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State Children’s Health Insurance Program

Phase 1 Effective Date: April 1, 1998 148 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 • Claims for intraoperative and postoperative radiographs will not be reimbursed. These will be considered inclusive with the treatment codes for endodontic procedures. Periodontal Guidelines Periodontal care must be approved by the plan prior to periodontal services being rendered. Pre-authorization for Periodontal treatment requires the following documentation: • Completed and signed Pre-Authorization Request form • Diagnosis including the periodontal disease classification • Mounted full mouth series of radiographs • Periodontal charting • Intra-oral pictures when submitting for codes 4210 and 4211 • Narrative

*Periodontal scaling and root planing is the responsibility of the general dentist. Approval from the plan is also required for referrals to a Periodonist with documentation indicated and listed above for the following: • Codes 4210, 4211, gingivectomy and/or gingivoplasty. • Codes 4240, 4241, gingival flap procedures. • Codes 4260, 4261, osseous surgery.

Pedodonist Guidelines A referral is required to a Pedodontist if a General Dentist is not able to see a child for behavioral management issues or any other issue expressed by the General Dentist. The plan will review and approve requests for referrals. An approval of the authorization must be obtained prior to the Pedodonist providing services. The plan requires submission of pre-authorization for everything except: • Exams, x-rays, fillings, cleanings and sealants Orthodontic Guidelines Orthodontic services are limited to those circumstances where the member’s condition creates a medical disability and impairment to their overall physical development, as defined in the Florida Medicaid Dental Services Coverage and Limitation Handbook. Referrals for Orthodontic Services All orthodontic referrals must be approved prior to orthodontic consultation being provided. Pre-authorization for Orthodontic services requires the following documentation:

• Completed and signed Pre-Authorization Request form • Clinical photographs (prints or slides) showing: