12 months postpartum; and (B) Documentation in the member’s record that supports the need for increased scaling and root planing; (b) The frequency of Periodontal maintenance (D4910) may be increased from the once (1) in six (6) months limitation when: (A) Medically necessary and dentally appropriate due to periodontal disease found during pregnancy or 12 months postpartum; (B) Documentation in the member’s record documents the need. Records must clearly document the clinical indications for all periodontal procedures, including current pocket depth and clinical attachment loss charting and radiographs; and (C) Periodontal maintenance is covered only following periodontal therapy (surgical or non-surgical) that is documented to have occurred within the past three (3) years. (4) Hospital dentistry always requires PA for the medical services provided by the facility: (a) If a member is enrolled in a CCO with plan type CCOA: (A) The dental subcontractor or dental provider is responsible for: (i) Contacting the CCO for PA requirements and arrangements; and (ii) Submitting documentation to the CCO associated with the member record. (B) The CCO must review the documentation and discuss any concerns they have, contacting the dentist as needed; and (C) The total response time must not exceed seven (7) calendar days from the date of receipt of all required documentation for routine dental care and must follow urgent or emergent dental care timelines. (b) If a member is enrolled in a CCO with plan type CCOB; (A) The dentist is responsible for: (i) Contacting the CCO for PA requirements and arrangements; and (ii) Submitting documentation to the CCO associated with the member record. (B) The CCO shall review the documentation and discuss any concerns they have, contacting the dentist as needed. This allows for mutual plan (CCO and FFS) involvement and monitoring; and (C) The CCO is responsible for payment of all facility and anesthesia services. The FFS program is responsible for payment of all dental services. (c) If a member is enrolled in a CCO with plan type CCOF or CCOG and is enrolled in FFS for physical health: (A) The dentist is responsible for sending, by secure email or faxing, documentation and a completed American Dental Association (ADA) form to the Authority (Refer to the Dental Services Provider Guide); (B) The member must have prior approval from the CCO for dental services, and from the Authority for the facility payment; (C) The Authority is responsible for payment of facility and anesthesia services; (D) The CCO is responsible for payment of all dental services; and (E) The Authority shall issue a decision on PA requests within seven (7) calendar days of date received. (d) If a member is enrolled in Fee-for-Service for both physical health and dental health or enrolled in the Coordinated Care Organization plan type CCOE, the: (A) Dental provider is responsible for sending, by secure email or faxing, documentation, and a completed ADA form to the Authority (Refer to the Dental Services Provider Guide); and (B) Authority is responsible for payment of all facility, anesthesia services and dental services. (5) How to request PA: (a) Refer to www.oregon.gov/oha/HSD/OHP/Pages/PA.aspx or the Dental Services Provider Guide for specific instructions and forms to use. PA requests made by telephone or sent through the mail are not accepted; (b) Submitted documentation must support the medical justification for the service. The PA request must contain: (A) A cover sheet detailing relevant provider and recipient Medicaid numbers; (B) Requested date(s) of service; (C) Healthcare Common Procedure Coding System (HCPCS) or Current Dental Terminology (CDT) Procedure code requested; (D) Amount of service or units requested; and (E) Any additional clinical information supporting medical justification for the services requested. (c) The Authority recommends inclusion of appropriate digital radiographs with the original PA request submission; and other clinical information that justifies the treatment. Radiographs must be: (A) Correctly identified of diagnostic quality; and (B) Clearly labeled with the dental provider’s name and address and the member's name. (6) The Authority shall issue a decision on PA requests within seven (7) calendar days upon receipt of the request. The Authority shall provide PA for services when: (a) The prognosis is favorable, which refers to a; (A) Prediction that an individual’s health condition is likely to improve or lead to a positive outcome; and (B) Determination made by a healthcare provider based on medical evidence; (b) The treatment is practical; (c) The services are medically necessary and dentally appropriate; and (d) A lesser-cost procedure may not achieve the same ultimate results. (7) PA approval does not guarantee member eligibility or reimbursement. It is the responsibility of the provider to check the member's eligibility on each date of service. (8) The Authority may seek a general practice or specialist consultant for: (a) Professional review to determine if a PA shall be approved; and (b) Shall deny PA if the consultant decides that the clinical information furnished does not support the treatment of services. (9) CDT billing codes are in accordance with Current Dental Terminology, © 2025 American Dental Association. All rights reserved.