01The billing team must obtain prior authorization for all orthodontic services before treatment.
02Authorizations will not be approved for treatment rendered prior to the date of the prior authorization submission.
03The orthodontist's request must include a completed and signed Dental Service Authorization (SA) Request, a scored HLD Index Report completed and signed by the orthodontist, an Orthodontic Referral Oral Health and Hygiene Assessment completed and signed by the referring dentist, panoramic films, intra and extra oral photos, a written comprehensive orthodontic treatment plan, and other pertinent medical or dental information.
04The forms are at http://manuals.medicaidalaska.com/docs/forms.htm.
05Prior approval for limited or interceptive treatment is not approval for interceptive or comprehensive treatment in a multi-phase plan.
06For limited treatment (D8010, D8020, D8030) and interceptive treatment (D8050, D8060), reimbursement is a one-time payment that includes the appliances and all medically necessary treatment, up to $1500.00, $1677.00, $2000.00, $2000.00 and $2145.00 respectively.
07If a second phase is anticipated, a completed HLD Index Report is mandatory, and if less than eighteen months have elapsed before an approved comprehensive plan begins, the limited or interceptive reimbursement will be deducted from the comprehensive reimbursement.
08For comprehensive treatment (D8070, D8080), initial placement is reimbursed when the appliance placement date and the date of service are the same.
09For D8670, reimbursement is provided for three units of service, the provider must examine the patient in the provider's office and document the actual service dates in the client's record, and claims are expected after 6 and 12 months of treatment with the final claim submitted after the braces are removed.
10If a recipient's eligibility ends before treatment concludes, payment for remaining services is the responsibility of the recipient, or the parent or guardian for a minor, and the provider may require the parent or guardian to sign a statement accepting that responsibility.
11Alaska Medicaid will not cover remaining treatment for a recipient who is no longer eligible.
12When treatment is terminated, send a statement reporting the termination to Xerox State Healthcare within 30 days of termination.
13Check the current applicability of these fees and forms before use, because this statement is dated November 23, 2022.