Introduction and Purpose:

The NJFC program has established a clinical criteria policy for all dental services included as benefits in the NJFC program to establish a single set of clinical guidelines to be used by the State and the MCOs and their third party administrators and vendors in the processing of claims and the review of prior authorizations for treatment requests based on medical necessity or where applicable within the established frequencies.

The reviewing consultant should use these policies and their clinical judgement along with any submitted documentation and diagnostic materials when reviewing treatment requests for medical necessity. Consideration for prior authorization of services should consider the overall general health, patient compliance and dental history, condition of the oral cavity, long-term prognosis and complete treatment plan that is both judicious in the use of program funds and provides a clinically acceptable treatment outcome.

The MCO must monitor their consultants or those of the third party vendor each calendar year to ensure prior authorization decisions and claim payments are being made in accordance with the clinical criteria policy. The monitoring outcomes will be available to the State upon request.

Guidelines and Criteria for Complete Treatment Plan Submission:

Submission of a complete treatment plan is required where requests for complex cases with multiple root canals, crowns (single or abutment), partial denture(s) and/or multiple surgical periodontal procedures are being considered. A complete treatment plan may be required and the provider may be asked to sequentially submit several prior authorization requests, one for each of the various stages of the treatment. Each prior authorization should be submitted as the provider is about to initiate that stage. This will ensure that the prior authorization will remain active during the stage of treatment.

Acronyms used:

• AMN – As Medically Necessary
• BR – By Report
• CRA – Caries Risk Assessment
• CY – Calendar Year
• DMN – Documentation of Medical Necessity
• DOS – Date of Service
• ECC – Early Childhood Caries
• EPSDT – Early and Periodic Screening, Diagnostic and Treatment
• FX – Fracture
• LTCF – Long Term Care Facility
• HLD (NJ-Mod) – New Jersey Orthodontic Assessment Tool for Comprehensive Treatment Index
• (most recent version)
• PA – Prior Authorization
• RCT – Root Canal Treatment
• RY – Rolling Year (1 year from the date of service)
• SHCN – Special Health Care Needs member
• TX – Treatment

Format:

The document is in a grid format and follows the listing sequence by category of service as found in the American Dental Association CDT book and includes the following headers: CDT code, short description (nomenclature with abbreviations), age limits, frequency limits, documentation requirements and clinical criteria. One unit of service per DOS is allowed where units per DOS are not specified. A provider may refer to an individual servicing provider or provider group. For completed nomenclature and descriptor of a CDT code, please refer to the current CDT book published by the American Dental Association.

The policy will be updated annually based on CDT revisions and DMAHS decisions. The Clinical Criteria Grid, which is a complete list of included codes and services included in the NJ FamilyCare program’s benefit package may be found on the New Jersey Medicaid Management Information System website: https://www.njmmis.com/hospitalinfo.aspx.

Early and Periodic Screening, Diagnostic and Treatment:

Please note that EPSDT guidelines for medically necessary services to children ages 0 through 20 supersede any restrictions included in the Clinical Criteria Grid, based on the following:

• Under Medicaid regulations a State must cover necessary health care, diagnostic services, treatment and other measures to correct or ameliorate defects and physical and mental illness and conditions.
• Services must be covered if they correct, compensate for, improve a condition, or prevent a condition from worsening-even if the condition cannot be prevented or cured.

Based on this lifetime limits cannot be applied to limit the frequency for services provided to children under the age of 21. As a result the CC Grid cannot indicate once per lifetime and multiple requests for AMN services with supporting documentation cannot be denied.

Patient Records:

Dental diagnosis is to be documented for all treatment rendered on that DOS as per N.J.A.C. 10:56-1.9. This applies to units of behavior management which also requires medical diagnosis and clinical presentation be documented.

CDT (Current Dental Procedure Codes):

The current CDT Dental Procedure Codes from the American Dental Association (ADA) should be used as a reference for procedure code selection as the Clinical Criteria Grid is a quick reference guide for the NJ FamilyCare Program and uses abbreviations. The CDT provides the Nomenclature (written title of a procedure code) and Descriptor (narrative that further defines the nature of the intended use of a single code) and is updated annually by the ADA to provide additions, deletions and revisions. Please note that many services such as complex oral and maxillofacial surgical procedures and maxillofacial prosthetics may be reimbursed by MCOs using the appropriate medical CPT codes. Either a CPT or a CDT code may be billed. Contact the MCO of enrollment for additional information.

Posting of the Clinical Criteria Grid:

The MCO shall post the Clinical Criteria Grid on their website and reference the location or provide a link in the provider manual. It shall be updated during the first quarter of the calendar year based on information provided by DMAHS.