Dental benefit plan updates: New prior-authorization process effective March 1, 2021

Please review the following updates to Horizon NJ Health’s dental benefits. All updates will be effective March 1, 2021.

Authorization for root canals, post/cores, build-ups and crowns

  • Currently, prior-authorization (PA) is required for root canal, post/core and crown procedures.
  • There will be a new authorization process for root canal, post/core and crown procedures.
    • A retro-authorization will be required when services are completed.
      • Clinical Criteria
        • Tooth is fully erupted and restorable
        • Lacks at least 50 percent tooth structure or cannot retain direct restoration
        • Tooth is in occlusion, or will be utilized as an abutment to a prosthesis
        • Crown to root ratio at least 50 percent
        • Bone support at least 50 percent, without mobility or furcation involvement
        • RCT is clinically acceptable
        • Not for esthetics
      • Documentation Required
        • Recent diagnostic full-mouth radiographs or panorex
        • Post-op PA (showing apex of tooth) and bitewing x-ray (BWX) of completed root canal, post/core and crown (cemented)
        • If tooth has no occlusion, narrative documenting that there is an opposing denture or tooth will be used as an abutment to a fixed or removable denture

Radiographs and Root Canals, Retreatment

  • All X-rays taken for root canals and retreatment of root canals will be considered as inherent to the procedure and not paid on the same date of service as D3310, D3320, D3330, D3331, D3346, D3347 and D3348.

NJ FamilyCare Dental Services Clinical Criteria Policy Clinical Criteria Grid and Policy

Clinical Criteria Grid

Thank you for your continued participation with Horizon NJ Health.

Published on: March 1, 2021, 05:56 AM ET
Last updated on: March 1, 2021, 14:07 PM ET