Prior Authorization

A list of dental services that require prior authorization can be obtained from SKYGEN USA Dental by visiting pwp.sciondental.com or calling 1-855-878-5368. Consideration for prior authorization shall be based on medical necessity.

Prior authorization of services should consider the overall general health, patient compliance and dental history, condition of the oral cavity and a complete treatment plan that is both judicious in the use of program funds and provides a clinically acceptable treatment outcome.

The dental treatment plan provided shall be in accordance with the ethical and professional standards of the dental profession and meet the same high standards of quality normally provided to the community at large.

In situations where a complex treatment plan is being considered, the provider may sequentially submit several prior authorization requests, one for each of the various stages of the treatment. Those services that require prior authorization are defined as “non-routine services.” Prior authorization requests cannot be transferred from one dentist to another. Horizon NJ Health will not impose an arbitrary number of attempted dental treatment visits by a PCD as a condition prior to the PCD initiating any specialty referral requests. The referring dentist is not obligated to supply diagnostic documentation similar to that required for a prior authorization request for treatment services as part of a referral request. The dentist receiving the referral is not obligated to prepare and submit diagnostic materials in order to approve or reimburse for a referral.

All final decisions regarding denials of referrals, prior authorizations, treatment and treatment plans for nonemergency services shall be made by a licensed New Jersey dentist/dental specialist. Prior authorization decisions for non-emergency services shall be made within 14 calendar days or sooner as required by the needs of the member.

All dental services requiring prior authorization should be submitted to:

Horizon NJ Health
PO Box 362
Milwaukee, WI 53201

Operating Room (OR)/Ambulatory Surgery Center (ASC) Authorization

When submitting authorization for code D9999, be sure to submit the facility ID, name of the facility and address in order to ensure accurate processing. If this is not included, processing can be delayed and/or denied.

View the list of OR/ASC Providers with facility IDs.

How to Submit Dental Claims Requiring Prior Authorization

Prior authorization request forms with applicable X-rays should be submitted to Horizon NJ Health. Do not staple X-rays to the forms. A copy of all dental prior authorization forms should be maintained by the dentist. Prior authorization request forms received by Horizon NJ Health will be reviewed by the dental consultant. Upon completion of the review, the dentist will be notified of a decision in writing.

All questions concerning prior authorizations may be directed to:

Horizon NJ Health
PO Box 362
Milwaukee, WI 53201
Or call 1-855-878-5368

Horizon NJ Health has policies and procedures for prior authorization and mechanisms to ensure consistent application of service criteria for authorization decisions. Prior authorization shall be conducted by a currently licensed New Jersey dentist, who is appropriately trained in the principles, procedures and standards of utilization review.

For more information on prior authorization, go to Appendix D of the Provider Administrative Manual.