MedicaidPrior AuthHigh impact
Newsletter Vol. 20, No. 14
New Jersey Medicaid·NJ · Dentistry, Pediatrics·Provider Notice
Effective date
Jul 1, 2010
We identified it
Jun 20, 2026
Summary
New Jersey Medicaid revised orthodontic treatment approval criteria effective July 1, 2010. All orthodontic services now require prior authorization and must demonstrate functional difficulties in speech/mastication (not cosmetic reasons). The HLD (NJ-Mod) Index replaces the previous FD-10 form for assessment. Cases with prior auth but no treatment started by July 1, 2010 must be resubmitted under new criteria. Comprehensive treatment is limited to 36 visits maximum and must start before age 18, ending at age 21 or loss of eligibility.
Action Required
By July 1, 2010 (URGENT - policy is now in effect): (1) Billing team must update prior authorization workflow to require submission of HLD (NJ-Mod) Index form instead of FD-10 form for all orthodontic cases. (2) Providers must obtain prior authorization for ALL orthodontic services (D8660, D8050, D8060, and all treatment codes) - no exceptions. (3) Update system to flag that comprehensive orthodontic cases require submission of: dental diagnosis, medical ICD-9 codes, completed HLD Index, diagnostic/digital models, photographs, X-rays/cephalometric film, narrative describing clinical findings on mastication/speech, and medical necessity attestation. (4) Implement visit limits: 12 visits for initial prior auth request; additional visits require separate prior auth submission with case progression notes. (5) Enforce age restrictions in billing system: active treatment must start before age 18; benefits end at age 21 or loss of eligibility. (6) For cases currently in treatment on July 1, 2010: immediately resubmit prior auth request using new HLD form with treatment notes and expected remaining treatment timeline. (7) Billing team must verify completed comprehensive treatment cases receive written attestation from provider before processing final claims. (8) Educate dental providers (dentists, pediatric dentists, FQHCs) that only functional criteria (speech/mastication difficulties from developmental anomalies, trauma, birth defects) qualify - cosmetic/point-score cases will be denied. Failure to obtain prior authorization will result in claim denials from NJ Medicaid.