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State Children’s Health Insurance Program

Phase 1 Effective Date: April 1, 1998 146 Revised: 1/26/98, 2/19/98, 3/3/98, 3/6/98 Phase 2 Effective Date: July 1, 1998

Revised: 8/20/98, 8/24/98, 10/1/99, 7/28/00, 1/31/01, 7/02/02, 7/22/02, 1/3/03, 2/13/04, 9/27/04, 11/15/05, 8/11/05, 10/1/06, 7/1/09, 7/1/10, 7/1/11, 7/1/12 Healthy Kids Dental Prior Authorization Process

Florida Healthy Kids Corporation contracts with two statewide dental plans to offer dental services to Healthy Kids enrollees. Healthy Kids does not have an annual dental benefit limit; however, the two dental plans require some services to be prior authorized by the plan.

The prior authorization requirements are not based on the dollar value of a service but are for designated specialty services or for services that tend to be over-used, abused or need special oversight or care management by the plan. There is an exception process in place by both contracted plans for emergency situations. The codes designated for prior authorization are reviewed and approved as part of Healthy Kids contracting process.

Florida Healthy Kids Corporation requires that all prior authorizations processes must be completed within fourteen (14) days of request by an enrollee for that service.

The Healthy Kids dental plans have very similar guidelines for their prior authorization process. For the purpose of Appendix D, the guidelines have been combined to provide a general overview of the codes and procedures requiring prior authorization and the conditions that may be required for referrals to specialty dentists. The following guidelines in its entirety, therefore, may or may not be required by both of the dental plans.

GENERAL DENTISTRY GUIDELINES The Healthy Kids dental plans may require prior authorizations for the following American Dental Association (ADA) Codes or may be reviewed after the dental treatment has been performed. The common practice is to always obtain a prior authorization, but a post authorization is acceptable. Post authorizations are usually limited to emergency or urgent care, when a wait for prior authorization would be detrimental to the child. If services are provided without a prior authorization, the provider can submit the claim for payment, and the claim will be reviewed for medical necessity. The claim will not pay if the authorization is denied for not meeting the medical necessity criteria. Providers do have the option to perform services without prior authorization, and submitting retrospectively.

• Codes beginning with D27 and D29, crowns requiring radiographs • Codes 3310, 3320, 3330 root canals requiring radiographs • Codes 4341, 4342, periodontal scaling and root planing requiring radiographs and perio chart • Code 4355, gross debridement requiring radiographs and narrative • Codes 5110, 5120, complete dentures requiring radiographs • Codes 5211, 5212, 5213, 5214, partial dentures requiring radiographs • Codes beginning with D62, D67, fixed bridges requiring radiographs