MedicaidCoverageHigh impact
Severe Malocclusion Policy Clarification
Wisconsin Medicaid (ForwardHealth)·WI · Dentistry, Oral & Maxillofacial Surgery·Medical Policy
Effective date
Oct 31, 2025
We identified it
Sep 29, 2026
Summary
ForwardHealth is replacing the Salzmann Index with Orthodontic Automatic Qualifiers (AQs) as the primary method to determine severe malocclusion eligible for orthodontic treatment under BadgerCare Plus and Medicaid. Effective October 31, 2025, providers must use specific clinical criteria (e.g., overjet ≥9mm, skeletal Class III malocclusion, crossbites affecting 3+ teeth) to qualify patients. If an AQ is not present, comprehensive medical history review is required to establish medical necessity.
Action Required
By October 31, 2025: Billing and clinical teams must transition from Salzmann Index scoring to the new Orthodontic Automatic Qualifiers system. (1) Obtain and distribute the AQ checklist (Attachment A) to all providers, dental staff, and billing personnel. (2) Update billing software and prior authorization templates to require documentation against the new AQ criteria instead of Salzmann Index scores. (3) Train all staff submitting orthodontic claims on the 15 specific AQs (e.g., crossbite of 3+ teeth, overjet ≥9mm with incompetent lips/functional difficulty, Skeletal Class III malocclusion, complete anterior crossbite, etc.). (4) For claims without an AQ match, ensure providers attach comprehensive clinical documentation (medical history, diagnosis, functional impact narrative) to support medical necessity determination. (5) Update encounter forms and pre-visit templates to prompt providers to document AQ status and clinical findings. (6) Retain all supporting documentation per Wisconsin Stat. § 49.45(3)(f) for audit purposes. Failure to provide required documentation or use outdated Salzmann Index criteria will result in claim denials and potential recoupment of paid claims. Contact ForwardHealth MCOs for implementation guidance on managed care plan transitions.