MedicaidPrior AuthHigh impact
Root Canal Therapy Prior Authorization Policy Clarifications
Wisconsin Medicaid (ForwardHealth)·WI · Dentistry·Prior Authorization
Effective date
Apr 1, 2025
We identified it
Aug 26, 2026
Summary
ForwardHealth (Wisconsin Medicaid/BadgerCare Plus) clarified prior authorization requirements for root canal therapy (anterior, bicuspid, and molar). PA is NOT required for members under 21 with ≤3 teeth needing treatment within 6 months; PA IS required for members 21+ regardless of tooth count, or any member needing ≥4 teeth treated. Billing teams must implement these age and tooth-count thresholds in their prior auth workflows immediately.
Action Required
Immediately: Billing and scheduling teams must update prior authorization submission workflows to implement the new tooth-count and age-based rules. (1) For members under 21: Do NOT require PA if ≤3 teeth need root canal therapy (any combination of D3310/D3320/D3330) within 6 months of last exam (D0120, D0140, or D0150). (2) For members 21 and older: ALWAYS require PA before submitting root canal claims, regardless of tooth count. (3) For any member: ALWAYS require PA if 4 or more teeth need treatment. Update billing software rules, encounter forms, and prior auth submission templates. Train providers and front desk staff on the new thresholds. Document the qualifying exam date (D0120/D0140/D0150) in the patient record to support the 6-month lookback. Failure to obtain required PA will result in claim denials and recoupment of paid claims per state audit rules.