??SKYGEN?USA?|?CONFIDENTIAL?&?PROPRIETARY?|?Horizon?NJ?Health?Dental?Program?|?Effective:?1/1/20?
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Provider?Manual?
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Effective?January?1,?2020?
NJ?FamilyCare?A?
NJ?FamilyCare?ABP?
NJ?FamilyCare?B?
NJ?FamilyCare?C??
NJ?FamilyCare?D?
Managed?Long?Term?Services?&?Supports?(MLTSS)?
Horizon?NJ?TotalCare?(HMO?D?SNP)?

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??SKYGEN?USA?|?CONFIDENTIAL?&?PROPRIETARY?|?Horizon?NJ?Health?Dental?Program?|?Effective:?1/1/20?
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pwp.sciondental.com?



??SKYGEN?USA?|?CONFIDENTIAL?&?PROPRIETARY?|?Horizon?NJ?Health?Dental?Program?|?Effective:?1/1/20?
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Contents?
Quick?Reference?Guide?............................................................................................................?8?
Provider?Web?Portal:?Online,?All?the?Time?.....................................................................................?8?
When?You?Need?Us???We?ll?Be?There!?............................................................................................?9?

Welcome?...............................................................................................................................?13?
Member?Rights?and?Responsibilities?......................................................................................?15?
Member?Rights?.............................................................................................................................?15?
Member?Responsibilities?..............................................................................................................?15?

Provider?Rights?&?Responsibilities?.........................................................................................?16?
Provider?Rights?..............................................................................................................................?16?
Provider?Responsibilities?...............................................................................................................?16?
Provider?Bill?of?Rights?....................................................................................................................?16?
Positive?Provider?Experience?........................................................................................................?17?
Consistent,?Transparent?Authorization?Decisions?........................................................................?17?
Cultural?Competency?....................................................................................................................?17?
Patients?with?Special?Health?Needs?..............................................................................................?18?
The?Head?Start?Initiative?...............................................................................................................?19?
Domestic?Violence?Reporting?.......................................................................................................?20?
Reporting?Abuse,?Neglect?or?Exploitation?....................................................................................?21?
Confidentiality?...............................................................................................................................?22?
Standards?of?Service?.....................................................................................................................?22?
Special?Standards?of?Services?.......................................................................................................?23?
Office?Practice?Standards?for?General?Dentists?............................................................................?23?
Recordkeeping?Requirements?......................................................................................................?23?

Provider?Web?Portal?..............................................................................................................?28?
Provider?Web?Portal?Registration?.................................................................................................?29?

Electronic?Payments?..............................................................................................................?30?
Electronic?Funds?Transfer?(EFT)?....................................................................................................?30?
Electronic?Remittance?Reports?.....................................................................................................?30?



??SKYGEN?USA?|?CONFIDENTIAL?&?PROPRIETARY?|?Horizon?NJ?Health?Dental?Program?|?Effective:?1/1/20?
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EFT?Authorization?Agreement?................................................................................................?31?
Eligibility?&?Member?Services?................................................................................................?32?
Member?ID?Cards?..........................................................................................................................?33?
Verifying?Member?Eligibility?.........................................................................................................?35?
Verifying?Eligibility?via?Provider?Web?Portal?.................................................................................?35?
Verifying?Eligibility?via?IVR?.............................................................................................................?36?
Specialist?Referrals?........................................................................................................................?36?
Appointment?Availability?Standards?.............................................................................................?36?
Summary:?Appointment?Availability?Standards?...........................................................................?37?
After?Hours?Calls?and?Coverage....................................................................................................?37?
Summary:?After?Hours?Call?Response?Standards?.........................................................................?38?
Missed?Appointments?...................................................................................................................?38?
Payment?for?Non?Covered?Services?.............................................................................................?39?

Prior?Authorization?&?Documentation?Requirements?............................................................?40?
Prior?Authorization?for?Treatment?...............................................................................................?40?
Dental?Treatment?Plan?..................................................................................................................?42?
Dental?OR/ASC?Services?................................................................................................................?42?
Appealing?an?Authorization?Decision?...........................................................................................?44?
Summary:?Prior?Authorization?Timelines?.....................................................................................?44?

Authorization?Submission?Procedures?...................................................................................?45?
Submitting?Authorizations?via?Provider?Web?Portal?....................................................................?45?
Submitting?Authorizations?via?Clearinghouses?.............................................................................?46?
Submitting?Authorizations?via?837D?File?......................................................................................?46?
Attaching?Electronic?Documents?..................................................................................................?46?
Submitting?Authorizations?on?Paper?Forms?.................................................................................?46?
Duplicate?Authorizations?Automatically?Denied?..........................................................................?47?
ADA?Approved?Dental?Claim?Form?...............................................................................................?48?

Claim?Submission?Procedures?................................................................................................?50?
Submitting?Claims?via?Provider?Web?Portal?.................................................................................?50?
Submitting?Claims?via?Clearinghouses?..........................................................................................?50?
Submitting?Claims?via?HIPAA?Compliant?837D?File?......................................................................?51?
Attaching?Electronic?Documents?..................................................................................................?51?



??SKYGEN?USA?|?CONFIDENTIAL?&?PROPRIETARY?|?Horizon?NJ?Health?Dental?Program?|?Effective:?1/1/20?
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Submitting?Claims?on?Paper?Forms?..............................................................................................?51?
Coordination?of?Benefits?(COB)?....................................................................................................?52?
Timely?Filing?Limits?........................................................................................................................?52?
Corrected?Claim?Process?...............................................................................................................?52?
Resubmitting?a?Denied?Claim?.......................................................................................................?52?
Submitting?a?Corrected?Claim?.......................................................................................................?53?
Receipt?&?Audit?of?Claims?.............................................................................................................?53?
Claims?Adjudication?&?Payment?...................................................................................................?53?
Total?Maximum?Payment?Allowance?............................................................................................?54?
Stage?of?Completion?.....................................................................................................................?54?
Missed?Appointments?...................................................................................................................?55?
Period?of?Eligibility?........................................................................................................................?55?
Third?Party?Liability?(TPL)?..............................................................................................................?56?

Complaints,?Grievances?&?Appeals?........................................................................................?57?
Making?a?Complaint?......................................................................................................................?58?
Submitting?Appeals?.......................................................................................................................?59?
Claims?Payment?Appeal?................................................................................................................?61?
Utilization?Management/Authorization?Appeal?...........................................................................?61?
Additional?Appeal?Resources?........................................................................................................?63?

Credentialing?&?Recredentialing?............................................................................................?64?
Credentialing?Process?...................................................................................................................?64?
Credentialing?Documentation?......................................................................................................?65?
Recredentialing?Process?................................................................................................................?66?
Submitting?an?Application?for?Credentialing/Recredentialing?.....................................................?66?
Appealing?a?Credentialing?Decision?..............................................................................................?66?

Health?Insurance?Portability?and?Accountability?Act?(HIPAA)?.................................................?67?
National?Provider?Identifier?(NPI)?.................................................................................................?67?

Utilization?Management?........................................................................................................?68?
Community?Practice?Patterns?.......................................................................................................?68?
Evaluation?.....................................................................................................................................?68?
Results?...........................................................................................................................................?68?
Peer?Review:?Reimbursement?Consequences?.............................................................................?68?



??SKYGEN?USA?|?CONFIDENTIAL?&?PROPRIETARY?|?Horizon?NJ?Health?Dental?Program?|?Effective:?1/1/20?
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TAMI?Review?.................................................................................................................................?69?
Non?Incentivization?Policy?............................................................................................................?69?
Fraud,?Waste?&?Abuse?..................................................................................................................?69?
Deficit?Reduction?Act:?The?False?Claims?Act?.................................................................................?70?
Sanctions?.......................................................................................................................................?71?

Practice?Guidelines?................................................................................................................?72?
NJ?Smiles?.......................................................................................................................................?73?
New?Jersey?Periodicity?Schedule?..................................................................................................?75?

Fluoride?Varnish?Provider?Incentive?Program?........................................................................?76?
Clinical?Criteria?......................................................................................................................?83?
Medical?Necessity?.........................................................................................................................?83?
Prior?Authorization?of?Treatment?.................................................................................................?83?
Emergency?Treatment?..................................................................................................................?84?
Informed?Consent?.........................................................................................................................?84?
Dental?OR/ASC?Services?................................................................................................................?85?
Oral?Surgery?Services?....................................................................................................................?87?
House?Calls?....................................................................................................................................?88?
Hospital?Calls?.................................................................................................................................?89?
Medical?vs.?Dental?Services?..........................................................................................................?90?
Amalgam?Restorations?..................................................................................................................?91?
Interproximal?Fillings?....................................................................................................................?91?
Proximal?Restorations?...................................................................................................................?91?
Proximal?Fillings?............................................................................................................................?91?
Diagnostic?Services?.......................................................................................................................?91?
Anesthesia?.....................................................................................................................................?92?
Intravenous?Sedation?....................................................................................................................?93?
Analgesia?.......................................................................................................................................?93?
Injections?.......................................................................................................................................?93?
Orthodontic?Services?....................................................................................................................?94?
Clinical?Criteria?Descriptions?.......................................................................................................?105?

Glossary................................................................................................................................?115?
Definitions?...................................................................................................................................?115?



??SKYGEN?USA?|?CONFIDENTIAL?&?PROPRIETARY?|?Horizon?NJ?Health?Dental?Program?|?Effective:?1/1/20?
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Benefit?Plan?Details?&?Authorization?Requirements?.............................................................?120?
Dental?Benefit?Schedule?.............................................................................................................?121?
Horizon?NJ?Health?Dental?Program.............................................................................................?123?
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??SKYGEN?USA?|?CONFIDENTIAL?&?PROPRIETARY?|?Horizon?NJ?Health?Dental?Program?|?Effective:?1/1/20?
8?

Quick?Reference?Guide?
Provider?Web?Portal:?Online,?All?the?Time?
Getting?paid?for?the?high?quality?care?you?ve?provided?to?patients?should?be?quick,?easy?and?
convenient.?Horizon?NJ?Health?s?user?friendly?Provider?Web?Portal?offers?a?full?set?of?self?service?
tools?that?help?you?get?more?done,?faster.??
Everything?You?Need???When?You?Need?It???24/7/365?
Use?the?Provider?Web?Portal?to:?

? Check?real?time?eligibility?for?multiple?patients?at?the?same?time.??
? Submit?electronic?authorization?requests?with?attachments.?
? Step?through?a?decision?tree?that?shows?you?the?same?clinical?guidelines?our?consultants?

use?to?evaluate?your?authorization?requests.?
? Use?our?claim?estimator?to?find?out?in?advance?whether?your?claim?is?likely?to?be?paid?or?

denied,?and?why?before?you?render?services.??
? Attach?supporting?documentation,?such?as?EOBs?and?x?rays?online,?for?no?charge.?
? Submit?pre?filled?claim?forms?and?review?claim?history?with?just?a?few?clicks.?
? Check?the?real?time?status?of?claims?and?authorizations?no?need?to?wait?for?paper?

letters?to?arrive?by?postal?mail.?
? View?and?print?Remittance?Reports,?newsletters,?manuals,?and?much?more.?

All?you?need?to?get?started?is?an?internet?connection?and?a?web?browser.?You?don?t?need?to?
download?or?purchase?any?software.?Just?visit?pwp.sciondental.com,?and?call?1?855?424?9239?to?
get?registered?for?the?Provider?Web?Portal.?

pwp.sciondental.com?
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??SKYGEN?USA?|?CONFIDENTIAL?&?PROPRIETARY?|?Horizon?NJ?Health?Dental?Program?|?Effective:?1/1/20?
9?

When?You?Need?Us???We?ll?Be?There!?
Horizon?NJ?Health?is?committed?to?delivering?world?class?service?to?you?and?your?patients.?Our?
customer?service?teams?offer?local?service?with?the?support?of?national?resources.?A?dedicated?
provider?relations?representative?is?available?to?answer?your?questions?and?arrange?in?person?
visits.?When?you?need?us,?we?ll?be?there!??
Contact?us?any?time?for?assistance,?training,?or?to?arrange?an?onsite?visit:?
Call?Provider?Services:?1?855?878?5368?
Email:?providerservices@skygenusa.com?
Quick?Contacts? ?
Authorizations?mailing?address? Horizon?NJ?Health:?Authorizations?

PO?Box?362?
Milwaukee,?WI?53201?

Claims?mailing?address? Horizon?NJ?Health:?Claims?
PO?Box?299?
Milwaukee,?WI?53201?

Corrected?Claims?mailing?address? Horizon?NJ?Health:?Corrected?Claims?
PO?Box?541?
Milwaukee,?WI?53201?

Complaints?and?Appeals?mailing?address? Horizon?NJ?Health:?Complaints/Appeals?
PO?Box?295?
Milwaukee,?WI?53201?

Contracting?mailing?address?? Horizon?NJ?Health:?Contracting?
PO?Box?2059?
Milwaukee,?WI?53201?

Credentialing?Team? 1?855?812?9211??
Email:?credentialing@skygenusa.com?

Electronic?Funds?Transfer? Fax:?1?262?721?0722??
Email:?providerservices@skygenusa.com?

Electronic?Outreach?Team? 1?855?434?9239??
Email:?providerportal@skygenusa.com?

Fraud?&?Abuse?Hotline? 1?877?378?5292?
Provider?Services? 1?855?878?5368??

Email:?providerservices@skygenusa.com?
Provider?Web?Portal? pwp.sciondental.com?

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??SKYGEN?USA?|?CONFIDENTIAL?&?PROPRIETARY?|?Horizon?NJ?Health?Dental?Program?|?Effective:?1/1/20?
10?

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Quick?Reference?to?Common?Questions?
Member?Eligibility? To?verify?member?eligibility,?you?can:?

? Log?on?to?Provider?Web?Portal:?pwp.sciondental.com?
? Call?Interactive?Voice?Response?(IVR)?eligibility?hotline:??

1?844?275?8753?
? Call?Horizon?NJ?Health?Main?Provider?Services:?1?800?682?9091?

Authorization?
Submission?

Submit?authorizations?in?one?of?the?following?formats:?
? Provider?Web?Portal:?pwp.sciondental.com?
? Electronic?submission?via?clearinghouse,?Payer?ID:?22099
? HIPAA?compliant?837D?file??
? Paper?ADA?Dental?Claim?Form,?sent?via?postal?mail:?

Horizon?NJ?Health:?Authorizations?
PO?Box?362??
Milwaukee,?WI?53201?

To?learn?about?the?Provider?Web?Portal,?call?the?Electronic?Outreach?
Team:?1?855?434?9239.?

Claims?Submission? The?timely?filing?requirement?is?180?calendar?days.??
Submit?claims?in?one?of?the?following?formats:?

? Provider?Web?Portal:?pwp.sciondental.com?
? Electronic?submission?via?clearinghouse,?Payer?ID:?22099
? HIPAA?compliant?837D?file??
? Paper?ADA?Dental?Claim?Form,?sent?via?postal?mail:?

Horizon?NJ?Health:?Claims??
PO?Box?299??
Milwaukee,?WI?53201?

To?learn?about?the?Provider?Web?Portal,?call?the?Electronic?Outreach?
Team:?1?855?434?9239.?



??SKYGEN?USA?|?CONFIDENTIAL?&?PROPRIETARY?|?Horizon?NJ?Health?Dental?Program?|?Effective:?1/1/20?
11?

Quick?Reference?to?Common?Questions?
Complaints?and?
Appeals?

To?make?a?complaint:?
? Write?to:?

Horizon?NJ?Health:?Complaints/Appeals?
PO?Box?295?
Milwaukee,?WI?53201?

? Call?Horizon?NJ?Health?Provider?Services:?1?800?682?9091?
For?more?resources,?or?to?file?an?appeal,?see?Complaints,?Grievances?&?
Appeals?for?various?options.?

Provider?Appeals???
Utilization?
Management?
(Authorizations)?

UM?appeals?must?be?filed?within?90?days?following?the?date?the?
authorization?denial?letter?was?mailed.?Horizon?NJ?Health?issues?a?
decision?within?30?calendar?days?if?an?extension?was?not?requested?
and?granted.?Expedited?resolution?is?within?72?hours.?
To?request?reconsideration?of?a?denied?authorization,?write?to:?

Horizon?NJ?Health:?Complaints/Appeals?
PO?Box?295?
Milwaukee,?WI?53201?

Provider?Appeals???
Claims?

Claim?appeals?must?be?filed?within?90?calendar?days?following?the?
date?the?denial?letter?was?mailed.?Horizon?NJ?Health?issues?a?decision?
within?30?calendar?days?if?an?extension?was?not?requested?and?
granted.??
To?request?reconsideration?of?a?claims?denial,?write?to:?

Horizon?NJ?Health:?Complaints/Appeals?
PO?Box?295?
Milwaukee,?WI?53201?

Member?Appeals?? To?submit?a?written?appeal?on?behalf?of?a?member,?write?to:?
Horizon?NJ?Health:?Complaints/Appeals?
PO?Box?295?
Milwaukee,?WI?53201?

Credentialing?Appeals? To?appeal?a?credentialing?decision,?send?a?request?for?a?
reconsideration?review?within?30?days?of?receiving?an?adverse?
recommendation.?Write?to:?

Horizon?NJ?Health:?Credentialing?Appeals?
PO?Box?2059?
Milwaukee,?WI?53201?



??SKYGEN?USA?|?CONFIDENTIAL?&?PROPRIETARY?|?Horizon?NJ?Health?Dental?Program?|?Effective:?1/1/20?
12?

Quick?Reference?to?Common?Questions?
EFT?(Direct?Deposit)?
Enrollment?

Send?a?completed?EFT?Authorization?Agreement?form?and?voided?
check?by?either?fax?or?email:?

? Fax:?1?262?721?0722?
? Email:?providerservices@skygenusa.com?

The?EFT?Authorization?Agreement?form?is?included?in?the?Provider?
Manual?and?posted?on?the?Provider?Web?Portal:?
pwp.sciondental.com.?

Provider?Web?Portal? For?training?or?questions?about?the?Provider?Web?Portal,?contact?the?
Electronic?Outreach?Team:??

? Email:?providerportal@skygenusa.com?
? Call:?1?855?434?9239?

Credentialing? Send?credentialing?and?recredentialing?applications?and?documents?
to?Horizon?NJ?Health?by?fax,?email,?or?mail.?

? Fax:?1?866?396?5686??
? Email:?credentialing@skygenusa.com?
? Write?to:?

Horizon?NJ?Health:?Credentialing?
PO?Box?2059?
Milwaukee,?WI?53201??

Additional?Provider?
Resources?

For?information?about?additional?provider?resources:?
Provider?Web?Portal:?pwp.sciondental.com?
Provider?Services:?1?855?878?5368?
providerservices@skygenusa.com?
Electronic?Outreach?Team:?1?855?434?9239?
providerportal@skygenusa.com?
Credentialing?Team:?1?855?812?9211?
credentialing@skygenusa.com?
Horizon?NJ?Health?Main?Provider?Services:?1?800?682?9091?
horizonnNJhealth.com?
Horizon?NJ?Health?Main?Member?Services:?1?877?765?4325?
Department?of?Billing?and?Insurance:?1?800?446?7467?
state.nj.us/dobi?



??SKYGEN?USA?|?CONFIDENTIAL?&?PROPRIETARY?|?Horizon?NJ?Health?Dental?Program?|?Effective:?1/1/20?
13?

Welcome?
Welcome?to?the?Horizon?NJ?Health?Dental?Program?provider?network!?We?are?Horizon?NJ?
Health,?a?program?of?Horizon?Blue?Cross?Blue?Shield?of?New?Jersey.?We?are?committed?to?
providing?our?members?the?best?possible?care,?keeping?them?healthy,?stable,?and?independent???
it?s?our?reason?for?being?here.?We?are?pleased?to?welcome?you?to?our?team.?
Horizon?NJ?Health?offers?comprehensive?dental?services?to?NJ?FamilyCare?A,?B,?C,?D,?and?ABP?
members?as?well?as?MLTSS?members?and?Horizon?NJ?TotalCare?(HMO?D?SNP)?members.?These?
services?include?preventive,?diagnostic,?restorative,?endodontic,?periodontal,?prosthodontic,?oral?
surgical,?and?adjunctive?dental?services.?Some?procedures?require?prior?authorization.?When?
necessary,?orthodontic?services?are?age?restricted?(covered?for?members?under?21?years?of?age?
or?as?allowed?by?Early?and?Periodic?Screening,?Diagnosis,?and?Treatment?(EPSDT)?and?only?
approved?with?adequate?documentation?of?medical?necessity.?Referral?to?a?dentist?is?mandatory?
when?a?member?reaches?1?year?of?age?and?annually?thereafter.??
Dental?services?include?an?initial?examination?and?any?required?dental?services?determined?to?be?
medically?necessary.?A?referral?to?a?dental?specialist?or?dentist?that?provides?dental?treatment?to?
patients?with?special?needs?shall?be?allowed?when?a?Primary?Care?Dentist?(PCD)?requires?a?
consultation?for?services?by?that?provider.?Any?Primary?Care?Provider?(PCD)?or?PCD?may?refer?a?
member?to?a?participating?dental?specialist.?All?dental?specialists?are?required?to?have?a?current?
NJ?specialty?permit?and?to?be?either?board?eligible?or?board?certified.?All?general?dentists?and?
dental?specialists?are?listed?in?the?Doctor?&?Hospital?Finder?at?horizonNJhealth.com/findadoctor.?
NJ?FamilyCare?C?and?D?members?are?responsible?for?a?$5?copayment?for?dental?services?with?the?
exception?of?diagnostic?and?preventive?dentistry?services.??
Additional?diagnostic,?preventive?and?periodontal?services?shall?be?available?beyond?the?
frequency?limitations?of?every?six?months?and?be?allowed?four?times?a?rolling?year?to?enrollees?
with?special?needs?when?medical?necessity?for?these?services?is?documented?and?submitted?for?
consideration.?Documentation?shall?include?the?expected?prognosis?and?improvement?in?the?oral?
condition?associated?with?the?increased?frequency?for?the?requested?service.?As?part?of?the?State?
contract?with?Horizon?NJ?Health,?members?have?the?option?to?obtain?a?second?opinion?for?
diagnosis?and?treatment?of?dental?conditions?that?are?treated?within?a?dental?specialty.??
The?Plan?may?arrange?for?the?member?to?obtain?a?second?opinion?outside?the?network?at?no?cost?
to?the?member?when?the?plan?s?network?of?providers?does?not?have?a?provider?located?in?the?
member?s?geo?access?area?to?provide?the?services?the?member?needs.?Every?effort?will?be?made?
to?locate?an?in?network?provider.?Members?who?seek?self?initiated?care?from?a?nonparticipating?
dentist?or?a?non?covered?service?will?be?responsible?for?the?cost?of?the?care.?
Throughout?your?ongoing?relationship?with?us,?refer?to?this?provider?manual?for?quick?answers?
and?useful?information,?including?how?to?contact?us,?how?to?submit?claims?and?authorizations,?
and?what?covered?benefits?are?offered?to?members.?
When?you?need?answers,?log?on?to?pwp.sciondental.com?or?horizonNJhealth.com,?send?an?email?
message?to?providerservices@skygenusa.com,?or?call?Provider?Services:?1?855?878?5368.?



??SKYGEN?USA?|?CONFIDENTIAL?&?PROPRIETARY?|?Horizon?NJ?Health?Dental?Program?|?Effective:?1/1/20?
14?

Horizon?NJ?Health,?under?New?Jersey?law,?has?the?right?to?make?any?changes?to?dental?policies?
and?procedures?in?this?manual,?which?become?effective?30?days?after?such?changes?are?posted?to?
horizonNJhealth.com.??

This?manual?describes?policies?and?procedures?that?govern?administration?of?dental?benefits?for?
Horizon?Blue?Cross?Blue?Shield?of?New?Jersey?for?the?State?of?New?Jersey.?Horizon?NJ?Health?
makes?every?effort?to?maintain?accurate?information?in?this?manual;?however,?we?will?not?be?held?
liable?for?any?damages?due?to?unintentional?errors.?If?you?discover?an?error,?please?report?it?to?us?
by?calling?1?800?682?9091.?If?information?in?this?manual?differs?from?your?Provider?Agreement,?the?
Provider?Agreement?takes?precedence?and?shall?control.??
This?document?contains?confidential?and?proprietary?information?and?may?not?be?disclosed?to?
others?without?written?permission?from?SKYGEN?USA.???2014?2019?SKYGEN?USA?All?rights?
reserved.?
Products?are?provided?by?Horizon?NJ?Health.?Communications?are?issued?by?Horizon?Blue?Cross?
Blue?Shield?of?New?Jersey?in?its?capacity?as?administrator?of?programs?and?provider?relations?for?
all?its?companies.?Both?are?independent?licensees?of?the?Blue?Cross?and?Blue?Shield?Association.?
The?Blue?Cross??and?Blue?Shield??names?and?symbols?are?registered?marks?of?the?Blue?Cross?and?
Blue?Shield?Association.?The?Horizon??name?and?symbols?are?registered?marks?of?Horizon?Blue?
Cross?Blue?Shield?of?New?Jersey.???2019?Horizon?Blue?Cross?Blue?Shield?of?New?Jersey,?Three?Penn?
Plaza?East,?Newark,?New?Jersey?07105.?
? ?



??SKYGEN?USA?|?CONFIDENTIAL?&?PROPRIETARY?|?Horizon?NJ?Health?Dental?Program?|?Effective:?1/1/20?
15?

Member?Rights?and?Responsibilities??
Members?of?Horizon?NJ?Health?have?the?following?rights?and?responsibilities.?
Member?Rights?
The?Horizon?NJ?Health?Dental?Program?is?committed?to?the?following?core?concepts?in?our?
approach?to?member?care:?

? Access?to?providers?and?services.?
? Wellness?programs,?which?include?member?education?and?disease?management?initiatives.?
? Outreach?programs?that?educate?members?and?give?them?the?tools?they?need?to?make?

informed?decisions?about?their?dental?care.?
? Feedback?that?measures?provider?and?member?satisfaction.?

We?believe?all?members?have?the?right?to:?
? Privacy,?respectful?treatment,?and?recognition?of?their?dignity?when?receiving?dental?care.?
? Participate?fully?with?caregivers?in?making?decisions?about?their?health?care.?
? Be?fully?informed?about?the?appropriate?or?medically?necessary?treatment?options?for?any?

condition,?regardless?of?the?coverage?or?cost?for?the?care?discussed.?
? Voice?a?complaint?against?the?Horizon?NJ?Health?Dental?Program,?or?any?of?its?participating?

dental?offices,?or?any?of?the?care?provided?by?these?groups?or?people,?when?their?performance?
has?not?met?the?member?s?expectations.?

? Appeal?any?decisions?related?to?patient?care?and?treatment.?
? Make?recommendations?regarding?our?member?rights?and?responsibilities?policies.?
? Receive?relevant,?updated?information?about?the?Horizon?NJ?Health?Dental?Program,?the?

services?provided,?the?participating?dentists?and?dental?offices,?as?well?as?member?rights?
and?responsibilities.?

Member?Responsibilities?
Along?with?rights,?members?have?important?responsibilities,?including:?

? Becoming?familiar?with?benefit?plan?coverage?and?rules.?
? Giving?dental?providers?complete?and?accurate?information?they?need?to?provide?care.?
? Following?treatment?plans?and?instructions?received?from?dental?providers.?
? Supporting?the?care?given?to?other?patients?and?behaving?in?a?way?that?helps?the?clinic,?

dental?office,?and?other?dental?locations?run?smoothly.?
? Notifying?Customer?Service?of?any?questions,?concerns,?problems,?or?suggestions.?

? ?



??SKYGEN?USA?|?CONFIDENTIAL?&?PROPRIETARY?|?Horizon?NJ?Health?Dental?Program?|?Effective:?1/1/20?
16?

Provider?Rights?&?
Responsibilities?
The?Horizon?NJ?Health?Dental?Program?has?established?the?following?core?concepts?in?our?
approach?to?a?positive?provider?experience:?

? Access?to?flexible?participation?options?in?provider?networks.?
? Outreach?programs?that?lower?provider?participation?costs.?
? Technology?tools?that?increase?efficiency?and?lower?administrative?costs.?
? Feedback?that?measures?provider?and?member?satisfaction.?

Provider?Rights?
Enrolled?participating?providers?have?the?right?to:?

? Communicate?with?patients?about?dental?treatment?options.?
? Recommend?a?course?of?treatment?to?a?member,?even?if?the?treatment?is?not?a?covered?

benefit?or?approved?by?the?Horizon?NJ?Health?Dental?Program.?
? File?an?appeal?or?complaint?about?the?procedures?of?Horizon?NJ?Health?Dental?Program.?
? Supply?accurate,?relevant,?and?factual?information?to?a?member?in?conjunction?with?an?

appeal?or?complaint?filed?by?the?member.?
? Object?to?policies,?procedures,?or?decisions?made?by?Horizon?NJ?Health?Dental?Program.?
? Be?informed?of?the?status?of?their?credentialing?or?recredentialing?application,?upon?request.?

Provider?Responsibilities?
Participating?providers?have?the?following?responsibilities:?

? If?a?recommended?treatment?plan?is?not?covered?(not?approved?by?the?Horizon?NJ?
Health?Dental?Program),?the?participating?dentist,?if?intending?to?charge?the?member?for?
the?non?covered?services,?must?notify?and?obtain?agreement?from?the?member?in?
advance.?(See?Payment?for?Non?Covered?Services?on?page?39.)??

? A?provider?wishing?to?terminate?participation?with?the?Horizon?NJ?Health?Dental?Program?
provider?network?must?follow?the?termination?guidelines?stipulated?in?the?provider?contract.?

? A?provider?may?not?bill?both?medical?codes?and?dental?codes?for?the?same?procedure.?
Provider?Bill?of?Rights?

? To?be?treated?with?respect?
? To?be?paid?accurately?
? To?be?paid?on?time?

? ?



??SKYGEN?USA?|?CONFIDENTIAL?&?PROPRIETARY?|?Horizon?NJ?Health?Dental?Program?|?Effective:?1/1/20?
17?

Positive?Provider?Experience?
We?consider?ourselves?to?be?your?partner?in?patient?care.?Committed?dentists?are?essential?to?the?
success?of?every?government?sponsored?dental?program.?The?Horizon?NJ?Health?Dental?Program?
invites?all?licensed?dentists,?regardless?of?their?past?commitment?to?government?sponsored?
dental?programs,?to?participate?in?our?provider?network.?You?can?choose?your?own?level?of?
participation?for?each?location?where?you?practice.?For?each?location?you?can?choose?to:?

? Be?listed?in?a?directory?and?accept?appointments?for?all?new?patients.?
? Be?excluded?from?directories?and?accept?appointments?for?only?new?patients?directed?to?

your?office?from?Horizon?NJ?Health.?
? Treat?only?emergencies?or?special?needs?cases?on?an?individual?basis.?

To?make?it?as?fast?and?easy?as?possible?to?join?our?network,?Horizon?NJ?Health?streamlines?the?
contracting?and?credentialing?process?by?accepting?electronic?documents.?
Consistent,?Transparent?Authorization?Decisions?
Trained?paraprofessionals?and?dental?consultants?use?predefined?clinical?guidelines?to?ensure?a?
consistent?approach?for?determining?authorizations?submitted?for?review.??
When?you?submit?an?online?authorization?through?the?Provider?Web?Portal,?you?have?the?option?
of?stepping?through?the?guideline?yourself,?for?a?quick?indication?of?whether?your?authorization?
request?is?likely?to?be?approved.?Authorization?requirements?are?also?outlined?in?this?provider?
manual.?See?Benefit?Plan?Details?&?Authorization?Requirements?on?page?120.?
In?addition,?when?you?submit?an?authorization?through?the?Provider?Web?Portal,?you?can?see?at?a?glance?
whether?documentation,?such?as?X?rays?or?medical?necessity?narratives,?are?required.?You?can?attach?and?
send?electronic?documents?as?part?of?your?online?authorization?request?saving?both?time?and?money.??
Cultural?Competency??
Your?office?and?staff?should?demonstrate?behaviors?and?policies?of?cultural?competency?by:?

? Assessing?and?documenting?cultural?and/or?language?barriers?to?member?care.?
? Seeking?information?from?community?resources?to?assist?in?servicing?the?needs?of?

culturally?and?ethnically?diverse?members?and?families.?
? Displaying?pictures,?posters,?and?other?materials?to?reflect?the?cultures?and?ethnic?

backgrounds?of?members?and?families.?
? Providing?magazines?and?brochures?in?the?waiting?area?that?emphasize?diversity.?
? Understanding?that?folk?and?religious?beliefs?may?influence?how?families?respond?to?illness,?

disease,?death,?and?their?reaction?and?approach?to?children?with?special?health?needs.?
? Accepting?that?the?family?unit?can?be?defined?differently?by?different?cultures.?
? Seeking?bilingual?staff?or?trained?personnel?to?serve?as?interpreters,?when?possible.?
? Understanding?that?a?limited?English?proficiency?in?no?way?reflects?intellect.?

? ?



??SKYGEN?USA?|?CONFIDENTIAL?&?PROPRIETARY?|?Horizon?NJ?Health?Dental?Program?|?Effective:?1/1/20?
18?

Patients?with?Special?Health?Needs?
Dentists?who?treat?patients?with?special?health?needs?(including?physical,?developmental,?or?
emotional?disabilities)?must?assist?and?consult?with?patient?caregivers.?When?a?caregiver?seeks?
advice,?clarification,?or?education,?you,?as?the?treating?dentist,?should?provide?this?information.?
Dentists?may?receive?a?behavior?management?fee?for?treating?patients?with?special?needs,?based?
on?the?needs?of?the?member.?If?the?patient?is,?by?clinical?presentation?or?medical?condition?
determined?to?be?a?member?to?have?special?needs,?we?will?allow?that?patient?to?receive?services?
as?a?special?needs?member.?Forward?a?narrative?to?providerservices@skygenusa.com,?or?call?
Provider?Services?at?1?855?878?5368.?Horizon?NJ?Health?pays?a?fee?per?15?minute?unit,?and?prior?
authorization?is?not?necessary.?Reimbursement?for?two?or?more?units?is?at?the?discretion?of?a?
Horizon?NJ?Health?Dental?Consultant?and?based?on?services?provided?in?the?patient?s?record.?This?
documentation?includes,?but?is?not?limited?to:??

? A?visual?examination?of?the?patient?
? Appropriate?radiographs?
? Dental?prophylaxis,?including?extra?scaling?and?topical?applications?such?as?fluoride?treatments?
? Nonsurgical?periodontal?treatment,?including?root?planing?and?scaling?
? Thorough?inquiries?regarding?the?patient?s?medical?history?
? Consultations?with?patient?caregivers?to?establish?a?thorough?understanding?of?proper?

dental?management?during?visits?
? ?



??SKYGEN?USA?|?CONFIDENTIAL?&?PROPRIETARY?|?Horizon?NJ?Health?Dental?Program?|?Effective:?1/1/20?
19?

The?Head?Start?Initiative?
The?Head?Start?Initiative?is?a?pediatric?oral?health?action?plan?established?to?ensure?Head?Start?
programs?in?the?State?of?New?Jersey?are?given?resources?for?all?Early?Head?Start/Head?Start?
children.?This?is?a?part?of?a?statewide?initiative?to?increase?optimal?oral?care?access?and?oral?
health?education?for?children?ages?0?6?in?communities?served?by?the?Head?Start?program.?
Horizon?NJ?Health?Dental?Operations?is?tasked?with:??

? Determining?the?status?of?early?childhood?oral?health?in?New?Jersey?and?educating?Head?
Start?staffers.?

? Increasing?access?to?high?quality,?comprehensive?oral?health?services?through?provider?
recruitment?and?engagement.?

? Promoting?the?importance?of?oral?health?to?all?health?care?professionals,?family?members,?
and?educators?through?the?individual?Head?Start?programs?by:?

o Identifying?and?reviewing?risk?factors?for?poor?oral?health?including?access?to?care.?
o Ongoing?discussions?on?health?disparities?and?underlying?medical?conditions.?
o Educating?on?the?best?practices?relative?to?collaborations?that?may?improve?

quality?healthcare.?
o Utilizing?resources?available?to?assist?in?this?endeavor,?NJDA,?NJAAPD,?The?

Pediatric?Oral?Health?Committee,?and?our?own?participating?dental?providers.?
? ?



??SKYGEN?USA?|?CONFIDENTIAL?&?PROPRIETARY?|?Horizon?NJ?Health?Dental?Program?|?Effective:?1/1/20?
20?

Domestic?Violence?Reporting?
The?health?care?provider?is?a?primary?source?in?identifying?members?who?may?have?been?
subjected?to?domestic?violence.?Domestic?violence?includes?both?abuse?and?battery.?Abuse?is?a?
pattern?of?coercive?control?that?one?person?exercises?over?another.?Battery?is?a?behavior?that?
physically?harms,?arouses?fear,?prevents?a?partner?from?doing?what?they?wish,?or?forces?them?to?
behave?in?ways?they?do?not?want.?
State?law?requires?the?reporting?of?child?abuse.?Reporting?can?be?done?anonymously.?Report?any?
injuries?from?firearms?and?other?weapons?to?the?police.?Immediately?report?any?suspected?child?
abuse?or?neglect?to?the?Division?of?Child?Protection?and?Permanency?at?1?877?NJABUSE?(1?877?
652?2873).?Calls?can?be?received?24?hours?a?day,?seven?days?a?week.?
The?provider?is?responsible?to?report?suspected?cases?of?elder?or?partner?abuse,?neglect,?or?
exploitation?that?occurs?in?the?community.?Immediately?report?any?suspected?elder?or?partner?
abuse?to?the?State?s?Department?of?Adult?Protective?Services?at?1?609?588?6501.?
State?law?provides?immunity?from?any?criminal?or?civil?liability?as?a?result?of?good?faith?reports?of?
child?abuse?or?neglect.?Any?person?who?knowingly?fails?to?report?suspected?abuse?or?neglect?may?
be?subject?to?a?fine?up?to?$1,000?or?imprisonment?up?to?six?months.?To?help?identify?domestic?
violence,?the?following?questions?have?been?developed?by?the?Family?Violence?Prevention?Fund.?
A?complete?copy?of?the?guidelines?can?be?found?at?futureswithoutviolence.org.?
Domestic?Violence?Screening?Tools??
Framing?Questions?

? ?Because?violence?is?so?common?in?many?people?s?lives,?I?ve?begun?to?ask?all?my?patients?
about?it.??

? ?I?m?concerned?that?your?symptoms?may?have?been?caused?by?someone?hurting?you.??
? ?I?don?t?know?if?this?is?a?problem?for?you,?but?many?of?the?women?I?see?as?patients?are?

dealing?with?abusive?relationships.?Some?are?too?afraid?or?uncomfortable?to?bring?it?up?
themselves,?so?I?ve?started?asking?about?it?routinely.??

Direct?Verbal?Questions?
? ?Are?you?in?a?relationship?with?a?person?who?physically?hurts?or?threatens?you???
? ?Did?someone?cause?these?injuries??Was?it?your?partner/husband???
? ?Has?your?partner?or?ex?partner?ever?hit?you?or?physically?hurt?you??Has?he?ever?

threatened?to?hurt?you?or?someone?close?to?you???
? ?Do?you?feel?controlled?or?isolated?by?your?partner???
? ?Do?you?ever?feel?afraid?of?your?partner??Do?you?feel?you?are?in?danger??Is?it?safe?for?you?

to?go?home???
? ?Has?your?partner?ever?forced?you?to?have?sex?when?you?didn?t?want?to??Has?your?

partner?ever?refused?to?practice?safe?sex???
? ?



??SKYGEN?USA?|?CONFIDENTIAL?&?PROPRIETARY?|?Horizon?NJ?Health?Dental?Program?|?Effective:?1/1/20?
21?

For?History?Intake?Forms/New?Patient?Questionnaires?
Option?1?

? ?Have?you?ever?been?hurt?or?threatened?by?your?boyfriend/husband/partner???
?OR??

? ?Have?you?ever?been?hit,?kicked,?slapped,?pushed?or?shoved?by?your?spouse/partner???
?OR??

? ?Have?you?ever?been?hit,?kicked,?slapped,?pushed?or?shoved?by?your?boyfriend/husband/?
partner?during?this?pregnancy???
?AND??

? ?Have?you?ever?been?raped?or?forced?to?engage?in?sexual?activity?against?your?will???
Option?2?

? ?Are?you?currently?or?have?you?ever?been?in?a?relationship?in?which?you?were?physically?
hurt,?threatened?or?made?to?feel?afraid???

Option?3?
? ?Have?you?ever?been?forced?or?pressured?to?have?sex?when?you?did?not?want?to???
? ?Have?you?ever?been?hit,?kicked,?slapped,?pushed?or?shoved?by?your?

boyfriend/husband/partner???
Reporting?Abuse,?Neglect?or?Exploitation?
All?members?have?the?right?to?be?free?from?exploitation,?fraud?and?abuse.?Providers?are?required?to?
report?suspected?abuse,?neglect,?or?exploitation?of?any?person?who?answers?in?the?affirmative?to:?

? ?Are?you?in?a?relationship?with?a?person?who?physically?hurts?or?threatens?you???
? ?Did?someone?cause?these?injuries??Was?it?your?partner/husband???

Adult?Protective?Services?
The?New?Jersey?Adult?Protective?Services?(APS)?program?has?offices?in?each?of?the?21?counties.?
Reports?may?be?made?to?those?County?APS?offices?or?to:?
The?Public?Awareness,?Information,?Assistance?&?Outreach?Unit:?1?800?792?8820?
Child?Protective?Services?
The?New?Jersey?Division?of?Child?Protection?and?Permanency?(DCP&P)?handles?all?reports?of?child?
abuse?and?neglect,?including?those?occurring?in?institutional?settings?such?as?child?care?centers,?
schools,?foster?homes?and?residential?treatment?centers.?These?must?be?reported?to?the?State?
Central?Registry?(SCR):?
Child?Abuse?Hotline?(SCR)?24?Hour?Toll?Free?Hotline:?1?877?NJ?ABUSE?(1?877?652?2873)?|?TTY:?1?
800?835?5510.?
? ?



??SKYGEN?USA?|?CONFIDENTIAL?&?PROPRIETARY?|?Horizon?NJ?Health?Dental?Program?|?Effective:?1/1/20?
22?

Facility?Based?Complaints?and?Investigation?
Office?of?the?Ombudsman?for?the?Institutionalized?Elderly?investigates?claims?of?abuse?and?
neglect?of?people?age?60?and?older?living?in?nursing?facilities?and?other?long?term?health?care?
facilities,?such?as?assisted?living?facilities.?

? 24?Hour?Toll?Free?Hotline:?1?877?582?6995??
? Fax:?1?609?943?3479?
? Email:?ombudsman@advocate.state.nj.us??
? Write?to:??

The?Office?of?the?Ombudsman?
PO?Box?852?
Trenton,?NJ?08625?0852?

NJ?Division?of?Health?Facilities?Evaluation?and?Licensing?investigates?all?complaints?against?health?
care?facilities,?nursing?homes,?assisted?living?residences,?comprehensive?personal?care?homes,?
adult?medical?day?care,?and?other?licensed?acute?and?long?term?care?facilities.?
24?Hour?Toll?Free?Hotline:?1?800?792?9770??
Write?to:?

New?Jersey?Department?of?Human?Services?Division?of?Health?Facilities??
Evaluation?and?Licensing?
PO?Box?367?
Trenton,?NJ?08625?0367?

Confidentiality??
All?participating?dentists?must?treat?their?member?dental?records?confidentially?and?comply?with?
all?federal?and?state?laws?and?regulations.?
The?enrollment?form,?signed?by?Horizon?NJ?Health?members,?authorizes?the?release?of?dental?
information?to?Horizon?NJ?Health?on?behalf?of?Horizon?NJ?Health?staff.??
Standards?of?Service?
The?level?of?care?specified?in?the?dental?treatment?plan?must?meet?the?ethical?and?professional?
standards?of?the?dental?profession?and?offer?the?same?high?standard?of?quality?provided?to?the?
community?at?large.?
All?materials?used,?and?all?therapeutic?agents?used?or?prescribed,?must?meet?the?specifications?
established?by?the?American?Dental?Association.?Horizon?NJ?Health?does?not?reimburse?
experimental?procedures?that?are?not?approved?by?the?New?Jersey?Board?of?Dental?Examiners.?
When?an?emergency?arises?and?the?attending?practitioner?is?unavailable?for?consultation,?due?
consideration?should?be?given?to?the?preservation?of?those?teeth?that?could?be?involved?in?the?
overall?treatment?plan?of?the?attending?practitioner.?
? ?



??SKYGEN?USA?|?CONFIDENTIAL?&?PROPRIETARY?|?Horizon?NJ?Health?Dental?Program?|?Effective:?1/1/20?
23?

Special?Standards?of?Services?
Dental?services?without?specific?provisions?or?services?limited?or?prohibited?in?these?policies?
and?procedures?may?be?considered?on?an?individual?basis.?Send?these?requests?and?all?
supporting?documentation?to:?

Horizon?NJ?Health:?Authorizations?
PO?Box?362?
Milwaukee,?WI?53201?

Office?Practice?Standards?for?General?Dentists?
The?State?of?New?Jersey?requires?the?following?Office?Practice?Standards?for?Primary?Care?
Dentists.?Compliance?with?these?standards?is?audited?by?periodic?onsite?reviews?of?offices,?chart?
sampling,?and?member?satisfaction?surveys.?General?dentists?must:?

? Render?dental?care?services?within?45?minutes?from?the?time?of?scheduled?appointment.?
? Implement?and?document?a?policy?to?track?missed?appointments,?and?follow?up?with?

rescheduling?to?maintain?continuity?of?care.?
? Offer?dental?care?in?an?office?environment?that?meets?OSHA?and?CDC?standards.?

Recordkeeping?Requirements?
Dentists?are?required?to?maintain?individual?records,?which?fully?disclose?the?type?and?extent?of?services?
provided?to?members?in?the?Horizon?NJ?Health?Dental?Program.?Providers?must?maintain?and?make?
these?records?available?per?state?law,?including?details?of?all?services?rendered?for?each?encounter?date.?
Office?Records?
Member?records?must?be?kept?in?the?dentist?s?office?regardless?of?the?actual?place?of?service?
(dental?office,?long?term?care?facility,?or?hospital).?Per?the?State?of?New?Jersey?requirements,?
these?records?must?be?available?for?a?minimum?of?seven?years?following?the?last?date?of?service.?
These?records?will?include,?but?not?be?limited?to,?the?following:?
Member?Identification?and?History?

? Name,?address,?telephone?number,?birth?date,?and?Medicaid?ID?number?of?the?member?
? If?the?member?is?a?minor,?names?of?parents?or?guardians?
? Documentation?of?any?cultural?or?linguistic?needs?of?the?member?
? Pertinent?dental?and?medical?history?

Clinical?Examination?Data?
Detailed?clinical?examination?data?to?include,?when?applicable:?

? Member?s?chief?complaint??
? Diagnosis?
? Caries?
? Missing?teeth?(Periodontal?charting,?when?necessary)?
? Abnormalities?
? Risk?assessment? ?



??SKYGEN?USA?|?CONFIDENTIAL?&?PROPRIETARY?|?Horizon?NJ?Health?Dental?Program?|?Effective:?1/1/20?
24?

Radiographs?
? Preoperative,?progressive,?and?postoperative?radiographs?retained?in?accordance?with?state?

law?for?a?minimum?of?seven?years?following?the?last?date?of?service?(To?accommodate?
possible?retention?for?longer?periods,?contact?professional?liability?insurance?companies.)?

? Number?and?type?of?radiographs?entered?on?the?member?s?record?
? Postoperative?radiographs,?taken?only?when?dentally?necessary?and?meriting?diagnostic?value?

Treatment?Plan?
The?treatment?plan?with?description?of?treatment?rendered,?including:?

? Tooth?number?
? Surfaces?involved?
? Site?and?size?of?treatment?area?(lesion,?laceration,?fracture,?etc.)?
? Materials?used?
? Dates?of?services?
? Description?of?treatment?or?services?rendered?at?each?visit?with?the?name?of?the?dentist?

or?hygienist?
? All?medications?
? Diagnostic?laboratory?and/or?radiographic?procedures?ordered?and?the?results?
? Copy?of?the?dental?prosthetic?work?authorizations?(prescriptions)?and?dental?prosthetic?

laboratory?receipts?
? Explanation?for?any?duplication?of?services?within?one?year?(Prosthetic?services?within?

seven?and?a?half?years)?
? Reasons?for?discontinuation?of?services,?and?attempts?to?complete?treatment?
? Referral?and?consultation?reports?

Hospital?Facility?Records??
For?any?members?treated?at?hospital?facilities,?providers?must?also?document?services?in?facility?
records?that?are?readily?available?to?Horizon?NJ?Health?representatives.?Enter?a?complete?
description?of?treatment,?as?described?above,?into?a?hospital?s?clinical?records?for?any?member?
you?treat?at?that?facility.?These?entries?must?also?meet?the?hospital?s?specific?regulations.?
? ?



??SKYGEN?USA?|?CONFIDENTIAL?&?PROPRIETARY?|?Horizon?NJ?Health?Dental?Program?|?Effective:?1/1/20?
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Nursing?Facility?Records??
In?addition?to?the?office?records,?dentists?who?provide?services?for?members?who?reside?at?a?
nursing?facility?regardless?of?the?place?of?service?must?provide?the?nursing?facility?with?an?
entry?for?the?member?s?clinical?record?as?follows:?

? The?results?of?an?examination?to?establish?an?admission?record?of?the?member?s?dental?
status.?If?an?examination?is?required?within?six?months?of?a?previous?examination?billed?
to?Horizon?NJ?Health?and?performed?by?the?same?physician?or?healthcare?professional,?
the?results?of?the?original?examination?must?also?appear?in?the?clinical?record?as?the?
current?dental?status.?

? A?time?frame,?established?on?an?individual?basis,?for?the?next?periodic?examination?of?the?
member.?The?time?frame?must?be?documented?either?at?the?time?of?examination?or?at?
the?completion?of?treatment.?The?clinical?record?may?reflect?six?months,?one?year,?two?
years,?three?years,?or?any?other?time?period?that?the?attending?dentist?learned?of?the?
member?s?dental?status.?

? A?record?of?dental?treatment?provided?at?each?encounter.?Horizon?NJ?Health?accepts?a?
photocopy?of?the?completed?and?signed?current?ADA?Claim?Form?with?the?examination?and?
treatment?instead?of?a?separate?entry?only?when?descriptions?of?treatments?preceding?or?
following?the?dates?of?service?entered?on?the?claim?form?are?listed?separately?on?the?
member?s?clinical?record?in?addition?to?the?other?recordkeeping?requirements.?

? ?



??SKYGEN?USA?|?CONFIDENTIAL?&?PROPRIETARY?|?Horizon?NJ?Health?Dental?Program?|?Effective:?1/1/20?
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Mobile?Dental?Practice?and?Mobile?Dental?Van?Definitions?
Mobile?Dental?Practice?(utilizing?portable?equipment)?is?a?provider?traveling?to?various?locations?
and?utilizing?portable?dental?equipment?to?provide?dental?services?outside?of?a?dental?office/clinic?
in?settings?to?include?but?not?limited?to?facilities,?schools?and?residences.??

? Facilities:?These?providers?are?expected?to?provide?on?site?comprehensive?dental?care?(to?
include?intra?oral?radiographs),?necessary?dental?referrals?to?general?dentist?or?specialists?
and?emergency?dental?care?in?accordance?with?all?New?Jersey?State?Board?of?Dentistry?
regulations?and?the?NJ?FamilyCare?MCO?Contract.?The?sites?served?by?the?Mobile?Dental?
Practice?must?allow?Member?access?to?treatment?and?allow?for?continuity?of?care.??

? Schools:?These?locations?are?not?considered?a?dental?home?and?are?limited?to?providing?
the?following?services:?oral?assessment/screening,?prophylaxis,?fluoride?treatment,?
emergency?care?and?referral?to?the?member?s?dental?home?when?known?or?their?MCO?for?
assistance?in?locating?a?dentist.??

Private?Residences?and?other?residential?settings:?These?providers?are?expected?to?provide?on?site?
dental?care?for?the?homebound?based?on?patient?safety?and?ability?to?tolerate?procedures?
outside?of?a?clinical?setting.??

? The?MCO?is?responsible?for?assisting?the?member,?family,?facility?or?school?in?locating?a?
dentist?when?referrals?are?issued.?Patient?records?must?be?maintained?at?the?facility?when?
this?is?a?long?term?care?facility,?skilled?nursing?facility?or?school?and?duplicates?may?also?be?
maintained?in?a?central?and?secure?area?in?accordance?with?State?Board?of?Dentistry?
regulations.?The?provider?must?submit?documentation?to?the?MCO?of?all?locations?they?
visit?and?serve?and?include?the?days?and?times?for?each?location,?except?when?a?visit?is?to?
a?residence.??

Mobile?Dental?Practice?(utilizing?van)?is?a?vehicle?specifically?equipped?with?stationary?dental?
equipment?and?is?used?to?provide?dental?services?within?the?van.??

? Providers?using?a?mobile?dental?van?to?render?dental?services?must?also?be?associated?
with?a?dental?practice?that?is?located?in?a??brick?and?mortar??facility?located?in?New?Jersey?
that?serves?as?a?dental?home?offering?comprehensive?care,?emergency?care?and?
appropriate?dental?specialty?referrals?to?the?mobile?dental?van?s?patients?of?record?
(Members).?They?must?demonstrate?their?ability?to?render?dental?treatment?services?and?
assist?with?dental?referrals?as?needed.??

? An?exception?to?the?brick?and?mortar?requirements?can?be?considered?for?providers?using?
mobile?dental?vans?that?demonstrate?they?are?only?providing?dental?services?to?NJ?
FamilyCare?enrollees?residing?in?a?long?term?care?facility?or?that?are?in?a?private?
residence/group?home?and?unable?to?travel.??

? The?distance?between?the?dental?practice?and?the?sites?and?locations?served?by?the?
mobile?dental?van?must?not?be?a?deterrent?to?the?Member?accessing?treatment?and?allow?
for?continuity?of?care?by?meeting?the?network?standards?for?distance?in?miles?as?
described?in?section?4.8.8?Provider?Network?Requirements.?? ?



??SKYGEN?USA?|?CONFIDENTIAL?&?PROPRIETARY?|?Horizon?NJ?Health?Dental?Program?|?Effective:?1/1/20?
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? When?a?mobile?dental?van?is?used?for?school?visits,?health?fairs?or?other?one?time?events,?
services?will?be?limited?to?oral?screenings,?exams,?fluoride?varnish/topical?fluoride?
treatment,?prophylaxis?and?palliative?care?to?treat?an?acute?condition.?State?Board?
regulations?must?still?be?followed?and?patient?records?are?to?be?maintained?in?accordance?
with?State?Board?of?Dentistry?regulations.??

? Providers?utilizing?Mobile?Dental?Vans?must?submit?to?the?MCO?documentation?of?all?
locations?they?will?visit?including?the?days?and?times?(except?when?visit?is?to?homebound?
members).??

Provisions?will?be?granted?for?visits?to?a?Member?s?place?of?residence,?long?term?care?facility,?
skilled?nursing?facility?or?medical?day?care?facility?when?medically?necessary?and?where?available.?
The?contractor?must?monitor?on?an?annual?basis?the?standard?of?dental?care?rendered?and?
ensure?that?needed?referrals?for?dental?treatment?that?cannot?be?provided?by?a?mobile?dental?
practice?occur.??
? ?



??SKYGEN?USA?|?CONFIDENTIAL?&?PROPRIETARY?|?Horizon?NJ?Health?Dental?Program?|?Effective:?1/1/20?
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Provider?Web?Portal?
Dental?services?may?be?provided?in?these?settings?through?the?following?modalities.?Our?Provider?
Web?Portal?offers?quick?access?to?easy?to?use?self?service?tools?for?managing?daily?administration?
tasks.?The?Provider?Web?Portal?offers?you?many?benefits?including:?

? Lower?administrative?and?participation?costs.?
? Faster?payment?through?streamlined?claim?and?authorization?submissions.?
? Real?time?member?eligibility?verification.?
? Immediate?access?to?member?information,?claim?and?authorization?history,?and?payment?

records?at?any?time,?24?hours?a?day,?7?days?a?week.?

Get?Started!?For?help?getting?started?with?
the?Provider?Web?Portal,?call?the?Electronic?
Outreach?Team?at?1?855?434?9239.?

A?web?browser,?internet?connection,?and?a?valid?User?ID?and?password?are?required?for?online?
access.?From?the?Provider?Web?Portal,?providers?and?authorized?office?staff?can?log?in?for?secure?
access?anytime?from?anywhere?and?handle?a?variety?of?day?to?day?tasks,?including:?

? Verify?eligibility?for?multiple?members?simultaneously,?and?review?individual?patient?
treatment?history.?

? Set?up?office?appointment?rosters?that?automatically?verify?eligibility?and?fill?in?claim?
forms?for?online?submission.?

? Submit?claims?and?authorizations?using?pre?filled?electronic?forms?and?data?entry?
shortcuts.?

? Step?through?clinical?guidelines?as?part?of?submitting?authorizations?for?a?quick?indication?
of?whether?a?service?request?is?likely?to?be?approved.?

? Attach?and?securely?send?supporting?documents,?such?as?digital?X?rays,?EOBs,?and?
treatment?plans,?for?no?extra?charge.?

? Generate?a?pricing?estimate?before?submitting?a?claim?for?a?quick?indication?of?whether?a?
service?may?be?denied?and?a?likely?reason?for?denial.?

? Check?the?real?time?status?of?in?process?claims?and?authorizations,?and?review?historical?
payment?records.?

? Review?provider?clinical?profiling?data?relative?to?your?peers.?
? Download?and?print?a?provider?manual,?remittance?reports,?and?more.?

Online?help?is?available?from?every?page?of?the?Provider?Web?Portal,?offering?quick?answers,?
animated?videos,?and?step?by?step?instructions.?
? ?



??SKYGEN?USA?|?CONFIDENTIAL?&?PROPRIETARY?|?Horizon?NJ?Health?Dental?Program?|?Effective:?1/1/20?
29?

Provider?Web?Portal?Registration?
The?Provider?Web?Portal?was?designed?to?help?you?keep?your?administrative?costs?low,?give?you?
immediate?access?to?real?time?information,?and?make?it?fast?and?easy?to?submit?claims?and?
authorizations.?
To?register?for?our?Provider?Web?Portal,?visit?pwp.sciondental.com?and?click?the?provider?login?
link.?On?the?login?page,?click?Register?Now.?
Call?the?Electronic?Outreach?Team?at?1?855?434?9239?to?register?for?the?Provider?Web?Portal.?
As?soon?as?you?register,?you?can?log?in?and?start?using?the?portal.?Quick?and?easy?online?help?is?
just?a?click?away?on?every?page?in?the?portal.??
If?you?don?t?find?answers?to?your?questions,?or?if?you?want?personalized?training?for?yourself?or?
your?office?staff,?call?the?Electronic?Outreach?Team?at?1?855?434?9239.?
? ?



??SKYGEN?USA?|?CONFIDENTIAL?&?PROPRIETARY?|?Horizon?NJ?Health?Dental?Program?|?Effective:?1/1/20?
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Electronic?Payments?
Electronic?Funds?Transfer?(EFT)??
Horizon?NJ?Health?offers?all?providers?the?option?of?Electronic?Funds?Transfer?(EFT)?for?claims?
payments.?With?EFT,?we?can?pay?claims?more?efficiently?and?you?can?receive?payments?faster?
because?funds?are?deposited?directly?into?your?bank?account,?eliminating?the?steps?of?printing?
and?mailing?paper?checks.?To?receive?claims?payments?through?the?EFT?program:?

1. Complete?and?sign?the?EFT?Authorization?Agreement.?The?form?is?included?in?this?manual?
and?is?also?available?from?the?Provider?Web?Portal?at?pwp.sciondental.com.??

2. Include?a?voided?check?with?the?EFT?Authorization?Agreement.?The?transaction?cannot?be?
processed?without?a?voided?check.?

3. Send?the?EFT?Authorization?Agreement?form?and?voided?check?to?Horizon?NJ?Health?by?
fax?or?email:?
? Fax:?1?262?721?0722?
? Email:?providerservices@skygenusa.com?

Allow?up?to?six?weeks?for?the?EFT?program?to?be?implemented?after?we?receive?your?completed?
paperwork.?Once?you?are?enrolled?in?the?EFT?program,?you?will?no?longer?receive?paper?
remittance?statements?through?postal?mail.?Instead,?your?Remittance?Reports?will?be?posted?
online?and?made?available?from?the?Provider?Web?Portal?as?soon?as?your?claims?are?paid:?
pwp.sciondental.com.?
Once?you?are?enrolled?in?the?EFT?program,?notify?us?of?any?changes?to?bank?accounts,?including?
changes?in?Routing?Number?or?Account?Number,?or?if?you?switch?to?a?different?bank.?Use?the?EFT?
Authorization?Agreement?form?to?submit?your?changes.?Allow?up?to?three?weeks?for?changes?to?
be?implemented?after?we?receive?your?change?request.?Horizon?NJ?Health?is?not?responsible?for?
delays?in?payment?if?we?are?not?properly?notified,?in?writing,?of?banking?changes.?
Electronic?Remittance?Reports?
If?you?enroll?in?the?Horizon?NJ?Health?EFT?program,?your?Remittance?Reports?will?be?made?
available?automatically?from?the?Provider?Web?Portal.?For?help?registering?for?the?portal?or?
accessing?your?Remittance?Reports,?call?the?Electronic?Outreach?team?at?1?855?434?9239.?
If?you?prefer?to?receive?paper?checks?rather?than?electronic?funds?transfers,?you?can?still?
eliminate?paper?Remittance?Reports?and?access?your?payment?reports?online.?To?have?quick,?
easy?access?to?Remittance?Reports?as?soon?as?your?claims?are?paid,?send?an?email?message?to?
Provider?Services?to?request?online?Remittance?Reports?at?providerservices@skygenusa.com.??
As?soon?as?the?Provider?Services?team?processes?your?request,?paper?Remittance?Reports?will?no?
longer?be?mailed?to?you.?Your?Remittance?Reports?will?be?available?online?through?the?Provider?
Web?Portal.?For?help,?or?for?more?information?about?electronic?Remittance?Reports,?call?the?
Electronic?Outreach?team?at?1?855?434?9239.?? ?



??SKYGEN?USA?|?CONFIDENTIAL?&?PROPRIETARY?|?Horizon?NJ?Health?Dental?Program?|?Effective:?1/1/20?
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EFT?Authorization?Agreement?
A?copy?of?the?Horizon?NJ?Health?EFT?Authorization?Agreement?form?is?included?on?the?following?
page.?The?form?is?also?available?for?download?from?the?Provider?Web?Portal:?
pwp.sciondental.com.?
Be?sure?to?include?a?voided?check?with?the?EFT?Authorization?Agreement.?The?transaction?cannot?
be?processed?without?a?voided?check.?
Send?the?EFT?Authorization?Agreement?form?and?voided?check?to?Horizon?NJ?Health?by?fax?or?
email:?

? Fax:?1?262?721?0722?
? Email:?providerservices@skygenusa.com?

? ?



??SKYGEN?USA?|?CONFIDENTIAL?&?PROPRIETARY?|?Horizon?NJ?Health?Dental?Program?|?Effective:?1/1/20?
32?

Eligibility?&?Member?Services?
The?Horizon?NJ?Health?Dental?Program?offers?dental?coverage?for?children?and?pregnant?women?
enrolled?in?the?State?of?New?Jersey?Medicaid?Program,?and?for?adult?members?with?disabilities,?
special?health?needs,?or?who?qualify?on?the?basis?of?financial?need.??
The?Horizon?NJ?Health?Dental?Program?includes?the?following?Medicaid?plans?and?Fully?
Integrated?Dual?Eligible?Special?Needs?Plans?(FIDE?SNP):??

? NJ?FamilyCare?A?
? NJ?FamilyCare?ABP?
? NJ?FamilyCare?B?
? NJ?FamilyCare?C?(requires?$5?copayment)?
? NJ?FamilyCare?D?(requires?$5?copayment)?
? Managed?Long?Term?Services?&?Supports?(MLTSS)?
? Horizon?NJ?TotalCare?(HMO?D?SNP)?

More?detailed?descriptions?of?these?Medicaid?dental?plans?are?available?in?the?Benefit?Plan?
Details?&?Authorization?Requirements?section?beginning?on?page?120.?
If?your?patients?have?questions?about?how?to?enroll?in?the?Horizon?NJ?Health?Dental?Program,?or?
if?they?have?questions?about?loss?of?eligibility,?refer?them?to?their?local?health?department,?or?ask?
them?to?call?Horizon?NJ?Health?Main?Member?Services?at?1?800?682?9090?(TTY/TDD?711).?
? ?



??SKYGEN?USA?|?CONFIDENTIAL?&?PROPRIETARY?|?Horizon?NJ?Health?Dental?Program?|?Effective:?1/1/20?
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Member?ID?Cards?
Members?enrolled?in?Horizon?NJ?Health?receive?blue?and?white?Horizon?NJ?Health?ID?cards?in?
addition?to?the?New?Jersey?Medicaid?Health?Benefit?ID?card?(HBID)?provided?by?the?State?of?New?
Jersey.?
The?Horizon?NJ?Health?ID?cards?contain?the?following?information:?

? Member?name?
? Member?Medicaid?ID?number?
? Primary?Care?Physician?name?and?phone?number?
? Coverage?effective?date?
? Copayment?amounts?(NJ?FamilyCare?C?and?NJ?FamilyCare?D?only)?
? Status?of?member?dental?coverage?(covered?or?not?covered)?
? Mailing?address?for?dental?claims?on?the?back?of?the?card?

Participating?providers?are?responsible?for?verifying?that?members?are?eligible?when?services?are?
rendered?and?for?determining?whether?members?have?other?health?insurance.?Because?it?is?
possible?for?a?member?s?eligibility?status?to?change?at?any?time?without?notice,?presenting?ID?
cards?does?not?guarantee?a?member?s?eligibility,?nor?does?it?guarantee?provider?payment.?
Horizon?NJ?Health?recommends?each?dental?office?make?a?photocopy?of?the?member?s?ID?card?
each?time?treatment?is?provided.?Horizon?NJ?Health?dentists?may?disregard?the?Horizon?NJ?Health?
codes?280,?780,?or?YHZ?prefixes?before?the?Member?Medicaid?ID?number.??

Presenting?a?Horizon?NJ?Health?ID?card?and?
New?Jersey?Medicaid?Health?Benefit?ID?card?
(HBID)?does?not?guarantee?that?a?person?is?
currently?eligible?for?benefits?in?the?Horizon?
NJ?Health?Dental?Program.?

? ?



??SKYGEN?USA?|?CONFIDENTIAL?&?PROPRIETARY?|?Horizon?NJ?Health?Dental?Program?|?Effective:?1/1/20?
34?

Sample?Horizon?NJ?Health?Member?ID?Cards??
NJ?FamilyCare?

?
Managed?Long?Term?Services?and?Supports?(MLTSS)?

?
Horizon?NJ?TotalCare?(HMO?D?SNP)?

? ?



??SKYGEN?USA?|?CONFIDENTIAL?&?PROPRIETARY?|?Horizon?NJ?Health?Dental?Program?|?Effective:?1/1/20?
35?

Verifying?Member?Eligibility?
To?verify?member?eligibility,?you?can:??

? Log?on?to?Provider?Web?Portal?at?pwp.sciondental.com.?
? Call?Interactive?Voice?Response?(IVR)?eligibility?line?at?1?844?275?8753.?
? Call?Horizon?NJ?Health?Main?Provider?Services?at?1?800?682?9091?

The?Provider?Web?Portal?and?IVR?system?are?both?available?24?hours?a?day,?seven?days?a?week???
giving?you?quick?access?to?information?without?requiring?you?to?wait?for?an?available?Customer?
Service?Representative?during?business?hours.?

Because?a?member?s?eligibility?can?change?
at?any?time?without?prior?notice,?verifying?
eligibility?does?not?guarantee?payment.?

Verifying?Eligibility?via?Provider?Web?Portal?
Our?Provider?Web?Portal?allows?quick,?accurate?verification?of?a?member?s?eligibility?for?covered?
benefits,?as?of?the?date?of?service.?Log?in?using?your?User?ID?and?password?at?
pwp.sciondental.com.?First?time?users?should?contact?the?Electronic?Outreach?Team?at?1?855?
434?9239?to?register?on?the?Provider?Web?Portal.?
For?help?registering?or?using?the?Provider?Web?Portal,?call?the?Electronic?Outreach?Team?at?1?855?
434?9239.?
Once?logged?in,?you?can?quickly?verify?eligibility?for?an?individual?patient?or?for?a?group?of?
patients,?and?you?can?print?an?online?eligibility?summary?report?for?your?records.??
? ?



??SKYGEN?USA?|?CONFIDENTIAL?&?PROPRIETARY?|?Horizon?NJ?Health?Dental?Program?|?Effective:?1/1/20?
36?

Verifying?Eligibility?via?IVR??
Use?our?Interactive?Voice?Response?(IVR)?system?to?verify?eligibility?for?an?unlimited?number?of?
patients.?Call?1?844?275?8753?and?follow?the?prompts?to?identify?yourself?and?the?patient?whose?
eligibility?you?are?verifying.??
Our?system?analyzes?the?information?entered?and?verifies?the?patient?s?eligibility.?If?the?system?
cannot?verify?the?member?information,?you?will?be?transferred?to?a?Customer?Service?
Representative.?You?also?have?the?option?of?transferring?to?a?Customer?Service?Representative?
after?completing?eligibility?checks,?if?you?have?other?inquiries.?
Specialist?Referrals?
A?patient?who?requires?a?referral?to?a?dental?specialist?can?be?referred?directly?to?any?specialist?
contracted?with?the?Horizon?NJ?Health?Dental?Program?provider?network?without?authorization?
from?Horizon?NJ?Health.?The?dental?specialist?is?responsible?for?obtaining?prior?authorization?for?
services,?as?defined?in?the?Benefit?Plan?Details?&?Authorization?Requirements?section?of?this?
provider?manual?on?page?120.??
If?you?are?unfamiliar?with?the?contracted?specialty?network?for?the?Horizon?NJ?Health?Dental?
Program?or?need?help?locating?a?specialist?provider,?call?Provider?Services?at?1?855?878?5368.?
Appointment?Availability?Standards?
The?Horizon?NJ?Health?Dental?Program?has?established?appointment?time?requirements?to?
ensure?patients?receive?dental?services?within?a?time?period?appropriate?to?their?health?
condition.?We?expect?dental?providers?to?meet?these?appointment?standards?for?a?number?of?
important?reasons,?including:?

? Ensure?patients?receive?the?care?they?need?to?protect?their?health.?
? Maintain?member?satisfaction.?
? Reduce?unnecessary?use?of?alternative?services?such?as?emergency?room?visits.?

Dentists?are?expected?to?meet?the?following?minimum?standards?for?appointment?availability:?
? Routine?appointments.?Routine?preventive?care?and?follow?up?appointments?must?be?

scheduled?within?four?weeks.?Participating?dentists?must?be?available?at?any?time?via?
answering?service?or?covering?dentist.?

? Specialist?referrals.?Specialty?care?appointments?must?be?scheduled?within?60?days?of?
initial?referral?from?the?patient?s?primary?or?general?dentist?or?more?quickly,?if?deemed?
necessary?by?the?primary?dentist.?

? Urgent?care.?Appointments?for?urgently?needed?care?must?be?made?available?within?72?
hours.?

? Emergency?situation.?Provide?care?immediately.?
? ?



??SKYGEN?USA?|?CONFIDENTIAL?&?PROPRIETARY?|?Horizon?NJ?Health?Dental?Program?|?Effective:?1/1/20?
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Horizon?NJ?Health?has?an?ongoing?monitoring?program?in?place?to?ensure?dental?offices?are?
meeting?standards?for?appointment?availability.?Non?compliance?may?result?in?a?Corrective?
Action?Program?(CAP)?for?providers.?
Summary:?Appointment?Availability?Standards?
Appointment?Type? Required?Appointment?Timeline?
Emergency? Provide?care?immediately?
Urgent?dental?care? Within?72?hours?
Specialist?referral? Within?60?days,?or?sooner,?per?request?from?referring?

dentist?
Routine?preventive,?follow?up?visits? Within?four?weeks?

After?Hours?Calls?and?Coverage??
A?true?dental?emergency?is?a?specific?condition?of?the?oral?cavity?or?contiguous?tissues?that?
causes?severe?or?intractable?pain,?and?could?compromise?the?life,?health,?or?safety?of?the?
member?unless?treated?immediately.??
Emergency?symptoms?may?include?the?following:??

? Pain?or?acute?infection?from?a?restorable?or?not?restorable?tooth?
? Pain?resulting?from?injuries?to?the?oral?cavity?and?related?structures?
? Extensive,?abnormal?bleeding?
? Fractures?of?the?maxilla,?mandible,?or?related?structures,?as?well?as?dislocation?of?the?

mandible?
If?members?experience?any?of?these?conditions?or?life?threating?situations,?they?should?go?to?the?
emergency?room?at?their?local?hospital.?Without?a?life?threatening?situation,?members?with?a?
sore?throat,?pain?in?the?ear,?etc.,?should?not?seek?emergency?room?care.??
All?after?hours?calls?for?dental?emergencies?are?handled?by?Horizon?NJ?Health?Main?Member?
Services?between?5?p.m.?and?8?a.m.?ET?at?1?609?203?7095.?Requests?are?routed?to?the?
appropriate?after?hours?Horizon?NJ?Health?nurse?via?the?after?hours?cell?phone.?

Response?Time?Requirements?
All?general?dentists?and?specialty?care?dentists?must?be?available?to?Horizon?NJ?Health?members?
24?hours?a?day,?seven?days?a?week,?as?stated?in?the?contractual?agreement.?General?dentists?and?
specialists?should?make?arrangements?with?an?answering?service?to?receive?calls?during?off?
hours.?Providers?must?respond?to?after?hours?telephone?calls?regarding?dental?care?within?15?
minutes?for?crisis?situations;?45?minutes?for?non?emergent,?symptomatic?issues;?and?same?day?
for?asymptomatic?concerns.??
? ?



??SKYGEN?USA?|?CONFIDENTIAL?&?PROPRIETARY?|?Horizon?NJ?Health?Dental?Program?|?Effective:?1/1/20?
38?

Response?times?are?contractually?required?and?monitored?by?Horizon?NJ?Health.?If?a?general?
dentist?or?specialist?is?identified?as?noncompliant,?we?make?every?effort?to?educate?the?dentist?
about?response?policies.?Continued?noncompliance?may?result?in?a?Corrective?Action?Program.?
For?information?about?Corrective?Action?Programs?to?address?noncompliance,?contact?Horizon?NJ?
Health?at?1?800?682?9094.?

Summary:?After?Hours?Call?Response?Standards?
After?Hours?Call?Type? Required?Response?Timeline?
Emergency?services? Within?15?minutes?
Non?emergent,?symptomatic?issues? Within?45?minutes?
Asymptomatic?concerns? Within?the?same?day?

Missed?Appointments??
Providers?who?participate?in?the?Horizon?NJ?Health?Dental?Program?are?not?allowed?to?charge?
members?for?missed?appointments.?
If?your?office?sends?letters?or?postcards?to?members?who?miss?appointments,?the?following?
language?may?be?helpful?to?include:?

? ?We?missed?you?when?you?did?not?come?for?your?dental?appointment?on?Month/Date.?
Regular?checkups?are?needed?to?keep?your?teeth?healthy.?Call?us?to?schedule?another?
appointment.??

? ?Please?call?to?reschedule?another?dental?appointment.?Call?us?in?advance?if?you?cannot?
keep?the?appointment.?Missed?appointments?are?very?costly?to?us.?Thank?you?for?your?
help.??

The?Centers?for?Medicare?&?Medicaid?Services?(CMS)?interpret?federal?law?to?prohibit?a?provider?
from?billing?any?Medicaid?Plan?member?for?a?missed?appointment.?In?addition,?your?missed?
appointment?policy?for?members?enrolled?in?the?Horizon?NJ?Health?Dental?Program?cannot?be?
stricter?than?your?policy?for?private?or?commercial?patients.?
If?a?Horizon?NJ?Health?Dental?Program?member?exceeds?your?office?policy?for?missed?
appointments?and?you?choose?to?discontinue?seeing?the?patient,?ask?them?to?contact?Horizon?NJ?
Health?for?a?referral?to?another?dentist.?
? ?



??SKYGEN?USA?|?CONFIDENTIAL?&?PROPRIETARY?|?Horizon?NJ?Health?Dental?Program?|?Effective:?1/1/20?
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Payment?for?Non?Covered?Services?
Non?covered?services?are?any?procedures?deemed?outside?the?benefit?package?per?our?dental?
consultants,?including?those?with?primarily?cosmetic?purposes?and?those?without?dental?
necessity.?
Horizon?NJ?Health?allows?medical?and?dental?supplies,?equipment,?and?other?devices?essential?to?
treat?member?conditions?unless?otherwise?available?at?no?charge?from?community?services?(such?
as?the?American?Cancer?Society?or?other?service?organizations).?
Standard?toothbrushes,?dental?floss,?and?like?items?are?considered?personal?hygiene?items?and?
not?covered?by?the?program.??

Providers?must?inform?patients?in?advance?
and?in?writing?when?a?member?is?
responsible?for?non?covered?services.?

Enrolled?participating?providers?shall?hold?members?and?the?Horizon?NJ?Health?Dental?Program?
harmless?for?the?payment?of?non?covered?services?except?as?provided?in?this?paragraph.?A?provider?
may?bill?a?patient?for?non?covered?services?if?the?provider?obtains?written?agreement?from?the?
patient?in?advance,?before?rendering?the?service.?The?written?agreement?must?indicate:??

? The?services?to?be?provided?(CDT?code);?
? The?Horizon?NJ?Health?Dental?Program?will?not?pay?for?or?be?liable?for?these?services;?and?
? Patient?will?be?financially?liable?for?such?services.?

? ?



??SKYGEN?USA?|?CONFIDENTIAL?&?PROPRIETARY?|?Horizon?NJ?Health?Dental?Program?|?Effective:?1/1/20?
40?

Prior?Authorization?&?
Documentation?Requirements?
Prior?Authorization?for?Treatment?
The?Horizon?NJ?Health?Dental?Program?has?specific?utilization?criteria,?as?well?as?a?prior?authorization?
review?process,?to?manage?the?utilization?of?services.?Whether?prior?authorization?is?required?for?a?
particular?service,?and?whether?supporting?documentation?is?also?required,?is?defined?in?this?provider?
manual?in?Benefit?Plan?Details?&?Authorization?Requirements?beginning?on?page?120.?
Non?emergency?services?requiring?prior?authorization?should?not?be?started?until?the?
authorization?request?is?reviewed?and?approved?by?a?Horizon?NJ?Health?Dental?Consultant.?Non?
emergency?treatment?started?prior?to?the?determination?of?coverage?will?be?performed?at?the?
financial?risk?of?the?dental?office.?If?coverage?is?denied,?the?treating?dentist?will?be?financially?
responsible?and?may?not?balance?bill?the?member?or?the?Horizon?NJ?Health?Dental?Program.?
Should?a?procedure?need?to?be?initiated?to?relieve?pain?and?suffering?in?an?emergency?situation,?
you?must?provide?treatment?to?alleviate?the?patient?s?condition.?For?more?details?regarding?
emergency?services,?see?Emergency?Treatment?on?page?84.?
Submit?requests?for?prior?authorization?online?through?the?Provider?Web?Portal?
(pwp.sciondental.com),?electronically?in?a?HIPAA?compliant?data?file,?or?via?postal?mail?on?a?paper?
ADA?Dental?Claim?Form.?(See?? ?



??SKYGEN?USA?|?CONFIDENTIAL?&?PROPRIETARY?|?Horizon?NJ?Health?Dental?Program?|?Effective:?1/1/20?
41?

Authorization?Submission?Procedures?on?page?45.)?Any?authorizations?submitted?without?the?
required?documentation?will?be?denied?and?must?be?resubmitted?for?determination.?
Do?not?submit?duplicate?authorizations.?Submitting?duplicate?authorizations?results?in?automated?
system?denials,?slower?claims?processing,?and?delayed?claims?payment.??
Horizon?NJ?Health?will?make?a?decision?on?a?request?for?prior?authorization?within?10?business?
days?from?the?date?we?receive?the?request,?provided?all?information?is?complete.?
Horizon?NJ?Health?will?honor?prior?authorizations?for?365?days?from?the?date?they?are?
determined.?An?authorization?does?not?guarantee?payment.?The?member?must?be?eligible?for?
benefits?at?the?time?services?are?provided.?Horizon?NJ?Health?reviewers?and?licensed?dental?
consultants?approve?or?deny?authorization?requests?based?on?whether:?

? The?item?or?service?is?medically?necessary.?
? A?less?expensive?service?would?adequately?meet?the?member?s?needs.?
? The?proposed?item?or?service?conforms?to?commonly?accepted?standards?in?the?dental?

community.?
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.?
? ?



??SKYGEN?USA?|?CONFIDENTIAL?&?PROPRIETARY?|?Horizon?NJ?Health?Dental?Program?|?Effective:?1/1/20?
42?

Dental?Treatment?Plan?
Following?a?comprehensive?examination?and?per?good?dental?practice,?providers?should?develop?
and?describe?a?treatment?plan?for?each?patient?on?the?current?ADA?Claim?Form.?Horizon?NJ?
Health?Dental?Consultants?may?review?any?dental?treatment?plan,?including?those?not?requiring?
prior?authorization.?
When?prior?authorization?is?necessary,?a?Horizon?NJ?Health?Dental?Consultant?may?deny?the?
dentist?s?treatment?plan?when?the?treatment?is?not?comprehensive?and/or?is?missing?appropriate?
supporting?documentation.??The?comprehensive?treatment?plan?must?be?based?on?the?New?
Jersey?Administrative?Code?10:56?and?the?State?Clinical?Criteria?Guidelines.?The?treatment?plan?
must?be?designed?to?provide?adequate?dental?treatment?to?correct?problems,?last?for?the?longest?
period?of?time,?and?represent?an?efficient?allocation?of?Horizon?NJ?Health?resources.?If?the?
professional?judgment?of?the?dentist?determines?the?denied?treatment?plan?is?appropriate?for?
the?member,?the?provider?may?appeal?the?denied?authorization.?
For?any?dental?treatment?plan,?the?dentist?must?discuss?the?proposed?treatment?and?receive?
approval?from?the?member?and/or?their?family?member?or?guardian?before?submission?for?
authorization?and?before?starting?treatment.?Horizon?NJ?Health?encourages?providers?to?get?
formal?approval?of?the?treatment?plan?with?a?member?signature?on?office?records?or?in?a?
separate?statement.?No?alteration?of?the?treatment?plan?is?reimbursed?based?on?subsequent?
rejection?of?all?or?part?of?plan?by?the?member,?family?member,?or?guardian.?
Following?post?utilization?review,?Horizon?NJ?Health?Dental?Consultants?may?review?any?dental?
treatment?plan?including?those?not?requiring?prior?authorization?to?determine?
appropriateness?of?treatment.?If?the?treatment?is?not?appropriate,?the?payment?may?be?
recovered.?
Authorization?for?a?dental?treatment?plan?does?not?guarantee?eligibility?for?payment?under?the?
Horizon?NJ?Health?Dental?Program.?Horizon?NJ?Health?recommends?providers?check?eligibility?on?
the?first?visit?of?each?month?through?the?Provider?Web?Portal?or?by?calling?Horizon?NJ?Health?
Main?Provider?Services?at?1?800?682?9091.?
Dental?OR/ASC?Services??
Dental?services?that?are?to?be?performed?outside?your?office,?either?in?an?outpatient?department?
of?a?hospital?or?at?an?ambulatory?surgical?center?(ASC),?must?be?approved?by?Horizon?NJ?Health?
to?ensure?the?services?meet?the?medical?necessity?criteria?for?services?rendered?in?an?outpatient?
facility?(hospital?or?ASC).?See?? ?



??SKYGEN?USA?|?CONFIDENTIAL?&?PROPRIETARY?|?Horizon?NJ?Health?Dental?Program?|?Effective:?1/1/20?
43?

Authorization?Submission?Procedures?on?page?45?and?Hospital?Calls?on?page?89.?
? ?



??SKYGEN?USA?|?CONFIDENTIAL?&?PROPRIETARY?|?Horizon?NJ?Health?Dental?Program?|?Effective:?1/1/20?
44?

Appealing?an?Authorization?Decision?
If?you?have?questions?about?a?prior?authorization?decision?or?wish?to?speak?to?the?dental?
reviewer,?call?Provider?Services?at?1?855?878?5368.?For?more?about?utilization?management?
appeals,?see?Utilization?Management/Authorization?Appeal?on?page?61.?
If?Horizon?NJ?Health?denies?approval?for?any?requested?service,?the?member?will?receive?written?
notice?of?the?reasons?for?each?denial?and?will?be?notified?of?how?to?appeal?the?decision.?The?
requesting?provider?will?also?receive?notice?of?the?decision.??
To?appeal?an?authorization?decision,?submit?the?appeal?in?writing?along?with?any?necessary?
documentation?within?90?days?of?the?original?determination?date?to:?

Horizon?NJ?Health:?Complaints/Appeals?
PO?Box?295?
Milwaukee,?WI?53201?

Summary:?Prior?Authorization?Timelines?
Authorization?Request? Timeline?
Decision?on?authorization?request? Horizon?NJ?Health?approves?or?denies?request?within?

10?business?days.?
Prior?authorization?expiration? Horizon?NJ?Health?honors?approved?prior?

authorizations?for?365?calendar?days?from?decision?
date.?

Authorization?decision?appeal?Members? Members?must?appeal?within?90?days?of?the?original?
authorization?denial?date.?

Authorization?decision?appeal?Providers? Providers?must?appeal?within?90?days?of?the?original?
authorization?denial?date.?
Providers?must?have?the?member?s?written?consent?
to?appeal?a?decision?on?the?member?s?behalf.?

UM/Authorization?appeal?decision?Non?
expedited?(Internal)?

Horizon?NJ?Health?renders?decision?within?30?
calendar?days?of?receiving?the?appeal.?

UM/Authorization?appeal?decision?Expedited?
(Internal)?

Horizon?NJ?Health?renders?decision?within?72?hours?
of?receiving?the?expedited?appeal.?

? ?



??SKYGEN?USA?|?CONFIDENTIAL?&?PROPRIETARY?|?Horizon?NJ?Health?Dental?Program?|?Effective:?1/1/20?
45?

Authorization?Submission?
Procedures?
Horizon?NJ?Health?accepts?authorizations?submitted?in?any?of?the?following?formats:?

? Provider?Web?Portal?at?pwp.sciondental.com?
? Electronic?submission?via?clearinghouse,?Payer?ID:?22099?
? HIPAA?compliant?837D?file?
? Paper?ADA?Dental?Claim?Form,?available?from?the?American?Dental?Association??

Submitting?Authorizations?via?Provider?Web?Portal?
Providers?may?submit?authorizations?along?with?any?required?treatment?documentation?directly?
to?Horizon?NJ?Health?through?our?Provider?Web?Portal?at?pwp.sciondental.com.??
Submitting?authorizations?via?the?web?portal?has?several?significant?advantages:?

? The?online?dental?form?has?built?in?features?that?automatically?verify?member?eligibility,?
pre?fill?the?authorization?form?with?member?information,?and?make?data?entry?quick?and?
easy.?

? The?online?authorization?process?steps?you?through?clinical?guidelines,?when?applicable,?
giving?you?a?quick?indication?of?how?your?authorization?request?will?be?evaluated?and?
whether?it?s?likely?to?be?approved.?(Successfully?completing?a?clinical?guideline?does?not?
guarantee?payment.)?

? The?online?authorization?process?indicates?whether?supporting?documentation?is?
required?and?allows?you?to?attach?and?send?documents?as?part?of?the?authorization?
request?for?no?charge.?

? Dental?reviewers?and?consultants?receive?your?authorization?requests?and?supporting?
documentation?as?soon?as?you?submit?them?online?which?means?you?receive?decisions?
faster.?

? As?soon?as?an?authorization?is?determined,?its?status?is?instantly?updated?online?and?
available?for?review.?You?don?t?have?to?wait?for?a?letter?to?find?out?whether?your?
authorization?request?is?approved.?

If?you?have?questions?about?submitting?authorizations?online,?attaching?electronic?documents,?or?
accessing?the?Provider?Web?Portal,?call?the?Electronic?Outreach?Team?at?1?855?434?9239.?
? ?



??SKYGEN?USA?|?CONFIDENTIAL?&?PROPRIETARY?|?Horizon?NJ?Health?Dental?Program?|?Effective:?1/1/20?
46?

Submitting?Authorizations?via?Clearinghouses?
Providers?may?submit?electronic?claims?and?authorizations?to?Horizon?NJ?Health?directly?via?
either?the?Change?Healthcare?(formerly?Emdeon)?or?DentalXChange?clearinghouses.?If?you?use?a?
different?clearinghouse,?your?software?vendor?can?provide?you?with?information?you?may?need?
to?ensure?electronic?files?are?forwarded?to?Horizon?NJ?Health.?
The?Horizon?NJ?Health?Payer?ID?is?22099.?By?using?this?unique?Payer?ID?with?electronic?files,?
Change?Healthcare?(formerly?Emdeon)?and?DentalXChange?can?ensure?that?claims?and?
authorizations?are?submitted?successfully?to?Horizon?NJ?Health.?
For?more?information?about?Change?Healthcare?(formerly?Emdeon)?and?DentalXChange,?visit?
their?websites:?changehealthcare.com?and?dentalxchange.com.?
Submitting?Authorizations?via?837D?File?
If?you?can?t?submit?claims?and?authorizations?electronically?through?the?Provider?Web?Portal?or?a?
clearinghouse,?Horizon?NJ?Health?will?work?with?you?individually?to?receive?electronic?files?
submitted?using?the?HIPAA?Compliant?837D?transaction?set?format.?To?inquire?about?this?option,?
call?Provider?Services?at?1?855?878?5368.??
Attaching?Electronic?Documents?
If?you?use?the?Provider?Web?Portal?(pwp.sciondental.com),?you?can?quickly?and?easily?send?
electronic?documents?as?part?of?submitting?a?claim?or?authorization?for?no?charge.??
Horizon?NJ?Health?also?accepts?dental?radiographs?and?other?documents?electronically?via?Fast?
Attach??for?authorization?requests.?For?more?information,?visit?nea?fast.com?or?call?the?National?
Electronic?Attachment,?Inc.?(NEA)?at?1?800?782?5150.?
Submitting?Authorizations?on?Paper?Forms?
To?ensure?timely?processing?of?submitted?authorizations,?the?following?information?must?be?
included?on?the?current?ADA?Dental?Claim?Form:??

? Member?Name?
? Member?Medicaid?ID?Number??
? Member?Date?of?Birth?
? Provider?Name?
? Provider?Location?
? Billing?Location?
? Provider?NPI??
? Payee?Tax?Identification?Number?(TIN)?

? ?



??SKYGEN?USA?|?CONFIDENTIAL?&?PROPRIETARY?|?Horizon?NJ?Health?Dental?Program?|?Effective:?1/1/20?
47?

Use?approved?ADA?dental?codes,?as?published?in?the?current?CDT?book?or?as?defined?in?this?
manual,?to?identify?all?services.?Include?on?the?form:?all?quadrants,?tooth?numbers,?and?surfaces?
for?dental?codes?that?require?identification?(extractions,?root?canals,?amalgams,?and?resin?fillings).??
Horizon?NJ?Health?recognizes?tooth?letters?A?through?T?for?primary?teeth?and?tooth?numbers?1?to?
32?for?permanent?teeth.?Designate?supernumerary?teeth?with?codes?AS?through?TS?or?51?through?
82.?Designation?of?the?tooth?can?be?determined?by?using?the?nearest?erupted?tooth.?If?the?tooth?
closest?to?the?supernumerary?tooth?is?1,?then?chart?the?supernumerary?tooth?as?51.?Likewise,?if?
the?nearest?tooth?is?A,?chart?the?supernumerary?tooth?as?AS.??
Missing,?incorrect,?or?illegible?information?could?result?in?the?authorization?being?returned?to?the?
submitting?provider?s?office,?causing?a?delay?in?determination.?Use?the?proper?postage?when?
mailing?bulk?documentation.?Mail?with?postage?due?will?be?returned.??
No?X?Ray?Return?Policy.?Providers?should?maintain?copies?of?all?dental?prior?authorization?forms?
and?supporting?documentation,?including?X?rays.?X?rays?and?other?documentation?are?shredded?
and?not?returned.?
Mail?paper?authorizations?to:?

Horizon?NJ?Health:?Authorizations?
PO?Box?362?
Milwaukee,?WI?53201?

Duplicate?Authorizations?Automatically?Denied?
Do?not?submit?duplicate?authorizations.?Submitting?duplicate?authorization?incurs?unnecessary?
administrative?costs?for?providers.?When?authorizations?are?processed,?they?are?automatically?
checked?to?verify?required?documentation?is?on?file.?Approved?authorizations?are?then?
automatically?matched?against?corresponding?claims,?ensuring?claims?are?paid?accurately?and?
efficiently.?Duplicate?authorizations?are?automatically?denied?and?result?in?slower?claims?
processing?and?delayed?claims?payment.??
For?the?fastest,?most?efficient?authorization?determinations?and?claim?payments,?be?sure?to:?

? Submit?just?one?original?authorization?with?all?required?documentation?attached,?and??
? Include?a?comprehensive?treatment?plan?because?a?fragmented?plan?will?be?denied.?



??SKYGEN?USA?|?CONFIDENTIAL?&?PROPRIETARY?|?Horizon?NJ?Health?Dental?Program?|?Effective:?1/1/20?
48?

ADA?Approved?Dental?Claim?Form?

?



??SKYGEN?USA?|?CONFIDENTIAL?&?PROPRIETARY?|?Horizon?NJ?Health?Dental?Program?|?Effective:?1/1/20?
49?

?
?



??SKYGEN?USA?|?CONFIDENTIAL?&?PROPRIETARY?|?Horizon?NJ?Health?Dental?Program?|?Effective:?1/1/20?
50?

Claim?Submission?Procedures?
Horizon?NJ?Health?accepts?claims?submitted?in?any?of?the?following?formats:?

? Provider?Web?Portal?at?pwp.sciondental.com?
? Electronic?submission?via?clearinghouse,?Payer?ID:?22099?
? HIPAA?compliant?837D?file?
? Paper?ADA?Dental?Claim?Form,?available?from?the?American?Dental?Association??

Submitting?Claims?via?Provider?Web?Portal?
Providers?may?submit?claims?directly?to?Horizon?NJ?Health?through?the?Provider?Web?Portal?at?
pwp.sciondental.com.?Submitting?claims?via?the?web?portal?has?several?significant?advantages:?

? The?online?dental?form?has?built?in?features?that?automatically?verify?member?eligibility,?
pre?fill?the?claim?form?with?member?information,?and?make?data?entry?quick?and?easy.?

? The?online?process?allows?you?to?attach?and?send?electronic?documents?as?part?of?
submitting?a?claim?for?no?charge.?

? Before?submitting?a?claim?or?before?rendering?services?you?can?generate?an?online?
claim?estimate?to?find?out?how?much?you?are?likely?to?be?paid?or?whether?your?claim?may?
be?denied?and?the?reasons?why.?

? Claims?enter?our?benefits?administration?system?faster?which?means?you?receive?
payment?faster.?

? As?soon?as?a?claim?is?paid,?its?status?is?instantly?updated?online,?and?a?Remittance?Report?
is?available?for?review.??

If?you?have?questions?about?submitting?claims?online,?attaching?electronic?documents,?or?
accessing?the?Provider?Web?Portal,?call?the?Electronic?Outreach?Team?at?1?855?434?9239.??
Submitting?Claims?via?Clearinghouses?
Providers?may?submit?electronic?claims?and?authorizations?to?Horizon?NJ?Health?directly?via?
either?the?Change?Healthcare?(formerly?Emdeon)?or?DentalXChange?clearinghouses.?If?you?use?a?
different?clearinghouse,?your?software?vendor?can?provide?you?with?information?you?may?need?
to?ensure?electronic?files?are?forwarded?to?Horizon?NJ?Health.?
The?Horizon?NJ?Health?Payer?ID?is?22099.?By?using?this?unique?Payer?ID?with?electronic?files,?
Change?Healthcare?(formerly?Emdeon)?and?DentalXChange?can?ensure?that?claims?and?
authorizations?are?submitted?successfully?to?Horizon?NJ?Health.?
For?more?information?about?Change?Healthcare?(formerly?Emdeon)?and?DentalXChange,?visit?
their?websites?at?changehealthcare.com?and?dentalxchange.com.?
? ?



??SKYGEN?USA?|?CONFIDENTIAL?&?PROPRIETARY?|?Horizon?NJ?Health?Dental?Program?|?Effective:?1/1/20?
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Submitting?Claims?via?HIPAA?Compliant?837D?File?
If?you?can?t?submit?claims?and?authorizations?electronically?through?the?Provider?Web?Portal?or?a?
clearinghouse,?Horizon?NJ?Health?will?work?with?you?individually?to?receive?electronic?files?
submitted?using?the?HIPAA?Compliant?837D?transaction?set?format.?To?inquire?about?this?option,?
call?Provider?Services:?1?855?878?5368.?
Attaching?Electronic?Documents?
If?you?use?the?Provider?Web?Portal?(pwp.sciondental.com),?you?can?quickly?and?easily?send?electronic?
documents?as?part?of?submitting?a?claim?or?authorization?for?no?charge.?Horizon?NJ?Health,?in?
conjunction?with?NEA?(National?Electronic?Attachment,?Inc.),?also?allows?enrolled?providers?to?submit?
documents?electronically?via?FastAttach?.?This?program?allows?secure?transmissions?of?radiographs,?
periodontics?charts,?intraoral?pictures,?narratives,?and?Explanation?of?Benefits?(EOBs).?FastAttach??is?
compatible?with?most?claims?clearinghouses?and?practice?management?systems.?For?more?
information,?visit?nea?fast.com?or?call?NEA?at?1?800?782?5150.?
Submitting?Claims?on?Paper?Forms?
To?ensure?timely?processing?of?paper?claims,?the?following?information?must?be?included?on?the?
current?ADA?Dental?Claim?Form:??

? Member?Name?
? Member?Medicaid?ID?Number??
? Member?Date?of?Birth?
? Provider?Name?
? Provider?Location?
? Billing?Location?
? Provider?NPI??
? Payee?Tax?Identification?Number?(TIN)?
? Date?of?Service?for?each?service?line?

Use?approved?ADA?dental?codes,?as?published?in?the?current?CDT?book?or?as?defined?in?this?
manual,?to?identify?all?services.?Include?on?the?form:?all?quadrants,?tooth?numbers,?and?surfaces?
for?dental?codes?that?require?identification?(extractions,?root?canals,?amalgams?and?resin?fillings).??
Horizon?NJ?Health?recognizes?tooth?letters?A?through?T?for?primary?teeth?and?tooth?numbers?1?to?
32?for?permanent?teeth.?Designate?supernumerary?teeth?with?codes?AS?through?TS?or?51?through?
82.?Designation?of?the?tooth?can?be?determined?by?using?the?nearest?erupted?tooth.?If?the?tooth?
closest?to?the?supernumerary?tooth?is?1,?then?chart?the?supernumerary?tooth?as?51.?Likewise,?if?
the?nearest?tooth?is?A,?chart?the?supernumerary?tooth?as?AS.?Missing,?incorrect,?or?illegible?
information?could?result?in?the?claim?being?returned?to?the?submitting?provider?s?office,?causing?a?
delay?in?payment.?Use?the?proper?postage?when?mailing?bulk?documentation.?Mail?with?postage?
due?will?be?returned.?Mail?paper?claims?to:?

Horizon?NJ?Health:?Claims?
PO?Box?299?
Milwaukee,?WI?53201? ?



??SKYGEN?USA?|?CONFIDENTIAL?&?PROPRIETARY?|?Horizon?NJ?Health?Dental?Program?|?Effective:?1/1/20?
52?

Coordination?of?Benefits?(COB)?
The?Horizon?NJ?Health?Dental?Program?is?the?payer?of?last?resort.?When?a?member?arrives?for?an?
appointment,?always?ask?if?they?have?other?dental?insurance?coverage.??
When?the?Horizon?NJ?Health?Dental?Program?is?the?secondary?insurance?carrier,?submit?a?copy?of?
the?primary?carrier?s?Explanation?of?Benefits?(EOB)?with?the?claim.?For?electronic?claim?
submissions,?indicate?the?payment?made?by?the?primary?carrier?in?the?appropriate?Coordination?
of?Benefits?(COB)?field,?and?attach?an?electronic?copy?of?the?EOB.??
When?a?primary?carrier?s?payment?meets?or?exceeds?a?provider?s?contracted?rate?or?fee?
schedule,?the?Horizon?NJ?Health?Dental?Program?will?consider?the?claim?paid?in?full?and?no?
further?payment?will?be?made?on?the?claim.?
Timely?Filing?Limits?
Horizon?NJ?Health?must?receive?claims?requesting?payment?within?180?calendar?days?from?the?
date?of?service.?Claims?submitted?more?than?180?calendar?days?from?the?date?of?service?will?be?
denied?for??untimely?filing.??If?a?claim?is?denied?for?untimely?filing,?you?may?not?bill?the?member.??
Timely?filing?for?corrected?claim?submissions?is?365?days?from?the?date?of?service.?
Corrected?Claim?Process?
If?a?claim?or?a?service?line?is?denied?because?information?was?missing?from?the?submitted?claim,?
or?if?you?have?additional?information?or?documentation?that?you?believe?may?change?the?
payment?decision,?simply?resubmit?the?claim?and?include?the?missing?information.??
For?example,?resubmit?a?claim?with?additional?information?if?a?service?was?denied?because?of?a?
missing?tooth?number?or?surface,?or?if?a?claim?was?denied?because?documentation?showing?
medical?necessity?was?not?originally?submitted.?
However,?if?a?service?line?on?a?claim?was?paid?that?should?not?have?been?paid?or?if?a?claim?was?
paid?to?the?wrong?payee?or?on?behalf?of?the?wrong?member,?then?submit?a?new??Corrected??
claim?to?reverse?the?incorrect?payment?and?reprocess?the?claim?with?the?corrected?information.??
For?example,?if?a?claim?is?submitted?and?paid?with?the?wrong?provider?NPI?or?clinic?location,?
incorrect?payee?Tax?ID,?wrong?member,?incorrect?procedure?code,?etc.,?then?the?paid?claim?must?
be?corrected?and?reprocessed.?
Resubmitting?a?Denied?Claim?
To?resubmit?a?denied?claim?with?additional?supporting?information,?follow?the?standard?Claim?
Submission?Procedures?on?page?50?of?this?provider?manual.?Timely?filing?limitations?apply?when?
a?claim?is?resubmitted?for?reprocessing.?
? ?



??SKYGEN?USA?|?CONFIDENTIAL?&?PROPRIETARY?|?Horizon?NJ?Health?Dental?Program?|?Effective:?1/1/20?
53?

Submitting?a?Corrected?Claim?
To?reverse?and?correct?a?payment?that?should?not?have?been?made,?submit?a?corrected?claim?on?
the?current?ADA?Dental?Claim?Form?via?postal?mail.?

? Identify?the?claim?as?Corrected?by?writing??Corrected??across?the?top?of?a?paper?claim?
form.??

? Identify?the?original?Claim/Encounter?Number?and?the?intended?change?by?writing?them?
in?the?Remarks?section?(Box?35)?on?a?paper?ADA?form.?

? Attach?supporting?documentation,?and?send?documentation?in?the?same?package?with?
the?paper?claim?form.?

Send?paper?forms?and?documents?to:?
Horizon?NJ?Health:?Corrected?Claims?
PO?Box?541?
Milwaukee,?WI?53201?

Receipt?&?Audit?of?Claims?
To?ensure?timely,?accurate?payment?to?each?participating?provider,?Horizon?NJ?Health?audits?
claims?for?completeness?as?they?are?received.?This?audit?validates?member?eligibility,?procedure?
codes,?and?provider?identification?information.?A?Dental?Reimbursement?Analyst?reviews?any?
claim?conditions?that?would?result?in?nonpayment.?When?potential?problems?are?identified,?your?
office?may?be?asked?to?help?resolve?the?issue.?For?questions?about?claims?submission?or?
remittances,?call?Provider?Services?at?1?855?878?5368.?
Claims?Adjudication?&?Payment?
The?Horizon?NJ?Health?software?system?imports?claim?and?authorization?data,?evaluates?and?
edits?the?data?for?completeness?and?correctness,?analyzes?the?data?for?clinical?appropriateness?
and?coding?correctness,?evaluates?services?against?plan?coverage?and?benefit?limits,?calculates?
the?appropriate?payment?amounts,?and?generates?payments?and?remittance?summaries.?The?
system?also?evaluates?and?automatically?matches?claims?and?services?against?prior?authorizations?
and?matches?claims?and?services?to?the?appropriate?member?record?for?efficient?and?accurate?
claims?processing.?
As?soon?as?the?system?prices?and?pays?claims,?checks?and?electronic?payments?are?generated,?
and?remittance?summaries?are?posted?and?available?for?online?review?from?the?Provider?Web?
Portal?at?pwp.sciondental.com.?
To?appeal?a?reimbursement?decision,?submit?the?appeal?in?writing?within?90?calendar?days?of?the?
decision?date,?along?with?any?necessary?documentation?to:?

Horizon?NJ?Health:?Complaints/Appeals?
PO?Box?295?
Milwaukee,?WI?53201?

? ?



??SKYGEN?USA?|?CONFIDENTIAL?&?PROPRIETARY?|?Horizon?NJ?Health?Dental?Program?|?Effective:?1/1/20?
54?

Total?Maximum?Payment?Allowance??
If?a?member?receives?care?from?more?than?one?provider?as?part?of?a?partnership?or?corporation?
in?the?same?discipline?for?the?same?service,?the?total?maximum?payment?allowance?is?the?same?
as?that?for?a?single?attending?dentist.?The?allowance?fee?for?a?given?service?is?considered?full?
payment.?Horizon?NJ?Health?does?not?allow?any?additional?charge?by?the?dentist?or?on?behalf?of?
the?member.?
The?Horizon?NJ?Health?Dental?Program?pays?a?fee?only?for?eligible?services?rendered.?If?a?member?
does?not?complete?the?treatment?plan,?providers?may?bill?only?for?those?services?already?performed.??
Stage?of?Completion??
If?a?provider?cannot?complete?a?service?and/or?an?authorized?appliance?for?a?member?due?to?
circumstances?beyond?their?control,?Horizon?NJ?Health?reimburses?the?provider?an?amount?
consistent?with?the?stage?of?completion?of?the?authorized?service?and/or?appliance.?The?current?
ADA?Claim?Form?must?document?the?stage?of?completion?of?the?service.?For?an?appliance,?
denture,?or?crown,?a?Horizon?NJ?Health?Dental?Consultant?reviews?and?prorates?the?case?
respective?to?the?point?of?completion.?The?case?is?then?sent?to?the?provider?to?retain?for?at?least?
one?year,?pending?the?possible?return?of?the?member.?
Partial?Reimbursement??
Horizon?NJ?Health?may?authorize?partial?reimbursement?for?an?appliance?that?is?completed?but?
not?delivered?to?the?member?due?to?circumstances?beyond?the?control?of?the?provider.?We?
deduct?an?amount?equivalent?to?the?professional?component?for?inserting?and?adjusting?the?
appliance?from?the?total?reimbursement?for?such?an?appliance.?If?the?member?returns?to?the?
provider?and?the?service?is?completed,?the?healthcare?professional?may?request?reimbursement?
for?the?deducted?amount.??
Prorated?Basis?for?Dental?Services?
Horizon?NJ?Health?will?pay?on?a?prorated?basis?for?dental?services?that?have?a?dental?lab?
component,?including?cast?crowns,?fixed?and?removable?prosthetics,?retainers,?and?habit?
appliances?based?on?stage?of?completion,?if?an?enrollee?dies?or?does?not?return?to?complete?
these?services?within?three?months?from?the?last?office?visit?for?that?service.??

? For?cast?restorative?and?fixed?prosthodontics,?the?prorate?shall?be?10?percent?of?the?total?
payment?for?preparation?of?tooth?with?or?without?temporary,?85?percent?of?the?total?
payment?for?impression?and?95?percent?of?the?total?payment?for?completed?not?inserted.??

? For?removable?prosthodontics,?the?prorate?shall?be?10?percent?of?the?total?payment?for?
impression,?55?percent?of?the?total?payment?for?bite?registration,?75?percent?of?the?total?
payment?for??try?in??stage?and?85?percent?of?the?total?payment?for?completed?not?
inserted.??

? For?appliances?and?retainers,?the?prorate?shall?be?10?percent?of?the?total?pay.??
This?information?will?be?available?in?the?Member?Handbook?and?by?visiting?horizonNJhealth.com/for?
providers.? ?



??SKYGEN?USA?|?CONFIDENTIAL?&?PROPRIETARY?|?Horizon?NJ?Health?Dental?Program?|?Effective:?1/1/20?
55?

Missed?Appointments??
Horizon?NJ?Health?does?not?reimburse?for?missed?appointments?and?does?not?allow?a?provider?to?
bill?a?member?for?any?payment.?For?more?information,?see?Missed?Appointments?on?page?38.?
Period?of?Eligibility??
Reimbursement?for?dental?treatment?can?be?made?only?during?the?period?of?member?eligibility.?
However,?exceptions?are?available?under?certain?circumstances.??
Eligibility?Exceptions??
When?authorized?and?in?process?of?being?rendered?for?an?eligible?member,?the?provider?may?bill?
for?the?following?treatments?if?all?services?are?completed?within?60?calendar?days?after?the?
termination?of?a?member?s?eligibility:?

? Prostheses,?such?as?dentures,?crowns,?space?maintainers,?and?appliances,?in?process?of?
fabrication.?

? Extractions?and?ancillary?services,?such?as?general?anesthesia?and?radiographs,?in?
conjunction?with?the?insertion?of?an?immediate?denture?if?initial?impressions?were?taken?
during?a?period?of?eligibility.?

? Endodontic?treatment?with?pulp?extirpated,?as?well?as?those?services?necessary?to?
complete?the?restoration?of?that?tooth,?such?as?filling?restorations?or?post?and?core?and?
crown,?if?authorized?during?a?period?of?eligibility.?

Dentures??
Horizon?NJ?Health?reimburses?for?dentures?furnished?after?termination?of?eligibility?when?the?last?
tooth?in?any?specific?arch?is?extracted?during?a?period?of?eligibility.?

? The?provider?may?furnish?a?complete?or?partial?denture?in?the?opposing?arch?if?it?meets?
the?guidelines?of?the?program?and?is?authorized?in?conjunction?with?such?a?denture.?

? To?receive?reimbursement?for?the?denture,?the?provider?must?initiate?the?primary?
impressions?within?120?days?and?insert?the?denture?within?180?days?after?the?extraction?
of?the?last?tooth.?Prior?authorization?procedures?apply.?

Immediate?Dentures??
For?immediate?dentures,?similar?to?procedures?for?dentures?inserted?after?the?healing?period,?
the?provider?must?obtain?prior?authorization?during?the?eligibility?period?and?complete?all?
preliminary?extractions?within?the?same?time?frame.?The?provider?must?complete?authorized?
complete?or?partial?dentures,?in?conjunction?with?immediate?replacement?codes,?within?180?days?
after?termination?of?eligibility.?

? The?provider?may?furnish?a?complete?or?partial?denture?in?the?opposing?arch?if?it?meets?
the?guidelines?of?the?program?and?is?authorized?in?conjunction?with?such?a?denture.?

? To?receive?reimbursement?for?this?denture,?the?provider?must?initiate?the?primary?
impression?within?120?days?and?insert?the?denture?within?180?days?after?the?last?
preliminary?extraction.?Prior?authorization?procedures?apply.?

? ?



??SKYGEN?USA?|?CONFIDENTIAL?&?PROPRIETARY?|?Horizon?NJ?Health?Dental?Program?|?Effective:?1/1/20?
56?

Third?Party?Liability?(TPL)?
When?available,?the?provider?must?utilize?and?report?any?other?public?or?private?third?party?
sources?of?payment?for?services?rendered?to?members.?As?a?Medicaid?plan,?Horizon?NJ?Health?is?
always?the?payer?of?last?resort.?Submit?all?claims?to?the?appropriate?third?party?first?before?
submitting?claims?to?Horizon?NJ?Health.?
If?the?provider?determines?that?the?third?party?will?neither?pay?nor?provide?the?covered?service,?
and?the?service?is?medically?necessary,?dentists?may?bill?Horizon?NJ?Health?without?a?written?
denial?from?the?third?party.?

? The?provider?must?notify?Horizon?NJ?Health?within?30?days?after?learning?a?member?has?
third?party?health?insurance?coverage?beyond?the?Horizon?NJ?Health?insurance.?Also,?
notify?Horizon?NJ?Health?of?any?casualty?insurance?coverage?or?any?change?in?the?
member?s?health?insurance?coverage.?

? If?a?member?retains?counsel?who?institutes?a?legal?cause?of?action?for?damages?against?a?
third?party,?the?provider?must?notify?Horizon?NJ?Health?in?writing.?This?notification?must?
include?the?member?s?name,?Member?Medicaid?ID?number,?date?of?accident?or?incident,?
nature?of?injury,?name?and?address?of?the?member?s?legal?representative,?copies?of?
pleadings,?and?any?other?document?related?to?the?action?in?possession?of?the?provider.?
This?information?may?include,?but?not?be?limited?to,?data?for?each?date?of?service?on?or?
subsequent?to?the?date?of?the?accident?or?incident,?the?member?diagnosis,?and?the?
nature?of?any?service?provided?to?the?member.?

? Providers?must?notify?Horizon?NJ?Health?within?30?days?of?the?date?when?they?learn?of?
the?death?of?a?Medicaid?member?age?55?or?older,?including?the?member?s?full?name,?
Social?Security?Number,?Member?Medicaid?ID?number,?and?date?of?death.?

? To?maximize?the?collection?of?third?party?payments,?the?provider?must?agree?to?
cooperate?with?Horizon?NJ?Health?and?State?efforts?to?offer?Horizon?NJ?Health?any?
updates?to?the?information?required?in?this?section?of?the?manual.?

? ?



??SKYGEN?USA?|?CONFIDENTIAL?&?PROPRIETARY?|?Horizon?NJ?Health?Dental?Program?|?Effective:?1/1/20?
57?

Complaints,?Grievances?&?
Appeals?
The?Horizon?NJ?Health?Dental?Program?is?committed?to?providing?high?quality?dental?services?to?
all?members.?As?part?of?that?commitment,?we?offer?both?providers?and?members?the?opportunity?
submit?complaints?about?care?or?services?received,?and?to?submit?appeals?requesting?adverse?
decisions?be?reviewed?and?reconsidered.??
Horizon?NJ?Health?provides?both?members?and?providers?a?copy?of?their?appeal?rights?with?each?
pre??or?post?service?denial.?A?designated?Horizon?NJ?Health?Appeals?Specialist?is?dedicated?to?the?
expedient,?satisfactory?resolution?of?both?provider?and?member?complaint?and?appeals.?
Our?procedures?for?handling?and?resolving?complaints?and?appeals?are?designed?to:??

? Ensure?fair,?just,?and?speedy?resolutions?by?working?cooperatively?with?providers?and?
supplying?any?documentation?related?to?complaints?and/or?appeals,?upon?request.?

? Treat?providers?and?members?with?dignity?and?respect?at?all?levels?of?the?complaints?and?
appeals?resolution?process.?

? Inform?providers?and?members?of?their?full?rights?as?they?relate?to?complaint?and?appeal?
resolutions,?including?their?rights?of?appeal?at?each?step?in?the?process.?

? Resolve?complaints?and?appeals?in?a?satisfactory?and?acceptable?manner?within?the?
Horizon?NJ?Health?Dental?Program?protocol.?

? Comply?with?all?regulatory?guidelines?and?policies?with?respect?to?complaints?and?
appeals.?

? Efficiently?monitor?the?resolution?of?complaints,?to?allow?for?tracking?and?identifying?
unacceptable?patterns?of?care?over?time.?

Differences?sometimes?arise?between?dental?providers?and?insurers?or?their?benefit?
administrators?regarding?prior?authorization?determinations?and?payment?decisions.?Since?many?
of?these?issues?result?from?misunderstanding?of?service?coverage,?processing?policy,?or?payment?
levels,?we?encourage?providers?to?contact?us?for?explanations?and?education.?For?assistance,?call?
Provider?Services?at?1?855?878?5368.?
Horizon?NJ?Health?will?never?penalize?any?provider?or?member?for?filing?a?complaint,?grievance,?
or?appeal.?We?are?committed?to?resolving?disputes?and?appeals?promptly,?with?a?fair?and?full?
investigation?and?resolution.?
? ?



??SKYGEN?USA?|?CONFIDENTIAL?&?PROPRIETARY?|?Horizon?NJ?Health?Dental?Program?|?Effective:?1/1/20?
58?

Making?a?Complaint?
If?providers?or?members?are?dissatisfied?with?care?or?services?received,?they?may?make?a?
complaint?by?calling?a?toll?free?number?or?by?sending?a?written?description?of?the?issue.?
Telephone?inquiries?will?be?answered?on?the?same?day?or?within?one?business?day.?
If?we?can?resolve?a?non?urgent?complaint?within?five?business?days,?we?will?notify?you?of?the?
decision?by?telephone.?If?we?can?t?reach?you?(or?the?member)?by?phone,?we?will?send?written?
notification?within?30?calendar?days.?
? Resolution?Timeline?
Complaint? Resolved?with?verbal?notification?within?5?business?days?or?written?

notification?within?30?calendar?days.?
Grievance? Complaint?not?resolved?within?5?business?days?is?considered?a?grievance.?

Resolved?with?written?notification?within?30?calendar?days.?
If?a?complaint?cannot?be?resolved?within?five?business?days,?we?classify?it?as?a??grievance,??and?
we?send?you?written?notification?of?the?resolution?within?30?calendar?days.??
Verbal?complaints?
To?initiate?a?verbal?complaint?about?care?or?services?received,?call?Horizon?NJ?Health?Customer?
Service:?

PROVIDERS:?? 1?800?682?9091?
MEMBERS:?? 1?800?682?9090?

Complaints?mailing?address?
Send?a?written?complaint?to:?

Horizon?NJ?Health:?Complaints/Appeals?
PO?Box?295?
Milwaukee,?WI?53201?

? ?



??SKYGEN?USA?|?CONFIDENTIAL?&?PROPRIETARY?|?Horizon?NJ?Health?Dental?Program?|?Effective:?1/1/20?
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Submitting?Appeals?
An?appeal?is?a?request?for?a?decision?to?be?reviewed?and?reconsidered.?Horizon?NJ?Health?has?
defined?several?different?types?of?appeals,?and?each?type?has?its?own?timelines,?requirements,?
and?processes,?described?below?and?on?the?following?pages.?
Types?of?appeals?include:?

? Claims?Payment?Appeal?
? Utilization?Management/Authorization?Appeal?

Expedited?Appeals?
If?a?member?is?in?pain?or?at?a?high?health?risk,?providers?or?members?may?request?an?expedited?
appeal,?either?verbally?or?in?writing.?For?an?expedited?verbal?request,?call?1?855?878?5371??
(TTY:?1?800?508?6975).?Horizon?NJ?Health?will?make?a?decision?as?soon?as?possible,?within?a?
maximum?of?72?hours?after?receiving?the?request?for?an?expedited?appeal.?
Appeal?Submission?Guidelines?
Appeals?may?be?submitted?by?providers,?by?members,?and?may?also?be?requested?by?
representatives?who?are?authorized?to?appeal?on?behalf?of?a?member,?such?as?a?lawyer,?parent?or?
guardian,?dental?provider,?or?other?authorized?representative.?Horizon?NJ?Health?provides?both?
members?and?providers?copies?of?their?appeal?rights?with?each?pre??or?post?service?denial.?
To?be?considered,?appeals?must?be?submitted?within?defined?timelines.?The?timelines?for?each?
type?of?appeal?are?summarized?on?the?following?pages.?
Providers:?

? Must?submit?all?appeal?requests?in?writing,?unless?the?request?is?expedited.?
? May?submit?a?utilization?management?appeal?on?behalf?of?a?member,?with?the?

member?s?written?consent.?Written?member?consent?can?be?waived?when?the?request?is?
for?an?expedited?resolution.?

? May?submit?only?one?utilization?management?appeal?for?a?particular?case.?The?appeal?
may?be?on?the?provider?s?behalf?or?the?member?s?behalf,?but?not?both.?

? May?request?written?documentation?for?the?clinical?rationale?Horizon?NJ?Health?used?to?
make?appeal?decisions.?

Members:?
? May?submit?appeal?requests?verbally?or?in?writing.??
? May?call?Horizon?NJ?Health?Main?Member?Services?for?help?with?complaints?or?appeals?

at?1?877?765?4325.?
? May?revoke?consent?for?a?provider?to?appeal?on?their?behalf?at?any?time.?

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??SKYGEN?USA?|?CONFIDENTIAL?&?PROPRIETARY?|?Horizon?NJ?Health?Dental?Program?|?Effective:?1/1/20?
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Documentation?Requirements?
Regardless?of?the?level?or?type?of?appeal,?the?following?information?must?be?included?with?each?
appeal?request:?

? Name,?address,?phone?number?of?the?provider?or?member?making?the?appeal?
? Member?Medicaid?ID?
? Dates?of?service?
? Names?of?providers?and/or?facilities?involved?in?the?situation?
? Description?and?specific?details?about?the?actions?or?decision?in?question?
? Reason?for?the?appeal?
? Desired?outcome?from?the?appeal?
? Supporting?documentation?(including?dental?record,?X?rays,?treatment?notes,?etc.)?
? Signed?member?consent?form?(if?applicable)?

Continuation?of?Benefits?
Services?are?covered?while?an?appeal?is?pending.?If?the?appeal?is?denied,?the?member?may?be?
required?to?pay?for?the?cost?of?these?services.??
To?request?continuation?of?benefits?while?a?Medicaid?Fair?Hearing?is?pending,?members?must?
submit?a?request?in?writing?within?10?days?of?receiving?notification?of?a?denied?appeal.?If?the?Fair?
Hearing?appeal?is?denied,?the?member?may?be?required?to?pay?for?the?cost?of?the?services.?
? ?



??SKYGEN?USA?|?CONFIDENTIAL?&?PROPRIETARY?|?Horizon?NJ?Health?Dental?Program?|?Effective:?1/1/20?
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Claims?Payment?Appeal?
If?you?are?dissatisfied?with?the?reimbursement?amount?or?timeliness?of?a?claims?payment,?you?
may?file?an?internal?claims?payment?appeal?within?90?calendar?days?after?receiving?notification?of?
the?claim?determination.?Submit?your?written?claim?appeal?on?the?appropriate?Department?of?
Banking?and?Insurance?(DOBI)?claim?form?(state.jn.us/dobi).?
The?ADR?organization?s?arbitrator?will?make?a?decision?within?30?calendar?days?after?receiving?all?
documentation?necessary?for?the?review.?The?arbitrator?s?decision?is?binding?and?cannot?be?
appealed.?Horizon?NJ?Health?may?change?the?ADR?arbitrator?at?any?time.?
Claims?Payment?Appeal?Timelines?
Stage? Appeal?Submission?Timeline? Resolution?Timeline?
One? Submit?appeal?on?DOBI?claim?form?within?90?

days?of?receiving?claim?dispute?resolution.?
Resolved?within?30?days.?

All?days?refer?to?calendar?days.?

Internal?review?
To?appeal?the?resolution?of?a?claim?dispute,?send?the?applicable?DOBI?appeal?form?and?
supporting?documentation?to:?

Horizon?NJ?Health:?Complaints/Appeals?
PO?Box?295?
Milwaukee,?WI?53201?

Utilization?Management/Authorization?Appeal?
Any?provider?or?member?who?has?questions?or?is?not?satisfied?with?a?utilization?management?
decision?may?request?to?speak?personally?with?the?dental?consultant?who?made?the?
determination?to?deny?services.?The?dental?consultant?should?return?the?phone?call?from?the?
provider?within?72?hours.?
If?you?are?not?satisfied?with?the?decision,?you?may?submit?an?internal?utilization?management?
appeal.?If?the?member?remains?dissatisfied,?a?provider?may?submit?a?written?appeal?on?behalf?of?
the?member?(with?the?member?s?written?consent),?or?the?member?may?appeal?the?decision.?As?a?
provider,?you?may?submit?only?one?UM?appeal?for?a?particular?case.?You?may?submit?an?appeal?
on?your?behalf?or?on?the?member?s?behalf,?but?not?both.?Requests?for?an?internal?appeal?must?be?
submitted?within?90?calendar?days?of?receiving?a?denial?letter.??
Providers?must?submit?written?appeals.?Members?may?submit?a?written?appeal?or?may?appeal?a?
decision?by?calling?1?800?682?9090.?Horizon?NJ?Health?will?notify?you?or?the?member?of?an?
internal?decision?within?10?calendar?days.?
? ?



??SKYGEN?USA?|?CONFIDENTIAL?&?PROPRIETARY?|?Horizon?NJ?Health?Dental?Program?|?Effective:?1/1/20?
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Member?Written?Consent?for?Appeal?
If?you,?as?a?provider,?submit?an?appeal?on?behalf?of?a?member,?you?must?include?a?consent?form?
signed?by?the?member?(unless?you?are?requesting?an?expedited?resolution).?You?must?also?notify?
the?member?when?you?initiate?the?appeal?and?each?time?the?appeal?advances?to?the?next?stage,?
including?any?appeal?to?an?Independent?Utilization?Review?Organization?(IURO).?The?member?s?
consent?remains?valid?unless?it?is?revoked.?A?member?may?revoke?consent?at?any?time.?
Utilization?Management?Appeal?Timelines?
Stage? Appeal?Submission?Timeline? Resolution?Timeline?
Expedited? May?be?either?written?or?verbal?request.? Resolved?as?soon?as?possible,?not?to?exceed?

72?hours?after?receiving?appeal?request.?
Internal? Submit?appeal?for?internal?reconsideration?

within?90?days?of?receiving?denial?letter.?
Resolved?within?10?days.?

External? Member?(or?provider?with?member?s?
consent)?may?submit?request?for?IURO?
review?within?4?months?of?receiving?
Internal?decision.?

Resolved?within?30?days.?

All?days?refer?to?calendar?days.?*Resolution?required?within?20?business?days,?not?to?exceed?30?calendar?days.?

Internal?review?
To?request?reconsideration?of?a?utilization?management?decision,?send?a?Stage?One?appeal?
request?to:?

Horizon?NJ?Health:?Complaints/Appeals?
PO?Box?295?
Milwaukee,?WI?53201?

External?review?
A?member,?or?a?provider?acting?with?a?member?s?written?content,?may?submit?an?External?UM?
Appeal?request,?along?with?all?required?documentation?for?the?case,?to:?

Independent?Utilization?Review?Organization?
Office?of?Managed?Care,?Division?of?Health?Care?Quality?and?Oversight?
PO?Box?360?
West?Trenton,?NJ?08625?0360?

? ?



??SKYGEN?USA?|?CONFIDENTIAL?&?PROPRIETARY?|?Horizon?NJ?Health?Dental?Program?|?Effective:?1/1/20?
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Additional?Appeal?Resources??
Providers?and?members?may?seek?assistance?with?complaints,?grievances,?and?appeals?at?any?
time?for?any?issue?by?contacting?the?New?Jersey?Department?of?Health?or?the?Department?of?
Banking?and?Insurance?(DOBI).?
New?Jersey?Department?of?Health?
Providers?may?submit?an?appeal?by?writing?to:?

New?Jersey?Department?of?Health?and?Senior?Services?
Office?of?Managed?Care?
PO?Box?367?
Trenton,?NJ?08625?0360?

Members?may?submit?an?appeal?by?writing?to:?
New?Jersey?State?Department?of?Health?and?Senior?Services?
Office?of?Managed?Care?
PO?Box?360?
Trenton,?NJ?08625?0360?

New?Jersey?Department?of?Banking?and?Insurance?(DOBI)?
Providers?and?members?may?call?the?department?with?a?complaint?(1?800?446?7467,?
state.nj.us/dobi)?or?may?submit?an?appeal?by?writing?to:?

Department?of?Banking?and?Insurance?
Office?of?Enforcement?and?Consumer?Protection?
20?West?State?St?
PO?Box?329?
Trenton,?NJ?08625?0329?

Medicaid?Fair?Hearing?
Members?may?request?a?Medicaid?Fair?Hearing?within?20?days?of?notice?of?an?adverse?action?by?
writing?to:?

New?Jersey?Division?of?Medical?Assistance?and?Health?Services?(DMAHS)?
Fair?Hearing?Services?
PO?Box?712?
Trenton,?NJ?08625?0712?

To?request?continuation?of?benefits?while?a?Medicaid?Fair?Hearing?is?pending,?members?must?
submit?a?request?in?writing?within?10?days?of?receiving?notification?of?a?denied?appeal.?If?the?Fair?
Hearing?appeal?is?denied,?the?member?may?be?required?to?pay?for?the?cost?of?the?services.?
? ?



??SKYGEN?USA?|?CONFIDENTIAL?&?PROPRIETARY?|?Horizon?NJ?Health?Dental?Program?|?Effective:?1/1/20?
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Credentialing?&?Recredentialing?
High?quality?dental?providers?are?essential?to?the?success?of?the?Horizon?NJ?Health?Dental?
Program,?and?even?more?importantly,?essential?to?the?health?of?members?enrolled?in?its?
Medicaid?benefit?plans.?
While?the?Horizon?NJ?Health?Dental?Program?has?an?open?recruitment?strategy?that?encourages?
all?providers?to?participate,?all?dentists?seeking?acceptance?into?the?network?must?undergo?a?
qualification?process,?which?includes?a?background?check,?licensing?verification,?and?primary?
source?verification?of?professional?credentials.??
As?required?by?law,?any?dentist?(DDS?or?DMD)?who?is?interested?in?participating?with?the?Horizon?
NJ?Health?Dental?Program?is?invited?to?apply?and?submit?a?credentialing?application?for?review?by?
Horizon?NJ?Health?s?Credentialing?Committee.?We?do?not?differentiate?or?discriminate?in?the?
treatment?of?providers?seeking?credentialing?on?the?basis?of?race,?ethnicity,?gender,?age,?national?
origin,?or?religion.??
Providers?must?be?credentialed?before?participating?in?the?Horizon?NJ?Health?Dental?Program?
network.?Providers?accepted?into?the?network?are?re?credentialed?at?least?every?36?months.??
Credentialing?Process?
The?Horizon?NJ?Health?credentialing?process?follows?NCQA?(National?Committee?for?Quality?
Assurance)?credentialing?guidelines?for?dentistry.?All?credentialing?applications?must?satisfy?
NCQA?and/or?URAC?standards?of?credentialing?as?they?apply?to?dental?services.?Horizon?NJ?Health?
has?the?sole?right?to?determine?which?dentists?it?accepts?and?continues?to?allow?as?participating?
providers?in?the?Horizon?NJ?Health?Dental?Program?network.?
In?reviewing?an?application,?the?Credentialing?Committee?may?request?further?information?from?
the?applicant.?The?Credentialing?Committee?may?postpone?a?decision?pending?the?outcome?of?an?
investigation?of?the?applicant?by?a?hospital,?licensing?board,?government?agency,?institution,?or?
any?other?organization,?or?the?Committee?may?recommend?other?actions?it?deems?appropriate.?
Horizon?NJ?Health?notifies?the?State?of?New?Jersey?of?all?disciplinary?actions?that?involve?
participating?providers.?
Any?acceptance?of?an?applicant?is?conditioned?upon?the?applicant?s?execution?of?a?participation?
agreement?with?the?Horizon?NJ?Health?Dental?Program?network.?
If?you?have?questions?about?the?credentialing?process?or?need?assistance,?call?the?Horizon?NJ?
Health?Credentialing?team?at?1?855?812?9211.?
? ?



??SKYGEN?USA?|?CONFIDENTIAL?&?PROPRIETARY?|?Horizon?NJ?Health?Dental?Program?|?Effective:?1/1/20?
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Credentialing?Documentation??
Horizon?NJ?Health?considers?effective?screening?and?credentialing?criteria?an?important?tool?for?
maintaining?the?quality?of?its?provider?network.?Horizon?NJ?Health?complies?with?state,?regulatory,?
and?accrediting?body?standards?for?credentialing?of?its?healthcare?professional?network.??
A?Doctor?of?Dental?Medicine?(DMD)?or?a?Doctor?of?Dental?Surgery?(DDS),?who?is?authorized?to?
provide?dental?and?surgical?services?by?the?State?of?New?Jersey?and?approved?by?Horizon?NJ?
Health,?is?eligible?to?provide?dental?and?surgical?dental?services?to?Horizon?NJ?Health?members.?
An?out?of?state?dentist,?credentialed?as?a?Horizon?NJ?Health?participating?dentist,?may?provide?
dental?and?surgical?services?if?documentation?and?licensing?requirements?are?met?for?the?state?in?
which?they?practice.?Participants?must?provide?information?on?the?following:?

? Education/training?
? Current?state?licensure?
? For?oral?surgeons,?full?admitting?privileges?at?Horizon?NJ?Health?participating?hospitals?
? For?Endodontists,?Prosthodontists,?Periodontists,?and?Oral?and?Maxillofacial?Surgeons,?proof?of?

a?current,?unrestricted?New?Jersey?Controlled?Drug?Substance?(CDS)?and?Drug?Enforcement?
Agency?(DEA)?certificates??

o Must?have?or?have?confirmation?of?application?submission?of?
? Information?regarding?breaks?in?practice/training?
? Current?adequate?professional?liability?insurance?(malpractice)?
? Satisfactory?history?of?malpractice?claims?and?settlements?
? Satisfactory?National?Practitioner?Data?Bank?inquiry?
? Satisfactory?inquiry?of?New?Jersey?Treasury?and?federal?Office?of?Inspector?General?(OIG)?websites?
? Copy?of?a?written?certification?to?perform?anesthesia,?intravenous?sedation,?and?analgesia,?if?

applicable?
? Work?history?
? Any?sanctions?imposed?by?Medicare?and/or?Medicaid?
? Any?censure?by?the?State?Board?of?Dental?Examiners?
? Physical/mental?health,?history?of?chemical?dependency/substance?abuse,?loss?of?license,?

and/or?felony?convictions,?loss?or?limitation?of?hospital?privileges?or?disciplinary?activity,?and?an?
attestation?to?the?correctness?and?completeness?of?the?submitted?information?

Horizon?NJ?Health?may?utilize?the?services?of?an?external?Credentialing?Verification?Organization?to?
meet?State?requirements.?We?require?cooperation?with?these?services?by?all?dentists?applying?for?
participation?in?the?program.?Failure?to?do?so?results?in?a?denied?application?by?the?Horizon?NJ?
Health?Credentialing?Committee.?In?addition,?all?primary?and?specialty?care?offices?must?cooperate?
with?site?reviews?to?ensure?our?members?receive?treatment?in?an?appropriate,?clean,?and?safe?
environment?that?also?respects?member?privacy.?An?initial?site?visit?is?required?in?conjunction?with?
credentialing?and?every?three?years?thereafter.?After?six?months?participation?with?Horizon?NJ?
Health,?reviews?of?dental?records?may?be?conducted?to?ensure?all?records?comply?with?our?dental?
recordkeeping?standards.?(See?Recordkeeping?Requirements?on?page?23.)? ?



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Recredentialing?Process?
Recredentialing?is?required?at?least?every?36?months,?per?NCQA?guidelines.?Six?months?before?you?
are?due?for?recredentialing,?Horizon?NJ?Health?will?notify?you?of?your?upcoming?recredentialing?
due?date.?Our?notification?letter?will?include?instructions?for?how?to?complete?the?recredentialing?
process.?If?you?have?questions?about?recredentialing?or?need?assistance,?call?the?Horizon?NJ?Health?
Credentialing?team:?1?855?812?9211.?The?recredentialing?process?for?Horizon?NJ?Health?includes?a?
review?and?update?of?all?credentialing?information,?as?well?as?the?following:?

? Correspondence?between?the?dental?program?and?the?dentist?or?healthcare?professional?
? Utilization?management?and?quality?reviews?
? Compliance?with?Horizon?NJ?Health?policies?and?procedures?
? Patient?satisfaction?or?complaint?response?information?
? Other?pertinent?data?

Submitting?an?Application?for?Credentialing/Recredentialing?
An?initial?site?visit?is?required?in?conjunction?with?credentialing?at?which?time?the?Credentialing?
Team?provides?an?application?form.?In?addition,?providers?can?complete?the?application?through?
the?Council?for?Affordable?Quality?Healthcare?(CAQH)?or?online?at?the?Horizon?NJ?Health?website.?
Send?credentialing?and?recredentialing?applications?and?documents?to?Horizon?NJ?Health?by?fax,?
email,?or?mail.?Or,?call?the?Credentialing?Team:?1?855?812?9211.?

? Fax:?1?866?396?5686??
? Email:?credentialing@skygenusa.com?
? Write?to:??

Horizon?NJ?Health:?Credentialing?
PO?Box?2059?
Milwaukee,?WI?53201??

Appealing?a?Credentialing?Decision?
The?Horizon?NJ?Health?Credentialing?Committee?has?the?discretion?and?authority?to?accept?an?
application?without?restrictions.?However,?if?the?Credentialing?Committee?determines?an?
application?should?be?accepted?with?restriction?or?declined,?the?Committee?recommends?the?
appropriate?action?to?the?Executive?Subcommittee?for?approval?and?offers?the?applicant?an?
opportunity?to?request?a?reconsideration?review?or?appeal?the?recommendation.?
If?the?applicant?accepts?the?opportunity?for?a?reconsideration?review,?the?Credentialing?Committee?
reviews?all?original?documents,?as?well?as?any?additional?information?submitted?for?the?
reconsideration?review.?If?an?applicant?appeals?the?Credentialing?Committee?s?recommendation,?a?
Peer?Review?Committee?completes?the?review.?Horizon?NJ?Health?retains?ultimate?responsibility?
for?the?credentialing?process?and?final?credentialing?decisions.?To?appeal?a?decision,?send?a?written?
request?for?a?reconsideration?review?within?30?days?of?receiving?an?adverse?recommendation?to:?

Horizon?NJ?Health:?Credentialing?Appeals?
PO?Box?2059?
Milwaukee,?WI?53201? ?



??SKYGEN?USA?|?CONFIDENTIAL?&?PROPRIETARY?|?Horizon?NJ?Health?Dental?Program?|?Effective:?1/1/20?
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Health?Insurance?Portability?and?
Accountability?Act?(HIPAA)?
As?a?healthcare?provider,?if?you?transmit?any?health?information?electronically,?your?office?is?
required?to?comply?with?all?aspects?of?the?Health?Insurance?Portability?and?Accountability?Act?
(HIPAA)?regulations?that?have?gone?and?will?go?into?effect?as?indicated?in?the?final?publications?of?
the?various?rules?covered?by?HIPAA.?
Horizon?NJ?Health?has?implemented?numerous?operational?policies?and?procedures?to?ensure?we?
comply?with?all?HIPAA?Privacy?Standards,?and?we?intend?to?comply?with?all?Administrative?
Simplification?and?Security?Standards?by?their?compliance?dates.?We?also?expect?all?providers?in?
our?networks?to?work?cooperatively?with?us?to?ensure?compliance?with?all?HIPAA?regulations.?
Together,?you?(the?provider)?and?Horizon?NJ?Health?agree?to?conduct?our?respective?activities?in?
accordance?with?the?applicable?provisions?of?HIPAA?and?such?implementing?regulations.?When?
you?contact?Provider?Services,?you?will?be?asked?to?supply?your?Tax?ID?or?NPI?number.?When?you?
call?regarding?member?inquiries,?you?will?be?asked?to?supply?specific?member?identification?such?
as?Member?Medicaid?ID?number?or?Social?Security?Number,?date?of?birth,?name,?and/or?address.?
As?regulated?by?the?Administrative?Simplification?Standards,?the?benefit?tables?included?in?this?
provider?manual?reflect?the?most?current?CDT?coding?standards?recognized?by?the?American?
Dental?Association?(ADA).?Effective?as?of?the?date?of?this?manual,?the?Horizon?NJ?Health?Dental?
Program?require?providers?to?submit?all?claims?with?the?proper?CDT?codes?listed?in?this?manual.?
In?addition,?all?paper?claims?must?be?submitted?on?the?current?ADA?claim?form.?
To?request?copies?of?Horizon?NJ?Health?HIPAA?policies,?call?Provider?Services?or?send?an?email?to?
providerservices@skygenusa.com.?

To?report?a?potential?security?issue,?call?our?
Hotline?at?1?877?378?5292.?

National?Provider?Identifier?(NPI)??
The?Health?Insurance?Portability?and?Accountability?Act?(HIPAA)?of?1996?required?the?adoption?of?a?
standard?unique?provider?identifier?for?healthcare?providers.?An?NPI?number?is?required?for?all?claims?
submitted?to?Horizon?NJ?Health?for?payment.?All?providers?must?register?as?an?individual?practitioner?
and?get?an?individual?NPI.?If?you?own?and?operate?a?group?practice,?you?must?also?register?as?a?group?
and?obtain?a?group?or?organizational?NPI.?To?apply?for?an?NPI,?do?one?of?the?following:?

? Complete?the?application?online?at?nppes.cms.hhs.gov.?
? Download?and?complete?a?paper?copy?from?nppes.cms.hhs.gov.?
? Call?1?800?465?3203?to?request?an?application.? ?



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Utilization?Management??
Community?Practice?Patterns?
To?ensure?fair?and?appropriate?reimbursement,?the?Horizon?NJ?Health?Utilization?Management?
philosophy?recognizes?the?relationships?between?the?dentist?s?treatment?planning,?treatment?
costs,?and?outcomes.?The?dynamics?of?these?relationships?are?typically?influenced?by?community?
practice?patterns.?With?this?in?mind,?our?Utilization?Management?guidelines?are?designed?to?
ensure?healthcare?dollars?are?distributed?fairly?and?appropriately,?as?defined?by?the?regionally?
based?community?practice?patterns?of?local?dentists?and?their?peers.?
All?Utilization?Management?analysis,?evaluations,?and?outcomes?are?related?to?these?community?
practice?patterns.?Horizon?NJ?Health?Utilization?Management?recognizes?individual?dentist?
variance?within?these?patterns?among?a?community?of?dentists?and?accounts?for?such?variance.?
To?ensure?fair?comparisons?within?peer?groups,?our?Utilization?Management?evaluates?specialty?
dentists?as?a?separate?group?and?not?with?general?dentists,?since?the?types?and?nature?of?
treatment?may?differ.?
Evaluation?
Horizon?NJ?Health?Utilization?Management?evaluates?claims?submissions?in?such?areas?as:?

? Diagnostic?and?preventive?treatment?
? Patient?treatment?planning?and?sequencing?
? Types?of?treatment?
? Treatment?outcomes?
? Treatment?cost?effectiveness?

Results?
With?the?objective?of?ensuring?fair?and?appropriate?reimbursement?to?providers,?Horizon?NJ?
Health?Utilization?Management?helps?identify?providers?whose?treatment?patterns?show?
significant?deviation?from?the?normal?practice?patterns?of?the?community?of?their?peers?(typically?
less?than?5?percent?of?all?dentists).??
Peer?Review:?Reimbursement?Consequences??
If?a?dentist?fails?to?respond?to?a?request?of?the?New?Jersey?Division?of?Medical?Assistance?and?
Health?Services?(DMAHS)?for?office?records,?radiographs,?correspondence,?or?other?materials?
within?30?days,?the?Division?may?recover?any?reimbursement?related?to?the?services?involved,?or?
if?in?reference?to?unpaid?services,?deny?any?payment.?
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TAMI?Review?
Horizon?NJ?Health?claims?examiners?use?Tooth?Allocation?Map?Inquiry?(TAMI)?Review?to?
systematically?review?payment?processing.?A?claims?examiner?selects?certain?claims?that?reveal?
duplication?of?services?or?services?presented?in?an?illogical?or?impossible?sequence?for?further?
review?and?investigation.?
Non?Incentivization?Policy?
It?is?Horizon?NJ?Health?practice?to?ensure?our?contracted?providers?make?treatment?decisions?
based?on?medical?necessity?for?individual?members.?Providers?are?never?offered,?nor?shall?they?
ever?accept,?any?kind?of?financial?incentives?or?any?other?encouragement?to?influence?their?
treatment?decisions.?
The?Horizon?NJ?Health?Utilization?Management?team?bases?their?decisions?on?only?
appropriateness?of?care,?service,?and?existence?of?coverage.?Horizon?NJ?Health?does?not?
specifically?reward?practitioners?or?other?individuals?for?issuing?denials?of?coverage?or?care.?If?
financial?incentives?exist?for?Utilization?Management?decision?makers,?they?do?not?include?or?
encourage?decisions?which?result?in?underutilization.?
Fraud,?Waste?&?Abuse?
Horizon?NJ?Health?conducts?our?business?operations?in?compliance?with?ethical?standards,?
contractual?obligations,?and?all?applicable?federal?and?state?statutes,?regulations,?and?rules.?We?
are?committed?to?detecting,?reporting,?and?preventing?potential?fraud,?waste,?and?abuse,?and?we?
look?to?our?providers?to?assist?us.?We?expect?our?dental?partners?to?share?this?same?
commitment,?conduct?their?businesses?similarly,?and?report?suspected?noncompliance,?fraud,?
waste?or?abuse.?
Definitions?
Fraud,?waste,?and?abuse?are?defined?as:?
Fraud.?Fraud?is?intentional?deception?or?misrepresentation?made?by?a?person?with?knowledge?the?
deception?could?result?in?some?unauthorized?benefit?to?themselves?or?some?other?person?or?
entity.?It?includes?any?act?which?constitutes?fraud?under?federal?or?state?law.?
Waste.?Waste?is?the?unintentional,?thoughtless,?or?careless?expenditures,?consumption,?
mismanagement,?use,?or?squandering?of?federal?or?state?resources.?Waste?also?includes?incurring?
unnecessary?costs?as?a?result?of?inefficient?or?ineffective?practices,?systems,?or?controls.?
Abuse.?Abuse?is?defined?as?practices?that?are?inconsistent?with?sound?fiscal,?business,?or?medical?
practices,?and?that?result?in?the?unnecessary?cost?to?the?government?healthcare?program?or?in?
reimbursement?for?services?medically?unnecessary?or?that?fail?to?meet?professionally?recognized?
standards?for?health?care.?Abuse?includes?intentional?infliction?of?physical?harm,?injury?caused?by?
negligent?acts,?or?omissions,?unreasonable?confinement,?sexual?abuse,?or?sexual?assault.?Abuse?
also?includes?beneficiary?practices?that?result?in?unnecessary?costs?to?the?healthcare?program.?
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Provider?Fraud.?Provider?fraud?is?any?deception?or?misrepresentation?committed?intentionally,?or?
through?willful?ignorance?or?reckless?disregard,?by?a?person?or?entity?in?order?to?receive?benefits?
or?funds?to?which?they?are?not?entitled.?This?may?include?deception?by?improper?coding?or?other?
false?statements?by?providers?seeking?reimbursement?or?false?representations?or?other?violations?
of?federal?healthcare?program?requirements,?its?associates,?or?contractors.?
Reporting?Suspected?Fraud,?Waste,?or?Abuse?
To?report?a?suspected?case?of?noncompliance,?fraud,?waste,?or?abuse,?call?the?Horizon?NJ?Health?
Fraud?and?Abuse?hotline:?1?877?378?5292?or?write?to:?

Horizon?NJ?Health?
Attention:?Fraud?and?Abuse?
10201?N?Port?Washington?Rd?
Mequon,?WI?53092?

To?report?potential?fraud?or?abuse,?call?our?
Hotline?at?1?877?378?5292.?

Deficit?Reduction?Act:?The?False?Claims?Act?
Section?6034?of?the?Deficit?Reduction?Act?of?2005?signed?into?law?in?2006?established?the?
Medicaid?Integrity?Program?in?section?1936?of?the?Social?Security?Act.?The?legislation?directed?the?
Secretary?of?the?United?States?Department?of?Health?and?Human?Services?(HHS)?to?establish?a?
comprehensive?plan?to?combat?provider?fraud,?waste,?and?abuse?in?the?Medicaid?program,?
beginning?in?2006.?The?Comprehensive?Medicaid?Integrity?Plan?is?issued?for?successive?five?year?
periods.??
Under?the?False?Claims?Act,?those?who?knowingly?submit?or?cause?another?person?to?submit?false?
claims?for?payment?of?government?funds?are?liable?for?up?to?three?times?the?government?s?
damages?plus?civil?penalties?of?$5,500?to?$11,000?for?each?false?claim.?
The?False?Claims?Act?allows?private?persons?to?bring?a?civil?action?against?those?who?knowingly?
submit?false?claims.?If?there?is?a?recovery?in?the?case?brought?under?the?False?Claims?Act,?the?
person?bringing?the?suit?may?receive?a?percentage?of?the?recovered?funds.?
For?the?party?found?responsible?for?the?false?claim,?the?government?may?exclude?them?from?
future?participation?in?federal?healthcare?programs?or?impose?additional?obligations?against?the?
individual.?
The?False?Claims?Act?is?the?most?effective?tool?U.S.?taxpayers?have?to?recover?the?billions?of?
dollars?stolen?through?fraud?every?year.?Billions?of?dollars?in?healthcare?fraud?have?been?exposed,?
largely?through?the?efforts?of?whistleblowers?acting?under?federal?and?state?false?claims?acts.?
For?more?information?about?the?False?Claims?Act?visit?www.TAF.org.?
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Whistleblower?Protection?
The?False?Claims?Act?(FCA)?provides?protection?to?qui?tam?relators?who?are?discharged,?demoted,?
suspended,?threatened,?harassed,?or?in?any?other?manner?discriminated?against?in?the?terms?and?
conditions?of?their?employment?as?a?result?of?their?furtherance?of?an?action?under?the?FCA?
31?U.S.C.???3730(h).?Remedies?include?reinstatement?with?comparable?seniority?as?the?qui?tam?
relator?would?have?had?but?for?the?discrimination,?two?times?the?amount?of?any?back?pay,?
interest?on?any?back?pay,?and?compensation?for?any?special?damages?sustained?as?a?result?of?the?
discrimination,?including?litigation?costs?and?reasonable?attorneys??fees.?
Sanctions?
To?resolve?identified?deficiencies?in?a?fair?manner,?Horizon?NJ?Health?allows?the?opportunity?for?
reeducation?and?fair?due?process.?When?noncompliance?significantly?affects?the?quality?of?care?
provided?to?a?member,?Horizon?NJ?Health?may?impose?sanctions?after?a?thorough?review?of?the?
issue?through?the?Corrective?Action?Program.?The?provider?under?review?is?afforded?ample?
opportunity?to?respond?to?the?issue.?
If?formal?sanctions?are?implemented?and?the?outcome?lasts?30?days?or?more,?Horizon?NJ?Health?
notifies?the?National?Practitioner?Data?Bank.??
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Practice?Guidelines?
Horizon?NJ?Health?accepts?the?periodicity?schedule?developed?by?the?State?of?New?Jersey?as?the?
dental?periodicity?schedule?for?the?Horizon?NJ?Health?Dental?Program.?
The?EPSDT?(Early?and?Periodic?Screening,?Diagnostic,?and?Treatment)?program?is?a?federally?
mandated?program?for?children?from?birth?through?20?years?that?emphasizes?the?importance?of?
prevention,?early?detection,?risk?assessment,?and?timely?treatment?of?conditions?identified?as?a?
result?of?dental?screening.?Children?enrolled?in?Medicaid?or?SCHIP?are?eligible?for?full?EPSDT?
benefits?in?the?state.?Members?attaining?the?age?of?21?are?treated?as?adults?beginning?with?the?
first?month?following?their?birthday.??
All?EPSDT?services?provided?to?children?enrolled?in?the?Horizon?NJ?Health?Dental?Program?must?
be?medically?necessary.?These?include:?

? Early.?A?child?s?dental?health?is?assessed?as?early?as?possible?in?the?child?s?life?by?the?
Primary?Care?Dentist?(PCD)?in?order?to?prevent?or?find?potential?diseases?and/or?
disabilities?in?their?early?stages,?when?they?are?most?effectively?treated.?

? Periodic.?The?PCD?will?assess?a?child?s?dental?health?at?regularly?scheduled?intervals?to?
assure?that?a?condition,?illness,?or?injury?is?not?incipient?or?present.?

? Screening.?A?dental?health?assessment?to?determine?if?a?child?is?at?risk?and/or?has?a?
condition,?illness,?or?injury?that?requires?more?definitive?evaluation?and/or?treatment.?

? Diagnosis.?The?definitive?evaluation?by?appropriate?dental?practitioners?to?determine?the?
nature,?extent?or?cause?of?a?condition,?illness,?or?injury.?

? Treatment.?The?dental?services?determined?to?be?medically?necessary?for?problems?
identified?during?screening?or?diagnostic?evaluations.?

Dental?services?should?be?provided?at?intervals?that?meet?reasonable?standards?of?dental?
practice.??
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NJ?Smiles?
NJ?Smiles?is?a?directory?listing?every?pediatric?and?general?dentist?seeing?children?through?6?years?
of?age?who?participates?with?Horizon?NJ?Health.?The?directory?is?available?on?
horizonNJhealth.com/membersupport.??
Dental?services?may?not?be?limited?to?emergency?services.?Dental?screening?by?the?PCP?in?this?
context?means,?at?a?minimum,?observation?of?tooth?eruption,?occlusion?pattern,?presence?of?
caries,?or?oral?infection.??

A. A?referral?to?a?dentist?by?one?year?of?age?or?soon?after?the?eruption?of?the?first?primary?
tooth?is?mandatory?and?at?a?minimum?a?dental?visit?twice?a?year?with?follow?up?during?
well?child?visits?to?ensure?that?all?needed?dental?preventive?and?treatment?services?are?
provided?thereafter?through?the?age?of?20.??

B. A?referral?to?a?dental?specialist?or?dentist?that?provides?dental?treatment?to?patients?with?
special?needs?shall?be?allowed?when?a?PCD?requires?a?consultation?for?services?by?that?
specialty?provider.??

Fluoride?varnish?application?will?be?combined?with?anticipatory?guidance,?risk?assessment?and?referral?to?
a?dentist?that?treats?children?under?the?age?of?six?and?will?be?linked?to?well?child?visits?for?children?
through?the?age?of?six.??

1. These?three?services?will?be?reimbursed?as?an?allinclusive?service?billed?using?CPT?code?
99188?and?can?be?provided?up?to?four?times?a?year.?This?frequency?does?not?affect?the?
frequency?of?this?service?by?the?dentist.?Training?for?Caries?Risk?Assessment,?Fluoride?Varnish?
&?Counseling?is?available?online?by?visiting?smilesforlifeoralhealth.org,?click?Learn?Online?
then?select?Course?Six:?Caries?Risk?Assessment,?Fluoride?Varnish?&?Counseling.??

2. PCPs?are?required?to?refer?members?by?12?months?of?age?to?a?dentist?for?a?dental?visit.?Every?
quarter?PCPs?receive?a?list?of?members?that?have?not?had?a?dental?appointment?in?the?past?
12?months.?PCPs?are?required?to?assist?the?member?with?getting?a?dental?appointment.??

3. Bidirectional?communication?between?PCPs?and?PCDs?is?required?between?these?provider?groups.??
4. Prescribing?fluoride?supplements?is?based?on?access?and?use?to?fluoridated?public?water.?

PCPs?and?PCDs?should?be?aware?of?the?towns?that?fluoridate?their?water.?According?to?the?
NJ?Dental?Association,?the?following?locations?have?fluoridated?water:??
? Atlantic?County:?Atlantic?City,?Egg?Harbor?City??
? Burlington?County:?McGuire?Air?force?base,?Willingboro,?Mt.?Laurel,?Fort?Dix?and?Aqua??
? Gloucester?County:?Washington??
? Hunterdon?County:?Flemington,?Readington,?Three?Bridges,?Whitehouse,?Whitehouse?Station??
? Mercer?County:?Ewing,?Hamilton,?Hightstown,?Hopewell?Township,?Lawrence,?

Pennington,?Princeton,?West?Windsor??
? Monmouth?County:?Allentown,?Colts?Neck,?Freehold,?NJ?American?Coastal?North??
? Somerset?County:?MJ?American??
? Sussex?County:?Newton??
? Union?County:?Rahway?? ?



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5. PCDs?and?PCPs?are?responsible?to?counsel?parents?and?guardians?of?young?children?on?
oral?health,?age?appropriate?oral?habits?and?safety?to?include?what?dental?emergencies?
are?and?use?of?the?emergency?room?for?dental?services.??

6. The?caries?risk?assessment?service?shall?also?be?allowed?by?the?PCD?and?is?billed?using?a?
CDT?procedure?code.?The?reimbursement?will?be?the?same?regardless?of?the?determined?
risk?level.?The?risk?assessment?must?be?provided?at?least?once?per?year?in?conjunction?
with?an?oral?evaluation?service?by?a?PCD?and?is?linked?to?the?provider?not?the?member.?It?
may?be?provided?a?second?time?with?prior?authorization?and?documentation?of?medical?
necessity.?

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New?Jersey?Periodicity?Schedule?
Periodicity?of?Dental?Services?for?Children?in?NJ?FamilyCare/Medicaid?
The?New?Jersey?Division?of?Medical?Assistance?and?Health?Services?(DMAHS)?recommends?the?
following?professional?dental?services?for?children.??
?
Dental?Service?

0?1?
year?

2?6?years? 7?20?years?

A1.?Oral?Evaluation?(Exam)???
A2.?Caries/Cavities?Risk?Assessment??

??
??

??
??

??
??

B.?Fluoride?Supplements?? ?? ?? ??
C.?Fluoride?Varnish*?? ?? ?? ??
D.?Prophylaxis?with?Fluoride?? ? ?? ??
E.?Sealants?????(Permanent?teeth?to?age?16?yrs)?? ? ?? ??
F.?Radiographs/x?rays??(Non?emergency)?? ?? ?? ??
G.?Dental?Treatment?? ?? ?? ??
? Oral?Evaluations?(including?oral?hygiene?instructions),?Fluoride?varnish?and?Cleanings?with?fluoride?

can?be?provided?twice?a?year?r?or?more?frequently?based?on?medical?necessity?and?for?children?
with?special?health?care?needs.??

? A?prescription?for?fluoride?supplements?may?be?given?by?either?your?dentist?or?primary?care?
provider?(PCP)?to?help?prevent?cavities.??

? *The?application?of?fluoride?varnish?to?protect?teeth?from?cavities?can?also?be?done?for?children?
under?the?age?og?4?by?their?PCP?followed?by?a?referral?to?the?dentist?for?an?oral?evaluation,?X?rays?
as?needed,?cleaning?and?dental?treatment.??

? A?Caries/Cavities?Risk?Assessment???should?be?done?once?a?year?to?determine?your?child?s?risk?of?
developing?cavities.?The?visit?includes?an?oral?evaluation,?instructions?on?brushing,?oral?health,?
safety?and?nutritional?counselling?to?parents/caregivers?and?children.??

? Sealants?and?repairs?of?sealants?should?be?provided?to?premolars?and?permanent?molars?of?
children?between?the?ages?of?6?through?16?to?help?prevent?cavities??

? Dental?treatment?services?for?primary??baby?teeth??and?permanent?teeth?include:?fillings,?stainless?
steel?crowns,?treatment?for?toothache?and?extractions?and?should?be?provided?when?
recommended?by?your?child?s?dentist.?

Providers?may?receive?reimbursement?for?the?cost?of?providing?oral?hygiene?instructions?to?caregivers?to?
maintain?a?patient?s?overall?oral?health?between?dental?visits.?In?situations?where?the?treating?dentist?
recommends?a?non?standard,?specialized?toothbrush?to?improve?a?member?s?oral?hygiene,?Horizon?NJ?
Health?will?include?these?devices?as?a?benefit.?Such?provisions?shall?include?designing?and?implementing?
a??dental?management??plan,?coordinated?by?the?Horizon?NJ?Health?Care?Manager,?for?overseeing?a?
patient?s?oral?health.?A?Care?Manager?will?be?assigned?to?members?requiring?these?additional?services?
and?reimbursed?by?report?to?the?Horizon?NJ?Health?Dental?Director.?? ?



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Fluoride?Varnish?Provider?
Incentive?Program?
In?an?effort?to?help?quell?the?alarming?rate?of?early?childhood?caries?for?Horizon?NJ?Health?
members?under?the?age?of?4,?Horizon?NJ?Health?has?developed?a?pediatric?fluoride?varnish?
program.?This?program?encourages?trained?non?dental?providers?in?pediatric?practices?to?apply?
fluoride?varnish?to?children?s?teeth,?perform?caries?risk?assessments?and?anticipatory?guidance,?
and?refer?our?young?members?to?a?dental?home.??
Horizon?NJ?Health?is?offering?reimbursement?to?trained?pediatrician?offices?when?their?
pediatricians,?nurse?practitioners?or?physician?assistants?or?other?trained?medical?staff?apply?
fluoride?varnish?to?the?teeth?of?Horizon?NJ?Health?members?at?well?child?visits?under?the?age?of?
4.?Pediatricians?will?receive?$15?for?each?fluoride?varnish?application?up?to?four?times?a?year,?per?
patient.?Pediatricians?are?also?encouraged?to?discuss?with?patients?the?importance?of?nutrition?
and?oral?hygiene?and?provide?anticipatory?guidance.??
In?order?to?receive?CME?training?credit?(in?some?cases)?and?collect?the?reimbursement,?
practitioners?must?complete?the?following?online?training?and?assessment:??

? Go?to?smilesforlifeoralhealth.org?and?click?Course?Six?in?the?right?column???Caries?Risk?
Assessment,?Fluoride?Varnish?&?Counseling.??

? One?provider?per?facility?may?complete?the?curriculum?and?agree?to?train?their?
colleagues.??

? After?completing?the?curriculum,?that?provider?must?sign?the?Fluoride?Varnish?Attestation?
Form?attesting?that?they?completed?the?training?and?agree?to?train?the?other?providers?in?
their?office.??

After?completing?the?curriculum,?that?provider?must?sign?and?fax?the?Fluoride?Varnish?Application?
Attestation?Form,?attesting?that?they?completed?the?training,?to?1?973?274?3865,?ATTN:?Fred?
DiOrio,?DMD.?Please?include?a?list?of?any?other?providers?in?your?office?that?you?trained.?All?
providers?under?the?PCP?s?TIN?should?be?listed?on?the?attestation?form.?Please?use?CPT?code?
99188.?A?copy?of?the?form?is?on?the?Horizon?NJ?Health?website?in?the?For?Providers?tab,?select?
Resources?and?then?Forms.??
Note?that?providers?who?have?not?completed?the?training?are?not?eligible?for?reimbursement.?
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Clinical?Criteria?
Medical?Necessity?
Horizon?NJ?Health?defines?medical?necessity?as?accepted?healthcare?services?and?supplies?
provided?by?healthcare?entities?appropriate?to?the?evaluation?and?treatment?of?a?disease,?
condition,?illness,?or?injury?and?consistent?with?the?applicable?standard?of?care.?
Dental?care?is?medically?necessary?to?prevent?and?eliminate?orofacial?disease,?infection,?and?pain,?
to?restore?form?and?function?to?the?dentition,?and?to?correct?facial?disfiguration?or?dysfunction.?
Medical?necessity?is?the?reason?why?a?test,?a?procedure,?or?an?instruction?is?performed.?
Medical?necessity?is?different?for?each?person?and?changes?as?the?individual?changes.?The?dental?
team?must?provide?consistent?methodical?documentation?of?medical?necessity?for?coding.?
Prior?Authorization?of?Treatment??
Some?procedures?require?prior?authorization?before?treatment?is?started.?When?submitting?
these?procedures?for?prior?review,?also?submit?supporting?documentation,?if?required.?Horizon?
NJ?Health?uses?the?criteria?and?guidelines?in?this?manual?to?approve?requested?dental?services.?
Prior?authorization?requirements?and?documentation?requirements?are?summarized?in?this?
manual?in?Benefit?Plan?Details?&?Authorization?Requirements?beginning?on?page?120.?
An?approved?authorization?does?not?guarantee?payment.?Dental?providers?must?verify?coverage?
prior?to?rendering?services.?Providers?are?prohibited?from?billing?Medicaid?or?NJ?FamilyCare?
members?for?any?amount,?except?under?specific?scenarios?(see?N.J.A.C?10?49?7.3(d).)?
For?information?about?submitting?prior?authorizations?and?required?documentation,?see??



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Authorization?Submission?Procedures?on?page?45.?
Emergency?Treatment?
To?relieve?pain?and?suffering?in?an?emergency?situation,?providers?should?initiate?treatment?to?
alleviate?the?patient?s?condition.?For?reimbursement?of?emergency?treatment,?submit?all?
required?documentation?along?with?the?claim?for?services?rendered.?Horizon?NJ?Health?applies?
the?same?clinical?criteria?and?requires?the?same?supporting?documentation?for?claims?submitted?
after?emergency?treatment?that?we?use?to?determine?prior?authorizations?for?the?same?services.?
Informed?Consent?
Prior?to?any?surgical?procedure,?the?provider?should?obtain?informed?consent,?signed?by?the?
patient?or?authorized?person.?Horizon?NJ?Health?Professional?Relations?Service?Representatives?
coordinate?all?dentally?necessary?hospitalizations?for?patients?with?developmental?disabilities.?
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Dental?OR/ASC?Services??
Reimbursement?of?the?facility?charges?for?dental?services?performed?in?the?outpatient?department?of?
a?hospital?or?at?an?ambulatory?surgical?center?(ASC)?are?part?of?the?dental?carve?out?and?will?be?
covered?by?the?State?of?New?Jersey?Medicaid?Program.?The?anesthesiologist?services?related?to?those?
dental?services?are?also?part?of?the?dental?carve?out?and?will?be?covered?and?reimbursed?by?the?State?
of?New?Jersey?Medicaid?Program.??
However,?dental?services?that?are?to?be?performed?outside?your?office,?either?in?an?outpatient?department?
of?a?hospital?or?at?an?ASC,?must?be?approved?by?Horizon?NJ?Health?to?ensure?the?services?meet?the?medical?
necessity?criteria?for?services?rendered?in?an?outpatient?facility?(hospital?or?ASC).?
Obtaining?a?Patient?Authorization?Number?
When?a?physician,?dentist,?or?healthcare?professional?determines?that?a?patient?needs?dental?
services?performed?at?a?surgical?facility,?an?authorization?number?is?required.?To?obtain?an?
authorization?number,?submit?a?prior?authorization?request?that?includes:?

? A?list?of?the?planned?dental?services?
? Procedure?code?D9999?
? Completed?General?Anesthesia?Checklist?
? Letter?of?necessity.?Include?the?member?s?name,?Member?Medicaid?ID?number,?and?date?

of?birth;?physician?submitting?the?request;?facility?location;?necessity?for?admission;?and?
required?dental?procedures.??

? Facility?ID,?name?of?the?facility?and?address.?If?this?is?not?included,?processing?can?be?
delayed?and/or?denied.??

For?more?information?on?OR/ASC,?visit?horizonNJhealth.com/dental?and?click?on?Prior?
Authorization?or?refer?to?the?Member?Handbook?by?visiting?horizonNJhealth.com/handbooks.?You?
can?also?view?a?list?of?OR/ASC?Facility?ID?s?on?the?Horizon?NJ?Health?website?at?
horizonNJhealth.com/ORASC.?Fax?the?authorization?request?and?required?documentation?to:?1?
866?899?6186.?
Horizon?NJ?Health?will?review?your?request?and?may?contact?you?to?determine?necessity.?Upon?approval,?
Horizon?NJ?Health?issues?an?authorization?number?for?the?patient.?When?submitting?prior?authorizations,?
remember?to:??

? Report?CDT?procedure?code?D9999?to?request?prior?authorization?on?ADA?2012?
Claim/prior?authorization?form.??

? Report?the?beneficiary?s?medical?condition?and?related?diagnosis?codes?on?office?letterhead.??
? Report?on?office?letterhead?how?the?clinical?presentation?of?the?beneficiary?prevents?the?

beneficiary?from?receiving?dental?treatment?in?an?office?or?clinic?setting,?including?
reason(s)?why?other?levels?of?sedation?are?not?an?option.??

? Report?the?planned?or?expected?treatment?(e.g.,?oral?examination,?cleaning,?restorative?dental?
treatment,?extractions)?to?be?provided?during?the?hospital?visit?and?a?summary?of?the?
beneficiary?s?most?recent?dental?history,?including?dental?treatment?provided?in?the?last?12?
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Submitting?an?Authorization?for?Dental?OR/ASC?Services??
To?ensure?services?rendered?in?a?hospital?operating?room?or?outpatient?facility?meet?the?criteria?for?
medical?necessity,?submit?an?authorization?for?procedure?code?D9999?and?include?the?following?
required?documentation?supporting?the?treatment?plan?(X?rays,?photographs,?etc.),?if?available.?
You?may?submit?authorizations?along?with?any?required?documentation?directly?to?Horizon?NJ?
Health?through?our?Provider?Web?Portal?at?pwp.sciondental.com.?Alternately,?mail?paper?
authorizations?along?with?all?required?documentation?to:?

Horizon?NJ?Health:?Authorizations?
PO?Box?362?
Milwaukee,?WI?53201?

In?an?emergency,?fax?the?authorization?request?for?D9999?(submitted?on?an?ADA?Dental?Claim?
form),?along?with?all?required?documentation?to?1?866?899?6186.?

Dental?Prior?Authorization?Procedures?for?Special?Health?Care?Needs?Members?
to?Access?Care?in?an?OR/ASC?
All?dental?services?requiring?prior?authorization?should?be?submitted?to:?

Horizon?NJ?Health?
PO?Box?362?
Milwaukee,?WI?53201?
?

When?submitted?prior?authorizations,?remember?to:?
? Report?CDT?procedure?code?D9999?to?request?prior?authorization?on?ADA?2012?

Claim/prior?authorization?form.?
? Report?the?beneficiary?s?medical?condition?and?related?diagnosis?codes?on?office?

letterhead.?
? Report?on?office?letterhead?how?the?clinical?presentation?of?the?beneficiary?prevents?the?

beneficiary?from?receiving?dental?treatment?in?an?office?or?clinic?setting,?including?
reason(s)?why?other?levels?of?sedation?are?not?an?option.?

? Report?the?planned?or?expected?treatment?(e.g.,?oral?examination,?cleaning,?restorative?
dental?treatment,?extractions)?to?be?provided?during?the?hospital?visit?and?a?summary?of?
the?beneficiary?s?most?recent?dental?history,?including?dental?treatment?provided?in?the?
last?12?calendar?months.?

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To?ensure?services?rendered?in?a?hospital?operating?room?or?outpatient?facility?meet?the?criteria?
for?medical?necessity,?submit?an?authorization?for?procedure?code?D9999?and?include?the?required?
documentation?supporting?the?treatment?plan.?Required?documentation?includes?X?rays,?letter?of?
medical?necessity,?general?anesthesia?attestation?form,?treatment?plan,?diagnosis?and?facility?ID.?A?
signed?informed?consent?along?with?the?dental?diagnosis?codes?are?also?required.?
Dental?Diagnosis?Codes:?
520.0,?520.1,?520.2,?520.3,?520.4,?520.5,?520.8,?520.9,?521.00,?521.01,?521.02,?521.03,?521.04,?
521.05,?521.06,?521.07,?521.08,?521.09,?521.10,?521.11,?521.12,?521.13,?521.14,?521.15,?521.20,?
521.21,?521.22,?521.23,?521.24,?521.25,?521.30,?521.31,?521.32,?521.33,?521.34,?521.35,?521.40,?
521.41,?521.42,?521.49,?521.5,?521.6,?521.7,?521.81,?521.89,?521.9,?522.0,?522.1,?522.2,?522.3,?
522.4,?522.5,?522.6,?522.8,?522.9,?523.00,?522.01,?523.10,?522.11,?523.20,?523.21,?523.22,?
523.23,?523.24,?523.25,?523.30,523.31,?523.32,?523.33,?523.40,?523.41?
Special?Health?Care?Needs?Clinical?Criteria?and?Medical?Exception?ICD?10?Codes?
The?codes?which?relate?to?clinical?criteria?for?medical?exceptions/disabilities/special?needs?are?
listed?below:?
E75?E756,?F03?F0391,?F06?F068,?F07?F079,?F09,?F48?F489,?F53,?F60?F609,?F70,?F71,?F72,?F73,?
F78,?F79,?F84?F849,?F88,?F89,?F90?F909,?F91?F919,?G10,?G25?G259,?G31?G319,?G40?G409,?G71?
G719,?G72?G729,?G73?G737,?G80?G809,?G93?G939,?P04?P049,?Q86,?Q90?Q99,?R56?R569,?S06?
S069X9,?F819,?I6783,?P154,?P158,?P159?
Oral?Surgery?Services?
Impacted?teeth?should?be?extracted?only?when?medically?necessary.?Horizon?NJ?Health?does?not?
reimburse?for?the?extraction?of?asymptomatic?impacted?teeth?or?those?teeth?where?dental?or?
medical?necessity?is?not?demonstrated.?
To?qualify?for?surgical?removal?of?a?tooth?with?partial?or?complete?bony?impaction,?providers?
must?establish?a?case?for?incision?of?overlying?soft?tissue,?removal?of?bone,?and/or?sectioning?of?
the?tooth.?Providers?must?justify?extractions?in?more?than?one?quadrant?of?the?mouth?as?
emergency?procedures.?
To?request?reimbursement?or?prior?authorization?of?oral?surgical?procedures?(when?necessary),?
submit?a?detailed?description,?including?dates,?diagnosis,?and?site?and?size?of?the?operative?area?
(i.e.,?number?of?lesions?and/or?number?and?size?of?lacerations).?Submit?prior?authorization,?
preoperative,?and?any?postoperative?radiographs?along?with?radiological,?operative,?and?
laboratory?reports?directly?to?the?Horizon?NJ?Health?Dental?Consultant?with?the?current?ADA?
Dental?Claim?Form.?Provide?all?other?reports,?such?as?hospital?radiographs,?upon?request.?
The?dentist?performing?a?biopsy?receives?reimbursement?for?only?the?surgical?portion.?The?
laboratory?performing?the?diagnostic?service?and?not?the?dentist?should?bill?the?program?
directly?for?the?diagnostic?services.?When?the?biopsy?is?performed?as?an?independent?procedure?
on?a?different?date?separate?and?apart?from?the?excision?of?the?entire?lesion,?the?dentist?may?
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House?Calls?
A?physician,?dentist,?or?healthcare?professional?may?bill?for?a?house?call?(D9410)?in?addition?to?
any?other?services?provided?on?that?day.?When?medically?necessary,?Horizon?NJ?Health?
reimburses?D9410?for?home?visits?for?patients?with?developmental?disabilities.?We?reimburse?
D9420?for?preoperative?and?postoperative?evaluations?associated?with?inpatient?operative?and?
surgical?procedures.?
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Hospital?Calls?
Services?performed?in?hospital?and?surgical?center?outpatient?dental?clinics?require?prior?
authorization.?An?authorization?approved?by?a?Horizon?NJ?Health?Dental?Consultant?covers?only?
dental?services;?it?does?not?authorize?the?place?of?service?and?does?not?guarantee?payment.?
Horizon?NJ?Health?reimburses?dental?services?rendered?in?an?approved,?licensed?hospital,?if?the?
patient?requires?that?level?care.?Medical?necessity?must?be?documented?in?the?hospital?records.?
Dental?services?are?also?reimbursed?if?a?member?is?admitted?for?an?eligible?non?dental?condition?
and?dental?services?are?rendered?as?part?of?the?prescribed?treatment?for?the?condition?or?to?
alleviate?the?member?s?discomfort?during?hospitalization.?
A?physician,?dentist,?or?healthcare?professional?may?bill?for?a?hospital?call?(D9420)?for?an?inpatient?
or?outpatient?hospital?visit,?in?addition?to?any?other?dental?services?provided?on?that?day.?
For?an?initial?hospital?call?or?same?day?surgery,?the?hospital?record?must?minimally?include:?

? The?chief?complaints?
? Complete?history?of?the?present?illness?and?related?systematic?review?including?pertinent?

negative?findings?
? Complete?pertinent?past?medical?history?
? Pertinent?family?history?
? Description?of?full?examination?pertaining?to?the?history?of?the?present?condition?
? Record?of?working?diagnosis?and?treatment?plan,?and?preparation?of?an??order?sheet??

Horizon?NJ?Health?does?not?reimburse?an?initial?hospital?call?or?same?day?surgery?call?(D9420)?if:??
? Billed?in?conjunction?with?a?consultation?or?other?hospital?calls?on?the?same?day.??
? The?same?practitioner,?members?of?the?same?group,?members?of?a?shared?healthcare?

facility,?or?practitioner?sharing?a?common?record?also?bill?for?this?procedure?code.?
? Billed?in?conjunction?with?a?consultation?(D9310)?for?the?same?hospital?admission?and/or?

stay?when?billed?by?the?same?practitioner,?members?of?the?same?group,?members?of?a?
shared?healthcare?facility,?or?practitioner?sharing?a?common?record.?

When?the?history?and?examination?required?for?D9420?is?not?personally?performed?by?the?billing?
practitioner,?the?dentist?or?healthcare?professional?should?bill?for?a?hospital?call?(D9420)?if?the?
code?criteria?are?met.??
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Medical?vs.?Dental?Services?
Horizon?NJ?Health?recognizes?that?medical?conditions?may?exist?that?can?exhibit?one?or?more?
dental?components.?These?dental?components/conditions?may?be?1)?causative?to?the?medical?
situation?of?the?patient,?2)?completely?unrelated,?or?3)?the?sequelae?of?the?medical?condition?or?
its?treatment.??
A?physician?or?oral?surgeon?may?perform?procedures?that?may?be?considered?medical?or?dental?
(e.g.,?surgical?procedures?for?fractured?jaw,?removal?of?cyst,?or?provision?of?maxillofacial?
prosthetics).?Please?see?Section?8.2?Precertification?Process?to?obtain?the?authorization?process?
or?you?may?call?the?Horizon?NJ?Health?Utilization?Management?Department?at?1?800?682?9094.??

? A?broad?definition?of?dental?services?would?be?those?procedures?used?to?treat?the?dental?
structures,?including?primary?and?permanent?dentition?and?supporting?structures?
including?the?periodontium?and?alveolar?bone.??

? Specific?procedures?that?would?fall?under?the?category?of?dental?treatment?are:??
? Restoration?of?tooth?structure?lost?by?decay,?fracture,?attrition?or?erosion?using?synthetic?

materials.?This?can?include?intra?coronal?restorations,?such?as?amalgam,?gold?or?
composite,?full?or?partial?coverage?crowns?and?tooth?strengthening?and?retention?
enhancement?for?endodontically?treated?teeth.??

? Endodontic?treatment?of?teeth,?including?re?treatment,?if?necessary,?and?any?necessary?
periapical?or?sectioning?surgical?intervention??

? Surgical?services?and?post?op?treatment?performed?on?the?dental?supporting?structures?
that?include?treatment?of?periodontal?disease,?osseous?surgery?and?any?other?surgery?to?
the?periodontium??

? Replacement?of?missing?teeth?using?full?dentures,?removable?partial?dentures?or?fixed?
prostheses?and?related?services??

? Removal?of?teeth?and?re?implantation?of?teeth?and?associated?services??
? Orthodontic?treatment,?even?if?a?component?of?an?eligible?medical?condition?or?

treatment??
Obtain?authorization?by?calling?Horizon?NJ?Health?s?Utilization?Management?Department?at?least?
five?business?days?prior?to?the?inpatient?or?outpatient?procedure?if?the?procedure?requires?
anesthesia?or?is?performed?in?an?inpatient?setting?or?non?participating?ambulatory?surgical?
center.?Utilization?Management?Department:?1?800?682?9094.?
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Amalgam?Restorations?
Reimbursement?for?amalgam?restoration?includes?treatment?of?pulp?exposure,?lining?or?base,?
restoration,?polishing?of?restoration,?and?local?anesthesia?or?analgesia.?Select?the?procedure?code?
based?on?the?number?of?surfaces?restored?per?individual?tooth?not?on?the?basis?of?individual?
restorations.?In?this?way,?the?fee?for?any?surface?includes?one?or?more?restorations?on?that?
surface.?Horizon?NJ?Health?reimburses?only?one?code?per?tooth.?Reimbursement?for?an?occlusal?
restoration?includes?any?extensions?onto?the?occlusal?one?third?of?the?buccal?or?lingual?surfaces?
of?the?tooth.?
Interproximal?Fillings?
Extensions?of?interproximal?fillings?into?self?cleansing?areas?are?not?considered?additional?
surfaces.?Horizon?NJ?Health?reimburses?an?additional?surface?only?when?the?buccal?(facial)?or?
lingual?margin?extends?beyond?the?proximal?one?third?of?the?buccal?(facial)?and/or?lingual?
surfaces.?
Proximal?Restorations?
Proximal?restorations?in?anterior?teeth?are?normally?considered?single?surface?restorations.?
When?the?dentist?gains?access?to?a?proximal?cavity?by?involvement?of?a?second?surface,?Horizon?
NJ?Health?permits?reimbursement?for?only?one?surface.?We?only?reimburse?a?two??or?three?
surface?proximal?restoration?when?the?facial?and/or?lingual?margins?of?the?restoration?extends?
beyond?the?proximal?one?third?of?the?facial?and/or?lingual?surfaces.?
Proximal?Fillings?
Extensions?of?proximal?fillings?into?self?cleansing?areas?are?not?considered?additional?surfaces.?
When?selecting?the?appropriate?code?for?an?individual?tooth,?note?that?only?one?code?is?
reimbursable?per?tooth.?The?fee?for?any?surface?includes?one?or?more?restorations?on?that?surface.?
A?reimbursement?for?an?occlusal?restoration?includes?any?extensions?onto?the?occlusal?one?third?
of?the?buccal?(facial)?or?lingual?surfaces?of?the?tooth.?Reimbursements?for?a?restoration?includes?
treatment?of?pulp?exposure,?lining?or?base,?restoration,?and?local?anesthesia?or?analgesia.?
Diagnostic?Services?
Clinical?laboratory?services?include?services?provided?by?the?following:?

? Independent?clinical?laboratories,?such?as?physician/dentist?operated?and?out?of?hospital?
laboratories?that?primarily?perform?diagnostic?work?referred?by?other?practitioners.?

? Hospital?laboratories?and?laboratories?of?educational?institutions?that?provide?laboratory?
services?to?ambulatory?members?as?requested?by?a?licensed?practitioner.?

Dentists?should?not?bill?for?any?services?provided?by?these?clinical?laboratories.?Instead,?the?
laboratories?should?bill?Horizon?NJ?Health?directly.?Horizon?NJ?Health?members?are?capitated?to?
LabCorp?for?all?laboratory?services,?except?during?an?inpatient?hospitalization.?
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All?facilities?or?entities?that?perform?clinical?laboratory?testing?must?be?certified?for?any?
performed?services.?Reimbursement?for?laboratory?testing?is?not?eligible?to?any?facility?without?
Clinical?Laboratory?Improvement?Amendments?(CLIA)?certification?and?a?valid?CLIA?identification?
number.?
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?Primary?Care?Dentist?
(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.?
Anesthesia??
Horizon?NJ?Health?considers?the?administration?of?local?anesthesia?part?of?the?operative?or?
surgical?procedure?and?does?not?allow?additional?reimbursement.?When?a?dentist?provides?
general?anesthesia?in?a?hospital?setting,?reimbursement?is?subject?to?demonstrating?dental?or?
medical?necessity.?
Reimbursement?is?made?only?to?a?dentist?who?satisfies?all?established?rules?and?regulations?and?
holds?a?written?certification?(permit),?which?may?be?required?by?the?State?of?New?Jersey?or?state?
where?service?is?rendered.?When?the?attending?dentist?performing?the?dental?service?also?
administers?the?general?anesthesia,?the?provider?should?submit?procedure?code?D9223.??
When?a?dentist?administers?the?general?anesthesia?whose?sole?function?is?to?administer?general?
anesthesia,?Horizon?NJ?Health?reimburses?the?service?if:??

? Anesthetic?management?is?necessary?to?perform?restorative?dentistry?alone?or?
restorative?dentistry?in?conjunction?with?other?dental?services.?

? The?documentation?contains?unique?general?anesthesia?codes.?
? An?anesthesia?record?is?maintained?and?submitted?with?the?current?ADA?Claim?Form?for?

anesthesia?and?treatment.?The?anesthesia?record?must?contain?the?elapsed?anesthesia?
time,?specific?time?and?amounts?of?drugs?administered,?pulse?rate?and?character,?blood?
pressure,?and?respiration.?(Note:?The?elapsed?anesthesia?time?means?the?time?from?
induction?of?the?general?anesthesia?to?the?point?in?time?when?the?anesthetist?is?no?
longer?in?personal?attendance).?

? ?



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Intravenous?Sedation??
Horizon?NJ?Health?reimburses?the?administration?of?intravenous?sedation?as?follows:?

? This?sedation?is?administered?continuously?during?the?operative?or?surgical?procedure.?
? We?offer?no?reimbursement?if?an?injection?is?administered?as?a?preoperative?medication.?
? The?practitioner?must?document?the?need?for?this?service.?
? Reimbursement?is?made?only?to?a?dentist?who?satisfies?all?established?rules?and?regulations,?

and?holds?a?written?certification?(permit),?which?may?be?required?by?the?State?of?New?Jersey?
or?state?where?service?is?rendered.?

Analgesia??
Horizon?NJ?Health?reimburses?an?inhalation?anesthetic?for?the?purposes?of?analgesia?as?part?of?an?
operative?or?surgical?procedure?as?follows:?

? Analgesia?is?administered,?as?needed,?continuously?during?the?operative?or?surgical?procedure.?
? We?offer?no?reimbursement?if?an?injection?is?administered?as?a?preoperative?medication.?
? The?practitioner?must?document?the?need?for?this?service.?
? Reimbursement?is?only?made?to?a?dentist?who?satisfies?all?established?rules?and?regulations,?

and?holds?a?written?certification?(permit),?which?may?be?required?by?the?State?of?New?Jersey?or?
state?where?service?is?rendered.?

? We?allow?only?one?charge?per?visit?for?analgesia.?
Injections??
Horizon?NJ?Health?reimburses?intradermal,?subcutaneous,?intramuscular,?and?intravenous?
injections?in?the?office?or?home?within?the?scope?of?accepted?dental?practice?as?follows:?

? Reimbursement?for?these?injections?applies?as?an?all?inclusive?flat?fee,?covering?both?the?cost?of?
the?service?and?the?drug.?

? A?dental?visit?for?the?sole?purpose?of?an?injection?is?reimbursable?for?only?the?injection.?If?other?
reimbursable?dental?procedures?are?performed,?we?reimburse?the?injection?when?medically?
necessary?as?well?as?the?other?procedures.?The?administered?drug?must?be?consistent?with?the?
diagnosis?and?conform?to?accepted?medical?and?pharmacological?principles?in?respect?to?dosage,?
frequency,?and?route?of?administration.?

? Intravenous?injections?are?reimbursable?only?when?performed?by?the?dentist.?
? We?do?not?reimburse?for?vitamins,?liver,?or?iron?injections?or?combinations?thereof?except?in?

laboratory?proven?deficiency?states?requiring?parenteral?therapy.?
? We?do?not?reimburse?placebos?or?any?injections?containing?amphetamines?or?derivatives?thereof.?
? We?do?not?reimburse?an?injection?administered?as?a?preoperative?medication?in?conjunction?with?

general?anesthesia?or?local?anesthetic?as?part?of?an?operative?or?surgical?procedure.?
? Annotate?the?Remarks?section?in?the?current?ADA?Claim?Form?with?the?following?items:?the?

appropriate?procedure?code,?name?of?the?injected?drug,?dosage,?route?of?administration,?and?the?
complete?diagnosis?for?the?injection.?

Horizon?NJ?Health?considers?drugs,?biologicals,?or?supplies?used,?administered,?or?provided?by?the?dentist?
part?of?the?professional?service,?and?does?not?allow?additional?reimbursement?for?them.?



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Orthodontic?Services??
The?following?standards?and?procedures?apply?to?the?provision?of?orthodontic?services?for?
children?in?NJ?FamilyCare?programs.??
Orthodontic?Consultation?(D9310) - must?include?a?visual?examination?and?may?also?include?a?
completed?HLD?(NJ?Mod3)?Assessment?Tool?by?the?attending?provider?or?a?provider?in?the?same?
group.?This?consultation?does?not?require?prior?authorization,?can?be?provided?once?a?year?and?
will?be?linked?to?the?provider?and?not?to?the?patient?(which?allows?for?a?second?opinion?with?a?
different?provider).
?
Pre?Orthodontic?Treatment?Visit?(D8660) - includes?the?diagnostic?workup,?clinical?evaluation,?
orthodontic?treatment?plan?and?completion?of?HLD?(NJ?Mod3)?assessment?tool.??
?
The?HLD?(NJ?Mod3)?is?only?required?for?consideration?of?comprehensive?orthodontic?treatment.?
The?HLD?(NJ?Mod3)?is?completed?by?the?dentist?that?will?be?rendering?the?orthodontic?treatment.??
?
If?the?HLD?(NJ?Mod3)?Assessment?Tool?has?an??X??and?correctly?documented?clinical?criteria?
found?in?sections1?6A?and?15?of?the?assessment?tool?or?a?total?score?that?is?equal?to?or?greater?
than?26,?the?pre?orthodontic?treatment?work?up?can?proceed.?A?total?score?of?less?than?26?points?
on?the?HLD?(NJ?Mod3)?Assessment?Tool?requires?documentation?of?the?extenuating?
circumstances,?functional?difficulties?and/or?medical?anomaly?be?included?in?the?submission.??

? The?visit?does?not?require?prior?authorization?and?should?occur?with?the?expectation?that?
the?case?will?be?completed?prior?to?the?client?exceeding?the?age?of?eligibility?for?the?
benefit;??

? This?service?can?be?provided?once?a?year?and?will?be?linked?to?the?provider?and?not?to?
the?patient;??

? The?orthodontic?work?up?includes?the?consultation;?therefore,?consultation?will?not?be?
reimbursed?separately.??

Minor?Treatment?to?Control?Harmful?Habits??
Minor?treatment?can?be?used?for?the?correction?of?oral?habits?in?any?dentition.?Approval?for?
treatment?to?control?harmful?habits?when?not?part?of?a?limited,?interceptive?or?comprehensive?
case?will?include?appliances,?removable?or?fixed,?insertion,?all?adjustments,?repairs,?removal,?
retention?and?treatment?visits?to?the?provider?of?placement.?Replacement?of?appliances?due?to?
loss?or?damage?beyond?repair?is?allowed?once?and?thereafter?requires?prior?authorization?and?
can?be?considered?with?documentation?of?incident?and?documentation?of?medical?necessity.??
?
For?prior?authorization,?a?narrative?of?the?clinical?findings,?treatment?plan,?estimated?treatment?
time?with?prognosis?and?diagnostic?photographs?and/or?models?shall?be?submitted?and?
maintained?in?the?treatment?records.??

Upon?completion?of?the?case?pre?treatment?and?post?treatment?photographs?must?be?
submitted. ? ?



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Orthodontic?Treatment?Services??
Limited,?interceptive?and?comprehensive?orthodontic?services?must?be?prior?authorized?and?will?
be?considered?for?the?treatment?of?the?primary?dentition,?permanent?dentition?or?mixed?
dentition?for?treatment?of?the?permanent?teeth.?
Prior?authorization?determinations?shall?be?made?and?notice?sent?to?the?provider?within?ten?(10)?
days?of?receipt?of?all?necessary?information?sufficient?for?a?dental?consultant?to?make?an?
informed?decision.??
In?cases?where?prior?authorization?is?denied,?the?denial?decision?must?be?made?by?an?
orthodontist.?The?denial?letter?must?contain?a?detailed?explanation?of?the?reason(s)?for?denial;?
indicate?whether?additional?information?is?needed?and?the?process?for?reconsideration.?It?must?
also?include?the?name?and?contact?information?of?the?orthodontic?consultant?that?reviewed?and?
denied?the?treatment?request?which?will?allow?the?treating?provider?an?opportunity?to?discuss?
the?case.??
An?approved?case?must?be?started?within?six?(6)?months?of?receiving?the?approval.??
Limited?Orthodontic?Treatment??
Limited?orthodontic?treatment?can?be?considered?for?treatment?not?involving?the?entire?
dentition?and?can?be?used?for?corrections?in?any?dentition.??
For?prior?authorization,?the?following?shall?be?submitted:??

? Narrative?of?clinical?findings,?treatment?plan?and?estimated?treatment?time??
? Diagnostic?photographs??
? Diagnostic?X?rays?or?digital?films?
? Diagnostic?study?models?or?diagnostic?digital?study?cast?images?
? The?referring?primary?care?dentist?must?provide?attestation?that?all?needed?preventive?

and?dental?treatment?services?have?been?completed.?A?copy?must?be?submitted?with?the?
orthodontic?treatment?request.??

The?reimbursement?for?the?service?includes?the?appliance,?insertion,?all?adjustments,?repairs,?
removal,?retention?and?treatment?visits?to?the?provider?of?placement.?Therefore,?the?case?shall?
be?completed?even?if?eligibility?is?terminated?at?no?additional?charge?to?the?member.?
Replacement?of?retainers?or?removable?appliances?due?to?loss?or?damage?beyond?repair?requires?
prior?authorization?and?can?be?considered?with?documentation?of?medical?necessity.??
If?it?is?determined?that?limited?orthodontic?treatment?is?part?of?a?comprehensive?treatment?plan?
which?will?occur?within?less?than?12?months,?it?will?be?considered?part?of?the?comprehensive?case?
and?will?not?be?reimbursed?separately.?In?this?case,?the?prior?authorization?should?be?submitted?
for?comprehensive?orthodontic?treatment?with?an?attached?treatment?plan?that?indicates?the?
limited?treatment?phase?including?the?expected?time?frame?for?this?and?the?expected?initiation?
(month/year)?of?the?comprehensive?treatment.?Upon?completion?of?the?case,?pre?treatment?and?
post?treatment?photographs?must?be?submitted.?? ?



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Interceptive?and?Comprehensive?Orthodontic?Treatment??
For?prior?authorization?requests?the?following?shall?be?submitted:??

? The?completed?HLD?(NJ?Mod3)?assessment?tool?for?comprehensive?orthodontic?
treatment?

? Narrative?of?clinical?findings?for?dysfunction?and?dental?diagnosis??
? The?interceptive?or?comprehensive?orthodontic?treatment?plan?and?estimated?treatment?

time??
? Attestation?from?the?referring?primary?care?dentist?that?all?needed?preventive?and?dental?

treatment?services?have?been?completed??
? Diagnostic?study?models?or?diagnostic?digital?study?models??
? Diagnostic?photographs?(which?may?suffice?in?place?of?models)?
? Diagnostic?x?rays,?digital?x?rays?or?cephlometric?film?with?tracing?(when?applicable);?and?
? When?applicable:??

o Medical?diagnosis?and?surgical?treatment?plan??
o Detailed?documentation?of?extenuating?circumstances?
o Detailed?documentation?from?a?mental?health?professional?as?described?in?the?

managed?care?contract?indicating?the?psychological?or?psychiatric?diagnosis,?
treatment?history?and?prognosis?and?an?attestation?stating?and?substantiating?
that?orthodontic?correction?will?result?in?a?favorable?prognosis?of?the?mental/?
psychological?condition.??

Interceptive?Orthodontics??
Interceptive?treatment?can?be?considered?for?localized?tooth?movement?and?may?be?for?
redirection?of?ectopic?eruptions,?correction?of?dental?crossbites?or?recovery?of?space?in?the?
primary?or?transitional?dentition.?Approval?for?the?interceptive?treatment?when?not?part?of?the?
comprehensive?case?will?include?all?appliances,?insertion,?all?adjustments,?repairs,?removal,?
retention?and?treatment?visits?and?initial?retainers?to?the?provider?of?placement.?Replacement?of?
retainers?or?removable?appliances?due?to?loss?or?damage?beyond?repair?requires?prior?
authorization?and?documentation?of?medical?necessity.??
If?it?is?determined?that?interceptive?orthodontic?treatment?is?part?of?a?comprehensive?treatment?
plan?which?will?occur?within?less?than?12?months,?it?will?be?considered?part?of?the?comprehensive?
case?and?will?not?be?reimbursed?separately?In?this?case,?the?prior?authorization?should?be?
submitted?for?comprehensive?orthodontic?treatment?with?an?attached?treatment?plan?that?
indicates?the?interceptive?treatment?phase,?including?the?expected?time?frame?and?expected?
initiation?(month/year)?of?comprehensive?treatment.
Upon?completion?of?the?case,?pre?treatment?and?posttreatment?diagnostic?photographs?must?be?
submitted.?? ?



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Comprehensive?Orthodontics??
Eligibility?should?be?checked?prior?to?each?visit.??
The?NJFC?Medicaid?Fee?for?Service?(FFS)?program?reimburses?for?periodic?treatment?visits?
(D8670)?which?are?billed?for?the?date?of?service.?A?maximum?of?36?units?of?D8670?are?allowed?for?
each?comprehensive?orthodontic?case,?which?is?expected?to?last?no?longer?than?36?months?from?
the?date?of?banding.??
The?reimbursement?for?comprehensive?treatment?is?requested?using?the?date?the?appliances?are?
placed?and?billed?as?D8080.?The?date?of?each?periodic?visit?(D8670)?is?billed?separately?on?the?
date?of?service.?Services?reimbursed?through?these?codes?will?include?all?appliances,?their?
insertions,?adjustments,?repairs?and?removal?as?well?as?the?retention?phase?of?treatment?to?the?
provider?of?placement.??
Initial?retainer(s)?are?included?with?the?service;?however?replacement?of?retainers?or?removable?
appliances?due?to?loss?or?damage?beyond?repair?is?allowed?once.?If?additional?replacements?are?
needed,?the?service?requires?prior?authorization?and?can?be?considered?with?documentation?of?
the?incident?and?medical?necessity.?
Reimbursement?for?orthodontic?services?includes?the?placement?and?removal?of?all?appliances?
and?brackets;?therefore?should?it?become?necessary?to?remove?the?bands?following?or?due?to?
loss?of?eligibility,?non?compliance?or?elective?discontinuation?of?treatment?by?the?parent,?
guardian?or?patient?the?appliance?shall?be?removed?with?no?additional?reimbursement?to?the?
provider?of?placement?because?reimbursement?for?comprehensive?orthodontics?includes?this?
service.?In?cases?where?treatment?is?discontinued,?a??Release?from?Treatment??letter?must?be?
provided?by?the?dental?office?which?documents?the?reason?for?discontinuing?care?and?releases?
the?dentist?from?the?responsibility?of?completing?the?case.?The?release?form?must?be?reviewed?
and?signed?by?the?parent/guardian?and?patient,?and?a?copy?maintained?in?the?patient?s?records.??
Requesting?Prior?Authorization?
Prior?authorization?for?comprehensive?orthodontic?treatment?will?only?be?considered?for?the?
permanent?dentition.?As?an?exception,?cases?with?late?mixed?dentition?will?require?
documentation?of?the?planned?treatment?for?the?existing?primary?teeth?and?the?reason?for?
starting?treatment?prior?to?their?natural?exfoliation.??
Beginning?Treatment?

? In?addition?to?submission?requirements?already?noted,?the?prior?authorization?form?to?
request?the?beginning?phase?of?treatment?should?be?completed?for?procedure?code?
D8080?and?the?treatment?visits?with?a?maximum?number?of?units?for?treatment?visits?to?
be?considered?on?any?one?prior?authorization?being?twelve?(12)?

? The?case?start?date?is?considered?to?be?the?banding?date?which?must?occur?within?six?(6)?
months?of?approval??

? If?the?prior?authorization?expires?before?all?approved?units?are?used,?a?prior?authorization?
may?be?submitted?for?the?remaining?units?along?with?an?explanation?that?includes?the?
original?prior?authorization?number?and?why?treatment?did?not?occur?within?the?active?
time?of?the?prior?authorization.?? ?



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Continuing?Treatment??
? Prior?authorization?for?the?continuation?of?treatment?visits?for?the?continuation?of?the?

case?shall?be?submitted?after?completing?the?first?twelve?(12)?units?of?treatment?visits?or?
at?the?mid?point?of?treatment.??

? The?maximum?number?of?additional?treatment?visits?allowed?to?continue?the?case?is?
twelve?(12).??

? If?the?prior?authorization?expires?before?all?approved?units?were?used,?a?prior?
authorization?may?be?submitted?for?the?remaining?units?along?with?an?explanation?that?
includes?the?original?prior?authorization?number?and?why?treatment?did?not?occur?within?
the?active?time?of?the?prior?authorization.??

? The?following?shall?be?included?with?the?prior?authorization?request:??
o A?copy?of?the?treatment?notes??
o Documentation?of?any?problems?with?compliance??

? Attestation?from?the?current?primary?care?dentist?that?recall?visits?occurred?and?that?all?
needed?preventive?and?dental?treatment?services?have?been?completed??

? Pre?treatment?and?current?treatment?diagnostic?photographs?and/or?diagnostic?
panoramic?radiographs?to?show?status?and?to?demonstrate?case?progression??

? A?copy?of?the?initial?approval?if?the?case?was?started?under?a?different?NJ?FamilyCare?
Medicaid?MCO?or?fee?for?service?program??

Prior?Authorization?for?Orthodontic?Services?Transferred?or?Started?Outside?of?the?NJ?FamilyCare?
Medicaid?Program??
For?continuation?of?care?for?transfer?cases?whether?they?were?or?were?not?started?by?another?NJ?
FamilyCare?Medicaid?provider,?a?prior?authorization?must?be?submitted?to?request?the?remaining?
treatment?visits?to?continue?a?case?with?a?maximum?of?twelve?(12)?per?prior?authorization?to?be?
considered.?The?following?must?be?submitted?with?the?prior?authorization:??

? A?copy?of?the?initial?orthodontic?case?approval?(if?applicable)??
? Attestation?from?the?referring?or?treating?primary?care?dentist?that?preventive?and?dental?

treatment?services?have?been?completed??
? A?copy?of?the?orthodontic?treatment?notes?from?provider?that?started?the?case?(if?

available)??
? Recent?diagnostic?photographs?and/or?panoramic?radiographs?and?if?available?pre?

treatment?photographs??
? The?date?when?active?treatment?was?started??
? The?expected?number?of?months?to?complete?the?case?along?with?the?number?of?units?for?

treatment?visits?with?maximum?number?of?24?units?allowed??
? If?applicable?a?new?treatment?plan?and?documentation?to?support?the?treatment?change?

if?re?banding?is?planned.??
A?case?in?treatment?cannot?be?denied?if?the?patient?is?eligible?for?orthodontic?coverage?based?on?age.??



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Orthognathic?Surgical?Cases?with?Comprehensive?Orthodontic?Treatment??
? The?surgical?consult,?treatment?plan?and?approval?for?surgical?case?must?be?included?with?

the?request?for?prior?authorization?of?the?orthodontic?services;??
? Prior?authorization?and?documentation?requirements?are?the?same?as?those?for?

comprehensive?treatment?and?shall?be?submitted?by?the?treating?orthodontist;??
? The?parent/guardian?and?patient?should?understand?that?loss?of?eligibility?at?any?time?during?

treatment?will?result?in?the?loss?of?all?benefits?and?payment?by?the?NJFC?Medicaid?program.??
Conclusion?of?Active?Treatment?

? Attestation?of?case?completion?must?be?submitted?to?document?that?active?treatment?
had?a?favorable?outcome?and?that?the?case?is?ready?for?retention.??

? Procedure?code?D8680,?orthodontic?retention,?shall?be?submitted?for?prior?authorization?
along?with?recent?panorex?and?photographs?when?the?active?phase?of?orthodontic?
treatment?is?completed.??

? Once?approved,?the?bands?can?be?removed?and?the?case?placed?in?retention.??
Documentation?for?Completion?of?Comprehensive?Cases???Final?Records??
The?following?must?be?submitted?to?document?the?completion?of?comprehensive?cases:??

? Final?diagnostic?photographs?and/or?panoramic?radiograph??
? Final?diagnostic?study?models?or?diagnostic?digital?study?models?must?be?taken?and?be?

available?upon?request.??
If?this?is?not?received,?reimbursement?provided?may?be?recovered?until?required?documentation?
is?submitted.??
Behavior?Not?Conducive?to?Favorable?Treatment?Outcomes??
It?is?the?expectation?that?the?case?selection?process?for?orthodontic?treatment?takes?into?
consideration?the?patient?s?ability,?over?the?course?of?treatment?to:??

? Tolerate?the?treatment??
? Keep?multiple?appointments?over?several?years??
? Maintain?an?oral?hygiene?regimen,?and??
? Be?cooperative?and?complete?all?needed?preventive?and?treatment?visits??

If?it?is?determined?that?treatment?is?not?progressing?because?the?patient?is?exhibiting?non?
compliant?behavior?which?may?include?any?of?the?following:?multiple?missed?orthodontic?or?
general?dental?appointments,?continued?poor?oral?hygiene,?failure?to?maintain?the?appliances?or?
untreated?dental?disease,?discontinuation?of?treatment?can?be?considered.??
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A?letter?must?be?sent?to?the?parent/guardian?and/or?patient?that?documents?the?factors?of?
concern,?the?corrective?actions?needed?and?informs?that?failure?to?comply?can?result?in?the?
discontinuation?of?treatment?with?de?banding.?A?copy?of?this?letter?and?the?patient?treatment?
records?must?be?sent?to?Horizon?NJ?Health,?1700?American?Blvd.,?Pennington,?NJ,?08534.?
If?the?case?is?discontinued?for?reasons?other?than?the?completion?of?treatment?(D8695),?the?
?Release?from?Treatment??letter?should?be?signed?by?parent/guardian?and/or?patient.?For?
members?enrolled?in?Horizon?NJ?Health,?a?copy?of?the?signed?form?and?the?patient?treatment?
records?must?be?sent?to?Horizon?NJ?Health,?1700?American?Blvd.,?Pennington,?NJ,?08534.?
The?reimbursement?for?appliance?placement?includes?their?removal;?however,?prior?authorization?
to?allow?reimbursement?can?be?considered?when?removal?is?by?a?provider?that?did?not?start?the?
case.?
? ?



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Instructions?for?Completing?the?New?Jersey?Orthodontic?Evaluation?HLD?(NJ?Mod3)?Index?Form:?
The?intent?of?the?HLD?(NJ?Mod3)?Index?is?to?measure?the?presence?or?absence?and?the?degree?of?
the?handicap?caused?by?the?components?to?be?scored?with?the?index?and?NOT?to?diagnose?
Malocclusion.?Presence?of?any?of?the?conditions?sections?1?through?6A?and?15,?or?a?score?total?
equal?to?or?greater?than?26?(when?scored?correctly)?qualifies?for?medical?necessity?exception.?Total?
scores?less?than?26?with?extenuating?circumstances?must?include?appropriate?documentation.?
?
GENERAL?INFORMATION:?

? Only?cases?with?late?mixed?and?permanent?dentition?will?be?considered?(see?Pre?
orthodontic?Treatment?Visit?(D8660)?for?exception).?

? A?Boley?Gauge?or?disposable?ruler?scaled?in?millimeters?should?be?used;?
? The?patient?s?teeth?are?positioned?in?centric?occlusion;?
? All?measurements?are?recorded?and?rounded?off?to?the?nearest?millimeter?(mm);?
? For?sections?1?to?6A?and?15?an?X?is?placed?if?the?condition?exists?and?scoring?is?completed,?

as?needed;?
? For?sections?6B?to?14,?indicate?the?measurement?or?if?a?condition?is?absent,?a?0?score?is?

entered;?
? Diagnostic?models?are?required?with?the?submission?of?prior?authorization.?Casts?must?be?

properly?poured,?adequately?trimmed?without?voids?or?bubbles??and?marked?for?centric?
occlusion;?or,?

? Diagnostic?Digital?models?may?be?submitted?to?show?right?and?left?lateral,?frontal?and?
posterior?and?maxillary?and?mandibular?occlusal?views;?

? Diagnostic?quality?photographs?to?show?facial,?frontal?and?profile,?intra?oral?front,?left?and?
right?side,?maxillary?and?mandibular?occlusal?views?(minimum?of?seven?views).?
Photographs?shall?include?views?with?a?millimeter?ruler?in?place?to?demonstrate?
measurement?for?the?following?condition(s)?when?present?as?found?in?sections?6A,?6B,?7,?
8,?9?and?13.?

INSTRUCTIONS?FOR?FORM?COMPLETION:?
1.??Cleft?Palate?Deformity???acceptable?documentation?must?include?at?least?one?of?the?following:?
intraoral? photographs? of? the? palate,?written? consultation? report? by? a? qualified? specialist? or?
craniofacial?panel.?Score?an?X?if?present.?
2.? ?Cranio?facial?Anomaly???acceptable?documentation?must? include?written? report?by?qualified?
specialist?or?craniofacial?panel?and?photographs.?Score?an?X?if?present.?
3.??Impacted?Permanent?Anterior?Teeth???demonstrate?that?anterior?tooth?or?teeth?(incisors?and?
cuspids)? is? or? are? impacted? (soft? or? hard? tissue);? not? indicated? for? extraction? and? treatment?
planned?to?be?brought?into?occlusion.?Arch?space?available?for?correction.?Score?an?X?if?present.?



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4.??Crossbite?of?Individual?Anterior?teeth???Score?an?X?if?present.???demonstrate?that?anterior?tooth?
or?teeth? (incisors?and?cuspids)? is?or?are? in?crossbite?resulting? in?occlusal?trauma?with?excessive?
wear,?significant?mobility?or?soft?tissue?damage.?A?narrative?to?include?the?class?of?mobility?for?the?
involved?teeth?and?photographs?of?all?areas?with? softtissue?damage.?Score?X?as?noted.? If?these?
conditions?do?not?exist,?it?is?to?be?considered?an?ectopic?eruption?and?scored?in?section?10.?
5.?Severe?Traumatic?Deviation???damage?to?skeletal?and?or?soft?tissue?as?a?result?of?trauma?or?other?
gross?pathology.?Include?written?report?and?intraoral?photographs.??Score?an?X?if?present.?
6A.?Overjet?greater?than?9mm?or?mandibular?protrusion?(reverse?overjet)?greater?than?3.5???Overjet?
is?recorded?with?the?patient?s?teeth? in?centric?occlusion?and? is?measured?from?the? labial?of?the?
lower?incisors?to?the?labial?of?the?corresponding?upper?central?incisors.?This?measurement?should?
record?the?greatest?distance?between?any?one?upper?central?incisor?and?its?corresponding?lower?
central?or? lateral? incisor.? If? the?overjet? is?greater? than?9mm?or?mandibular?protrusion? (reverse?
overjet)?is?greater?than?3.5mm,?score?an?X?if?present.?
6B.?Overjet?equal? to?or? less? than?9mm???Overjet? is? recorded?as? in?condition? in?section?6A.?The?
measurement?is?rounded?to?the?nearest?millimeter?and?entered?on?the?score?form.?
7.?Overbite? ?? A? pencil?mark? on? the? tooth? indicating? the? extent? of? the? overlap? facilitates? the?
measurement.?It?is?measured?and?rounded?off?the?nearest?millimeter?and?entered?on?the?score?
form.?
8.??Mandibular?protrusion?(reverse?overjet)?equal?to?or?less?than?3.5?mm???Mandibular?protrusion?
(reverse?overjet)?is?recorded?as?a?condition?and?rounded?to?the?nearest?millimeter.?Enter?the?score?
on?the?form?and?multiply?the?measurement?by?five?(5).?
9.??Open?Bite?in?millimeters???This?condition?is?defined?as?the?absence?of?occlusal?contact?in?the?
anterior?region.? It? is?measured?from?the? incisal?edge?of?a?maxillary?central? incisor?to?the? incisal?
edge?of?a?corresponding?mandibular?incisor,?in?millimeters.?Enter?the?measurement?on?the?score?
form?and?multiply?the?measurement?by?four?(4).? If?measurement? is?not?possible,?measurement?
can?usually?be?estimated.?
10.?Ectopic?Eruption???Count?each?tooth,?excluding?third?molars.?Each?qualifying?tooth?must?be?
more?than?50%?blocked?out?of?the?arch.?Enter?the?number?of?qualifying?teeth?on?the?score?form?
and?multiply?by?three?(3).?If?anterior?crowding?(see?condition?12)?also?exists?in?the?same?arch,?score?
the?condition?that?produces?the?most?points.?DO?NOT?COUNT?BOTH?CONDITIONS.?The?exception?
to? this? rule? is:? (a)?posterior?ectopic?eruptions? in? the? same?arch? (b)? if?ectopic?eruption? score? is?
transferred?due? to?anterior?crossbite?without? trauma,?excessive?wear?of?mobility.? In? these? two?
exceptions,?count?ectopic?eruption?PLUS?the?crowding.?
11.?Deep?Impinging?Overbite???This?occurs?when?either?destruction?of?soft?tissue?on?palate,?
gingival?recession?and?mobility?and/or?abrasion?of?teeth?are?present.?Submit?intraoral?
photographs?of?tissue?damage/impingment.?The?presence?of?deep?impinging?overbite?is?
indicated?by?a?total?score?of?three?(3)?on?the?score?form.? ?



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12.?Anterior?Crowding???Arch?length?insufficiency?must?exceed?3.5?mm.?Mild?rotations?are?not?to?
be?scored?as?crowded.?Score?one?(1)?crowding?per?arch.?Enter?thetotal?on?score?form?and?
multiply?the?measurement?by?five?(5).?If?ectopic?eruption?is?scored?in?section?10?(not?from?
crossbite?in?section?4)?this?crowding?cannot?be?scored?in?addition.?However?if?ectopic?eruption?is?
due?to?a?transfer?of?score?from?section?4?to?section?10,?because?crossbite?did?not?result?in?
damage,?both?ectopic?and?crowding?can?be?counted.?
13.?Labio?Lingual?Spread???A?Boley?Gauge?(or?disposable?ruler)?is?used?to?determine?the?extent?of?
deviation? from?a?normal?arch.?Where? there? is?only?a?protruded?or? lingually?displaced?anterior?
tooth,?the?measurement?should?be?made?from?the?incisal?edge?of?that?tooth?to?the?normal?arch?
line.?Otherwise,? the? total?distance?between? the?most?protruded? anterior? tooth? and? the?most?
lingually? displaced? adjacent? anterior? tooth? is? measured.? In? the? event? that? multiple? anterior?
crowding?of?teeth? is?observed,?all?deviations?from?the?normal?arch?should?be?measured?for?the?
labio?lingual?spread,?but?only?the?most?severe?individual?measurement?should?be?entered?on?the?
score?form.?
14.?Posterior?Unilateral?Crossbite???This?condition? involves? two?or?more?adjacent? teeth,?one?of?
which?must?be?a?molar.?The?crossbite?must?be?one?in?which?the?maxillary?posterior?teeth?involved?
may?either?be?both?palatal?or?both?completely?buccal?in?relation?to?the?mandibular?posterior?teeth.?
The?presence?of?posterior?unilateral?crossbite?is?indicated?by?a?total?score?of?four?(4)?on?the?score?
form.?THERE?IS?NO?ADDITIONAL?SCORE?FOR?BI?LATERAL?CROSSBITE.?
15.? Psychological? factors? affecting? child?s? development? ?? This? condition? requires? detailed?
documentation?by? a?mental?health?provider?as?described? in? the?NJFC?Medicaid?managed? care?
contract?that?contains?the?psychological?or?psychiatric?diagnosis,?treatment?history?and?prognosis.?
An? attestation? from? the?mental?health?provider?must? state? and? substantiate? that?orthodontic?
correction?will?result?in?a?favorable?prognosis?of?the?mental/psychological?condition.?
? ?



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?



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Clinical?Criteria?Descriptions?
Horizon?NJ?Health?clinical?criteria?for?determining?medical?necessity?were?developed?from?
information?collected?from?American?Dental?Association's?Code?Manuals,?clinical?articles?and?
guidelines,?as?well?as?dental?schools,?practicing?dentists,?insurance?companies,?other?dental?
related?organizations,?and?local?state?or?health?plan?requirements.?A?number?of?procedures?
require?prior?authorization?before?initiating?treatment.?When?submitting?authorization?requests?
for?these?procedures,?note?the?documentation?requirements,?and?include?required?
documentation?when?submitting?authorizations?to?Horizon?NJ?Health.??
Horizon?NJ?Health?reviewers?use?the?following?clinical?criteria?to?approve?authorization?requests.?
Crowns?/?onlays?/?coping??

? Minimum?50%?bone?support?
? No?periodontal?furcation?
? No?subcrestal?caries?
? Clinically?acceptable?RCT?if?present?
? Planned?RCT?if?necessary?
? Anterior???50%?incisal?edge?/?4+?surfaces?involved?
? Bicuspid???1?cusp?/?3+?surfaces?involved?
? Molar???2?cusps?/?4+?surfaces?involved?
? Member?s?home?care?and?long?term?prognosis?of?restoration?must?be?considered?when?

requesting?prior?authorization?for?crown?
Additional?procedures?to?construct?new?crown?under?existing?partial?

? Documentation?supports?procedure,?missing?teeth?on?at?least?one?side?of?requested?
crown.?

Root?canals??
? Minimum?50%?bone?support?
? No?periodontal?furcation?
? No?subcrestal?caries?
? Evidence?of?apical?pathology/fistula?
? Pain?from?percussion/temperature?
? Closed?apex?
? Member?s?home?care?and?long?term?prognosis?of?restoration?must?be?considered?when?

requesting?prior?authorization?for?root?canal,?retreatment?of?root?canal?
? ?



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Apexification?/?recalcification??
? Minimum?50%?bone?support?
? Evidence?of?apical?pathology/fistula?
? Evidence?of?deep?caries/restoration,?fracture,?near?pulpal?exposure?with?open?apex?
? Percussion?or?temperature?with?open?apex?
? File?X?ray?with?claim?

Apicoectomy?/?periradicular?services?
? Minimum?50%?bone?support?
? History?of?RCT?
? Apical?pathology?

Retrograde?filling?
? History?of?apicoectomy?

Gingivectomy?or?gingivoplasty??
? Hyperplasia?or?hypertrophy?from?drug?therapy,?hormonal?disturbances,?or?congenital?

defects?
? Generalized?5?mm?or?more?pocketing?indicated?on?the?perio?charting?
? Member?s?home?care?and?long?term?perio?prognosis?must?be?considered?when?

requesting?prior?authorizations?for?periodontal?surgery;?Additional?consideration?should?
be?given?to?members?who?are?compliant?with?exams,?prophys,?and?X?rays?

Gingival?flap?procedure?(D4240)?
? Perio?classification?of?Type?III?or?IV?
? Lack?of?attached?gingiva?
? Member?s?home?care?and?long?term?perio?prognosis?must?be?considered?when?

requesting?prior?authorizations?for?periodontal?surgery;?Additional?consideration?should?
be?given?to?members?who?are?compliant?with?exams,?prophys,?and?X?rays?

Crown?Lengthening?(D4249)?
? Documentation?supports?procedure,?greater?than?50%?bone?support?after?surgery?due?to?

coronal?fracture/caries?and?not?on?same?day?as?restoration?preparation?
? Member?s?home?care?and?long?term?perio?prognosis?must?be?considered?when?

requesting?prior?authorizations?for?periodontal?surgery;?Additional?consideration?should?
be?given?to?members?who?are?compliant?with?exams,?prophys,?and?X?rays?

? ?



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Osseous?Surgery?(D4260,?D4261)?
? History?of?periodontal?scaling?and?root?planing?
? No?previous?recent?history?of?osseous?surgery?
? Perio?classification?of?Type?III?or?IV?
? Member?s?home?care?and?long?term?perio?prognosis?must?be?considered?when?

requesting?prior?authorizations?for?periodontal?surgery;?Additional?consideration?should?
be?given?to?members?who?are?compliant?with?exams,?prophys,?and?X?rays?

? Provider?must?submit?an?attestation?stating?member?s?home?care?is?excellent?and?
member?is?compliant?3?6?weeks?after?D4341?or?D4342;?Can?allow?only?one?quadrant?of?
surgery?and?then?follow?up?with?the?same?documentation?before?allowing?additional?
quadrants?

Bone?Replacement?Graft?(D4263,?D4264)?
? Documentation?supports?need?to?correct?bone?defect.?
? Tooth?must?be?present?and?not?allowed?in?area?of?missing?tooth?or?extraction?on?same?

date?of?service?
Biologic?Materials?(D4265)?

? Biologic?materials?to?aid?in?soft?and?osseous?tissue?regeneration?
Guided?Tissue?Regeneration?(D4266,?D4267)?

? Documentation?supports?need?in?conjunction?with?bone?replacement?or?to?correct?
deformities?resulting?from?inadequate?faciolingual?bone?

? Member?s?home?care?and?long?term?perio?prognosis?must?be?considered?when?
requesting?prior?authorizations?for?periodontal?surgery;?Additional?consideration?should?
be?given?to?members?who?are?compliant?with?exams,?prophys,?and?X?rays?

Surgical?Revision?(D4268)?
? Documentation?supports?need?to?refine?results?of?previous?surgical?procedure.?

Pedicle?Soft?Tissue?Graft?(D4270)?
? Cover?exposed?root;?eliminate?gingival?defect?

Connective?Tissue?Graft?(D4273,?D4276,?D4277,?D4278,?D4283,?D4285)?
? Eliminate?root?sensitivity?
? Eliminate?frenum?pull?
? Extend?vestibule?
? Cover?gingival?interface?with?restoration?
? Cover?bone?or?ridge?regeneration?site?

? ?



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Distal?or?Proximal?Wedge?(D4274)?
? No?history?of?D4260?or?D4261?within?12?months?
? More?than?50%?bone?to?remain?after?procedure?
? To?expose?coronal?fracture?or?caries?but?not?on?same?day?as?restorative?procedure?

Soft?tissue?Allograft?(D4275)?
? Eliminate?frenum?pull?
? Extend?vestibule?
? Eliminate?gingival?recession?

Splinting?(D4320,?D4321)?
? Documentation?supports?need?for?procedure?(i.e.,?facial?trauma,?accident,?etc.)?
? Scaling?and?root?planing?

Scaling?and?root?planing?(D4341,?D4342)?
? D4341?

o Four?or?more?teeth?in?the?quadrant?
o 5?mm?pocketing?on?4?or?more?teeth?indicated?
o Presence?of?root?surface?calculus?and/or?noticeable?loss?of?bone?support?on?X?rays?

? D4342?
o One?to?three?teeth?in?the?quadrant?
o 5?mm?pocketing?on?1?or?more?teeth?indicated?
o Presence?of?root?surface?calculus?and/or?noticeable?loss?of?bone?support?on?X?rays?

Localized?Delivery?of?Antimicrobial?Agents?(D4381)?
? Documentation?supports?need?for?procedure.?

Periodontal?maintenance??
? History?of?active?treatment/D4910?within?last?36?months,?not?sooner?than?90?days?(if?

history?alternate?to?prophy)?
Full?dentures??

? Existing?denture?greater?than?7.5?years?old??
? Remaining?teeth?do?not?have?adequate?bone?support?or?are?non?restorable?

Immediate?Denture?(D5130,?D5140)?
? Remaining?teeth?do?not?have?adequate?bone?support?or?are?non?restorable?

? ?



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Partial?dentures??
? Less?than?8?points?of?contact?on?posterior?teeth?
? 8?points?of?contact?must?produce?a?balanced,?functional?occlusion?
? If?one?partial?makes?the?mouth?meet?criteria,?than?one?partial?allowed?and?the?other?denied?
? If?one?or?more?anterior?max?or?mand?tooth?missing?or?will?be?extracted?regardless?of?

posterior?teeth?
? Existing?partial?denture?greater?than?7.5?years?old?
? Remaining?teeth?have?greater?than?50%?bone?support?and?are?restorable?for?cast?partials,?

otherwise?resin?partial?considered?
Full/partial?dentures?adjustments,?repairs,?replacement,?add?ons?(teeth?and?clasps)??

? Not?within?6?months?of?delivery?reline/rebase?or?3?months?of?D5510?or?D5610?
Rebase?/?reline?denture?/?tissue?conditioning?(D5710???D5851)?

? Documentation?supports?need?
? Not?within?12?months?of?delivery?except?for?D5130?and?D5140?

Overdenture?
? Remaining?teeth?supporting?overdenture?have?adequate?bone?support?

Pediatric?partial?denture?
? Documentation?indicates?missing?anterior?teeth?

Maxillofacial?prosthetics??
? Documentation?supports?need?

Surgical?Implants?/?abutments?/?maintenance?
? History?of?congenitally?missing?tooth?
? Healthy?bone?and?periodontia?
? History?of?the?inability?to?wear?a?full?upper?or?full?lower?denture?or?maxillofacial?

prosthesis?over?a?two?year?period;?by?report?
? Surgical?implant?present?or?approved?
? Documentation?supports?medical?necessity?
? Implants?are?only?allowed?under?specific?circumstances?of?having?a?facial?anomaly?or?

deformity?or?being?edentulous?with?a?history?of?inability?to?function?with?complete?
dentures?for?at?least?two?years?

Pontics?/?Crowns?
? Only?allowed?when?replacing?a?defective?bridge;?New?bridge?must?be?exactly?like?the?

existing?bridge.?Cannot?extend?to?add?additional?teeth?
? Minimum?50%?bone?support?
? Clinically?acceptable?RCT?if?present?
? Planned?RCT?if?necessary? ?



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Connector?bar?/?stress?breaker?/?precision?attachment?/?re?cement?/?coping?/?repair?
? Attachment?will?significantly?enhance?function?
? Documentation?is?self?explanatory?as?to?procedure?code?
? Crowns?present?on?X?rays?or?approved?authorization?for?crown?
? Documentation?describes?medical?necessity?

Fixed?partial?denture?repair,?by?report??
? Documentation?describes?medical?necessity.?
? Not?within?6?months?of?delivery?

Impacted?teeth???(asymptomatic?impactions?will?not?be?approved)?(D7220,?D7230,?D7240,?
D7241)?

? Documentation?describes?pain,?swelling,?etc.,?around?tooth?(must?be?symptomatic)?and?
documentation?noted?in?patient?record?

? Documentation?supports?procedure?for?unusual?surgical?complications?(D7241)?
? X?rays?match?type?of?impaction?code?described?

Surgical?removal?of?residual?tooth?roots??
? Tooth?root?is?completely?covered?by?tissue?on?x?ray?
? Documentation?describes?pain,?swelling,?etc.,?around?tooth?and?documentation?noted?in?

patient?record?
Oroantral?fistula?closure?/?sinus?perforation?

? Documentation?supports?procedure.?
Tooth?reimplantation?and/or?stabilization?

? Documentation?supports?procedure.?
Surgical?access?of?an?unerupted?tooth?

? Documentation?supports?impacted/unerupted?tooth?
? Tooth?is?beyond?one?year?of?normal?eruption?pattern?

Mobilization?of?erupted?tooth?
? Documentation?supports?procedure?

Placement?of?device?to?facilitate?eruption?
? Documentation?supports?procedure?

Biopsy?/?exfoliative?cytological?sample?collection?
? Documentation?supports?procedure?

Surgical?Repositioning?of?Teeth?
? Documentation?supports?procedure?

? ?



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Harvest?of?bone?
? Documentation?indicates?autogenous?grafting?procedure?that?does?not?include?harvest?of?

bone?
Alveoloplasty?

? Documentation?supports?procedure?
Excision?of?lesion?/?tumor??

? Documentation?supports?procedure?
Excision?of?bone?tissue?

? Documentation?supports?procedure?
Radical?resection?of?maxilla?or?mandible?

? Documentation?supports?procedure?
Incision?/?drain?abscess?

? Documentation?supports?procedure?
Removal?of?foreign?body?/?reaction?producing?foreign?bodies?

? Documentation?supports?procedure?
Partial?ostectomy?

? Documentation?supports?procedure?
Maxillary?sinusotomy?

? Documentation?supports?procedure?
Fractures??simple?/?compound?

? Documentation?supports?procedure?
Arthroscopy?

? Documentation?supports?procedure?
Reduction?and?dislocation?and?management?of?TMJ?dysfunctions?

? Documentation?supports?history?of?TMJ?pain?
? Not?for?bruxism?

Suture?repairs?
? Documentation?describes?accident?
? Not?for?tooth?extraction?or?to?close?surgical?incision?

Skin?Graft?
? Documentation?describes?location?and?type?of?graft?

Osteoplasty?/?osteotomy?
? Documentation?describes?and?supports?congenital?defect?condition? ?



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Other?repair?procedure?(Oral?&?Maxillofacial?Surgery)?
? Narrative,?X?rays,?or?photos?support?medical?necessity?for?procedure?

Frenulectomy?
? Documentation?describes?tongue?tied,?diastema,?or?tissue?pull?condition?

Frenuloplasty?
? Documentation?indicates?frenum?will?be?repositioned?instead?of?being?excised?

Excision?of?hyperplastic?tissue?
? Documentation?describes?medical?necessity?due?to?ill?fitting?dentures?

Excision?of?pericoronal?gingiva?
? Documentation?shows?tissue?partially?covers?occlusal?surface?

Surgical?reduction?of?fibrous?tuberosity?
? Documentation?indicates?medical?necessity?need?for?future?denture?placement?

Sialolithotomy?/?excision?of?salivary?gland?/?sialodochoplasty?/?closure?of?salivary?fistula?
? Narrative,?X?rays,?or?photos?support?medical?necessity?for?procedure?

Emergency?tracheotomy?
? Narrative,?X?rays,?or?photos?support?medical?necessity?for?procedure?

Coronoidectomy?
? Narrative,?X?rays,?or?photos?support?medical?necessity?for?procedure?

Synthetic?Graft?/?Implant?Mandible?for?augmentation?/?appliance?removal?/?intraoral?
placement?of?a?fixation?device?

? Narrative,?X?rays,?or?photos?support?medical?necessity?for?procedure?
Unspecified?Oral?Surgery?Procedure?

? Narrative,?X?rays,?or?photos?support?medical?necessity?for?procedure?
Limited?Orthodontic?Treatment?

? Partial?treatment?to?correct?crowding?in?one?arch?
? Minor?tooth?movement?
? Up?righting?teeth?
? Rotating?teeth?
? Opening?space(s)?
? Closing?space(s)?
? Palatal?expansion,?skeletal?disharmonies,?space?deficiency?to?lessen?future?effects?of?

malformation?dentition?(primary?/?transitional?dentition)?
? ?



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Comprehensive?Orthodontic?Treatment?
? Case?must?be?submitted?for?authorization?a?minimum?of?36?months?prior?to?age?limit?for?

this?benefit?
Appliance?Therapy?

? Documentation?of?thumb?sucking?or?tongue?thrusting?habit?
? Not?covered?in?conjunction?with?interceptive?/?comprehensive?ortho?

Pre?Orthodontic?Treatment?
? Narrative,?X?rays,?or?photos?support?medical?necessity?for?procedure?
? Mid?course?treatment?evaluation???For?additional?retention?payments?beyond?first?12?

payments?
Orthodontic?Retention?

? Documentation?substantiating?completed?orthodontic?treatment?
Removable?Retainer?Adjustment?

? History?of?removable?retainer?insertion?
Repair?/?Replacement?of?Orthodontic?Appliance?

? Documentation?of?an?active?ortho?case?
Unspecified?Orthodontic?Procedure,?by?report?

? Documentation?supports?need?for?transfer?case?
General?anesthesia?/?IV?sedation?(Dental?Office?Setting)?1?or?more?of?the?criteria?below?

? Extractions?of?impacted?teeth?or?unerupted?cuspids?or?wisdom?teeth?or?surgical?exposure?
of?unerupted?cuspids?

? 2?or?more?extractions?in?2?or?more?quadrants?
? 4?or?more?extractions?in?1?quadrant?
? Excision?of?lesions?greater?than?1.25?cm?
? Surgical?recovery?from?the?maxillary?antrum?
? Documentation?that?patient?is?less?than?9?years?old?with?extensive?treatment?(described)?
? Documentation?of?failed?local?anesthesia?and?documentation?noted?in?patient?record?
? Documentation?of?situational?anxiety?and?documentation?noted?in?patient?record?
? Documentation?and?narrative?of?medical?necessity?supported?by?submitted?medical?

records?(cardiac,?cerebral?palsy,?epilepsy,?or?condition?that?would?render?patient?
noncompliant)?

? ?



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Non?intravenous?conscious?sedation?(Dental?Office?Setting)???1?or?more?of?the?following?criteria??
? Extractions?of?impacted?or?unerupted?cuspids?or?wisdom?teeth?or?surgical?exposure?of?

unerupted?cuspids?
? 2?or?more?extractions?in?2?or?more?quadrants?
? 4?or?more?extractions?in?1?quadrant?
? Excision?of?lesions?greater?than?1.25?cm?
? Surgical?recovery?from?the?maxillary?antrum?
? Documentation?that?patient?is?less?than?9?years?old?with?extensive?treatment?(described)?
? Documentation?of?failed?local?anesthesia?and?documentation?noted?in?patient?record?
? Documentation?of?situational?anxiety?and?documentation?noted?in?patient?record?
? Documentation?and?narrative?of?medical?necessity?supported?by?submitted?medical?records?

(cardiac,?cerebral?palsy,?epilepsy?or?condition?that?would?render?patient?noncompliant)?
House/Extended?Care?Facility?Call?(D9410)?

? Documentation?and?narrative?of?medical?necessity?supported?by?submitted?medical?records?
Hospital?Call?(D9420)?

? Use?for?OR?(Hospital?Operating?Room?or?Outpatient?Facility)?request??
? Patient?under?the?age?of?6?years?with?extensive?treatment?needed??
? Documentation?supports?indication?of?patient?with?a?medical?condition?(cardiac,?cerebral?

palsy,?epilepsy),?or?other?condition?that?would?render?the?patient?non?compliant?
Therapeutic?drug?injection?

? Documentation?and?narrative?of?medical?necessity?supported?by?submitted?medical?records?
Behavior?Management?

? Documentation?(treatment?history)?supports?indication?of?non?cooperative?child?under?
the?age?of?9?years?

? Documentation?supports?indication?of?patient?with?a?medical?condition?(cardiac,?cerebral?
palsy,?epilepsy),?or?other?condition?that?would?render?the?patient?non?compliant?

? Not?in?conjunction?with?D9223?or?D9243;?Two?units?allowed?per?same?date?of?service?
Treatment?of?complications?(post?surgical)?

? By?report?
Occlusal?Guard?to?include?adjustments?

? Removable?dental?appliances,?which?were?designed?to?minimize?the?effects?of?bruxism?
and?other?occlusal?factors?

Unspecified?procedures,?by?report?
? By?report?

OR?(Hospital?Operating?Room?or?Outpatient?Facility)?request???use?D9999?
? Patient?under?the?age?of?6?years?with?extensive?treatment?needed?
? Documentation?supports?indication?of?patient?with?a?medical?condition?(cardiac,?cerebral?

palsy,?epilepsy),?or?other?condition?that?would?render?the?patient?non?compliant?



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Glossary?
Definitions??
Unless?the?context?in?this?manual?clearly?indicates?otherwise,?these?terms?are?defined?as?follows.?
Abuse.?Provider?practices?inconsistent?with?sound?fiscal,?business,?or?medical?practices?that?
result?in?unnecessary?costs?to?the?Medicaid?or?NJ?FamilyCare?program,?or?reimbursement?for?
services?that?are?not?medically?necessary,?or?services?that?fail?to?meet?professionally?recognized?
standards?for?health?care.?(See?42?C.F.R.???455.2.)?
Clinical?Laboratory?Services.?Professional?and?technical?laboratory?services?ordered?by?a?dentist?
within?the?scope?of?practice?as?defined?by?the?laws?of?the?state?in?which?the?dentist?practices.?
Concurrent?Care.?A?type?of?service?rendered?to?a?member?by?practitioners?when?dental?necessity?
requires?the?service?of?dentists?of?different?specialties?and?the?Primary?Care?Dentist.?
Consultation.?A?service?rendered?by?a?qualified?dentist,?upon?the?request?of?another?practitioner,?
to?evaluate?through?personal?examination?of?the?member,?history,?physical?finding,?and/or?other?
ancillary?means,?the?nature?and?progress?of?a?dental?or?related?disease,?illness?or?condition,?
and/or?establish?or?confirm?a?diagnosis,?determine?the?prognosis,?and/or?suggest?treatment.?
(Note:?A?consultation?should?not?be?confused?with??referral?for?treatment??when?one?
practitioner?refers?a?member?to?another?practitioner?for?either?specific?or?general?treatment.?
Examples?include:??Endodontic?treatment?on?teeth?Nos.?3?and?5,???Extract?teeth?Nos.?7,?8,?9,?and?
10,??or??Extract?tooth?or?teeth?causing?pain.?)?
Cultural?Competency.?A?set?of?interpersonal?skills?that?allow?individuals?to?increase?their?
understanding,?appreciation,?acceptance?of?and?respect?for?cultural?differences?and?similarities?
within,?among?and?between?groups?and?the?sensitivity?to?how?these?differences?influence?
relationships?with?enrollees.?This?requires?a?willingness?and?ability?to?draw?on?community?based?
values,?traditions?and?customs,?to?devise?strategies?to?better?meet?culturally?diverse?enrollee?
needs,?and?to?work?with?knowledgeable?persons?of?and?from?the?community?in?developing?
focused?interactions,?communications,?and?other?supports.?
Dental?Records.?The?complete,?comprehensive?records?of?dental?services,?to?include?date?of?
service/visit,?chief?complaint,?treatment?needed,?treatment?planned?and?treatment?provided?
during?each?patient?visit.?The?dental?record?shall?include?charting?of?the?existing?dentition,?hard?
and?soft?tissue?findings,?completed?assessment?tools?and?diagnostic?images?to?include?
radiographs?and?digital?views?as?well?as?photographs?where?medically?necessary.?Dental?records?
shall?also?be?kept?in?compliance?with?all?DMAHS?and?NJ?State?Board?of?Dentistry?regulations.?The?
dental?record?is?to?be?accessible?at?the?office/clinic?location?of?Member?s?participating?dentist?
and?also?in?the?records?of?a?residential?facility?for?those?Members?residing?in?a?facility.?Providers?
who?render?dental?services?in?other?settings?such?as?in?an?operating?room?shall?also?include?a?
record?that?documents?provided?treatment?in?the?Member?s?dental?record?located?in?the?
office/clinic.?
? ?



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Dental?Review.?The?current,?ongoing?quality?review?of?the?delivery?of?continuing?dental?services?
and?health?care,?which?is?constantly?monitored?and?maintained?by?the?provision?of?direction,?
coordination,?and?regulation.?
Dental?Services.?Any?diagnostic,?preventive,?or?corrective?procedures?administered?by?or?under?
the?direct?personal?supervision?of?a?dentist?in?the?practice?or?the?practitioner?s?professional?
specialty.?(These?services?include:?treatment?of?the?teeth;?associated?structures?of?the?oral?cavity?
and?contiguous?tissues;?and?the?treatment?of?disease,?injury,?or?impairment,?which?may?affect?
the?oral?or?general?health?of?the?individual.?Such?services?maintain?a?high?standard?of?quality?
within?reasonable?limits?and?are?typically?available?to?most?persons?in?the?community.)?
Direct?Personal?Supervision.?The?actual?physical?presence?of?the?dentist?on?the?premises.?
Early?and?Periodic?Screening,?Diagnostic?and?Treatment?(EPSDT).?A?Title?XIX?mandated?program?
that?covers?screening?and?diagnostic?services?to?determine?physical?and?mental?defects?in?
enrollees?under?the?age?of?21,?and?health?care,?treatment,?and?other?measures?to?correct?or?
ameliorate?any?defects?and?chronic?conditions?discovered,?pursuant?to?Federal?Regulations?
found?in?Title?XIX?of?the?Social?Security?Act.?
Emergency?Dental.?A?specific?condition?of?the?oral?cavity?and/or?contiguous?tissues?that?causes?
severe?pain,?intractable?pain,?and/or?compromises?the?life,?health,?or?safety?of?the?member?
unless?treated?immediately.?(Examples?include:?pain?or?acute?infection?from?a?restorable?or?non?
restorable?tooth;?pain?resulting?from?injuries?to?the?oral?cavity?and?related?structures;?extensive,?
abnormal?bleeding;?fractures?of?the?maxilla,?mandible,?or?related?structures;?or?dislocation?of?the?
mandible.)?
General?Dentist/Primary?Care?Dentist.?Dentist?who?assumes?responsibility?for?the?primary?and?
continuing?dental?care?of?the?member.?
Horizon?NJ?Health.?A?Medicaid?managed?care?organization?and?a?product?of?Horizon?HMO.?
Managed?Care.?A?comprehensive?approach?to?the?provision?of?health?care?committed?to?
combining?clinical?preventive,?restorative,?and?emergency?services,?as?well?as?administrative?
procedures?within?an?integrated,?coordinated?system?to?provide?timely?access?to?primary?care?
and?other?medically?necessary?healthcare?services?in?a?cost?effective?manner.?
Medically?Necessary?Services.?Services?or?supplies?necessary?to?accomplish?the?following:?
prevent,?evaluate,?diagnose,?correct,?prevent?the?worsening?of,?alleviate,?ameliorate,?or?cure?a?
physical?or?mental?illness?or?condition;?maintain?health;?prevent?the?onset?of?an?illness,?
condition,?or?disability;?prevent?or?treat?a?condition?that?endangers?life,?causes?suffering?or?pain,?
or?results?in?illness?or?infirmity;?prevent?the?deterioration?of?a?condition;?promote?the?
development?or?maintenance?of?maximal?functioning?capacity?in?performing?daily?activities,?
taking?into?account?functional?capacities?of?the?individual?and?other?individuals?of?the?same?age;?
prevent?or?treat?a?condition?that?threatens?to?cause?or?aggravate?a?handicap,?cause?physical?
deformity,?or?malfunction.?(Note:?There?is?no?other?equally?effective,?more?conservative?or?
substantially?less?costly?course?of?treatment?available?or?suitable?for?the?enrollee.)?? ?



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The?services?provided,?as?well?as?the?type?of?provider?and?setting,?must?reflect?the?level?of?
services?that?can?be?safely?provided,?support?the?diagnosis?of?the?condition,?and?remain?
appropriate?to?the?specific?medical?needs?of?the?enrollee.?Services?should?exist?in?accordance?
with?standards?of?good?medical?practice?and?be?recognized?as?effective?by?the?medical?scientific?
community,?and?they?should?not?be?initiated?solely?for?the?convenience?of?the?enrollee?or?
provider.?The?course?of?treatment?may?include?mere?observation?or,?where?appropriate,?no?
treatment?at?all.?Experimental?services?or?services?generally?regarded?by?the?medical?profession?
as?unacceptable?treatment?are?not?medically?necessary?for?purposes?of?the?Horizon?NJ?Health?
Dental?Program.?
Medically?necessary?services?are?based?on?peer?reviewed?publications,?expert?pediatric,?
psychiatric,?medical?opinion,?and?medical/pediatric?community?acceptance.?
For?pediatric?enrollees,?this?definition?applies?with?additional?criteria,?including?services?needed?
for?a?child?based?on?a?comprehensive?screening?visit?or?an?inter?periodic?encounter,?whether?or?
not?they?are?ordinarily?covered?services?for?all?other?Medicaid?enrollees,?appropriate?for?the?age?
and?health?status?of?the?individual,?aid?in?the?overall?physical?and?mental?growth?and?
development?of?the?individual,?and?achieve?or?maintain?functional?capacity.?
Member.?Anyone?enrolled?and?eligible?to?receive?services?provided?by?Horizon?NJ?Health.?
Mobile?Dental?Practice.?A?provider?traveling?to?various?locations?and?utilizing?portable?dental?
equipment?as?their?primary?method?of?delivering?dental?services.?They?shall?only?provide?dental?
services?to?facilities?and?residences.?They?cannot?provide?dental?services?at?a?school,?with?the?
exception?of?school?health?fairs,?where?they?can?provide?screenings?and?findings?summaries?to?
parents/guardians,?school?nurses?and?assist?patients?with?referrals?to?a?dental?home.?
Facilities:?These?providers?are?expected?to?provide?on?site?comprehensive?dental?care?(to?include?
intra?oral?radiographs),?necessary?dental?referrals?to?general?dentist?or?specialists?and?
emergency?dental?care?in?accordance?with?all?New?Jersey?State?Board?of?Dentistry?regulations?
and?the?NJ?FamilyCare?Managed?Care?Contract.?The?sites?served?by?the?Mobile?Dental?Practice?
must?allow?Member?access?to?treatment?and?allow?for?continuity?of?care.?
Residences:?These?providers?are?expected?to?provide?on?site?dental?care?for?the?homebound?
based?on?patient?safety?and?ability?to?tolerate?procedures?outside?of?a?clinical?setting.?
The?Contractor?is?responsible?for?assisting?the?Member,?family,?facility?or?school?in?locating?a?
dentist?when?referrals?are?issued.?Patient?records?must?be?maintained?at?the?facility?when?this?is?
a?long?term?care?facility,?skilled?nursing?facility?or?school?and?duplicates?may?also?be?maintained?
in?a?central?and?secure?area?in?accordance?with?State?Board?of?Dentistry?regulations.?The?Mobile?
Dental?Practice?must?submit?documentation?to?the?Contractor?of?all?locations?they?visit?and?
serve,?and?include?the?days?and?times?for?each?location,?except?when?a?visit?is?to?a?residence.?
? ?



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Mobile?Dental?Van.?A?vehicle?specifically?equipped?with?stationary?dental?equipment?and?is?used?
to?provide?dental?services?within?the?van.?A?mobile?dental?van?is?not?to?be?considered?a?dental?
practice.?Providers?using?a?mobile?dental?van?to?render?dental?services?must?also?be?associated?
with?a?dental?practice?that?is?located?in?a??brick?and?mortar??facility?located?in?New?Jersey?that?
serves?as?a?dental?home?offering?comprehensive?care,?emergency?care?and?appropriate?dental?
specialty?referrals?to?the?mobile?dental?van?s?patients?of?record?(Members).?They?must?
demonstrate?their?ability?to?render?dental?treatment?services?and?assist?with?dental?referrals?as?
needed.?
An?exception?from?these?requirements?can?be?considered?for?providers?using?mobile?dental?vans?
that?demonstrate?they?are?only?providing?dental?services?to?NJ?FamilyCare?Members?residing?in?a?
long?term?care?facility?or?who?are?homebound.?
The?distance?between?the?dental?practice?and?the?sites?and?locations?served?by?the?mobile?
dental?van?must?not?be?a?deterrent?to?the?Member?accessing?treatment?and?allow?for?continuity?
of?care?by?meeting?the?network?standards?for?distance?in?miles?as?described?in?section?4.8.8?
Provider?Network?Requirements.?
When?a?mobile?dental?van?is?used?for?school?visits,?health?fairs?or?other?one?time?events,?services?
will?be?limited?to?oral?screenings,?exams,?fluoride?varnish/topical?fluoride?treatment,?prophylaxis?
and?palliative?care?to?treat?an?acute?condition.?State?Board?regulations?must?still?be?followed?and?
patient?records?are?to?be?maintained?in?accordance?with?State?Board?of?Dentistry?regulations.?
Providers?utilizing?Mobile?Dental?Vans?must?submit?to?the?Contractor?documentation?of?all?
locations?they?will?visit?including?the?days?and?times?(except?when?visits?are?to?homebound?
members).?
Non?Routine?Dental?Service.?Any?dental?service?that?requires?prior?authorization?by?a?Horizon?NJ?
Health?Dental?Consultant?in?order?to?be?reimbursed?by?Horizon?NJ?Health.?
Participating?Dentist.?Any?dentist?licensed?and?currently?registered?to?practice?dentistry?by?the?
licensing?agency?of?the?state?where?the?dental?services?are?rendered,?who?accepts?the?
requirements?of?the?New?Jersey?Division?of?Medical?Assistance?and?Health?Services?(DMAHS),?
and?signs?an?agreement?with?Horizon?NJ?Health?for?the?purpose?of?treating?Horizon?NJ?Health?
members.?
Peer?Review.?The?evaluation?by?practicing?dentists?and?other?healthcare?providers?as?to?the?
quality?and?efficiency?of?services?ordered?and/or?performed?by?other?practicing?dentists,?as?well?
as?the?all?inclusive?term?for?dental?review?efforts,?including?dental?practice?analysis,?inpatient?
hospital?and?extended?care?utilization?review,?and?dental?claims?audit?and?review.?
Prior?Authorization.?Approval?by?a?Horizon?NJ?Health?Dental?Consultant?before?a?service?is?
rendered.?
Program.?The?Horizon?NJ?Health?Managed?Dental?Program.?
? ?



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Quality.?The?standard?of?dental?care?or?degree?of?excellence?generally?prevailing?throughout?the?
profession?by?those?who?provide?similar?services,?not?related?to?any?geographical?area?or?
population?group?when?judged?by?competent?practitioners?who?are?qualified?to?perform?those?
procedures.?
Referral.?Directing?a?member?from?one?participating?dentist?to?another?for?diagnosis?and/or?
treatment?though?not?required?for?the?purpose?of?claim?payments.?
Routine?Dental?Service.?Any?dental?service?reimbursable?by?the?program?without?authorization?by?
a?Horizon?NJ?Health?Dental?Consultant.?
Specialist.?A?dentist?licensed?to?practice?dentistry?in?the?state?where?treatment?is?rendered?that?
limits?the?practice?to?a?single?specialty?recognized?by?the?American?Dental?Association?and?
registered?with?the?licensing?agency?in?the?state.?
Transfer.?Relinquishing?responsibility?for?continuing?care?of?a?member?from?one?dentist?to?
another?dentist.?
Urgent?Dental?Care.?Care?for?a?specific?condition?of?the?oral?cavity?and/or?contiguous?tissues?that?
not?compromise?the?life,?health,?or?safety?of?the?member?if?not?treated?immediately.?(Examples?
include:?a?fractured?tooth?with?no?pulpal?involvement,?a?broken?denture,?denture?adjustments,?
and?recementation?of?a?crown.)?
Utilization.?The?service,?procedure,?or?item?provided?to?a?member?by?a?qualified?physician?or?
healthcare?professional,?in?a?setting,?at?a?time,?and?in?an?amount?appropriate?and?acceptable?to?
the?standards?of?the?profession.?
Utilization?Review.?The?retrospective?analysis?of?a?dentist?s?performance?for?evaluation?of?the?
efficient?provision?of?dental?services.?
? ?



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Benefit?Plan?Details?&?
Authorization?Requirements?
The?following?benefit?plan?details?and?related?authorization?requirements?apply?to?the?Horizon?
NJ?Health?Dental?Program?benefit?plans.?The?three?types?of?plans?include?Non?Special?Needs?
Plans,?Special?Needs?Plans,?and?Not?Payable?Plans.?All?members?of?New?Jersey?FamilyCare?have?
the?same?dental?benefit?package.??
Horizon?Non?Special?Needs?Plans??

? FamilyCare?A?
? FamilyCare?ABP?
? FamilyCare?B?
? FamilyCare?C?
? FamilyCare?D?
? MLTSS???Custodial???Nursing?Facility?with?Medicare?
? MLTSS???Custodial???Nursing?Facility?without?Medicare?
? MLTSS???Home?and?Community?based?Services?(HCBS)?with?Medicare?
? MLTSS???Home?and?Community?based?Services?(HCBS)?without?Medicare?
? MLTSS???Specialty?Care???Nursing?Facility?with?Medicare???Other?
? MLTSS???Specialty?Care???Nursing?Facility?with?Medicare?Ventilator?and/or?Pediatric?
? MLTSS???Specialty?Care???Nursing?Facility?without?Medicare???Other?
? MLTSS???Specialty?Care???Nursing?Facility?without?Medicare?Ventilator?and/or?Pediatric?

Horizon?Special?Needs?Plans??
? FIDE?SNP???Aged,?Blind,?and?Disabled?(ABD)?
? FIDE?SNP???MLTSS???Home?and?Community?based?Services?(HCBS)?
? FIDE?SNP???MLTSS???Nursing?Facility?
? FIDE?SNP???MLTSS???Pediatric?Ventilator?Specialty?Care???Nursing?Facility?
? FIDE?SNP???MLTSS???Specialty?Care???Nursing?Facility?
? Existing?Medicaid???Special?Needs?
? Medicaid?Expansion???Special?Needs?

Note:?Members?enrolled?in?Horizon?Special?Needs?plans?may?qualify?for?additional?frequency?of?
some?services.?A?provider?shall?contact?the?Dental?Director?if?a?member?is?not?enrolled?in?a?
special?needs?benefit?plan,?but?based?on?clinical?experience?the?provider?has?grounds?to?believe?
the?member?has?special?needs.?? ?



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? The?provider?shall?provide?narrative?of?medical?necessity?requesting?the?member?receive?the?
enhanced?special?needs?benefit?for?a?particular?service?and?date?of?service.??

? If?approved,?the?Dental?Director?will?notify?SKYGEN?USA?to?allow?the?special?needs?level?of?
service?for?that?particular?service?and?date?of?service??

? The?provider?will?work?with?SKYGEN?USA?Provider?Services?to?submit?that?claim?accordingly.?
Horizon?Not?Payable?Plans??

? Acute?Care?Inpatient???Fee?for?Service?(FFS)?Only?
? DEEM*???Aged,?Blind,?and?Disabled?(ABD)?
? DEEM*???Home?and?Community?based?Services?(HCBS)?
? DEEM*???Nursing?Facility?
? DEEM*???Pediatric?Ventilator?Specialty?Care???Nursing?Facility?
? DEEM*???Specialty?Care???Nursing?Facility?

*?The??DEEM??classification?indicates?that?such?members?have?lost?their?Medicaid?coverage?and?cannot?receive?any?Medicaid?
benefits?during?the?60?days?in?which?they?are??deemed?ineligible.???
Note:?The?Not?Payable?Plans?are?not?payable?and?provided?for?plan?use?only.?Therefore,?all?claims?
submitted?for?these?plans?will?be?denied.?Treatments?should?not?be?performed?when?they?are?
designated?for?one?of?these?benefit?plans.?As?a?result,?there?are?no?relevant?codes?for?these?plans?
in?the?Dental?Benefit?Schedule.?Please?verify?the?member?s?eligibility?online?or?by?calling?
Members?Services?before?designating?them?for?one?of?these?benefits?and?to?establish?member?s?
possible?eligibility?through?another?NJ?FamilyCare?health?plan.??
Dental?Benefit?Schedule?
The?Horizon?NJ?Health?Plan?includes?Medicaid?benefits?for?the?Horizon?NJ?Health?Dental?Program.?
In?the?following?tables,?if?Yes?is?indicated?in?the?Auth?Req?column,?then?a?service?requires?a?prior?
authorization.?If?documentation?is?indicated?in?the?Requirement?column,?then?supporting?
documentation?is?required?before?the?authorization?can?be?approved?or?the?claim?can?be?paid.?
When?a?prior?authorization?is?required,?submit?it?(along?with?any?required?documentation)?to?
Horizon?NJ?Health?for?approval?before?beginning?non?emergency?or?routine?treatment.?If?
immediate?treatment?is?required?in?an?emergency?situation,?submit?required?documentation?
with?the?claim?after?treatment.??
Members?have?the?option?to?obtain?a?second?opinion?for?diagnosis?and?treatment?of?dental?
conditions?that?are?treated?within?a?dental?specialty.?
In?addition,?members?may?receive?a?second?opinion?within?Horizon?NJ?Health?s?network,?or?
Horizon?NJ?Health?may?arrange?for?the?member?to?obtain?for?a?second?opinion?outside?of?the?
network?with?no?cost?to?the?member.?
? ?



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Your?Benefits?and?Services?
What?Horizon?
NJ?Health?
Covers?

BENEFIT?PLAN?TYPE?
BENEFIT? NJ?

FAMILYCARE?
A?

NJ?
FAMILYCARE?

ABP?
NJ?

FAMILYCARE?B?
NJ?

FAMILYCARE?C?
NJ?FAMILYCARE?

D?
EPSDT??
(Early?and?
Periodic?
Screening,?
Diagnosis?&?
Treatment)?

Covered,?including?medical?exams,?dental,?vision,?hearing?and?lead?screening?
services.?Covered?for?treatment?services?identified?through?the?exam?

Orthodontic?
Services?

Coverage?is?limited?to?members?up?to?age?21?or?
loss?of?eligibility?who?require?these?services?due?
to?medical?need,?including?developmental?
problems?or?jaw?injury.?Prior?authorization?
required.?

Coverage?is?limited?to?members?
up?to?age?21?or?loss?of?eligibility?
who?require?these?services?due?
to?medical?need,?including?
developmental?problems?or?jaw?
injury,?with?a?$5?copayment?for?
Plans?C?and?D?only.?Prior?
authorization?required.?

?
For?more?information?on?Horizon?NJ?Health?benefits?and?services,?visit?
horizonNJhealth.com/covered_benefits.??
? ?



Horizon?NJ?Health?Dental?Program?
Benefit?Plan?Details?&?Authorization?Requirements?

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Horizon?NJ?Health?Dental?Program?
Note:?If?a?No?Special?Needs?or?Special?Needs?notice?appears?beneath?a?code?number?in?the?table,?the?code?number?and?its?accompanying?requirements?
are?only?applicable?to?the?designated?Non?Special?Needs?or?Special?Needs?plans.?If?neither?notice?appears,?the?code?number?applies?to?all?dental?plans.?
(Also,?there?are?no?applicable?codes?for?any?Not?Payable?Plans?in?the?Dental?Benefit?Schedule.)?
Please?be?aware?that?the?provision?of?dental?services?is?based?on?demonstrated?medical?necessity?and?EPSDT?requirements?(for?members?under?the?age?
of?twenty?one).???
All?denials?based?on?frequency?limits?can?be?appealed?with?appropriate?documentation?of?medical?necessity.?This?includes?those?codes?indicated?as?
?once?in?a?life?time?,?which?in?the?case?of?certain?endodontic,?periodontic?or?surgical?codes?refers?to?the?tooth?or?area?of?the?mouth?and?not?the?
procedure?itself.??

Dental?Benefit?Schedule?
Horizon?NJ?Health?Dental?Program:?Non?Special?Needs?Plans?&?Special?Needs?Plans?
Code? Description? Age? Tooth?/?

Quad?/?Arch?
Limitations? Auth?

Req?
Requirement?

D0120?
No?
Special?
Needs?

Periodic?oral?evaluation???
established?patient?

0?999? ?? Twice?per?floating?year?per?payee.?
Not?paid?on?same?date?of?service?as?D0140,?D0145,?
D0150,?D0180,?or?D0190.?
Not?paid?within?6?months?of?D0150.?

No? ??

D0120?
Special?
Needs?

Periodic?oral?evaluation???
established?patient?

0?999? ?? Four?per?floating?year?per?payee.?
Not?paid?on?same?date?of?service?as?D0140,?D0145,?
D0150,?D0180,?or?D0190.?
Not?paid?within?6?months?of?D0150.?

No? ??

D0140? Limited?oral?evaluation???
problem?focused?

0?999? ?? Twice?per?rolling?year?per?payee.?
Not?paid?on?same?date?of?service?as?D0120,?D0145,?
D0150,?D0180,?or?D0190.?

No? ??

D0145? Oral?evaluation?for?a?patient?
under?three?years?of?age?and?
counseling?with?primary?
caregiver?

0?2? ?? Twice?per?floating?year?per?payee.?
Not?paid?on?same?date?of?service?as?D0120,?D0140,?
D0150,?D0180,?or?D0190.?

No? ??



Horizon?NJ?Health?Dental?Program?
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Horizon?NJ?Health?Dental?Program:?Non?Special?Needs?Plans?&?Special?Needs?Plans?
Code? Description? Age? Tooth?/?

Quad?/?Arch?
Limitations? Auth?

Req?
Requirement?

D0150? Comprehensive?oral?
evaluation???new?or?
established?patient?

0?999? ?? One?per?36?months?per?payee.?
Not?paid?on?same?date?of?service?as?D0120,?D0140,?
D0145,?D0180,?or?D0190.?
Not?paid?within?6?months?of?D0120.?

No? ??

D0160? Detailed?and?extensive?oral?
evaluation???problem?
focused,?by?report?

0?999? ?? One?per?6?months?per?payee.?
D0220,?D0270,?D0277?and?D0330?are?the?only?other?
services?paid?for?on?same?date?of?service?per?payee.?

No? ??

D0170? Re?evaluation???limited,?
problem?focused?(established?
patient;?not?post?operative?
visit)?

0?999? ?? Twice?per?rolling?year?per?payee.?
D0220,?D0270,?D0277?and?D0330?are?the?only?other?
services?paid?for?on?same?date?of?service.?

No? ??

D0171? Re?evaluation???post?
operative?office?visit?

0?999? ?? Twice?per?rolling?year?per?payee.?
D0220,?D0270,?D0277?and?D0330?are?the?only?other?
services?paid?for?on?same?date?of?service.?

No? ??

D0180? Comprehensive?periodontal?
evaluation???new?or?
established?patient?

0?999? ?? One?per?36?months?per?payee.?
Not?paid?on?same?date?of?service?as?D0120,?D0140,?
D0145,?D0150?or?D0190.?

No? ??

D0190? Screening?of?a?patient? 0?19? ?? Once?per?rolling?year?per?payee.?
Not?paid?on?same?date?of?service?as?D0120,?D0140,?
D0145,?D0150,?or?D0180.?

No? ??

D0210? Intraoral???complete?series?of?
radiographic?images?

0?999? ?? One?per?36?months?per?payee.? No? ??

D0220? Intraoral???periapical?first?
radiographic?image?

0?999? ?? ?? No? ??

D0230? Intraoral???periapical?each?
additional?radiograph?image?

0?999? ?? ?? No? ??



Horizon?NJ?Health?Dental?Program?
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Horizon?NJ?Health?Dental?Program:?Non?Special?Needs?Plans?&?Special?Needs?Plans?
Code? Description? Age? Tooth?/?

Quad?/?Arch?
Limitations? Auth?

Req?
Requirement?

D0240? Intraoral???occlusal?
radiograph?image?

0?999? ?? Twice?per?floating?year?per?payee.? No? ??

D0250? Extraoral???first?radiograph?
image?

0?999? ?? Twice?per?rolling?year?per?payee.? No? ??

D0251? Extra?Oral?Posterior?Dental?
Radiographic?Image?

0?999? ? One?per?rolling?6?months?per?payee?(combined?with?
D0274).?

No? ?

D0260? Extraoral???each?additional?
radiograph?image?

0?999? ?? One?per?rolling?6?months?per?payee.? No? ??

D0270? Bitewing???single?radiograph?
image?

0?999? ?? Twice?per?rolling?6?months?per?payee.? No? ??

D0272? Bitewings???two?radiographic?
images?

0?999? ?? Twice?per?rolling?6?months?per?payee.? No? ??

D0273? Bitewings???three?
radiographic?images?

0?999? ?? Once?per?rolling?year?per?payee.? No? ??

D0274? Bitewings???four?radiographic?
images?

0?999? ?? Once?per?rolling?year?per?payee.? No? ??

D0277? Vertical?bitewings???7?to?8?
radiographic?images?

0?999? ?? Once?per?rolling?year?per?payee.? No? ??

D0310? Sialography? 0?999? ?? Documentation?supports?procedure.? Yes? Narrative?of?medical?
necessity?



Horizon?NJ?Health?Dental?Program?
Benefit?Plan?Details?&?Authorization?Requirements?

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Horizon?NJ?Health?Dental?Program:?Non?Special?Needs?Plans?&?Special?Needs?Plans?
Code? Description? Age? Tooth?/?

Quad?/?Arch?
Limitations? Auth?

Req?
Requirement?

D0320? Temporomandibular?joint?
arthrogram,?including?
injection?

0?999? ?? Documentation?supports?procedure.? Yes? Narrative?of?medical?
necessity?

D0321? Other?temporomandibular?
joint?radiographic?images,?by?
report?

0?999? ?? Documentation?supports?procedure.? Yes? Narrative?of?medical?
necessity?

D0322? Tomographic?survey? 0?999? ?? Documentation?supports?procedure.? Yes? Narrative?of?medical?
necessity?

D0330? Panoramic?radiographic?
image?

0?999? ?? One?per?36?months?per?payee.? No? ??

D0340? Cephalometric?radiographic?
image?

0?999? ?? One?per?36?months?per?payee.? No? ??

D0350? 2D?oral/facial?photographic?
image?obtained?intra???orally?
or?extra?orally?

0?999? ?? Four?per?rolling?year?per?payee.?
May?be?used?in?lieu?of?X?rays?for?services?rendered?in?
a?nursing?facility.?

No? ??

D0351? 3D?photographic?image? 0?999? ?? Once?per?rolling?year?per?payee.?
Allowed?in?conjunction?with?orthodontic?and/or?
orthognathic?procedure.?
Only?payable?to?oral?surgeons.?

Yes? Narrative?of?medical?
necessity?



Horizon?NJ?Health?Dental?Program?
Benefit?Plan?Details?&?Authorization?Requirements?

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Code? Description? Age? Tooth?/?

Quad?/?Arch?
Limitations? Auth?

Req?
Requirement?

D0364? Cone?beam?CT?capture?and?
interpretation?with?limited?
fields?of?view???less?than?one?
whole?jaw?

0?999? ?? Once?per?rolling?year?per?payee.?
Limited?to?specialists?only;?not?payable?to?general?and?
pediatric?dentists?and?pedodontists.?

Yes? PA?x?ray?and?narrative?of?
medical?necessity?

D0365? Cone?beam?CT?capture?and?
interpretation?with?field?of?
view?of?one?full?dental?arch???
mandible?

0?999? ?? Once?per?rolling?year?per?payee.?
Limited?to?specialists?only;?not?payable?to?general?and?
pediatric?dentists?and?pedodontists.?

Yes? PA?x?ray?and?narrative?of?
medical?necessity?

D0366? Cone?beam?CT?capture?and?
interpretation?with?field?of?
view?of?one?full?dental?arch???
maxilla,?with?or?without?
cranium?

0?999? ?? Once?per?rolling?year?per?payee.?
Limited?to?specialists?only;?not?payable?to?general?and?
pediatric?dentists?and?pedodontists.?

Yes? PA?x?ray?and?narrative?of?
medical?necessity?

D0367? Cone?beam?CT?capture?and?
interpretation?with?field?of?
view?of?both?jaws;?with?or?
without?cranium?

0?999? ?? Once?per?rolling?year?per?payee.?
Limited?to?specialists?only;?not?payable?to?general?and?
pediatric?dentists?and?pedodontists.?

Yes? PA?x?ray?and?narrative?of?
medical?necessity?

D0368? Cone?beam?CT?capture?and?
interpretation?for?TNJ?series?
including?two?or?more?
exposures?

0?999? ?? Once?per?rolling?year?per?payee.?
Limited?to?specialists?only;?not?payable?to?general?and?
pediatric?dentists?and?pedodontists.?

Yes? PA?x?ray?and?narrative?of?
medical?necessity?

D0369? Maxillofacial?MRI?capture?and?
interpretation?

0?999? ?? Documentation?supports?procedure.? Yes? Narrative?of?medical?
necessity?

D0370? Maxillofacial?ultrasound?
capture?and?interpretation?

0?999? ?? Documentation?supports?procedure.? Yes? Narrative?of?medical?
necessity?



Horizon?NJ?Health?Dental?Program?
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Horizon?NJ?Health?Dental?Program:?Non?Special?Needs?Plans?&?Special?Needs?Plans?
Code? Description? Age? Tooth?/?

Quad?/?Arch?
Limitations? Auth?

Req?
Requirement?

D0371? Sialoendoscopy?capture?and?
interpretation?

0?999? ?? Documentation?supports?procedure.? Yes? Narrative?of?medical?
necessity?

D0380? Cone?beam?CT?image?capture?
with?limited?field?of?view?less?
than?one?whole?jaw?

0?999? ?? Once?per?rolling?year?per?payee.?
Limited?to?specialists?only;?not?payable?to?general?and?
pediatric?dentists?and?pedodontists.?

Yes? PA?x?ray?and?narrative?of?
medical?necessity?

D0381? Cone?beam?CT?image?capture?
with?field?of?view?of?one?full?
dental?arch???mandible?

0?999? ?? Once?per?rolling?year?per?payee.?
Limited?to?specialists?only;?not?payable?to?general?and?
pediatric?dentists?and?pedodontists.?

Yes? PA?x?ray?and?narrative?of?
medical?necessity?

D0382? Cone?beam?CT?image?capture?
with?field?of?view?of?one?full?
dental?arch???maxilla,?with?or?
without?cranium?

0?999? ?? Once?per?rolling?year?per?payee.?
Limited?to?specialists?only;?not?payable?to?general?and?
pediatric?dentists?and?pedodontists.?

Yes? PA?x?ray?and?narrative?of?
medical?necessity?

D0383? Cone?beam?CT?image?capture?
with?field?of?view?of?both?
jaws,?with?or?without?cranium?

0?999? ?? Once?per?rolling?year?per?payee.?
Limited?to?specialists?only;?not?payable?to?general?and?
pediatric?dentists?and?pedodontists.?

Yes? PA?x?ray?and?narrative?of?
medical?necessity?

D0384? Cone?beam?CT?image?capture?
for?TMJ?series,?including?two?
or?more?exposures?

0?999? ?? Once?per?rolling?year?per?payee.?
Limited?to?specialists?only;?not?payable?to?general?and?
pediatric?dentists?and?pedodontists.?

Yes? PA?x?ray?and?narrative?of?
medical?necessity?

D0393? Treatment?simulation?using?
3D?image?volume?

0?999? ?? Documentation?supports?procedure.? Yes? Narrative?of?medical?
necessity?

D0394? Digital?subtraction?of?two?or?
more?images?or?image?
volumes?of?the?same?modality?

0?999? ?? Documentation?supports?procedure.? Yes? Narrative?of?medical?
necessity?



Horizon?NJ?Health?Dental?Program?
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Horizon?NJ?Health?Dental?Program:?Non?Special?Needs?Plans?&?Special?Needs?Plans?
Code? Description? Age? Tooth?/?

Quad?/?Arch?
Limitations? Auth?

Req?
Requirement?

D0395? Fusion?of?two?or?more?3D?
image?volumes?of?one?or?
more?modalities?

0?999? ?? Documentation?supports?procedure.? Yes? Narrative?of?medical?
necessity?

D0416? Viral?culture? 0?999? ?? Documentation?supports?procedure.? Yes? Narrative?of?medical?
necessity?

D0417? Collection?and?preparation?of?
saliva?sample?for?laboratory?
diagnostic?testing?

0?999? ?? Documentation?supports?procedure.? Yes? Narrative?of?medical?
necessity?

D0470? Diagnostic?casts? 0?999? ?? Documentation?supports?procedure;?digital?casts?only.? Yes? Narrative?of?medical?
necessity?

D0472? Accession?of?tissue,?gross?
examination,?and?preparation?
and?transmission?of?written?
report?

0?999? ?? Documentation?supports?procedure.? Yes? Narrative?of?medical?
necessity?

D0473? Accession?of?tissue,?gross?and?
microscopic?examination,?and?
preparation?and?transmission?
of?written?report?

0?999? ?? Documentation?supports?procedure.? Yes? Narrative?of?medical?
necessity?



Horizon?NJ?Health?Dental?Program?
Benefit?Plan?Details?&?Authorization?Requirements?

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Horizon?NJ?Health?Dental?Program:?Non?Special?Needs?Plans?&?Special?Needs?Plans?
Code? Description? Age? Tooth?/?

Quad?/?Arch?
Limitations? Auth?

Req?
Requirement?

D0474? Accession?of?tissue,?gross?and?
microscopic?examination,?
including?assessment?of?
surgical?margins?for?presence?
of?disease,?and?preparation?
and?transmission?of?written?
report?

0?999? ?? Documentation?supports?procedure.? Yes? Narrative?of?medical?
necessity?

D0480? Accession?of?exfoliate?
cytologic?smears,?microscopic?
examination,?and?preparation?
and?transmission?of?written?
report?

0?999? ?? Documentation?supports?procedure.? Yes? Narrative?of?medical?
necessity?

D0502? Other?oral?pathology?
procedures,?by?report?

0?999? ?? Documentation?supports?procedure.? Yes? Narrative?of?medical?
necessity?

D0601? Caries?risk?assessment?and?
documentation,?with?a?finding?
of?low?risk?

0?20? ?? Once?per?rolling?year?per?payee.?
If?medically?necessary,?a?second?risk?assessment?can?
be?approved?through?the?appeal?process.?
Only?allowed?on?the?same?date?of?service?as?D0120,?
D0145,?or?D0150?per?payee.?

No? ??

D0602? Caries?risk?assessment?and?
documentation,?with?a?finding?
of?moderate?risk?

0?20? ?? Once?per?rolling?year?per?payee.?
If?medically?necessary,?a?second?risk?assessment?can?
be?approved?through?the?appeal?process.?
Only?allowed?on?the?same?date?of?service?as?D0120,?
D0145,?or?D0150?per?payee.?

No? ??



Horizon?NJ?Health?Dental?Program?
Benefit?Plan?Details?&?Authorization?Requirements?

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Horizon?NJ?Health?Dental?Program:?Non?Special?Needs?Plans?&?Special?Needs?Plans?
Code? Description? Age? Tooth?/?

Quad?/?Arch?
Limitations? Auth?

Req?
Requirement?

D0603? Caries?risk?assessment?and?
documentation,?with?a?finding?
of?high?risk?

0?20? ?? Once?per?rolling?year?per?payee.?
If?medically?necessary,?a?second?risk?assessment?can?
be?approved?through?the?appeal?process.?
Only?allowed?on?the?same?date?of?service?as?D0120,?
D0145,?or?D0150?per?payee.?

No? ??

D0999? Unspecified?diagnostic?
procedure,?by?report?

0?999? ?? As?required?by?documentation?and?narrative.? Yes? Description?of?procedure?
and?narrative?of?medical?
necessity?

D1110?
No?
Special?
Needs?

Prophylaxis???adult? 16?999? ?? Twice?per?floating?year?per?payee.?
Not?payable?on?the?same?date?of?service?as?any?other?
D4000?series?codes.??

No? ??

D1110?
Special?
Needs?

Prophylaxis???adult? 16?999? ?? Four?per?floating?year?per?payee.?
Not?payable?on?the?same?date?of?service?as?any?other?
D4000?series?codes.?

No? ??

D1120?
No?
Special?
Needs?

Prophylaxis???child? 0?15? ?? Twice?per?floating?year?per?payee.?
Not?payable?on?the?same?date?of?service?as?any?other?
D4000?series?codes.?

No? ??

D1120?
Special?
Needs?

Prophylaxis???child? 0?15? ?? Four?per?floating?year?per?payee.?
Not?payable?on?the?same?date?of?service?as?any?other?
D4000?series?codes.?

No? ??



Horizon?NJ?Health?Dental?Program?
Benefit?Plan?Details?&?Authorization?Requirements?

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Horizon?NJ?Health?Dental?Program:?Non?Special?Needs?Plans?&?Special?Needs?Plans?
Code? Description? Age? Tooth?/?

Quad?/?Arch?
Limitations? Auth?

Req?
Requirement?

D1206?
No?
Special?
Needs,?
Age??
0?20?

Topical?application?of?fluoride?
varnish?

0?20? ?? Age?0?6:?Four?per?floating?year?per?payee.?
Age?7?20:?Twice?per?floating?year?per?payee.?
Combined?frequency?(codeset?limitation)?with?D1208.?

No? ??

D1206?
Special?
Needs,?
Age??
0?999?

Topical?application?of?fluoride?
varnish?

0?999? ?? Four?per?floating?year?per?payee.?
Combined?frequency?(codeset?limitation)?with?D1208.?

No? ??

D1208?
No?
Special?
Needs,?
Age??
0?20?

Topical?application?of?fluoride?
??excluding?varnish?

0?20? ?? Age?0?6:?Four?per?floating?year?per?payee.?
Age?7?20:?Twice?per?floating?year?per?payee.?
Combined?frequency?(codeset?limitation)?with?D1206.?

No? ??

D1208?
Special?
Needs,?
Age??
0?999?

Topical?application?of?fluoride?
??excluding?varnish?

0?999? ?? Four?per?floating?year?per?payee.?
Combined?frequency?(codeset?limitation)?with?D1206.?

No? ??

D1351? Sealant?per?tooth? 0?16? 1?5,?12?21,?
28?32?

One?per?3?rolling?years?per?tooth?per?payee.?
Not?payable?with?history?of?a?filling.?

No? ??



Horizon?NJ?Health?Dental?Program?
Benefit?Plan?Details?&?Authorization?Requirements?

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133?

Horizon?NJ?Health?Dental?Program:?Non?Special?Needs?Plans?&?Special?Needs?Plans?
Code? Description? Age? Tooth?/?

Quad?/?Arch?
Limitations? Auth?

Req?
Requirement?

D1352? Preventive?resin?restoration?
in?a?moderate?to?high?caries?
risk?patient???permanent?
tooth?

16?999? 1?5,?12?21,?
28?32?

One?per?3?years?per?tooth?per?payee.? No? ??

D1353? Sealant?repair???per?tooth? 0?16? 1?5,?12?21,?
28?32?

One?per?3?rolling?years?per?tooth?per?payee.?
Not?payable?with?history?of?a?filling.?
Must?have?a?history?of?D1351?more?than?36?months?
prior.?

No? ??

D1354?
Special?
Needs,?
Age?0?
999?

Interim?Caries?Arresting?
Medicament?Application???per?
tooth?

0?6? ? Twice?per?rolling?year?per?tooth?per?payee? No? ?

D1510? Space?maintainer???fixed???
unilateral?

0?15? 2?15,?18?31,?
and?A?T?

One?per?lifetime?per?payee.?
Not?in?conjunction?with?active?ortho.?

Yes? Pre?operative?X?rays?

D1516? Space?maintainer???fixed???
bilateral,?maxillary?

0?15? 2?15,?18?31,?
and?A?T?

One?per?lifetime?per?payee.?
Not?in?conjunction?with?active?ortho.?

Yes? Pre?operative?X?rays?

D1517? Space?maintainer???fixed???
bilateral,?mandibular?

0?15? 2?15,?18?31,?
and?A?T?

One?per?lifetime?per?payee.?
Not?in?conjunction?with?active?ortho.?

Yes? Pre?operative?X?rays?

D1526? Space?maintainer???
removable???bilateral,?
maxillary?

0?15? 2?15,?18?31,?
and?A?T?

One?per?lifetime?per?payee.??
Not?in?conjunction?with?active?ortho.?

Yes? Pre?operative?X?rays?



Horizon?NJ?Health?Dental?Program?
Benefit?Plan?Details?&?Authorization?Requirements?

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134?

Horizon?NJ?Health?Dental?Program:?Non?Special?Needs?Plans?&?Special?Needs?Plans?
Code? Description? Age? Tooth?/?

Quad?/?Arch?
Limitations? Auth?

Req?
Requirement?

D1527? Space?maintainer???
removable???bilateral,?
mandibular?

0?15? 2?15,?18?31,?
and?A?T?

One?per?lifetime?per?payee.??
Not?in?conjunction?with?active?ortho.?

Yes? Pre?operative?X?rays?

D1550? Re?cement?or?re?bond?space?
maintainer?

0?15? 2?15,?18?31,?
and?A?T?

One?per?lifetime?per?payee.? No? ??

D1555? Removal?of?fixed?space?
maintainer?

0?15? 2?15,?18?31,?
and?A?T?

One?per?lifetime?per?patient.?
Not?by?the?same?payee?as?D1510,?D1515,?D1516,?
D1517,?D1525,?D1525,?D1527?

No? ??

D1575? Distal?shoe?space?maintainer?
??fixed???unilateral?

0?15? 2?15,?18?31,?
and?A?T?

One?per?lifetime?per?payee.?
Not?in?conjunction?with?active?ortho.?

Yes? Pre?operative?X?rays?

D1999? Unspecified?preventive?
procedure??by?report?

0?999? ?? Documentation?supports?procedure.? Yes? Narrative?of?medical?
necessity?

D2140? Amalgam???one?surface,?
primary?or?permanent?

0?999? All?teeth;??
A?T;?1?32?

One?per?364?days?per?payee.?
Duplicate?services?are?denied?if?less?than?365?days.?
The?provider?must?replace?a?filling?placed?within?one?
year?of?restoration?when?performed?at?the?same?time.?

No? ??

D2150? Amalgam???two?surfaces,?
primary?or?permanent?

0?999? All?teeth;??
A?T;?1?32?

One?per?364?days?per?payee.?
Duplicate?services?are?denied?if?less?than?365?days.?
The?provider?must?replace?a?filling?placed?within?one?
year?of?restoration?when?performed?at?the?same?time.?

No? ??



Horizon?NJ?Health?Dental?Program?
Benefit?Plan?Details?&?Authorization?Requirements?

??SKYGEN?USA?|?CONFIDENTIAL?&?PROPRIETARY?|?Horizon?NJ?Health?Dental?Program?|?Effective:?1/1/20?
135?

Horizon?NJ?Health?Dental?Program:?Non?Special?Needs?Plans?&?Special?Needs?Plans?
Code? Description? Age? Tooth?/?

Quad?/?Arch?
Limitations? Auth?

Req?
Requirement?

D2160? Amalgam???three?surfaces,?
primary?or?permanent?

0?999? All?teeth;??
A?T;?1?32?

One?per?364?days?per?payee.?
Duplicate?services?are?denied?if?less?than?365?days.?
The?provider?must?replace?a?filling?placed?within?one?
year?of?restoration?when?performed?at?the?same?time.?

No? ??

D2161? Amalgam???four?or?more?
surfaces,?primary?or?
permanent?

0?999? All?teeth;??
A?T;?1?32?

One?per?364?days?per?payee.?
Duplicate?services?are?denied?if?less?than?365?days.?
The?provider?must?replace?a?filling?placed?within?one?
year?of?restoration?when?performed?at?the?same?time.?

No? ??

D2330? Resin?based?composite???one?
surface,?anterior?

0?999? Anterior?
Teeth?(6?11,?
22?27,?C?H,?
M?R)?

One?per?364?days?per?payee.?
Duplicate?services?are?denied?if?less?than?365?days.?
The?provider?must?replace?a?filling?placed?within?one?
year?of?restoration?when?performed?at?the?same?time.?

No? ??

D2331? Resin?based?composite???two?
surfaces,?anterior?

0?999? Anterior?
Teeth?(6?11,?
22?27,?C?H,?
M?R)?

One?per?364?days?per?payee.?
Duplicate?services?are?denied?if?less?than?365?days.?
The?provider?must?replace?a?filling?placed?within?one?
year?of?restoration?when?performed?at?the?same?time.?

No? ??

D2332? Resin?based?composite???
three?surfaces,?anterior?

0?999? Anterior?
Teeth?(6?11,?
22?27?,?C?H,?
M?R)?

One?per?364?days?per?payee.?
Duplicate?services?are?denied?if?less?than?365?days.?
The?provider?must?replace?a?filling?placed?within?one?
year?of?restoration?when?performed?at?the?same?time.?

No? ??



Horizon?NJ?Health?Dental?Program?
Benefit?Plan?Details?&?Authorization?Requirements?

??SKYGEN?USA?|?CONFIDENTIAL?&?PROPRIETARY?|?Horizon?NJ?Health?Dental?Program?|?Effective:?1/1/20?
136?

Horizon?NJ?Health?Dental?Program:?Non?Special?Needs?Plans?&?Special?Needs?Plans?
Code? Description? Age? Tooth?/?

Quad?/?Arch?
Limitations? Auth?

Req?
Requirement?

D2335? Resin?based?composite???four?
or?more?surfaces?or?involving?
incisal?angle?(anterior)?

0?999? Anterior?
Teeth?(6?11,?
22?27,?C?H,?
M?R)?

One?per?364?days?per?payee.?
Duplicate?services?are?denied?if?less?than?365?days.?
The?provider?must?replace?a?filling?placed?within?one?
year?of?restoration?when?performed?at?the?same?time.?

No? ??

D2390? Resin?based?composite?
crown,?anterior?

0?999? Anterior?
Teeth?(6?11,?
22?27,?C?H,?
M?R)?

One?per?364?days?per?payee.?
Duplicate?services?are?denied?if?less?than?365?days.?
The?provider?must?replace?a?filling?placed?within?one?
year?of?restoration?when?performed?at?the?same?time.?

No? ??

D2391? Resin?based?composite???one?
surface,?posterior?

0?999? Posterior?
teeth?(1?5,?
12?21,??
28?32,?A,?B,?I,?
J,?K,?L,?S,?T)?

One?per?364?days?per?payee.?
Duplicate?services?are?denied?if?less?than?365?days.?
The?provider?must?replace?a?filling?placed?within?one?
year?of?restoration?when?performed?at?the?same?time.?

No? ??

D2392? Resin?based?composite???two?
surfaces,?posterior?

0?999? Posterior?
teeth?(1?5,?
12?21,??
28?32,?A,?B,?I,?
J,?K,?L,?S,?T)?

One?per?364?days?per?payee.?
Duplicate?services?are?denied?if?less?than?365?days.?
The?provider?must?replace?a?filling?placed?within?one?
year?of?restoration?when?performed?at?the?same?time.?

No? ??

D2393? Resin?based?composite???
three?surfaces,?posterior?

0?999? Posterior?
teeth?(1?5,?
12?21,??
28?32,?A,?B,?I,?
J,?K,?L,?S,?T)?

One?per?364?days?per?payee.?
Duplicate?services?are?denied?if?less?than?365?days.?
The?provider?must?replace?a?filling?placed?within?one?
year?of?restoration?when?performed?at?the?same?time.?

No? ??



Horizon?NJ?Health?Dental?Program?
Benefit?Plan?Details?&?Authorization?Requirements?

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137?

Horizon?NJ?Health?Dental?Program:?Non?Special?Needs?Plans?&?Special?Needs?Plans?
Code? Description? Age? Tooth?/?

Quad?/?Arch?
Limitations? Auth?

Req?
Requirement?

D2394? Resin?based?composite???four?
or?more?surfaces,?posterior?

0?999? Posterior?
teeth?(1?5,?
12?21,??
28?32,?A,?B,?I,?
J,?K,?L,?S,?T)?

One?per?364?days?per?payee.??
Duplicate?services?are?denied?if?less?than?365?days.?
The?provider?must?replace?a?filling?placed?within?one?
year?of?restoration?when?performed?at?the?same?time.?

No? ??

D2510? Inlay???metallic???one?surface? 0?999? Permanent?
Teeth?1?32?

One?per?5?years;?dental?school?only.? Yes? Full?mouth?X?rays?or?
panorex,?and?narrative?
of?medical?necessity?

D2520? Inlay???metallic???two?surfaces? 0?999? Permanent?
Teeth?1?32?

One?per?5?years;?dental?school?only.? Yes? Full?mouth?X?rays?or?
panorex,?and?narrative?
of?medical?necessity?

D2530? Inlay???metallic???three?or?
more?surfaces?

0?999? Permanent?
Teeth?1?32?

One?per?5?years;?dental?school?only.? Yes? Full?mouth?X?rays?or?
panorex,?and?narrative?
of?medical?necessity?

D2542? Onlay???metallic???two?
surfaces?

0?999? Permanent?
Teeth?1?32?

One?per?5?years;?dental?school?only.? Yes? Full?mouth?X?rays?or?
panorex,?and?narrative?
of?medical?necessity?

D2543? Onlay???metallic???three?
surfaces?

0?999? Permanent?
Teeth?1?32?

One?per?5?years;?dental?school?only.? Yes? Full?mouth?X?rays?or?
panorex,?and?narrative?
of?medical?necessity?

D2544? Onlay???metallic???four?or?
more?surfaces?

0?999? Permanent?
Teeth?1?32?

One?per?5?years;?dental?school?only.? Yes? Full?mouth?X?rays?or?
panorex,?and?narrative?
of?medical?necessity?



Horizon?NJ?Health?Dental?Program?
Benefit?Plan?Details?&?Authorization?Requirements?

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138?

Horizon?NJ?Health?Dental?Program:?Non?Special?Needs?Plans?&?Special?Needs?Plans?
Code? Description? Age? Tooth?/?

Quad?/?Arch?
Limitations? Auth?

Req?
Requirement?

D2610? Inlay???porcelain/ceramic???
one?surface?

0?999? Permanent?
Teeth?1?32?

One?per?5?years;?dental?school?only.? Yes? Full?mouth?X?rays?or?
panorex,?and?narrative?
of?medical?necessity?

D2620? Inlay???porcelain/ceramic???
two?surfaces?

0?999? Permanent?
Teeth?1?32?

One?per?5?years;?dental?school?only.? Yes? Full?mouth?X?rays?or?
panorex,?and?narrative?
of?medical?necessity?

D2630? Inlay???porcelain/ceramic???
three?or?more?surfaces?

0?999? Permanent?
Teeth?1?32?

One?per?5?years;?dental?school?only.? Yes? Full?mouth?X?rays?or?
panorex,?and?narrative?
of?medical?necessity?

D2642? Onlay???porcelain/ceramic???
two?surfaces?

0?999? Permanent?
Teeth?1?32?

One?per?5?years;?dental?school?only.? Yes? Full?mouth?X?rays?or?
panorex,?and?narrative?
of?medical?necessity?

D2643? Onlay???porcelain/ceramic???
three?surfaces?

0?999? Permanent?
Teeth?1?32?

One?per?5?years;?dental?school?only.? Yes? Full?mouth?X?rays?or?
panorex,?and?narrative?
of?medical?necessity?

D2644? Onlay???porcelain/ceramic???
four?or?more?surfaces?

0?999? Permanent?
Teeth?1?32?

One?per?5?years;?dental?school?only.? Yes? Full?mouth?X?rays?or?
panorex,?and?narrative?
of?medical?necessity?

D2650? Inlay???resin?based?composite?
??one?surface?

0?999? Permanent?
Teeth?1?32?

One?per?5?years;?dental?school?only.? Yes? Full?mouth?X?rays?or?
panorex,?and?narrative?
of?medical?necessity?



Horizon?NJ?Health?Dental?Program?
Benefit?Plan?Details?&?Authorization?Requirements?

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139?

Horizon?NJ?Health?Dental?Program:?Non?Special?Needs?Plans?&?Special?Needs?Plans?
Code? Description? Age? Tooth?/?

Quad?/?Arch?
Limitations? Auth?

Req?
Requirement?

D2651? Inlay???resin?based?composite?
??two?surfaces?

0?999? Permanent?
Teeth?1?32?

One?per?5?years;?dental?school?only.? Yes? Full?mouth?X?rays?or?
panorex,?and?narrative?
of?medical?necessity?

D2652? Inlay???resin?based?composite?
??three?or?more?surfaces?

0?999? Permanent?
Teeth?1?32?

One?per?5?years;?dental?school?only.? Yes? Full?mouth?X?rays?or?
panorex,?and?narrative?
of?medical?necessity?

D2662? Onlay???resin?based?
composite???two?surfaces?

0?999? Permanent?
Teeth?1?32?

One?per?5?years;?dental?school?only.? Yes? Full?mouth?X?rays?or?
panorex,?and?narrative?
of?medical?necessity?

D2663? Onlay???resin?based?
composite???three?surfaces?

0?999? Permanent?
Teeth?1?32?

One?per?5?years;?dental?school?only.? Yes? Full?mouth?X?rays?or?
panorex,?and?narrative?
of?medical?necessity?

D2664? Onlay???resin?based?
composite???four?or?more?
surfaces?

0?999? Permanent?
Teeth?1?32?

One?per?5?years;?dental?school?only.? Yes? Full?mouth?X?rays?or?
panorex,?and?narrative?
of?medical?necessity?

D2710? Crown???resin?based?
composite?(indirect)?

0?999? Permanent?
Teeth?1?32?

One?per?5?years;?dental?school?only.? Yes? Full?mouth?X?rays?or?
panorex?

D2712? Crown?????resin?based?
composite?(indirect)?

0?999? Permanent?
Teeth?1?32?

One?per?5?years;?dental?school?only.? Yes? Full?mouth?X?rays?or?
panorex?

D2720? Crown???resin?with?high?noble?
metal?

0?999? Permanent?
Teeth?1?32?

One?per?5?years?per?payee.? Yes? Full?mouth?X?rays?or?
panorex?



Horizon?NJ?Health?Dental?Program?
Benefit?Plan?Details?&?Authorization?Requirements?

??SKYGEN?USA?|?CONFIDENTIAL?&?PROPRIETARY?|?Horizon?NJ?Health?Dental?Program?|?Effective:?1/1/20?
140?

Horizon?NJ?Health?Dental?Program:?Non?Special?Needs?Plans?&?Special?Needs?Plans?
Code? Description? Age? Tooth?/?

Quad?/?Arch?
Limitations? Auth?

Req?
Requirement?

D2721? Crown???resin?with?
predominantly?base?metal?

0?999? Permanent?
Teeth?1?32?

One?per?5?years?per?payee.? Yes? Full?mouth?X?rays?or?
panorex?

D2722? Crown???resin?with?noble?
metal?

0?999? Permanent?
Teeth?1?32?

One?per?5?years?per?payee.? Yes? Full?mouth?X?rays?or?
panorex?

D2740? Crown???porcelain/ceramic?
substrate?

0?999? Permanent?
Teeth?1?32?

One?per?5?years?per?payee.? Yes? Full?mouth?X?rays?or?
panorex?

D2750? Crown???porcelain?fused?to?
high?noble?metal?

0?999? Permanent?
Teeth?1?32?

One?per?5?years?per?payee.? Yes? Full?mouth?X?rays?or?
panorex?

D2751? Crown???porcelain?fused?to?
predominantly?base?metal?

0?999? Permanent?
Teeth?1?32?

One?per?5?years?per?payee.? Yes? Full?mouth?X?rays?or?
panorex?

D2752? Crown???porcelain?fused?to?
noble?metal?

0?999? Permanent?
Teeth?1?32?

One?per?5?years?per?payee.? Yes? Full?mouth?X?rays?or?
panorex?

D2780? Crown?????cast?high?noble?
metal?

0?999? Permanent?
Teeth?1?32?

One?per?5?years?per?payee.? Yes? Full?mouth?X?rays?or?
panorex?

D2781? Crown?????cast?
predominantly?base?metal?

0?999? Permanent?
Teeth?1?32?

One?per?5?years?per?payee.? Yes? Full?mouth?X?rays?or?
panorex?

D2782? Crown?????cast?noble?metal? 0?999? Permanent?
Teeth?1?32?

One?per?5?years?per?payee.? Yes? Full?mouth?X?rays?or?
panorex?



Horizon?NJ?Health?Dental?Program?
Benefit?Plan?Details?&?Authorization?Requirements?

??SKYGEN?USA?|?CONFIDENTIAL?&?PROPRIETARY?|?Horizon?NJ?Health?Dental?Program?|?Effective:?1/1/20?
141?

Horizon?NJ?Health?Dental?Program:?Non?Special?Needs?Plans?&?Special?Needs?Plans?
Code? Description? Age? Tooth?/?

Quad?/?Arch?
Limitations? Auth?

Req?
Requirement?

D2783? Crown?????porcelain/ceramic? 0?999? Permanent?
Teeth?1?32?

One?per?5?years?per?payee.? Yes? Full?mouth?X?rays?or?
panorex?

D2790? Crown???full?cast?high?noble?
metal?

0?999? Permanent?
Teeth?1?32?

One?per?5?years?per?payee.? Yes? Full?mouth?X?rays?or?
panorex?

D2791? Crown???full?cast?
predominantly?base?metal?

0?999? Permanent?
Teeth?1?32?

One?per?5?years?per?payee.? Yes? Full?mouth?X?rays?or?
panorex?

D2792? Crown???full?cast?noble?metal? 0?999? Permanent?
Teeth?1?32?

One?per?5?years?per?payee.? Yes? Full?mouth?X?rays?or?
panorex?

D2910? Re?cement?or?re?bond?inlay,?
onlay,?veneer?or?partial?
coverage?restoration?

0?999? Permanent?
Teeth?1?32?

?? No? ??

D2915? Re?cement?or?re?bond?
indirectly?fabricated?or?
prefabricated?post?and?core?

0?999? Permanent?
Teeth?1?32?

?? No? ??

D2920? Re?cement?or?re?bond?crown? 0?999? All?teeth;??
A?T;?1?32?

?? No? ??

D2921? Reattachment?of?tooth?
fragment,?incisal?edge?or?cusp?

0?999? All?teeth;??
A?T;?1?32?

?? No? ??

D2929? Prefabricated?
porcelain/ceramic?crown???
primary?tooth?

0?999? Primary?
Teeth?A?T?

One?per?5?years?per?payee.? No?
?



Horizon?NJ?Health?Dental?Program?
Benefit?Plan?Details?&?Authorization?Requirements?

??SKYGEN?USA?|?CONFIDENTIAL?&?PROPRIETARY?|?Horizon?NJ?Health?Dental?Program?|?Effective:?1/1/20?
142?

Horizon?NJ?Health?Dental?Program:?Non?Special?Needs?Plans?&?Special?Needs?Plans?
Code? Description? Age? Tooth?/?

Quad?/?Arch?
Limitations? Auth?

Req?
Requirement?

D2930? Prefabricated?stainless?steel?
crown???primary?tooth?

0?999? Primary?
Teeth?A?T?

One?per?5?years?per?payee.? No? ??

D2931? Prefabricated?stainless?steel?
crown???permanent?tooth?

0?999? Permanent?
Teeth?1?32?

One?per?5?years?per?payee.? No? ??

D2932? Prefabricated?resin?crown? 0?999? Anterior?
Teeth?(6?11,?
22?27,?C?H,?
M?R)?

One?per?5?years?per?payee.? No? ??

D2933? Prefabricated?stainless?steel?
crown?with?resin?window?

0?999? Primary?
Anterior?
Teeth?(C?H,?
M?R)?

One?per?5?years?per?payee.? No? ??

D2934? Prefabricated?esthetic?coated?
stainless?steel?crown???
primary?tooth?

0?999? C,?D,?E,?F,?G,?
H,?M,?N,?O,?P,?
Q,?R?

One?per?5?years?per?payee.? No? ??

D2940? Protective?
restoration/sedative?filling?

0?999? All?teeth;??
A?T;?1?32?

?? No? ??

D2950? Core?buildup,?including?any?
pins?when?required?

0?999? Permanent?
Teeth?1?32?

One?per?5?years?per?payee.? Yes? Full?mouth?X?rays?or?
panorex?

D2951? Pin?retention???per?tooth,?in?
addition?to?restoration?

0?999? Permanent?
Teeth?1?32?

One?per?5?years?per?payee.? No? ??



Horizon?NJ?Health?Dental?Program?
Benefit?Plan?Details?&?Authorization?Requirements?

??SKYGEN?USA?|?CONFIDENTIAL?&?PROPRIETARY?|?Horizon?NJ?Health?Dental?Program?|?Effective:?1/1/20?
143?

Horizon?NJ?Health?Dental?Program:?Non?Special?Needs?Plans?&?Special?Needs?Plans?
Code? Description? Age? Tooth?/?

Quad?/?Arch?
Limitations? Auth?

Req?
Requirement?

D2952? Post?and?core?in?addition?to?
crown,?indirectly?fabricated?

0?999? Permanent?
Teeth?1?32?

One?per?5?years?per?payee.? Yes? Full?mouth?X?rays?or?
panorex?

D2953? Each?additional?indirectly?
fabricated?post???same?tooth?

0?999? Permanent?
Teeth?1?32?

One?per?5?years?per?payee.? Yes? Full?mouth?X?rays?or?
panorex?

D2954? Prefabricated?post?and?core?
in?addition?to?crown?

0?999? Permanent?
Teeth?1?32?

One?per?5?years?per?payee.? Yes? Full?mouth?X?rays?or?
panorex?

D2955? Post?removal? 0?999? Permanent?
Teeth?1?32?

One?per?lifetime?per?tooth?per?member.?
Not?covered?on?same?date?of?service?as?D3346,?
D3347,?or?D3348.?
Not?payable?to?the?same?provider?as?D3346,?D3347,?or?
D3348.?

No? ??

D2957? Each?additional?prefabricated?
post???same?tooth?

0?999? Permanent?
Teeth?1?32?

One?per?5?years?per?payee.? Yes? Pre?operative?X?rays?of?
adjacent?teeth?and?
opposing?teeth?

D2970? Temporary?crown?(fractured?
tooth)?

0?999? Permanent?
Teeth?1?32?

?? No? ??

D2971? Additional?procedures?to?
construct?new?crown?under?
existing?partial?denture?
framework?

0?999? Permanent?
Teeth?1?32?

One?per?5?years?per?payee.? Yes? Pre?operative?X?rays?of?
adjacent?teeth?and?
opposing?teeth?



Horizon?NJ?Health?Dental?Program?
Benefit?Plan?Details?&?Authorization?Requirements?

??SKYGEN?USA?|?CONFIDENTIAL?&?PROPRIETARY?|?Horizon?NJ?Health?Dental?Program?|?Effective:?1/1/20?
144?

Horizon?NJ?Health?Dental?Program:?Non?Special?Needs?Plans?&?Special?Needs?Plans?
Code? Description? Age? Tooth?/?

Quad?/?Arch?
Limitations? Auth?

Req?
Requirement?

D2975? Coping? 0?999? Permanent?
Teeth?1?32?

One?per?5?years?per?payee.? Yes? Pre?operative?X?rays?of?
adjacent?teeth?and?
opposing?teeth?

D2980? Crown?repair?necessitated?by?
restorative?material?failure?

0?999? Permanent?
Teeth?1?32?

?? Yes? Full?mouth?X?rays?or?
panorex?

D2981? Inlay?repair?necessitated?by?
restorative?material?failure?

0?999? Permanent?
Teeth?1?32?

?? Yes? Full?mouth?X?rays?or?
panorex?

D2982? Onlay?repair?necessitated?by?
restorative?material?failure?

0?999? Permanent?
Teeth?1?32?

?? Yes? Full?mouth?X?rays?or?
panorex?

D2983? Veneer?repair?necessitated?by?
restorative?material?failure?
unspecified?restorative?
procedure,?by?report?

0?999? Permanent?
Teeth?1?32?

?? Yes? Full?mouth?X?rays?or?
panorex?

D2999? Unspecified?restorative?
procedure,?by?report?

0?999?
?

Used?only?for?authorization?of?transfer?of?member?
cases?other?than?orthodontics.?
Not?to?be?billed.?

Yes? Evidence?of?prior?
approval,?requested?CDT?
codes?

D3220? Therapeutic?pulpotomy?
(excluding?final?restoration)???
removal?of?pulp?coronal?to?
the?dentinocemental?junction?
and?application?of?
medicament?

0?999? All?teeth;??
A?T;?1?32?

One?per?lifetime.?
Not?allowed?on?the?same?date?of?service?as?D3310,?
D3320,?or?D3330?per?payee.??

No? ??



Horizon?NJ?Health?Dental?Program?
Benefit?Plan?Details?&?Authorization?Requirements?

??SKYGEN?USA?|?CONFIDENTIAL?&?PROPRIETARY?|?Horizon?NJ?Health?Dental?Program?|?Effective:?1/1/20?
145?

Horizon?NJ?Health?Dental?Program:?Non?Special?Needs?Plans?&?Special?Needs?Plans?
Code? Description? Age? Tooth?/?

Quad?/?Arch?
Limitations? Auth?

Req?
Requirement?

D3221? Pulpal?debridement,?primary?
and?permanent?teeth?

0?999? All?teeth;??
A?T;?1?32?

One?per?lifetime.?
Not?allowed?on?the?same?date?of?service?as?D3310,?
D3320,?or?D3330?per?payee.?

No? ??

D3222? Partial?pulpotomy?for?
apexogenesis???permanent?
tooth?with?incomplete?root?
development?

0?999? Permanent?
Teeth?1?32?

One?per?lifetime.? No? ??

D3230? Pulpal?therapy?(resorbable?
filling)???anterior,?primary?
tooth?(excluding?final?
restoration)?

0?999? Primary?
Anterior?
Teeth?(C?H,?
M?R)?

One?per?lifetime.? No? ??

D3240? Pulpal?therapy?(resorbable?
filling)???posterior,?primary?
tooth?(excluding?final?
restoration)?

0?999? Primary?
Posterior?
Teeth?(A,?B,?I,?
J,?K,?L,?S,?T)?

One?per?lifetime.? No? ??

D3310? Endodontic?therapy,?anterior?
tooth?(excluding?final?
restoration)?

0?999? Permanent?
Anterior?
Teeth?(6?11,?
22?27)?

One?per?lifetime.? Yes? Full?mouth?X?rays?or?
panorex?

D3320? Endodontic?therapy,?bicuspid?
tooth?(excluding?final?
restoration)?

0?999? Bicuspids?(4,?
5,?12,?13,?20,?
21,?28,?29)?

One?per?lifetime.? Yes? Full?mouth?X?rays?or?
panorex?



Horizon?NJ?Health?Dental?Program?
Benefit?Plan?Details?&?Authorization?Requirements?

??SKYGEN?USA?|?CONFIDENTIAL?&?PROPRIETARY?|?Horizon?NJ?Health?Dental?Program?|?Effective:?1/1/20?
146?

Horizon?NJ?Health?Dental?Program:?Non?Special?Needs?Plans?&?Special?Needs?Plans?
Code? Description? Age? Tooth?/?

Quad?/?Arch?
Limitations? Auth?

Req?
Requirement?

D3330? Endodontic?therapy,?molar?
(excluding?final?restoration)?

0?999? Permanent?
Molars?(1?3,?
14?19,??
30?32)?

One?per?lifetime.? Yes? Full?mouth?X?rays?or?
panorex?

D3331? Treatment?of?root?canal?
obstruction;?non?surgical?
access?

0?999? Permanent?
Teeth?1?32?

One?per?lifetime.? Yes? Pre?operative?X?rays?
(excluding?bitewing??
X?rays)?and?narrative?of?
medical?necessity?

D3332? Incomplete?endodontic?
therapy;?inoperable,?
unrestorable?or?fractured?
tooth?

0?999? Permanent?
Teeth?1?32?

One?per?lifetime.? Yes? Pre?operative?x?rays?
(excluding?bitewing??
X?rays)?

D3333? Internal?root?repair?of?
perforation?defects?

0?999? Permanent?
Teeth?1?32?

One?per?lifetime.? Yes? Pre?operative?x?rays?
(excluding?bitewing??
X?rays)?

D3346? Retreatment?of?previous?root?
canal?therapy???anterior?

0?999? Permanent?
Anterior?
Teeth?(6?11,?
22?27)?

One?per?lifetime.?
Not?less?than?36?months?after?D3310?by?same?payee.?

Yes? Full?mouth?X?rays?or?
panorex?

D3347? Retreatment?of?previous?root?
canal?therapy???bicuspid?

0?999? Bicuspids?(4,?
5,?12,?13,?20,?
21,?28,?29)?

One?per?lifetime.?
Not?less?than?36?months?after?D3320?by?same?payee.?

Yes? Full?mouth?X?rays?or?
panorex?



Horizon?NJ?Health?Dental?Program?
Benefit?Plan?Details?&?Authorization?Requirements?

??SKYGEN?USA?|?CONFIDENTIAL?&?PROPRIETARY?|?Horizon?NJ?Health?Dental?Program?|?Effective:?1/1/20?
147?

Horizon?NJ?Health?Dental?Program:?Non?Special?Needs?Plans?&?Special?Needs?Plans?
Code? Description? Age? Tooth?/?

Quad?/?Arch?
Limitations? Auth?

Req?
Requirement?

D3348? Retreatment?of?previous?root?
canal?therapy???molar?

0?999? Permanent?
Molars?(1?3,?
14?19,??
30?32)?

One?per?lifetime.?
Not?less?than?36?months?after?D3330?by?same?payee.?

Yes? Full?mouth?X?rays?or?
panorex?

D3351? Apexification/recalcification???
initial?visit?(apical?
closure/calcific?repair?of?
perforations,?root?resorption,?
etc.)?

0?999? Permanent?
Teeth?1?32?

One?per?lifetime.? Yes? Pre?operative?X?rays?
(excluding?bitewing??
X?rays)?

D3352? Apexification/recalcification???
interim?medication?
replacement?

0?999? Permanent?
Teeth?1?32?

?
Yes? Date?of?initial?

apexification?visit?with?
claim?

D3353? Apexification/recalcification???
final?visit?(includes?completed?
root?canal?therapy???apical?
closure/?calcific?repair?of?
perforations,?root?resorption,?
etc.)?

0?999? Permanent?
Teeth?1?32?

One?per?lifetime.?
This?code?includes?the?payment?for?D3310,?D3320,?or?
D3330.?

Yes? Date?of?initial?
apexification?visit,?fill??
X?ray?with?claim?

D3355? Pulpal?regeneration???initial?
visit?

0?999? Permanent?
Teeth?1?32?

One?per?lifetime.? Yes? Pre?operative?X?rays?
(excluding?bitewing??
X?rays)?

D3356? Pulpal?regeneration???interim?
medication?replacement?

0?999? Permanent?
Teeth?1?32?

One?per?lifetime.? Yes? Pre?operative?X?rays?
(excluding?bitewing??
X?rays)?



Horizon?NJ?Health?Dental?Program?
Benefit?Plan?Details?&?Authorization?Requirements?

??SKYGEN?USA?|?CONFIDENTIAL?&?PROPRIETARY?|?Horizon?NJ?Health?Dental?Program?|?Effective:?1/1/20?
148?

Horizon?NJ?Health?Dental?Program:?Non?Special?Needs?Plans?&?Special?Needs?Plans?
Code? Description? Age? Tooth?/?

Quad?/?Arch?
Limitations? Auth?

Req?
Requirement?

D3357? Pulpal?regeneration???
completion?of?treatment?

0?999? Permanent?
Teeth?1?32?

One?per?lifetime.? Yes? Pre?operative?X?rays?
(excluding?bitewing??
X?rays)?

D3410? Apicoectomy???anterior? 0?999? Permanent?
Anterior?
Teeth?(6?11,?
22?27)?

One?per?lifetime.? Yes? Pre?operative?X?rays?of?
adjacent?teeth?and?
opposing?teeth?

D3421? Apicoectomy???bicuspid?(first?
root)?

0?999? Bicuspids?(4,?
5,?12,?13,?20,?
21,?28,?29)?

One?per?lifetime.? Yes? Pre?operative?X?rays?of?
adjacent?teeth?and?
opposing?teeth?

D3425? Apicoectomy???molar?(first?
root)?

0?999? Permanent?
Molars?(1?3,?
14?19,??
30?32)?

One?per?lifetime.? Yes? Pre?operative?X?rays?of?
adjacent?teeth?and?
opposing?teeth?

D3426? Apicoectomy?(each?additional?
root)?

0?999? Permanent?
Posterior?(1?
5,?12?21,?28?
32)?

One?per?lifetime.? Yes? Pre?operative?X?rays?of?
adjacent?teeth?and?
opposing?teeth?

D3427? Periradicular?surgery?without?
apicoectomy?

0?999? Permanent?
Teeth?1?32?

One?per?lifetime.? Yes? Pre?operative?X?rays?of?
adjacent?teeth?and?
opposing?teeth?



Horizon?NJ?Health?Dental?Program?
Benefit?Plan?Details?&?Authorization?Requirements?

??SKYGEN?USA?|?CONFIDENTIAL?&?PROPRIETARY?|?Horizon?NJ?Health?Dental?Program?|?Effective:?1/1/20?
149?

Horizon?NJ?Health?Dental?Program:?Non?Special?Needs?Plans?&?Special?Needs?Plans?
Code? Description? Age? Tooth?/?

Quad?/?Arch?
Limitations? Auth?

Req?
Requirement?

D3428? Bone?graft?in?conjunction?
with?periradicular?surgery???
per?tooth,?single?site?

0?999? Permanent?
Teeth?1?32?

One?per?lifetime.? Yes? Pre?operative?X?rays?of?
adjacent?teeth?and?
opposing?teeth?

D3429? Bone?graft?in?conjunction?
with?periradicular?surgery???
each?additional?contiguous?
tooth?in?the?same?surgical?site?

0?999? Permanent?
Teeth?1?32?

One?per?lifetime.? Yes? Pre?operative?X?rays?of?
adjacent?teeth?and?
opposing?teeth?

D3430? Retrograde?filling???per?root? 0?999? Permanent?
Teeth?1?32?

One?per?lifetime.? Yes? Pre?operative?X?rays?of?
adjacent?teeth?and?
opposing?teeth?

D3450? Root?amputation???per?root? 0?999? Permanent?
Posterior??
(1?5,?12?21,?
28?32)?

One?per?lifetime.? Yes? Pre?operative?X?rays?of?
adjacent?teeth?and?
opposing?teeth?

D3910? Surgical?procedure?for?
isolation?of?tooth?with?rubber?
dam?

0?999? Permanent?
Teeth?1?32?

One?per?lifetime.? Yes? Pre?operative?X?rays?of?
adjacent?teeth?and?
opposing?teeth?

D3920? Hemisection?(including?any?
root?removal),?not?including?
root?canal?therapy?

0?999? Permanent?
Molars?(1?3,?
14?19,??
30?32)?

One?per?lifetime.? Yes? Pre?operative?X?rays?of?
adjacent?teeth?and?
opposing?teeth?

D3950? Canal?preparation?and?fitting?
of?preformed?dowel?or?post?

0?999? Permanent?
Teeth?1?32?

One?per?lifetime.?
Not?payable?to?the?same?provider?as?D2952,?D2953,?
D2954,?or?D2957?per?lifetime?per?provider.??

Yes? Pre?operative?X?rays?of?
adjacent?teeth?and?
opposing?teeth?



Horizon?NJ?Health?Dental?Program?
Benefit?Plan?Details?&?Authorization?Requirements?

??SKYGEN?USA?|?CONFIDENTIAL?&?PROPRIETARY?|?Horizon?NJ?Health?Dental?Program?|?Effective:?1/1/20?
150?

Horizon?NJ?Health?Dental?Program:?Non?Special?Needs?Plans?&?Special?Needs?Plans?
Code? Description? Age? Tooth?/?

Quad?/?Arch?
Limitations? Auth?

Req?
Requirement?

D3999? Unspecified?endodontic?
procedure;?by?report?

0?999? Permanent?
Teeth?1?32?

One?per?lifetime.? Yes? Narrative?of?medical?
necessity?

D4210? Gingivectomy?or?gingivoplasty?
??four?or?more?contiguous?
teeth?or?tooth?bounded?
spaces?per?quadrant?

0?999? Quadrants?
(LL,?LR,?UR,?
UL)?

One?per?3?years.? Yes? Pre?operative?X?rays,?
periodontal?charting,?
narrative?of?medical?
necessity,?photo?
(optional)?

D4211? Gingivectomy?or?gingivoplasty?
??one?to?three?contiguous?
teeth?or?tooth?bounded?
spaces?per?quadrant?

0?999? Quadrants?
(LL,?LR,?UR,?
UL)?

One?per?3?years.? Yes? Pre?operative?X?rays,?
periodontal?charting,?
narrative?of?medical?
necessity,?photo?
(optional)?

D4212? Gingivectomy?or?gingivoplasty?
to?allow?access?for?restorative?
procedure,?per?tooth?

0?999? Permanent?
Teeth?1?32?

One?per?3?years.? Yes? Pre?operative?X?rays,?
periodontal?charting,?
narrative?of?medical?
necessity,?photo?
(optional)?

D4240? Gingival?flap?procedure,?
including?root?planning???four?
or?more?contiguous?teeth?or?
tooth?bounded?spaces?per?
quadrant?

18?999? Quadrants?
(LL,?LR,?UR,?
UL)?

One?per?3?years.? Yes? Pre?operative?X?rays,?
periodontal?charting,?
narrative?of?medical?
necessity,?photo?
(optional)?



Horizon?NJ?Health?Dental?Program?
Benefit?Plan?Details?&?Authorization?Requirements?

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Code? Description? Age? Tooth?/?

Quad?/?Arch?
Limitations? Auth?

Req?
Requirement?

D4241? Gingival?flap?procedure,?
including?root?planing???one?
to?three?contiguous?teeth?or?
tooth?bounded?spaces?per?
quadrant?

18?999? Quadrants?
(LL,?LR,?UR,?
UL)?

One?per?3?years.? Yes? Pre?operative?X?rays,?
periodontal?charting,?
narrative?of?medical?
necessity,?photo?
(optional)?

D4245? Apically?positioned?flap? 18?999? Quadrants?
(LL,?LR,?UR,?
UL)?

One?per?floating?year.? Yes? Pre?operative?X?rays,?
periodontal?charting,?
narrative?of?medical?
necessity,?photo?
(optional)?

D4249? Clinical?crown?lengthening???
hard?tissue?

0?999? Permanent?
Teeth?1?32?

One?per?lifetime.? Yes? Pre?operative?X?rays,?
periodontal?charting,?
narrative?of?medical?
necessity,?photo?
(optional)?

D4260? Osseous?surgery?(including?
elevation?of?a?full?thickness?
flap?and?closure)???four?or?
more?contiguous?teeth?or?
tooth?bounded?spaces?per?
quadrant?

18?999? Quadrants?
(LL,?LR,?UR,?
UL)?

One?per?3?years.? Yes? Pre?operative?X?rays,?
periodontal?charting,?
narrative?of?medical?
necessity,?photos?



Horizon?NJ?Health?Dental?Program?
Benefit?Plan?Details?&?Authorization?Requirements?

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Horizon?NJ?Health?Dental?Program:?Non?Special?Needs?Plans?&?Special?Needs?Plans?
Code? Description? Age? Tooth?/?

Quad?/?Arch?
Limitations? Auth?

Req?
Requirement?

D4261? Osseous?surgery?(including?
elevation?of?a?full?thickness?
flap?and?closure)???one?to?
three?contiguous?teeth?or?
tooth?bounded?spaces?per?
quadrant?

18?999? Quadrants?
(LL,?LR,?UR,?
UL)?

One?per?3?years.? Yes? Pre?operative?X?rays,?
periodontal?charting,?
narrative?of?medical?
necessity,?photos?

D4263? Bone?replacement?graft???first?
site?in?quadrant?

18?999? Permanent?
Teeth?1?32?

Once?per?lifetime.?
Not?allowed?on?same?date?of?service?as?D7140,?D7210,?
D7220,?D7230,?D7240,?or?D7241.?
Tooth?cannot?have?a?history?of?being?extracted.?

Yes? Pre?operative?X?rays,?
periodontal?charting,?
narrative?of?medical?
necessity,?photo?
(optional)?

D4264? Bone?replacement?graft???
each?additional?site?in?
quadrant?

18?999? Permanent?
Teeth?1?32?

Once?per?lifetime.?
Not?allowed?on?same?date?of?service?as?D7140,?D7210,?
D7220,?D7230,?D7240,?or?D7241.?
Tooth?cannot?have?a?history?of?being?extracted.?

Yes? Pre?operative?X?rays,?
periodontal?charting,?
narrative?of?medical?
necessity,?photo?
(optional)?

D4265? Biologic?materials?to?aid?in?
soft?and?osseous?tissue?
regeneration?

18?999? Permanent?
Teeth?1?32?

One?per?lifetime.? Yes? Pre?operative?X?rays,?
periodontal?charting,?
narrative?of?medical?
necessity,?photo?
(optional)?

D4266? Guided?tissue?regeneration???
resorbable?barrier,?per?site?

18?999? Permanent?
Teeth?1?32?

One?per?3?years.? Yes? Pre?operative?X?rays,?
periodontal?charting,?
narrative?of?medical?
necessity,?photo?
(optional)?



Horizon?NJ?Health?Dental?Program?
Benefit?Plan?Details?&?Authorization?Requirements?

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Horizon?NJ?Health?Dental?Program:?Non?Special?Needs?Plans?&?Special?Needs?Plans?
Code? Description? Age? Tooth?/?

Quad?/?Arch?
Limitations? Auth?

Req?
Requirement?

D4267? Guided?tissue?regeneration???
non?resorbable?barrier,?per?
site?(includes?membrane?
removal)?

18?999? Permanent?
Teeth?1?32?

One?per?3?years.? Yes? Pre?operative?X?rays,?
periodontal?charting,?
narrative?of?medical?
necessity,?photo?
(optional)?

D4268? Surgical?revision?procedure,?
per?tooth?

18?999? Permanent?
Teeth?1?32?

One?per?3?years.? Yes? Pre?operative?X?rays,?
periodontal?charting,?
narrative?of?medical?
necessity,?photo?
(optional)?

D4270? Pedicle?soft?tissue?graft?
procedure?

18?999? Permanent?
Teeth?1?32?

One?per?3?years.? Yes? Pre?operative?X?rays,?
periodontal?charting,?
narrative?of?medical?
necessity,?photo?
(optional)?

D4273? Subepithelial?connective?
tissue?graft?procedures,?per?
tooth?

18?999? Permanent?
Teeth?1?32?

One?per?3?years.? Yes? Pre?operative?X?rays,?
periodontal?charting,?
narrative?of?medical?
necessity,?photo?
(optional)?

D4274? Distal?or?proximal?wedge?
procedure?(when?not?
performed?in?conjunction?
with?surgical?procedures?in?
the?same?anatomical?area)?

18?999? Permanent?
Teeth?1?32?

One?per?3?years.? Yes? Pre?operative?X?rays,?
periodontal?charting,?
narrative?of?medical?
necessity,?photo?
(optional)?



Horizon?NJ?Health?Dental?Program?
Benefit?Plan?Details?&?Authorization?Requirements?

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154?

Horizon?NJ?Health?Dental?Program:?Non?Special?Needs?Plans?&?Special?Needs?Plans?
Code? Description? Age? Tooth?/?

Quad?/?Arch?
Limitations? Auth?

Req?
Requirement?

D4275? Soft?tissue?allograft? 18?999? Permanent?
Teeth?1?32?

One?per?3?years.? Yes? Pre?operative?X?rays,?
periodontal?charting,?
narrative?of?medical?
necessity,?photo?
(optional)?

D4276? Combined?connective?tissue?
and?double?pedicle?graft,?per?
tooth?

18?999? Permanent?
Teeth?1?32?

One?per?3?years.? Yes? Pre?operative?X?rays,?
periodontal?charting,?
narrative?of?medical?
necessity,?photo?
(optional)?

D4277? Free?soft?tissue?graft?
procedure?(including?donor?
site?surgery),?first?tooth?or?
edentulous?tooth?position?in?
graft?

18?999? Permanent?
Teeth?1?32?

One?per?3?years.? Yes? Pre?operative?X?rays,?
periodontal?charting,?
narrative?of?medical?
necessity,?photo?
(optional)?

D4278? Free?soft?tissue?graft?
procedure?(including?donor?
site?surgery),?each?additional?
contiguous?tooth?or?
edentulous?tooth?position?in?
same?graft?site?

18?999? Permanent?
Teeth?1?32?

One?per?3?years.? Yes? Pre?operative?X?rays,?
periodontal?charting,?
narrative?of?medical?
necessity,?photo?
(optional)?



Horizon?NJ?Health?Dental?Program?
Benefit?Plan?Details?&?Authorization?Requirements?

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155?

Horizon?NJ?Health?Dental?Program:?Non?Special?Needs?Plans?&?Special?Needs?Plans?
Code? Description? Age? Tooth?/?

Quad?/?Arch?
Limitations? Auth?

Req?
Requirement?

D4283? Autogenous?connective?tissue?
graft?procedure?(including?
donor?and?surgical?sites)???
each?additional?contiguous?
tooth,?implant?or?edentulous?
tooth?position?in?same?graft?
site?

18?999? Permanent?
Teeth?1?32?

One?per?3?years.? Yes? Pre?operative?X?rays,?
periodontal?charting,?
narrative?of?medical?
necessity,?photo?
(optional)?

D4285? Non?Autogenous?connective?
tissue?graft?procedure?
(including?donor?and?surgical?
sites)???each?additional?
contiguous?tooth,?implant?or?
edentulous?tooth?position?in?
same?graft?site?

18?999? Permanent?
Teeth?1?32?

One?per?3?years.? Yes? Pre?operative?X?rays,?
periodontal?charting,?
narrative?of?medical?
necessity,?photo?
(optional)?

D4320? Provisional?splinting???
intracoronal?

0?999? Arches?(UA,?
LA)?

?? Yes? Documentation?of?
medical?necessity?

D4321? Provisional?splinting???
extracoronal?

0?999? Arches?(UA,?
LA)?

?? Yes? Documentation?of?
medical?necessity?

D4341?
No?
Special?
Needs?

Periodontal?scaling?and?root?
planing???four?or?more?teeth?
per?quadrant?

0?999? Quadrants?
(LL,?LR,?UR,?
UL)?

One?per?floating?year.? Yes? Periodontal?charting?and?
pre?operative?X?rays?



Horizon?NJ?Health?Dental?Program?
Benefit?Plan?Details?&?Authorization?Requirements?

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156?

Horizon?NJ?Health?Dental?Program:?Non?Special?Needs?Plans?&?Special?Needs?Plans?
Code? Description? Age? Tooth?/?

Quad?/?Arch?
Limitations? Auth?

Req?
Requirement?

D4341?
Special?
Needs?

Periodontal?scaling?and?root?
planing???four?or?more?teeth?
per?quadrant?

0?999? Quadrants?
(LL,?LR,?UR,?
UL)?

One?per?floating?year.? Yes? Periodontal?charting?and?
pre?operative?X?rays;?
letter?of?medical?
necessity?for?additional?
frequency?

D4342?
No?
Special?
Needs?

Periodontal?scaling?and?root?
planing???one?to?three?teeth?
per?quadrant?

0?999? Quadrants?
(LL,?LR,?UR,?
UL)?

One?per?floating?year.? Yes? Periodontal?charting?and?
pre?operative?X?rays?

D4342?
Special?
Needs?

Periodontal?scaling?and?root?
planing???one?to?three?teeth?
per?quadrant?

0?999? Quadrants?
(LL,?LR,?UR,?
UL)?

One?per?floating?year.? Yes? Periodontal?charting?and?
pre?operative?X?rays;?
letter?of?medical?
necessity?for?less?than?3?
years?

D4346? Scaling?in?presence?of?
generalized?moderate?or?
severe?gingival?inflammation?
??full?mouth,?after?oral?
evaluation?

0?999? ?? One?per?floating?year.?
Not?allowable?within?6?months?of?D1110,?D1120,?
D4341,?D4342,?D4260,?D4261?or?D4910.?

No? ??

D4355?
No?
Special?
Needs,?
MLTSS?

Full?mouth?debridement?to?
enable?comprehensive?
evaluation?and?diagnosis?

0?999? ?? One?per?three?floating?years.?
Not?allowable?within?6?months?of?D4341,?D4342,?
D4260,?D4261,?D4346,?or?D4910.?
Not?allowable?on?the?same?date?of?service?as?D0150,?
D0160,?D0180,?D1110,?D1120?or?any?other?D4000?
series?code.?

No? ??



Horizon?NJ?Health?Dental?Program?
Benefit?Plan?Details?&?Authorization?Requirements?

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157?

Horizon?NJ?Health?Dental?Program:?Non?Special?Needs?Plans?&?Special?Needs?Plans?
Code? Description? Age? Tooth?/?

Quad?/?Arch?
Limitations? Auth?

Req?
Requirement?

D4355?
Special?
Needs,?
MLTSS?

Full?mouth?debridement?to?
enable?comprehensive?
evaluation?and?diagnosis?

0?999? ?? One?per?floating?year.?
Not?allowable?within?6?months?of?D4341,?D4342,?
D4260,?D4261,?D4346,?or?D4910.?
Not?allowable?on?the?same?date?of?service?as?D0150,?
D0160,?D0180,?D1110,?D1120?or?any?other?D4000?
series?code.?

No? ??

D4381? Localized?delivery?of?
antimicrobial?agents?via?a?
controlled?release?vehicle?into?
diseased?crevicular?tissue,?per?
tooth?

0?999? Permanent?
Teeth?1?32?

One?per?2?years.? Yes? Description?of?procedure?
and?narrative?of?medical?
necessity?

D4910? Periodontal?maintenance? 0?999? ?? Allowable?twice?per?rolling?year?per?member.?
Requires?history?of?active?perio?treatment?(D4341,?
D4342,?D4260,?D4261,?or?D4910)?within?the?last?36?
months.??
Not?allowed?sooner?than?90?days?after?D1110,?D4210,?
D4211,?D4240,?D4241,?D4245,?D4260,?D4261,?D4263,?
D4264,?D4266,?D4267,?D4268,?D4270,?D4271,?D4273,?
D4274,?D4275,?D4276,?D4341,?or?D4342.?

No? ??

D4999? Unspecified?periodontal?
procedure,?by?report?

0?999? All?teeth;??
A?T;?1?32?

?? Yes? Description?of?procedure?
and?narrative?of?medical?
necessity?

D5110? Complete?denture???maxillary? 0?999? ?? One?per?90?months.? Yes? Full?mouth?X?rays?or?
panorex?



Horizon?NJ?Health?Dental?Program?
Benefit?Plan?Details?&?Authorization?Requirements?

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158?

Horizon?NJ?Health?Dental?Program:?Non?Special?Needs?Plans?&?Special?Needs?Plans?
Code? Description? Age? Tooth?/?

Quad?/?Arch?
Limitations? Auth?

Req?
Requirement?

D5120? Complete?denture???
mandibular?

0?999? ?? One?per?90?months.? Yes? Full?mouth?X?rays?or?
panorex?

D5130? Immediate?denture???
maxillary?

0?999? ?? One?per?lifetime;?allowed?within?14?days?of?D7140,?
D7210,?D7220,?D7230,?D7240,?D7241,?or?D7250.?
D5710,?D5711,?D5720,?D5721,?D5730,?D5731,?D5740,?
D5741,?D5750,?D5751,?D5760,?D5761,?D5850,?D5851?
not?payable?within?6?months?after?this?code.?

Yes? Full?mouth?X?rays?or?
panorex?

D5140? Immediate?denture???
mandibular?

0?999? ?? One?per?lifetime;?allowed?within?14?days?of?D7140,?
D7210,?D7220,?D7230,?D7240,?D7241,?or?D7250.?
D5710,?D5711,?D5720,?D5721,?D5730,?D5731,?D5740,?
D5741,?D5750,?D5751,?D5760,?D5761,?D5850,?D5851?
not?payable?within?6?months?after?this?code.?

Yes? Full?mouth?X?rays?or?
panorex?

D5211? Maxillary?partial?denture???
resin?base?(including?any?
conventional?clasps,?rests?and?
teeth)?

0?999? ?? One?per?90?months.? Yes? Full?mouth?X?rays?or?
panorex?

D5212? Mandibular?partial?denture???
resin?base?(including?any?
conventional?clasps,?rests?and?
teeth)?

0?999? ?? One?per?90?months.? Yes? Full?mouth?X?rays?or?
panorex?

D5213? Maxillary?partial?denture???
cast?metal?framework?with?
resin?denture?bases?

0?999? ?? One?per?90?months.? Yes? Full?mouth?X?rays?or?
panorex?



Horizon?NJ?Health?Dental?Program?
Benefit?Plan?Details?&?Authorization?Requirements?

??SKYGEN?USA?|?CONFIDENTIAL?&?PROPRIETARY?|?Horizon?NJ?Health?Dental?Program?|?Effective:?1/1/20?
159?

Horizon?NJ?Health?Dental?Program:?Non?Special?Needs?Plans?&?Special?Needs?Plans?
Code? Description? Age? Tooth?/?

Quad?/?Arch?
Limitations? Auth?

Req?
Requirement?

D5214? Mandibular?partial?denture???
cast?metal?framework?with?
resin?denture?bases?

0?999? ?? One?per?90?months.? Yes? Full?mouth?X?rays?or?
panorex?

D5221? Immediate?Maxillary?partial?
denture???resin?base?
(including?any?conventional?
clasps,?rests,?and?teeth)?

0?999? ?? One?per?90?months.? Yes? Full?mouth?X?rays?or?
panorex?

D5222? Immediate?Mandibular?partial?
denture???resin?base?
(including?any?conventional?
clasps,?rests,?and?teeth)?

0?999? ?? One?per?90?months.? Yes? Full?mouth?X?rays?or?
panorex?

D5223? Immediate?Maxillary?partial?
denture???cast?metal?base?
(including?any?conventional?
clasps,?rests,?and?teeth)?

0?999? ?? One?per?90?months.? Yes? Full?mouth?X?rays?or?
panorex?

D5224? Immediate?Mandibular?partial?
denture???cast?metal?base?
(including?any?conventional?
clasps,?rests,?and?teeth)?

0?999? ?? One?per?90?months.? Yes? Full?mouth?X?rays?or?
panorex?

D5225? Maxillary?partial?denture???
flexible?base?(including?any?
clasps,?rests,?and?teeth)?

0?999? ?? One?per?90?months.? Yes? Full?mouth?X?rays?or?
panorex?



Horizon?NJ?Health?Dental?Program?
Benefit?Plan?Details?&?Authorization?Requirements?

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160?

Horizon?NJ?Health?Dental?Program:?Non?Special?Needs?Plans?&?Special?Needs?Plans?
Code? Description? Age? Tooth?/?

Quad?/?Arch?
Limitations? Auth?

Req?
Requirement?

D5226? Mandibular?partial?denture???
flexible?base?(including?any?
clasps,?rests,?and?teeth)?

0?999? ?? One?per?90?months.? Yes? Full?mouth?X?rays?or?
panorex?

D5410? Adjust?complete?denture???
maxillary?

0?999? ?? One?per?6?months.??
Not?within?6?months?of?reline/rebase?or?3?months?of?
D5510?or?D5610.?

No? ??

D5411? Adjust?complete?denture???
mandibular?

0?999? ?? One?per?6?months.?
Not?within?6?months?of?reline/rebase?or?3?months?of?
D5510?or?D5610.?

No? ??

D5421? Adjust?partial?denture???
maxillary?

0?999? ?? One?per?6?months.?
Not?within?6?months?of?reline/rebase?or?3?months?of?
D5510?or?D5610.?

No? ??

D5422? Adjust?partial?denture???
mandibular?

0?999? ?? One?per?6?months.?
Not?within?6?months?of?reline/rebase?or?3?months?of?
D5510?or?D5610.?

No? ??

D5511? Repair?broken?complete?
denture?base???Mandibular?

0?999? Lower?Arch? One?per?3?rolling?years.? No? ??

D5512? Repair?broken?complete?
denture?base???Maxillary?

0?999? Upper?Arch? One?per?3?rolling?years.? No? ?



Horizon?NJ?Health?Dental?Program?
Benefit?Plan?Details?&?Authorization?Requirements?

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161?

Horizon?NJ?Health?Dental?Program:?Non?Special?Needs?Plans?&?Special?Needs?Plans?
Code? Description? Age? Tooth?/?

Quad?/?Arch?
Limitations? Auth?

Req?
Requirement?

D5520? Replace?missing?or?broken?
teeth???complete?denture?
(each?tooth)?

0?999? Permanent?
Teeth?1?32?

One?per?6?months.? No? ??

D5611? Repair?resin?partial?denture?
base???Mandibular?

0?999? Lower?Arch? One?per?3?rolling?years.? No? ??

D5612? Repair?resin?partial?denture?
base???Maxillary?

0?999? Upper?Arch? One?per?3?rolling?years.? No? ?

D5621? Repair?cast?partial?framework?
??Mandibular?

0?999? Lower?Arch? One?per?3?rolling?years.? No? ??

D5622? Repair?cast?partial?framework?
??Maxillary?

0?999? Upper?Arch? One?per?3?rolling?years.? No? ?

D5630? Repair?or?replace?broken?
clasp?

0?999? Permanent?
Teeth?1?32?

One?per?6?months.? No? ??

D5640? Replace?broken?teeth???per?
tooth?

0?999? Permanent?
Teeth?1?32?

One?per?6?months.? No? ??

D5650? Add?tooth?to?existing?partial?
denture?

0?999? Permanent?
Teeth?1?32?

One?per?6?months.? No? ??

D5660? Add?clasp?to?existing?partial?
denture?

0?999? Permanent?
Teeth?1?32?

One?per?6?months.? No? ??



Horizon?NJ?Health?Dental?Program?
Benefit?Plan?Details?&?Authorization?Requirements?

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Horizon?NJ?Health?Dental?Program:?Non?Special?Needs?Plans?&?Special?Needs?Plans?
Code? Description? Age? Tooth?/?

Quad?/?Arch?
Limitations? Auth?

Req?
Requirement?

D5710? Rebase?complete?maxillary?
denture?

0?999? ?? One?per?3?years.?
Not?allowed?within?6?months?after?D5110?or?D5130.?

No? ??

D5711? Rebase?complete?mandibular?
denture?

0?999? ?? One?per?3?years.?
Not?allowed?within?6?months?after?D5120?or?D5140.?

No? ??

D5720? Rebase?maxillary?partial?
denture?

0?999? ?? One?per?3?years.? No? ??

D5721? Rebase?mandibular?partial?
denture?

0?999? ?? One?per?3?years.? No? ??

D5730? Reline?complete?maxillary?
denture?(chairside)?

0?999? ?? One?per?12?months.? No? ??

D5731? Reline?complete?mandibular?
denture?(chairside)?

0?999? ?? One?per?12?months.? No? ??

D5740? Reline?maxillary?partial?
denture?(chairside)?

0?999? ?? One?per?12?months.? No? ??

D5741? Reline?mandibular?partial?
denture?(chairside)?

0?999? ?? One?per?12?months.? No? ??

D5750? Reline?complete?maxillary?
denture?(laboratory)?

0?999? ?? One?per?12?months.? No? ??

D5751? Reline?complete?mandibular?
denture?(laboratory)?

0?999? ?? One?per?12?months.? No? ??



Horizon?NJ?Health?Dental?Program?
Benefit?Plan?Details?&?Authorization?Requirements?

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Horizon?NJ?Health?Dental?Program:?Non?Special?Needs?Plans?&?Special?Needs?Plans?
Code? Description? Age? Tooth?/?

Quad?/?Arch?
Limitations? Auth?

Req?
Requirement?

D5760? Reline?maxillary?partial?
denture?(laboratory)?

0?999? ?? One?per?12?months.? No? ??

D5761? Reline?mandibular?partial?
denture?(laboratory)?

0?999? ?? One?per?12?months.? No? ??

D5850? Tissue?conditioning,?maxillary? 18?999? ?? One?per?12?months.? No? ??

D5851? Tissue?conditioning,?
mandibular?

18?999? ?? One?per?12?months.? No? ??

D5862? Precision?attachment,?by?
report?

18?999? Permanent?
Teeth?1?32?

?? Yes? Narrative?describing?
type?of?attachment?and?
the?medical?necessity?

D5863? Overdenture???complete?
maxillary?

18?999? Arches?(UA,?
LA)?

One?per?90?months.? Yes? Full?mouth?X?rays?or?
panorex?

D5864? Overdenture???partial?
maxillary?

18?999? Arches?(UA,?
LA)?

One?per?90?months.? Yes? Full?mouth?X?rays?or?
panorex?

D5865? Overdenture???complete?
mandibular?

18?999? Arches?(UA,?
LA)?

One?per?90?months.? Yes? Full?mouth?X?rays?or?
panorex?

D5866? Overdenture???partial?
mandibular?

18?999? Arches?(UA,?
LA)?

One?per?90?months.? Yes? Full?mouth?X?rays?or?
panorex?



Horizon?NJ?Health?Dental?Program?
Benefit?Plan?Details?&?Authorization?Requirements?

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Horizon?NJ?Health?Dental?Program:?Non?Special?Needs?Plans?&?Special?Needs?Plans?
Code? Description? Age? Tooth?/?

Quad?/?Arch?
Limitations? Auth?

Req?
Requirement?

D5867? Replacement?of?replaceable?
part?of?semi?precision?or?
precision?attachment?

18?999? Permanent?
Teeth?1?32?

?? Yes? Narrative?describing?
type?of?attachment?and?
the?medical?necessity?

D5875? Modification?of?removable?
prosthesis?following?implant?
surgery?

0?999? Arches?(UA,?
LA)?

?? Yes? Narrative?of?date?of?
implant?placement?with?
claim?

D5899? Unspecified?removable?
prosthodontic?procedure,?by?
report?

0?999? Arches?(UA,?
LA)?

?? Yes? Description?of?procedure?
and?narrative?of?medical?
necessity?

D5911? Facial?moulage?(sectional)? 0?999? ?? ?? Yes? Narrative?of?medical?
necessity?with?
preauthorization?

D5912? Facial?moulage?(complete)? 0?999? ?? ?? Yes? Narrative?of?medical?
necessity?with?
preauthorization?

D5913? Nasal?prosthesis? 0?999? ?? ?? Yes? Narrative?of?medical?
necessity?with?
preauthorization?

D5914? Auricular?prosthesis? 0?999? ?? ?? Yes? Narrative?of?medical?
necessity?with?
preauthorization?



Horizon?NJ?Health?Dental?Program?
Benefit?Plan?Details?&?Authorization?Requirements?

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Horizon?NJ?Health?Dental?Program:?Non?Special?Needs?Plans?&?Special?Needs?Plans?
Code? Description? Age? Tooth?/?

Quad?/?Arch?
Limitations? Auth?

Req?
Requirement?

D5915? Orbital?prosthesis? 0?999? ?? ?? Yes? Narrative?of?medical?
necessity?with?
preauthorization?

D5916? Ocular?prosthesis? 0?999? ?? ?? Yes? Narrative?of?medical?
necessity?with?
preauthorization?

D5919? Facial?prosthesis? 0?999? ?? ?? Yes? Narrative?of?medical?
necessity?with?
preauthorization?

D5922? Nasal?septal?prosthesis? 0?999? ?? ?? Yes? Narrative?of?medical?
necessity?with?
preauthorization?

D5923? Ocular?prosthesis,?interim? 0?999? ?? ?? Yes? Narrative?of?medical?
necessity?with?
preauthorization?

D5924? Cranial?prosthesis? 0?999? ?? ?? Yes? Narrative?of?medical?
necessity?with?
preauthorization?

D5925? Facial?augmentation?implant?
prosthesis?

0?999? ?? ?? Yes? Narrative?of?medical?
necessity?with?
preauthorization?



Horizon?NJ?Health?Dental?Program?
Benefit?Plan?Details?&?Authorization?Requirements?

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Horizon?NJ?Health?Dental?Program:?Non?Special?Needs?Plans?&?Special?Needs?Plans?
Code? Description? Age? Tooth?/?

Quad?/?Arch?
Limitations? Auth?

Req?
Requirement?

D5926? Nasal?prosthesis,?replacement? 0?999? ?? ?? Yes? Narrative?of?medical?
necessity?with?
preauthorization?

D5927? Auricular?prosthesis,?
replacement?

0?999? ?? ?? Yes? Narrative?of?medical?
necessity?with?
preauthorization?

D5928? Orbital?prosthesis,?
replacement?

0?999? ?? ?? Yes? Narrative?of?medical?
necessity?with?
preauthorization?

D5929? Facial?prosthesis,?
replacement?

0?999? ?? ?? Yes? Narrative?of?medical?
necessity?with?
preauthorization?

D5931? Obturator?prosthesis,?surgical? 0?999? ?? ?? Yes? Narrative?of?medical?
necessity?with?
preauthorization?

D5932? Obturator?prosthesis,?
definitive?

0?999? ?? ?? Yes? Narrative?of?medical?
necessity?with?
preauthorization?

D5933? Obturator?prosthesis,?
modification?

0?999? ?? ?? Yes? Narrative?of?medical?
necessity?with?
preauthorization?



Horizon?NJ?Health?Dental?Program?
Benefit?Plan?Details?&?Authorization?Requirements?

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Horizon?NJ?Health?Dental?Program:?Non?Special?Needs?Plans?&?Special?Needs?Plans?
Code? Description? Age? Tooth?/?

Quad?/?Arch?
Limitations? Auth?

Req?
Requirement?

D5935? Mandibular?resection?
prosthesis?without?guide?
flange?

0?999? ?? ?? Yes? Narrative?of?medical?
necessity?with?
preauthorization?

D5936? Obturator?prosthesis,?interim? 0?999? ?? ?? Yes? Narrative?of?medical?
necessity?with?
preauthorization?

D5937? Trismus?appliance?(not?for?
TMD?treatment)?

0?999? ?? ?? Yes? Narrative?of?medical?
necessity?with?
preauthorization?

D5951? Feeding?aid? 0?999? ?? ?? Yes? Narrative?of?medical?
necessity?with?
preauthorization?

D5952? Speech?aid?prosthesis,?
pediatric?

0?999? ?? ?? Yes? Narrative?of?medical?
necessity?with?
preauthorization?

D5953? Speech?aid?prosthesis,?adult? 0?999? ?? ?? Yes? Narrative?of?medical?
necessity?with?
preauthorization?

D5954? Palatal?augmentation?
prosthesis?

0?999? ?? ?? Yes? Narrative?of?medical?
necessity?with?
preauthorization?



Horizon?NJ?Health?Dental?Program?
Benefit?Plan?Details?&?Authorization?Requirements?

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Horizon?NJ?Health?Dental?Program:?Non?Special?Needs?Plans?&?Special?Needs?Plans?
Code? Description? Age? Tooth?/?

Quad?/?Arch?
Limitations? Auth?

Req?
Requirement?

D5955? Palatal?lift?prosthesis,?
definitive?

0?999? ?? ?? Yes? Narrative?of?medical?
necessity?with?
preauthorization?

D5958? Palatal?lift?prosthesis,?interim? 0?999? ?? ?? Yes? Narrative?of?medical?
necessity?with?
preauthorization?

D5959? Palatal?lift?prosthesis,?
modification?

0?999? ?? ?? Yes? Narrative?of?medical?
necessity?with?
preauthorization?

D5960? Speech?aid?prosthesis,?
modification?

0?999? ?? ?? Yes? Narrative?of?medical?
necessity?with?
preauthorization?

D5982? Surgical?stent? 0?999? ?? ?? Yes? Narrative?of?medical?
necessity?with?
preauthorization?

D5983? Radiation?carrier? 0?999? ?? ?? Yes? Narrative?of?medical?
necessity?with?
preauthorization?

D5984? Radiation?shield? 0?999? ?? ?? Yes? Narrative?of?medical?
necessity?with?
preauthorization?



Horizon?NJ?Health?Dental?Program?
Benefit?Plan?Details?&?Authorization?Requirements?

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Horizon?NJ?Health?Dental?Program:?Non?Special?Needs?Plans?&?Special?Needs?Plans?
Code? Description? Age? Tooth?/?

Quad?/?Arch?
Limitations? Auth?

Req?
Requirement?

D5985? Radiation?cone?locator? 0?999? ?? ?? Yes? Narrative?of?medical?
necessity?with?
preauthorization?

D5986? Fluoride?gel?carrier? 0?999? ?? ?? Yes? Narrative?of?medical?
necessity?with?
preauthorization?

D5987? Commissure?splint? 0?999? ?? ?? Yes? Narrative?of?medical?
necessity?with?
preauthorization?

D5988? Surgical?splint? 0?999? ?? ?? Yes? Narrative?of?medical?
necessity?with?
preauthorization?

D5991? Vesiculobullous?disease?
medicament?carrier?

0?999? ?? ?? Yes? Narrative?of?medical?
necessity?with?claim?

D5992? Adjust?maxillofacial?prosthetic?
appliance,?by?report?

0?999? ?? ?? Yes? Narrative?of?medical?
necessity?with?claim?

D5993? Maintenance?and?cleaning?of?
a?maxillofacial?prosthesis?
(extra??or?intra?oral)?other?
than?required?adjustments,?
by?report?

0?999? ?? One?per?floating?year.? Yes? Narrative?of?medical?
necessity?with?claim?



Horizon?NJ?Health?Dental?Program?
Benefit?Plan?Details?&?Authorization?Requirements?

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Horizon?NJ?Health?Dental?Program:?Non?Special?Needs?Plans?&?Special?Needs?Plans?
Code? Description? Age? Tooth?/?

Quad?/?Arch?
Limitations? Auth?

Req?
Requirement?

D5999? Unspecified?maxillofacial?
prosthesis,?by?report?

0?999? ?? ?? Yes? Description?of?procedure?
and?narrative?of?medical?
necessity?

D6010? Surgical?placement?of?implant?
body:?endosteal?implant?

0?999? Permanent?
Teeth?1?32?

One?per?tooth?per?lifetime.?
Four?teeth?per?arch.?

Yes? Full?mouth?X?rays?or?
panorex?

D6040? Surgical?placement:?epostial?
implant?

0?999? Arches?(UA,?
LA)?

One?per?90?months.? Yes? Full?mouth?X?rays?or?
panorex?

D6050? Surgical?placement?of?
transosteal?implant?

0?999? Permanent?
Teeth?1?32?

One?per?90?months.? Yes? Full?mouth?X?rays?or?
panorex?

D6052? Semi?precision?attachment?
abutment?(tooth)?

0?999? Permanent?
Teeth?1?32?

One?per?90?months.? Yes? Pre?operative?X?rays?

D6055? Dental?implant?supported?
connecting?bar?

0?999? Permanent?
Teeth?1?32?

One?per?90?months.? Yes? Pre?operative?X?rays?

D6056? Prefabricated?abutment?
includes?placement?

0?999? Permanent?
Teeth?1?32?

One?per?90?months.? Yes? Pre?operative?X?rays?

D6057? Custom?abutment?includes?
placement?

0?999? Permanent?
Teeth?1?32?

One?per?90?months.? Yes? Pre?operative?X?rays?



Horizon?NJ?Health?Dental?Program?
Benefit?Plan?Details?&?Authorization?Requirements?

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Horizon?NJ?Health?Dental?Program:?Non?Special?Needs?Plans?&?Special?Needs?Plans?
Code? Description? Age? Tooth?/?

Quad?/?Arch?
Limitations? Auth?

Req?
Requirement?

D6080? Implant?maintenance?
procedures?when?prostheses?
are?removed?and?reinserted,?
including?cleansing?of?
prostheses?

0?999? Permanent?
Teeth?1?32?

Twice?per?year.? Yes? Pre?operative?X?rays?

D6081? Scaling?and?debridement?in?
the?presence?of?inflammation?
or?mucositis?of?a?single?
implant,?including?cleaning?of?
the?implant?surfaces,?without?
flap?entry?and?closure?

21?999? Permanent?
Teeth?1?32?

Once?per?3?rolling?years.?
Not?in?conjunction?with?D1110,?D4346,?D4355,?D4910?
on?same?date?of?service?per?payee.?

Yes? Recent?full?mouth?perio?
charting?and?
radiographs;?narrative?
and?photos?if?bone?loss?
not?visible?on?x?rays?or?
for?Special?Health?Care?
Needs?Member?or?LTC?
resident?

D6090? Repair?implant?supported?
prosthesis,?by?report?

0?999? Permanent?
Teeth?1?32?

?? Yes? X?rays?

D6091? Replacement?of?semi?
precision?or?precision?
attachment?(male?or?female?
component)?of?
implant/abutment??

0?999? Permanent?
Teeth?1?32?

?? Yes? X?rays?

D6092? Re?cement?or?re?bond?
implant/abutment?supported?
crown?

0?999? Permanent?
Teeth?1?32?

?? Yes? X?rays?

D6095? Repair?implant?abutment,?by?
report?

0?999? Permanent?
Teeth?1?32?

?? Yes? X?rays?



Horizon?NJ?Health?Dental?Program?
Benefit?Plan?Details?&?Authorization?Requirements?

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Horizon?NJ?Health?Dental?Program:?Non?Special?Needs?Plans?&?Special?Needs?Plans?
Code? Description? Age? Tooth?/?

Quad?/?Arch?
Limitations? Auth?

Req?
Requirement?

D6096? Remove?Broken?Implant?
Retaining?Screw?

0?999? Permanent?
Teeth?1?32?

? Yes? PA?x?ray?and?narrative?of?
medical?necessity?with?
complete?treatment?
plan?

D6100? Implant?Removal,?by?report? 0?999? Permanent?
Teeth?1?32?

?? Yes? X?rays?

D6101? Debridement?of?peri?implant?
defect?

0?999? Permanent?
Teeth?1?32?

?? Yes? Pre?operative?X?rays?and?
narrative?of?medical?
necessity?

D6102? Debridement?and?osseous?
contouring?of?a?peri?implant?
defect,?includes?surface?

0?999? Permanent?
Teeth?1?32?

?? Yes? Pre?operative?X?rays?and?
narrative?of?medical?
necessity?

D6103? Bone?graft?for?repair?of?peri?
implant?defect?not?including?
flap?entry??

0?999? Permanent?
Teeth?1?32?

?? Yes? Pre?operative?X?rays?and?
narrative?of?medical?
necessity?

D6104? Bone?graft?at?implant?
placement?

0?999? Permanent?
Teeth?1?32?

?? Yes? Pre?operative?X?rays?and?
narrative?of?medical?
necessity?

D6110? Implant/Abut?Removable?
Denture/Max?

0?999? Permanent?
Teeth?1?32?

?? Yes? Pre?operative?X?rays?and?
narrative?of?medical?
necessity?

D6111? Implant/Abut?Removable?
Denture/Mand?

0?999? Permanent?
Teeth?1?32?

?? Yes? Pre?operative?X?rays?and?
narrative?of?medical?
necessity?



Horizon?NJ?Health?Dental?Program?
Benefit?Plan?Details?&?Authorization?Requirements?

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Horizon?NJ?Health?Dental?Program:?Non?Special?Needs?Plans?&?Special?Needs?Plans?
Code? Description? Age? Tooth?/?

Quad?/?Arch?
Limitations? Auth?

Req?
Requirement?

D6190? Radiographic/surgical?implant?
index?

0?999? Permanent?
Teeth?1?32?

?? Yes? Pre?operative?X?rays?and?
narrative?of?medical?
necessity?

D6199? Unspecified?implant?
procedure?

0?999? Permanent?
Teeth?1?32?

?? Yes? Pre?operative?X?rays?and?
narrative?of?medical?
necessity?

D6210? Pontic???cast?high?noble?metal? 16?999? Permanent?
Teeth?1?32?

One?per?5?years.? Yes? Full?mouth?X?rays?or?
panorex?with?bitewings;?
narrative?of?medical?
necessity?for?members?
with?special?needs.?

D6211? Pontic???cast?predominantly?
base?metal?

16?999? Permanent?
Teeth?1?32?

One?per?5?years.? Yes? Full?mouth?X?rays?or?
panorex?

D6212? Pontic???cast?noble?metal? 16?999? Permanent?
Teeth?1?32?

One?per?5?years.? Yes? Full?mouth?X?rays?or?
panorex?

D6240? Pontic???porcelain?fused?to?
high?noble?metal?

16?999? Permanent?
Teeth?1?32?

One?per?5?years.? Yes? Full?mouth?X?rays?or?
panorex?

D6241? Pontic???porcelain?fused?to?
predominantly?base?metal?

16?999? Permanent?
Teeth?1?32?

One?per?5?years.? Yes? Full?mouth?X?rays?or?
panorex?

D6242? Pontic???porcelain?fused?to?
noble?metal?

16?999? Permanent?
Teeth?1?32?

One?per?5?years.? Yes? Full?mouth?X?rays?or?
panorex?



Horizon?NJ?Health?Dental?Program?
Benefit?Plan?Details?&?Authorization?Requirements?

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Code? Description? Age? Tooth?/?

Quad?/?Arch?
Limitations? Auth?

Req?
Requirement?

D6250? Pontic???resin?with?high?noble?
metal?

16?999? Permanent?
Teeth?1?32?

One?per?5?years.? Yes? Full?mouth?X?rays?or?
panorex?

D6251? Pontic???resin?with?
predominantly?base?metal?

16?999? Permanent?
Teeth?1?32?

One?per?5?years.? Yes? Full?mouth?X?rays?or?
panorex?

D6252 Pontic?resin?with?
predominantly?noble?metal?

16?999? Permanent?
Teeth?1?32?

One?per?5?years.? Yes? Full?mouth?X?rays?or?
panorex?

D6545? Retainer???cast?metal?for?resin?
bonded?fixed?prosthesis?

16?999? Permanent?
Teeth?1?32?

One?per?5?years.? Yes? Full?mouth?X?rays?or?
panorex?

D6720? Crown???resin?with?high?noble?
metal?

16?999? Permanent?
Teeth?1?32?

One?per?5?years.? Yes? Full?mouth?X?rays?or?
panorex?

D6721? Crown???resin?with?
predominantly?base?metal?

16?999? Permanent?
Teeth?1?32?

One?per?5?years.? Yes? Full?mouth?X?rays?or?
panorex?

D6722? Crown???resin?with?noble?
metal?

16?999? Permanent?
Teeth?1?32?

One?per?5?years.? Yes? Full?mouth?X?rays?or?
panorex?

D6750? Crown???porcelain?fused?to?
high?noble?metal?

16?999? Permanent?
Teeth?1?32?

One?per?5?years.? Yes? Full?mouth?X?rays?or?
panorex?

D6751? Crown???porcelain?fused?to?
predominantly?base?metal?

16?999? Permanent?
Teeth?1?32?

One?per?5?years.? Yes? Full?mouth?X?rays?or?
panorex?



Horizon?NJ?Health?Dental?Program?
Benefit?Plan?Details?&?Authorization?Requirements?

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Horizon?NJ?Health?Dental?Program:?Non?Special?Needs?Plans?&?Special?Needs?Plans?
Code? Description? Age? Tooth?/?

Quad?/?Arch?
Limitations? Auth?

Req?
Requirement?

D6752? Crown???porcelain?fused?to?
noble?metal?

16?999? Permanent?
Teeth?1?32?

One?per?5?years.? Yes? Full?mouth?X?rays?or?
panorex?

D6790? Crown???full?cast?high?noble?
metal?

16?999? Permanent?
Teeth?1?32?

One?per?5?years.? Yes? Full?mouth?X?rays?or?
panorex?

D6791? Crown???full?cast?
predominantly?base?metal?

16?999? Permanent?
Teeth?1?32?

One?per?5?years.? Yes? Full?mouth?X?rays?or?
panorex?

D6792? Crown???full?cast?noble?metal? 16?999? Permanent?
Teeth?1?32?

One?per?5?years.? Yes? Full?mouth?X?rays?or?
panorex?

D6920? Connector?bar? 16?999? Arches?(UA,?
LA)?

One?per?5?years.? Yes? Full?mouth?X?rays?or?
panorex?

D6930? Re?cement?or?re?bond?fixed?
partial?denture?

16?999? Permanent?
Teeth?1?32?

One?per?5?years.? Yes? Full?mouth?X?rays?or?
panorex?

D6940? Stress?breaker? 16?999? Permanent?
Teeth?1?32?

One?per?5?years.? Yes? Full?mouth?X?rays?or?
panorex?

D6950? Precision?attachment? 16?999? Permanent?
Teeth?1?32?

One?per?5?years.? Yes? Full?mouth?X?rays?or?
panorex?

D6980? Fixed?partial?denture?repair?
necessitated?by?restorative?
material?failure?

16?999? ?? One?per?5?years.? Yes? Full?mouth?X?rays?or?
panorex,?and?narrative?
of?medical?necessity?



Horizon?NJ?Health?Dental?Program?
Benefit?Plan?Details?&?Authorization?Requirements?

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Code? Description? Age? Tooth?/?

Quad?/?Arch?
Limitations? Auth?

Req?
Requirement?

D6985? Pediatric?partial?denture,?
fixed?

16?999? Upper?Arch? One?per?lifetime.? Yes? Full?mouth?X?rays?or?
panorex,?and?narrative?
of?medical?necessity?

D6999? Unspecified?fixed?
prosthodontic?procedure,?by?
report?

16?999? Permanent?
Teeth?1?32?

?? Yes? Full?mouth?X?rays?or?
panorex,?and?narrative?
of?medical?necessity?

D7111? Extraction,?coronal?remnants?
??deciduous?tooth?

0?999? Primary?
Teeth?A?T?

One?per?lifetime.? No? ??

D7140? Extraction,?erupted?tooth?or?
exposed?root?(elevation?
and/or?forceps?removal)?

0?999? All?teeth;??
A?T;?1?32?

One?per?lifetime.? No? ??

D7210? Surgical?removal?of?erupted?
tooth?requiring?removal?of?
bone?and/or?sectioning?of?
tooth,?and?including?elevation?
of?mucoperiosteal?flap?if?
indicated?

0?999? All?teeth;??
A?T;?1?32?

One?per?lifetime.? No? ??

D7220? Removal?of?impacted?tooth???
soft?tissue?

0?999? All?teeth;??
A?T;?1?32?

One?per?lifetime.? Yes? Pre?operative?X?rays?
(excluding?bitewings)?
and?narrative?of?medical?
necessity??

D7230? Removal?of?impacted?tooth???
partially?bony?

0?999? All?teeth;??
A?T;?1?32?

One?per?lifetime.? Yes? Pre?operative?X?rays?
(excluding?bitewings)?
and?narrative?of?medical?
necessity??



Horizon?NJ?Health?Dental?Program?
Benefit?Plan?Details?&?Authorization?Requirements?

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Code? Description? Age? Tooth?/?

Quad?/?Arch?
Limitations? Auth?

Req?
Requirement?

D7240? Removal?of?impacted?tooth???
completely?bony?

0?999? All?teeth;??
A?T;?1?32?

One?per?lifetime?combined?with?D7241.? Yes? Pre?operative?X?rays?
(excluding?bitewings)?
and?narrative?of?medical?
necessity??

D7241? Removal?of?impacted?tooth???
completely?bony,?with?
unusual?surgical?
complications?

0?999? All?teeth;??
A?T;?1?32?

One?per?lifetime?combined?with?D7240.? Yes? Pre?operative?X?rays?
(excluding?bitewings)?
and?narrative?of?medical?
necessity??

D7250? Surgical?removal?of?residual?
tooth?roots?(cutting?
procedure)?

0?999? All?teeth;??
A?T;?1?32?

One?per?lifetime.? Yes? Pre?operative?X?rays?
(excluding?bitewings)?
and?narrative?of?medical?
necessity??

D7260? Oro?antral?fistula?closure? 0?999? ?? ?? Yes? Pre?operative?X?rays?
(excluding?bitewings)?
and?narrative?of?medical?
necessity??

D7261? Primary?closure?of?a?sinus?
perforation?

0?999? ?? ?? Yes? Pre?operative?X?rays?
(excluding?bitewings)?
and?narrative?of?medical?
necessity??

D7270? Tooth?re?implantation?and/or?
stabilization?of?accidentally?
evulsed?or?displaced?tooth?

0?999? Permanent?
Teeth?1?32?

?? Yes? Narrative?of?medical?
necessity?and?treatment?
plan??



Horizon?NJ?Health?Dental?Program?
Benefit?Plan?Details?&?Authorization?Requirements?

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Horizon?NJ?Health?Dental?Program:?Non?Special?Needs?Plans?&?Special?Needs?Plans?
Code? Description? Age? Tooth?/?

Quad?/?Arch?
Limitations? Auth?

Req?
Requirement?

D7280? Surgical?access?of?an?
unerupted?tooth?

0?999? Teeth?2?15,?
18?31?

One?per?lifetime.? Yes? Narrative?of?medical?
necessity?and?treatment?
plan?

D7282? Mobilization?of?erupted?or?
malpositioned?tooth?to?aid?
eruption?

0?999? Permanent?
Teeth?1?32?

One?per?lifetime.? Yes? Narrative?of?medical?
necessity?and?treatment?
plan?

D7283? Placement?of?device?to?
facilitate?eruption?of?
impacted?tooth?

0?999? Teeth?2?15,?
18?31?

One?per?lifetime.? Yes? Narrative?of?medical?
necessity?and?treatment?
plan?

D7285? Incisional?biopsy?of?oral?tissue?
??hard?(bone,?tooth)?

0?999? ?? ?? Yes? Narrative?of?medical?
necessity?

D7286? Incisional?biopsy?of?oral?tissue?
??soft?

0?999? ?? ?? Yes? Narrative?of?medical?
necessity?

D7287? Exfoliative?cytological?sample?
collection?

0?999? ?? ?? Yes? Narrative?of?medical?
necessity?

D7288? Brush?biopsy???transepithelial?
sample?collection?

0?999? ?? ?? Yes? Narrative?of?medical?
necessity?

D7290? Surgical?repositioning?of?teeth? 0?20? Permanent?
Teeth?1?32?

?? Yes? Pre?operative?X?rays?and?
narrative?of?medical?
necessity?



Horizon?NJ?Health?Dental?Program?
Benefit?Plan?Details?&?Authorization?Requirements?

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Horizon?NJ?Health?Dental?Program:?Non?Special?Needs?Plans?&?Special?Needs?Plans?
Code? Description? Age? Tooth?/?

Quad?/?Arch?
Limitations? Auth?

Req?
Requirement?

D7291? Transseptal?
Fiberotomy/Supra?Crestal?
Fiberotomy,?By?Report?

0?20? Permanent?
Teeth?1?32?

Once?per?lifetime.? Yes? Narrative?of?medical?
necessity?

D7292? Surgical?placement?of?
temporary?anchorage?device?
[screw?retained?plate]?
requiring?flap;?includes?device?
removal?

0?999? ?? ?? Yes? Narrative?of?medical?
necessity?with?
preauthorization?

D7293? Surgical?placement?of?
temporary?anchorage?device?
requiring?flap;?includes?device?
removal?

0?999? ?? ?? Yes? Narrative?of?medical?
necessity?with?
preauthorization?

D7294? Surgical?placement?of?
temporary?anchorage?device?
without?flap;?includes?device?
removal?

0?999? ?? ?? Yes? Narrative?of?medical?
necessity?with?
preauthorization?

D7295? Harvest?of?bone?for?use?in?
autogenous?grafting?
procedure?

0?999? ?? ?? Yes? Narrative?of?medical?
necessity?with?
preauthorization?

D7310? Alveoloplasty?in?conjunction?
with?extractions???four?or?
more?teeth?or?tooth?spaces,?
per?quadrant?

0?999? Quadrants?
(LL,?LR,?UR,?
UL)?

?Only?payable?on?the?same?date?of?service?as?D7140.? Yes? Pre?operative?X?rays?and?
narrative?of?medical?
necessity?



Horizon?NJ?Health?Dental?Program?
Benefit?Plan?Details?&?Authorization?Requirements?

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Horizon?NJ?Health?Dental?Program:?Non?Special?Needs?Plans?&?Special?Needs?Plans?
Code? Description? Age? Tooth?/?

Quad?/?Arch?
Limitations? Auth?

Req?
Requirement?

D7311? Alveoloplasty?in?conjunction?
with?extractions???one?to?
three?teeth?or?tooth?spaces,?
per?quadrant?

0?999? Quadrants?
(LL,?LR,?UR,?
UL)?

?Only?payable?on?the?same?date?of?service?as?D7140.? Yes? Pre?operative?X?rays?and?
narrative?of?medical?
necessity?

D7320? Alveoloplasty?not?in?
conjunction?with?extractions?
??four?or?more?teeth?or?tooth?
spaces,?per?quadrant?

0?999? Quadrants?
(LL,?LR,?UR,?
UL)?

?? Yes? Pre?operative?X?rays?and?
narrative?of?medical?
necessity?

D7321? Alveoloplasty?not?in?
conjunction?with?extractions?
??one?to?three?teeth?or?tooth?
spaces,?per?quadrant?

0?999? Quadrants?
(LL,?LR,?UR,?
UL)?

?? Yes? Pre?operative?X?rays?and?
narrative?of?medical?
necessity?

D7340? Vestibuloplasty???ridge?
extension?(secondary?
epithelialization)?

0?999? Quadrants?
(LL,?LR,?UR,?
UL)?

?? Yes? Narrative?of?medical?
necessity?

D7350? Vestibuloplasty???ridge?
extension?(including?soft?
tissue?grafts,?muscle?
reattachment,?revision?of?soft?
tissue?attachment?and?
management?of?
hypertrophied?and?
hyperplastic?tissue)?

0?999? Quadrants?
(LL,?LR,?UR,?
UL)?

?? Yes? Narrative?of?medical?
necessity?

D7410? Excision?of?benign?lesion?up?
to?1.25?cm?

0?999? ?? ?? Yes? Copy?of?pathology?
report?with?claim?



Horizon?NJ?Health?Dental?Program?
Benefit?Plan?Details?&?Authorization?Requirements?

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Horizon?NJ?Health?Dental?Program:?Non?Special?Needs?Plans?&?Special?Needs?Plans?
Code? Description? Age? Tooth?/?

Quad?/?Arch?
Limitations? Auth?

Req?
Requirement?

D7411? Excision?of?benign?lesion?
greater?than?1.25?cm?

0?999? ?? ?? Yes? Copy?of?pathology?
report?with?claim?

D7412? Excision?of?benign?lesion,?
complicated?

0?999? ?? ?? Yes? Copy?of?pathology?
report?with?claim?

D7413? Excision?of?malignant?lesion?
up?to?1.25?cm?

0?999? ?? ?? Yes? Copy?of?pathology?
report?with?claim?

D7414? Excision?of?malignant?lesion?
greater?than?1.25?cm?

0?999? ?? ?? Yes? Copy?of?pathology?
report?with?claim?

D7415? Excision?of?malignant?lesion,?
complicated?

0?999? ?? ?? Yes? Copy?of?pathology?
report?with?claim?

D7440? Excision?of?malignant?tumor???
lesion?diameter?up?to?1.25?cm?

0?999? ?? ?? Yes? Copy?of?pathology?
report?with?claim?

D7441? Excision?of?malignant?tumor???
lesion?diameter?greater?than?
1.25?cm?

0?999? ?? ?? Yes? Copy?of?pathology?
report?with?claim?

D7450? Removal?of?benign?
odontogenic?cyst?or?tumor???
lesion?diameter?up?to?1.25?cm?

0?999? ?? ?? Yes? Copy?of?pathology?
report?with?claim?



Horizon?NJ?Health?Dental?Program?
Benefit?Plan?Details?&?Authorization?Requirements?

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Horizon?NJ?Health?Dental?Program:?Non?Special?Needs?Plans?&?Special?Needs?Plans?
Code? Description? Age? Tooth?/?

Quad?/?Arch?
Limitations? Auth?

Req?
Requirement?

D7451? Removal?of?benign?
odontogenic?cyst?or?tumor???
lesion?diameter?greater?than?
1.25?cm?

0?999? ?? ?? Yes? Copy?of?pathology?
report?with?claim?

D7460? Removal?of?benign?
nonodontogenic?cyst?or?
tumor???lesion?diameter?up?to?
1.25?cm?

0?999? ?? ?? Yes? Copy?of?pathology?
report?with?claim?

D7461? Removal?of?benign?
nonodontogenic?cyst?or?
tumor???lesion??diameter?
greater?than?1.25?cm?

0?999? ?? ?? Yes? Copy?of?pathology?
report?with?claim?

D7465? Destruction?of?lesion(s)?by?
physical?or?chemical?method,?
by?report?

0?999? ?? ?? Yes? Narrative?of?medical?
necessity?

D7471? Removal?of?lateral?exostosis?
(maxilla?or?mandible)?

0?999? Arches?(UA,?
LA)?

?? Yes? Narrative?of?medical?
necessity,?X?rays?or?
photos?optional?

D7472? Removal?of?torus?palatinus? 0?999? ?? ?? Yes? Narrative?of?medical?
necessity?with?claim,??
X?rays?or?photos?
optional?

D7473? Removal?of?torus?
mandibularis?

0?999? ?? ?? Yes? Narrative?of?medical?
necessity,?X?rays?or?
photos?optional?



Horizon?NJ?Health?Dental?Program?
Benefit?Plan?Details?&?Authorization?Requirements?

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Horizon?NJ?Health?Dental?Program:?Non?Special?Needs?Plans?&?Special?Needs?Plans?
Code? Description? Age? Tooth?/?

Quad?/?Arch?
Limitations? Auth?

Req?
Requirement?

D7485? Surgical?reduction?of?osseous?
tuberosity?

0?999? ?? ?? Yes? Narrative?of?medical?
necessity?with?claim,??
X?rays?or?photos?
optional?

D7490? Radical?resection?of?maxilla?or?
mandible?

0?999? ?? ?? Yes? Narrative?of?medical?
necessity?

D7510? Incision?and?drainage?of?
abscess???intraoral?soft?tissue?

0?999? ?? One?per?date?of?service.? Yes? Narrative?of?medical?
necessity?

D7511? Incision?and?drainage?of?
abscess???intraoral?soft?tissue?
??complicated?(includes?
drainage?of?multiple?fascial?
spaces)?

0?999? ?? ?? Yes? Narrative?of?medical?
necessity?

D7520? Incision?and?drainage?of?
abscess???extraoral?soft?tissue?

0?999? ?? ?? Yes? Narrative?of?medical?
necessity?

D7521? Incision?and?drainage?of?
abscess???extraoral?soft?tissue?
??complicated?(includes?
drainage?of?multiple?fascial?
spaces)?

0?999? ?? ?? Yes? Narrative?of?medical?
necessity?

D7530? Removal?of?foreign?body?from?
mucosa,?skin,?or?
subcutaneous?alveolar?tissue?

0?999? ?? ?? Yes? Narrative?of?medical?
necessity,?X?rays?or?
photos?optional?



Horizon?NJ?Health?Dental?Program?
Benefit?Plan?Details?&?Authorization?Requirements?

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Horizon?NJ?Health?Dental?Program:?Non?Special?Needs?Plans?&?Special?Needs?Plans?
Code? Description? Age? Tooth?/?

Quad?/?Arch?
Limitations? Auth?

Req?
Requirement?

D7540? Removal?of?reaction?
producing?foreign?bodies,?
musculoskeletal?system?

0?999? ?? ?? Yes? Narrative?of?medical?
necessity,?X?rays?or?
photos?optional?

D7550? Partial?ostectomy/?
sequestrectomy?for?removal?
of?non?vital?bone?

0?999? Quadrants?
(LL,?LR,?UR,?
UL)?

?? Yes? Pre?operative?X?rays?and?
narrative?of?medical?
necessity?

D7560? Maxillary?sinusotomy?for?
removal?of?tooth?fragment?or?
foreign?body?

0?999? ?? ?? Yes? Pre?operative?X?rays?and?
narrative?of?medical?
necessity?

D7610? Maxilla???open?reduction?
(teeth?immobilized,?if?
present)?

0?999? ?? ?? Yes? Pre?operative?X?rays?and?
narrative?of?medical?
necessity?

D7620? Maxilla???closed?reduction?
(teeth?immobilized,?if?
present)?

0?999? ?? ?? Yes? Pre?operative?X?rays?and?
narrative?of?medical?
necessity?

D7630? Mandible???open?reduction?
(teeth?immobilized,?if?
present)?

0?999? ?? ?? Yes? Pre?operative?X?rays?and?
narrative?of?medical?
necessity?

D7640? Mandible???closed?reduction?
(teeth?immobilized,?if?
present)?

0?999? ?? ?? Yes? Pre?operative?X?rays?and?
narrative?of?medical?
necessity?



Horizon?NJ?Health?Dental?Program?
Benefit?Plan?Details?&?Authorization?Requirements?

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Horizon?NJ?Health?Dental?Program:?Non?Special?Needs?Plans?&?Special?Needs?Plans?
Code? Description? Age? Tooth?/?

Quad?/?Arch?
Limitations? Auth?

Req?
Requirement?

D7650? Malar?and/or?zygomatic?arch?
??open?reduction?

0?999? ?? ?? Yes? Pre?operative?X?rays?and?
narrative?of?medical?
necessity?

D7660? Malar?and/or?zygomatic?arch?
??closed?reduction?

0?999? ?? ?? Yes? Pre?operative?X?rays?and?
narrative?of?medical?
necessity?

D7670? Alveolus???closed?reduction,?
may?include?stabilization?of?
teeth?

0?999? ?? ?? Yes? Pre?operative?X?rays?and?
narrative?of?medical?
necessity?

D7671? Alveolus???open?reduction,?
may?include?stabilization?of?
teeth?

0?999? ?? ?? Yes? Pre?operative?X?rays?and?
narrative?of?medical?
necessity?

D7680? Facial?bones???complicated?
reduction?with?fixation?and?
multiple?surgical?approaches?

0?999? ?? ?? Yes? Pre?operative?X?rays?and?
narrative?of?medical?
necessity?

D7710? Maxilla???open?reduction? 0?999? ?? ?? Yes? Pre?operative?X?rays?and?
narrative?of?medical?
necessity?

D7720? Maxilla???closed?reduction? 0?999? ?? ?? Yes? Pre?operative?X?rays?and?
narrative?of?medical?
necessity?



Horizon?NJ?Health?Dental?Program?
Benefit?Plan?Details?&?Authorization?Requirements?

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186?

Horizon?NJ?Health?Dental?Program:?Non?Special?Needs?Plans?&?Special?Needs?Plans?
Code? Description? Age? Tooth?/?

Quad?/?Arch?
Limitations? Auth?

Req?
Requirement?

D7730? Mandible???open?reduction? 0?999? ?? ?? Yes? Pre?operative?X?rays?and?
narrative?of?medical?
necessity?

D7740? Mandible???closed?reduction? 0?999? ?? ?? Yes? Pre?operative?X?rays?and?
narrative?of?medical?
necessity?

D7750? Malar?and/or?zygomatic?arch?
??open?reduction?

0?999? ?? ?? Yes? Pre?operative?X?rays?and?
narrative?of?medical?
necessity?

D7760? Malar?and/or?zygomatic?arch?
??closed?reduction?

0?999? ?? ?? Yes? Pre?operative?X?rays?and?
narrative?of?medical?
necessity?

D7770? Alveolus???open?reduction?
stabilization?of?teeth?

0?999? ?? ?? Yes? Pre?operative?X?rays?and?
narrative?of?medical?
necessity?

D7771? Alveolus,?closed?reduction?
stabilization?of?teeth?

0?999? ?? ?? Yes? Pre?operative?X?rays?and?
narrative?of?medical?
necessity?

D7780? Facial?bones???complicated?
reduction?with?fixation?and?
multiple?surgical?approaches?

0?999? ?? ?? Yes? Pre?operative?X?rays?and?
narrative?of?medical?
necessity?



Horizon?NJ?Health?Dental?Program?
Benefit?Plan?Details?&?Authorization?Requirements?

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187?

Horizon?NJ?Health?Dental?Program:?Non?Special?Needs?Plans?&?Special?Needs?Plans?
Code? Description? Age? Tooth?/?

Quad?/?Arch?
Limitations? Auth?

Req?
Requirement?

D7810? Open?reduction?of?dislocation? 0?999? ?? ?? Yes? Narrative?of?medical?
necessity,?X?rays?or?
photos?optional?

D7820? Closed?reduction?of?
dislocation?

0?999? ?? ?? Yes? Narrative?of?medical?
necessity,?X?rays?or?
photos?optional?

D7830? Manipulation?under?
anesthesia?

0?999? ?? ?? Yes? Narrative?of?medical?
necessity,?X?rays?or?
photos?optional?

D7840? Condylectomy? 0?999? ?? ?? Yes? Narrative?of?medical?
necessity,?X?rays?or?
photos?optional?

D7850? Surgical?discectomy,?
with/without?implant?

0?999? ?? ?? Yes? Narrative?of?medical?
necessity,?X?rays?or?
photos?optional?

D7852? Disc?repair? 0?999? ?? ?? Yes? Narrative?of?medical?
necessity,?X?rays?or?
photos?optional?

D7854? Synovectomy? 0?999? ?? ?? Yes? Narrative?of?medical?
necessity,?X?rays?or?
photos?optional?



Horizon?NJ?Health?Dental?Program?
Benefit?Plan?Details?&?Authorization?Requirements?

??SKYGEN?USA?|?CONFIDENTIAL?&?PROPRIETARY?|?Horizon?NJ?Health?Dental?Program?|?Effective:?1/1/20?
188?

Horizon?NJ?Health?Dental?Program:?Non?Special?Needs?Plans?&?Special?Needs?Plans?
Code? Description? Age? Tooth?/?

Quad?/?Arch?
Limitations? Auth?

Req?
Requirement?

D7856? Myotomy? 0?999? ?? ?? Yes? Narrative?of?medical?
necessity,?X?rays?or?
photos?optional?

D7858? Joint?reconstruction? 0?999? ?? ?? Yes? Narrative?of?medical?
necessity,?X?rays?or?
photos?optional?

D7860? Arthrotomy? 0?999? ?? ?? Yes? Narrative?of?medical?
necessity,?X?rays?or?
photos?optional?

D7865? Arthroplasty? 0?999? ?? ?? Yes? Narrative?of?medical?
necessity,?X?rays?or?
photos?optional?

D7870? Arthrocentesis? 0?999? ?? ?? Yes? Narrative?of?medical?
necessity,?X?rays?or?
photos?optional?

D7871? Non?arthroscopic?lysis?and?
lavage?

0?999? ?? ?? Yes? Narrative?of?medical?
necessity,?X?rays?or?
photos?optional?

D7872? Arthroscopy???diagnosis,?with?
or?without?biopsy?

0?999? ?? ?? Yes? Narrative?of?medical?
necessity,?X?rays?or?
photos?optional?



Horizon?NJ?Health?Dental?Program?
Benefit?Plan?Details?&?Authorization?Requirements?

??SKYGEN?USA?|?CONFIDENTIAL?&?PROPRIETARY?|?Horizon?NJ?Health?Dental?Program?|?Effective:?1/1/20?
189?

Horizon?NJ?Health?Dental?Program:?Non?Special?Needs?Plans?&?Special?Needs?Plans?
Code? Description? Age? Tooth?/?

Quad?/?Arch?
Limitations? Auth?

Req?
Requirement?

D7873? Arthroscopy???surgical:?lavage?
and?lysis?of?adhesions?

0?999? ?? ?? Yes? Narrative?of?medical?
necessity,?X?rays?or?
photos?optional?

D7874? Arthroscopy???surgical:?disc?
repositioning?and?stabilization?

0?999? ?? ?? Yes? Narrative?of?medical?
necessity,?X?rays?or?
photos?optional?

D7875? Arthroscopy???surgical:?
synovectomy?

0?999? ?? ?? Yes? Narrative?of?medical?
necessity,?X?rays?or?
photos?optional?

D7876? Arthroscopy???surgical:?
discectomy?

0?999? ?? ?? Yes? Narrative?of?medical?
necessity,?X?rays?or?
photos?optional?

D7877? Arthroscopy???surgical:?
debridement?

0?999? ?? ?? Yes? Narrative?of?medical?
necessity,?X?rays?or?
photos?optional?

D7880? Occlusal?orthotic?device?to?
include?adjustments,?by?
report?

0?999? ?? ?? Yes? Narrative?of?medical?
necessity,?X?rays?or?
photos?optional?

D7881? Excision?of?salivary?gland,?by?
report?

0?999? ?? ?? Yes? Narrative?of?medical?
necessity,?X?rays?or?
photos?optional?



Horizon?NJ?Health?Dental?Program?
Benefit?Plan?Details?&?Authorization?Requirements?

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190?

Horizon?NJ?Health?Dental?Program:?Non?Special?Needs?Plans?&?Special?Needs?Plans?
Code? Description? Age? Tooth?/?

Quad?/?Arch?
Limitations? Auth?

Req?
Requirement?

D7899? Unspecified?TMD?therapy,?by?
report?

0?999? ?? ?? Yes? Pre?operative?X?rays?and?
narrative?of?medical?
necessity?

D7910? Suture?of?recent?small?
wounds?up?to?5?cm?

0?999? ?? ?? Yes? Narrative?of?medical?
necessity,?X?rays?or?
photos?optional?

D7911? Complicated?suture???up?to?5?
cm?

0?999? ?? ?? Yes? Narrative?of?medical?
necessity,?X?rays?or?
photos?optional?

D7912? Complicated?suture???greater?
than?5?cm?

0?999? ?? ?? Yes? Narrative?of?medical?
necessity,?X?rays?or?
photos?optional?

D7920? Skin?graft?(identify?defect?
covered,?location?and?type?of?
graft)?

0?999? ?? ?? Yes? Narrative?of?medical?
necessity,?X?rays?or?
photos?optional?

D7940? Osteoplasty???for?
orthognathic?deformities?

0?999? ?? ?? Yes? Narrative?of?medical?
necessity,?X?rays?or?
photos?optional?

D7941? Osteotomy???mandibular?rami? 0?999? ?? ?? Yes? Narrative?of?medical?
necessity,?X?rays?or?
photos?optional?



Horizon?NJ?Health?Dental?Program?
Benefit?Plan?Details?&?Authorization?Requirements?

??SKYGEN?USA?|?CONFIDENTIAL?&?PROPRIETARY?|?Horizon?NJ?Health?Dental?Program?|?Effective:?1/1/20?
191?

Horizon?NJ?Health?Dental?Program:?Non?Special?Needs?Plans?&?Special?Needs?Plans?
Code? Description? Age? Tooth?/?

Quad?/?Arch?
Limitations? Auth?

Req?
Requirement?

D7943? Osteotomy???mandibular?rami?
with?bone?graft;?includes?
obtaining?the?graft?

0?999? ?? ?? Yes? Narrative?of?medical?
necessity,?X?rays?or?
photos?optional?

D7944? Osteotomy???segmented?or?
subapical?

0?999? Quadrants?
(LL,?LR,?UR,?
UL)?

?? Yes? Narrative?of?medical?
necessity,?X?rays?or?
photos?optional?

D7945? Osteotomy???body?of?
mandible?

0?999? ?? ?? Yes? Narrative?of?medical?
necessity,?X?rays?or?
photos?optional?

D7946? LeFort?I?(maxilla???total)? 0?999? ?? ?? Yes? Narrative?of?medical?
necessity,?X?rays?or?
photos?optional?

D7947? LeFort?I?(maxilla???
segmented)?

0?999? ?? ?? Yes? Narrative?of?medical?
necessity,?X?rays?or?
photos?optional?

D7948? LeFort?II?or?LeFort?III?
(osteoplasty?of?facial?bones?
for?midface?hypoplasia?or?
retrusion)???without?bone?
graft?

0?999? ?? ?? Yes? Narrative?of?medical?
necessity,?X?rays?or?
photos?optional?

D7949? LeFort?II?or?LeFort?III???with?
bone?graft?

0?999? ?? ?? Yes? Narrative?of?medical?
necessity,?X?rays?or?
photos?optional?



Horizon?NJ?Health?Dental?Program?
Benefit?Plan?Details?&?Authorization?Requirements?

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192?

Horizon?NJ?Health?Dental?Program:?Non?Special?Needs?Plans?&?Special?Needs?Plans?
Code? Description? Age? Tooth?/?

Quad?/?Arch?
Limitations? Auth?

Req?
Requirement?

D7950? Osseous,?osteoperiosteal,?or?
cartilage?graft?of?the?
mandible?or?maxilla???
autogenous?or?
nonautogenous,?by?report?

0?999? ?? ?? Yes? Narrative?of?medical?
necessity,?X?rays?or?
photos?optional?

D7951? Sinus?augmentation?with?
bone?or?bone?substitutes?via?
a?lateral?open?approach?

0?999? ?? ?? Yes? Narrative?of?medical?
necessity,?X?rays?or?
photos?optional?

D7952? Sinus?augmentation?via?a?
vertical?approach?

0?999? ?? ?? Yes? Narrative?of?medical?
necessity,?X?rays?or?
photos?optional?

D7955? Repair?of?maxillofacial?soft?
and/or?hard?tissue?defect?

0?999? ?? ?? Yes? Narrative?of?medical?
necessity,?X?rays?or?
photos?optional?

D7960? Frenulectomy???also?known?
as?frenectomy?or?frenotomy???
separate?procedure?not?
incidental?to?another?
procedure?

0?999? ?? ?? Yes? Narrative?of?medical?
necessity,?X?rays?or?
photos?optional?

D7963? Frenuloplasty? 0?999? ?? ?? Yes? Narrative?of?medical?
necessity,?X?rays?or?
photos?optional?



Horizon?NJ?Health?Dental?Program?
Benefit?Plan?Details?&?Authorization?Requirements?

??SKYGEN?USA?|?CONFIDENTIAL?&?PROPRIETARY?|?Horizon?NJ?Health?Dental?Program?|?Effective:?1/1/20?
193?

Horizon?NJ?Health?Dental?Program:?Non?Special?Needs?Plans?&?Special?Needs?Plans?
Code? Description? Age? Tooth?/?

Quad?/?Arch?
Limitations? Auth?

Req?
Requirement?

D7970? Excision?of?hyperplastic?tissue?
??per?arch?

0?999? Arches?(UA,?
LA)?

?? Yes? Narrative?of?medical?
necessity,?X?rays?or?
photos?optional?

D7971? Excision?of?pericoronal?
gingiva?

0?999? Permanent?
Teeth?1?32?

?? Yes? Narrative?of?medical?
necessity,?X?rays?or?
photos?optional?

D7972? Surgical?reduction?of?fibrous?
tuberosity?

0?999? ?? ?? Yes? Narrative?of?medical?
necessity,?X?rays?or?
photos?optional?

D7979? Non?Surgical?Sialolithotomy? 0?999? ? Once?per?lifetime.? Yes? Narrative?of?medical?
necessity?

D7980? Sialolithotomy? 0?999? ?? ?? Yes? Narrative?of?medical?
necessity,?X?rays?or?
photos?optional?

D7981? Excision?of?salivary?gland,?by?
report?

0?999? ?? ?? Yes? Narrative?of?medical?
necessity,?X?rays?or?
photos?optional?

D7982? Sialodochoplasty? 0?999? ?? ?? Yes? Narrative?of?medical?
necessity,?X?rays?or?
photos?optional?



Horizon?NJ?Health?Dental?Program?
Benefit?Plan?Details?&?Authorization?Requirements?

??SKYGEN?USA?|?CONFIDENTIAL?&?PROPRIETARY?|?Horizon?NJ?Health?Dental?Program?|?Effective:?1/1/20?
194?

Horizon?NJ?Health?Dental?Program:?Non?Special?Needs?Plans?&?Special?Needs?Plans?
Code? Description? Age? Tooth?/?

Quad?/?Arch?
Limitations? Auth?

Req?
Requirement?

D7983? Closure?of?salivary?fistula? 0?999? ?? ?? Yes? Narrative?of?medical?
necessity,?X?rays?or?
photos?optional?

D7990? Emergency?tracheotomy? 0?999? ?? ?? Yes? Narrative?of?medical?
necessity,?X?rays?or?
photos?optional?

D7991? Coronoidectomy? 0?999? ?? ?? Yes? Narrative?of?medical?
necessity,?X?rays?or?
photos?optional?

D7995? Synthetic?graft???mandible?or?
facial?bones,?by?report?

0?999? ?? ?? Yes? Narrative?of?medical?
necessity,?X?rays?or?
photos?optional?

D7996? Implant?mandible?for?
augmentation?purposes?
(excluding?alveolar?ridge),?by?
report?

0?999? ?? ?? Yes? Narrative?of?medical?
necessity,?X?rays?or?
photos?optional?

D7997? Appliance?removal?(not?by?
dentist?who?placed?
appliance),?includes?removal?
of?archbar?

0?999? ?? ?? Yes? Narrative?of?medical?
necessity,?X?rays?or?
photos?optional?

D7998? Intraoral?placement?of?a?
fixation?device?not?in?
conjunction?with?a?fracture?

0?999? ?? ?? Yes? Narrative?of?medical?
necessity,?X?rays?or?
photos?optional?



Horizon?NJ?Health?Dental?Program?
Benefit?Plan?Details?&?Authorization?Requirements?

??SKYGEN?USA?|?CONFIDENTIAL?&?PROPRIETARY?|?Horizon?NJ?Health?Dental?Program?|?Effective:?1/1/20?
195?

Horizon?NJ?Health?Dental?Program:?Non?Special?Needs?Plans?&?Special?Needs?Plans?
Code? Description? Age? Tooth?/?

Quad?/?Arch?
Limitations? Auth?

Req?
Requirement?

D7999? Unspecified?oral?surgery?
procedure,?by?report?

0?999? ?? ?? Yes? Narrative?of?medical?
necessity,?X?rays?or?
photos?optional?

D8010? Limited?orthodontic?
treatment?of?the?primary?
dentition?

0?20? ?? One?per?lifetime;?combined?frequency?with?D8010,?
D8020,?D8030,?D8040,?D8050,?or?D8060.?

Yes? Narrative,?general?
dentist?attestation,?
photos,?X?rays?

D8020? Limited?orthodontic?
treatment?of?the?transitional?
dentition?

0?20? ?? One?per?lifetime;?combined?frequency?with?D8010,?
D8020,?D8030,?D8040,?D8050,?or?D8060.?

Yes? Narrative,?general?
dentist?attestation,?
photos,?X?rays?

D8030? Limited?orthodontic?
treatment?of?the?adolescent?
dentition?

8?20? ?? One?per?lifetime;?combined?frequency?with?D8010,?
D8020,?D8030,?D8040,?D8050,?or?D8060.?

Yes? Narrative,?general?
dentist?attestation,?
photos,?X?rays?

D8040? Limited?orthodontic?
treatment?for?adult?dentition?

8?20? ?? One?per?lifetime;?combined?frequency?with?D8010,?
D8020,?D8030,?D8040,?D8050,?or?D8060?

Yes? Narrative,?general?
dentist?attestation,?
photos,?X?rays?



Horizon?NJ?Health?Dental?Program?
Benefit?Plan?Details?&?Authorization?Requirements?

??SKYGEN?USA?|?CONFIDENTIAL?&?PROPRIETARY?|?Horizon?NJ?Health?Dental?Program?|?Effective:?1/1/20?
196?

Horizon?NJ?Health?Dental?Program:?Non?Special?Needs?Plans?&?Special?Needs?Plans?
Code? Description? Age? Tooth?/?

Quad?/?Arch?
Limitations? Auth?

Req?
Requirement?

D8050? Interceptive?orthodontic?
treatment?of?the?primary?
dentition?

4?8? ?? One?per?lifetime;?combined?frequency?with?D8010,?
D8020,?D8030,?D8040,?D8050,?or?D8060.?

Yes? Narrative,?treatment?
plan,?general?dentist?
attestation,?photos,??
X?rays,?medical?narrative?
if?applicable?

D8060? Interceptive?orthodontic?
treatment?of?the?transitional?
dentition?

6?20? ?? One?per?lifetime;?combined?frequency?with?D8010,?
D8020,?D8030,?D8040,?D8050,?or?D8060.?

Yes? Narrative,?treatment?
plan,?general?dentist?
attestation,?photos,??
X?rays,?medical?narrative?
if?applicable?

D8080? Comprehensive?orthodontic?
treatment?of?the?adolescent?
dentition?

0?20? ?? One?per?lifetime.? Yes? HLD?score?sheet,?
narrative,?treatment?
plan,?general?dentist?
attestation,?photos,??
X?rays,?medical?narrative?
if?applicable?

D8210? Removable?appliance?therapy? 0?20? ?? One?per?lifetime.?
Not?on?the?same?date?of?service?as?D8010,?D8020,?
D8030,?D8040,?D8050,?D8060.?

Yes? Treatment?plan?and?
narrative?of?medical?
necessity?

D8220? Fixed?appliance?therapy? 0?20? ?? One?per?lifetime.?
Not?on?the?same?date?of?service?as?D8010,?D8020,?
D8030,?D8040,?D8050,?D8060.?

Yes? Treatment?plan?and?
narrative?of?medical?
necessity?



Horizon?NJ?Health?Dental?Program?
Benefit?Plan?Details?&?Authorization?Requirements?

??SKYGEN?USA?|?CONFIDENTIAL?&?PROPRIETARY?|?Horizon?NJ?Health?Dental?Program?|?Effective:?1/1/20?
197?

Horizon?NJ?Health?Dental?Program:?Non?Special?Needs?Plans?&?Special?Needs?Plans?
Code? Description? Age? Tooth?/?

Quad?/?Arch?
Limitations? Auth?

Req?
Requirement?

D8660? Pre?orthodontic?treatment?
examination?to?monitor?
growth?and?development?

0?20? ?? Once?per?rolling?year?per?provider.?? No? ??

D8670? Periodic?orthodontic?
treatment?visit?

0?20? ?? ?? Yes? Treatment?notes,?
documentation?of?
compliance,?general?
dentist?attestation,?
photos,?panorex,?copy?of?
initial?approval?if?
applicable?

D8680? Orthodontic?retention?
(removal?of?appliances,?
construction?and?placement?
of?retainer?or?retainers);?to?
include?adjustments?

0?20? ?? ?? Yes? Diagnostic?quality?
posttreatment?photos?

D8681? Removable?retainer?
adjustment?

0?20? ?? ?? No? ??

D8691? Repair?of?orthodontic?
appliance?

0?20? Arches?(UA,?
LA)?

?? Yes? Treatment?history,?
photos?optional?

D8692? Replacement?of?lost?or?
broken?retainer?

0?20? Arches?(UA,?
LA)?

One?per?lifetime.? Yes? Copy?of?approved?D8680?



Horizon?NJ?Health?Dental?Program?
Benefit?Plan?Details?&?Authorization?Requirements?

??SKYGEN?USA?|?CONFIDENTIAL?&?PROPRIETARY?|?Horizon?NJ?Health?Dental?Program?|?Effective:?1/1/20?
198?

Horizon?NJ?Health?Dental?Program:?Non?Special?Needs?Plans?&?Special?Needs?Plans?
Code? Description? Age? Tooth?/?

Quad?/?Arch?
Limitations? Auth?

Req?
Requirement?

D8693? Re?cement?or?re?bond?fixed?
retainer?

0?20? Arches?(UA,?
LA)?

?? No? ??

D8694? Repair?of?fixed?retainers,?
includes?reattachment?

0?20? Arches?(UA,?
LA)?

?? No? ??

D8695? Removal?Of?Fixed?
Orthodontic?Appliances?

0?999? ? Once?per?lifetime.? Yes? Narrative?of?medical?
necessity?

D8999? Unspecified?orthodontic?
procedure,?by?report?

0?20? ?? ?? Yes? Transfer?plan,?fee,?
reason?for?transfer,?orig?
rcds,?payment,?history,?
panorex,?ceph?x?ray,?HLD?
score?sheet?

D9110? Palliative?(emergency)?
treatment?of?dental?pain???
minor?procedure?

0?999? All?teeth;??
A?T;?1?32?

?Once?per?date?of?service?per?payee.? No? ??

D9210? Local?anesthesia?not?in?
conjunction?with?operative?or?
surgical?procedures?

0?999? ?? Twice?per?year?per?provider.?
Must?be?on?the?same?date?of?service?as?D0100?D0999.??
Not?allowed?on?the?same?date?of?service?as?any?other?
code.??

Yes? Radiographs?and/or?
photographs?and?
narrative?of?medical?
necessity?

D9211? Regional?block?anesthesia? 0?999? ?? Twice?per?year?per?provider.?
Must?be?on?the?same?date?of?service?as?D0100?D0999.??

Yes? Radiographs?and/or?
photographs?and?



Horizon?NJ?Health?Dental?Program?
Benefit?Plan?Details?&?Authorization?Requirements?

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199?

Horizon?NJ?Health?Dental?Program:?Non?Special?Needs?Plans?&?Special?Needs?Plans?
Code? Description? Age? Tooth?/?

Quad?/?Arch?
Limitations? Auth?

Req?
Requirement?

Not?allowed?on?the?same?date?of?service?as?any?other?
code.??

narrative?of?medical?
necessity?

D9212? Trigeminal?division?block?
anesthesia?

0?999? ?? Twice?per?year?per?provider.?
Must?be?on?the?same?date?of?service?as?D0100?D0999.??
Not?allowed?on?the?same?date?of?service?as?any?other?
code.??

Yes? Radiographs?and/or?
photographs?and?
narrative?of?medical?
necessity?

D9222? Deep?Sedation/General?
Anesthesia???First?15?Minutes?

0?999? All?teeth;??
A?T;?1?32?

Once?per?date?of?service.?
Not?in?conjunction?with?D9230,?D9239,?D9243,?or?
D9248?on?same?date?of?service?

Yes? Narrative?of?medical?
necessity?

D9223? Deep?sedation/general?
anesthesia???each?subsequent?
15?minute?increment?

0?999? All?teeth;??
A?T;?1?32?

?Seven?per?date?of?service.?
Not?in?conjunction?with?D9230,?D9239,?D9243,?or?
D9248?on?same?date?of?service?

Yes? Narrative?of?medical?
necessity?

D9230? Inhalation?of?nitrous?
oxide/analgesia,?anxiolysis?

0?999? ?? One?per?date?of?service.?
Not?in?conjunction?with?D9222,?D9223,?D9239,?or?
D9243?on?same?date?of?service?per?payee.?

No? ??

D9239? Intravenous?Moderate?
(Conscious)?
Sedation/Analgesia???First?15?
Minutes?

0?999? ? One?per?date?of?service.?
Not?in?conjunction?with?D9222,?D9223,?D9230,?or?
D9248?on?same?date?of?service?

Yes? Documentation?of?
medical?necessity?

D9243? Intravenous?moderate?
(conscious)?
sedation/analgesia???each?
subsequent?15?minute?
increment?

0?999? ?? ?Seven?per?date?of?service.?
Not?in?conjunction?with?D9222,?D9223,?D9230,?or?
D9248?on?same?date?of?service?

Yes? Documentation?of?
medical?necessity?



Horizon?NJ?Health?Dental?Program?
Benefit?Plan?Details?&?Authorization?Requirements?

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200?

Horizon?NJ?Health?Dental?Program:?Non?Special?Needs?Plans?&?Special?Needs?Plans?
Code? Description? Age? Tooth?/?

Quad?/?Arch?
Limitations? Auth?

Req?
Requirement?

D9248? Non?intravenous?moderate?
(conscious)?sedation??

0?999? ?? Not?in?conjunction?with?D9222,?D9223,?D9239,?or?
D9243?on?same?date?of?service.?

Yes? Documentation?of?
medical?necessity?

D9310? Consultation???diagnostic?
service?provided?by?dentist?or?
physician?other?than?
requesting?dentist?or?
physician?

0?999? ?? Will?not?be?paid?on?same?date?of?service?as?any?other?
service.?

No? ??

D9311? Treating?dentist?consults?with?
a?medical?health?care?
professional?concerning?
medical?issues?that?may?affect?
member?s?planned?dental?
treatment?

0?999? ?? ?? No? ??

D9410? House/extended?care?facility?
call?

0?999? ?? ?? Yes? Documentation?of?
medical?necessity?

D9420? Hospital?or?ambulatory?
surgical?center?call?

0?999? ?? One?per?date?of?service?per?patient.? Yes? Documentation?of?
medical?necessity?

D9430? Office?visit?for?observation?
(during?regularly?scheduled?
hours)???no?other?services?
performed?

0?999? ?? Not?allowable?on?the?same?date?of?service?as?any?
other?code.?
Only?payable?to?oral?surgeons.??

No?
?

D9610? Therapeutic?parenteral?drug,?
single?administration?

0?999? ?? Not?allowable?on?the?same?date?of?service?as?D9222,?
D9223,?D9239,?or?D9243.?

No? ??



Horizon?NJ?Health?Dental?Program?
Benefit?Plan?Details?&?Authorization?Requirements?

??SKYGEN?USA?|?CONFIDENTIAL?&?PROPRIETARY?|?Horizon?NJ?Health?Dental?Program?|?Effective:?1/1/20?
201?

Horizon?NJ?Health?Dental?Program:?Non?Special?Needs?Plans?&?Special?Needs?Plans?
Code? Description? Age? Tooth?/?

Quad?/?Arch?
Limitations? Auth?

Req?
Requirement?

D9612? Therapeutic?parenteral?drugs,?
two?or?more?administrations,?
different?medications?

0?999? ?? Not?allowable?on?the?same?date?of?service?as?D9222,?
D9223,?D9239,?or?D9243.?

Yes? Documentation?of?
medical?necessity?

D9630? Other?drugs?and/or?
medicaments,?by?report?

0?999? ?? ?Once?per?date?of?service.? Yes? Documentation?of?
medical?necessity?

D9910? Application?of?desensitizing?
medicament?

16?999? ?? Once?per?floating?year.?
Not?payable?on?the?same?date?of?service?as?D9911.?

No? ??

D9911? Application?of?desensitizing?
resin?for?cervical?and/or?root?
surface,?per?tooth?

16?999? Permanent?
Teeth?1?32?

Once?per?floating?year.?
Not?payable?on?the?same?date?of?service?as?D9910.?

No? ??

D9920?
Special?
Needs,?
Age?0?
999?

Behavior?management,?by?
report?

0?9? All?teeth;??
A?T;?1?32?

Two?per?date?of?service?per?patient?per?payee.?
Not?allowable?on?same?date?of?service?as?D9220,?
D9221,?D9223,?D9241,?D9243,?or?D9248.?

No?
?

D9930? Treatment?of?complications?
(post?surgical)???unusual?
circumstances,?by?report?

0?999? All?teeth;??
A?T;?1?32?

?Only?payable?to?oral?surgeons.? Yes? Documentation?of?
medical?necessity?

D9944? Occlusal?guard?? 16?999? ?? Once?per?3?years?combined?with?D9945.? Yes? Documentation?of?
medical?necessity?



Horizon?NJ?Health?Dental?Program?
Benefit?Plan?Details?&?Authorization?Requirements?

??SKYGEN?USA?|?CONFIDENTIAL?&?PROPRIETARY?|?Horizon?NJ?Health?Dental?Program?|?Effective:?1/1/20?
202?

Horizon?NJ?Health?Dental?Program:?Non?Special?Needs?Plans?&?Special?Needs?Plans?
Code? Description? Age? Tooth?/?

Quad?/?Arch?
Limitations? Auth?

Req?
Requirement?

D9945? Occlusal?guard? 16?999? ? Once?per?3?years?combined?with?D9944.? Yes? Documentation?of?
medical?necessity?

D9951? Occlusal?adjustment???limited? 16?999? ?? Not?in?conjunction?with?D9223,?D9243,?and?D9920?on?
same?date?of?service?per?payee.?
Once?per?1?rolling?year?per?payee.?
Not?allowable?on?the?same?DOS?as?D2140,?D2150,?
D2160,?D2161,?D2330,?D2331,?D2332,?D2335,?D2390,?
D2391,?D2392,?D2393,?D2394,?D2740,?D2750,?D2751,?
D2752,?D2790,?D2791,?D2792,?D2799,?D3310,?D3320,?
D3330,?D3346,?D3347,?or?D3348.?

No? ??

D9952? Occlusal?adjustment?
complete?

16?999? ?? Once?per?3?rolling?years?per?patient.?
Not?allowable?on?the?same?DOS?as?any?other?code.?

No? ??

D9971? Odontoplasty???1?2?teeth? 16?999? Permanent?
Teeth?1?32?

?? No? ??

D9974? Internal?Bleaching?per?tooth? 16?999? Permanent?
Teeth?1?32?

Once?per?lifetime?per?payee.? No? ??



Horizon?NJ?Health?Dental?Program?
Benefit?Plan?Details?&?Authorization?Requirements?

??SKYGEN?USA?|?CONFIDENTIAL?&?PROPRIETARY?|?Horizon?NJ?Health?Dental?Program?|?Effective:?1/1/20?
203?

Horizon?NJ?Health?Dental?Program:?Non?Special?Needs?Plans?&?Special?Needs?Plans?
Code? Description? Age? Tooth?/?

Quad?/?Arch?
Limitations? Auth?

Req?
Requirement?

D9999? Unspecified?adjunctive?
procedure,?by?report?

0?999? ?? Used?only?for?authorization?of?operating?room?/?
ambulatory?surgery?center.?
Not?to?be?billed.?

Yes? Description?of?
procedure,?narrative?of?
medical?necessity,?GA?
checklist,?hospital?/?
outpatient?name?(as?
needed)?



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SKYGEN?USA?
Provider?Manual??
Program?Effective:?January?1,?2012?
Revision?Effective:?January?1,?2020?



??SKYGEN?USA?|?CONFIDENTIAL?&?PROPRIETARY?|?Horizon?NJ?Health?Dental?Program?|?Effective:?1/1/20?
1?

Provider?Manual?
?
Effective?January?1,?2020?
NJ?FamilyCare?A?
NJ?FamilyCare?ABP?
NJ?FamilyCare?B?
NJ?FamilyCare?C??
NJ?FamilyCare?D?
Managed?Long?Term?Services?&?Supports?(MLTSS)?
Horizon?NJ?TotalCare?(HMO?D?SNP)?

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??SKYGEN?USA?|?CONFIDENTIAL?&?PROPRIETARY?|?Horizon?NJ?Health?Dental?Program?|?Effective:?1/1/20?
2?

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pwp.sciondental.com?



??SKYGEN?USA?|?CONFIDENTIAL?&?PROPRIETARY?|?Horizon?NJ?Health?Dental?Program?|?Effective:?1/1/20?
3?

Contents?
Quick?Reference?Guide?............................................................................................................?8?
Provider?Web?Portal:?Online,?All?the?Time?.....................................................................................?8?
When?You?Need?Us???We?ll?Be?There!?............................................................................................?9?

Welcome?...............................................................................................................................?13?
Member?Rights?and?Responsibilities?......................................................................................?15?
Member?Rights?.............................................................................................................................?15?
Member?Responsibilities?..............................................................................................................?15?

Provider?Rights?&?Responsibilities?.........................................................................................?16?
Provider?Rights?..............................................................................................................................?16?
Provider?Responsibilities?...............................................................................................................?16?
Provider?Bill?of?Rights?....................................................................................................................?16?
Positive?Provider?Experience?........................................................................................................?17?
Consistent,?Transparent?Authorization?Decisions?........................................................................?17?
Cultural?Competency?....................................................................................................................?17?
Patients?with?Special?Health?Needs?..............................................................................................?18?
The?Head?Start?Initiative?...............................................................................................................?19?
Domestic?Violence?Reporting?.......................................................................................................?20?
Reporting?Abuse,?Neglect?or?Exploitation?....................................................................................?21?
Confidentiality?...............................................................................................................................?22?
Standards?of?Service?.....................................................................................................................?22?
Special?Standards?of?Services?.......................................................................................................?23?
Office?Practice?Standards?for?General?Dentists?............................................................................?23?
Recordkeeping?Requirements?......................................................................................................?23?

Provider?Web?Portal?..............................................................................................................?28?
Provider?Web?Portal?Registration?.................................................................................................?29?

Electronic?Payments?..............................................................................................................?30?
Electronic?Funds?Transfer?(EFT)?....................................................................................................?30?
Electronic?Remittance?Reports?.....................................................................................................?30?



??SKYGEN?USA?|?CONFIDENTIAL?&?PROPRIETARY?|?Horizon?NJ?Health?Dental?Program?|?Effective:?1/1/20?
4?

EFT?Authorization?Agreement?................................................................................................?31?
Eligibility?&?Member?Services?................................................................................................?32?
Member?ID?Cards?..........................................................................................................................?33?
Verifying?Member?Eligibility?.........................................................................................................?35?
Verifying?Eligibility?via?Provider?Web?Portal?.................................................................................?35?
Verifying?Eligibility?via?IVR?.............................................................................................................?36?
Specialist?Referrals?........................................................................................................................?36?
Appointment?Availability?Standards?.............................................................................................?36?
Summary:?Appointment?Availability?Standards?...........................................................................?37?
After?Hours?Calls?and?Coverage....................................................................................................?37?
Summary:?After?Hours?Call?Response?Standards?.........................................................................?38?
Missed?Appointments?...................................................................................................................?38?
Payment?for?Non?Covered?Services?.............................................................................................?39?

Prior?Authorization?&?Documentation?Requirements?............................................................?40?
Prior?Authorization?for?Treatment?...............................................................................................?40?
Dental?Treatment?Plan?..................................................................................................................?42?
Dental?OR/ASC?Services?................................................................................................................?42?
Appealing?an?Authorization?Decision?...........................................................................................?44?
Summary:?Prior?Authorization?Timelines?.....................................................................................?44?

Authorization?Submission?Procedures?...................................................................................?45?
Submitting?Authorizations?via?Provider?Web?Portal?....................................................................?45?
Submitting?Authorizations?via?Clearinghouses?.............................................................................?46?
Submitting?Authorizations?via?837D?File?......................................................................................?46?
Attaching?Electronic?Documents?..................................................................................................?46?
Submitting?Authorizations?on?Paper?Forms?.................................................................................?46?
Duplicate?Authorizations?Automatically?Denied?..........................................................................?47?
ADA?Approved?Dental?Claim?Form?...............................................................................................?48?

Claim?Submission?Procedures?................................................................................................?50?
Submitting?Claims?via?Provider?Web?Portal?.................................................................................?50?
Submitting?Claims?via?Clearinghouses?..........................................................................................?50?
Submitting?Claims?via?HIPAA?Compliant?837D?File?......................................................................?51?
Attaching?Electronic?Documents?..................................................................................................?51?



??SKYGEN?USA?|?CONFIDENTIAL?&?PROPRIETARY?|?Horizon?NJ?Health?Dental?Program?|?Effective:?1/1/20?
5?

Submitting?Claims?on?Paper?Forms?..............................................................................................?51?
Coordination?of?Benefits?(COB)?....................................................................................................?52?
Timely?Filing?Limits?........................................................................................................................?52?
Corrected?Claim?Process?...............................................................................................................?52?
Resubmitting?a?Denied?Claim?.......................................................................................................?52?
Submitting?a?Corrected?Claim?.......................................................................................................?53?
Receipt?&?Audit?of?Claims?.............................................................................................................?53?
Claims?Adjudication?&?Payment?...................................................................................................?53?
Total?Maximum?Payment?Allowance?............................................................................................?54?
Stage?of?Completion?.....................................................................................................................?54?
Missed?Appointments?...................................................................................................................?55?
Period?of?Eligibility?........................................................................................................................?55?
Third?Party?Liability?(TPL)?..............................................................................................................?56?

Complaints,?Grievances?&?Appeals?........................................................................................?57?
Making?a?Complaint?......................................................................................................................?58?
Submitting?Appeals?.......................................................................................................................?59?
Claims?Payment?Appeal?................................................................................................................?61?
Utilization?Management/Authorization?Appeal?...........................................................................?61?
Additional?Appeal?Resources?........................................................................................................?63?

Credentialing?&?Recredentialing?............................................................................................?64?
Credentialing?Process?...................................................................................................................?64?
Credentialing?Documentation?......................................................................................................?65?
Recredentialing?Process?................................................................................................................?66?
Submitting?an?Application?for?Credentialing/Recredentialing?.....................................................?66?
Appealing?a?Credentialing?Decision?..............................................................................................?66?

Health?Insurance?Portability?and?Accountability?Act?(HIPAA)?.................................................?67?
National?Provider?Identifier?(NPI)?.................................................................................................?67?

Utilization?Management?........................................................................................................?68?
Community?Practice?Patterns?.......................................................................................................?68?
Evaluation?.....................................................................................................................................?68?
Results?...........................................................................................................................................?68?
Peer?Review:?Reimbursement?Consequences?.............................................................................?68?



??SKYGEN?USA?|?CONFIDENTIAL?&?PROPRIETARY?|?Horizon?NJ?Health?Dental?Program?|?Effective:?1/1/20?
6?

TAMI?Review?.................................................................................................................................?69?
Non?Incentivization?Policy?............................................................................................................?69?
Fraud,?Waste?&?Abuse?..................................................................................................................?69?
Deficit?Reduction?Act:?The?False?Claims?Act?.................................................................................?70?
Sanctions?.......................................................................................................................................?71?

Practice?Guidelines?................................................................................................................?72?
NJ?Smiles?.......................................................................................................................................?73?
New?Jersey?Periodicity?Schedule?..................................................................................................?75?

Fluoride?Varnish?Provider?Incentive?Program?........................................................................?76?
Clinical?Criteria?......................................................................................................................?83?
Medical?Necessity?.........................................................................................................................?83?
Prior?Authorization?of?Treatment?.................................................................................................?83?
Emergency?Treatment?..................................................................................................................?84?
Informed?Consent?.........................................................................................................................?84?
Dental?OR/ASC?Services?................................................................................................................?85?
Oral?Surgery?Services?....................................................................................................................?87?
House?Calls?....................................................................................................................................?88?
Hospital?Calls?.................................................................................................................................?89?
Medical?vs.?Dental?Services?..........................................................................................................?90?
Amalgam?Restorations?..................................................................................................................?91?
Interproximal?Fillings?....................................................................................................................?91?
Proximal?Restorations?...................................................................................................................?91?
Proximal?Fillings?............................................................................................................................?91?
Diagnostic?Services?.......................................................................................................................?91?
Anesthesia?.....................................................................................................................................?92?
Intravenous?Sedation?....................................................................................................................?93?
Analgesia?.......................................................................................................................................?93?
Injections?.......................................................................................................................................?93?
Orthodontic?Services?....................................................................................................................?94?
Clinical?Criteria?Descriptions?.......................................................................................................?105?

Glossary................................................................................................................................?115?
Definitions?...................................................................................................................................?115?



??SKYGEN?USA?|?CONFIDENTIAL?&?PROPRIETARY?|?Horizon?NJ?Health?Dental?Program?|?Effective:?1/1/20?
7?

Benefit?Plan?Details?&?Authorization?Requirements?.............................................................?120?
Dental?Benefit?Schedule?.............................................................................................................?121?
Horizon?NJ?Health?Dental?Program.............................................................................................?123?
? ?



??SKYGEN?USA?|?CONFIDENTIAL?&?PROPRIETARY?|?Horizon?NJ?Health?Dental?Program?|?Effective:?1/1/20?
8?

Quick?Reference?Guide?
Provider?Web?Portal:?Online,?All?the?Time?
Getting?paid?for?the?high?quality?care?you?ve?provided?to?patients?should?be?quick,?easy?and?
convenient.?Horizon?NJ?Health?s?user?friendly?Provider?Web?Portal?offers?a?full?set?of?self?service?
tools?that?help?you?get?more?done,?faster.??
Everything?You?Need???When?You?Need?It???24/7/365?
Use?the?Provider?Web?Portal?to:?

? Check?real?time?eligibility?for?multiple?patients?at?the?same?time.??
? Submit?electronic?authorization?requests?with?attachments.?
? Step?through?a?decision?tree?that?shows?you?the?same?clinical?guidelines?our?consultants?

use?to?evaluate?your?authorization?requests.?
? Use?our?claim?estimator?to?find?out?in?advance?whether?your?claim?is?likely?to?be?paid?or?

denied,?and?why?before?you?render?services.??
? Attach?supporting?documentation,?such?as?EOBs?and?x?rays?online,?for?no?charge.?
? Submit?pre?filled?claim?forms?and?review?claim?history?with?just?a?few?clicks.?
? Check?the?real?time?status?of?claims?and?authorizations?no?need?to?wait?for?paper?

letters?to?arrive?by?postal?mail.?
? View?and?print?Remittance?Reports,?newsletters,?manuals,?and?much?more.?

All?you?need?to?get?started?is?an?internet?connection?and?a?web?browser.?You?don?t?need?to?
download?or?purchase?any?software.?Just?visit?pwp.sciondental.com,?and?call?1?855?424?9239?to?
get?registered?for?the?Provider?Web?Portal.?

pwp.sciondental.com?
? ?



??SKYGEN?USA?|?CONFIDENTIAL?&?PROPRIETARY?|?Horizon?NJ?Health?Dental?Program?|?Effective:?1/1/20?
9?

When?You?Need?Us???We?ll?Be?There!?
Horizon?NJ?Health?is?committed?to?delivering?world?class?service?to?you?and?your?patients.?Our?
customer?service?teams?offer?local?service?with?the?support?of?national?resources.?A?dedicated?
provider?relations?representative?is?available?to?answer?your?questions?and?arrange?in?person?
visits.?When?you?need?us,?we?ll?be?there!??
Contact?us?any?time?for?assistance,?training,?or?to?arrange?an?onsite?visit:?
Call?Provider?Services:?1?855?878?5368?
Email:?providerservices@skygenusa.com?
Quick?Contacts? ?
Authorizations?mailing?address? Horizon?NJ?Health:?Authorizations?

PO?Box?362?
Milwaukee,?WI?53201?

Claims?mailing?address? Horizon?NJ?Health:?Claims?
PO?Box?299?
Milwaukee,?WI?53201?

Corrected?Claims?mailing?address? Horizon?NJ?Health:?Corrected?Claims?
PO?Box?541?
Milwaukee,?WI?53201?

Complaints?and?Appeals?mailing?address? Horizon?NJ?Health:?Complaints/Appeals?
PO?Box?295?
Milwaukee,?WI?53201?

Contracting?mailing?address?? Horizon?NJ?Health:?Contracting?
PO?Box?2059?
Milwaukee,?WI?53201?

Credentialing?Team? 1?855?812?9211??
Email:?credentialing@skygenusa.com?

Electronic?Funds?Transfer? Fax:?1?262?721?0722??
Email:?providerservices@skygenusa.com?

Electronic?Outreach?Team? 1?855?434?9239??
Email:?providerportal@skygenusa.com?

Fraud?&?Abuse?Hotline? 1?877?378?5292?
Provider?Services? 1?855?878?5368??

Email:?providerservices@skygenusa.com?
Provider?Web?Portal? pwp.sciondental.com?

? ?



??SKYGEN?USA?|?CONFIDENTIAL?&?PROPRIETARY?|?Horizon?NJ?Health?Dental?Program?|?Effective:?1/1/20?
10?

?

Quick?Reference?to?Common?Questions?
Member?Eligibility? To?verify?member?eligibility,?you?can:?

? Log?on?to?Provider?Web?Portal:?pwp.sciondental.com?
? Call?Interactive?Voice?Response?(IVR)?eligibility?hotline:??

1?844?275?8753?
? Call?Horizon?NJ?Health?Main?Provider?Services:?1?800?682?9091?

Authorization?
Submission?

Submit?authorizations?in?one?of?the?following?formats:?
? Provider?Web?Portal:?pwp.sciondental.com?
? Electronic?submission?via?clearinghouse,?Payer?ID:?22099
? HIPAA?compliant?837D?file??
? Paper?ADA?Dental?Claim?Form,?sent?via?postal?mail:?

Horizon?NJ?Health:?Authorizations?
PO?Box?362??
Milwaukee,?WI?53201?

To?learn?about?the?Provider?Web?Portal,?call?the?Electronic?Outreach?
Team:?1?855?434?9239.?

Claims?Submission? The?timely?filing?requirement?is?180?calendar?days.??
Submit?claims?in?one?of?the?following?formats:?

? Provider?Web?Portal:?pwp.sciondental.com?
? Electronic?submission?via?clearinghouse,?Payer?ID:?22099
? HIPAA?compliant?837D?file??
? Paper?ADA?Dental?Claim?Form,?sent?via?postal?mail:?

Horizon?NJ?Health:?Claims??
PO?Box?299??
Milwaukee,?WI?53201?

To?learn?about?the?Provider?Web?Portal,?call?the?Electronic?Outreach?
Team:?1?855?434?9239.?



??SKYGEN?USA?|?CONFIDENTIAL?&?PROPRIETARY?|?Horizon?NJ?Health?Dental?Program?|?Effective:?1/1/20?
11?

Quick?Reference?to?Common?Questions?
Complaints?and?
Appeals?

To?make?a?complaint:?
? Write?to:?

Horizon?NJ?Health:?Complaints/Appeals?
PO?Box?295?
Milwaukee,?WI?53201?

? Call?Horizon?NJ?Health?Provider?Services:?1?800?682?9091?
For?more?resources,?or?to?file?an?appeal,?see?Complaints,?Grievances?&?
Appeals?for?various?options.?

Provider?Appeals???
Utilization?
Management?
(Authorizations)?

UM?appeals?must?be?filed?within?60?days?following?the?date?the?
authorization?denial?letter?was?mailed.?Horizon?NJ?Health?issues?a?
decision?within?30?calendar?days?if?an?extension?was?not?requested?
and?granted.?Expedited?resolution?is?within?72?hours.?
To?request?reconsideration?of?a?denied?authorization,?write?to:?

Horizon?NJ?Health:?Complaints/Appeals?
PO?Box?295?
Milwaukee,?WI?53201?

Provider?Appeals???
Claims?

Claim?appeals?must?be?filed?within?90?calendar?days?following?the?
date?the?denial?letter?was?mailed.?Horizon?NJ?Health?issues?a?decision?
within?30?calendar?days?if?an?extension?was?not?requested?and?
granted.??
To?request?reconsideration?of?a?claims?denial,?write?to:?

Horizon?NJ?Health:?Complaints/Appeals?
PO?Box?295?
Milwaukee,?WI?53201?

Member?Appeals?? To?submit?a?written?appeal?on?behalf?of?a?member,?write?to:?
Horizon?NJ?Health:?Complaints/Appeals?
PO?Box?295?
Milwaukee,?WI?53201?

Credentialing?Appeals? To?appeal?a?credentialing?decision,?send?a?request?for?a?
reconsideration?review?within?30?days?of?receiving?an?adverse?
recommendation.?Write?to:?

Horizon?NJ?Health:?Credentialing?Appeals?
PO?Box?2059?
Milwaukee,?WI?53201?



??SKYGEN?USA?|?CONFIDENTIAL?&?PROPRIETARY?|?Horizon?NJ?Health?Dental?Program?|?Effective:?1/1/20?
12?

Quick?Reference?to?Common?Questions?
EFT?(Direct?Deposit)?
Enrollment?

Send?a?completed?EFT?Authorization?Agreement?form?and?voided?
check?by?either?fax?or?email:?

? Fax:?1?262?721?0722?
? Email:?providerservices@skygenusa.com?

The?EFT?Authorization?Agreement?form?is?included?in?the?Provider?
Manual?and?posted?on?the?Provider?Web?Portal:?
pwp.sciondental.com.?

Provider?Web?Portal? For?training?or?questions?about?the?Provider?Web?Portal,?contact?the?
Electronic?Outreach?Team:??

? Email:?providerportal@skygenusa.com?
? Call:?1?855?434?9239?

Credentialing? Send?credentialing?and?recredentialing?applications?and?documents?
to?Horizon?NJ?Health?by?fax,?email,?or?mail.?

? Fax:?1?866?396?5686??
? Email:?credentialing@skygenusa.com?
? Write?to:?

Horizon?NJ?Health:?Credentialing?
PO?Box?2059?
Milwaukee,?WI?53201??

Additional?Provider?
Resources?

For?information?about?additional?provider?resources:?
Provider?Web?Portal:?pwp.sciondental.com?
Provider?Services:?1?855?878?5368?
providerservices@skygenusa.com?
Electronic?Outreach?Team:?1?855?434?9239?
providerportal@skygenusa.com?
Credentialing?Team:?1?855?812?9211?
credentialing@skygenusa.com?
Horizon?NJ?Health?Main?Provider?Services:?1?800?682?9091?
horizonnNJhealth.com?
Horizon?NJ?Health?Main?Member?Services:?1?877?765?4325?
Department?of?Billing?and?Insurance:?1?800?446?7467?
state.nj.us/dobi?



??SKYGEN?USA?|?CONFIDENTIAL?&?PROPRIETARY?|?Horizon?NJ?Health?Dental?Program?|?Effective:?1/1/20?
13?

Welcome?
Welcome?to?the?Horizon?NJ?Health?Dental?Program?provider?network!?We?are?Horizon?NJ?
Health,?a?program?of?Horizon?Blue?Cross?Blue?Shield?of?New?Jersey.?We?are?committed?to?
providing?our?members?the?best?possible?care,?keeping?them?healthy,?stable,?and?independent???
it?s?our?reason?for?being?here.?We?are?pleased?to?welcome?you?to?our?team.?
Horizon?NJ?Health?offers?comprehensive?dental?services?to?NJ?FamilyCare?A,?B,?C,?D,?and?ABP?
members?as?well?as?MLTSS?members?and?Horizon?NJ?TotalCare?(HMO?D?SNP)?members.?These?
services?include?preventive,?diagnostic,?restorative,?endodontic,?periodontal,?prosthodontic,?oral?
surgical,?and?adjunctive?dental?services.?Some?procedures?require?prior?authorization.?When?
necessary,?orthodontic?services?are?age?restricted?(covered?for?members?under?21?years?of?age?
or?as?allowed?by?Early?and?Periodic?Screening,?Diagnosis,?and?Treatment?(EPSDT)?and?only?
approved?with?adequate?documentation?of?medical?necessity.?Referral?to?a?dentist?is?mandatory?
when?a?member?reaches?1?year?of?age?and?annually?thereafter.??
Dental?services?include?an?initial?examination?and?any?required?dental?services?determined?to?be?
medically?necessary.?A?referral?to?a?dental?specialist?or?dentist?that?provides?dental?treatment?to?
patients?with?special?needs?shall?be?allowed?when?a?Primary?Care?Dentist?(PCD)?requires?a?
consultation?for?services?by?that?provider.?Any?Primary?Care?Provider?(PCD)?or?PCD?may?refer?a?
member?to?a?participating?dental?specialist.?All?dental?specialists?are?required?to?have?a?current?
NJ?specialty?permit?and?to?be?either?board?eligible?or?board?certified.?All?general?dentists?and?
dental?specialists?are?listed?in?the?Doctor?&?Hospital?Finder?at?horizonNJhealth.com/findadoctor.?
NJ?FamilyCare?C?and?D?members?are?responsible?for?a?$5?copayment?for?dental?services?with?the?
exception?of?diagnostic?and?preventive?dentistry?services.??
Additional?diagnostic,?preventive?and?periodontal?services?shall?be?available?beyond?the?
frequency?limitations?of?every?six?months?and?be?allowed?four?times?a?rolling?year?to?enrollees?
with?special?needs?when?medical?necessity?for?these?services?is?documented?and?submitted?for?
consideration.?Documentation?shall?include?the?expected?prognosis?and?improvement?in?the?oral?
condition?associated?with?the?increased?frequency?for?the?requested?service.?As?part?of?the?State?
contract?with?Horizon?NJ?Health,?members?have?the?option?to?obtain?a?second?opinion?for?
diagnosis?and?treatment?of?dental?conditions?that?are?treated?within?a?dental?specialty.??
The?Plan?may?arrange?for?the?member?to?obtain?a?second?opinion?outside?the?network?at?no?cost?
to?the?member?when?the?plan?s?network?of?providers?does?not?have?a?provider?located?in?the?
member?s?geo?access?area?to?provide?the?services?the?member?needs.?Every?effort?will?be?made?
to?locate?an?in?network?provider.?Members?who?seek?self?initiated?care?from?a?nonparticipating?
dentist?or?a?non?covered?service?will?be?responsible?for?the?cost?of?the?care.?
Throughout?your?ongoing?relationship?with?us,?refer?to?this?provider?manual?for?quick?answers?
and?useful?information,?including?how?to?contact?us,?how?to?submit?claims?and?authorizations,?
and?what?covered?benefits?are?offered?to?members.?
When?you?need?answers,?log?on?to?pwp.sciondental.com?or?horizonNJhealth.com,?send?an?email?
message?to?providerservices@skygenusa.com,?or?call?Provider?Services:?1?855?878?5368.?



??SKYGEN?USA?|?CONFIDENTIAL?&?PROPRIETARY?|?Horizon?NJ?Health?Dental?Program?|?Effective:?1/1/20?
14?

Horizon?NJ?Health,?under?New?Jersey?law,?has?the?right?to?make?any?changes?to?dental?policies?
and?procedures?in?this?manual,?which?become?effective?30?days?after?such?changes?are?posted?to?
horizonNJhealth.com.??

This?manual?describes?policies?and?procedures?that?govern?administration?of?dental?benefits?for?
Horizon?Blue?Cross?Blue?Shield?of?New?Jersey?for?the?State?of?New?Jersey.?Horizon?NJ?Health?
makes?every?effort?to?maintain?accurate?information?in?this?manual;?however,?we?will?not?be?held?
liable?for?any?damages?due?to?unintentional?errors.?If?you?discover?an?error,?please?report?it?to?us?
by?calling?1?800?682?9091.?If?information?in?this?manual?differs?from?your?Provider?Agreement,?the?
Provider?Agreement?takes?precedence?and?shall?control.??
This?document?contains?confidential?and?proprietary?information?and?may?not?be?disclosed?to?
others?without?written?permission?from?SKYGEN?USA.???2014?2019?SKYGEN?USA?All?rights?
reserved.?
Products?are?provided?by?Horizon?NJ?Health.?Communications?are?issued?by?Horizon?Blue?Cross?
Blue?Shield?of?New?Jersey?in?its?capacity?as?administrator?of?programs?and?provider?relations?for?
all?its?companies.?Both?are?independent?licensees?of?the?Blue?Cross?and?Blue?Shield?Association.?
The?Blue?Cross??and?Blue?Shield??names?and?symbols?are?registered?marks?of?the?Blue?Cross?and?
Blue?Shield?Association.?The?Horizon??name?and?symbols?are?registered?marks?of?Horizon?Blue?
Cross?Blue?Shield?of?New?Jersey.???2019?Horizon?Blue?Cross?Blue?Shield?of?New?Jersey,?Three?Penn?
Plaza?East,?Newark,?New?Jersey?07105.?
? ?



??SKYGEN?USA?|?CONFIDENTIAL?&?PROPRIETARY?|?Horizon?NJ?Health?Dental?Program?|?Effective:?1/1/20?
15?

Member?Rights?and?Responsibilities??
Members?of?Horizon?NJ?Health?have?the?following?rights?and?responsibilities.?
Member?Rights?
The?Horizon?NJ?Health?Dental?Program?is?committed?to?the?following?core?concepts?in?our?
approach?to?member?care:?

? Access?to?providers?and?services.?
? Wellness?programs,?which?include?member?education?and?disease?management?initiatives.?
? Outreach?programs?that?educate?members?and?give?them?the?tools?they?need?to?make?

informed?decisions?about?their?dental?care.?
? Feedback?that?measures?provider?and?member?satisfaction.?

We?believe?all?members?have?the?right?to:?
? Privacy,?respectful?treatment,?and?recognition?of?their?dignity?when?receiving?dental?care.?
? Participate?fully?with?caregivers?in?making?decisions?about?their?health?care.?
? Be?fully?informed?about?the?appropriate?or?medically?necessary?treatment?options?for?any?

condition,?regardless?of?the?coverage?or?cost?for?the?care?discussed.?
? Voice?a?complaint?against?the?Horizon?NJ?Health?Dental?Program,?or?any?of?its?participating?

dental?offices,?or?any?of?the?care?provided?by?these?groups?or?people,?when?their?performance?
has?not?met?the?member?s?expectations.?

? Appeal?any?decisions?related?to?patient?care?and?treatment.?
? Make?recommendations?regarding?our?member?rights?and?responsibilities?policies.?
? Receive?relevant,?updated?information?about?the?Horizon?NJ?Health?Dental?Program,?the?

services?provided,?the?participating?dentists?and?dental?offices,?as?well?as?member?rights?
and?responsibilities.?

Member?Responsibilities?
Along?with?rights,?members?have?important?responsibilities,?including:?

? Becoming?familiar?with?benefit?plan?coverage?and?rules.?
? Giving?dental?providers?complete?and?accurate?information?they?need?to?provide?care.?
? Following?treatment?plans?and?instructions?received?from?dental?providers.?
? Supporting?the?care?given?to?other?patients?and?behaving?in?a?way?that?helps?the?clinic,?

dental?office,?and?other?dental?locations?run?smoothly.?
? Notifying?Customer?Service?of?any?questions,?concerns,?problems,?or?suggestions.?

? ?



??SKYGEN?USA?|?CONFIDENTIAL?&?PROPRIETARY?|?Horizon?NJ?Health?Dental?Program?|?Effective:?1/1/20?
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Provider?Rights?&?
Responsibilities?
The?Horizon?NJ?Health?Dental?Program?has?established?the?following?core?concepts?in?our?
approach?to?a?positive?provider?experience:?

? Access?to?flexible?participation?options?in?provider?networks.?
? Outreach?programs?that?lower?provider?participation?costs.?
? Technology?tools?that?increase?efficiency?and?lower?administrative?costs.?
? Feedback?that?measures?provider?and?member?satisfaction.?

Provider?Rights?
Enrolled?participating?providers?have?the?right?to:?

? Communicate?with?patients?about?dental?treatment?options.?
? Recommend?a?course?of?treatment?to?a?member,?even?if?the?treatment?is?not?a?covered?

benefit?or?approved?by?the?Horizon?NJ?Health?Dental?Program.?
? File?an?appeal?or?complaint?about?the?procedures?of?Horizon?NJ?Health?Dental?Program.?
? Supply?accurate,?relevant,?and?factual?information?to?a?member?in?conjunction?with?an?

appeal?or?complaint?filed?by?the?member.?
? Object?to?policies,?procedures,?or?decisions?made?by?Horizon?NJ?Health?Dental?Program.?
? Be?informed?of?the?status?of?their?credentialing?or?recredentialing?application,?upon?request.?

Provider?Responsibilities?
Participating?providers?have?the?following?responsibilities:?

? If?a?recommended?treatment?plan?is?not?covered?(not?approved?by?the?Horizon?NJ?
Health?Dental?Program),?the?participating?dentist,?if?intending?to?charge?the?member?for?
the?non?covered?services,?must?notify?and?obtain?agreement?from?the?member?in?
advance.?(See?Payment?for?Non?Covered?Services?on?page?39.)??

? A?provider?wishing?to?terminate?participation?with?the?Horizon?NJ?Health?Dental?Program?
provider?network?must?follow?the?termination?guidelines?stipulated?in?the?provider?contract.?

? A?provider?may?not?bill?both?medical?codes?and?dental?codes?for?the?same?procedure.?
Provider?Bill?of?Rights?

? To?be?treated?with?respect?
? To?be?paid?accurately?
? To?be?paid?on?time?

? ?



??SKYGEN?USA?|?CONFIDENTIAL?&?PROPRIETARY?|?Horizon?NJ?Health?Dental?Program?|?Effective:?1/1/20?
17?

Positive?Provider?Experience?
We?consider?ourselves?to?be?your?partner?in?patient?care.?Committed?dentists?are?essential?to?the?
success?of?every?government?sponsored?dental?program.?The?Horizon?NJ?Health?Dental?Program?
invites?all?licensed?dentists,?regardless?of?their?past?commitment?to?government?sponsored?
dental?programs,?to?participate?in?our?provider?network.?You?can?choose?your?own?level?of?
participation?for?each?location?where?you?practice.?For?each?location?you?can?choose?to:?

? Be?listed?in?a?directory?and?accept?appointments?for?all?new?patients.?
? Be?excluded?from?directories?and?accept?appointments?for?only?new?patients?directed?to?

your?office?from?Horizon?NJ?Health.?
? Treat?only?emergencies?or?special?needs?cases?on?an?individual?basis.?

To?make?it?as?fast?and?easy?as?possible?to?join?our?network,?Horizon?NJ?Health?streamlines?the?
contracting?and?credentialing?process?by?accepting?electronic?documents.?
Consistent,?Transparent?Authorization?Decisions?
Trained?paraprofessionals?and?dental?consultants?use?predefined?clinical?guidelines?to?ensure?a?
consistent?approach?for?determining?authorizations?submitted?for?review.??
When?you?submit?an?online?authorization?through?the?Provider?Web?Portal,?you?have?the?option?
of?stepping?through?the?guideline?yourself,?for?a?quick?indication?of?whether?your?authorization?
request?is?likely?to?be?approved.?Authorization?requirements?are?also?outlined?in?this?provider?
manual.?See?Benefit?Plan?Details?&?Authorization?Requirements?on?page?120.?
In?addition,?when?you?submit?an?authorization?through?the?Provider?Web?Portal,?you?can?see?at?a?glance?
whether?documentation,?such?as?X?rays?or?medical?necessity?narratives,?are?required.?You?can?attach?and?
send?electronic?documents?as?part?of?your?online?authorization?request?saving?both?time?and?money.??
Cultural?Competency??
Your?office?and?staff?should?demonstrate?behaviors?and?policies?of?cultural?competency?by:?

? Assessing?and?documenting?cultural?and/or?language?barriers?to?member?care.?
? Seeking?information?from?community?resources?to?assist?in?servicing?the?needs?of?

culturally?and?ethnically?diverse?members?and?families.?
? Displaying?pictures,?posters,?and?other?materials?to?reflect?the?cultures?and?ethnic?

backgrounds?of?members?and?families.?
? Providing?magazines?and?brochures?in?the?waiting?area?that?emphasize?diversity.?
? Understanding?that?folk?and?religious?beliefs?may?influence?how?families?respond?to?illness,?

disease,?death,?and?their?reaction?and?approach?to?children?with?special?health?needs.?
? Accepting?that?the?family?unit?can?be?defined?differently?by?different?cultures.?
? Seeking?bilingual?staff?or?trained?personnel?to?serve?as?interpreters,?when?possible.?
? Understanding?that?a?limited?English?proficiency?in?no?way?reflects?intellect.?

? ?



??SKYGEN?USA?|?CONFIDENTIAL?&?PROPRIETARY?|?Horizon?NJ?Health?Dental?Program?|?Effective:?1/1/20?
18?

Patients?with?Special?Health?Needs?
Dentists?who?treat?patients?with?special?health?needs?(including?physical,?developmental,?or?
emotional?disabilities)?must?assist?and?consult?with?patient?caregivers.?When?a?caregiver?seeks?
advice,?clarification,?or?education,?you,?as?the?treating?dentist,?should?provide?this?information.?
Dentists?may?receive?a?behavior?management?fee?for?treating?patients?with?special?needs,?based?
on?the?needs?of?the?member.?If?the?patient?is,?by?clinical?presentation?or?medical?condition?
determined?to?be?a?member?to?have?special?needs,?we?will?allow?that?patient?to?receive?services?
as?a?special?needs?member.?Forward?a?narrative?to?providerservices@skygenusa.com,?or?call?
Provider?Services?at?1?855?878?5368.?Horizon?NJ?Health?pays?a?fee?per?15?minute?unit,?and?prior?
authorization?is?not?necessary.?Reimbursement?for?two?or?more?units?is?at?the?discretion?of?a?
Horizon?NJ?Health?Dental?Consultant?and?based?on?services?provided?in?the?patient?s?record.?This?
documentation?includes,?but?is?not?limited?to:??

? A?visual?examination?of?the?patient?
? Appropriate?radiographs?
? Dental?prophylaxis,?including?extra?scaling?and?topical?applications?such?as?fluoride?treatments?
? Nonsurgical?periodontal?treatment,?including?root?planing?and?scaling?
? Thorough?inquiries?regarding?the?patient?s?medical?history?
? Consultations?with?patient?caregivers?to?establish?a?thorough?understanding?of?proper?

dental?management?during?visits?
? ?



??SKYGEN?USA?|?CONFIDENTIAL?&?PROPRIETARY?|?Horizon?NJ?Health?Dental?Program?|?Effective:?1/1/20?
19?

The?Head?Start?Initiative?
The?Head?Start?Initiative?is?a?pediatric?oral?health?action?plan?established?to?ensure?Head?Start?
programs?in?the?State?of?New?Jersey?are?given?resources?for?all?Early?Head?Start/Head?Start?
children.?This?is?a?part?of?a?statewide?initiative?to?increase?optimal?oral?care?access?and?oral?
health?education?for?children?ages?0?6?in?communities?served?by?the?Head?Start?program.?
Horizon?NJ?Health?Dental?Operations?is?tasked?with:??

? Determining?the?status?of?early?childhood?oral?health?in?New?Jersey?and?educating?Head?
Start?staffers.?

? Increasing?access?to?high?quality,?comprehensive?oral?health?services?through?provider?
recruitment?and?engagement.?

? Promoting?the?importance?of?oral?health?to?all?health?care?professionals,?family?members,?
and?educators?through?the?individual?Head?Start?programs?by:?

o Identifying?and?reviewing?risk?factors?for?poor?oral?health?including?access?to?care.?
o Ongoing?discussions?on?health?disparities?and?underlying?medical?conditions.?
o Educating?on?the?best?practices?relative?to?collaborations?that?may?improve?

quality?healthcare.?
o Utilizing?resources?available?to?assist?in?this?endeavor,?NJDA,?NJAAPD,?The?

Pediatric?Oral?Health?Committee,?and?our?own?participating?dental?providers.?
? ?



??SKYGEN?USA?|?CONFIDENTIAL?&?PROPRIETARY?|?Horizon?NJ?Health?Dental?Program?|?Effective:?1/1/20?
20?

Domestic?Violence?Reporting?
The?health?care?provider?is?a?primary?source?in?identifying?members?who?may?have?been?
subjected?to?domestic?violence.?Domestic?violence?includes?both?abuse?and?battery.?Abuse?is?a?
pattern?of?coercive?control?that?one?person?exercises?over?another.?Battery?is?a?behavior?that?
physically?harms,?arouses?fear,?prevents?a?partner?from?doing?what?they?wish,?or?forces?them?to?
behave?in?ways?they?do?not?want.?
State?law?requires?the?reporting?of?child?abuse.?Reporting?can?be?done?anonymously.?Report?any?
injuries?from?firearms?and?other?weapons?to?the?police.?Immediately?report?any?suspected?child?
abuse?or?neglect?to?the?Division?of?Child?Protection?and?Permanency?at?1?877?NJABUSE?(1?877?
652?2873).?Calls?can?be?received?24?hours?a?day,?seven?days?a?week.?
The?provider?is?responsible?to?report?suspected?cases?of?elder?or?partner?abuse,?neglect,?or?
exploitation?that?occurs?in?the?community.?Immediately?report?any?suspected?elder?or?partner?
abuse?to?the?State?s?Department?of?Adult?Protective?Services?at?1?609?588?6501.?
State?law?provides?immunity?from?any?criminal?or?civil?liability?as?a?result?of?good?faith?reports?of?
child?abuse?or?neglect.?Any?person?who?knowingly?fails?to?report?suspected?abuse?or?neglect?may?
be?subject?to?a?fine?up?to?$1,000?or?imprisonment?up?to?six?months.?To?help?identify?domestic?
violence,?the?following?questions?have?been?developed?by?the?Family?Violence?Prevention?Fund.?
A?complete?copy?of?the?guidelines?can?be?found?at?futureswithoutviolence.org.?
Domestic?Violence?Screening?Tools??
Framing?Questions?

? ?Because?violence?is?so?common?in?many?people?s?lives,?I?ve?begun?to?ask?all?my?patients?
about?it.??

? ?I?m?concerned?that?your?symptoms?may?have?been?caused?by?someone?hurting?you.??
? ?I?don?t?know?if?this?is?a?problem?for?you,?but?many?of?the?women?I?see?as?patients?are?

dealing?with?abusive?relationships.?Some?are?too?afraid?or?uncomfortable?to?bring?it?up?
themselves,?so?I?ve?started?asking?about?it?routinely.??

Direct?Verbal?Questions?
? ?Are?you?in?a?relationship?with?a?person?who?physically?hurts?or?threatens?you???
? ?Did?someone?cause?these?injuries??Was?it?your?partner/husband???
? ?Has?your?partner?or?ex?partner?ever?hit?you?or?physically?hurt?you??Has?he?ever?

threatened?to?hurt?you?or?someone?close?to?you???
? ?Do?you?feel?controlled?or?isolated?by?your?partner???
? ?Do?you?ever?feel?afraid?of?your?partner??Do?you?feel?you?are?in?danger??Is?it?safe?for?you?

to?go?home???
? ?Has?your?partner?ever?forced?you?to?have?sex?when?you?didn?t?want?to??Has?your?

partner?ever?refused?to?practice?safe?sex???
? ?



??SKYGEN?USA?|?CONFIDENTIAL?&?PROPRIETARY?|?Horizon?NJ?Health?Dental?Program?|?Effective:?1/1/20?
21?

For?History?Intake?Forms/New?Patient?Questionnaires?
Option?1?

? ?Have?you?ever?been?hurt?or?threatened?by?your?boyfriend/husband/partner???
?OR??

? ?Have?you?ever?been?hit,?kicked,?slapped,?pushed?or?shoved?by?your?spouse/partner???
?OR??

? ?Have?you?ever?been?hit,?kicked,?slapped,?pushed?or?shoved?by?your?boyfriend/husband/?
partner?during?this?pregnancy???
?AND??

? ?Have?you?ever?been?raped?or?forced?to?engage?in?sexual?activity?against?your?will???
Option?2?

? ?Are?you?currently?or?have?you?ever?been?in?a?relationship?in?which?you?were?physically?
hurt,?threatened?or?made?to?feel?afraid???

Option?3?
? ?Have?you?ever?been?forced?or?pressured?to?have?sex?when?you?did?not?want?to???
? ?Have?you?ever?been?hit,?kicked,?slapped,?pushed?or?shoved?by?your?

boyfriend/husband/partner???
Reporting?Abuse,?Neglect?or?Exploitation?
All?members?have?the?right?to?be?free?from?exploitation,?fraud?and?abuse.?Providers?are?required?to?
report?suspected?abuse,?neglect,?or?exploitation?of?any?person?who?answers?in?the?affirmative?to:?

? ?Are?you?in?a?relationship?with?a?person?who?physically?hurts?or?threatens?you???
? ?Did?someone?cause?these?injuries??Was?it?your?partner/husband???

Adult?Protective?Services?
The?New?Jersey?Adult?Protective?Services?(APS)?program?has?offices?in?each?of?the?21?counties.?
Reports?may?be?made?to?those?County?APS?offices?or?to:?
The?Public?Awareness,?Information,?Assistance?&?Outreach?Unit:?1?800?792?8820?
Child?Protective?Services?
The?New?Jersey?Division?of?Child?Protection?and?Permanency?(DCP&P)?handles?all?reports?of?child?
abuse?and?neglect,?including?those?occurring?in?institutional?settings?such?as?child?care?centers,?
schools,?foster?homes?and?residential?treatment?centers.?These?must?be?reported?to?the?State?
Central?Registry?(SCR):?
Child?Abuse?Hotline?(SCR)?24?Hour?Toll?Free?Hotline:?1?877?NJ?ABUSE?(1?877?652?2873)?|?TTY:?1?
800?835?5510.?
? ?



??SKYGEN?USA?|?CONFIDENTIAL?&?PROPRIETARY?|?Horizon?NJ?Health?Dental?Program?|?Effective:?1/1/20?
22?

Facility?Based?Complaints?and?Investigation?
Office?of?the?Ombudsman?for?the?Institutionalized?Elderly?investigates?claims?of?abuse?and?
neglect?of?people?age?60?and?older?living?in?nursing?facilities?and?other?long?term?health?care?
facilities,?such?as?assisted?living?facilities.?

? 24?Hour?Toll?Free?Hotline:?1?877?582?6995??
? Fax:?1?609?943?3479?
? Email:?ombudsman@advocate.state.nj.us??
? Write?to:??

The?Office?of?the?Ombudsman?
PO?Box?852?
Trenton,?NJ?08625?0852?

NJ?Division?of?Health?Facilities?Evaluation?and?Licensing?investigates?all?complaints?against?health?
care?facilities,?nursing?homes,?assisted?living?residences,?comprehensive?personal?care?homes,?
adult?medical?day?care,?and?other?licensed?acute?and?long?term?care?facilities.?
24?Hour?Toll?Free?Hotline:?1?800?792?9770??
Write?to:?

New?Jersey?Department?of?Human?Services?Division?of?Health?Facilities??
Evaluation?and?Licensing?
PO?Box?367?
Trenton,?NJ?08625?0367?

Confidentiality??
All?participating?dentists?must?treat?their?member?dental?records?confidentially?and?comply?with?
all?federal?and?state?laws?and?regulations.?
The?enrollment?form,?signed?by?Horizon?NJ?Health?members,?authorizes?the?release?of?dental?
information?to?Horizon?NJ?Health?on?behalf?of?Horizon?NJ?Health?staff.??
Standards?of?Service?
The?level?of?care?specified?in?the?dental?treatment?plan?must?meet?the?ethical?and?professional?
standards?of?the?dental?profession?and?offer?the?same?high?standard?of?quality?provided?to?the?
community?at?large.?
All?materials?used,?and?all?therapeutic?agents?used?or?prescribed,?must?meet?the?specifications?
established?by?the?American?Dental?Association.?Horizon?NJ?Health?does?not?reimburse?
experimental?procedures?that?are?not?approved?by?the?New?Jersey?Board?of?Dental?Examiners.?
When?an?emergency?arises?and?the?attending?practitioner?is?unavailable?for?consultation,?due?
consideration?should?be?given?to?the?preservation?of?those?teeth?that?could?be?involved?in?the?
overall?treatment?plan?of?the?attending?practitioner.?
? ?



??SKYGEN?USA?|?CONFIDENTIAL?&?PROPRIETARY?|?Horizon?NJ?Health?Dental?Program?|?Effective:?1/1/20?
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Special?Standards?of?Services?
Dental?services?without?specific?provisions?or?services?limited?or?prohibited?in?these?policies?
and?procedures?may?be?considered?on?an?individual?basis.?Send?these?requests?and?all?
supporting?documentation?to:?

Horizon?NJ?Health:?Authorizations?
PO?Box?362?
Milwaukee,?WI?53201?

Office?Practice?Standards?for?General?Dentists?
The?State?of?New?Jersey?requires?the?following?Office?Practice?Standards?for?Primary?Care?
Dentists.?Compliance?with?these?standards?is?audited?by?periodic?onsite?reviews?of?offices,?chart?
sampling,?and?member?satisfaction?surveys.?General?dentists?must:?

? Render?dental?care?services?within?45?minutes?from?the?time?of?scheduled?appointment.?
? Implement?and?document?a?policy?to?track?missed?appointments,?and?follow?up?with?

rescheduling?to?maintain?continuity?of?care.?
? Offer?dental?care?in?an?office?environment?that?meets?OSHA?and?CDC?standards.?

Recordkeeping?Requirements?
Dentists?are?required?to?maintain?individual?records,?which?fully?disclose?the?type?and?extent?of?services?
provided?to?members?in?the?Horizon?NJ?Health?Dental?Program.?Providers?must?maintain?and?make?
these?records?available?per?state?law,?including?details?of?all?services?rendered?for?each?encounter?date.?
Office?Records?
Member?records?must?be?kept?in?the?dentist?s?office?regardless?of?the?actual?place?of?service?
(dental?office,?long?term?care?facility,?or?hospital).?Per?the?State?of?New?Jersey?requirements,?
these?records?must?be?available?for?a?minimum?of?seven?years?following?the?last?date?of?service.?
These?records?will?include,?but?not?be?limited?to,?the?following:?
Member?Identification?and?History?

? Name,?address,?telephone?number,?birth?date,?and?Medicaid?ID?number?of?the?member?
? If?the?member?is?a?minor,?names?of?parents?or?guardians?
? Documentation?of?any?cultural?or?linguistic?needs?of?the?member?
? Pertinent?dental?and?medical?history?

Clinical?Examination?Data?
Detailed?clinical?examination?data?to?include,?when?applicable:?

? Member?s?chief?complaint??
? Diagnosis?
? Caries?
? Missing?teeth?(Periodontal?charting,?when?necessary)?
? Abnormalities?
? Risk?assessment? ?



??SKYGEN?USA?|?CONFIDENTIAL?&?PROPRIETARY?|?Horizon?NJ?Health?Dental?Program?|?Effective:?1/1/20?
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Radiographs?
? Preoperative,?progressive,?and?postoperative?radiographs?retained?in?accordance?with?state?

law?for?a?minimum?of?seven?years?following?the?last?date?of?service?(To?accommodate?
possible?retention?for?longer?periods,?contact?professional?liability?insurance?companies.)?

? Number?and?type?of?radiographs?entered?on?the?member?s?record?
? Postoperative?radiographs,?taken?only?when?dentally?necessary?and?meriting?diagnostic?value?

Treatment?Plan?
The?treatment?plan?with?description?of?treatment?rendered,?including:?

? Tooth?number?
? Surfaces?involved?
? Site?and?size?of?treatment?area?(lesion,?laceration,?fracture,?etc.)?
? Materials?used?
? Dates?of?services?
? Description?of?treatment?or?services?rendered?at?each?visit?with?the?name?of?the?dentist?

or?hygienist?
? All?medications?
? Diagnostic?laboratory?and/or?radiographic?procedures?ordered?and?the?results?
? Copy?of?the?dental?prosthetic?work?authorizations?(prescriptions)?and?dental?prosthetic?

laboratory?receipts?
? Explanation?for?any?duplication?of?services?within?one?year?(Prosthetic?services?within?

seven?and?a?half?years)?
? Reasons?for?discontinuation?of?services,?and?attempts?to?complete?treatment?
? Referral?and?consultation?reports?

Hospital?Facility?Records??
For?any?members?treated?at?hospital?facilities,?providers?must?also?document?services?in?facility?
records?that?are?readily?available?to?Horizon?NJ?Health?representatives.?Enter?a?complete?
description?of?treatment,?as?described?above,?into?a?hospital?s?clinical?records?for?any?member?
you?treat?at?that?facility.?These?entries?must?also?meet?the?hospital?s?specific?regulations.?
? ?



??SKYGEN?USA?|?CONFIDENTIAL?&?PROPRIETARY?|?Horizon?NJ?Health?Dental?Program?|?Effective:?1/1/20?
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Nursing?Facility?Records??
In?addition?to?the?office?records,?dentists?who?provide?services?for?members?who?reside?at?a?
nursing?facility?regardless?of?the?place?of?service?must?provide?the?nursing?facility?with?an?
entry?for?the?member?s?clinical?record?as?follows:?

? The?results?of?an?examination?to?establish?an?admission?record?of?the?member?s?dental?
status.?If?an?examination?is?required?within?six?months?of?a?previous?examination?billed?
to?Horizon?NJ?Health?and?performed?by?the?same?physician?or?healthcare?professional,?
the?results?of?the?original?examination?must?also?appear?in?the?clinical?record?as?the?
current?dental?status.?

? A?time?frame,?established?on?an?individual?basis,?for?the?next?periodic?examination?of?the?
member.?The?time?frame?must?be?documented?either?at?the?time?of?examination?or?at?
the?completion?of?treatment.?The?clinical?record?may?reflect?six?months,?one?year,?two?
years,?three?years,?or?any?other?time?period?that?the?attending?dentist?learned?of?the?
member?s?dental?status.?

? A?record?of?dental?treatment?provided?at?each?encounter.?Horizon?NJ?Health?accepts?a?
photocopy?of?the?completed?and?signed?current?ADA?Claim?Form?with?the?examination?and?
treatment?instead?of?a?separate?entry?only?when?descriptions?of?treatments?preceding?or?
following?the?dates?of?service?entered?on?the?claim?form?are?listed?separately?on?the?
member?s?clinical?record?in?addition?to?the?other?recordkeeping?requirements.?

? ?



??SKYGEN?USA?|?CONFIDENTIAL?&?PROPRIETARY?|?Horizon?NJ?Health?Dental?Program?|?Effective:?1/1/20?
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Mobile?Dental?Practice?and?Mobile?Dental?Van?Definitions?
Mobile?Dental?Practice?(utilizing?portable?equipment)?is?a?provider?traveling?to?various?locations?
and?utilizing?portable?dental?equipment?to?provide?dental?services?outside?of?a?dental?office/clinic?
in?settings?to?include?but?not?limited?to?facilities,?schools?and?residences.??

? Facilities:?These?providers?are?expected?to?provide?on?site?comprehensive?dental?care?(to?
include?intra?oral?radiographs),?necessary?dental?referrals?to?general?dentist?or?specialists?
and?emergency?dental?care?in?accordance?with?all?New?Jersey?State?Board?of?Dentistry?
regulations?and?the?NJ?FamilyCare?MCO?Contract.?The?sites?served?by?the?Mobile?Dental?
Practice?must?allow?Member?access?to?treatment?and?allow?for?continuity?of?care.??

? Schools:?These?locations?are?not?considered?a?dental?home?and?are?limited?to?providing?
the?following?services:?oral?assessment/screening,?prophylaxis,?fluoride?treatment,?
emergency?care?and?referral?to?the?member?s?dental?home?when?known?or?their?MCO?for?
assistance?in?locating?a?dentist.??

Private?Residences?and?other?residential?settings:?These?providers?are?expected?to?provide?on?site?
dental?care?for?the?homebound?based?on?patient?safety?and?ability?to?tolerate?procedures?
outside?of?a?clinical?setting.??

? The?MCO?is?responsible?for?assisting?the?member,?family,?facility?or?school?in?locating?a?
dentist?when?referrals?are?issued.?Patient?records?must?be?maintained?at?the?facility?when?
this?is?a?long?term?care?facility,?skilled?nursing?facility?or?school?and?duplicates?may?also?be?
maintained?in?a?central?and?secure?area?in?accordance?with?State?Board?of?Dentistry?
regulations.?The?provider?must?submit?documentation?to?the?MCO?of?all?locations?they?
visit?and?serve?and?include?the?days?and?times?for?each?location,?except?when?a?visit?is?to?
a?residence.??

Mobile?Dental?Practice?(utilizing?van)?is?a?vehicle?specifically?equipped?with?stationary?dental?
equipment?and?is?used?to?provide?dental?services?within?the?van.??

? Providers?using?a?mobile?dental?van?to?render?dental?services?must?also?be?associated?
with?a?dental?practice?that?is?located?in?a??brick?and?mortar??facility?located?in?New?Jersey?
that?serves?as?a?dental?home?offering?comprehensive?care,?emergency?care?and?
appropriate?dental?specialty?referrals?to?the?mobile?dental?van?s?patients?of?record?
(Members).?They?must?demonstrate?their?ability?to?render?dental?treatment?services?and?
assist?with?dental?referrals?as?needed.??

? An?exception?to?the?brick?and?mortar?requirements?can?be?considered?for?providers?using?
mobile?dental?vans?that?demonstrate?they?are?only?providing?dental?services?to?NJ?
FamilyCare?enrollees?residing?in?a?long?term?care?facility?or?that?are?in?a?private?
residence/group?home?and?unable?to?travel.??

? The?distance?between?the?dental?practice?and?the?sites?and?locations?served?by?the?
mobile?dental?van?must?not?be?a?deterrent?to?the?Member?accessing?treatment?and?allow?
for?continuity?of?care?by?meeting?the?network?standards?for?distance?in?miles?as?
described?in?section?4.8.8?Provider?Network?Requirements.?? ?



??SKYGEN?USA?|?CONFIDENTIAL?&?PROPRIETARY?|?Horizon?NJ?Health?Dental?Program?|?Effective:?1/1/20?
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? When?a?mobile?dental?van?is?used?for?school?visits,?health?fairs?or?other?one?time?events,?
services?will?be?limited?to?oral?screenings,?exams,?fluoride?varnish/topical?fluoride?
treatment,?prophylaxis?and?palliative?care?to?treat?an?acute?condition.?State?Board?
regulations?must?still?be?followed?and?patient?records?are?to?be?maintained?in?accordance?
with?State?Board?of?Dentistry?regulations.??

? Providers?utilizing?Mobile?Dental?Vans?must?submit?to?the?MCO?documentation?of?all?
locations?they?will?visit?including?the?days?and?times?(except?when?visit?is?to?homebound?
members).??

Provisions?will?be?granted?for?visits?to?a?Member?s?place?of?residence,?long?term?care?facility,?
skilled?nursing?facility?or?medical?day?care?facility?when?medically?necessary?and?where?available.?
The?contractor?must?monitor?on?an?annual?basis?the?standard?of?dental?care?rendered?and?
ensure?that?needed?referrals?for?dental?treatment?that?cannot?be?provided?by?a?mobile?dental?
practice?occur.??
? ?



??SKYGEN?USA?|?CONFIDENTIAL?&?PROPRIETARY?|?Horizon?NJ?Health?Dental?Program?|?Effective:?1/1/20?
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Provider?Web?Portal?
Dental?services?may?be?provided?in?these?settings?through?the?following?modalities.?Our?Provider?
Web?Portal?offers?quick?access?to?easy?to?use?self?service?tools?for?managing?daily?administration?
tasks.?The?Provider?Web?Portal?offers?you?many?benefits?including:?

? Lower?administrative?and?participation?costs.?
? Faster?payment?through?streamlined?claim?and?authorization?submissions.?
? Real?time?member?eligibility?verification.?
? Immediate?access?to?member?information,?claim?and?authorization?history,?and?payment?

records?at?any?time,?24?hours?a?day,?7?days?a?week.?

Get?Started!?For?help?getting?started?with?
the?Provider?Web?Portal,?call?the?Electronic?
Outreach?Team?at?1?855?434?9239.?

A?web?browser,?internet?connection,?and?a?valid?User?ID?and?password?are?required?for?online?
access.?From?the?Provider?Web?Portal,?providers?and?authorized?office?staff?can?log?in?for?secure?
access?anytime?from?anywhere?and?handle?a?variety?of?day?to?day?tasks,?including:?

? Verify?eligibility?for?multiple?members?simultaneously,?and?review?individual?patient?
treatment?history.?

? Set?up?office?appointment?rosters?that?automatically?verify?eligibility?and?fill?in?claim?
forms?for?online?submission.?

? Submit?claims?and?authorizations?using?pre?filled?electronic?forms?and?data?entry?
shortcuts.?

? Step?through?clinical?guidelines?as?part?of?submitting?authorizations?for?a?quick?indication?
of?whether?a?service?request?is?likely?to?be?approved.?

? Attach?and?securely?send?supporting?documents,?such?as?digital?X?rays,?EOBs,?and?
treatment?plans,?for?no?extra?charge.?

? Generate?a?pricing?estimate?before?submitting?a?claim?for?a?quick?indication?of?whether?a?
service?may?be?denied?and?a?likely?reason?for?denial.?

? Check?the?real?time?status?of?in?process?claims?and?authorizations,?and?review?historical?
payment?records.?

? Review?provider?clinical?profiling?data?relative?to?your?peers.?
? Download?and?print?a?provider?manual,?remittance?reports,?and?more.?

Online?help?is?available?from?every?page?of?the?Provider?Web?Portal,?offering?quick?answers,?
animated?videos,?and?step?by?step?instructions.?
? ?



??SKYGEN?USA?|?CONFIDENTIAL?&?PROPRIETARY?|?Horizon?NJ?Health?Dental?Program?|?Effective:?1/1/20?
29?

Provider?Web?Portal?Registration?
The?Provider?Web?Portal?was?designed?to?help?you?keep?your?administrative?costs?low,?give?you?
immediate?access?to?real?time?information,?and?make?it?fast?and?easy?to?submit?claims?and?
authorizations.?
To?register?for?our?Provider?Web?Portal,?visit?pwp.sciondental.com?and?click?the?provider?login?
link.?On?the?login?page,?click?Register?Now.?
Call?the?Electronic?Outreach?Team?at?1?855?434?9239?to?register?for?the?Provider?Web?Portal.?
As?soon?as?you?register,?you?can?log?in?and?start?using?the?portal.?Quick?and?easy?online?help?is?
just?a?click?away?on?every?page?in?the?portal.??
If?you?don?t?find?answers?to?your?questions,?or?if?you?want?personalized?training?for?yourself?or?
your?office?staff,?call?the?Electronic?Outreach?Team?at?1?855?434?9239.?
? ?



??SKYGEN?USA?|?CONFIDENTIAL?&?PROPRIETARY?|?Horizon?NJ?Health?Dental?Program?|?Effective:?1/1/20?
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Electronic?Payments?
Electronic?Funds?Transfer?(EFT)??
Horizon?NJ?Health?offers?all?providers?the?option?of?Electronic?Funds?Transfer?(EFT)?for?claims?
payments.?With?EFT,?we?can?pay?claims?more?efficiently?and?you?can?receive?payments?faster?
because?funds?are?deposited?directly?into?your?bank?account,?eliminating?the?steps?of?printing?
and?mailing?paper?checks.?To?receive?claims?payments?through?the?EFT?program:?

1. Complete?and?sign?the?EFT?Authorization?Agreement.?The?form?is?included?in?this?manual?
and?is?also?available?from?the?Provider?Web?Portal?at?pwp.sciondental.com.??

2. Include?a?voided?check?with?the?EFT?Authorization?Agreement.?The?transaction?cannot?be?
processed?without?a?voided?check.?

3. Send?the?EFT?Authorization?Agreement?form?and?voided?check?to?Horizon?NJ?Health?by?
fax?or?email:?
? Fax:?1?262?721?0722?
? Email:?providerservices@skygenusa.com?

Allow?up?to?six?weeks?for?the?EFT?program?to?be?implemented?after?we?receive?your?completed?
paperwork.?Once?you?are?enrolled?in?the?EFT?program,?you?will?no?longer?receive?paper?
remittance?statements?through?postal?mail.?Instead,?your?Remittance?Reports?will?be?posted?
online?and?made?available?from?the?Provider?Web?Portal?as?soon?as?your?claims?are?paid:?
pwp.sciondental.com.?
Once?you?are?enrolled?in?the?EFT?program,?notify?us?of?any?changes?to?bank?accounts,?including?
changes?in?Routing?Number?or?Account?Number,?or?if?you?switch?to?a?different?bank.?Use?the?EFT?
Authorization?Agreement?form?to?submit?your?changes.?Allow?up?to?three?weeks?for?changes?to?
be?implemented?after?we?receive?your?change?request.?Horizon?NJ?Health?is?not?responsible?for?
delays?in?payment?if?we?are?not?properly?notified,?in?writing,?of?banking?changes.?
Electronic?Remittance?Reports?
If?you?enroll?in?the?Horizon?NJ?Health?EFT?program,?your?Remittance?Reports?will?be?made?
available?automatically?from?the?Provider?Web?Portal.?For?help?registering?for?the?portal?or?
accessing?your?Remittance?Reports,?call?the?Electronic?Outreach?team?at?1?855?434?9239.?
If?you?prefer?to?receive?paper?checks?rather?than?electronic?funds?transfers,?you?can?still?
eliminate?paper?Remittance?Reports?and?access?your?payment?reports?online.?To?have?quick,?
easy?access?to?Remittance?Reports?as?soon?as?your?claims?are?paid,?send?an?email?message?to?
Provider?Services?to?request?online?Remittance?Reports?at?providerservices@skygenusa.com.??
As?soon?as?the?Provider?Services?team?processes?your?request,?paper?Remittance?Reports?will?no?
longer?be?mailed?to?you.?Your?Remittance?Reports?will?be?available?online?through?the?Provider?
Web?Portal.?For?help,?or?for?more?information?about?electronic?Remittance?Reports,?call?the?
Electronic?Outreach?team?at?1?855?434?9239.?? ?



??SKYGEN?USA?|?CONFIDENTIAL?&?PROPRIETARY?|?Horizon?NJ?Health?Dental?Program?|?Effective:?1/1/20?
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EFT?Authorization?Agreement?
A?copy?of?the?Horizon?NJ?Health?EFT?Authorization?Agreement?form?is?included?on?the?following?
page.?The?form?is?also?available?for?download?from?the?Provider?Web?Portal:?
pwp.sciondental.com.?
Be?sure?to?include?a?voided?check?with?the?EFT?Authorization?Agreement.?The?transaction?cannot?
be?processed?without?a?voided?check.?
Send?the?EFT?Authorization?Agreement?form?and?voided?check?to?Horizon?NJ?Health?by?fax?or?
email:?

? Fax:?1?262?721?0722?
? Email:?providerservices@skygenusa.com?

? ?



??SKYGEN?USA?|?CONFIDENTIAL?&?PROPRIETARY?|?Horizon?NJ?Health?Dental?Program?|?Effective:?1/1/20?
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Eligibility?&?Member?Services?
The?Horizon?NJ?Health?Dental?Program?offers?dental?coverage?for?children?and?pregnant?women?
enrolled?in?the?State?of?New?Jersey?Medicaid?Program,?and?for?adult?members?with?disabilities,?
special?health?needs,?or?who?qualify?on?the?basis?of?financial?need.??
The?Horizon?NJ?Health?Dental?Program?includes?the?following?Medicaid?plans?and?Fully?
Integrated?Dual?Eligible?Special?Needs?Plans?(FIDE?SNP):??

? NJ?FamilyCare?A?
? NJ?FamilyCare?ABP?
? NJ?FamilyCare?B?
? NJ?FamilyCare?C?(requires?$5?copayment)?
? NJ?FamilyCare?D?(requires?$5?copayment)?
? Managed?Long?Term?Services?&?Supports?(MLTSS)?
? Horizon?NJ?TotalCare?(HMO?D?SNP)?

More?detailed?descriptions?of?these?Medicaid?dental?plans?are?available?in?the?Benefit?Plan?
Details?&?Authorization?Requirements?section?beginning?on?page?120.?
If?your?patients?have?questions?about?how?to?enroll?in?the?Horizon?NJ?Health?Dental?Program,?or?
if?they?have?questions?about?loss?of?eligibility,?refer?them?to?their?local?health?department,?or?ask?
them?to?call?Horizon?NJ?Health?Main?Member?Services?at?1?800?682?9090?(TTY/TDD?711).?
? ?



??SKYGEN?USA?|?CONFIDENTIAL?&?PROPRIETARY?|?Horizon?NJ?Health?Dental?Program?|?Effective:?1/1/20?
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Member?ID?Cards?
Members?enrolled?in?Horizon?NJ?Health?receive?blue?and?white?Horizon?NJ?Health?ID?cards?in?
addition?to?the?New?Jersey?Medicaid?Health?Benefit?ID?card?(HBID)?provided?by?the?State?of?New?
Jersey.?
The?Horizon?NJ?Health?ID?cards?contain?the?following?information:?

? Member?name?
? Member?Medicaid?ID?number?
? Primary?Care?Physician?name?and?phone?number?
? Coverage?effective?date?
? Copayment?amounts?(NJ?FamilyCare?C?and?NJ?FamilyCare?D?only)?
? Status?of?member?dental?coverage?(covered?or?not?covered)?
? Mailing?address?for?dental?claims?on?the?back?of?the?card?

Participating?providers?are?responsible?for?verifying?that?members?are?eligible?when?services?are?
rendered?and?for?determining?whether?members?have?other?health?insurance.?Because?it?is?
possible?for?a?member?s?eligibility?status?to?change?at?any?time?without?notice,?presenting?ID?
cards?does?not?guarantee?a?member?s?eligibility,?nor?does?it?guarantee?provider?payment.?
Horizon?NJ?Health?recommends?each?dental?office?make?a?photocopy?of?the?member?s?ID?card?
each?time?treatment?is?provided.?Horizon?NJ?Health?dentists?may?disregard?the?Horizon?NJ?Health?
codes?280,?780,?or?YHZ?prefixes?before?the?Member?Medicaid?ID?number.??

Presenting?a?Horizon?NJ?Health?ID?card?and?
New?Jersey?Medicaid?Health?Benefit?ID?card?
(HBID)?does?not?guarantee?that?a?person?is?
currently?eligible?for?benefits?in?the?Horizon?
NJ?Health?Dental?Program.?

? ?



??SKYGEN?USA?|?CONFIDENTIAL?&?PROPRIETARY?|?Horizon?NJ?Health?Dental?Program?|?Effective:?1/1/20?
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Sample?Horizon?NJ?Health?Member?ID?Cards??
NJ?FamilyCare?

?
Managed?Long?Term?Services?and?Supports?(MLTSS)?

?
Horizon?NJ?TotalCare?(HMO?D?SNP)?

? ?



??SKYGEN?USA?|?CONFIDENTIAL?&?PROPRIETARY?|?Horizon?NJ?Health?Dental?Program?|?Effective:?1/1/20?
35?

Verifying?Member?Eligibility?
To?verify?member?eligibility,?you?can:??

? Log?on?to?Provider?Web?Portal?at?pwp.sciondental.com.?
? Call?Interactive?Voice?Response?(IVR)?eligibility?line?at?1?844?275?8753.?
? Call?Horizon?NJ?Health?Main?Provider?Services?at?1?800?682?9091?

The?Provider?Web?Portal?and?IVR?system?are?both?available?24?hours?a?day,?seven?days?a?week???
giving?you?quick?access?to?information?without?requiring?you?to?wait?for?an?available?Customer?
Service?Representative?during?business?hours.?

Because?a?member?s?eligibility?can?change?
at?any?time?without?prior?notice,?verifying?
eligibility?does?not?guarantee?payment.?

Verifying?Eligibility?via?Provider?Web?Portal?
Our?Provider?Web?Portal?allows?quick,?accurate?verification?of?a?member?s?eligibility?for?covered?
benefits,?as?of?the?date?of?service.?Log?in?using?your?User?ID?and?password?at?
pwp.sciondental.com.?First?time?users?should?contact?the?Electronic?Outreach?Team?at?1?855?
434?9239?to?register?on?the?Provider?Web?Portal.?
For?help?registering?or?using?the?Provider?Web?Portal,?call?the?Electronic?Outreach?Team?at?1?855?
434?9239.?
Once?logged?in,?you?can?quickly?verify?eligibility?for?an?individual?patient?or?for?a?group?of?
patients,?and?you?can?print?an?online?eligibility?summary?report?for?your?records.??
? ?



??SKYGEN?USA?|?CONFIDENTIAL?&?PROPRIETARY?|?Horizon?NJ?Health?Dental?Program?|?Effective:?1/1/20?
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Verifying?Eligibility?via?IVR??
Use?our?Interactive?Voice?Response?(IVR)?system?to?verify?eligibility?for?an?unlimited?number?of?
patients.?Call?1?844?275?8753?and?follow?the?prompts?to?identify?yourself?and?the?patient?whose?
eligibility?you?are?verifying.??
Our?system?analyzes?the?information?entered?and?verifies?the?patient?s?eligibility.?If?the?system?
cannot?verify?the?member?information,?you?will?be?transferred?to?a?Customer?Service?
Representative.?You?also?have?the?option?of?transferring?to?a?Customer?Service?Representative?
after?completing?eligibility?checks,?if?you?have?other?inquiries.?
Specialist?Referrals?
A?patient?who?requires?a?referral?to?a?dental?specialist?can?be?referred?directly?to?any?specialist?
contracted?with?the?Horizon?NJ?Health?Dental?Program?provider?network?without?authorization?
from?Horizon?NJ?Health.?The?dental?specialist?is?responsible?for?obtaining?prior?authorization?for?
services,?as?defined?in?the?Benefit?Plan?Details?&?Authorization?Requirements?section?of?this?
provider?manual?on?page?120.??
If?you?are?unfamiliar?with?the?contracted?specialty?network?for?the?Horizon?NJ?Health?Dental?
Program?or?need?help?locating?a?specialist?provider,?call?Provider?Services?at?1?855?878?5368.?
Appointment?Availability?Standards?
The?Horizon?NJ?Health?Dental?Program?has?established?appointment?time?requirements?to?
ensure?patients?receive?dental?services?within?a?time?period?appropriate?to?their?health?
condition.?We?expect?dental?providers?to?meet?these?appointment?standards?for?a?number?of?
important?reasons,?including:?

? Ensure?patients?receive?the?care?they?need?to?protect?their?health.?
? Maintain?member?satisfaction.?
? Reduce?unnecessary?use?of?alternative?services?such?as?emergency?room?visits.?

Dentists?are?expected?to?meet?the?following?minimum?standards?for?appointment?availability:?
? Routine?appointments.?Routine?preventive?care?and?follow?up?appointments?must?be?

scheduled?within?four?weeks.?Participating?dentists?must?be?available?at?any?time?via?
answering?service?or?covering?dentist.?

? Specialist?referrals.?Specialty?care?appointments?must?be?scheduled?within?60?days?of?
initial?referral?from?the?patient?s?primary?or?general?dentist?or?more?quickly,?if?deemed?
necessary?by?the?primary?dentist.?

? Urgent?care.?Appointments?for?urgently?needed?care?must?be?made?available?within?72?
hours.?

? Emergency?situation.?Provide?care?immediately.?
? ?



??SKYGEN?USA?|?CONFIDENTIAL?&?PROPRIETARY?|?Horizon?NJ?Health?Dental?Program?|?Effective:?1/1/20?
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Horizon?NJ?Health?has?an?ongoing?monitoring?program?in?place?to?ensure?dental?offices?are?
meeting?standards?for?appointment?availability.?Non?compliance?may?result?in?a?Corrective?
Action?Program?(CAP)?for?providers.?
Summary:?Appointment?Availability?Standards?
Appointment?Type? Required?Appointment?Timeline?
Emergency? Provide?care?immediately?
Urgent?dental?care? Within?72?hours?
Specialist?referral? Within?60?days,?or?sooner,?per?request?from?referring?

dentist?
Routine?preventive,?follow?up?visits? Within?four?weeks?

After?Hours?Calls?and?Coverage??
A?true?dental?emergency?is?a?specific?condition?of?the?oral?cavity?or?contiguous?tissues?that?
causes?severe?or?intractable?pain,?and?could?compromise?the?life,?health,?or?safety?of?the?
member?unless?treated?immediately.??
Emergency?symptoms?may?include?the?following:??

? Pain?or?acute?infection?from?a?restorable?or?not?restorable?tooth?
? Pain?resulting?from?injuries?to?the?oral?cavity?and?related?structures?
? Extensive,?abnormal?bleeding?
? Fractures?of?the?maxilla,?mandible,?or?related?structures,?as?well?as?dislocation?of?the?

mandible?
If?members?experience?any?of?these?conditions?or?life?threating?situations,?they?should?go?to?the?
emergency?room?at?their?local?hospital.?Without?a?life?threatening?situation,?members?with?a?
sore?throat,?pain?in?the?ear,?etc.,?should?not?seek?emergency?room?care.??
All?after?hours?calls?for?dental?emergencies?are?handled?by?Horizon?NJ?Health?Main?Member?
Services?between?5?p.m.?and?8?a.m.?ET?at?1?609?203?7095.?Requests?are?routed?to?the?
appropriate?after?hours?Horizon?NJ?Health?nurse?via?the?after?hours?cell?phone.?

Response?Time?Requirements?
All?general?dentists?and?specialty?care?dentists?must?be?available?to?Horizon?NJ?Health?members?
24?hours?a?day,?seven?days?a?week,?as?stated?in?the?contractual?agreement.?General?dentists?and?
specialists?should?make?arrangements?with?an?answering?service?to?receive?calls?during?off?
hours.?Providers?must?respond?to?after?hours?telephone?calls?regarding?dental?care?within?15?
minutes?for?crisis?situations;?45?minutes?for?non?emergent,?symptomatic?issues;?and?same?day?
for?asymptomatic?concerns.??
? ?



??SKYGEN?USA?|?CONFIDENTIAL?&?PROPRIETARY?|?Horizon?NJ?Health?Dental?Program?|?Effective:?1/1/20?
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Response?times?are?contractually?required?and?monitored?by?Horizon?NJ?Health.?If?a?general?
dentist?or?specialist?is?identified?as?noncompliant,?we?make?every?effort?to?educate?the?dentist?
about?response?policies.?Continued?noncompliance?may?result?in?a?Corrective?Action?Program.?
For?information?about?Corrective?Action?Programs?to?address?noncompliance,?contact?Horizon?NJ?
Health?at?1?800?682?9094.?

Summary:?After?Hours?Call?Response?Standards?
After?Hours?Call?Type? Required?Response?Timeline?
Emergency?services? Within?15?minutes?
Non?emergent,?symptomatic?issues? Within?45?minutes?
Asymptomatic?concerns? Within?the?same?day?

Missed?Appointments??
Providers?who?participate?in?the?Horizon?NJ?Health?Dental?Program?are?not?allowed?to?charge?
members?for?missed?appointments.?
If?your?office?sends?letters?or?postcards?to?members?who?miss?appointments,?the?following?
language?may?be?helpful?to?include:?

? ?We?missed?you?when?you?did?not?come?for?your?dental?appointment?on?Month/Date.?
Regular?checkups?are?needed?to?keep?your?teeth?healthy.?Call?us?to?schedule?another?
appointment.??

? ?Please?call?to?reschedule?another?dental?appointment.?Call?us?in?advance?if?you?cannot?
keep?the?appointment.?Missed?appointments?are?very?costly?to?us.?Thank?you?for?your?
help.??

The?Centers?for?Medicare?&?Medicaid?Services?(CMS)?interpret?federal?law?to?prohibit?a?provider?
from?billing?any?Medicaid?Plan?member?for?a?missed?appointment.?In?addition,?your?missed?
appointment?policy?for?members?enrolled?in?the?Horizon?NJ?Health?Dental?Program?cannot?be?
stricter?than?your?policy?for?private?or?commercial?patients.?
If?a?Horizon?NJ?Health?Dental?Program?member?exceeds?your?office?policy?for?missed?
appointments?and?you?choose?to?discontinue?seeing?the?patient,?ask?them?to?contact?Horizon?NJ?
Health?for?a?referral?to?another?dentist.?
? ?



??SKYGEN?USA?|?CONFIDENTIAL?&?PROPRIETARY?|?Horizon?NJ?Health?Dental?Program?|?Effective:?1/1/20?
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Payment?for?Non?Covered?Services?
Non?covered?services?are?any?procedures?deemed?outside?the?benefit?package?per?our?dental?
consultants,?including?those?with?primarily?cosmetic?purposes?and?those?without?dental?
necessity.?
Horizon?NJ?Health?allows?medical?and?dental?supplies,?equipment,?and?other?devices?essential?to?
treat?member?conditions?unless?otherwise?available?at?no?charge?from?community?services?(such?
as?the?American?Cancer?Society?or?other?service?organizations).?
Standard?toothbrushes,?dental?floss,?and?like?items?are?considered?personal?hygiene?items?and?
not?covered?by?the?program.??

Providers?must?inform?patients?in?advance?
and?in?writing?when?a?member?is?
responsible?for?non?covered?services.?

Enrolled?participating?providers?shall?hold?members?and?the?Horizon?NJ?Health?Dental?Program?
harmless?for?the?payment?of?non?covered?services?except?as?provided?in?this?paragraph.?A?provider?
may?bill?a?patient?for?non?covered?services?if?the?provider?obtains?written?agreement?from?the?
patient?in?advance,?before?rendering?the?service.?The?written?agreement?must?indicate:??

? The?services?to?be?provided?(CDT?code);?
? The?Horizon?NJ?Health?Dental?Program?will?not?pay?for?or?be?liable?for?these?services;?and?
? Patient?will?be?financially?liable?for?such?services.?

? ?



??SKYGEN?USA?|?CONFIDENTIAL?&?PROPRIETARY?|?Horizon?NJ?Health?Dental?Program?|?Effective:?1/1/20?
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Prior?Authorization?&?
Documentation?Requirements?
Prior?Authorization?for?Treatment?
The?Horizon?NJ?Health?Dental?Program?has?specific?utilization?criteria,?as?well?as?a?prior?authorization?
review?process,?to?manage?the?utilization?of?services.?Whether?prior?authorization?is?required?for?a?
particular?service,?and?whether?supporting?documentation?is?also?required,?is?defined?in?this?provider?
manual?in?Benefit?Plan?Details?&?Authorization?Requirements?beginning?on?page?120.?
Non?emergency?services?requiring?prior?authorization?should?not?be?started?until?the?
authorization?request?is?reviewed?and?approved?by?a?Horizon?NJ?Health?Dental?Consultant.?Non?
emergency?treatment?started?prior?to?the?determination?of?coverage?will?be?performed?at?the?
financial?risk?of?the?dental?office.?If?coverage?is?denied,?the?treating?dentist?will?be?financially?
responsible?and?may?not?balance?bill?the?member?or?the?Horizon?NJ?Health?Dental?Program.?
Should?a?procedure?need?to?be?initiated?to?relieve?pain?and?suffering?in?an?emergency?situation,?
you?must?provide?treatment?to?alleviate?the?patient?s?condition.?For?more?details?regarding?
emergency?services,?see?Emergency?Treatment?on?page?84.?
Submit?requests?for?prior?authorization?online?through?the?Provider?Web?Portal?
(pwp.sciondental.com),?electronically?in?a?HIPAA?compliant?data?file,?or?via?postal?mail?on?a?paper?
ADA?Dental?Claim?Form.?(See?? ?



??SKYGEN?USA?|?CONFIDENTIAL?&?PROPRIETARY?|?Horizon?NJ?Health?Dental?Program?|?Effective:?1/1/20?
41?

Authorization?Submission?Procedures?on?page?45.)?Any?authorizations?submitted?without?the?
required?documentation?will?be?denied?and?must?be?resubmitted?for?determination.?
Do?not?submit?duplicate?authorizations.?Submitting?duplicate?authorizations?results?in?automated?
system?denials,?slower?claims?processing,?and?delayed?claims?payment.??
Horizon?NJ?Health?will?make?a?decision?on?a?request?for?prior?authorization?within?10?business?
days?from?the?date?we?receive?the?request,?provided?all?information?is?complete.?
Horizon?NJ?Health?will?honor?prior?authorizations?for?365?days?from?the?date?they?are?
determined.?An?authorization?does?not?guarantee?payment.?The?member?must?be?eligible?for?
benefits?at?the?time?services?are?provided.?Horizon?NJ?Health?reviewers?and?licensed?dental?
consultants?approve?or?deny?authorization?requests?based?on?whether:?

? The?item?or?service?is?medically?necessary.?
? A?less?expensive?service?would?adequately?meet?the?member?s?needs.?
? The?proposed?item?or?service?conforms?to?commonly?accepted?standards?in?the?dental?

community.?
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.?
? ?



??SKYGEN?USA?|?CONFIDENTIAL?&?PROPRIETARY?|?Horizon?NJ?Health?Dental?Program?|?Effective:?1/1/20?
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Dental?Treatment?Plan?
Following?a?comprehensive?examination?and?per?good?dental?practice,?providers?should?develop?
and?describe?a?treatment?plan?for?each?patient?on?the?current?ADA?Claim?Form.?Horizon?NJ?
Health?Dental?Consultants?may?review?any?dental?treatment?plan,?including?those?not?requiring?
prior?authorization.?
When?prior?authorization?is?necessary,?a?Horizon?NJ?Health?Dental?Consultant?may?deny?the?
dentist?s?treatment?plan?when?the?treatment?is?not?comprehensive?and/or?is?missing?appropriate?
supporting?documentation.??The?comprehensive?treatment?plan?must?be?based?on?the?New?
Jersey?Administrative?Code?10:56?and?the?State?Clinical?Criteria?Guidelines.?The?treatment?plan?
must?be?designed?to?provide?adequate?dental?treatment?to?correct?problems,?last?for?the?longest?
period?of?time,?and?represent?an?efficient?allocation?of?Horizon?NJ?Health?resources.?If?the?
professional?judgment?of?the?dentist?determines?the?denied?treatment?plan?is?appropriate?for?
the?member,?the?provider?may?appeal?the?denied?authorization.?
For?any?dental?treatment?plan,?the?dentist?must?discuss?the?proposed?treatment?and?receive?
approval?from?the?member?and/or?their?family?member?or?guardian?before?submission?for?
authorization?and?before?starting?treatment.?Horizon?NJ?Health?encourages?providers?to?get?
formal?approval?of?the?treatment?plan?with?a?member?signature?on?office?records?or?in?a?
separate?statement.?No?alteration?of?the?treatment?plan?is?reimbursed?based?on?subsequent?
rejection?of?all?or?part?of?plan?by?the?member,?family?member,?or?guardian.?
Following?post?utilization?review,?Horizon?NJ?Health?Dental?Consultants?may?review?any?dental?
treatment?plan?including?those?not?requiring?prior?authorization?to?determine?
appropriateness?of?treatment.?If?the?treatment?is?not?appropriate,?the?payment?may?be?
recovered.?
Authorization?for?a?dental?treatment?plan?does?not?guarantee?eligibility?for?payment?under?the?
Horizon?NJ?Health?Dental?Program.?Horizon?NJ?Health?recommends?providers?check?eligibility?on?
the?first?visit?of?each?month?through?the?Provider?Web?Portal?or?by?calling?Horizon?NJ?Health?
Main?Provider?Services?at?1?800?682?9091.?
Dental?OR/ASC?Services??
Dental?services?that?are?to?be?performed?outside?your?office,?either?in?an?outpatient?department?
of?a?hospital?or?at?an?ambulatory?surgical?center?(ASC),?must?be?approved?by?Horizon?NJ?Health?
to?ensure?the?services?meet?the?medical?necessity?criteria?for?services?rendered?in?an?outpatient?
facility?(hospital?or?ASC).?See?? ?



??SKYGEN?USA?|?CONFIDENTIAL?&?PROPRIETARY?|?Horizon?NJ?Health?Dental?Program?|?Effective:?1/1/20?
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Authorization?Submission?Procedures?on?page?45?and?Hospital?Calls?on?page?89.?
? ?



??SKYGEN?USA?|?CONFIDENTIAL?&?PROPRIETARY?|?Horizon?NJ?Health?Dental?Program?|?Effective:?1/1/20?
44?

Appealing?an?Authorization?Decision?
If?you?have?questions?about?a?prior?authorization?decision?or?wish?to?speak?to?the?dental?
reviewer,?call?Provider?Services?at?1?855?878?5368.?For?more?about?utilization?management?
appeals,?see?Utilization?Management/Authorization?Appeal?on?page?61.?
If?Horizon?NJ?Health?denies?approval?for?any?requested?service,?the?member?will?receive?written?
notice?of?the?reasons?for?each?denial?and?will?be?notified?of?how?to?appeal?the?decision.?The?
requesting?provider?will?also?receive?notice?of?the?decision.??
To?appeal?an?authorization?decision,?submit?the?appeal?in?writing?along?with?any?necessary?
documentation?within?60?days?of?the?original?determination?date?to:?

Horizon?NJ?Health:?Complaints/Appeals?
PO?Box?295?
Milwaukee,?WI?53201?

Summary:?Prior?Authorization?Timelines?
Authorization?Request? Timeline?
Decision?on?authorization?request? Horizon?NJ?Health?approves?or?denies?request?within?

10?business?days.?
Prior?authorization?expiration? Horizon?NJ?Health?honors?approved?prior?

authorizations?for?365?calendar?days?from?decision?
date.?

Authorization?decision?appeal?Members? Members?must?appeal?within?60?days?of?the?original?
authorization?denial?date.?

Authorization?decision?appeal?Providers? Providers?must?appeal?within?60?days?of?the?original?
authorization?denial?date.?
Providers?must?have?the?member?s?written?consent?
to?appeal?a?decision?on?the?member?s?behalf.?

UM/Authorization?appeal?decision?Non?
expedited?(Internal)?

Horizon?NJ?Health?renders?decision?within?30?
calendar?days?of?receiving?the?appeal.?

UM/Authorization?appeal?decision?Expedited?
(Internal)?

Horizon?NJ?Health?renders?decision?within?72?hours?
of?receiving?the?expedited?appeal.?

? ?



??SKYGEN?USA?|?CONFIDENTIAL?&?PROPRIETARY?|?Horizon?NJ?Health?Dental?Program?|?Effective:?1/1/20?
45?

Authorization?Submission?
Procedures?
Horizon?NJ?Health?accepts?authorizations?submitted?in?any?of?the?following?formats:?

? Provider?Web?Portal?at?pwp.sciondental.com?
? Electronic?submission?via?clearinghouse,?Payer?ID:?22099?
? HIPAA?compliant?837D?file?
? Paper?ADA?Dental?Claim?Form,?available?from?the?American?Dental?Association??

Submitting?Authorizations?via?Provider?Web?Portal?
Providers?may?submit?authorizations?along?with?any?required?treatment?documentation?directly?
to?Horizon?NJ?Health?through?our?Provider?Web?Portal?at?pwp.sciondental.com.??
Submitting?authorizations?via?the?web?portal?has?several?significant?advantages:?

? The?online?dental?form?has?built?in?features?that?automatically?verify?member?eligibility,?
pre?fill?the?authorization?form?with?member?information,?and?make?data?entry?quick?and?
easy.?

? The?online?authorization?process?steps?you?through?clinical?guidelines,?when?applicable,?
giving?you?a?quick?indication?of?how?your?authorization?request?will?be?evaluated?and?
whether?it?s?likely?to?be?approved.?(Successfully?completing?a?clinical?guideline?does?not?
guarantee?payment.)?

? The?online?authorization?process?indicates?whether?supporting?documentation?is?
required?and?allows?you?to?attach?and?send?documents?as?part?of?the?authorization?
request?for?no?charge.?

? Dental?reviewers?and?consultants?receive?your?authorization?requests?and?supporting?
documentation?as?soon?as?you?submit?them?online?which?means?you?receive?decisions?
faster.?

? As?soon?as?an?authorization?is?determined,?its?status?is?instantly?updated?online?and?
available?for?review.?You?don?t?have?to?wait?for?a?letter?to?find?out?whether?your?
authorization?request?is?approved.?

If?you?have?questions?about?submitting?authorizations?online,?attaching?electronic?documents,?or?
accessing?the?Provider?Web?Portal,?call?the?Electronic?Outreach?Team?at?1?855?434?9239.?
? ?



??SKYGEN?USA?|?CONFIDENTIAL?&?PROPRIETARY?|?Horizon?NJ?Health?Dental?Program?|?Effective:?1/1/20?
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Submitting?Authorizations?via?Clearinghouses?
Providers?may?submit?electronic?claims?and?authorizations?to?Horizon?NJ?Health?directly?via?
either?the?Change?Healthcare?(formerly?Emdeon)?or?DentalXChange?clearinghouses.?If?you?use?a?
different?clearinghouse,?your?software?vendor?can?provide?you?with?information?you?may?need?
to?ensure?electronic?files?are?forwarded?to?Horizon?NJ?Health.?
The?Horizon?NJ?Health?Payer?ID?is?22099.?By?using?this?unique?Payer?ID?with?electronic?files,?
Change?Healthcare?(formerly?Emdeon)?and?DentalXChange?can?ensure?that?claims?and?
authorizations?are?submitted?successfully?to?Horizon?NJ?Health.?
For?more?information?about?Change?Healthcare?(formerly?Emdeon)?and?DentalXChange,?visit?
their?websites:?changehealthcare.com?and?dentalxchange.com.?
Submitting?Authorizations?via?837D?File?
If?you?can?t?submit?claims?and?authorizations?electronically?through?the?Provider?Web?Portal?or?a?
clearinghouse,?Horizon?NJ?Health?will?work?with?you?individually?to?receive?electronic?files?
submitted?using?the?HIPAA?Compliant?837D?transaction?set?format.?To?inquire?about?this?option,?
call?Provider?Services?at?1?855?878?5368.??
Attaching?Electronic?Documents?
If?you?use?the?Provider?Web?Portal?(pwp.sciondental.com),?you?can?quickly?and?easily?send?
electronic?documents?as?part?of?submitting?a?claim?or?authorization?for?no?charge.??
Horizon?NJ?Health?also?accepts?dental?radiographs?and?other?documents?electronically?via?Fast?
Attach??for?authorization?requests.?For?more?information,?visit?nea?fast.com?or?call?the?National?
Electronic?Attachment,?Inc.?(NEA)?at?1?800?782?5150.?
Submitting?Authorizations?on?Paper?Forms?
To?ensure?timely?processing?of?submitted?authorizations,?the?following?information?must?be?
included?on?the?current?ADA?Dental?Claim?Form:??

? Member?Name?
? Member?Medicaid?ID?Number??
? Member?Date?of?Birth?
? Provider?Name?
? Provider?Location?
? Billing?Location?
? Provider?NPI??
? Payee?Tax?Identification?Number?(TIN)?

? ?



??SKYGEN?USA?|?CONFIDENTIAL?&?PROPRIETARY?|?Horizon?NJ?Health?Dental?Program?|?Effective:?1/1/20?
47?

Use?approved?ADA?dental?codes,?as?published?in?the?current?CDT?book?or?as?defined?in?this?
manual,?to?identify?all?services.?Include?on?the?form:?all?quadrants,?tooth?numbers,?and?surfaces?
for?dental?codes?that?require?identification?(extractions,?root?canals,?amalgams,?and?resin?fillings).??
Horizon?NJ?Health?recognizes?tooth?letters?A?through?T?for?primary?teeth?and?tooth?numbers?1?to?
32?for?permanent?teeth.?Designate?supernumerary?teeth?with?codes?AS?through?TS?or?51?through?
82.?Designation?of?the?tooth?can?be?determined?by?using?the?nearest?erupted?tooth.?If?the?tooth?
closest?to?the?supernumerary?tooth?is?1,?then?chart?the?supernumerary?tooth?as?51.?Likewise,?if?
the?nearest?tooth?is?A,?chart?the?supernumerary?tooth?as?AS.??
Missing,?incorrect,?or?illegible?information?could?result?in?the?authorization?being?returned?to?the?
submitting?provider?s?office,?causing?a?delay?in?determination.?Use?the?proper?postage?when?
mailing?bulk?documentation.?Mail?with?postage?due?will?be?returned.??
No?X?Ray?Return?Policy.?Providers?should?maintain?copies?of?all?dental?prior?authorization?forms?
and?supporting?documentation,?including?X?rays.?X?rays?and?other?documentation?are?shredded?
and?not?returned.?
Mail?paper?authorizations?to:?

Horizon?NJ?Health:?Authorizations?
PO?Box?362?
Milwaukee,?WI?53201?

Duplicate?Authorizations?Automatically?Denied?
Do?not?submit?duplicate?authorizations.?Submitting?duplicate?authorization?incurs?unnecessary?
administrative?costs?for?providers.?When?authorizations?are?processed,?they?are?automatically?
checked?to?verify?required?documentation?is?on?file.?Approved?authorizations?are?then?
automatically?matched?against?corresponding?claims,?ensuring?claims?are?paid?accurately?and?
efficiently.?Duplicate?authorizations?are?automatically?denied?and?result?in?slower?claims?
processing?and?delayed?claims?payment.??
For?the?fastest,?most?efficient?authorization?determinations?and?claim?payments,?be?sure?to:?

? Submit?just?one?original?authorization?with?all?required?documentation?attached,?and??
? Include?a?comprehensive?treatment?plan?because?a?fragmented?plan?will?be?denied.?



??SKYGEN?USA?|?CONFIDENTIAL?&?PROPRIETARY?|?Horizon?NJ?Health?Dental?Program?|?Effective:?1/1/20?
48?

ADA?Approved?Dental?Claim?Form?

?



??SKYGEN?USA?|?CONFIDENTIAL?&?PROPRIETARY?|?Horizon?NJ?Health?Dental?Program?|?Effective:?1/1/20?
49?

?
?



??SKYGEN?USA?|?CONFIDENTIAL?&?PROPRIETARY?|?Horizon?NJ?Health?Dental?Program?|?Effective:?1/1/20?
50?

Claim?Submission?Procedures?
Horizon?NJ?Health?accepts?claims?submitted?in?any?of?the?following?formats:?

? Provider?Web?Portal?at?pwp.sciondental.com?
? Electronic?submission?via?clearinghouse,?Payer?ID:?22099?
? HIPAA?compliant?837D?file?
? Paper?ADA?Dental?Claim?Form,?available?from?the?American?Dental?Association??

Submitting?Claims?via?Provider?Web?Portal?
Providers?may?submit?claims?directly?to?Horizon?NJ?Health?through?the?Provider?Web?Portal?at?
pwp.sciondental.com.?Submitting?claims?via?the?web?portal?has?several?significant?advantages:?

? The?online?dental?form?has?built?in?features?that?automatically?verify?member?eligibility,?
pre?fill?the?claim?form?with?member?information,?and?make?data?entry?quick?and?easy.?

? The?online?process?allows?you?to?attach?and?send?electronic?documents?as?part?of?
submitting?a?claim?for?no?charge.?

? Before?submitting?a?claim?or?before?rendering?services?you?can?generate?an?online?
claim?estimate?to?find?out?how?much?you?are?likely?to?be?paid?or?whether?your?claim?may?
be?denied?and?the?reasons?why.?

? Claims?enter?our?benefits?administration?system?faster?which?means?you?receive?
payment?faster.?

? As?soon?as?a?claim?is?paid,?its?status?is?instantly?updated?online,?and?a?Remittance?Report?
is?available?for?review.??

If?you?have?questions?about?submitting?claims?online,?attaching?electronic?documents,?or?
accessing?the?Provider?Web?Portal,?call?the?Electronic?Outreach?Team?at?1?855?434?9239.??
Submitting?Claims?via?Clearinghouses?
Providers?may?submit?electronic?claims?and?authorizations?to?Horizon?NJ?Health?directly?via?
either?the?Change?Healthcare?(formerly?Emdeon)?or?DentalXChange?clearinghouses.?If?you?use?a?
different?clearinghouse,?your?software?vendor?can?provide?you?with?information?you?may?need?
to?ensure?electronic?files?are?forwarded?to?Horizon?NJ?Health.?
The?Horizon?NJ?Health?Payer?ID?is?22099.?By?using?this?unique?Payer?ID?with?electronic?files,?
Change?Healthcare?(formerly?Emdeon)?and?DentalXChange?can?ensure?that?claims?and?
authorizations?are?submitted?successfully?to?Horizon?NJ?Health.?
For?more?information?about?Change?Healthcare?(formerly?Emdeon)?and?DentalXChange,?visit?
their?websites?at?changehealthcare.com?and?dentalxchange.com.?
? ?



??SKYGEN?USA?|?CONFIDENTIAL?&?PROPRIETARY?|?Horizon?NJ?Health?Dental?Program?|?Effective:?1/1/20?
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Submitting?Claims?via?HIPAA?Compliant?837D?File?
If?you?can?t?submit?claims?and?authorizations?electronically?through?the?Provider?Web?Portal?or?a?
clearinghouse,?Horizon?NJ?Health?will?work?with?you?individually?to?receive?electronic?files?
submitted?using?the?HIPAA?Compliant?837D?transaction?set?format.?To?inquire?about?this?option,?
call?Provider?Services:?1?855?878?5368.?
Attaching?Electronic?Documents?
If?you?use?the?Provider?Web?Portal?(pwp.sciondental.com),?you?can?quickly?and?easily?send?electronic?
documents?as?part?of?submitting?a?claim?or?authorization?for?no?charge.?Horizon?NJ?Health,?in?
conjunction?with?NEA?(National?Electronic?Attachment,?Inc.),?also?allows?enrolled?providers?to?submit?
documents?electronically?via?FastAttach?.?This?program?allows?secure?transmissions?of?radiographs,?
periodontics?charts,?intraoral?pictures,?narratives,?and?Explanation?of?Benefits?(EOBs).?FastAttach??is?
compatible?with?most?claims?clearinghouses?and?practice?management?systems.?For?more?
information,?visit?nea?fast.com?or?call?NEA?at?1?800?782?5150.?
Submitting?Claims?on?Paper?Forms?
To?ensure?timely?processing?of?paper?claims,?the?following?information?must?be?included?on?the?
current?ADA?Dental?Claim?Form:??

? Member?Name?
? Member?Medicaid?ID?Number??
? Member?Date?of?Birth?
? Provider?Name?
? Provider?Location?
? Billing?Location?
? Provider?NPI??
? Payee?Tax?Identification?Number?(TIN)?
? Date?of?Service?for?each?service?line?

Use?approved?ADA?dental?codes,?as?published?in?the?current?CDT?book?or?as?defined?in?this?
manual,?to?identify?all?services.?Include?on?the?form:?all?quadrants,?tooth?numbers,?and?surfaces?
for?dental?codes?that?require?identification?(extractions,?root?canals,?amalgams?and?resin?fillings).??
Horizon?NJ?Health?recognizes?tooth?letters?A?through?T?for?primary?teeth?and?tooth?numbers?1?to?
32?for?permanent?teeth.?Designate?supernumerary?teeth?with?codes?AS?through?TS?or?51?through?
82.?Designation?of?the?tooth?can?be?determined?by?using?the?nearest?erupted?tooth.?If?the?tooth?
closest?to?the?supernumerary?tooth?is?1,?then?chart?the?supernumerary?tooth?as?51.?Likewise,?if?
the?nearest?tooth?is?A,?chart?the?supernumerary?tooth?as?AS.?Missing,?incorrect,?or?illegible?
information?could?result?in?the?claim?being?returned?to?the?submitting?provider?s?office,?causing?a?
delay?in?payment.?Use?the?proper?postage?when?mailing?bulk?documentation.?Mail?with?postage?
due?will?be?returned.?Mail?paper?claims?to:?

Horizon?NJ?Health:?Claims?
PO?Box?299?
Milwaukee,?WI?53201? ?



??SKYGEN?USA?|?CONFIDENTIAL?&?PROPRIETARY?|?Horizon?NJ?Health?Dental?Program?|?Effective:?1/1/20?
52?

Coordination?of?Benefits?(COB)?
The?Horizon?NJ?Health?Dental?Program?is?the?payer?of?last?resort.?When?a?member?arrives?for?an?
appointment,?always?ask?if?they?have?other?dental?insurance?coverage.??
When?the?Horizon?NJ?Health?Dental?Program?is?the?secondary?insurance?carrier,?submit?a?copy?of?
the?primary?carrier?s?Explanation?of?Benefits?(EOB)?with?the?claim.?For?electronic?claim?
submissions,?indicate?the?payment?made?by?the?primary?carrier?in?the?appropriate?Coordination?
of?Benefits?(COB)?field,?and?attach?an?electronic?copy?of?the?EOB.??
When?a?primary?carrier?s?payment?meets?or?exceeds?a?provider?s?contracted?rate?or?fee?
schedule,?the?Horizon?NJ?Health?Dental?Program?will?consider?the?claim?paid?in?full?and?no?
further?payment?will?be?made?on?the?claim.?
Timely?Filing?Limits?
Horizon?NJ?Health?must?receive?claims?requesting?payment?within?180?calendar?days?from?the?
date?of?service.?Claims?submitted?more?than?180?calendar?days?from?the?date?of?service?will?be?
denied?for??untimely?filing.??If?a?claim?is?denied?for?untimely?filing,?you?may?not?bill?the?member.??
Timely?filing?for?corrected?claim?submissions?is?365?days?from?the?date?of?service.?
Corrected?Claim?Process?
If?a?claim?or?a?service?line?is?denied?because?information?was?missing?from?the?submitted?claim,?
or?if?you?have?additional?information?or?documentation?that?you?believe?may?change?the?
payment?decision,?simply?resubmit?the?claim?and?include?the?missing?information.??
For?example,?resubmit?a?claim?with?additional?information?if?a?service?was?denied?because?of?a?
missing?tooth?number?or?surface,?or?if?a?claim?was?denied?because?documentation?showing?
medical?necessity?was?not?originally?submitted.?
However,?if?a?service?line?on?a?claim?was?paid?that?should?not?have?been?paid?or?if?a?claim?was?
paid?to?the?wrong?payee?or?on?behalf?of?the?wrong?member,?then?submit?a?new??Corrected??
claim?to?reverse?the?incorrect?payment?and?reprocess?the?claim?with?the?corrected?information.??
For?example,?if?a?claim?is?submitted?and?paid?with?the?wrong?provider?NPI?or?clinic?location,?
incorrect?payee?Tax?ID,?wrong?member,?incorrect?procedure?code,?etc.,?then?the?paid?claim?must?
be?corrected?and?reprocessed.?
Resubmitting?a?Denied?Claim?
To?resubmit?a?denied?claim?with?additional?supporting?information,?follow?the?standard?Claim?
Submission?Procedures?on?page?50?of?this?provider?manual.?Timely?filing?limitations?apply?when?
a?claim?is?resubmitted?for?reprocessing.?
? ?



??SKYGEN?USA?|?CONFIDENTIAL?&?PROPRIETARY?|?Horizon?NJ?Health?Dental?Program?|?Effective:?1/1/20?
53?

Submitting?a?Corrected?Claim?
To?reverse?and?correct?a?payment?that?should?not?have?been?made,?submit?a?corrected?claim?on?
the?current?ADA?Dental?Claim?Form?via?postal?mail.?

? Identify?the?claim?as?Corrected?by?writing??Corrected??across?the?top?of?a?paper?claim?
form.??

? Identify?the?original?Claim/Encounter?Number?and?the?intended?change?by?writing?them?
in?the?Remarks?section?(Box?35)?on?a?paper?ADA?form.?

? Attach?supporting?documentation,?and?send?documentation?in?the?same?package?with?
the?paper?claim?form.?

Send?paper?forms?and?documents?to:?
Horizon?NJ?Health:?Corrected?Claims?
PO?Box?541?
Milwaukee,?WI?53201?

Receipt?&?Audit?of?Claims?
To?ensure?timely,?accurate?payment?to?each?participating?provider,?Horizon?NJ?Health?audits?
claims?for?completeness?as?they?are?received.?This?audit?validates?member?eligibility,?procedure?
codes,?and?provider?identification?information.?A?Dental?Reimbursement?Analyst?reviews?any?
claim?conditions?that?would?result?in?nonpayment.?When?potential?problems?are?identified,?your?
office?may?be?asked?to?help?resolve?the?issue.?For?questions?about?claims?submission?or?
remittances,?call?Provider?Services?at?1?855?878?5368.?
Claims?Adjudication?&?Payment?
The?Horizon?NJ?Health?software?system?imports?claim?and?authorization?data,?evaluates?and?
edits?the?data?for?completeness?and?correctness,?analyzes?the?data?for?clinical?appropriateness?
and?coding?correctness,?evaluates?services?against?plan?coverage?and?benefit?limits,?calculates?
the?appropriate?payment?amounts,?and?generates?payments?and?remittance?summaries.?The?
system?also?evaluates?and?automatically?matches?claims?and?services?against?prior?authorizations?
and?matches?claims?and?services?to?the?appropriate?member?record?for?efficient?and?accurate?
claims?processing.?
As?soon?as?the?system?prices?and?pays?claims,?checks?and?electronic?payments?are?generated,?
and?remittance?summaries?are?posted?and?available?for?online?review?from?the?Provider?Web?
Portal?at?pwp.sciondental.com.?
To?appeal?a?reimbursement?decision,?submit?the?appeal?in?writing?within?90?calendar?days?of?the?
decision?date,?along?with?any?necessary?documentation?to:?

Horizon?NJ?Health:?Complaints/Appeals?
PO?Box?295?
Milwaukee,?WI?53201?

? ?



??SKYGEN?USA?|?CONFIDENTIAL?&?PROPRIETARY?|?Horizon?NJ?Health?Dental?Program?|?Effective:?1/1/20?
54?

Total?Maximum?Payment?Allowance??
If?a?member?receives?care?from?more?than?one?provider?as?part?of?a?partnership?or?corporation?
in?the?same?discipline?for?the?same?service,?the?total?maximum?payment?allowance?is?the?same?
as?that?for?a?single?attending?dentist.?The?allowance?fee?for?a?given?service?is?considered?full?
payment.?Horizon?NJ?Health?does?not?allow?any?additional?charge?by?the?dentist?or?on?behalf?of?
the?member.?
The?Horizon?NJ?Health?Dental?Program?pays?a?fee?only?for?eligible?services?rendered.?If?a?member?
does?not?complete?the?treatment?plan,?providers?may?bill?only?for?those?services?already?performed.??
Stage?of?Completion??
If?a?provider?cannot?complete?a?service?and/or?an?authorized?appliance?for?a?member?due?to?
circumstances?beyond?their?control,?Horizon?NJ?Health?reimburses?the?provider?an?amount?
consistent?with?the?stage?of?completion?of?the?authorized?service?and/or?appliance.?The?current?
ADA?Claim?Form?must?document?the?stage?of?completion?of?the?service.?For?an?appliance,?
denture,?or?crown,?a?Horizon?NJ?Health?Dental?Consultant?reviews?and?prorates?the?case?
respective?to?the?point?of?completion.?The?case?is?then?sent?to?the?provider?to?retain?for?at?least?
one?year,?pending?the?possible?return?of?the?member.?
Partial?Reimbursement??
Horizon?NJ?Health?may?authorize?partial?reimbursement?for?an?appliance?that?is?completed?but?
not?delivered?to?the?member?due?to?circumstances?beyond?the?control?of?the?provider.?We?
deduct?an?amount?equivalent?to?the?professional?component?for?inserting?and?adjusting?the?
appliance?from?the?total?reimbursement?for?such?an?appliance.?If?the?member?returns?to?the?
provider?and?the?service?is?completed,?the?healthcare?professional?may?request?reimbursement?
for?the?deducted?amount.??
Prorated?Basis?for?Dental?Services?
Horizon?NJ?Health?will?pay?on?a?prorated?basis?for?dental?services?that?have?a?dental?lab?
component,?including?cast?crowns,?fixed?and?removable?prosthetics,?retainers,?and?habit?
appliances?based?on?stage?of?completion,?if?an?enrollee?dies?or?does?not?return?to?complete?
these?services?within?three?months?from?the?last?office?visit?for?that?service.??

? For?cast?restorative?and?fixed?prosthodontics,?the?prorate?shall?be?10?percent?of?the?total?
payment?for?preparation?of?tooth?with?or?without?temporary,?85?percent?of?the?total?
payment?for?impression?and?95?percent?of?the?total?payment?for?completed?not?inserted.??

? For?removable?prosthodontics,?the?prorate?shall?be?10?percent?of?the?total?payment?for?
impression,?55?percent?of?the?total?payment?for?bite?registration,?75?percent?of?the?total?
payment?for??try?in??stage?and?85?percent?of?the?total?payment?for?completed?not?
inserted.??

? For?appliances?and?retainers,?the?prorate?shall?be?10?percent?of?the?total?pay.??
This?information?will?be?available?in?the?Member?Handbook?and?by?visiting?horizonNJhealth.com/for?
providers.? ?



??SKYGEN?USA?|?CONFIDENTIAL?&?PROPRIETARY?|?Horizon?NJ?Health?Dental?Program?|?Effective:?1/1/20?
55?

Missed?Appointments??
Horizon?NJ?Health?does?not?reimburse?for?missed?appointments?and?does?not?allow?a?provider?to?
bill?a?member?for?any?payment.?For?more?information,?see?Missed?Appointments?on?page?38.?
Period?of?Eligibility??
Reimbursement?for?dental?treatment?can?be?made?only?during?the?period?of?member?eligibility.?
However,?exceptions?are?available?under?certain?circumstances.??
Eligibility?Exceptions??
When?authorized?and?in?process?of?being?rendered?for?an?eligible?member,?the?provider?may?bill?
for?the?following?treatments?if?all?services?are?completed?within?60?calendar?days?after?the?
termination?of?a?member?s?eligibility:?

? Prostheses,?such?as?dentures,?crowns,?space?maintainers,?and?appliances,?in?process?of?
fabrication.?

? Extractions?and?ancillary?services,?such?as?general?anesthesia?and?radiographs,?in?
conjunction?with?the?insertion?of?an?immediate?denture?if?initial?impressions?were?taken?
during?a?period?of?eligibility.?

? Endodontic?treatment?with?pulp?extirpated,?as?well?as?those?services?necessary?to?
complete?the?restoration?of?that?tooth,?such?as?filling?restorations?or?post?and?core?and?
crown,?if?authorized?during?a?period?of?eligibility.?

Dentures??
Horizon?NJ?Health?reimburses?for?dentures?furnished?after?termination?of?eligibility?when?the?last?
tooth?in?any?specific?arch?is?extracted?during?a?period?of?eligibility.?

? The?provider?may?furnish?a?complete?or?partial?denture?in?the?opposing?arch?if?it?meets?
the?guidelines?of?the?program?and?is?authorized?in?conjunction?with?such?a?denture.?

? To?receive?reimbursement?for?the?denture,?the?provider?must?initiate?the?primary?
impressions?within?120?days?and?insert?the?denture?within?180?days?after?the?extraction?
of?the?last?tooth.?Prior?authorization?procedures?apply.?

Immediate?Dentures??
For?immediate?dentures,?similar?to?procedures?for?dentures?inserted?after?the?healing?period,?
the?provider?must?obtain?prior?authorization?during?the?eligibility?period?and?complete?all?
preliminary?extractions?within?the?same?time?frame.?The?provider?must?complete?authorized?
complete?or?partial?dentures,?in?conjunction?with?immediate?replacement?codes,?within?180?days?
after?termination?of?eligibility.?

? The?provider?may?furnish?a?complete?or?partial?denture?in?the?opposing?arch?if?it?meets?
the?guidelines?of?the?program?and?is?authorized?in?conjunction?with?such?a?denture.?

? To?receive?reimbursement?for?this?denture,?the?provider?must?initiate?the?primary?
impression?within?120?days?and?insert?the?denture?within?180?days?after?the?last?
preliminary?extraction.?Prior?authorization?procedures?apply.?

? ?



??SKYGEN?USA?|?CONFIDENTIAL?&?PROPRIETARY?|?Horizon?NJ?Health?Dental?Program?|?Effective:?1/1/20?
56?

Third?Party?Liability?(TPL)?
When?available,?the?provider?must?utilize?and?report?any?other?public?or?private?third?party?
sources?of?payment?for?services?rendered?to?members.?As?a?Medicaid?plan,?Horizon?NJ?Health?is?
always?the?payer?of?last?resort.?Submit?all?claims?to?the?appropriate?third?party?first?before?
submitting?claims?to?Horizon?NJ?Health.?
If?the?provider?determines?that?the?third?party?will?neither?pay?nor?provide?the?covered?service,?
and?the?service?is?medically?necessary,?dentists?may?bill?Horizon?NJ?Health?without?a?written?
denial?from?the?third?party.?

? The?provider?must?notify?Horizon?NJ?Health?within?30?days?after?learning?a?member?has?
third?party?health?insurance?coverage?beyond?the?Horizon?NJ?Health?insurance.?Also,?
notify?Horizon?NJ?Health?of?any?casualty?insurance?coverage?or?any?change?in?the?
member?s?health?insurance?coverage.?

? If?a?member?retains?counsel?who?institutes?a?legal?cause?of?action?for?damages?against?a?
third?party,?the?provider?must?notify?Horizon?NJ?Health?in?writing.?This?notification?must?
include?the?member?s?name,?Member?Medicaid?ID?number,?date?of?accident?or?incident,?
nature?of?injury,?name?and?address?of?the?member?s?legal?representative,?copies?of?
pleadings,?and?any?other?document?related?to?the?action?in?possession?of?the?provider.?
This?information?may?include,?but?not?be?limited?to,?data?for?each?date?of?service?on?or?
subsequent?to?the?date?of?the?accident?or?incident,?the?member?diagnosis,?and?the?
nature?of?any?service?provided?to?the?member.?

? Providers?must?notify?Horizon?NJ?Health?within?30?days?of?the?date?when?they?learn?of?
the?death?of?a?Medicaid?member?age?55?or?older,?including?the?member?s?full?name,?
Social?Security?Number,?Member?Medicaid?ID?number,?and?date?of?death.?

? To?maximize?the?collection?of?third?party?payments,?the?provider?must?agree?to?
cooperate?with?Horizon?NJ?Health?and?State?efforts?to?offer?Horizon?NJ?Health?any?
updates?to?the?information?required?in?this?section?of?the?manual.?

? ?



??SKYGEN?USA?|?CONFIDENTIAL?&?PROPRIETARY?|?Horizon?NJ?Health?Dental?Program?|?Effective:?1/1/20?
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Complaints,?Grievances?&?
Appeals?
The?Horizon?NJ?Health?Dental?Program?is?committed?to?providing?high?quality?dental?services?to?
all?members.?As?part?of?that?commitment,?we?offer?both?providers?and?members?the?opportunity?
submit?complaints?about?care?or?services?received,?and?to?submit?appeals?requesting?adverse?
decisions?be?reviewed?and?reconsidered.??
Horizon?NJ?Health?provides?both?members?and?providers?a?copy?of?their?appeal?rights?with?each?
pre??or?post?service?denial.?A?designated?Horizon?NJ?Health?Appeals?Specialist?is?dedicated?to?the?
expedient,?satisfactory?resolution?of?both?provider?and?member?complaint?and?appeals.?
Our?procedures?for?handling?and?resolving?complaints?and?appeals?are?designed?to:??

? Ensure?fair,?just,?and?speedy?resolutions?by?working?cooperatively?with?providers?and?
supplying?any?documentation?related?to?complaints?and/or?appeals,?upon?request.?

? Treat?providers?and?members?with?dignity?and?respect?at?all?levels?of?the?complaints?and?
appeals?resolution?process.?

? Inform?providers?and?members?of?their?full?rights?as?they?relate?to?complaint?and?appeal?
resolutions,?including?their?rights?of?appeal?at?each?step?in?the?process.?

? Resolve?complaints?and?appeals?in?a?satisfactory?and?acceptable?manner?within?the?
Horizon?NJ?Health?Dental?Program?protocol.?

? Comply?with?all?regulatory?guidelines?and?policies?with?respect?to?complaints?and?
appeals.?

? Efficiently?monitor?the?resolution?of?complaints,?to?allow?for?tracking?and?identifying?
unacceptable?patterns?of?care?over?time.?

Differences?sometimes?arise?between?dental?providers?and?insurers?or?their?benefit?
administrators?regarding?prior?authorization?determinations?and?payment?decisions.?Since?many?
of?these?issues?result?from?misunderstanding?of?service?coverage,?processing?policy,?or?payment?
levels,?we?encourage?providers?to?contact?us?for?explanations?and?education.?For?assistance,?call?
Provider?Services?at?1?855?878?5368.?
Horizon?NJ?Health?will?never?penalize?any?provider?or?member?for?filing?a?complaint,?grievance,?
or?appeal.?We?are?committed?to?resolving?disputes?and?appeals?promptly,?with?a?fair?and?full?
investigation?and?resolution.?
? ?



??SKYGEN?USA?|?CONFIDENTIAL?&?PROPRIETARY?|?Horizon?NJ?Health?Dental?Program?|?Effective:?1/1/20?
58?

Making?a?Complaint?
If?providers?or?members?are?dissatisfied?with?care?or?services?received,?they?may?make?a?
complaint?by?calling?a?toll?free?number?or?by?sending?a?written?description?of?the?issue.?
Telephone?inquiries?will?be?answered?on?the?same?day?or?within?one?business?day.?
If?we?can?resolve?a?non?urgent?complaint?within?five?business?days,?we?will?notify?you?of?the?
decision?by?telephone.?If?we?can?t?reach?you?(or?the?member)?by?phone,?we?will?send?written?
notification?within?30?calendar?days.?
? Resolution?Timeline?
Complaint? Resolved?with?verbal?notification?within?5?business?days?or?written?

notification?within?30?calendar?days.?
Grievance? Complaint?not?resolved?within?5?business?days?is?considered?a?grievance.?

Resolved?with?written?notification?within?30?calendar?days.?
If?a?complaint?cannot?be?resolved?within?five?business?days,?we?classify?it?as?a??grievance,??and?
we?send?you?written?notification?of?the?resolution?within?30?calendar?days.??
Verbal?complaints?
To?initiate?a?verbal?complaint?about?care?or?services?received,?call?Horizon?NJ?Health?Customer?
Service:?

PROVIDERS:?? 1?800?682?9091?
MEMBERS:?? 1?800?682?9090?

Complaints?mailing?address?
Send?a?written?complaint?to:?

Horizon?NJ?Health:?Complaints/Appeals?
PO?Box?295?
Milwaukee,?WI?53201?

? ?



??SKYGEN?USA?|?CONFIDENTIAL?&?PROPRIETARY?|?Horizon?NJ?Health?Dental?Program?|?Effective:?1/1/20?
59?

Submitting?Appeals?
An?appeal?is?a?request?for?a?decision?to?be?reviewed?and?reconsidered.?Horizon?NJ?Health?has?
defined?several?different?types?of?appeals,?and?each?type?has?its?own?timelines,?requirements,?
and?processes,?described?below?and?on?the?following?pages.?
Types?of?appeals?include:?

? Claims?Payment?Appeal?
? Utilization?Management/Authorization?Appeal?

Expedited?Appeals?
If?a?member?is?in?pain?or?at?a?high?health?risk,?providers?or?members?may?request?an?expedited?
appeal,?either?verbally?or?in?writing.?For?an?expedited?verbal?request,?call?1?855?878?5371??
(TTY:?1?800?508?6975).?Horizon?NJ?Health?will?make?a?decision?as?soon?as?possible,?within?a?
maximum?of?72?hours?after?receiving?the?request?for?an?expedited?appeal.?
Appeal?Submission?Guidelines?
Appeals?may?be?submitted?by?providers,?by?members,?and?may?also?be?requested?by?
representatives?who?are?authorized?to?appeal?on?behalf?of?a?member,?such?as?a?lawyer,?parent?or?
guardian,?dental?provider,?or?other?authorized?representative.?Horizon?NJ?Health?provides?both?
members?and?providers?copies?of?their?appeal?rights?with?each?pre??or?post?service?denial.?
To?be?considered,?appeals?must?be?submitted?within?defined?timelines.?The?timelines?for?each?
type?of?appeal?are?summarized?on?the?following?pages.?
Providers:?

? Must?submit?all?appeal?requests?in?writing,?unless?the?request?is?expedited.?
? May?submit?a?utilization?management?appeal?on?behalf?of?a?member,?with?the?

member?s?written?consent.?Written?member?consent?can?be?waived?when?the?request?is?
for?an?expedited?resolution.?

? May?submit?only?one?utilization?management?appeal?for?a?particular?case.?The?appeal?
may?be?on?the?provider?s?behalf?or?the?member?s?behalf,?but?not?both.?

? May?request?written?documentation?for?the?clinical?rationale?Horizon?NJ?Health?used?to?
make?appeal?decisions.?

Members:?
? May?submit?appeal?requests?verbally?or?in?writing.??
? May?call?Horizon?NJ?Health?Main?Member?Services?for?help?with?complaints?or?appeals?

at?1?877?765?4325.?
? May?revoke?consent?for?a?provider?to?appeal?on?their?behalf?at?any?time.?

? ?



??SKYGEN?USA?|?CONFIDENTIAL?&?PROPRIETARY?|?Horizon?NJ?Health?Dental?Program?|?Effective:?1/1/20?
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Documentation?Requirements?
Regardless?of?the?level?or?type?of?appeal,?the?following?information?must?be?included?with?each?
appeal?request:?

? Name,?address,?phone?number?of?the?provider?or?member?making?the?appeal?
? Member?Medicaid?ID?
? Dates?of?service?
? Names?of?providers?and/or?facilities?involved?in?the?situation?
? Description?and?specific?details?about?the?actions?or?decision?in?question?
? Reason?for?the?appeal?
? Desired?outcome?from?the?appeal?
? Supporting?documentation?(including?dental?record,?X?rays,?treatment?notes,?etc.)?
? Signed?member?consent?form?(if?applicable)?

Continuation?of?Benefits?
Services?are?covered?while?an?appeal?is?pending.?If?the?appeal?is?denied,?the?member?may?be?
required?to?pay?for?the?cost?of?these?services.??
To?request?continuation?of?benefits?while?a?Medicaid?Fair?Hearing?is?pending,?members?must?
submit?a?request?in?writing?within?10?days?of?receiving?notification?of?a?denied?appeal.?If?the?Fair?
Hearing?appeal?is?denied,?the?member?may?be?required?to?pay?for?the?cost?of?the?services.?
? ?



??SKYGEN?USA?|?CONFIDENTIAL?&?PROPRIETARY?|?Horizon?NJ?Health?Dental?Program?|?Effective:?1/1/20?
61?

Claims?Payment?Appeal?
If?you?are?dissatisfied?with?the?reimbursement?amount?or?timeliness?of?a?claims?payment,?you?
may?file?an?internal?claims?payment?appeal?within?90?calendar?days?after?receiving?notification?of?
the?claim?determination.?Submit?your?written?claim?appeal?on?the?appropriate?Department?of?
Banking?and?Insurance?(DOBI)?claim?form?(state.jn.us/dobi).?
The?ADR?organization?s?arbitrator?will?make?a?decision?within?30?calendar?days?after?receiving?all?
documentation?necessary?for?the?review.?The?arbitrator?s?decision?is?binding?and?cannot?be?
appealed.?Horizon?NJ?Health?may?change?the?ADR?arbitrator?at?any?time.?
Claims?Payment?Appeal?Timelines?
Stage? Appeal?Submission?Timeline? Resolution?Timeline?
One? Submit?appeal?on?DOBI?claim?form?within?90?

days?of?receiving?claim?dispute?resolution.?
Resolved?within?30?days.?

All?days?refer?to?calendar?days.?

Internal?review?
To?appeal?the?resolution?of?a?claim?dispute,?send?the?applicable?DOBI?appeal?form?and?
supporting?documentation?to:?

Horizon?NJ?Health:?Complaints/Appeals?
PO?Box?295?
Milwaukee,?WI?53201?

Utilization?Management/Authorization?Appeal?
Any?provider?or?member?who?has?questions?or?is?not?satisfied?with?a?utilization?management?
decision?may?request?to?speak?personally?with?the?dental?consultant?who?made?the?
determination?to?deny?services.?The?dental?consultant?should?return?the?phone?call?from?the?
provider?within?72?hours.?
If?you?are?not?satisfied?with?the?decision,?you?may?submit?an?internal?utilization?management?
appeal.?If?the?member?remains?dissatisfied,?a?provider?may?submit?a?written?appeal?on?behalf?of?
the?member?(with?the?member?s?written?consent),?or?the?member?may?appeal?the?decision.?As?a?
provider,?you?may?submit?only?one?UM?appeal?for?a?particular?case.?You?may?submit?an?appeal?
on?your?behalf?or?on?the?member?s?behalf,?but?not?both.?Requests?for?an?internal?appeal?must?be?
submitted?within?60?calendar?days?of?receiving?a?denial?letter.??
Providers?must?submit?written?appeals.?Members?may?submit?a?written?appeal?or?may?appeal?a?
decision?by?calling?1?800?682?9090.?Horizon?NJ?Health?will?notify?you?or?the?member?of?an?
internal?decision?within?10?calendar?days.?
? ?



??SKYGEN?USA?|?CONFIDENTIAL?&?PROPRIETARY?|?Horizon?NJ?Health?Dental?Program?|?Effective:?1/1/20?
62?

Member?Written?Consent?for?Appeal?
If?you,?as?a?provider,?submit?an?appeal?on?behalf?of?a?member,?you?must?include?a?consent?form?
signed?by?the?member?(unless?you?are?requesting?an?expedited?resolution).?You?must?also?notify?
the?member?when?you?initiate?the?appeal?and?each?time?the?appeal?advances?to?the?next?stage,?
including?any?appeal?to?an?Independent?Utilization?Review?Organization?(IURO).?The?member?s?
consent?remains?valid?unless?it?is?revoked.?A?member?may?revoke?consent?at?any?time.?
Utilization?Management?Appeal?Timelines?
Stage? Appeal?Submission?Timeline? Resolution?Timeline?
Expedited? May?be?either?written?or?verbal?request.? Resolved?as?soon?as?possible,?not?to?exceed?

72?hours?after?receiving?appeal?request.?
Internal? Submit?appeal?for?internal?reconsideration?

within?60?days?of?receiving?denial?letter.?
Resolved?within?10?days.?

External? Member?(or?provider?with?member?s?
consent)?may?submit?request?for?IURO?
review?within?4?months?of?receiving?
Internal?decision.?

Resolved?within?30?days.?

All?days?refer?to?calendar?days.?*Resolution?required?within?20?business?days,?not?to?exceed?30?calendar?days.?

Internal?review?
To?request?reconsideration?of?a?utilization?management?decision,?send?a?Stage?One?appeal?
request?to:?

Horizon?NJ?Health:?Complaints/Appeals?
PO?Box?295?
Milwaukee,?WI?53201?

External?review?
A?member,?or?a?provider?acting?with?a?member?s?written?content,?may?submit?an?External?UM?
Appeal?request,?along?with?all?required?documentation?for?the?case,?to:?

Independent?Utilization?Review?Organization?
Office?of?Managed?Care,?Division?of?Health?Care?Quality?and?Oversight?
PO?Box?360?
West?Trenton,?NJ?08625?0360?

? ?



??SKYGEN?USA?|?CONFIDENTIAL?&?PROPRIETARY?|?Horizon?NJ?Health?Dental?Program?|?Effective:?1/1/20?
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Additional?Appeal?Resources??
Providers?and?members?may?seek?assistance?with?complaints,?grievances,?and?appeals?at?any?
time?for?any?issue?by?contacting?the?New?Jersey?Department?of?Health?or?the?Department?of?
Banking?and?Insurance?(DOBI).?
New?Jersey?Department?of?Health?
Providers?may?submit?an?appeal?by?writing?to:?

New?Jersey?Department?of?Health?and?Senior?Services?
Office?of?Managed?Care?
PO?Box?367?
Trenton,?NJ?08625?0360?

Members?may?submit?an?appeal?by?writing?to:?
New?Jersey?State?Department?of?Health?and?Senior?Services?
Office?of?Managed?Care?
PO?Box?360?
Trenton,?NJ?08625?0360?

New?Jersey?Department?of?Banking?and?Insurance?(DOBI)?
Providers?and?members?may?call?the?department?with?a?complaint?(1?800?446?7467,?
state.nj.us/dobi)?or?may?submit?an?appeal?by?writing?to:?

Department?of?Banking?and?Insurance?
Office?of?Enforcement?and?Consumer?Protection?
20?West?State?St?
PO?Box?329?
Trenton,?NJ?08625?0329?

Medicaid?Fair?Hearing?
Members?may?request?a?Medicaid?Fair?Hearing?within?20?days?of?notice?of?an?adverse?action?by?
writing?to:?

New?Jersey?Division?of?Medical?Assistance?and?Health?Services?(DMAHS)?
Fair?Hearing?Services?
PO?Box?712?
Trenton,?NJ?08625?0712?

To?request?continuation?of?benefits?while?a?Medicaid?Fair?Hearing?is?pending,?members?must?
submit?a?request?in?writing?within?10?days?of?receiving?notification?of?a?denied?appeal.?If?the?Fair?
Hearing?appeal?is?denied,?the?member?may?be?required?to?pay?for?the?cost?of?the?services.?
? ?



??SKYGEN?USA?|?CONFIDENTIAL?&?PROPRIETARY?|?Horizon?NJ?Health?Dental?Program?|?Effective:?1/1/20?
64?

Credentialing?&?Recredentialing?
High?quality?dental?providers?are?essential?to?the?success?of?the?Horizon?NJ?Health?Dental?
Program,?and?even?more?importantly,?essential?to?the?health?of?members?enrolled?in?its?
Medicaid?benefit?plans.?
While?the?Horizon?NJ?Health?Dental?Program?has?an?open?recruitment?strategy?that?encourages?
all?providers?to?participate,?all?dentists?seeking?acceptance?into?the?network?must?undergo?a?
qualification?process,?which?includes?a?background?check,?licensing?verification,?and?primary?
source?verification?of?professional?credentials.??
As?required?by?law,?any?dentist?(DDS?or?DMD)?who?is?interested?in?participating?with?the?Horizon?
NJ?Health?Dental?Program?is?invited?to?apply?and?submit?a?credentialing?application?for?review?by?
Horizon?NJ?Health?s?Credentialing?Committee.?We?do?not?differentiate?or?discriminate?in?the?
treatment?of?providers?seeking?credentialing?on?the?basis?of?race,?ethnicity,?gender,?age,?national?
origin,?or?religion.??
Providers?must?be?credentialed?before?participating?in?the?Horizon?NJ?Health?Dental?Program?
network.?Providers?accepted?into?the?network?are?re?credentialed?at?least?every?36?months.??
Credentialing?Process?
The?Horizon?NJ?Health?credentialing?process?follows?NCQA?(National?Committee?for?Quality?
Assurance)?credentialing?guidelines?for?dentistry.?All?credentialing?applications?must?satisfy?
NCQA?and/or?URAC?standards?of?credentialing?as?they?apply?to?dental?services.?Horizon?NJ?Health?
has?the?sole?right?to?determine?which?dentists?it?accepts?and?continues?to?allow?as?participating?
providers?in?the?Horizon?NJ?Health?Dental?Program?network.?
In?reviewing?an?application,?the?Credentialing?Committee?may?request?further?information?from?
the?applicant.?The?Credentialing?Committee?may?postpone?a?decision?pending?the?outcome?of?an?
investigation?of?the?applicant?by?a?hospital,?licensing?board,?government?agency,?institution,?or?
any?other?organization,?or?the?Committee?may?recommend?other?actions?it?deems?appropriate.?
Horizon?NJ?Health?notifies?the?State?of?New?Jersey?of?all?disciplinary?actions?that?involve?
participating?providers.?
Any?acceptance?of?an?applicant?is?conditioned?upon?the?applicant?s?execution?of?a?participation?
agreement?with?the?Horizon?NJ?Health?Dental?Program?network.?
If?you?have?questions?about?the?credentialing?process?or?need?assistance,?call?the?Horizon?NJ?
Health?Credentialing?team?at?1?855?812?9211.?
? ?



??SKYGEN?USA?|?CONFIDENTIAL?&?PROPRIETARY?|?Horizon?NJ?Health?Dental?Program?|?Effective:?1/1/20?
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Credentialing?Documentation??
Horizon?NJ?Health?considers?effective?screening?and?credentialing?criteria?an?important?tool?for?
maintaining?the?quality?of?its?provider?network.?Horizon?NJ?Health?complies?with?state,?regulatory,?
and?accrediting?body?standards?for?credentialing?of?its?healthcare?professional?network.??
A?Doctor?of?Dental?Medicine?(DMD)?or?a?Doctor?of?Dental?Surgery?(DDS),?who?is?authorized?to?
provide?dental?and?surgical?services?by?the?State?of?New?Jersey?and?approved?by?Horizon?NJ?
Health,?is?eligible?to?provide?dental?and?surgical?dental?services?to?Horizon?NJ?Health?members.?
An?out?of?state?dentist,?credentialed?as?a?Horizon?NJ?Health?participating?dentist,?may?provide?
dental?and?surgical?services?if?documentation?and?licensing?requirements?are?met?for?the?state?in?
which?they?practice.?Participants?must?provide?information?on?the?following:?

? Education/training?
? Current?state?licensure?
? For?oral?surgeons,?full?admitting?privileges?at?Horizon?NJ?Health?participating?hospitals?
? For?Endodontists,?Prosthodontists,?Periodontists,?and?Oral?and?Maxillofacial?Surgeons,?proof?of?

a?current,?unrestricted?New?Jersey?Controlled?Drug?Substance?(CDS)?and?Drug?Enforcement?
Agency?(DEA)?certificates??

o Must?have?or?have?confirmation?of?application?submission?of?
? Information?regarding?breaks?in?practice/training?
? Current?adequate?professional?liability?insurance?(malpractice)?
? Satisfactory?history?of?malpractice?claims?and?settlements?
? Satisfactory?National?Practitioner?Data?Bank?inquiry?
? Satisfactory?inquiry?of?New?Jersey?Treasury?and?federal?Office?of?Inspector?General?(OIG)?websites?
? Copy?of?a?written?certification?to?perform?anesthesia,?intravenous?sedation,?and?analgesia,?if?

applicable?
? Work?history?
? Any?sanctions?imposed?by?Medicare?and/or?Medicaid?
? Any?censure?by?the?State?Board?of?Dental?Examiners?
? Physical/mental?health,?history?of?chemical?dependency/substance?abuse,?loss?of?license,?

and/or?felony?convictions,?loss?or?limitation?of?hospital?privileges?or?disciplinary?activity,?and?an?
attestation?to?the?correctness?and?completeness?of?the?submitted?information?

Horizon?NJ?Health?may?utilize?the?services?of?an?external?Credentialing?Verification?Organization?to?
meet?State?requirements.?We?require?cooperation?with?these?services?by?all?dentists?applying?for?
participation?in?the?program.?Failure?to?do?so?results?in?a?denied?application?by?the?Horizon?NJ?
Health?Credentialing?Committee.?In?addition,?all?primary?and?specialty?care?offices?must?cooperate?
with?site?reviews?to?ensure?our?members?receive?treatment?in?an?appropriate,?clean,?and?safe?
environment?that?also?respects?member?privacy.?An?initial?site?visit?is?required?in?conjunction?with?
credentialing?and?every?three?years?thereafter.?After?six?months?participation?with?Horizon?NJ?
Health,?reviews?of?dental?records?may?be?conducted?to?ensure?all?records?comply?with?our?dental?
recordkeeping?standards.?(See?Recordkeeping?Requirements?on?page?23.)? ?



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Recredentialing?Process?
Recredentialing?is?required?at?least?every?36?months,?per?NCQA?guidelines.?Six?months?before?you?
are?due?for?recredentialing,?Horizon?NJ?Health?will?notify?you?of?your?upcoming?recredentialing?
due?date.?Our?notification?letter?will?include?instructions?for?how?to?complete?the?recredentialing?
process.?If?you?have?questions?about?recredentialing?or?need?assistance,?call?the?Horizon?NJ?Health?
Credentialing?team:?1?855?812?9211.?The?recredentialing?process?for?Horizon?NJ?Health?includes?a?
review?and?update?of?all?credentialing?information,?as?well?as?the?following:?

? Correspondence?between?the?dental?program?and?the?dentist?or?healthcare?professional?
? Utilization?management?and?quality?reviews?
? Compliance?with?Horizon?NJ?Health?policies?and?procedures?
? Patient?satisfaction?or?complaint?response?information?
? Other?pertinent?data?

Submitting?an?Application?for?Credentialing/Recredentialing?
An?initial?site?visit?is?required?in?conjunction?with?credentialing?at?which?time?the?Credentialing?
Team?provides?an?application?form.?In?addition,?providers?can?complete?the?application?through?
the?Council?for?Affordable?Quality?Healthcare?(CAQH)?or?online?at?the?Horizon?NJ?Health?website.?
Send?credentialing?and?recredentialing?applications?and?documents?to?Horizon?NJ?Health?by?fax,?
email,?or?mail.?Or,?call?the?Credentialing?Team:?1?855?812?9211.?

? Fax:?1?866?396?5686??
? Email:?credentialing@skygenusa.com?
? Write?to:??

Horizon?NJ?Health:?Credentialing?
PO?Box?2059?
Milwaukee,?WI?53201??

Appealing?a?Credentialing?Decision?
The?Horizon?NJ?Health?Credentialing?Committee?has?the?discretion?and?authority?to?accept?an?
application?without?restrictions.?However,?if?the?Credentialing?Committee?determines?an?
application?should?be?accepted?with?restriction?or?declined,?the?Committee?recommends?the?
appropriate?action?to?the?Executive?Subcommittee?for?approval?and?offers?the?applicant?an?
opportunity?to?request?a?reconsideration?review?or?appeal?the?recommendation.?
If?the?applicant?accepts?the?opportunity?for?a?reconsideration?review,?the?Credentialing?Committee?
reviews?all?original?documents,?as?well?as?any?additional?information?submitted?for?the?
reconsideration?review.?If?an?applicant?appeals?the?Credentialing?Committee?s?recommendation,?a?
Peer?Review?Committee?completes?the?review.?Horizon?NJ?Health?retains?ultimate?responsibility?
for?the?credentialing?process?and?final?credentialing?decisions.?To?appeal?a?decision,?send?a?written?
request?for?a?reconsideration?review?within?30?days?of?receiving?an?adverse?recommendation?to:?

Horizon?NJ?Health:?Credentialing?Appeals?
PO?Box?2059?
Milwaukee,?WI?53201? ?



??SKYGEN?USA?|?CONFIDENTIAL?&?PROPRIETARY?|?Horizon?NJ?Health?Dental?Program?|?Effective:?1/1/20?
67?

Health?Insurance?Portability?and?
Accountability?Act?(HIPAA)?
As?a?healthcare?provider,?if?you?transmit?any?health?information?electronically,?your?office?is?
required?to?comply?with?all?aspects?of?the?Health?Insurance?Portability?and?Accountability?Act?
(HIPAA)?regulations?that?have?gone?and?will?go?into?effect?as?indicated?in?the?final?publications?of?
the?various?rules?covered?by?HIPAA.?
Horizon?NJ?Health?has?implemented?numerous?operational?policies?and?procedures?to?ensure?we?
comply?with?all?HIPAA?Privacy?Standards,?and?we?intend?to?comply?with?all?Administrative?
Simplification?and?Security?Standards?by?their?compliance?dates.?We?also?expect?all?providers?in?
our?networks?to?work?cooperatively?with?us?to?ensure?compliance?with?all?HIPAA?regulations.?
Together,?you?(the?provider)?and?Horizon?NJ?Health?agree?to?conduct?our?respective?activities?in?
accordance?with?the?applicable?provisions?of?HIPAA?and?such?implementing?regulations.?When?
you?contact?Provider?Services,?you?will?be?asked?to?supply?your?Tax?ID?or?NPI?number.?When?you?
call?regarding?member?inquiries,?you?will?be?asked?to?supply?specific?member?identification?such?
as?Member?Medicaid?ID?number?or?Social?Security?Number,?date?of?birth,?name,?and/or?address.?
As?regulated?by?the?Administrative?Simplification?Standards,?the?benefit?tables?included?in?this?
provider?manual?reflect?the?most?current?CDT?coding?standards?recognized?by?the?American?
Dental?Association?(ADA).?Effective?as?of?the?date?of?this?manual,?the?Horizon?NJ?Health?Dental?
Program?require?providers?to?submit?all?claims?with?the?proper?CDT?codes?listed?in?this?manual.?
In?addition,?all?paper?claims?must?be?submitted?on?the?current?ADA?claim?form.?
To?request?copies?of?Horizon?NJ?Health?HIPAA?policies,?call?Provider?Services?or?send?an?email?to?
providerservices@skygenusa.com.?

To?report?a?potential?security?issue,?call?our?
Hotline?at?1?877?378?5292.?

National?Provider?Identifier?(NPI)??
The?Health?Insurance?Portability?and?Accountability?Act?(HIPAA)?of?1996?required?the?adoption?of?a?
standard?unique?provider?identifier?for?healthcare?providers.?An?NPI?number?is?required?for?all?claims?
submitted?to?Horizon?NJ?Health?for?payment.?All?providers?must?register?as?an?individual?practitioner?
and?get?an?individual?NPI.?If?you?own?and?operate?a?group?practice,?you?must?also?register?as?a?group?
and?obtain?a?group?or?organizational?NPI.?To?apply?for?an?NPI,?do?one?of?the?following:?

? Complete?the?application?online?at?nppes.cms.hhs.gov.?
? Download?and?complete?a?paper?copy?from?nppes.cms.hhs.gov.?
? Call?1?800?465?3203?to?request?an?application.? ?



??SKYGEN?USA?|?CONFIDENTIAL?&?PROPRIETARY?|?Horizon?NJ?Health?Dental?Program?|?Effective:?1/1/20?
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Utilization?Management??
Community?Practice?Patterns?
To?ensure?fair?and?appropriate?reimbursement,?the?Horizon?NJ?Health?Utilization?Management?
philosophy?recognizes?the?relationships?between?the?dentist?s?treatment?planning,?treatment?
costs,?and?outcomes.?The?dynamics?of?these?relationships?are?typically?influenced?by?community?
practice?patterns.?With?this?in?mind,?our?Utilization?Management?guidelines?are?designed?to?
ensure?healthcare?dollars?are?distributed?fairly?and?appropriately,?as?defined?by?the?regionally?
based?community?practice?patterns?of?local?dentists?and?their?peers.?
All?Utilization?Management?analysis,?evaluations,?and?outcomes?are?related?to?these?community?
practice?patterns.?Horizon?NJ?Health?Utilization?Management?recognizes?individual?dentist?
variance?within?these?patterns?among?a?community?of?dentists?and?accounts?for?such?variance.?
To?ensure?fair?comparisons?within?peer?groups,?our?Utilization?Management?evaluates?specialty?
dentists?as?a?separate?group?and?not?with?general?dentists,?since?the?types?and?nature?of?
treatment?may?differ.?
Evaluation?
Horizon?NJ?Health?Utilization?Management?evaluates?claims?submissions?in?such?areas?as:?

? Diagnostic?and?preventive?treatment?
? Patient?treatment?planning?and?sequencing?
? Types?of?treatment?
? Treatment?outcomes?
? Treatment?cost?effectiveness?

Results?
With?the?objective?of?ensuring?fair?and?appropriate?reimbursement?to?providers,?Horizon?NJ?
Health?Utilization?Management?helps?identify?providers?whose?treatment?patterns?show?
significant?deviation?from?the?normal?practice?patterns?of?the?community?of?their?peers?(typically?
less?than?5?percent?of?all?dentists).??
Peer?Review:?Reimbursement?Consequences??
If?a?dentist?fails?to?respond?to?a?request?of?the?New?Jersey?Division?of?Medical?Assistance?and?
Health?Services?(DMAHS)?for?office?records,?radiographs,?correspondence,?or?other?materials?
within?30?days,?the?Division?may?recover?any?reimbursement?related?to?the?services?involved,?or?
if?in?reference?to?unpaid?services,?deny?any?payment.?
? ?



??SKYGEN?USA?|?CONFIDENTIAL?&?PROPRIETARY?|?Horizon?NJ?Health?Dental?Program?|?Effective:?1/1/20?
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TAMI?Review?
Horizon?NJ?Health?claims?examiners?use?Tooth?Allocation?Map?Inquiry?(TAMI)?Review?to?
systematically?review?payment?processing.?A?claims?examiner?selects?certain?claims?that?reveal?
duplication?of?services?or?services?presented?in?an?illogical?or?impossible?sequence?for?further?
review?and?investigation.?
Non?Incentivization?Policy?
It?is?Horizon?NJ?Health?practice?to?ensure?our?contracted?providers?make?treatment?decisions?
based?on?medical?necessity?for?individual?members.?Providers?are?never?offered,?nor?shall?they?
ever?accept,?any?kind?of?financial?incentives?or?any?other?encouragement?to?influence?their?
treatment?decisions.?
The?Horizon?NJ?Health?Utilization?Management?team?bases?their?decisions?on?only?
appropriateness?of?care,?service,?and?existence?of?coverage.?Horizon?NJ?Health?does?not?
specifically?reward?practitioners?or?other?individuals?for?issuing?denials?of?coverage?or?care.?If?
financial?incentives?exist?for?Utilization?Management?decision?makers,?they?do?not?include?or?
encourage?decisions?which?result?in?underutilization.?
Fraud,?Waste?&?Abuse?
Horizon?NJ?Health?conducts?our?business?operations?in?compliance?with?ethical?standards,?
contractual?obligations,?and?all?applicable?federal?and?state?statutes,?regulations,?and?rules.?We?
are?committed?to?detecting,?reporting,?and?preventing?potential?fraud,?waste,?and?abuse,?and?we?
look?to?our?providers?to?assist?us.?We?expect?our?dental?partners?to?share?this?same?
commitment,?conduct?their?businesses?similarly,?and?report?suspected?noncompliance,?fraud,?
waste?or?abuse.?
Definitions?
Fraud,?waste,?and?abuse?are?defined?as:?
Fraud.?Fraud?is?intentional?deception?or?misrepresentation?made?by?a?person?with?knowledge?the?
deception?could?result?in?some?unauthorized?benefit?to?themselves?or?some?other?person?or?
entity.?It?includes?any?act?which?constitutes?fraud?under?federal?or?state?law.?
Waste.?Waste?is?the?unintentional,?thoughtless,?or?careless?expenditures,?consumption,?
mismanagement,?use,?or?squandering?of?federal?or?state?resources.?Waste?also?includes?incurring?
unnecessary?costs?as?a?result?of?inefficient?or?ineffective?practices,?systems,?or?controls.?
Abuse.?Abuse?is?defined?as?practices?that?are?inconsistent?with?sound?fiscal,?business,?or?medical?
practices,?and?that?result?in?the?unnecessary?cost?to?the?government?healthcare?program?or?in?
reimbursement?for?services?medically?unnecessary?or?that?fail?to?meet?professionally?recognized?
standards?for?health?care.?Abuse?includes?intentional?infliction?of?physical?harm,?injury?caused?by?
negligent?acts,?or?omissions,?unreasonable?confinement,?sexual?abuse,?or?sexual?assault.?Abuse?
also?includes?beneficiary?practices?that?result?in?unnecessary?costs?to?the?healthcare?program.?
? ?



??SKYGEN?USA?|?CONFIDENTIAL?&?PROPRIETARY?|?Horizon?NJ?Health?Dental?Program?|?Effective:?1/1/20?
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Provider?Fraud.?Provider?fraud?is?any?deception?or?misrepresentation?committed?intentionally,?or?
through?willful?ignorance?or?reckless?disregard,?by?a?person?or?entity?in?order?to?receive?benefits?
or?funds?to?which?they?are?not?entitled.?This?may?include?deception?by?improper?coding?or?other?
false?statements?by?providers?seeking?reimbursement?or?false?representations?or?other?violations?
of?federal?healthcare?program?requirements,?its?associates,?or?contractors.?
Reporting?Suspected?Fraud,?Waste,?or?Abuse?
To?report?a?suspected?case?of?noncompliance,?fraud,?waste,?or?abuse,?call?the?Horizon?NJ?Health?
Fraud?and?Abuse?hotline:?1?877?378?5292?or?write?to:?

Horizon?NJ?Health?
Attention:?Fraud?and?Abuse?
10201?N?Port?Washington?Rd?
Mequon,?WI?53092?

To?report?potential?fraud?or?abuse,?call?our?
Hotline?at?1?877?378?5292.?

Deficit?Reduction?Act:?The?False?Claims?Act?
Section?6034?of?the?Deficit?Reduction?Act?of?2005?signed?into?law?in?2006?established?the?
Medicaid?Integrity?Program?in?section?1936?of?the?Social?Security?Act.?The?legislation?directed?the?
Secretary?of?the?United?States?Department?of?Health?and?Human?Services?(HHS)?to?establish?a?
comprehensive?plan?to?combat?provider?fraud,?waste,?and?abuse?in?the?Medicaid?program,?
beginning?in?2006.?The?Comprehensive?Medicaid?Integrity?Plan?is?issued?for?successive?five?year?
periods.??
Under?the?False?Claims?Act,?those?who?knowingly?submit?or?cause?another?person?to?submit?false?
claims?for?payment?of?government?funds?are?liable?for?up?to?three?times?the?government?s?
damages?plus?civil?penalties?of?$5,500?to?$11,000?for?each?false?claim.?
The?False?Claims?Act?allows?private?persons?to?bring?a?civil?action?against?those?who?knowingly?
submit?false?claims.?If?there?is?a?recovery?in?the?case?brought?under?the?False?Claims?Act,?the?
person?bringing?the?suit?may?receive?a?percentage?of?the?recovered?funds.?
For?the?party?found?responsible?for?the?false?claim,?the?government?may?exclude?them?from?
future?participation?in?federal?healthcare?programs?or?impose?additional?obligations?against?the?
individual.?
The?False?Claims?Act?is?the?most?effective?tool?U.S.?taxpayers?have?to?recover?the?billions?of?
dollars?stolen?through?fraud?every?year.?Billions?of?dollars?in?healthcare?fraud?have?been?exposed,?
largely?through?the?efforts?of?whistleblowers?acting?under?federal?and?state?false?claims?acts.?
For?more?information?about?the?False?Claims?Act?visit?www.TAF.org.?
? ?



??SKYGEN?USA?|?CONFIDENTIAL?&?PROPRIETARY?|?Horizon?NJ?Health?Dental?Program?|?Effective:?1/1/20?
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Whistleblower?Protection?
The?False?Claims?Act?(FCA)?provides?protection?to?qui?tam?relators?who?are?discharged,?demoted,?
suspended,?threatened,?harassed,?or?in?any?other?manner?discriminated?against?in?the?terms?and?
conditions?of?their?employment?as?a?result?of?their?furtherance?of?an?action?under?the?FCA?
31?U.S.C.???3730(h).?Remedies?include?reinstatement?with?comparable?seniority?as?the?qui?tam?
relator?would?have?had?but?for?the?discrimination,?two?times?the?amount?of?any?back?pay,?
interest?on?any?back?pay,?and?compensation?for?any?special?damages?sustained?as?a?result?of?the?
discrimination,?including?litigation?costs?and?reasonable?attorneys??fees.?
Sanctions?
To?resolve?identified?deficiencies?in?a?fair?manner,?Horizon?NJ?Health?allows?the?opportunity?for?
reeducation?and?fair?due?process.?When?noncompliance?significantly?affects?the?quality?of?care?
provided?to?a?member,?Horizon?NJ?Health?may?impose?sanctions?after?a?thorough?review?of?the?
issue?through?the?Corrective?Action?Program.?The?provider?under?review?is?afforded?ample?
opportunity?to?respond?to?the?issue.?
If?formal?sanctions?are?implemented?and?the?outcome?lasts?30?days?or?more,?Horizon?NJ?Health?
notifies?the?National?Practitioner?Data?Bank.??
? ?



??SKYGEN?USA?|?CONFIDENTIAL?&?PROPRIETARY?|?Horizon?NJ?Health?Dental?Program?|?Effective:?1/1/20?
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Practice?Guidelines?
Horizon?NJ?Health?accepts?the?periodicity?schedule?developed?by?the?State?of?New?Jersey?as?the?
dental?periodicity?schedule?for?the?Horizon?NJ?Health?Dental?Program.?
The?EPSDT?(Early?and?Periodic?Screening,?Diagnostic,?and?Treatment)?program?is?a?federally?
mandated?program?for?children?from?birth?through?20?years?that?emphasizes?the?importance?of?
prevention,?early?detection,?risk?assessment,?and?timely?treatment?of?conditions?identified?as?a?
result?of?dental?screening.?Children?enrolled?in?Medicaid?or?SCHIP?are?eligible?for?full?EPSDT?
benefits?in?the?state.?Members?attaining?the?age?of?21?are?treated?as?adults?beginning?with?the?
first?month?following?their?birthday.??
All?EPSDT?services?provided?to?children?enrolled?in?the?Horizon?NJ?Health?Dental?Program?must?
be?medically?necessary.?These?include:?

? Early.?A?child?s?dental?health?is?assessed?as?early?as?possible?in?the?child?s?life?by?the?
Primary?Care?Dentist?(PCD)?in?order?to?prevent?or?find?potential?diseases?and/or?
disabilities?in?their?early?stages,?when?they?are?most?effectively?treated.?

? Periodic.?The?PCD?will?assess?a?child?s?dental?health?at?regularly?scheduled?intervals?to?
assure?that?a?condition,?illness,?or?injury?is?not?incipient?or?present.?

? Screening.?A?dental?health?assessment?to?determine?if?a?child?is?at?risk?and/or?has?a?
condition,?illness,?or?injury?that?requires?more?definitive?evaluation?and/or?treatment.?

? Diagnosis.?The?definitive?evaluation?by?appropriate?dental?practitioners?to?determine?the?
nature,?extent?or?cause?of?a?condition,?illness,?or?injury.?

? Treatment.?The?dental?services?determined?to?be?medically?necessary?for?problems?
identified?during?screening?or?diagnostic?evaluations.?

Dental?services?should?be?provided?at?intervals?that?meet?reasonable?standards?of?dental?
practice.??
? ?



??SKYGEN?USA?|?CONFIDENTIAL?&?PROPRIETARY?|?Horizon?NJ?Health?Dental?Program?|?Effective:?1/1/20?
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NJ?Smiles?
NJ?Smiles?is?a?directory?listing?every?pediatric?and?general?dentist?seeing?children?through?6?years?
of?age?who?participates?with?Horizon?NJ?Health.?The?directory?is?available?on?
horizonNJhealth.com/membersupport.??
Dental?services?may?not?be?limited?to?emergency?services.?Dental?screening?by?the?PCP?in?this?
context?means,?at?a?minimum,?observation?of?tooth?eruption,?occlusion?pattern,?presence?of?
caries,?or?oral?infection.??

A. A?referral?to?a?dentist?by?one?year?of?age?or?soon?after?the?eruption?of?the?first?primary?
tooth?is?mandatory?and?at?a?minimum?a?dental?visit?twice?a?year?with?follow?up?during?
well?child?visits?to?ensure?that?all?needed?dental?preventive?and?treatment?services?are?
provided?thereafter?through?the?age?of?20.??

B. A?referral?to?a?dental?specialist?or?dentist?that?provides?dental?treatment?to?patients?with?
special?needs?shall?be?allowed?when?a?PCD?requires?a?consultation?for?services?by?that?
specialty?provider.??

Fluoride?varnish?application?will?be?combined?with?anticipatory?guidance,?risk?assessment?and?referral?to?
a?dentist?that?treats?children?under?the?age?of?six?and?will?be?linked?to?well?child?visits?for?children?
through?the?age?of?six.??

1. These?three?services?will?be?reimbursed?as?an?allinclusive?service?billed?using?CPT?code?
99188?and?can?be?provided?up?to?four?times?a?year.?This?frequency?does?not?affect?the?
frequency?of?this?service?by?the?dentist.?Training?for?Caries?Risk?Assessment,?Fluoride?Varnish?
&?Counseling?is?available?online?by?visiting?smilesforlifeoralhealth.org,?click?Learn?Online?
then?select?Course?Six:?Caries?Risk?Assessment,?Fluoride?Varnish?&?Counseling.??

2. PCPs?are?required?to?refer?members?by?12?months?of?age?to?a?dentist?for?a?dental?visit.?Every?
quarter?PCPs?receive?a?list?of?members?that?have?not?had?a?dental?appointment?in?the?past?
12?months.?PCPs?are?required?to?assist?the?member?with?getting?a?dental?appointment.??

3. Bidirectional?communication?between?PCPs?and?PCDs?is?required?between?these?provider?groups.??
4. Prescribing?fluoride?supplements?is?based?on?access?and?use?to?fluoridated?public?water.?

PCPs?and?PCDs?should?be?aware?of?the?towns?that?fluoridate?their?water.?According?to?the?
NJ?Dental?Association,?the?following?locations?have?fluoridated?water:??
? Atlantic?County:?Atlantic?City,?Egg?Harbor?City??
? Burlington?County:?McGuire?Air?force?base,?Willingboro,?Mt.?Laurel,?Fort?Dix?and?Aqua??
? Gloucester?County:?Washington??
? Hunterdon?County:?Flemington,?Readington,?Three?Bridges,?Whitehouse,?Whitehouse?Station??
? Mercer?County:?Ewing,?Hamilton,?Hightstown,?Hopewell?Township,?Lawrence,?

Pennington,?Princeton,?West?Windsor??
? Monmouth?County:?Allentown,?Colts?Neck,?Freehold,?NJ?American?Coastal?North??
? Somerset?County:?MJ?American??
? Sussex?County:?Newton??
? Union?County:?Rahway?? ?



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5. PCDs?and?PCPs?are?responsible?to?counsel?parents?and?guardians?of?young?children?on?
oral?health,?age?appropriate?oral?habits?and?safety?to?include?what?dental?emergencies?
are?and?use?of?the?emergency?room?for?dental?services.??

6. The?caries?risk?assessment?service?shall?also?be?allowed?by?the?PCD?and?is?billed?using?a?
CDT?procedure?code.?The?reimbursement?will?be?the?same?regardless?of?the?determined?
risk?level.?The?risk?assessment?must?be?provided?at?least?once?per?year?in?conjunction?
with?an?oral?evaluation?service?by?a?PCD?and?is?linked?to?the?provider?not?the?member.?It?
may?be?provided?a?second?time?with?prior?authorization?and?documentation?of?medical?
necessity.?

? ?



??SKYGEN?USA?|?CONFIDENTIAL?&?PROPRIETARY?|?Horizon?NJ?Health?Dental?Program?|?Effective:?1/1/20?
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New?Jersey?Periodicity?Schedule?
Periodicity?of?Dental?Services?for?Children?in?NJ?FamilyCare/Medicaid?
The?New?Jersey?Division?of?Medical?Assistance?and?Health?Services?(DMAHS)?recommends?the?
following?professional?dental?services?for?children.??
?
Dental?Service?

0?1?
year?

2?6?years? 7?20?years?

A1.?Oral?Evaluation?(Exam)???
A2.?Caries/Cavities?Risk?Assessment??

??
??

??
??

??
??

B.?Fluoride?Supplements?? ?? ?? ??
C.?Fluoride?Varnish*?? ?? ?? ??
D.?Prophylaxis?with?Fluoride?? ? ?? ??
E.?Sealants?????(Permanent?teeth?to?age?16?yrs)?? ? ?? ??
F.?Radiographs/x?rays??(Non?emergency)?? ?? ?? ??
G.?Dental?Treatment?? ?? ?? ??
? Oral?Evaluations?(including?oral?hygiene?instructions),?Fluoride?varnish?and?Cleanings?with?fluoride?

can?be?provided?twice?a?year?r?or?more?frequently?based?on?medical?necessity?and?for?children?
with?special?health?care?needs.??

? A?prescription?for?fluoride?supplements?may?be?given?by?either?your?dentist?or?primary?care?
provider?(PCP)?to?help?prevent?cavities.??

? *The?application?of?fluoride?varnish?to?protect?teeth?from?cavities?can?also?be?done?for?children?
under?the?age?og?4?by?their?PCP?followed?by?a?referral?to?the?dentist?for?an?oral?evaluation,?X?rays?
as?needed,?cleaning?and?dental?treatment.??

? A?Caries/Cavities?Risk?Assessment???should?be?done?once?a?year?to?determine?your?child?s?risk?of?
developing?cavities.?The?visit?includes?an?oral?evaluation,?instructions?on?brushing,?oral?health,?
safety?and?nutritional?counselling?to?parents/caregivers?and?children.??

? Sealants?and?repairs?of?sealants?should?be?provided?to?premolars?and?permanent?molars?of?
children?between?the?ages?of?6?through?16?to?help?prevent?cavities??

? Dental?treatment?services?for?primary??baby?teeth??and?permanent?teeth?include:?fillings,?stainless?
steel?crowns,?treatment?for?toothache?and?extractions?and?should?be?provided?when?
recommended?by?your?child?s?dentist.?

Providers?may?receive?reimbursement?for?the?cost?of?providing?oral?hygiene?instructions?to?caregivers?to?
maintain?a?patient?s?overall?oral?health?between?dental?visits.?In?situations?where?the?treating?dentist?
recommends?a?non?standard,?specialized?toothbrush?to?improve?a?member?s?oral?hygiene,?Horizon?NJ?
Health?will?include?these?devices?as?a?benefit.?Such?provisions?shall?include?designing?and?implementing?
a??dental?management??plan,?coordinated?by?the?Horizon?NJ?Health?Care?Manager,?for?overseeing?a?
patient?s?oral?health.?A?Care?Manager?will?be?assigned?to?members?requiring?these?additional?services?
and?reimbursed?by?report?to?the?Horizon?NJ?Health?Dental?Director.?? ?



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Fluoride?Varnish?Provider?
Incentive?Program?
In?an?effort?to?help?quell?the?alarming?rate?of?early?childhood?caries?for?Horizon?NJ?Health?
members?under?the?age?of?4,?Horizon?NJ?Health?has?developed?a?pediatric?fluoride?varnish?
program.?This?program?encourages?trained?non?dental?providers?in?pediatric?practices?to?apply?
fluoride?varnish?to?children?s?teeth,?perform?caries?risk?assessments?and?anticipatory?guidance,?
and?refer?our?young?members?to?a?dental?home.??
Horizon?NJ?Health?is?offering?reimbursement?to?trained?pediatrician?offices?when?their?
pediatricians,?nurse?practitioners?or?physician?assistants?or?other?trained?medical?staff?apply?
fluoride?varnish?to?the?teeth?of?Horizon?NJ?Health?members?at?well?child?visits?under?the?age?of?
4.?Pediatricians?will?receive?$15?for?each?fluoride?varnish?application?up?to?four?times?a?year,?per?
patient.?Pediatricians?are?also?encouraged?to?discuss?with?patients?the?importance?of?nutrition?
and?oral?hygiene?and?provide?anticipatory?guidance.??
In?order?to?receive?CME?training?credit?(in?some?cases)?and?collect?the?reimbursement,?
practitioners?must?complete?the?following?online?training?and?assessment:??

? Go?to?smilesforlifeoralhealth.org?and?click?Course?Six?in?the?right?column???Caries?Risk?
Assessment,?Fluoride?Varnish?&?Counseling.??

? One?provider?per?facility?may?complete?the?curriculum?and?agree?to?train?their?
colleagues.??

? After?completing?the?curriculum,?that?provider?must?sign?the?Fluoride?Varnish?Attestation?
Form?attesting?that?they?completed?the?training?and?agree?to?train?the?other?providers?in?
their?office.??

After?completing?the?curriculum,?that?provider?must?sign?and?fax?the?Fluoride?Varnish?Application?
Attestation?Form,?attesting?that?they?completed?the?training,?to?1?973?274?3865,?ATTN:?Fred?
DiOrio,?DMD.?Please?include?a?list?of?any?other?providers?in?your?office?that?you?trained.?All?
providers?under?the?PCP?s?TIN?should?be?listed?on?the?attestation?form.?Please?use?CPT?code?
99188.?A?copy?of?the?form?is?on?the?Horizon?NJ?Health?website?in?the?For?Providers?tab,?select?
Resources?and?then?Forms.??
Note?that?providers?who?have?not?completed?the?training?are?not?eligible?for?reimbursement.?
? ?



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Clinical?Criteria?
Medical?Necessity?
Horizon?NJ?Health?defines?medical?necessity?as?accepted?healthcare?services?and?supplies?
provided?by?healthcare?entities?appropriate?to?the?evaluation?and?treatment?of?a?disease,?
condition,?illness,?or?injury?and?consistent?with?the?applicable?standard?of?care.?
Dental?care?is?medically?necessary?to?prevent?and?eliminate?orofacial?disease,?infection,?and?pain,?
to?restore?form?and?function?to?the?dentition,?and?to?correct?facial?disfiguration?or?dysfunction.?
Medical?necessity?is?the?reason?why?a?test,?a?procedure,?or?an?instruction?is?performed.?
Medical?necessity?is?different?for?each?person?and?changes?as?the?individual?changes.?The?dental?
team?must?provide?consistent?methodical?documentation?of?medical?necessity?for?coding.?
Prior?Authorization?of?Treatment??
Some?procedures?require?prior?authorization?before?treatment?is?started.?When?submitting?
these?procedures?for?prior?review,?also?submit?supporting?documentation,?if?required.?Horizon?
NJ?Health?uses?the?criteria?and?guidelines?in?this?manual?to?approve?requested?dental?services.?
Prior?authorization?requirements?and?documentation?requirements?are?summarized?in?this?
manual?in?Benefit?Plan?Details?&?Authorization?Requirements?beginning?on?page?120.?
An?approved?authorization?does?not?guarantee?payment.?Dental?providers?must?verify?coverage?
prior?to?rendering?services.?Providers?are?prohibited?from?billing?Medicaid?or?NJ?FamilyCare?
members?for?any?amount,?except?under?specific?scenarios?(see?N.J.A.C?10?49?7.3(d).)?
For?information?about?submitting?prior?authorizations?and?required?documentation,?see??



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Authorization?Submission?Procedures?on?page?45.?
Emergency?Treatment?
To?relieve?pain?and?suffering?in?an?emergency?situation,?providers?should?initiate?treatment?to?
alleviate?the?patient?s?condition.?For?reimbursement?of?emergency?treatment,?submit?all?
required?documentation?along?with?the?claim?for?services?rendered.?Horizon?NJ?Health?applies?
the?same?clinical?criteria?and?requires?the?same?supporting?documentation?for?claims?submitted?
after?emergency?treatment?that?we?use?to?determine?prior?authorizations?for?the?same?services.?
Informed?Consent?
Prior?to?any?surgical?procedure,?the?provider?should?obtain?informed?consent,?signed?by?the?
patient?or?authorized?person.?Horizon?NJ?Health?Professional?Relations?Service?Representatives?
coordinate?all?dentally?necessary?hospitalizations?for?patients?with?developmental?disabilities.?
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Dental?OR/ASC?Services??
Reimbursement?of?the?facility?charges?for?dental?services?performed?in?the?outpatient?department?of?
a?hospital?or?at?an?ambulatory?surgical?center?(ASC)?are?part?of?the?dental?carve?out?and?will?be?
covered?by?the?State?of?New?Jersey?Medicaid?Program.?The?anesthesiologist?services?related?to?those?
dental?services?are?also?part?of?the?dental?carve?out?and?will?be?covered?and?reimbursed?by?the?State?
of?New?Jersey?Medicaid?Program.??
However,?dental?services?that?are?to?be?performed?outside?your?office,?either?in?an?outpatient?department?
of?a?hospital?or?at?an?ASC,?must?be?approved?by?Horizon?NJ?Health?to?ensure?the?services?meet?the?medical?
necessity?criteria?for?services?rendered?in?an?outpatient?facility?(hospital?or?ASC).?
Obtaining?a?Patient?Authorization?Number?
When?a?physician,?dentist,?or?healthcare?professional?determines?that?a?patient?needs?dental?
services?performed?at?a?surgical?facility,?an?authorization?number?is?required.?To?obtain?an?
authorization?number,?submit?a?prior?authorization?request?that?includes:?

? A?list?of?the?planned?dental?services?
? Procedure?code?D9999?
? Completed?General?Anesthesia?Checklist?
? Letter?of?necessity.?Include?the?member?s?name,?Member?Medicaid?ID?number,?and?date?

of?birth;?physician?submitting?the?request;?facility?location;?necessity?for?admission;?and?
required?dental?procedures.??

? Facility?ID,?name?of?the?facility?and?address.?If?this?is?not?included,?processing?can?be?
delayed?and/or?denied.??

For?more?information?on?OR/ASC,?visit?horizonNJhealth.com/dental?and?click?on?Prior?
Authorization?or?refer?to?the?Member?Handbook?by?visiting?horizonNJhealth.com/handbooks.?You?
can?also?view?a?list?of?OR/ASC?Facility?ID?s?on?the?Horizon?NJ?Health?website?at?
horizonNJhealth.com/ORASC.?Fax?the?authorization?request?and?required?documentation?to:?1?
866?899?6186.?
Horizon?NJ?Health?will?review?your?request?and?may?contact?you?to?determine?necessity.?Upon?approval,?
Horizon?NJ?Health?issues?an?authorization?number?for?the?patient.?When?submitting?prior?authorizations,?
remember?to:??

? Report?CDT?procedure?code?D9999?to?request?prior?authorization?on?ADA?2012?
Claim/prior?authorization?form.??

? Report?the?beneficiary?s?medical?condition?and?related?diagnosis?codes?on?office?letterhead.??
? Report?on?office?letterhead?how?the?clinical?presentation?of?the?beneficiary?prevents?the?

beneficiary?from?receiving?dental?treatment?in?an?office?or?clinic?setting,?including?
reason(s)?why?other?levels?of?sedation?are?not?an?option.??

? Report?the?planned?or?expected?treatment?(e.g.,?oral?examination,?cleaning,?restorative?dental?
treatment,?extractions)?to?be?provided?during?the?hospital?visit?and?a?summary?of?the?
beneficiary?s?most?recent?dental?history,?including?dental?treatment?provided?in?the?last?12?
calendar?months.? ?



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Submitting?an?Authorization?for?Dental?OR/ASC?Services??
To?ensure?services?rendered?in?a?hospital?operating?room?or?outpatient?facility?meet?the?criteria?for?
medical?necessity,?submit?an?authorization?for?procedure?code?D9999?and?include?the?following?
required?documentation?supporting?the?treatment?plan?(X?rays,?photographs,?etc.),?if?available.?
You?may?submit?authorizations?along?with?any?required?documentation?directly?to?Horizon?NJ?
Health?through?our?Provider?Web?Portal?at?pwp.sciondental.com.?Alternately,?mail?paper?
authorizations?along?with?all?required?documentation?to:?

Horizon?NJ?Health:?Authorizations?
PO?Box?362?
Milwaukee,?WI?53201?

In?an?emergency,?fax?the?authorization?request?for?D9999?(submitted?on?an?ADA?Dental?Claim?
form),?along?with?all?required?documentation?to?1?866?899?6186.?

Dental?Prior?Authorization?Procedures?for?Special?Health?Care?Needs?Members?
to?Access?Care?in?an?OR/ASC?
All?dental?services?requiring?prior?authorization?should?be?submitted?to:?

Horizon?NJ?Health?
PO?Box?362?
Milwaukee,?WI?53201?
?

When?submitted?prior?authorizations,?remember?to:?
? Report?CDT?procedure?code?D9999?to?request?prior?authorization?on?ADA?2012?

Claim/prior?authorization?form.?
? Report?the?beneficiary?s?medical?condition?and?related?diagnosis?codes?on?office?

letterhead.?
? Report?on?office?letterhead?how?the?clinical?presentation?of?the?beneficiary?prevents?the?

beneficiary?from?receiving?dental?treatment?in?an?office?or?clinic?setting,?including?
reason(s)?why?other?levels?of?sedation?are?not?an?option.?

? Report?the?planned?or?expected?treatment?(e.g.,?oral?examination,?cleaning,?restorative?
dental?treatment,?extractions)?to?be?provided?during?the?hospital?visit?and?a?summary?of?
the?beneficiary?s?most?recent?dental?history,?including?dental?treatment?provided?in?the?
last?12?calendar?months.?

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To?ensure?services?rendered?in?a?hospital?operating?room?or?outpatient?facility?meet?the?criteria?
for?medical?necessity,?submit?an?authorization?for?procedure?code?D9999?and?include?the?required?
documentation?supporting?the?treatment?plan.?Required?documentation?includes?X?rays,?letter?of?
medical?necessity,?general?anesthesia?attestation?form,?treatment?plan,?diagnosis?and?facility?ID.?A?
signed?informed?consent?along?with?the?dental?diagnosis?codes?are?also?required.?
Dental?Diagnosis?Codes:?
520.0,?520.1,?520.2,?520.3,?520.4,?520.5,?520.8,?520.9,?521.00,?521.01,?521.02,?521.03,?521.04,?
521.05,?521.06,?521.07,?521.08,?521.09,?521.10,?521.11,?521.12,?521.13,?521.14,?521.15,?521.20,?
521.21,?521.22,?521.23,?521.24,?521.25,?521.30,?521.31,?521.32,?521.33,?521.34,?521.35,?521.40,?
521.41,?521.42,?521.49,?521.5,?521.6,?521.7,?521.81,?521.89,?521.9,?522.0,?522.1,?522.2,?522.3,?
522.4,?522.5,?522.6,?522.8,?522.9,?523.00,?522.01,?523.10,?522.11,?523.20,?523.21,?523.22,?
523.23,?523.24,?523.25,?523.30,523.31,?523.32,?523.33,?523.40,?523.41?
Special?Health?Care?Needs?Clinical?Criteria?and?Medical?Exception?ICD?10?Codes?
The?codes?which?relate?to?clinical?criteria?for?medical?exceptions/disabilities/special?needs?are?
listed?below:?
E75?E756,?F03?F0391,?F06?F068,?F07?F079,?F09,?F48?F489,?F53,?F60?F609,?F70,?F71,?F72,?F73,?
F78,?F79,?F84?F849,?F88,?F89,?F90?F909,?F91?F919,?G10,?G25?G259,?G31?G319,?G40?G409,?G71?
G719,?G72?G729,?G73?G737,?G80?G809,?G93?G939,?P04?P049,?Q86,?Q90?Q99,?R56?R569,?S06?
S069X9,?F819,?I6783,?P154,?P158,?P159?
Oral?Surgery?Services?
Impacted?teeth?should?be?extracted?only?when?medically?necessary.?Horizon?NJ?Health?does?not?
reimburse?for?the?extraction?of?asymptomatic?impacted?teeth?or?those?teeth?where?dental?or?
medical?necessity?is?not?demonstrated.?
To?qualify?for?surgical?removal?of?a?tooth?with?partial?or?complete?bony?impaction,?providers?
must?establish?a?case?for?incision?of?overlying?soft?tissue,?removal?of?bone,?and/or?sectioning?of?
the?tooth.?Providers?must?justify?extractions?in?more?than?one?quadrant?of?the?mouth?as?
emergency?procedures.?
To?request?reimbursement?or?prior?authorization?of?oral?surgical?procedures?(when?necessary),?
submit?a?detailed?description,?including?dates,?diagnosis,?and?site?and?size?of?the?operative?area?
(i.e.,?number?of?lesions?and/or?number?and?size?of?lacerations).?Submit?prior?authorization,?
preoperative,?and?any?postoperative?radiographs?along?with?radiological,?operative,?and?
laboratory?reports?directly?to?the?Horizon?NJ?Health?Dental?Consultant?with?the?current?ADA?
Dental?Claim?Form.?Provide?all?other?reports,?such?as?hospital?radiographs,?upon?request.?
The?dentist?performing?a?biopsy?receives?reimbursement?for?only?the?surgical?portion.?The?
laboratory?performing?the?diagnostic?service?and?not?the?dentist?should?bill?the?program?
directly?for?the?diagnostic?services.?When?the?biopsy?is?performed?as?an?independent?procedure?
on?a?different?date?separate?and?apart?from?the?excision?of?the?entire?lesion,?the?dentist?may?
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House?Calls?
A?physician,?dentist,?or?healthcare?professional?may?bill?for?a?house?call?(D9410)?in?addition?to?
any?other?services?provided?on?that?day.?When?medically?necessary,?Horizon?NJ?Health?
reimburses?D9410?for?home?visits?for?patients?with?developmental?disabilities.?We?reimburse?
D9420?for?preoperative?and?postoperative?evaluations?associated?with?inpatient?operative?and?
surgical?procedures.?
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Hospital?Calls?
Services?performed?in?hospital?and?surgical?center?outpatient?dental?clinics?require?prior?
authorization.?An?authorization?approved?by?a?Horizon?NJ?Health?Dental?Consultant?covers?only?
dental?services;?it?does?not?authorize?the?place?of?service?and?does?not?guarantee?payment.?
Horizon?NJ?Health?reimburses?dental?services?rendered?in?an?approved,?licensed?hospital,?if?the?
patient?requires?that?level?care.?Medical?necessity?must?be?documented?in?the?hospital?records.?
Dental?services?are?also?reimbursed?if?a?member?is?admitted?for?an?eligible?non?dental?condition?
and?dental?services?are?rendered?as?part?of?the?prescribed?treatment?for?the?condition?or?to?
alleviate?the?member?s?discomfort?during?hospitalization.?
A?physician,?dentist,?or?healthcare?professional?may?bill?for?a?hospital?call?(D9420)?for?an?inpatient?
or?outpatient?hospital?visit,?in?addition?to?any?other?dental?services?provided?on?that?day.?
For?an?initial?hospital?call?or?same?day?surgery,?the?hospital?record?must?minimally?include:?

? The?chief?complaints?
? Complete?history?of?the?present?illness?and?related?systematic?review?including?pertinent?

negative?findings?
? Complete?pertinent?past?medical?history?
? Pertinent?family?history?
? Description?of?full?examination?pertaining?to?the?history?of?the?present?condition?
? Record?of?working?diagnosis?and?treatment?plan,?and?preparation?of?an??order?sheet??

Horizon?NJ?Health?does?not?reimburse?an?initial?hospital?call?or?same?day?surgery?call?(D9420)?if:??
? Billed?in?conjunction?with?a?consultation?or?other?hospital?calls?on?the?same?day.??
? The?same?practitioner,?members?of?the?same?group,?members?of?a?shared?healthcare?

facility,?or?practitioner?sharing?a?common?record?also?bill?for?this?procedure?code.?
? Billed?in?conjunction?with?a?consultation?(D9310)?for?the?same?hospital?admission?and/or?

stay?when?billed?by?the?same?practitioner,?members?of?the?same?group,?members?of?a?
shared?healthcare?facility,?or?practitioner?sharing?a?common?record.?

When?the?history?and?examination?required?for?D9420?is?not?personally?performed?by?the?billing?
practitioner,?the?dentist?or?healthcare?professional?should?bill?for?a?hospital?call?(D9420)?if?the?
code?criteria?are?met.??
? ?



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Medical?vs.?Dental?Services?
Horizon?NJ?Health?recognizes?that?medical?conditions?may?exist?that?can?exhibit?one?or?more?
dental?components.?These?dental?components/conditions?may?be?1)?causative?to?the?medical?
situation?of?the?patient,?2)?completely?unrelated,?or?3)?the?sequelae?of?the?medical?condition?or?
its?treatment.??
A?physician?or?oral?surgeon?may?perform?procedures?that?may?be?considered?medical?or?dental?
(e.g.,?surgical?procedures?for?fractured?jaw,?removal?of?cyst,?or?provision?of?maxillofacial?
prosthetics).?Please?see?Section?8.2?Precertification?Process?to?obtain?the?authorization?process?
or?you?may?call?the?Horizon?NJ?Health?Utilization?Management?Department?at?1?800?682?9094.??

? A?broad?definition?of?dental?services?would?be?those?procedures?used?to?treat?the?dental?
structures,?including?primary?and?permanent?dentition?and?supporting?structures?
including?the?periodontium?and?alveolar?bone.??

? Specific?procedures?that?would?fall?under?the?category?of?dental?treatment?are:??
? Restoration?of?tooth?structure?lost?by?decay,?fracture,?attrition?or?erosion?using?synthetic?

materials.?This?can?include?intra?coronal?restorations,?such?as?amalgam,?gold?or?
composite,?full?or?partial?coverage?crowns?and?tooth?strengthening?and?retention?
enhancement?for?endodontically?treated?teeth.??

? Endodontic?treatment?of?teeth,?including?re?treatment,?if?necessary,?and?any?necessary?
periapical?or?sectioning?surgical?intervention??

? Surgical?services?and?post?op?treatment?performed?on?the?dental?supporting?structures?
that?include?treatment?of?periodontal?disease,?osseous?surgery?and?any?other?surgery?to?
the?periodontium??

? Replacement?of?missing?teeth?using?full?dentures,?removable?partial?dentures?or?fixed?
prostheses?and?related?services??

? Removal?of?teeth?and?re?implantation?of?teeth?and?associated?services??
? Orthodontic?treatment,?even?if?a?component?of?an?eligible?medical?condition?or?

treatment??
Obtain?authorization?by?calling?Horizon?NJ?Health?s?Utilization?Management?Department?at?least?
five?business?days?prior?to?the?inpatient?or?outpatient?procedure?if?the?procedure?requires?
anesthesia?or?is?performed?in?an?inpatient?setting?or?non?participating?ambulatory?surgical?
center.?Utilization?Management?Department:?1?800?682?9094.?
? ?



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Amalgam?Restorations?
Reimbursement?for?amalgam?restoration?includes?treatment?of?pulp?exposure,?lining?or?base,?
restoration,?polishing?of?restoration,?and?local?anesthesia?or?analgesia.?Select?the?procedure?code?
based?on?the?number?of?surfaces?restored?per?individual?tooth?not?on?the?basis?of?individual?
restorations.?In?this?way,?the?fee?for?any?surface?includes?one?or?more?restorations?on?that?
surface.?Horizon?NJ?Health?reimburses?only?one?code?per?tooth.?Reimbursement?for?an?occlusal?
restoration?includes?any?extensions?onto?the?occlusal?one?third?of?the?buccal?or?lingual?surfaces?
of?the?tooth.?
Interproximal?Fillings?
Extensions?of?interproximal?fillings?into?self?cleansing?areas?are?not?considered?additional?
surfaces.?Horizon?NJ?Health?reimburses?an?additional?surface?only?when?the?buccal?(facial)?or?
lingual?margin?extends?beyond?the?proximal?one?third?of?the?buccal?(facial)?and/or?lingual?
surfaces.?
Proximal?Restorations?
Proximal?restorations?in?anterior?teeth?are?normally?considered?single?surface?restorations.?
When?the?dentist?gains?access?to?a?proximal?cavity?by?involvement?of?a?second?surface,?Horizon?
NJ?Health?permits?reimbursement?for?only?one?surface.?We?only?reimburse?a?two??or?three?
surface?proximal?restoration?when?the?facial?and/or?lingual?margins?of?the?restoration?extends?
beyond?the?proximal?one?third?of?the?facial?and/or?lingual?surfaces.?
Proximal?Fillings?
Extensions?of?proximal?fillings?into?self?cleansing?areas?are?not?considered?additional?surfaces.?
When?selecting?the?appropriate?code?for?an?individual?tooth,?note?that?only?one?code?is?
reimbursable?per?tooth.?The?fee?for?any?surface?includes?one?or?more?restorations?on?that?surface.?
A?reimbursement?for?an?occlusal?restoration?includes?any?extensions?onto?the?occlusal?one?third?
of?the?buccal?(facial)?or?lingual?surfaces?of?the?tooth.?Reimbursements?for?a?restoration?includes?
treatment?of?pulp?exposure,?lining?or?base,?restoration,?and?local?anesthesia?or?analgesia.?
Diagnostic?Services?
Clinical?laboratory?services?include?services?provided?by?the?following:?

? Independent?clinical?laboratories,?such?as?physician/dentist?operated?and?out?of?hospital?
laboratories?that?primarily?perform?diagnostic?work?referred?by?other?practitioners.?

? Hospital?laboratories?and?laboratories?of?educational?institutions?that?provide?laboratory?
services?to?ambulatory?members?as?requested?by?a?licensed?practitioner.?

Dentists?should?not?bill?for?any?services?provided?by?these?clinical?laboratories.?Instead,?the?
laboratories?should?bill?Horizon?NJ?Health?directly.?Horizon?NJ?Health?members?are?capitated?to?
LabCorp?for?all?laboratory?services,?except?during?an?inpatient?hospitalization.?
? ?



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All?facilities?or?entities?that?perform?clinical?laboratory?testing?must?be?certified?for?any?
performed?services.?Reimbursement?for?laboratory?testing?is?not?eligible?to?any?facility?without?
Clinical?Laboratory?Improvement?Amendments?(CLIA)?certification?and?a?valid?CLIA?identification?
number.?
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?Primary?Care?Dentist?
(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.?
Anesthesia??
Horizon?NJ?Health?considers?the?administration?of?local?anesthesia?part?of?the?operative?or?
surgical?procedure?and?does?not?allow?additional?reimbursement.?When?a?dentist?provides?
general?anesthesia?in?a?hospital?setting,?reimbursement?is?subject?to?demonstrating?dental?or?
medical?necessity.?
Reimbursement?is?made?only?to?a?dentist?who?satisfies?all?established?rules?and?regulations?and?
holds?a?written?certification?(permit),?which?may?be?required?by?the?State?of?New?Jersey?or?state?
where?service?is?rendered.?When?the?attending?dentist?performing?the?dental?service?also?
administers?the?general?anesthesia,?the?provider?should?submit?procedure?code?D9223.??
When?a?dentist?administers?the?general?anesthesia?whose?sole?function?is?to?administer?general?
anesthesia,?Horizon?NJ?Health?reimburses?the?service?if:??

? Anesthetic?management?is?necessary?to?perform?restorative?dentistry?alone?or?
restorative?dentistry?in?conjunction?with?other?dental?services.?

? The?documentation?contains?unique?general?anesthesia?codes.?
? An?anesthesia?record?is?maintained?and?submitted?with?the?current?ADA?Claim?Form?for?

anesthesia?and?treatment.?The?anesthesia?record?must?contain?the?elapsed?anesthesia?
time,?specific?time?and?amounts?of?drugs?administered,?pulse?rate?and?character,?blood?
pressure,?and?respiration.?(Note:?The?elapsed?anesthesia?time?means?the?time?from?
induction?of?the?general?anesthesia?to?the?point?in?time?when?the?anesthetist?is?no?
longer?in?personal?attendance).?

? ?



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Intravenous?Sedation??
Horizon?NJ?Health?reimburses?the?administration?of?intravenous?sedation?as?follows:?

? This?sedation?is?administered?continuously?during?the?operative?or?surgical?procedure.?
? We?offer?no?reimbursement?if?an?injection?is?administered?as?a?preoperative?medication.?
? The?practitioner?must?document?the?need?for?this?service.?
? Reimbursement?is?made?only?to?a?dentist?who?satisfies?all?established?rules?and?regulations,?

and?holds?a?written?certification?(permit),?which?may?be?required?by?the?State?of?New?Jersey?
or?state?where?service?is?rendered.?

Analgesia??
Horizon?NJ?Health?reimburses?an?inhalation?anesthetic?for?the?purposes?of?analgesia?as?part?of?an?
operative?or?surgical?procedure?as?follows:?

? Analgesia?is?administered,?as?needed,?continuously?during?the?operative?or?surgical?procedure.?
? We?offer?no?reimbursement?if?an?injection?is?administered?as?a?preoperative?medication.?
? The?practitioner?must?document?the?need?for?this?service.?
? Reimbursement?is?only?made?to?a?dentist?who?satisfies?all?established?rules?and?regulations,?

and?holds?a?written?certification?(permit),?which?may?be?required?by?the?State?of?New?Jersey?or?
state?where?service?is?rendered.?

? We?allow?only?one?charge?per?visit?for?analgesia.?
Injections??
Horizon?NJ?Health?reimburses?intradermal,?subcutaneous,?intramuscular,?and?intravenous?
injections?in?the?office?or?home?within?the?scope?of?accepted?dental?practice?as?follows:?

? Reimbursement?for?these?injections?applies?as?an?all?inclusive?flat?fee,?covering?both?the?cost?of?
the?service?and?the?drug.?

? A?dental?visit?for?the?sole?purpose?of?an?injection?is?reimbursable?for?only?the?injection.?If?other?
reimbursable?dental?procedures?are?performed,?we?reimburse?the?injection?when?medically?
necessary?as?well?as?the?other?procedures.?The?administered?drug?must?be?consistent?with?the?
diagnosis?and?conform?to?accepted?medical?and?pharmacological?principles?in?respect?to?dosage,?
frequency,?and?route?of?administration.?

? Intravenous?injections?are?reimbursable?only?when?performed?by?the?dentist.?
? We?do?not?reimburse?for?vitamins,?liver,?or?iron?injections?or?combinations?thereof?except?in?

laboratory?proven?deficiency?states?requiring?parenteral?therapy.?
? We?do?not?reimburse?placebos?or?any?injections?containing?amphetamines?or?derivatives?thereof.?
? We?do?not?reimburse?an?injection?administered?as?a?preoperative?medication?in?conjunction?with?

general?anesthesia?or?local?anesthetic?as?part?of?an?operative?or?surgical?procedure.?
? Annotate?the?Remarks?section?in?the?current?ADA?Claim?Form?with?the?following?items:?the?

appropriate?procedure?code,?name?of?the?injected?drug,?dosage,?route?of?administration,?and?the?
complete?diagnosis?for?the?injection.?

Horizon?NJ?Health?considers?drugs,?biologicals,?or?supplies?used,?administered,?or?provided?by?the?dentist?
part?of?the?professional?service,?and?does?not?allow?additional?reimbursement?for?them.?



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Orthodontic?Services??
The?following?standards?and?procedures?apply?to?the?provision?of?orthodontic?services?for?
children?in?NJ?FamilyCare?programs.??
Orthodontic?Consultation?(D9310) - must?include?a?visual?examination?and?may?also?include?a?
completed?HLD?(NJ?Mod3)?Assessment?Tool?by?the?attending?provider?or?a?provider?in?the?same?
group.?This?consultation?does?not?require?prior?authorization,?can?be?provided?once?a?year?and?
will?be?linked?to?the?provider?and?not?to?the?patient?(which?allows?for?a?second?opinion?with?a?
different?provider).
?
Pre?Orthodontic?Treatment?Visit?(D8660) - includes?the?diagnostic?workup,?clinical?evaluation,?
orthodontic?treatment?plan?and?completion?of?HLD?(NJ?Mod3)?assessment?tool.??
?
The?HLD?(NJ?Mod3)?is?only?required?for?consideration?of?comprehensive?orthodontic?treatment.?
The?HLD?(NJ?Mod3)?is?completed?by?the?dentist?that?will?be?rendering?the?orthodontic?treatment.??
?
If?the?HLD?(NJ?Mod3)?Assessment?Tool?has?an??X??and?correctly?documented?clinical?criteria?
found?in?sections1?6A?and?15?of?the?assessment?tool?or?a?total?score?that?is?equal?to?or?greater?
than?26,?the?pre?orthodontic?treatment?work?up?can?proceed.?A?total?score?of?less?than?26?points?
on?the?HLD?(NJ?Mod3)?Assessment?Tool?requires?documentation?of?the?extenuating?
circumstances,?functional?difficulties?and/or?medical?anomaly?be?included?in?the?submission.??

? The?visit?does?not?require?prior?authorization?and?should?occur?with?the?expectation?that?
the?case?will?be?completed?prior?to?the?client?exceeding?the?age?of?eligibility?for?the?
benefit;??

? This?service?can?be?provided?once?a?year?and?will?be?linked?to?the?provider?and?not?to?
the?patient;??

? The?orthodontic?work?up?includes?the?consultation;?therefore,?consultation?will?not?be?
reimbursed?separately.??

Minor?Treatment?to?Control?Harmful?Habits??
Minor?treatment?can?be?used?for?the?correction?of?oral?habits?in?any?dentition.?Approval?for?
treatment?to?control?harmful?habits?when?not?part?of?a?limited,?interceptive?or?comprehensive?
case?will?include?appliances,?removable?or?fixed,?insertion,?all?adjustments,?repairs,?removal,?
retention?and?treatment?visits?to?the?provider?of?placement.?Replacement?of?appliances?due?to?
loss?or?damage?beyond?repair?is?allowed?once?and?thereafter?requires?prior?authorization?and?
can?be?considered?with?documentation?of?incident?and?documentation?of?medical?necessity.??
?
For?prior?authorization,?a?narrative?of?the?clinical?findings,?treatment?plan,?estimated?treatment?
time?with?prognosis?and?diagnostic?photographs?and/or?models?shall?be?submitted?and?
maintained?in?the?treatment?records.??

Upon?completion?of?the?case?pre?treatment?and?post?treatment?photographs?must?be?
submitted. ? ?



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Orthodontic?Treatment?Services??
Limited,?interceptive?and?comprehensive?orthodontic?services?must?be?prior?authorized?and?will?
be?considered?for?the?treatment?of?the?primary?dentition,?permanent?dentition?or?mixed?
dentition?for?treatment?of?the?permanent?teeth.?
Prior?authorization?determinations?shall?be?made?and?notice?sent?to?the?provider?within?ten?(10)?
days?of?receipt?of?all?necessary?information?sufficient?for?a?dental?consultant?to?make?an?
informed?decision.??
In?cases?where?prior?authorization?is?denied,?the?denial?decision?must?be?made?by?an?
orthodontist.?The?denial?letter?must?contain?a?detailed?explanation?of?the?reason(s)?for?denial;?
indicate?whether?additional?information?is?needed?and?the?process?for?reconsideration.?It?must?
also?include?the?name?and?contact?information?of?the?orthodontic?consultant?that?reviewed?and?
denied?the?treatment?request?which?will?allow?the?treating?provider?an?opportunity?to?discuss?
the?case.??
An?approved?case?must?be?started?within?six?(6)?months?of?receiving?the?approval.??
Limited?Orthodontic?Treatment??
Limited?orthodontic?treatment?can?be?considered?for?treatment?not?involving?the?entire?
dentition?and?can?be?used?for?corrections?in?any?dentition.??
For?prior?authorization,?the?following?shall?be?submitted:??

? Narrative?of?clinical?findings,?treatment?plan?and?estimated?treatment?time??
? Diagnostic?photographs??
? Diagnostic?X?rays?or?digital?films?
? Diagnostic?study?models?or?diagnostic?digital?study?cast?images?
? The?referring?primary?care?dentist?must?provide?attestation?that?all?needed?preventive?

and?dental?treatment?services?have?been?completed.?A?copy?must?be?submitted?with?the?
orthodontic?treatment?request.??

The?reimbursement?for?the?service?includes?the?appliance,?insertion,?all?adjustments,?repairs,?
removal,?retention?and?treatment?visits?to?the?provider?of?placement.?Therefore,?the?case?shall?
be?completed?even?if?eligibility?is?terminated?at?no?additional?charge?to?the?member.?
Replacement?of?retainers?or?removable?appliances?due?to?loss?or?damage?beyond?repair?requires?
prior?authorization?and?can?be?considered?with?documentation?of?medical?necessity.??
If?it?is?determined?that?limited?orthodontic?treatment?is?part?of?a?comprehensive?treatment?plan?
which?will?occur?within?less?than?12?months,?it?will?be?considered?part?of?the?comprehensive?case?
and?will?not?be?reimbursed?separately.?In?this?case,?the?prior?authorization?should?be?submitted?
for?comprehensive?orthodontic?treatment?with?an?attached?treatment?plan?that?indicates?the?
limited?treatment?phase?including?the?expected?time?frame?for?this?and?the?expected?initiation?
(month/year)?of?the?comprehensive?treatment.?Upon?completion?of?the?case,?pre?treatment?and?
post?treatment?photographs?must?be?submitted.?? ?



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Interceptive?and?Comprehensive?Orthodontic?Treatment??
For?prior?authorization?requests?the?following?shall?be?submitted:??

? The?completed?HLD?(NJ?Mod3)?assessment?tool?for?comprehensive?orthodontic?
treatment?

? Narrative?of?clinical?findings?for?dysfunction?and?dental?diagnosis??
? The?interceptive?or?comprehensive?orthodontic?treatment?plan?and?estimated?treatment?

time??
? Attestation?from?the?referring?primary?care?dentist?that?all?needed?preventive?and?dental?

treatment?services?have?been?completed??
? Diagnostic?study?models?or?diagnostic?digital?study?models??
? Diagnostic?photographs?(which?may?suffice?in?place?of?models)?
? Diagnostic?x?rays,?digital?x?rays?or?cephlometric?film?with?tracing?(when?applicable);?and?
? When?applicable:??

o Medical?diagnosis?and?surgical?treatment?plan??
o Detailed?documentation?of?extenuating?circumstances?
o Detailed?documentation?from?a?mental?health?professional?as?described?in?the?

managed?care?contract?indicating?the?psychological?or?psychiatric?diagnosis,?
treatment?history?and?prognosis?and?an?attestation?stating?and?substantiating?
that?orthodontic?correction?will?result?in?a?favorable?prognosis?of?the?mental/?
psychological?condition.??

Interceptive?Orthodontics??
Interceptive?treatment?can?be?considered?for?localized?tooth?movement?and?may?be?for?
redirection?of?ectopic?eruptions,?correction?of?dental?crossbites?or?recovery?of?space?in?the?
primary?or?transitional?dentition.?Approval?for?the?interceptive?treatment?when?not?part?of?the?
comprehensive?case?will?include?all?appliances,?insertion,?all?adjustments,?repairs,?removal,?
retention?and?treatment?visits?and?initial?retainers?to?the?provider?of?placement.?Replacement?of?
retainers?or?removable?appliances?due?to?loss?or?damage?beyond?repair?requires?prior?
authorization?and?documentation?of?medical?necessity.??
If?it?is?determined?that?interceptive?orthodontic?treatment?is?part?of?a?comprehensive?treatment?
plan?which?will?occur?within?less?than?12?months,?it?will?be?considered?part?of?the?comprehensive?
case?and?will?not?be?reimbursed?separately?In?this?case,?the?prior?authorization?should?be?
submitted?for?comprehensive?orthodontic?treatment?with?an?attached?treatment?plan?that?
indicates?the?interceptive?treatment?phase,?including?the?expected?time?frame?and?expected?
initiation?(month/year)?of?comprehensive?treatment.
Upon?completion?of?the?case,?pre?treatment?and?posttreatment?diagnostic?photographs?must?be?
submitted.?? ?



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Comprehensive?Orthodontics??
Eligibility?should?be?checked?prior?to?each?visit.??
The?NJFC?Medicaid?Fee?for?Service?(FFS)?program?reimburses?for?periodic?treatment?visits?
(D8670)?which?are?billed?for?the?date?of?service.?A?maximum?of?36?units?of?D8670?are?allowed?for?
each?comprehensive?orthodontic?case,?which?is?expected?to?last?no?longer?than?36?months?from?
the?date?of?banding.??
The?reimbursement?for?comprehensive?treatment?is?requested?using?the?date?the?appliances?are?
placed?and?billed?as?D8080.?The?date?of?each?periodic?visit?(D8670)?is?billed?separately?on?the?
date?of?service.?Services?reimbursed?through?these?codes?will?include?all?appliances,?their?
insertions,?adjustments,?repairs?and?removal?as?well?as?the?retention?phase?of?treatment?to?the?
provider?of?placement.??
Initial?retainer(s)?are?included?with?the?service;?however?replacement?of?retainers?or?removable?
appliances?due?to?loss?or?damage?beyond?repair?is?allowed?once.?If?additional?replacements?are?
needed,?the?service?requires?prior?authorization?and?can?be?considered?with?documentation?of?
the?incident?and?medical?necessity.?
Reimbursement?for?orthodontic?services?includes?the?placement?and?removal?of?all?appliances?
and?brackets;?therefore?should?it?become?necessary?to?remove?the?bands?following?or?due?to?
loss?of?eligibility,?non?compliance?or?elective?discontinuation?of?treatment?by?the?parent,?
guardian?or?patient?the?appliance?shall?be?removed?with?no?additional?reimbursement?to?the?
provider?of?placement?because?reimbursement?for?comprehensive?orthodontics?includes?this?
service.?In?cases?where?treatment?is?discontinued,?a??Release?from?Treatment??letter?must?be?
provided?by?the?dental?office?which?documents?the?reason?for?discontinuing?care?and?releases?
the?dentist?from?the?responsibility?of?completing?the?case.?The?release?form?must?be?reviewed?
and?signed?by?the?parent/guardian?and?patient,?and?a?copy?maintained?in?the?patient?s?records.??
Requesting?Prior?Authorization?
Prior?authorization?for?comprehensive?orthodontic?treatment?will?only?be?considered?for?the?
permanent?dentition.?As?an?exception,?cases?with?late?mixed?dentition?will?require?
documentation?of?the?planned?treatment?for?the?existing?primary?teeth?and?the?reason?for?
starting?treatment?prior?to?their?natural?exfoliation.??
Beginning?Treatment?

? In?addition?to?submission?requirements?already?noted,?the?prior?authorization?form?to?
request?the?beginning?phase?of?treatment?should?be?completed?for?procedure?code?
D8080?and?the?treatment?visits?with?a?maximum?number?of?units?for?treatment?visits?to?
be?considered?on?any?one?prior?authorization?being?twelve?(12)?

? The?case?start?date?is?considered?to?be?the?banding?date?which?must?occur?within?six?(6)?
months?of?approval??

? If?the?prior?authorization?expires?before?all?approved?units?are?used,?a?prior?authorization?
may?be?submitted?for?the?remaining?units?along?with?an?explanation?that?includes?the?
original?prior?authorization?number?and?why?treatment?did?not?occur?within?the?active?
time?of?the?prior?authorization.?? ?



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Continuing?Treatment??
? Prior?authorization?for?the?continuation?of?treatment?visits?for?the?continuation?of?the?

case?shall?be?submitted?after?completing?the?first?twelve?(12)?units?of?treatment?visits?or?
at?the?mid?point?of?treatment.??

? The?maximum?number?of?additional?treatment?visits?allowed?to?continue?the?case?is?
twelve?(12).??

? If?the?prior?authorization?expires?before?all?approved?units?were?used,?a?prior?
authorization?may?be?submitted?for?the?remaining?units?along?with?an?explanation?that?
includes?the?original?prior?authorization?number?and?why?treatment?did?not?occur?within?
the?active?time?of?the?prior?authorization.??

? The?following?shall?be?included?with?the?prior?authorization?request:??
o A?copy?of?the?treatment?notes??
o Documentation?of?any?problems?with?compliance??

? Attestation?from?the?current?primary?care?dentist?that?recall?visits?occurred?and?that?all?
needed?preventive?and?dental?treatment?services?have?been?completed??

? Pre?treatment?and?current?treatment?diagnostic?photographs?and/or?diagnostic?
panoramic?radiographs?to?show?status?and?to?demonstrate?case?progression??

? A?copy?of?the?initial?approval?if?the?case?was?started?under?a?different?NJ?FamilyCare?
Medicaid?MCO?or?fee?for?service?program??

Prior?Authorization?for?Orthodontic?Services?Transferred?or?Started?Outside?of?the?NJ?FamilyCare?
Medicaid?Program??
For?continuation?of?care?for?transfer?cases?whether?they?were?or?were?not?started?by?another?NJ?
FamilyCare?Medicaid?provider,?a?prior?authorization?must?be?submitted?to?request?the?remaining?
treatment?visits?to?continue?a?case?with?a?maximum?of?twelve?(12)?per?prior?authorization?to?be?
considered.?The?following?must?be?submitted?with?the?prior?authorization:??

? A?copy?of?the?initial?orthodontic?case?approval?(if?applicable)??
? Attestation?from?the?referring?or?treating?primary?care?dentist?that?preventive?and?dental?

treatment?services?have?been?completed??
? A?copy?of?the?orthodontic?treatment?notes?from?provider?that?started?the?case?(if?

available)??
? Recent?diagnostic?photographs?and/or?panoramic?radiographs?and?if?available?pre?

treatment?photographs??
? The?date?when?active?treatment?was?started??
? The?expected?number?of?months?to?complete?the?case?along?with?the?number?of?units?for?

treatment?visits?with?maximum?number?of?24?units?allowed??
? If?applicable?a?new?treatment?plan?and?documentation?to?support?the?treatment?change?

if?re?banding?is?planned.??
A?case?in?treatment?cannot?be?denied?if?the?patient?is?eligible?for?orthodontic?coverage?based?on?age.??



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Orthognathic?Surgical?Cases?with?Comprehensive?Orthodontic?Treatment??
? The?surgical?consult,?treatment?plan?and?approval?for?surgical?case?must?be?included?with?

the?request?for?prior?authorization?of?the?orthodontic?services;??
? Prior?authorization?and?documentation?requirements?are?the?same?as?those?for?

comprehensive?treatment?and?shall?be?submitted?by?the?treating?orthodontist;??
? The?parent/guardian?and?patient?should?understand?that?loss?of?eligibility?at?any?time?during?

treatment?will?result?in?the?loss?of?all?benefits?and?payment?by?the?NJFC?Medicaid?program.??
Conclusion?of?Active?Treatment?

? Attestation?of?case?completion?must?be?submitted?to?document?that?active?treatment?
had?a?favorable?outcome?and?that?the?case?is?ready?for?retention.??

? Procedure?code?D8680,?orthodontic?retention,?shall?be?submitted?for?prior?authorization?
along?with?recent?panorex?and?photographs?when?the?active?phase?of?orthodontic?
treatment?is?completed.??

? Once?approved,?the?bands?can?be?removed?and?the?case?placed?in?retention.??
Documentation?for?Completion?of?Comprehensive?Cases???Final?Records??
The?following?must?be?submitted?to?document?the?completion?of?comprehensive?cases:??

? Final?diagnostic?photographs?and/or?panoramic?radiograph??
? Final?diagnostic?study?models?or?diagnostic?digital?study?models?must?be?taken?and?be?

available?upon?request.??
If?this?is?not?received,?reimbursement?provided?may?be?recovered?until?required?documentation?
is?submitted.??
Behavior?Not?Conducive?to?Favorable?Treatment?Outcomes??
It?is?the?expectation?that?the?case?selection?process?for?orthodontic?treatment?takes?into?
consideration?the?patient?s?ability,?over?the?course?of?treatment?to:??

? Tolerate?the?treatment??
? Keep?multiple?appointments?over?several?years??
? Maintain?an?oral?hygiene?regimen,?and??
? Be?cooperative?and?complete?all?needed?preventive?and?treatment?visits??

If?it?is?determined?that?treatment?is?not?progressing?because?the?patient?is?exhibiting?non?
compliant?behavior?which?may?include?any?of?the?following:?multiple?missed?orthodontic?or?
general?dental?appointments,?continued?poor?oral?hygiene,?failure?to?maintain?the?appliances?or?
untreated?dental?disease,?discontinuation?of?treatment?can?be?considered.??
? ?



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A?letter?must?be?sent?to?the?parent/guardian?and/or?patient?that?documents?the?factors?of?
concern,?the?corrective?actions?needed?and?informs?that?failure?to?comply?can?result?in?the?
discontinuation?of?treatment?with?de?banding.?A?copy?of?this?letter?and?the?patient?treatment?
records?must?be?sent?to?Horizon?NJ?Health,?1700?American?Blvd.,?Pennington,?NJ,?08534.?
If?the?case?is?discontinued?for?reasons?other?than?the?completion?of?treatment?(D8695),?the?
?Release?from?Treatment??letter?should?be?signed?by?parent/guardian?and/or?patient.?For?
members?enrolled?in?Horizon?NJ?Health,?a?copy?of?the?signed?form?and?the?patient?treatment?
records?must?be?sent?to?Horizon?NJ?Health,?1700?American?Blvd.,?Pennington,?NJ,?08534.?
The?reimbursement?for?appliance?placement?includes?their?removal;?however,?prior?authorization?
to?allow?reimbursement?can?be?considered?when?removal?is?by?a?provider?that?did?not?start?the?
case.?
? ?



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Instructions?for?Completing?the?New?Jersey?Orthodontic?Evaluation?HLD?(NJ?Mod3)?Index?Form:?
The?intent?of?the?HLD?(NJ?Mod3)?Index?is?to?measure?the?presence?or?absence?and?the?degree?of?
the?handicap?caused?by?the?components?to?be?scored?with?the?index?and?NOT?to?diagnose?
Malocclusion.?Presence?of?any?of?the?conditions?sections?1?through?6A?and?15,?or?a?score?total?
equal?to?or?greater?than?26?(when?scored?correctly)?qualifies?for?medical?necessity?exception.?Total?
scores?less?than?26?with?extenuating?circumstances?must?include?appropriate?documentation.?
?
GENERAL?INFORMATION:?

? Only?cases?with?late?mixed?and?permanent?dentition?will?be?considered?(see?Pre?
orthodontic?Treatment?Visit?(D8660)?for?exception).?

? A?Boley?Gauge?or?disposable?ruler?scaled?in?millimeters?should?be?used;?
? The?patient?s?teeth?are?positioned?in?centric?occlusion;?
? All?measurements?are?recorded?and?rounded?off?to?the?nearest?millimeter?(mm);?
? For?sections?1?to?6A?and?15?an?X?is?placed?if?the?condition?exists?and?scoring?is?completed,?

as?needed;?
? For?sections?6B?to?14,?indicate?the?measurement?or?if?a?condition?is?absent,?a?0?score?is?

entered;?
? Diagnostic?models?are?required?with?the?submission?of?prior?authorization.?Casts?must?be?

properly?poured,?adequately?trimmed?without?voids?or?bubbles??and?marked?for?centric?
occlusion;?or,?

? Diagnostic?Digital?models?may?be?submitted?to?show?right?and?left?lateral,?frontal?and?
posterior?and?maxillary?and?mandibular?occlusal?views;?

? Diagnostic?quality?photographs?to?show?facial,?frontal?and?profile,?intra?oral?front,?left?and?
right?side,?maxillary?and?mandibular?occlusal?views?(minimum?of?seven?views).?
Photographs?shall?include?views?with?a?millimeter?ruler?in?place?to?demonstrate?
measurement?for?the?following?condition(s)?when?present?as?found?in?sections?6A,?6B,?7,?
8,?9?and?13.?

INSTRUCTIONS?FOR?FORM?COMPLETION:?
1.??Cleft?Palate?Deformity???acceptable?documentation?must?include?at?least?one?of?the?following:?
intraoral? photographs? of? the? palate,?written? consultation? report? by? a? qualified? specialist? or?
craniofacial?panel.?Score?an?X?if?present.?
2.? ?Cranio?facial?Anomaly???acceptable?documentation?must? include?written? report?by?qualified?
specialist?or?craniofacial?panel?and?photographs.?Score?an?X?if?present.?
3.??Impacted?Permanent?Anterior?Teeth???demonstrate?that?anterior?tooth?or?teeth?(incisors?and?
cuspids)? is? or? are? impacted? (soft? or? hard? tissue);? not? indicated? for? extraction? and? treatment?
planned?to?be?brought?into?occlusion.?Arch?space?available?for?correction.?Score?an?X?if?present.?



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4.??Crossbite?of?Individual?Anterior?teeth???Score?an?X?if?present.???demonstrate?that?anterior?tooth?
or?teeth? (incisors?and?cuspids)? is?or?are? in?crossbite?resulting? in?occlusal?trauma?with?excessive?
wear,?significant?mobility?or?soft?tissue?damage.?A?narrative?to?include?the?class?of?mobility?for?the?
involved?teeth?and?photographs?of?all?areas?with? softtissue?damage.?Score?X?as?noted.? If?these?
conditions?do?not?exist,?it?is?to?be?considered?an?ectopic?eruption?and?scored?in?section?10.?
5.?Severe?Traumatic?Deviation???damage?to?skeletal?and?or?soft?tissue?as?a?result?of?trauma?or?other?
gross?pathology.?Include?written?report?and?intraoral?photographs.??Score?an?X?if?present.?
6A.?Overjet?greater?than?9mm?or?mandibular?protrusion?(reverse?overjet)?greater?than?3.5???Overjet?
is?recorded?with?the?patient?s?teeth? in?centric?occlusion?and? is?measured?from?the? labial?of?the?
lower?incisors?to?the?labial?of?the?corresponding?upper?central?incisors.?This?measurement?should?
record?the?greatest?distance?between?any?one?upper?central?incisor?and?its?corresponding?lower?
central?or? lateral? incisor.? If? the?overjet? is?greater? than?9mm?or?mandibular?protrusion? (reverse?
overjet)?is?greater?than?3.5mm,?score?an?X?if?present.?
6B.?Overjet?equal? to?or? less? than?9mm???Overjet? is? recorded?as? in?condition? in?section?6A.?The?
measurement?is?rounded?to?the?nearest?millimeter?and?entered?on?the?score?form.?
7.?Overbite? ?? A? pencil?mark? on? the? tooth? indicating? the? extent? of? the? overlap? facilitates? the?
measurement.?It?is?measured?and?rounded?off?the?nearest?millimeter?and?entered?on?the?score?
form.?
8.??Mandibular?protrusion?(reverse?overjet)?equal?to?or?less?than?3.5?mm???Mandibular?protrusion?
(reverse?overjet)?is?recorded?as?a?condition?and?rounded?to?the?nearest?millimeter.?Enter?the?score?
on?the?form?and?multiply?the?measurement?by?five?(5).?
9.??Open?Bite?in?millimeters???This?condition?is?defined?as?the?absence?of?occlusal?contact?in?the?
anterior?region.? It? is?measured?from?the? incisal?edge?of?a?maxillary?central? incisor?to?the? incisal?
edge?of?a?corresponding?mandibular?incisor,?in?millimeters.?Enter?the?measurement?on?the?score?
form?and?multiply?the?measurement?by?four?(4).? If?measurement? is?not?possible,?measurement?
can?usually?be?estimated.?
10.?Ectopic?Eruption???Count?each?tooth,?excluding?third?molars.?Each?qualifying?tooth?must?be?
more?than?50%?blocked?out?of?the?arch.?Enter?the?number?of?qualifying?teeth?on?the?score?form?
and?multiply?by?three?(3).?If?anterior?crowding?(see?condition?12)?also?exists?in?the?same?arch,?score?
the?condition?that?produces?the?most?points.?DO?NOT?COUNT?BOTH?CONDITIONS.?The?exception?
to? this? rule? is:? (a)?posterior?ectopic?eruptions? in? the? same?arch? (b)? if?ectopic?eruption? score? is?
transferred?due? to?anterior?crossbite?without? trauma,?excessive?wear?of?mobility.? In? these? two?
exceptions,?count?ectopic?eruption?PLUS?the?crowding.?
11.?Deep?Impinging?Overbite???This?occurs?when?either?destruction?of?soft?tissue?on?palate,?
gingival?recession?and?mobility?and/or?abrasion?of?teeth?are?present.?Submit?intraoral?
photographs?of?tissue?damage/impingment.?The?presence?of?deep?impinging?overbite?is?
indicated?by?a?total?score?of?three?(3)?on?the?score?form.? ?



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12.?Anterior?Crowding???Arch?length?insufficiency?must?exceed?3.5?mm.?Mild?rotations?are?not?to?
be?scored?as?crowded.?Score?one?(1)?crowding?per?arch.?Enter?thetotal?on?score?form?and?
multiply?the?measurement?by?five?(5).?If?ectopic?eruption?is?scored?in?section?10?(not?from?
crossbite?in?section?4)?this?crowding?cannot?be?scored?in?addition.?However?if?ectopic?eruption?is?
due?to?a?transfer?of?score?from?section?4?to?section?10,?because?crossbite?did?not?result?in?
damage,?both?ectopic?and?crowding?can?be?counted.?
13.?Labio?Lingual?Spread???A?Boley?Gauge?(or?disposable?ruler)?is?used?to?determine?the?extent?of?
deviation? from?a?normal?arch.?Where? there? is?only?a?protruded?or? lingually?displaced?anterior?
tooth,?the?measurement?should?be?made?from?the?incisal?edge?of?that?tooth?to?the?normal?arch?
line.?Otherwise,? the? total?distance?between? the?most?protruded? anterior? tooth? and? the?most?
lingually? displaced? adjacent? anterior? tooth? is? measured.? In? the? event? that? multiple? anterior?
crowding?of?teeth? is?observed,?all?deviations?from?the?normal?arch?should?be?measured?for?the?
labio?lingual?spread,?but?only?the?most?severe?individual?measurement?should?be?entered?on?the?
score?form.?
14.?Posterior?Unilateral?Crossbite???This?condition? involves? two?or?more?adjacent? teeth,?one?of?
which?must?be?a?molar.?The?crossbite?must?be?one?in?which?the?maxillary?posterior?teeth?involved?
may?either?be?both?palatal?or?both?completely?buccal?in?relation?to?the?mandibular?posterior?teeth.?
The?presence?of?posterior?unilateral?crossbite?is?indicated?by?a?total?score?of?four?(4)?on?the?score?
form.?THERE?IS?NO?ADDITIONAL?SCORE?FOR?BI?LATERAL?CROSSBITE.?
15.? Psychological? factors? affecting? child?s? development? ?? This? condition? requires? detailed?
documentation?by? a?mental?health?provider?as?described? in? the?NJFC?Medicaid?managed? care?
contract?that?contains?the?psychological?or?psychiatric?diagnosis,?treatment?history?and?prognosis.?
An? attestation? from? the?mental?health?provider?must? state? and? substantiate? that?orthodontic?
correction?will?result?in?a?favorable?prognosis?of?the?mental/psychological?condition.?
? ?



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?



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Clinical?Criteria?Descriptions?
Horizon?NJ?Health?clinical?criteria?for?determining?medical?necessity?were?developed?from?
information?collected?from?American?Dental?Association's?Code?Manuals,?clinical?articles?and?
guidelines,?as?well?as?dental?schools,?practicing?dentists,?insurance?companies,?other?dental?
related?organizations,?and?local?state?or?health?plan?requirements.?A?number?of?procedures?
require?prior?authorization?before?initiating?treatment.?When?submitting?authorization?requests?
for?these?procedures,?note?the?documentation?requirements,?and?include?required?
documentation?when?submitting?authorizations?to?Horizon?NJ?Health.??
Horizon?NJ?Health?reviewers?use?the?following?clinical?criteria?to?approve?authorization?requests.?
Crowns?/?onlays?/?coping??

? Minimum?50%?bone?support?
? No?periodontal?furcation?
? No?subcrestal?caries?
? Clinically?acceptable?RCT?if?present?
? Planned?RCT?if?necessary?
? Anterior???50%?incisal?edge?/?4+?surfaces?involved?
? Bicuspid???1?cusp?/?3+?surfaces?involved?
? Molar???2?cusps?/?4+?surfaces?involved?
? Member?s?home?care?and?long?term?prognosis?of?restoration?must?be?considered?when?

requesting?prior?authorization?for?crown?
Additional?procedures?to?construct?new?crown?under?existing?partial?

? Documentation?supports?procedure,?missing?teeth?on?at?least?one?side?of?requested?
crown.?

Root?canals??
? Minimum?50%?bone?support?
? No?periodontal?furcation?
? No?subcrestal?caries?
? Evidence?of?apical?pathology/fistula?
? Pain?from?percussion/temperature?
? Closed?apex?
? Member?s?home?care?and?long?term?prognosis?of?restoration?must?be?considered?when?

requesting?prior?authorization?for?root?canal,?retreatment?of?root?canal?
? ?



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Apexification?/?recalcification??
? Minimum?50%?bone?support?
? Evidence?of?apical?pathology/fistula?
? Evidence?of?deep?caries/restoration,?fracture,?near?pulpal?exposure?with?open?apex?
? Percussion?or?temperature?with?open?apex?
? File?X?ray?with?claim?

Apicoectomy?/?periradicular?services?
? Minimum?50%?bone?support?
? History?of?RCT?
? Apical?pathology?

Retrograde?filling?
? History?of?apicoectomy?

Gingivectomy?or?gingivoplasty??
? Hyperplasia?or?hypertrophy?from?drug?therapy,?hormonal?disturbances,?or?congenital?

defects?
? Generalized?5?mm?or?more?pocketing?indicated?on?the?perio?charting?
? Member?s?home?care?and?long?term?perio?prognosis?must?be?considered?when?

requesting?prior?authorizations?for?periodontal?surgery;?Additional?consideration?should?
be?given?to?members?who?are?compliant?with?exams,?prophys,?and?X?rays?

Gingival?flap?procedure?(D4240)?
? Perio?classification?of?Type?III?or?IV?
? Lack?of?attached?gingiva?
? Member?s?home?care?and?long?term?perio?prognosis?must?be?considered?when?

requesting?prior?authorizations?for?periodontal?surgery;?Additional?consideration?should?
be?given?to?members?who?are?compliant?with?exams,?prophys,?and?X?rays?

Crown?Lengthening?(D4249)?
? Documentation?supports?procedure,?greater?than?50%?bone?support?after?surgery?due?to?

coronal?fracture/caries?and?not?on?same?day?as?restoration?preparation?
? Member?s?home?care?and?long?term?perio?prognosis?must?be?considered?when?

requesting?prior?authorizations?for?periodontal?surgery;?Additional?consideration?should?
be?given?to?members?who?are?compliant?with?exams,?prophys,?and?X?rays?

? ?



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Osseous?Surgery?(D4260,?D4261)?
? History?of?periodontal?scaling?and?root?planing?
? No?previous?recent?history?of?osseous?surgery?
? Perio?classification?of?Type?III?or?IV?
? Member?s?home?care?and?long?term?perio?prognosis?must?be?considered?when?

requesting?prior?authorizations?for?periodontal?surgery;?Additional?consideration?should?
be?given?to?members?who?are?compliant?with?exams,?prophys,?and?X?rays?

? Provider?must?submit?an?attestation?stating?member?s?home?care?is?excellent?and?
member?is?compliant?3?6?weeks?after?D4341?or?D4342;?Can?allow?only?one?quadrant?of?
surgery?and?then?follow?up?with?the?same?documentation?before?allowing?additional?
quadrants?

Bone?Replacement?Graft?(D4263,?D4264)?
? Documentation?supports?need?to?correct?bone?defect.?
? Tooth?must?be?present?and?not?allowed?in?area?of?missing?tooth?or?extraction?on?same?

date?of?service?
Biologic?Materials?(D4265)?

? Biologic?materials?to?aid?in?soft?and?osseous?tissue?regeneration?
Guided?Tissue?Regeneration?(D4266,?D4267)?

? Documentation?supports?need?in?conjunction?with?bone?replacement?or?to?correct?
deformities?resulting?from?inadequate?faciolingual?bone?

? Member?s?home?care?and?long?term?perio?prognosis?must?be?considered?when?
requesting?prior?authorizations?for?periodontal?surgery;?Additional?consideration?should?
be?given?to?members?who?are?compliant?with?exams,?prophys,?and?X?rays?

Surgical?Revision?(D4268)?
? Documentation?supports?need?to?refine?results?of?previous?surgical?procedure.?

Pedicle?Soft?Tissue?Graft?(D4270)?
? Cover?exposed?root;?eliminate?gingival?defect?

Connective?Tissue?Graft?(D4273,?D4276,?D4277,?D4278,?D4283,?D4285)?
? Eliminate?root?sensitivity?
? Eliminate?frenum?pull?
? Extend?vestibule?
? Cover?gingival?interface?with?restoration?
? Cover?bone?or?ridge?regeneration?site?

? ?



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Distal?or?Proximal?Wedge?(D4274)?
? No?history?of?D4260?or?D4261?within?12?months?
? More?than?50%?bone?to?remain?after?procedure?
? To?expose?coronal?fracture?or?caries?but?not?on?same?day?as?restorative?procedure?

Soft?tissue?Allograft?(D4275)?
? Eliminate?frenum?pull?
? Extend?vestibule?
? Eliminate?gingival?recession?

Splinting?(D4320,?D4321)?
? Documentation?supports?need?for?procedure?(i.e.,?facial?trauma,?accident,?etc.)?
? Scaling?and?root?planing?

Scaling?and?root?planing?(D4341,?D4342)?
? D4341?

o Four?or?more?teeth?in?the?quadrant?
o 5?mm?pocketing?on?4?or?more?teeth?indicated?
o Presence?of?root?surface?calculus?and/or?noticeable?loss?of?bone?support?on?X?rays?

? D4342?
o One?to?three?teeth?in?the?quadrant?
o 5?mm?pocketing?on?1?or?more?teeth?indicated?
o Presence?of?root?surface?calculus?and/or?noticeable?loss?of?bone?support?on?X?rays?

Localized?Delivery?of?Antimicrobial?Agents?(D4381)?
? Documentation?supports?need?for?procedure.?

Periodontal?maintenance??
? History?of?active?treatment/D4910?within?last?36?months,?not?sooner?than?90?days?(if?

history?alternate?to?prophy)?
Full?dentures??

? Existing?denture?greater?than?7.5?years?old??
? Remaining?teeth?do?not?have?adequate?bone?support?or?are?non?restorable?

Immediate?Denture?(D5130,?D5140)?
? Remaining?teeth?do?not?have?adequate?bone?support?or?are?non?restorable?

? ?



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Partial?dentures??
? Less?than?8?points?of?contact?on?posterior?teeth?
? 8?points?of?contact?must?produce?a?balanced,?functional?occlusion?
? If?one?partial?makes?the?mouth?meet?criteria,?than?one?partial?allowed?and?the?other?denied?
? If?one?or?more?anterior?max?or?mand?tooth?missing?or?will?be?extracted?regardless?of?

posterior?teeth?
? Existing?partial?denture?greater?than?7.5?years?old?
? Remaining?teeth?have?greater?than?50%?bone?support?and?are?restorable?for?cast?partials,?

otherwise?resin?partial?considered?
Full/partial?dentures?adjustments,?repairs,?replacement,?add?ons?(teeth?and?clasps)??

? Not?within?6?months?of?delivery?reline/rebase?or?3?months?of?D5510?or?D5610?
Rebase?/?reline?denture?/?tissue?conditioning?(D5710???D5851)?

? Documentation?supports?need?
? Not?within?12?months?of?delivery?except?for?D5130?and?D5140?

Overdenture?
? Remaining?teeth?supporting?overdenture?have?adequate?bone?support?

Pediatric?partial?denture?
? Documentation?indicates?missing?anterior?teeth?

Maxillofacial?prosthetics??
? Documentation?supports?need?

Surgical?Implants?/?abutments?/?maintenance?
? History?of?congenitally?missing?tooth?
? Healthy?bone?and?periodontia?
? History?of?the?inability?to?wear?a?full?upper?or?full?lower?denture?or?maxillofacial?

prosthesis?over?a?two?year?period;?by?report?
? Surgical?implant?present?or?approved?
? Documentation?supports?medical?necessity?
? Implants?are?only?allowed?under?specific?circumstances?of?having?a?facial?anomaly?or?

deformity?or?being?edentulous?with?a?history?of?inability?to?function?with?complete?
dentures?for?at?least?two?years?

Pontics?/?Crowns?
? Only?allowed?when?replacing?a?defective?bridge;?New?bridge?must?be?exactly?like?the?

existing?bridge.?Cannot?extend?to?add?additional?teeth?
? Minimum?50%?bone?support?
? Clinically?acceptable?RCT?if?present?
? Planned?RCT?if?necessary? ?



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Connector?bar?/?stress?breaker?/?precision?attachment?/?re?cement?/?coping?/?repair?
? Attachment?will?significantly?enhance?function?
? Documentation?is?self?explanatory?as?to?procedure?code?
? Crowns?present?on?X?rays?or?approved?authorization?for?crown?
? Documentation?describes?medical?necessity?

Fixed?partial?denture?repair,?by?report??
? Documentation?describes?medical?necessity.?
? Not?within?6?months?of?delivery?

Impacted?teeth???(asymptomatic?impactions?will?not?be?approved)?(D7220,?D7230,?D7240,?
D7241)?

? Documentation?describes?pain,?swelling,?etc.,?around?tooth?(must?be?symptomatic)?and?
documentation?noted?in?patient?record?

? Documentation?supports?procedure?for?unusual?surgical?complications?(D7241)?
? X?rays?match?type?of?impaction?code?described?

Surgical?removal?of?residual?tooth?roots??
? Tooth?root?is?completely?covered?by?tissue?on?x?ray?
? Documentation?describes?pain,?swelling,?etc.,?around?tooth?and?documentation?noted?in?

patient?record?
Oroantral?fistula?closure?/?sinus?perforation?

? Documentation?supports?procedure.?
Tooth?reimplantation?and/or?stabilization?

? Documentation?supports?procedure.?
Surgical?access?of?an?unerupted?tooth?

? Documentation?supports?impacted/unerupted?tooth?
? Tooth?is?beyond?one?year?of?normal?eruption?pattern?

Mobilization?of?erupted?tooth?
? Documentation?supports?procedure?

Placement?of?device?to?facilitate?eruption?
? Documentation?supports?procedure?

Biopsy?/?exfoliative?cytological?sample?collection?
? Documentation?supports?procedure?

Surgical?Repositioning?of?Teeth?
? Documentation?supports?procedure?

? ?



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Harvest?of?bone?
? Documentation?indicates?autogenous?grafting?procedure?that?does?not?include?harvest?of?

bone?
Alveoloplasty?

? Documentation?supports?procedure?
Excision?of?lesion?/?tumor??

? Documentation?supports?procedure?
Excision?of?bone?tissue?

? Documentation?supports?procedure?
Radical?resection?of?maxilla?or?mandible?

? Documentation?supports?procedure?
Incision?/?drain?abscess?

? Documentation?supports?procedure?
Removal?of?foreign?body?/?reaction?producing?foreign?bodies?

? Documentation?supports?procedure?
Partial?ostectomy?

? Documentation?supports?procedure?
Maxillary?sinusotomy?

? Documentation?supports?procedure?
Fractures??simple?/?compound?

? Documentation?supports?procedure?
Arthroscopy?

? Documentation?supports?procedure?
Reduction?and?dislocation?and?management?of?TMJ?dysfunctions?

? Documentation?supports?history?of?TMJ?pain?
? Not?for?bruxism?

Suture?repairs?
? Documentation?describes?accident?
? Not?for?tooth?extraction?or?to?close?surgical?incision?

Skin?Graft?
? Documentation?describes?location?and?type?of?graft?

Osteoplasty?/?osteotomy?
? Documentation?describes?and?supports?congenital?defect?condition? ?



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Other?repair?procedure?(Oral?&?Maxillofacial?Surgery)?
? Narrative,?X?rays,?or?photos?support?medical?necessity?for?procedure?

Frenulectomy?
? Documentation?describes?tongue?tied,?diastema,?or?tissue?pull?condition?

Frenuloplasty?
? Documentation?indicates?frenum?will?be?repositioned?instead?of?being?excised?

Excision?of?hyperplastic?tissue?
? Documentation?describes?medical?necessity?due?to?ill?fitting?dentures?

Excision?of?pericoronal?gingiva?
? Documentation?shows?tissue?partially?covers?occlusal?surface?

Surgical?reduction?of?fibrous?tuberosity?
? Documentation?indicates?medical?necessity?need?for?future?denture?placement?

Sialolithotomy?/?excision?of?salivary?gland?/?sialodochoplasty?/?closure?of?salivary?fistula?
? Narrative,?X?rays,?or?photos?support?medical?necessity?for?procedure?

Emergency?tracheotomy?
? Narrative,?X?rays,?or?photos?support?medical?necessity?for?procedure?

Coronoidectomy?
? Narrative,?X?rays,?or?photos?support?medical?necessity?for?procedure?

Synthetic?Graft?/?Implant?Mandible?for?augmentation?/?appliance?removal?/?intraoral?
placement?of?a?fixation?device?

? Narrative,?X?rays,?or?photos?support?medical?necessity?for?procedure?
Unspecified?Oral?Surgery?Procedure?

? Narrative,?X?rays,?or?photos?support?medical?necessity?for?procedure?
Limited?Orthodontic?Treatment?

? Partial?treatment?to?correct?crowding?in?one?arch?
? Minor?tooth?movement?
? Up?righting?teeth?
? Rotating?teeth?
? Opening?space(s)?
? Closing?space(s)?
? Palatal?expansion,?skeletal?disharmonies,?space?deficiency?to?lessen?future?effects?of?

malformation?dentition?(primary?/?transitional?dentition)?
? ?



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Comprehensive?Orthodontic?Treatment?
? Case?must?be?submitted?for?authorization?a?minimum?of?36?months?prior?to?age?limit?for?

this?benefit?
Appliance?Therapy?

? Documentation?of?thumb?sucking?or?tongue?thrusting?habit?
? Not?covered?in?conjunction?with?interceptive?/?comprehensive?ortho?

Pre?Orthodontic?Treatment?
? Narrative,?X?rays,?or?photos?support?medical?necessity?for?procedure?
? Mid?course?treatment?evaluation???For?additional?retention?payments?beyond?first?12?

payments?
Orthodontic?Retention?

? Documentation?substantiating?completed?orthodontic?treatment?
Removable?Retainer?Adjustment?

? History?of?removable?retainer?insertion?
Repair?/?Replacement?of?Orthodontic?Appliance?

? Documentation?of?an?active?ortho?case?
Unspecified?Orthodontic?Procedure,?by?report?

? Documentation?supports?need?for?transfer?case?
General?anesthesia?/?IV?sedation?(Dental?Office?Setting)?1?or?more?of?the?criteria?below?

? Extractions?of?impacted?teeth?or?unerupted?cuspids?or?wisdom?teeth?or?surgical?exposure?
of?unerupted?cuspids?

? 2?or?more?extractions?in?2?or?more?quadrants?
? 4?or?more?extractions?in?1?quadrant?
? Excision?of?lesions?greater?than?1.25?cm?
? Surgical?recovery?from?the?maxillary?antrum?
? Documentation?that?patient?is?less?than?9?years?old?with?extensive?treatment?(described)?
? Documentation?of?failed?local?anesthesia?and?documentation?noted?in?patient?record?
? Documentation?of?situational?anxiety?and?documentation?noted?in?patient?record?
? Documentation?and?narrative?of?medical?necessity?supported?by?submitted?medical?

records?(cardiac,?cerebral?palsy,?epilepsy,?or?condition?that?would?render?patient?
noncompliant)?

? ?



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Non?intravenous?conscious?sedation?(Dental?Office?Setting)???1?or?more?of?the?following?criteria??
? Extractions?of?impacted?or?unerupted?cuspids?or?wisdom?teeth?or?surgical?exposure?of?

unerupted?cuspids?
? 2?or?more?extractions?in?2?or?more?quadrants?
? 4?or?more?extractions?in?1?quadrant?
? Excision?of?lesions?greater?than?1.25?cm?
? Surgical?recovery?from?the?maxillary?antrum?
? Documentation?that?patient?is?less?than?9?years?old?with?extensive?treatment?(described)?
? Documentation?of?failed?local?anesthesia?and?documentation?noted?in?patient?record?
? Documentation?of?situational?anxiety?and?documentation?noted?in?patient?record?
? Documentation?and?narrative?of?medical?necessity?supported?by?submitted?medical?records?

(cardiac,?cerebral?palsy,?epilepsy?or?condition?that?would?render?patient?noncompliant)?
House/Extended?Care?Facility?Call?(D9410)?

? Documentation?and?narrative?of?medical?necessity?supported?by?submitted?medical?records?
Hospital?Call?(D9420)?

? Use?for?OR?(Hospital?Operating?Room?or?Outpatient?Facility)?request??
? Patient?under?the?age?of?6?years?with?extensive?treatment?needed??
? Documentation?supports?indication?of?patient?with?a?medical?condition?(cardiac,?cerebral?

palsy,?epilepsy),?or?other?condition?that?would?render?the?patient?non?compliant?
Therapeutic?drug?injection?

? Documentation?and?narrative?of?medical?necessity?supported?by?submitted?medical?records?
Behavior?Management?

? Documentation?(treatment?history)?supports?indication?of?non?cooperative?child?under?
the?age?of?9?years?

? Documentation?supports?indication?of?patient?with?a?medical?condition?(cardiac,?cerebral?
palsy,?epilepsy),?or?other?condition?that?would?render?the?patient?non?compliant?

? Not?in?conjunction?with?D9223?or?D9243;?Two?units?allowed?per?same?date?of?service?
Treatment?of?complications?(post?surgical)?

? By?report?
Occlusal?Guard?to?include?adjustments?

? Removable?dental?appliances,?which?were?designed?to?minimize?the?effects?of?bruxism?
and?other?occlusal?factors?

Unspecified?procedures,?by?report?
? By?report?

OR?(Hospital?Operating?Room?or?Outpatient?Facility)?request???use?D9999?
? Patient?under?the?age?of?6?years?with?extensive?treatment?needed?
? Documentation?supports?indication?of?patient?with?a?medical?condition?(cardiac,?cerebral?

palsy,?epilepsy),?or?other?condition?that?would?render?the?patient?non?compliant?



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Glossary?
Definitions??
Unless?the?context?in?this?manual?clearly?indicates?otherwise,?these?terms?are?defined?as?follows.?
Abuse.?Provider?practices?inconsistent?with?sound?fiscal,?business,?or?medical?practices?that?
result?in?unnecessary?costs?to?the?Medicaid?or?NJ?FamilyCare?program,?or?reimbursement?for?
services?that?are?not?medically?necessary,?or?services?that?fail?to?meet?professionally?recognized?
standards?for?health?care.?(See?42?C.F.R.???455.2.)?
Clinical?Laboratory?Services.?Professional?and?technical?laboratory?services?ordered?by?a?dentist?
within?the?scope?of?practice?as?defined?by?the?laws?of?the?state?in?which?the?dentist?practices.?
Concurrent?Care.?A?type?of?service?rendered?to?a?member?by?practitioners?when?dental?necessity?
requires?the?service?of?dentists?of?different?specialties?and?the?Primary?Care?Dentist.?
Consultation.?A?service?rendered?by?a?qualified?dentist,?upon?the?request?of?another?practitioner,?
to?evaluate?through?personal?examination?of?the?member,?history,?physical?finding,?and/or?other?
ancillary?means,?the?nature?and?progress?of?a?dental?or?related?disease,?illness?or?condition,?
and/or?establish?or?confirm?a?diagnosis,?determine?the?prognosis,?and/or?suggest?treatment.?
(Note:?A?consultation?should?not?be?confused?with??referral?for?treatment??when?one?
practitioner?refers?a?member?to?another?practitioner?for?either?specific?or?general?treatment.?
Examples?include:??Endodontic?treatment?on?teeth?Nos.?3?and?5,???Extract?teeth?Nos.?7,?8,?9,?and?
10,??or??Extract?tooth?or?teeth?causing?pain.?)?
Cultural?Competency.?A?set?of?interpersonal?skills?that?allow?individuals?to?increase?their?
understanding,?appreciation,?acceptance?of?and?respect?for?cultural?differences?and?similarities?
within,?among?and?between?groups?and?the?sensitivity?to?how?these?differences?influence?
relationships?with?enrollees.?This?requires?a?willingness?and?ability?to?draw?on?community?based?
values,?traditions?and?customs,?to?devise?strategies?to?better?meet?culturally?diverse?enrollee?
needs,?and?to?work?with?knowledgeable?persons?of?and?from?the?community?in?developing?
focused?interactions,?communications,?and?other?supports.?
Dental?Records.?The?complete,?comprehensive?records?of?dental?services,?to?include?date?of?
service/visit,?chief?complaint,?treatment?needed,?treatment?planned?and?treatment?provided?
during?each?patient?visit.?The?dental?record?shall?include?charting?of?the?existing?dentition,?hard?
and?soft?tissue?findings,?completed?assessment?tools?and?diagnostic?images?to?include?
radiographs?and?digital?views?as?well?as?photographs?where?medically?necessary.?Dental?records?
shall?also?be?kept?in?compliance?with?all?DMAHS?and?NJ?State?Board?of?Dentistry?regulations.?The?
dental?record?is?to?be?accessible?at?the?office/clinic?location?of?Member?s?participating?dentist?
and?also?in?the?records?of?a?residential?facility?for?those?Members?residing?in?a?facility.?Providers?
who?render?dental?services?in?other?settings?such?as?in?an?operating?room?shall?also?include?a?
record?that?documents?provided?treatment?in?the?Member?s?dental?record?located?in?the?
office/clinic.?
? ?



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Dental?Review.?The?current,?ongoing?quality?review?of?the?delivery?of?continuing?dental?services?
and?health?care,?which?is?constantly?monitored?and?maintained?by?the?provision?of?direction,?
coordination,?and?regulation.?
Dental?Services.?Any?diagnostic,?preventive,?or?corrective?procedures?administered?by?or?under?
the?direct?personal?supervision?of?a?dentist?in?the?practice?or?the?practitioner?s?professional?
specialty.?(These?services?include:?treatment?of?the?teeth;?associated?structures?of?the?oral?cavity?
and?contiguous?tissues;?and?the?treatment?of?disease,?injury,?or?impairment,?which?may?affect?
the?oral?or?general?health?of?the?individual.?Such?services?maintain?a?high?standard?of?quality?
within?reasonable?limits?and?are?typically?available?to?most?persons?in?the?community.)?
Direct?Personal?Supervision.?The?actual?physical?presence?of?the?dentist?on?the?premises.?
Early?and?Periodic?Screening,?Diagnostic?and?Treatment?(EPSDT).?A?Title?XIX?mandated?program?
that?covers?screening?and?diagnostic?services?to?determine?physical?and?mental?defects?in?
enrollees?under?the?age?of?21,?and?health?care,?treatment,?and?other?measures?to?correct?or?
ameliorate?any?defects?and?chronic?conditions?discovered,?pursuant?to?Federal?Regulations?
found?in?Title?XIX?of?the?Social?Security?Act.?
Emergency?Dental.?A?specific?condition?of?the?oral?cavity?and/or?contiguous?tissues?that?causes?
severe?pain,?intractable?pain,?and/or?compromises?the?life,?health,?or?safety?of?the?member?
unless?treated?immediately.?(Examples?include:?pain?or?acute?infection?from?a?restorable?or?non?
restorable?tooth;?pain?resulting?from?injuries?to?the?oral?cavity?and?related?structures;?extensive,?
abnormal?bleeding;?fractures?of?the?maxilla,?mandible,?or?related?structures;?or?dislocation?of?the?
mandible.)?
General?Dentist/Primary?Care?Dentist.?Dentist?who?assumes?responsibility?for?the?primary?and?
continuing?dental?care?of?the?member.?
Horizon?NJ?Health.?A?Medicaid?managed?care?organization?and?a?product?of?Horizon?HMO.?
Managed?Care.?A?comprehensive?approach?to?the?provision?of?health?care?committed?to?
combining?clinical?preventive,?restorative,?and?emergency?services,?as?well?as?administrative?
procedures?within?an?integrated,?coordinated?system?to?provide?timely?access?to?primary?care?
and?other?medically?necessary?healthcare?services?in?a?cost?effective?manner.?
Medically?Necessary?Services.?Services?or?supplies?necessary?to?accomplish?the?following:?
prevent,?evaluate,?diagnose,?correct,?prevent?the?worsening?of,?alleviate,?ameliorate,?or?cure?a?
physical?or?mental?illness?or?condition;?maintain?health;?prevent?the?onset?of?an?illness,?
condition,?or?disability;?prevent?or?treat?a?condition?that?endangers?life,?causes?suffering?or?pain,?
or?results?in?illness?or?infirmity;?prevent?the?deterioration?of?a?condition;?promote?the?
development?or?maintenance?of?maximal?functioning?capacity?in?performing?daily?activities,?
taking?into?account?functional?capacities?of?the?individual?and?other?individuals?of?the?same?age;?
prevent?or?treat?a?condition?that?threatens?to?cause?or?aggravate?a?handicap,?cause?physical?
deformity,?or?malfunction.?(Note:?There?is?no?other?equally?effective,?more?conservative?or?
substantially?less?costly?course?of?treatment?available?or?suitable?for?the?enrollee.)?? ?



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The?services?provided,?as?well?as?the?type?of?provider?and?setting,?must?reflect?the?level?of?
services?that?can?be?safely?provided,?support?the?diagnosis?of?the?condition,?and?remain?
appropriate?to?the?specific?medical?needs?of?the?enrollee.?Services?should?exist?in?accordance?
with?standards?of?good?medical?practice?and?be?recognized?as?effective?by?the?medical?scientific?
community,?and?they?should?not?be?initiated?solely?for?the?convenience?of?the?enrollee?or?
provider.?The?course?of?treatment?may?include?mere?observation?or,?where?appropriate,?no?
treatment?at?all.?Experimental?services?or?services?generally?regarded?by?the?medical?profession?
as?unacceptable?treatment?are?not?medically?necessary?for?purposes?of?the?Horizon?NJ?Health?
Dental?Program.?
Medically?necessary?services?are?based?on?peer?reviewed?publications,?expert?pediatric,?
psychiatric,?medical?opinion,?and?medical/pediatric?community?acceptance.?
For?pediatric?enrollees,?this?definition?applies?with?additional?criteria,?including?services?needed?
for?a?child?based?on?a?comprehensive?screening?visit?or?an?inter?periodic?encounter,?whether?or?
not?they?are?ordinarily?covered?services?for?all?other?Medicaid?enrollees,?appropriate?for?the?age?
and?health?status?of?the?individual,?aid?in?the?overall?physical?and?mental?growth?and?
development?of?the?individual,?and?achieve?or?maintain?functional?capacity.?
Member.?Anyone?enrolled?and?eligible?to?receive?services?provided?by?Horizon?NJ?Health.?
Mobile?Dental?Practice.?A?provider?traveling?to?various?locations?and?utilizing?portable?dental?
equipment?as?their?primary?method?of?delivering?dental?services.?They?shall?only?provide?dental?
services?to?facilities?and?residences.?They?cannot?provide?dental?services?at?a?school,?with?the?
exception?of?school?health?fairs,?where?they?can?provide?screenings?and?findings?summaries?to?
parents/guardians,?school?nurses?and?assist?patients?with?referrals?to?a?dental?home.?
Facilities:?These?providers?are?expected?to?provide?on?site?comprehensive?dental?care?(to?include?
intra?oral?radiographs),?necessary?dental?referrals?to?general?dentist?or?specialists?and?
emergency?dental?care?in?accordance?with?all?New?Jersey?State?Board?of?Dentistry?regulations?
and?the?NJ?FamilyCare?Managed?Care?Contract.?The?sites?served?by?the?Mobile?Dental?Practice?
must?allow?Member?access?to?treatment?and?allow?for?continuity?of?care.?
Residences:?These?providers?are?expected?to?provide?on?site?dental?care?for?the?homebound?
based?on?patient?safety?and?ability?to?tolerate?procedures?outside?of?a?clinical?setting.?
The?Contractor?is?responsible?for?assisting?the?Member,?family,?facility?or?school?in?locating?a?
dentist?when?referrals?are?issued.?Patient?records?must?be?maintained?at?the?facility?when?this?is?
a?long?term?care?facility,?skilled?nursing?facility?or?school?and?duplicates?may?also?be?maintained?
in?a?central?and?secure?area?in?accordance?with?State?Board?of?Dentistry?regulations.?The?Mobile?
Dental?Practice?must?submit?documentation?to?the?Contractor?of?all?locations?they?visit?and?
serve,?and?include?the?days?and?times?for?each?location,?except?when?a?visit?is?to?a?residence.?
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Mobile?Dental?Van.?A?vehicle?specifically?equipped?with?stationary?dental?equipment?and?is?used?
to?provide?dental?services?within?the?van.?A?mobile?dental?van?is?not?to?be?considered?a?dental?
practice.?Providers?using?a?mobile?dental?van?to?render?dental?services?must?also?be?associated?
with?a?dental?practice?that?is?located?in?a??brick?and?mortar??facility?located?in?New?Jersey?that?
serves?as?a?dental?home?offering?comprehensive?care,?emergency?care?and?appropriate?dental?
specialty?referrals?to?the?mobile?dental?van?s?patients?of?record?(Members).?They?must?
demonstrate?their?ability?to?render?dental?treatment?services?and?assist?with?dental?referrals?as?
needed.?
An?exception?from?these?requirements?can?be?considered?for?providers?using?mobile?dental?vans?
that?demonstrate?they?are?only?providing?dental?services?to?NJ?FamilyCare?Members?residing?in?a?
long?term?care?facility?or?who?are?homebound.?
The?distance?between?the?dental?practice?and?the?sites?and?locations?served?by?the?mobile?
dental?van?must?not?be?a?deterrent?to?the?Member?accessing?treatment?and?allow?for?continuity?
of?care?by?meeting?the?network?standards?for?distance?in?miles?as?described?in?section?4.8.8?
Provider?Network?Requirements.?
When?a?mobile?dental?van?is?used?for?school?visits,?health?fairs?or?other?one?time?events,?services?
will?be?limited?to?oral?screenings,?exams,?fluoride?varnish/topical?fluoride?treatment,?prophylaxis?
and?palliative?care?to?treat?an?acute?condition.?State?Board?regulations?must?still?be?followed?and?
patient?records?are?to?be?maintained?in?accordance?with?State?Board?of?Dentistry?regulations.?
Providers?utilizing?Mobile?Dental?Vans?must?submit?to?the?Contractor?documentation?of?all?
locations?they?will?visit?including?the?days?and?times?(except?when?visits?are?to?homebound?
members).?
Non?Routine?Dental?Service.?Any?dental?service?that?requires?prior?authorization?by?a?Horizon?NJ?
Health?Dental?Consultant?in?order?to?be?reimbursed?by?Horizon?NJ?Health.?
Participating?Dentist.?Any?dentist?licensed?and?currently?registered?to?practice?dentistry?by?the?
licensing?agency?of?the?state?where?the?dental?services?are?rendered,?who?accepts?the?
requirements?of?the?New?Jersey?Division?of?Medical?Assistance?and?Health?Services?(DMAHS),?
and?signs?an?agreement?with?Horizon?NJ?Health?for?the?purpose?of?treating?Horizon?NJ?Health?
members.?
Peer?Review.?The?evaluation?by?practicing?dentists?and?other?healthcare?providers?as?to?the?
quality?and?efficiency?of?services?ordered?and/or?performed?by?other?practicing?dentists,?as?well?
as?the?all?inclusive?term?for?dental?review?efforts,?including?dental?practice?analysis,?inpatient?
hospital?and?extended?care?utilization?review,?and?dental?claims?audit?and?review.?
Prior?Authorization.?Approval?by?a?Horizon?NJ?Health?Dental?Consultant?before?a?service?is?
rendered.?
Program.?The?Horizon?NJ?Health?Managed?Dental?Program.?
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Quality.?The?standard?of?dental?care?or?degree?of?excellence?generally?prevailing?throughout?the?
profession?by?those?who?provide?similar?services,?not?related?to?any?geographical?area?or?
population?group?when?judged?by?competent?practitioners?who?are?qualified?to?perform?those?
procedures.?
Referral.?Directing?a?member?from?one?participating?dentist?to?another?for?diagnosis?and/or?
treatment?though?not?required?for?the?purpose?of?claim?payments.?
Routine?Dental?Service.?Any?dental?service?reimbursable?by?the?program?without?authorization?by?
a?Horizon?NJ?Health?Dental?Consultant.?
Specialist.?A?dentist?licensed?to?practice?dentistry?in?the?state?where?treatment?is?rendered?that?
limits?the?practice?to?a?single?specialty?recognized?by?the?American?Dental?Association?and?
registered?with?the?licensing?agency?in?the?state.?
Transfer.?Relinquishing?responsibility?for?continuing?care?of?a?member?from?one?dentist?to?
another?dentist.?
Urgent?Dental?Care.?Care?for?a?specific?condition?of?the?oral?cavity?and/or?contiguous?tissues?that?
not?compromise?the?life,?health,?or?safety?of?the?member?if?not?treated?immediately.?(Examples?
include:?a?fractured?tooth?with?no?pulpal?involvement,?a?broken?denture,?denture?adjustments,?
and?recementation?of?a?crown.)?
Utilization.?The?service,?procedure,?or?item?provided?to?a?member?by?a?qualified?physician?or?
healthcare?professional,?in?a?setting,?at?a?time,?and?in?an?amount?appropriate?and?acceptable?to?
the?standards?of?the?profession.?
Utilization?Review.?The?retrospective?analysis?of?a?dentist?s?performance?for?evaluation?of?the?
efficient?provision?of?dental?services.?
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Benefit?Plan?Details?&?
Authorization?Requirements?
The?following?benefit?plan?details?and?related?authorization?requirements?apply?to?the?Horizon?
NJ?Health?Dental?Program?benefit?plans.?The?three?types?of?plans?include?Non?Special?Needs?
Plans,?Special?Needs?Plans,?and?Not?Payable?Plans.?All?members?of?New?Jersey?FamilyCare?have?
the?same?dental?benefit?package.??
Horizon?Non?Special?Needs?Plans??

? FamilyCare?A?
? FamilyCare?ABP?
? FamilyCare?B?
? FamilyCare?C?
? FamilyCare?D?
? MLTSS???Custodial???Nursing?Facility?with?Medicare?
? MLTSS???Custodial???Nursing?Facility?without?Medicare?
? MLTSS???Home?and?Community?based?Services?(HCBS)?with?Medicare?
? MLTSS???Home?and?Community?based?Services?(HCBS)?without?Medicare?
? MLTSS???Specialty?Care???Nursing?Facility?with?Medicare???Other?
? MLTSS???Specialty?Care???Nursing?Facility?with?Medicare?Ventilator?and/or?Pediatric?
? MLTSS???Specialty?Care???Nursing?Facility?without?Medicare???Other?
? MLTSS???Specialty?Care???Nursing?Facility?without?Medicare?Ventilator?and/or?Pediatric?

Horizon?Special?Needs?Plans??
? FIDE?SNP???Aged,?Blind,?and?Disabled?(ABD)?
? FIDE?SNP???MLTSS???Home?and?Community?based?Services?(HCBS)?
? FIDE?SNP???MLTSS???Nursing?Facility?
? FIDE?SNP???MLTSS???Pediatric?Ventilator?Specialty?Care???Nursing?Facility?
? FIDE?SNP???MLTSS???Specialty?Care???Nursing?Facility?
? Existing?Medicaid???Special?Needs?
? Medicaid?Expansion???Special?Needs?

Note:?Members?enrolled?in?Horizon?Special?Needs?plans?may?qualify?for?additional?frequency?of?
some?services.?A?provider?shall?contact?the?Dental?Director?if?a?member?is?not?enrolled?in?a?
special?needs?benefit?plan,?but?based?on?clinical?experience?the?provider?has?grounds?to?believe?
the?member?has?special?needs.?? ?



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? The?provider?shall?provide?narrative?of?medical?necessity?requesting?the?member?receive?the?
enhanced?special?needs?benefit?for?a?particular?service?and?date?of?service.??

? If?approved,?the?Dental?Director?will?notify?SKYGEN?USA?to?allow?the?special?needs?level?of?
service?for?that?particular?service?and?date?of?service??

? The?provider?will?work?with?SKYGEN?USA?Provider?Services?to?submit?that?claim?accordingly.?
Horizon?Not?Payable?Plans??

? Acute?Care?Inpatient???Fee?for?Service?(FFS)?Only?
? DEEM*???Aged,?Blind,?and?Disabled?(ABD)?
? DEEM*???Home?and?Community?based?Services?(HCBS)?
? DEEM*???Nursing?Facility?
? DEEM*???Pediatric?Ventilator?Specialty?Care???Nursing?Facility?
? DEEM*???Specialty?Care???Nursing?Facility?

*?The??DEEM??classification?indicates?that?such?members?have?lost?their?Medicaid?coverage?and?cannot?receive?any?Medicaid?
benefits?during?the?60?days?in?which?they?are??deemed?ineligible.???
Note:?The?Not?Payable?Plans?are?not?payable?and?provided?for?plan?use?only.?Therefore,?all?claims?
submitted?for?these?plans?will?be?denied.?Treatments?should?not?be?performed?when?they?are?
designated?for?one?of?these?benefit?plans.?As?a?result,?there?are?no?relevant?codes?for?these?plans?
in?the?Dental?Benefit?Schedule.?Please?verify?the?member?s?eligibility?online?or?by?calling?
Members?Services?before?designating?them?for?one?of?these?benefits?and?to?establish?member?s?
possible?eligibility?through?another?NJ?FamilyCare?health?plan.??
Dental?Benefit?Schedule?
The?Horizon?NJ?Health?Plan?includes?Medicaid?benefits?for?the?Horizon?NJ?Health?Dental?Program.?
In?the?following?tables,?if?Yes?is?indicated?in?the?Auth?Req?column,?then?a?service?requires?a?prior?
authorization.?If?documentation?is?indicated?in?the?Requirement?column,?then?supporting?
documentation?is?required?before?the?authorization?can?be?approved?or?the?claim?can?be?paid.?
When?a?prior?authorization?is?required,?submit?it?(along?with?any?required?documentation)?to?
Horizon?NJ?Health?for?approval?before?beginning?non?emergency?or?routine?treatment.?If?
immediate?treatment?is?required?in?an?emergency?situation,?submit?required?documentation?
with?the?claim?after?treatment.??
Members?have?the?option?to?obtain?a?second?opinion?for?diagnosis?and?treatment?of?dental?
conditions?that?are?treated?within?a?dental?specialty.?
In?addition,?members?may?receive?a?second?opinion?within?Horizon?NJ?Health?s?network,?or?
Horizon?NJ?Health?may?arrange?for?the?member?to?obtain?for?a?second?opinion?outside?of?the?
network?with?no?cost?to?the?member.?
? ?



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Your?Benefits?and?Services?
What?Horizon?
NJ?Health?
Covers?

BENEFIT?PLAN?TYPE?
BENEFIT? NJ?

FAMILYCARE?
A?

NJ?
FAMILYCARE?

ABP?
NJ?

FAMILYCARE?B?
NJ?

FAMILYCARE?C?
NJ?FAMILYCARE?

D?
EPSDT??
(Early?and?
Periodic?
Screening,?
Diagnosis?&?
Treatment)?

Covered,?including?medical?exams,?dental,?vision,?hearing?and?lead?screening?
services.?Covered?for?treatment?services?identified?through?the?exam?

Orthodontic?
Services?

Coverage?is?limited?to?members?up?to?age?21?or?
loss?of?eligibility?who?require?these?services?due?
to?medical?need,?including?developmental?
problems?or?jaw?injury.?Prior?authorization?
required.?

Coverage?is?limited?to?members?
up?to?age?21?or?loss?of?eligibility?
who?require?these?services?due?
to?medical?need,?including?
developmental?problems?or?jaw?
injury,?with?a?$5?copayment?for?
Plans?C?and?D?only.?Prior?
authorization?required.?

?
For?more?information?on?Horizon?NJ?Health?benefits?and?services,?visit?
horizonNJhealth.com/covered_benefits.??
? ?



Horizon?NJ?Health?Dental?Program?
Benefit?Plan?Details?&?Authorization?Requirements?

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Horizon?NJ?Health?Dental?Program?
Note:?If?a?No?Special?Needs?or?Special?Needs?notice?appears?beneath?a?code?number?in?the?table,?the?code?number?and?its?accompanying?requirements?
are?only?applicable?to?the?designated?Non?Special?Needs?or?Special?Needs?plans.?If?neither?notice?appears,?the?code?number?applies?to?all?dental?plans.?
(Also,?there?are?no?applicable?codes?for?any?Not?Payable?Plans?in?the?Dental?Benefit?Schedule.)?
Please?be?aware?that?the?provision?of?dental?services?is?based?on?demonstrated?medical?necessity?and?EPSDT?requirements?(for?members?under?the?age?
of?twenty?one).???
All?denials?based?on?frequency?limits?can?be?appealed?with?appropriate?documentation?of?medical?necessity.?This?includes?those?codes?indicated?as?
?once?in?a?life?time?,?which?in?the?case?of?certain?endodontic,?periodontic?or?surgical?codes?refers?to?the?tooth?or?area?of?the?mouth?and?not?the?
procedure?itself.??

Dental?Benefit?Schedule?
Horizon?NJ?Health?Dental?Program:?Non?Special?Needs?Plans?&?Special?Needs?Plans?
Code? Description? Age? Tooth?/?

Quad?/?Arch?
Limitations? Auth?

Req?
Requirement?

D0120?
No?
Special?
Needs?

Periodic?oral?evaluation???
established?patient?

0?999? ?? Twice?per?floating?year?per?payee.?
Not?paid?on?same?date?of?service?as?D0140,?D0145,?
D0150,?D0180,?or?D0190.?
Not?paid?within?6?months?of?D0150.?

No? ??

D0120?
Special?
Needs?

Periodic?oral?evaluation???
established?patient?

0?999? ?? Four?per?floating?year?per?payee.?
Not?paid?on?same?date?of?service?as?D0140,?D0145,?
D0150,?D0180,?or?D0190.?
Not?paid?within?6?months?of?D0150.?

No? ??

D0140? Limited?oral?evaluation???
problem?focused?

0?999? ?? Twice?per?rolling?year?per?payee.?
Not?paid?on?same?date?of?service?as?D0120,?D0145,?
D0150,?D0180,?or?D0190.?

No? ??

D0145? Oral?evaluation?for?a?patient?
under?three?years?of?age?and?
counseling?with?primary?
caregiver?

0?2? ?? Twice?per?floating?year?per?payee.?
Not?paid?on?same?date?of?service?as?D0120,?D0140,?
D0150,?D0180,?or?D0190.?

No? ??



Horizon?NJ?Health?Dental?Program?
Benefit?Plan?Details?&?Authorization?Requirements?

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Horizon?NJ?Health?Dental?Program:?Non?Special?Needs?Plans?&?Special?Needs?Plans?
Code? Description? Age? Tooth?/?

Quad?/?Arch?
Limitations? Auth?

Req?
Requirement?

D0150? Comprehensive?oral?
evaluation???new?or?
established?patient?

0?999? ?? One?per?36?months?per?payee.?
Not?paid?on?same?date?of?service?as?D0120,?D0140,?
D0145,?D0180,?or?D0190.?
Not?paid?within?6?months?of?D0120.?

No? ??

D0160? Detailed?and?extensive?oral?
evaluation???problem?
focused,?by?report?

0?999? ?? One?per?6?months?per?payee.?
D0220,?D0270,?D0277?and?D0330?are?the?only?other?
services?paid?for?on?same?date?of?service?per?payee.?

No? ??

D0170? Re?evaluation???limited,?
problem?focused?(established?
patient;?not?post?operative?
visit)?

0?999? ?? Twice?per?rolling?year?per?payee.?
D0220,?D0270,?D0277?and?D0330?are?the?only?other?
services?paid?for?on?same?date?of?service.?

No? ??

D0171? Re?evaluation???post?
operative?office?visit?

0?999? ?? Twice?per?rolling?year?per?payee.?
D0220,?D0270,?D0277?and?D0330?are?the?only?other?
services?paid?for?on?same?date?of?service.?

No? ??

D0180? Comprehensive?periodontal?
evaluation???new?or?
established?patient?

0?999? ?? One?per?36?months?per?payee.?
Not?paid?on?same?date?of?service?as?D0120,?D0140,?
D0145,?D0150?or?D0190.?

No? ??

D0190? Screening?of?a?patient? 0?19? ?? Once?per?rolling?year?per?payee.?
Not?paid?on?same?date?of?service?as?D0120,?D0140,?
D0145,?D0150,?or?D0180.?

No? ??

D0210? Intraoral???complete?series?of?
radiographic?images?

0?999? ?? One?per?36?months?per?payee.? No? ??

D0220? Intraoral???periapical?first?
radiographic?image?

0?999? ?? ?? No? ??

D0230? Intraoral???periapical?each?
additional?radiograph?image?

0?999? ?? ?? No? ??



Horizon?NJ?Health?Dental?Program?
Benefit?Plan?Details?&?Authorization?Requirements?

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Horizon?NJ?Health?Dental?Program:?Non?Special?Needs?Plans?&?Special?Needs?Plans?
Code? Description? Age? Tooth?/?

Quad?/?Arch?
Limitations? Auth?

Req?
Requirement?

D0240? Intraoral???occlusal?
radiograph?image?

0?999? ?? Twice?per?floating?year?per?payee.? No? ??

D0250? Extraoral???first?radiograph?
image?

0?999? ?? Twice?per?rolling?year?per?payee.? No? ??

D0251? Extra?Oral?Posterior?Dental?
Radiographic?Image?

0?999? ? One?per?rolling?6?months?per?payee?(combined?with?
D0274).?

No? ?

D0260? Extraoral???each?additional?
radiograph?image?

0?999? ?? One?per?rolling?6?months?per?payee.? No? ??

D0270? Bitewing???single?radiograph?
image?

0?999? ?? Twice?per?rolling?6?months?per?payee.? No? ??

D0272? Bitewings???two?radiographic?
images?

0?999? ?? Twice?per?rolling?6?months?per?payee.? No? ??

D0273? Bitewings???three?
radiographic?images?

0?999? ?? Once?per?rolling?year?per?payee.? No? ??

D0274? Bitewings???four?radiographic?
images?

0?999? ?? Once?per?rolling?year?per?payee.? No? ??

D0277? Vertical?bitewings???7?to?8?
radiographic?images?

0?999? ?? Once?per?rolling?year?per?payee.? No? ??

D0310? Sialography? 0?999? ?? Documentation?supports?procedure.? Yes? Narrative?of?medical?
necessity?



Horizon?NJ?Health?Dental?Program?
Benefit?Plan?Details?&?Authorization?Requirements?

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Horizon?NJ?Health?Dental?Program:?Non?Special?Needs?Plans?&?Special?Needs?Plans?
Code? Description? Age? Tooth?/?

Quad?/?Arch?
Limitations? Auth?

Req?
Requirement?

D0320? Temporomandibular?joint?
arthrogram,?including?
injection?

0?999? ?? Documentation?supports?procedure.? Yes? Narrative?of?medical?
necessity?

D0321? Other?temporomandibular?
joint?radiographic?images,?by?
report?

0?999? ?? Documentation?supports?procedure.? Yes? Narrative?of?medical?
necessity?

D0322? Tomographic?survey? 0?999? ?? Documentation?supports?procedure.? Yes? Narrative?of?medical?
necessity?

D0330? Panoramic?radiographic?
image?

0?999? ?? One?per?36?months?per?payee.? No? ??

D0340? Cephalometric?radiographic?
image?

0?999? ?? One?per?36?months?per?payee.? No? ??

D0350? 2D?oral/facial?photographic?
image?obtained?intra???orally?
or?extra?orally?

0?999? ?? Four?per?rolling?year?per?payee.?
May?be?used?in?lieu?of?X?rays?for?services?rendered?in?
a?nursing?facility.?

No? ??

D0351? 3D?photographic?image? 0?999? ?? Once?per?rolling?year?per?payee.?
Allowed?in?conjunction?with?orthodontic?and/or?
orthognathic?procedure.?
Only?payable?to?oral?surgeons.?

Yes? Narrative?of?medical?
necessity?



Horizon?NJ?Health?Dental?Program?
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Horizon?NJ?Health?Dental?Program:?Non?Special?Needs?Plans?&?Special?Needs?Plans?
Code? Description? Age? Tooth?/?

Quad?/?Arch?
Limitations? Auth?

Req?
Requirement?

D0364? Cone?beam?CT?capture?and?
interpretation?with?limited?
fields?of?view???less?than?one?
whole?jaw?

0?999? ?? Once?per?rolling?year?per?payee.?
Limited?to?specialists?only;?not?payable?to?general?and?
pediatric?dentists?and?pedodontists.?

Yes? PA?x?ray?and?narrative?of?
medical?necessity?

D0365? Cone?beam?CT?capture?and?
interpretation?with?field?of?
view?of?one?full?dental?arch???
mandible?

0?999? ?? Once?per?rolling?year?per?payee.?
Limited?to?specialists?only;?not?payable?to?general?and?
pediatric?dentists?and?pedodontists.?

Yes? PA?x?ray?and?narrative?of?
medical?necessity?

D0366? Cone?beam?CT?capture?and?
interpretation?with?field?of?
view?of?one?full?dental?arch???
maxilla,?with?or?without?
cranium?

0?999? ?? Once?per?rolling?year?per?payee.?
Limited?to?specialists?only;?not?payable?to?general?and?
pediatric?dentists?and?pedodontists.?

Yes? PA?x?ray?and?narrative?of?
medical?necessity?

D0367? Cone?beam?CT?capture?and?
interpretation?with?field?of?
view?of?both?jaws;?with?or?
without?cranium?

0?999? ?? Once?per?rolling?year?per?payee.?
Limited?to?specialists?only;?not?payable?to?general?and?
pediatric?dentists?and?pedodontists.?

Yes? PA?x?ray?and?narrative?of?
medical?necessity?

D0368? Cone?beam?CT?capture?and?
interpretation?for?TNJ?series?
including?two?or?more?
exposures?

0?999? ?? Once?per?rolling?year?per?payee.?
Limited?to?specialists?only;?not?payable?to?general?and?
pediatric?dentists?and?pedodontists.?

Yes? PA?x?ray?and?narrative?of?
medical?necessity?

D0369? Maxillofacial?MRI?capture?and?
interpretation?

0?999? ?? Documentation?supports?procedure.? Yes? Narrative?of?medical?
necessity?

D0370? Maxillofacial?ultrasound?
capture?and?interpretation?

0?999? ?? Documentation?supports?procedure.? Yes? Narrative?of?medical?
necessity?



Horizon?NJ?Health?Dental?Program?
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Horizon?NJ?Health?Dental?Program:?Non?Special?Needs?Plans?&?Special?Needs?Plans?
Code? Description? Age? Tooth?/?

Quad?/?Arch?
Limitations? Auth?

Req?
Requirement?

D0371? Sialoendoscopy?capture?and?
interpretation?

0?999? ?? Documentation?supports?procedure.? Yes? Narrative?of?medical?
necessity?

D0380? Cone?beam?CT?image?capture?
with?limited?field?of?view?less?
than?one?whole?jaw?

0?999? ?? Once?per?rolling?year?per?payee.?
Limited?to?specialists?only;?not?payable?to?general?and?
pediatric?dentists?and?pedodontists.?

Yes? PA?x?ray?and?narrative?of?
medical?necessity?

D0381? Cone?beam?CT?image?capture?
with?field?of?view?of?one?full?
dental?arch???mandible?

0?999? ?? Once?per?rolling?year?per?payee.?
Limited?to?specialists?only;?not?payable?to?general?and?
pediatric?dentists?and?pedodontists.?

Yes? PA?x?ray?and?narrative?of?
medical?necessity?

D0382? Cone?beam?CT?image?capture?
with?field?of?view?of?one?full?
dental?arch???maxilla,?with?or?
without?cranium?

0?999? ?? Once?per?rolling?year?per?payee.?
Limited?to?specialists?only;?not?payable?to?general?and?
pediatric?dentists?and?pedodontists.?

Yes? PA?x?ray?and?narrative?of?
medical?necessity?

D0383? Cone?beam?CT?image?capture?
with?field?of?view?of?both?
jaws,?with?or?without?cranium?

0?999? ?? Once?per?rolling?year?per?payee.?
Limited?to?specialists?only;?not?payable?to?general?and?
pediatric?dentists?and?pedodontists.?

Yes? PA?x?ray?and?narrative?of?
medical?necessity?

D0384? Cone?beam?CT?image?capture?
for?TMJ?series,?including?two?
or?more?exposures?

0?999? ?? Once?per?rolling?year?per?payee.?
Limited?to?specialists?only;?not?payable?to?general?and?
pediatric?dentists?and?pedodontists.?

Yes? PA?x?ray?and?narrative?of?
medical?necessity?

D0393? Treatment?simulation?using?
3D?image?volume?

0?999? ?? Documentation?supports?procedure.? Yes? Narrative?of?medical?
necessity?

D0394? Digital?subtraction?of?two?or?
more?images?or?image?
volumes?of?the?same?modality?

0?999? ?? Documentation?supports?procedure.? Yes? Narrative?of?medical?
necessity?



Horizon?NJ?Health?Dental?Program?
Benefit?Plan?Details?&?Authorization?Requirements?

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Horizon?NJ?Health?Dental?Program:?Non?Special?Needs?Plans?&?Special?Needs?Plans?
Code? Description? Age? Tooth?/?

Quad?/?Arch?
Limitations? Auth?

Req?
Requirement?

D0395? Fusion?of?two?or?more?3D?
image?volumes?of?one?or?
more?modalities?

0?999? ?? Documentation?supports?procedure.? Yes? Narrative?of?medical?
necessity?

D0416? Viral?culture? 0?999? ?? Documentation?supports?procedure.? Yes? Narrative?of?medical?
necessity?

D0417? Collection?and?preparation?of?
saliva?sample?for?laboratory?
diagnostic?testing?

0?999? ?? Documentation?supports?procedure.? Yes? Narrative?of?medical?
necessity?

D0470? Diagnostic?casts? 0?999? ?? Documentation?supports?procedure;?digital?casts?only.? Yes? Narrative?of?medical?
necessity?

D0472? Accession?of?tissue,?gross?
examination,?and?preparation?
and?transmission?of?written?
report?

0?999? ?? Documentation?supports?procedure.? Yes? Narrative?of?medical?
necessity?

D0473? Accession?of?tissue,?gross?and?
microscopic?examination,?and?
preparation?and?transmission?
of?written?report?

0?999? ?? Documentation?supports?procedure.? Yes? Narrative?of?medical?
necessity?



Horizon?NJ?Health?Dental?Program?
Benefit?Plan?Details?&?Authorization?Requirements?

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130?

Horizon?NJ?Health?Dental?Program:?Non?Special?Needs?Plans?&?Special?Needs?Plans?
Code? Description? Age? Tooth?/?

Quad?/?Arch?
Limitations? Auth?

Req?
Requirement?

D0474? Accession?of?tissue,?gross?and?
microscopic?examination,?
including?assessment?of?
surgical?margins?for?presence?
of?disease,?and?preparation?
and?transmission?of?written?
report?

0?999? ?? Documentation?supports?procedure.? Yes? Narrative?of?medical?
necessity?

D0480? Accession?of?exfoliate?
cytologic?smears,?microscopic?
examination,?and?preparation?
and?transmission?of?written?
report?

0?999? ?? Documentation?supports?procedure.? Yes? Narrative?of?medical?
necessity?

D0502? Other?oral?pathology?
procedures,?by?report?

0?999? ?? Documentation?supports?procedure.? Yes? Narrative?of?medical?
necessity?

D0601? Caries?risk?assessment?and?
documentation,?with?a?finding?
of?low?risk?

0?20? ?? Once?per?rolling?year?per?payee.?
If?medically?necessary,?a?second?risk?assessment?can?
be?approved?through?the?appeal?process.?
Only?allowed?on?the?same?date?of?service?as?D0120,?
D0145,?or?D0150?per?payee.?

No? ??

D0602? Caries?risk?assessment?and?
documentation,?with?a?finding?
of?moderate?risk?

0?20? ?? Once?per?rolling?year?per?payee.?
If?medically?necessary,?a?second?risk?assessment?can?
be?approved?through?the?appeal?process.?
Only?allowed?on?the?same?date?of?service?as?D0120,?
D0145,?or?D0150?per?payee.?

No? ??



Horizon?NJ?Health?Dental?Program?
Benefit?Plan?Details?&?Authorization?Requirements?

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Horizon?NJ?Health?Dental?Program:?Non?Special?Needs?Plans?&?Special?Needs?Plans?
Code? Description? Age? Tooth?/?

Quad?/?Arch?
Limitations? Auth?

Req?
Requirement?

D0603? Caries?risk?assessment?and?
documentation,?with?a?finding?
of?high?risk?

0?20? ?? Once?per?rolling?year?per?payee.?
If?medically?necessary,?a?second?risk?assessment?can?
be?approved?through?the?appeal?process.?
Only?allowed?on?the?same?date?of?service?as?D0120,?
D0145,?or?D0150?per?payee.?

No? ??

D0999? Unspecified?diagnostic?
procedure,?by?report?

0?999? ?? As?required?by?documentation?and?narrative.? Yes? Description?of?procedure?
and?narrative?of?medical?
necessity?

D1110?
No?
Special?
Needs?

Prophylaxis???adult? 16?999? ?? Twice?per?floating?year?per?payee.?
Not?payable?on?the?same?date?of?service?as?any?other?
D4000?series?codes.??

No? ??

D1110?
Special?
Needs?

Prophylaxis???adult? 16?999? ?? Four?per?floating?year?per?payee.?
Not?payable?on?the?same?date?of?service?as?any?other?
D4000?series?codes.?

No? ??

D1120?
No?
Special?
Needs?

Prophylaxis???child? 0?15? ?? Twice?per?floating?year?per?payee.?
Not?payable?on?the?same?date?of?service?as?any?other?
D4000?series?codes.?

No? ??

D1120?
Special?
Needs?

Prophylaxis???child? 0?15? ?? Four?per?floating?year?per?payee.?
Not?payable?on?the?same?date?of?service?as?any?other?
D4000?series?codes.?

No? ??



Horizon?NJ?Health?Dental?Program?
Benefit?Plan?Details?&?Authorization?Requirements?

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Horizon?NJ?Health?Dental?Program:?Non?Special?Needs?Plans?&?Special?Needs?Plans?
Code? Description? Age? Tooth?/?

Quad?/?Arch?
Limitations? Auth?

Req?
Requirement?

D1206?
No?
Special?
Needs,?
Age??
0?20?

Topical?application?of?fluoride?
varnish?

0?20? ?? Age?0?6:?Four?per?floating?year?per?payee.?
Age?7?20:?Twice?per?floating?year?per?payee.?
Combined?frequency?(codeset?limitation)?with?D1208.?

No? ??

D1206?
Special?
Needs,?
Age??
0?999?

Topical?application?of?fluoride?
varnish?

0?999? ?? Four?per?floating?year?per?payee.?
Combined?frequency?(codeset?limitation)?with?D1208.?

No? ??

D1208?
No?
Special?
Needs,?
Age??
0?20?

Topical?application?of?fluoride?
??excluding?varnish?

0?20? ?? Age?0?6:?Four?per?floating?year?per?payee.?
Age?7?20:?Twice?per?floating?year?per?payee.?
Combined?frequency?(codeset?limitation)?with?D1206.?

No? ??

D1208?
Special?
Needs,?
Age??
0?999?

Topical?application?of?fluoride?
??excluding?varnish?

0?999? ?? Four?per?floating?year?per?payee.?
Combined?frequency?(codeset?limitation)?with?D1206.?

No? ??

D1351? Sealant?per?tooth? 0?16? 1?5,?12?21,?
28?32?

One?per?3?rolling?years?per?tooth?per?payee.?
Not?payable?with?history?of?a?filling.?

No? ??



Horizon?NJ?Health?Dental?Program?
Benefit?Plan?Details?&?Authorization?Requirements?

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Horizon?NJ?Health?Dental?Program:?Non?Special?Needs?Plans?&?Special?Needs?Plans?
Code? Description? Age? Tooth?/?

Quad?/?Arch?
Limitations? Auth?

Req?
Requirement?

D1352? Preventive?resin?restoration?
in?a?moderate?to?high?caries?
risk?patient???permanent?
tooth?

16?999? 1?5,?12?21,?
28?32?

One?per?3?years?per?tooth?per?payee.? No? ??

D1353? Sealant?repair???per?tooth? 0?16? 1?5,?12?21,?
28?32?

One?per?3?rolling?years?per?tooth?per?payee.?
Not?payable?with?history?of?a?filling.?
Must?have?a?history?of?D1351?more?than?36?months?
prior.?

No? ??

D1354?
Special?
Needs,?
Age?0?
999?

Interim?Caries?Arresting?
Medicament?Application???per?
tooth?

0?6? ? Twice?per?rolling?year?per?tooth?per?payee? No? ?

D1510? Space?maintainer???fixed???
unilateral?

0?15? 2?15,?18?31,?
and?A?T?

One?per?lifetime?per?payee.?
Not?in?conjunction?with?active?ortho.?

Yes? Pre?operative?X?rays?

D1516? Space?maintainer???fixed???
bilateral,?maxillary?

0?15? 2?15,?18?31,?
and?A?T?

One?per?lifetime?per?payee.?
Not?in?conjunction?with?active?ortho.?

Yes? Pre?operative?X?rays?

D1517? Space?maintainer???fixed???
bilateral,?mandibular?

0?15? 2?15,?18?31,?
and?A?T?

One?per?lifetime?per?payee.?
Not?in?conjunction?with?active?ortho.?

Yes? Pre?operative?X?rays?

D1526? Space?maintainer???
removable???bilateral,?
maxillary?

0?15? 2?15,?18?31,?
and?A?T?

One?per?lifetime?per?payee.??
Not?in?conjunction?with?active?ortho.?

Yes? Pre?operative?X?rays?



Horizon?NJ?Health?Dental?Program?
Benefit?Plan?Details?&?Authorization?Requirements?

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134?

Horizon?NJ?Health?Dental?Program:?Non?Special?Needs?Plans?&?Special?Needs?Plans?
Code? Description? Age? Tooth?/?

Quad?/?Arch?
Limitations? Auth?

Req?
Requirement?

D1527? Space?maintainer???
removable???bilateral,?
mandibular?

0?15? 2?15,?18?31,?
and?A?T?

One?per?lifetime?per?payee.??
Not?in?conjunction?with?active?ortho.?

Yes? Pre?operative?X?rays?

D1550? Re?cement?or?re?bond?space?
maintainer?

0?15? 2?15,?18?31,?
and?A?T?

One?per?lifetime?per?payee.? No? ??

D1555? Removal?of?fixed?space?
maintainer?

0?15? 2?15,?18?31,?
and?A?T?

One?per?lifetime?per?patient.?
Not?by?the?same?payee?as?D1510,?D1515,?D1516,?
D1517,?D1525,?D1525,?D1527?

No? ??

D1575? Distal?shoe?space?maintainer?
??fixed???unilateral?

0?15? 2?15,?18?31,?
and?A?T?

One?per?lifetime?per?payee.?
Not?in?conjunction?with?active?ortho.?

Yes? Pre?operative?X?rays?

D1999? Unspecified?preventive?
procedure??by?report?

0?999? ?? Documentation?supports?procedure.? Yes? Narrative?of?medical?
necessity?

D2140? Amalgam???one?surface,?
primary?or?permanent?

0?999? All?teeth;??
A?T;?1?32?

One?per?364?days?per?payee.?
Duplicate?services?are?denied?if?less?than?365?days.?
The?provider?must?replace?a?filling?placed?within?one?
year?of?restoration?when?performed?at?the?same?time.?

No? ??

D2150? Amalgam???two?surfaces,?
primary?or?permanent?

0?999? All?teeth;??
A?T;?1?32?

One?per?364?days?per?payee.?
Duplicate?services?are?denied?if?less?than?365?days.?
The?provider?must?replace?a?filling?placed?within?one?
year?of?restoration?when?performed?at?the?same?time.?

No? ??



Horizon?NJ?Health?Dental?Program?
Benefit?Plan?Details?&?Authorization?Requirements?

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135?

Horizon?NJ?Health?Dental?Program:?Non?Special?Needs?Plans?&?Special?Needs?Plans?
Code? Description? Age? Tooth?/?

Quad?/?Arch?
Limitations? Auth?

Req?
Requirement?

D2160? Amalgam???three?surfaces,?
primary?or?permanent?

0?999? All?teeth;??
A?T;?1?32?

One?per?364?days?per?payee.?
Duplicate?services?are?denied?if?less?than?365?days.?
The?provider?must?replace?a?filling?placed?within?one?
year?of?restoration?when?performed?at?the?same?time.?

No? ??

D2161? Amalgam???four?or?more?
surfaces,?primary?or?
permanent?

0?999? All?teeth;??
A?T;?1?32?

One?per?364?days?per?payee.?
Duplicate?services?are?denied?if?less?than?365?days.?
The?provider?must?replace?a?filling?placed?within?one?
year?of?restoration?when?performed?at?the?same?time.?

No? ??

D2330? Resin?based?composite???one?
surface,?anterior?

0?999? Anterior?
Teeth?(6?11,?
22?27,?C?H,?
M?R)?

One?per?364?days?per?payee.?
Duplicate?services?are?denied?if?less?than?365?days.?
The?provider?must?replace?a?filling?placed?within?one?
year?of?restoration?when?performed?at?the?same?time.?

No? ??

D2331? Resin?based?composite???two?
surfaces,?anterior?

0?999? Anterior?
Teeth?(6?11,?
22?27,?C?H,?
M?R)?

One?per?364?days?per?payee.?
Duplicate?services?are?denied?if?less?than?365?days.?
The?provider?must?replace?a?filling?placed?within?one?
year?of?restoration?when?performed?at?the?same?time.?

No? ??

D2332? Resin?based?composite???
three?surfaces,?anterior?

0?999? Anterior?
Teeth?(6?11,?
22?27?,?C?H,?
M?R)?

One?per?364?days?per?payee.?
Duplicate?services?are?denied?if?less?than?365?days.?
The?provider?must?replace?a?filling?placed?within?one?
year?of?restoration?when?performed?at?the?same?time.?

No? ??



Horizon?NJ?Health?Dental?Program?
Benefit?Plan?Details?&?Authorization?Requirements?

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Horizon?NJ?Health?Dental?Program:?Non?Special?Needs?Plans?&?Special?Needs?Plans?
Code? Description? Age? Tooth?/?

Quad?/?Arch?
Limitations? Auth?

Req?
Requirement?

D2335? Resin?based?composite???four?
or?more?surfaces?or?involving?
incisal?angle?(anterior)?

0?999? Anterior?
Teeth?(6?11,?
22?27,?C?H,?
M?R)?

One?per?364?days?per?payee.?
Duplicate?services?are?denied?if?less?than?365?days.?
The?provider?must?replace?a?filling?placed?within?one?
year?of?restoration?when?performed?at?the?same?time.?

No? ??

D2390? Resin?based?composite?
crown,?anterior?

0?999? Anterior?
Teeth?(6?11,?
22?27,?C?H,?
M?R)?

One?per?364?days?per?payee.?
Duplicate?services?are?denied?if?less?than?365?days.?
The?provider?must?replace?a?filling?placed?within?one?
year?of?restoration?when?performed?at?the?same?time.?

No? ??

D2391? Resin?based?composite???one?
surface,?posterior?

0?999? Posterior?
teeth?(1?5,?
12?21,??
28?32,?A,?B,?I,?
J,?K,?L,?S,?T)?

One?per?364?days?per?payee.?
Duplicate?services?are?denied?if?less?than?365?days.?
The?provider?must?replace?a?filling?placed?within?one?
year?of?restoration?when?performed?at?the?same?time.?

No? ??

D2392? Resin?based?composite???two?
surfaces,?posterior?

0?999? Posterior?
teeth?(1?5,?
12?21,??
28?32,?A,?B,?I,?
J,?K,?L,?S,?T)?

One?per?364?days?per?payee.?
Duplicate?services?are?denied?if?less?than?365?days.?
The?provider?must?replace?a?filling?placed?within?one?
year?of?restoration?when?performed?at?the?same?time.?

No? ??

D2393? Resin?based?composite???
three?surfaces,?posterior?

0?999? Posterior?
teeth?(1?5,?
12?21,??
28?32,?A,?B,?I,?
J,?K,?L,?S,?T)?

One?per?364?days?per?payee.?
Duplicate?services?are?denied?if?less?than?365?days.?
The?provider?must?replace?a?filling?placed?within?one?
year?of?restoration?when?performed?at?the?same?time.?

No? ??



Horizon?NJ?Health?Dental?Program?
Benefit?Plan?Details?&?Authorization?Requirements?

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Horizon?NJ?Health?Dental?Program:?Non?Special?Needs?Plans?&?Special?Needs?Plans?
Code? Description? Age? Tooth?/?

Quad?/?Arch?
Limitations? Auth?

Req?
Requirement?

D2394? Resin?based?composite???four?
or?more?surfaces,?posterior?

0?999? Posterior?
teeth?(1?5,?
12?21,??
28?32,?A,?B,?I,?
J,?K,?L,?S,?T)?

One?per?364?days?per?payee.??
Duplicate?services?are?denied?if?less?than?365?days.?
The?provider?must?replace?a?filling?placed?within?one?
year?of?restoration?when?performed?at?the?same?time.?

No? ??

D2510? Inlay???metallic???one?surface? 0?999? Permanent?
Teeth?1?32?

One?per?5?years;?dental?school?only.? Yes? Full?mouth?X?rays?or?
panorex,?and?narrative?
of?medical?necessity?

D2520? Inlay???metallic???two?surfaces? 0?999? Permanent?
Teeth?1?32?

One?per?5?years;?dental?school?only.? Yes? Full?mouth?X?rays?or?
panorex,?and?narrative?
of?medical?necessity?

D2530? Inlay???metallic???three?or?
more?surfaces?

0?999? Permanent?
Teeth?1?32?

One?per?5?years;?dental?school?only.? Yes? Full?mouth?X?rays?or?
panorex,?and?narrative?
of?medical?necessity?

D2542? Onlay???metallic???two?
surfaces?

0?999? Permanent?
Teeth?1?32?

One?per?5?years;?dental?school?only.? Yes? Full?mouth?X?rays?or?
panorex,?and?narrative?
of?medical?necessity?

D2543? Onlay???metallic???three?
surfaces?

0?999? Permanent?
Teeth?1?32?

One?per?5?years;?dental?school?only.? Yes? Full?mouth?X?rays?or?
panorex,?and?narrative?
of?medical?necessity?

D2544? Onlay???metallic???four?or?
more?surfaces?

0?999? Permanent?
Teeth?1?32?

One?per?5?years;?dental?school?only.? Yes? Full?mouth?X?rays?or?
panorex,?and?narrative?
of?medical?necessity?



Horizon?NJ?Health?Dental?Program?
Benefit?Plan?Details?&?Authorization?Requirements?

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Horizon?NJ?Health?Dental?Program:?Non?Special?Needs?Plans?&?Special?Needs?Plans?
Code? Description? Age? Tooth?/?

Quad?/?Arch?
Limitations? Auth?

Req?
Requirement?

D2610? Inlay???porcelain/ceramic???
one?surface?

0?999? Permanent?
Teeth?1?32?

One?per?5?years;?dental?school?only.? Yes? Full?mouth?X?rays?or?
panorex,?and?narrative?
of?medical?necessity?

D2620? Inlay???porcelain/ceramic???
two?surfaces?

0?999? Permanent?
Teeth?1?32?

One?per?5?years;?dental?school?only.? Yes? Full?mouth?X?rays?or?
panorex,?and?narrative?
of?medical?necessity?

D2630? Inlay???porcelain/ceramic???
three?or?more?surfaces?

0?999? Permanent?
Teeth?1?32?

One?per?5?years;?dental?school?only.? Yes? Full?mouth?X?rays?or?
panorex,?and?narrative?
of?medical?necessity?

D2642? Onlay???porcelain/ceramic???
two?surfaces?

0?999? Permanent?
Teeth?1?32?

One?per?5?years;?dental?school?only.? Yes? Full?mouth?X?rays?or?
panorex,?and?narrative?
of?medical?necessity?

D2643? Onlay???porcelain/ceramic???
three?surfaces?

0?999? Permanent?
Teeth?1?32?

One?per?5?years;?dental?school?only.? Yes? Full?mouth?X?rays?or?
panorex,?and?narrative?
of?medical?necessity?

D2644? Onlay???porcelain/ceramic???
four?or?more?surfaces?

0?999? Permanent?
Teeth?1?32?

One?per?5?years;?dental?school?only.? Yes? Full?mouth?X?rays?or?
panorex,?and?narrative?
of?medical?necessity?

D2650? Inlay???resin?based?composite?
??one?surface?

0?999? Permanent?
Teeth?1?32?

One?per?5?years;?dental?school?only.? Yes? Full?mouth?X?rays?or?
panorex,?and?narrative?
of?medical?necessity?



Horizon?NJ?Health?Dental?Program?
Benefit?Plan?Details?&?Authorization?Requirements?

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139?

Horizon?NJ?Health?Dental?Program:?Non?Special?Needs?Plans?&?Special?Needs?Plans?
Code? Description? Age? Tooth?/?

Quad?/?Arch?
Limitations? Auth?

Req?
Requirement?

D2651? Inlay???resin?based?composite?
??two?surfaces?

0?999? Permanent?
Teeth?1?32?

One?per?5?years;?dental?school?only.? Yes? Full?mouth?X?rays?or?
panorex,?and?narrative?
of?medical?necessity?

D2652? Inlay???resin?based?composite?
??three?or?more?surfaces?

0?999? Permanent?
Teeth?1?32?

One?per?5?years;?dental?school?only.? Yes? Full?mouth?X?rays?or?
panorex,?and?narrative?
of?medical?necessity?

D2662? Onlay???resin?based?
composite???two?surfaces?

0?999? Permanent?
Teeth?1?32?

One?per?5?years;?dental?school?only.? Yes? Full?mouth?X?rays?or?
panorex,?and?narrative?
of?medical?necessity?

D2663? Onlay???resin?based?
composite???three?surfaces?

0?999? Permanent?
Teeth?1?32?

One?per?5?years;?dental?school?only.? Yes? Full?mouth?X?rays?or?
panorex,?and?narrative?
of?medical?necessity?

D2664? Onlay???resin?based?
composite???four?or?more?
surfaces?

0?999? Permanent?
Teeth?1?32?

One?per?5?years;?dental?school?only.? Yes? Full?mouth?X?rays?or?
panorex,?and?narrative?
of?medical?necessity?

D2710? Crown???resin?based?
composite?(indirect)?

0?999? Permanent?
Teeth?1?32?

One?per?5?years;?dental?school?only.? Yes? Full?mouth?X?rays?or?
panorex?

D2712? Crown?????resin?based?
composite?(indirect)?

0?999? Permanent?
Teeth?1?32?

One?per?5?years;?dental?school?only.? Yes? Full?mouth?X?rays?or?
panorex?

D2720? Crown???resin?with?high?noble?
metal?

0?999? Permanent?
Teeth?1?32?

One?per?5?years?per?payee.? Yes? Full?mouth?X?rays?or?
panorex?



Horizon?NJ?Health?Dental?Program?
Benefit?Plan?Details?&?Authorization?Requirements?

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Horizon?NJ?Health?Dental?Program:?Non?Special?Needs?Plans?&?Special?Needs?Plans?
Code? Description? Age? Tooth?/?

Quad?/?Arch?
Limitations? Auth?

Req?
Requirement?

D2721? Crown???resin?with?
predominantly?base?metal?

0?999? Permanent?
Teeth?1?32?

One?per?5?years?per?payee.? Yes? Full?mouth?X?rays?or?
panorex?

D2722? Crown???resin?with?noble?
metal?

0?999? Permanent?
Teeth?1?32?

One?per?5?years?per?payee.? Yes? Full?mouth?X?rays?or?
panorex?

D2740? Crown???porcelain/ceramic?
substrate?

0?999? Permanent?
Teeth?1?32?

One?per?5?years?per?payee.? Yes? Full?mouth?X?rays?or?
panorex?

D2750? Crown???porcelain?fused?to?
high?noble?metal?

0?999? Permanent?
Teeth?1?32?

One?per?5?years?per?payee.? Yes? Full?mouth?X?rays?or?
panorex?

D2751? Crown???porcelain?fused?to?
predominantly?base?metal?

0?999? Permanent?
Teeth?1?32?

One?per?5?years?per?payee.? Yes? Full?mouth?X?rays?or?
panorex?

D2752? Crown???porcelain?fused?to?
noble?metal?

0?999? Permanent?
Teeth?1?32?

One?per?5?years?per?payee.? Yes? Full?mouth?X?rays?or?
panorex?

D2780? Crown?????cast?high?noble?
metal?

0?999? Permanent?
Teeth?1?32?

One?per?5?years?per?payee.? Yes? Full?mouth?X?rays?or?
panorex?

D2781? Crown?????cast?
predominantly?base?metal?

0?999? Permanent?
Teeth?1?32?

One?per?5?years?per?payee.? Yes? Full?mouth?X?rays?or?
panorex?

D2782? Crown?????cast?noble?metal? 0?999? Permanent?
Teeth?1?32?

One?per?5?years?per?payee.? Yes? Full?mouth?X?rays?or?
panorex?



Horizon?NJ?Health?Dental?Program?
Benefit?Plan?Details?&?Authorization?Requirements?

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141?

Horizon?NJ?Health?Dental?Program:?Non?Special?Needs?Plans?&?Special?Needs?Plans?
Code? Description? Age? Tooth?/?

Quad?/?Arch?
Limitations? Auth?

Req?
Requirement?

D2783? Crown?????porcelain/ceramic? 0?999? Permanent?
Teeth?1?32?

One?per?5?years?per?payee.? Yes? Full?mouth?X?rays?or?
panorex?

D2790? Crown???full?cast?high?noble?
metal?

0?999? Permanent?
Teeth?1?32?

One?per?5?years?per?payee.? Yes? Full?mouth?X?rays?or?
panorex?

D2791? Crown???full?cast?
predominantly?base?metal?

0?999? Permanent?
Teeth?1?32?

One?per?5?years?per?payee.? Yes? Full?mouth?X?rays?or?
panorex?

D2792? Crown???full?cast?noble?metal? 0?999? Permanent?
Teeth?1?32?

One?per?5?years?per?payee.? Yes? Full?mouth?X?rays?or?
panorex?

D2910? Re?cement?or?re?bond?inlay,?
onlay,?veneer?or?partial?
coverage?restoration?

0?999? Permanent?
Teeth?1?32?

?? No? ??

D2915? Re?cement?or?re?bond?
indirectly?fabricated?or?
prefabricated?post?and?core?

0?999? Permanent?
Teeth?1?32?

?? No? ??

D2920? Re?cement?or?re?bond?crown? 0?999? All?teeth;??
A?T;?1?32?

?? No? ??

D2921? Reattachment?of?tooth?
fragment,?incisal?edge?or?cusp?

0?999? All?teeth;??
A?T;?1?32?

?? No? ??

D2929? Prefabricated?
porcelain/ceramic?crown???
primary?tooth?

0?999? Primary?
Teeth?A?T?

One?per?5?years?per?payee.? No?
?



Horizon?NJ?Health?Dental?Program?
Benefit?Plan?Details?&?Authorization?Requirements?

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Horizon?NJ?Health?Dental?Program:?Non?Special?Needs?Plans?&?Special?Needs?Plans?
Code? Description? Age? Tooth?/?

Quad?/?Arch?
Limitations? Auth?

Req?
Requirement?

D2930? Prefabricated?stainless?steel?
crown???primary?tooth?

0?999? Primary?
Teeth?A?T?

One?per?5?years?per?payee.? No? ??

D2931? Prefabricated?stainless?steel?
crown???permanent?tooth?

0?999? Permanent?
Teeth?1?32?

One?per?5?years?per?payee.? No? ??

D2932? Prefabricated?resin?crown? 0?999? Anterior?
Teeth?(6?11,?
22?27,?C?H,?
M?R)?

One?per?5?years?per?payee.? No? ??

D2933? Prefabricated?stainless?steel?
crown?with?resin?window?

0?999? Primary?
Anterior?
Teeth?(C?H,?
M?R)?

One?per?5?years?per?payee.? No? ??

D2934? Prefabricated?esthetic?coated?
stainless?steel?crown???
primary?tooth?

0?999? C,?D,?E,?F,?G,?
H,?M,?N,?O,?P,?
Q,?R?

One?per?5?years?per?payee.? No? ??

D2940? Protective?
restoration/sedative?filling?

0?999? All?teeth;??
A?T;?1?32?

?? No? ??

D2950? Core?buildup,?including?any?
pins?when?required?

0?999? Permanent?
Teeth?1?32?

One?per?5?years?per?payee.? Yes? Full?mouth?X?rays?or?
panorex?

D2951? Pin?retention???per?tooth,?in?
addition?to?restoration?

0?999? Permanent?
Teeth?1?32?

One?per?5?years?per?payee.? No? ??



Horizon?NJ?Health?Dental?Program?
Benefit?Plan?Details?&?Authorization?Requirements?

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143?

Horizon?NJ?Health?Dental?Program:?Non?Special?Needs?Plans?&?Special?Needs?Plans?
Code? Description? Age? Tooth?/?

Quad?/?Arch?
Limitations? Auth?

Req?
Requirement?

D2952? Post?and?core?in?addition?to?
crown,?indirectly?fabricated?

0?999? Permanent?
Teeth?1?32?

One?per?5?years?per?payee.? Yes? Full?mouth?X?rays?or?
panorex?

D2953? Each?additional?indirectly?
fabricated?post???same?tooth?

0?999? Permanent?
Teeth?1?32?

One?per?5?years?per?payee.? Yes? Full?mouth?X?rays?or?
panorex?

D2954? Prefabricated?post?and?core?
in?addition?to?crown?

0?999? Permanent?
Teeth?1?32?

One?per?5?years?per?payee.? Yes? Full?mouth?X?rays?or?
panorex?

D2955? Post?removal? 0?999? Permanent?
Teeth?1?32?

One?per?lifetime?per?tooth?per?member.?
Not?covered?on?same?date?of?service?as?D3346,?
D3347,?or?D3348.?
Not?payable?to?the?same?provider?as?D3346,?D3347,?or?
D3348.?

No? ??

D2957? Each?additional?prefabricated?
post???same?tooth?

0?999? Permanent?
Teeth?1?32?

One?per?5?years?per?payee.? Yes? Pre?operative?X?rays?of?
adjacent?teeth?and?
opposing?teeth?

D2970? Temporary?crown?(fractured?
tooth)?

0?999? Permanent?
Teeth?1?32?

?? No? ??

D2971? Additional?procedures?to?
construct?new?crown?under?
existing?partial?denture?
framework?

0?999? Permanent?
Teeth?1?32?

One?per?5?years?per?payee.? Yes? Pre?operative?X?rays?of?
adjacent?teeth?and?
opposing?teeth?



Horizon?NJ?Health?Dental?Program?
Benefit?Plan?Details?&?Authorization?Requirements?

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144?

Horizon?NJ?Health?Dental?Program:?Non?Special?Needs?Plans?&?Special?Needs?Plans?
Code? Description? Age? Tooth?/?

Quad?/?Arch?
Limitations? Auth?

Req?
Requirement?

D2975? Coping? 0?999? Permanent?
Teeth?1?32?

One?per?5?years?per?payee.? Yes? Pre?operative?X?rays?of?
adjacent?teeth?and?
opposing?teeth?

D2980? Crown?repair?necessitated?by?
restorative?material?failure?

0?999? Permanent?
Teeth?1?32?

?? Yes? Full?mouth?X?rays?or?
panorex?

D2981? Inlay?repair?necessitated?by?
restorative?material?failure?

0?999? Permanent?
Teeth?1?32?

?? Yes? Full?mouth?X?rays?or?
panorex?

D2982? Onlay?repair?necessitated?by?
restorative?material?failure?

0?999? Permanent?
Teeth?1?32?

?? Yes? Full?mouth?X?rays?or?
panorex?

D2983? Veneer?repair?necessitated?by?
restorative?material?failure?
unspecified?restorative?
procedure,?by?report?

0?999? Permanent?
Teeth?1?32?

?? Yes? Full?mouth?X?rays?or?
panorex?

D2999? Unspecified?restorative?
procedure,?by?report?

0?999?
?

Used?only?for?authorization?of?transfer?of?member?
cases?other?than?orthodontics.?
Not?to?be?billed.?

Yes? Evidence?of?prior?
approval,?requested?CDT?
codes?

D3220? Therapeutic?pulpotomy?
(excluding?final?restoration)???
removal?of?pulp?coronal?to?
the?dentinocemental?junction?
and?application?of?
medicament?

0?999? All?teeth;??
A?T;?1?32?

One?per?lifetime.?
Not?allowed?on?the?same?date?of?service?as?D3310,?
D3320,?or?D3330?per?payee.??

No? ??



Horizon?NJ?Health?Dental?Program?
Benefit?Plan?Details?&?Authorization?Requirements?

??SKYGEN?USA?|?CONFIDENTIAL?&?PROPRIETARY?|?Horizon?NJ?Health?Dental?Program?|?Effective:?1/1/20?
145?

Horizon?NJ?Health?Dental?Program:?Non?Special?Needs?Plans?&?Special?Needs?Plans?
Code? Description? Age? Tooth?/?

Quad?/?Arch?
Limitations? Auth?

Req?
Requirement?

D3221? Pulpal?debridement,?primary?
and?permanent?teeth?

0?999? All?teeth;??
A?T;?1?32?

One?per?lifetime.?
Not?allowed?on?the?same?date?of?service?as?D3310,?
D3320,?or?D3330?per?payee.?

No? ??

D3222? Partial?pulpotomy?for?
apexogenesis???permanent?
tooth?with?incomplete?root?
development?

0?999? Permanent?
Teeth?1?32?

One?per?lifetime.? No? ??

D3230? Pulpal?therapy?(resorbable?
filling)???anterior,?primary?
tooth?(excluding?final?
restoration)?

0?999? Primary?
Anterior?
Teeth?(C?H,?
M?R)?

One?per?lifetime.? No? ??

D3240? Pulpal?therapy?(resorbable?
filling)???posterior,?primary?
tooth?(excluding?final?
restoration)?

0?999? Primary?
Posterior?
Teeth?(A,?B,?I,?
J,?K,?L,?S,?T)?

One?per?lifetime.? No? ??

D3310? Endodontic?therapy,?anterior?
tooth?(excluding?final?
restoration)?

0?999? Permanent?
Anterior?
Teeth?(6?11,?
22?27)?

One?per?lifetime.? Yes? Full?mouth?X?rays?or?
panorex?

D3320? Endodontic?therapy,?bicuspid?
tooth?(excluding?final?
restoration)?

0?999? Bicuspids?(4,?
5,?12,?13,?20,?
21,?28,?29)?

One?per?lifetime.? Yes? Full?mouth?X?rays?or?
panorex?



Horizon?NJ?Health?Dental?Program?
Benefit?Plan?Details?&?Authorization?Requirements?

??SKYGEN?USA?|?CONFIDENTIAL?&?PROPRIETARY?|?Horizon?NJ?Health?Dental?Program?|?Effective:?1/1/20?
146?

Horizon?NJ?Health?Dental?Program:?Non?Special?Needs?Plans?&?Special?Needs?Plans?
Code? Description? Age? Tooth?/?

Quad?/?Arch?
Limitations? Auth?

Req?
Requirement?

D3330? Endodontic?therapy,?molar?
(excluding?final?restoration)?

0?999? Permanent?
Molars?(1?3,?
14?19,??
30?32)?

One?per?lifetime.? Yes? Full?mouth?X?rays?or?
panorex?

D3331? Treatment?of?root?canal?
obstruction;?non?surgical?
access?

0?999? Permanent?
Teeth?1?32?

One?per?lifetime.? Yes? Pre?operative?X?rays?
(excluding?bitewing??
X?rays)?and?narrative?of?
medical?necessity?

D3332? Incomplete?endodontic?
therapy;?inoperable,?
unrestorable?or?fractured?
tooth?

0?999? Permanent?
Teeth?1?32?

One?per?lifetime.? Yes? Pre?operative?x?rays?
(excluding?bitewing??
X?rays)?

D3333? Internal?root?repair?of?
perforation?defects?

0?999? Permanent?
Teeth?1?32?

One?per?lifetime.? Yes? Pre?operative?x?rays?
(excluding?bitewing??
X?rays)?

D3346? Retreatment?of?previous?root?
canal?therapy???anterior?

0?999? Permanent?
Anterior?
Teeth?(6?11,?
22?27)?

One?per?lifetime.?
Not?less?than?36?months?after?D3310?by?same?payee.?

Yes? Full?mouth?X?rays?or?
panorex?

D3347? Retreatment?of?previous?root?
canal?therapy???bicuspid?

0?999? Bicuspids?(4,?
5,?12,?13,?20,?
21,?28,?29)?

One?per?lifetime.?
Not?less?than?36?months?after?D3320?by?same?payee.?

Yes? Full?mouth?X?rays?or?
panorex?



Horizon?NJ?Health?Dental?Program?
Benefit?Plan?Details?&?Authorization?Requirements?

??SKYGEN?USA?|?CONFIDENTIAL?&?PROPRIETARY?|?Horizon?NJ?Health?Dental?Program?|?Effective:?1/1/20?
147?

Horizon?NJ?Health?Dental?Program:?Non?Special?Needs?Plans?&?Special?Needs?Plans?
Code? Description? Age? Tooth?/?

Quad?/?Arch?
Limitations? Auth?

Req?
Requirement?

D3348? Retreatment?of?previous?root?
canal?therapy???molar?

0?999? Permanent?
Molars?(1?3,?
14?19,??
30?32)?

One?per?lifetime.?
Not?less?than?36?months?after?D3330?by?same?payee.?

Yes? Full?mouth?X?rays?or?
panorex?

D3351? Apexification/recalcification???
initial?visit?(apical?
closure/calcific?repair?of?
perforations,?root?resorption,?
etc.)?

0?999? Permanent?
Teeth?1?32?

One?per?lifetime.? Yes? Pre?operative?X?rays?
(excluding?bitewing??
X?rays)?

D3352? Apexification/recalcification???
interim?medication?
replacement?

0?999? Permanent?
Teeth?1?32?

?
Yes? Date?of?initial?

apexification?visit?with?
claim?

D3353? Apexification/recalcification???
final?visit?(includes?completed?
root?canal?therapy???apical?
closure/?calcific?repair?of?
perforations,?root?resorption,?
etc.)?

0?999? Permanent?
Teeth?1?32?

One?per?lifetime.?
This?code?includes?the?payment?for?D3310,?D3320,?or?
D3330.?

Yes? Date?of?initial?
apexification?visit,?fill??
X?ray?with?claim?

D3355? Pulpal?regeneration???initial?
visit?

0?999? Permanent?
Teeth?1?32?

One?per?lifetime.? Yes? Pre?operative?X?rays?
(excluding?bitewing??
X?rays)?

D3356? Pulpal?regeneration???interim?
medication?replacement?

0?999? Permanent?
Teeth?1?32?

One?per?lifetime.? Yes? Pre?operative?X?rays?
(excluding?bitewing??
X?rays)?



Horizon?NJ?Health?Dental?Program?
Benefit?Plan?Details?&?Authorization?Requirements?

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Horizon?NJ?Health?Dental?Program:?Non?Special?Needs?Plans?&?Special?Needs?Plans?
Code? Description? Age? Tooth?/?

Quad?/?Arch?
Limitations? Auth?

Req?
Requirement?

D3357? Pulpal?regeneration???
completion?of?treatment?

0?999? Permanent?
Teeth?1?32?

One?per?lifetime.? Yes? Pre?operative?X?rays?
(excluding?bitewing??
X?rays)?

D3410? Apicoectomy???anterior? 0?999? Permanent?
Anterior?
Teeth?(6?11,?
22?27)?

One?per?lifetime.? Yes? Pre?operative?X?rays?of?
adjacent?teeth?and?
opposing?teeth?

D3421? Apicoectomy???bicuspid?(first?
root)?

0?999? Bicuspids?(4,?
5,?12,?13,?20,?
21,?28,?29)?

One?per?lifetime.? Yes? Pre?operative?X?rays?of?
adjacent?teeth?and?
opposing?teeth?

D3425? Apicoectomy???molar?(first?
root)?

0?999? Permanent?
Molars?(1?3,?
14?19,??
30?32)?

One?per?lifetime.? Yes? Pre?operative?X?rays?of?
adjacent?teeth?and?
opposing?teeth?

D3426? Apicoectomy?(each?additional?
root)?

0?999? Permanent?
Posterior?(1?
5,?12?21,?28?
32)?

One?per?lifetime.? Yes? Pre?operative?X?rays?of?
adjacent?teeth?and?
opposing?teeth?

D3427? Periradicular?surgery?without?
apicoectomy?

0?999? Permanent?
Teeth?1?32?

One?per?lifetime.? Yes? Pre?operative?X?rays?of?
adjacent?teeth?and?
opposing?teeth?



Horizon?NJ?Health?Dental?Program?
Benefit?Plan?Details?&?Authorization?Requirements?

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Horizon?NJ?Health?Dental?Program:?Non?Special?Needs?Plans?&?Special?Needs?Plans?
Code? Description? Age? Tooth?/?

Quad?/?Arch?
Limitations? Auth?

Req?
Requirement?

D3428? Bone?graft?in?conjunction?
with?periradicular?surgery???
per?tooth,?single?site?

0?999? Permanent?
Teeth?1?32?

One?per?lifetime.? Yes? Pre?operative?X?rays?of?
adjacent?teeth?and?
opposing?teeth?

D3429? Bone?graft?in?conjunction?
with?periradicular?surgery???
each?additional?contiguous?
tooth?in?the?same?surgical?site?

0?999? Permanent?
Teeth?1?32?

One?per?lifetime.? Yes? Pre?operative?X?rays?of?
adjacent?teeth?and?
opposing?teeth?

D3430? Retrograde?filling???per?root? 0?999? Permanent?
Teeth?1?32?

One?per?lifetime.? Yes? Pre?operative?X?rays?of?
adjacent?teeth?and?
opposing?teeth?

D3450? Root?amputation???per?root? 0?999? Permanent?
Posterior??
(1?5,?12?21,?
28?32)?

One?per?lifetime.? Yes? Pre?operative?X?rays?of?
adjacent?teeth?and?
opposing?teeth?

D3910? Surgical?procedure?for?
isolation?of?tooth?with?rubber?
dam?

0?999? Permanent?
Teeth?1?32?

One?per?lifetime.? Yes? Pre?operative?X?rays?of?
adjacent?teeth?and?
opposing?teeth?

D3920? Hemisection?(including?any?
root?removal),?not?including?
root?canal?therapy?

0?999? Permanent?
Molars?(1?3,?
14?19,??
30?32)?

One?per?lifetime.? Yes? Pre?operative?X?rays?of?
adjacent?teeth?and?
opposing?teeth?

D3950? Canal?preparation?and?fitting?
of?preformed?dowel?or?post?

0?999? Permanent?
Teeth?1?32?

One?per?lifetime.?
Not?payable?to?the?same?provider?as?D2952,?D2953,?
D2954,?or?D2957?per?lifetime?per?provider.??

Yes? Pre?operative?X?rays?of?
adjacent?teeth?and?
opposing?teeth?



Horizon?NJ?Health?Dental?Program?
Benefit?Plan?Details?&?Authorization?Requirements?

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150?

Horizon?NJ?Health?Dental?Program:?Non?Special?Needs?Plans?&?Special?Needs?Plans?
Code? Description? Age? Tooth?/?

Quad?/?Arch?
Limitations? Auth?

Req?
Requirement?

D3999? Unspecified?endodontic?
procedure;?by?report?

0?999? Permanent?
Teeth?1?32?

One?per?lifetime.? Yes? Narrative?of?medical?
necessity?

D4210? Gingivectomy?or?gingivoplasty?
??four?or?more?contiguous?
teeth?or?tooth?bounded?
spaces?per?quadrant?

0?999? Quadrants?
(LL,?LR,?UR,?
UL)?

One?per?3?years.? Yes? Pre?operative?X?rays,?
periodontal?charting,?
narrative?of?medical?
necessity,?photo?
(optional)?

D4211? Gingivectomy?or?gingivoplasty?
??one?to?three?contiguous?
teeth?or?tooth?bounded?
spaces?per?quadrant?

0?999? Quadrants?
(LL,?LR,?UR,?
UL)?

One?per?3?years.? Yes? Pre?operative?X?rays,?
periodontal?charting,?
narrative?of?medical?
necessity,?photo?
(optional)?

D4212? Gingivectomy?or?gingivoplasty?
to?allow?access?for?restorative?
procedure,?per?tooth?

0?999? Permanent?
Teeth?1?32?

One?per?3?years.? Yes? Pre?operative?X?rays,?
periodontal?charting,?
narrative?of?medical?
necessity,?photo?
(optional)?

D4240? Gingival?flap?procedure,?
including?root?planning???four?
or?more?contiguous?teeth?or?
tooth?bounded?spaces?per?
quadrant?

18?999? Quadrants?
(LL,?LR,?UR,?
UL)?

One?per?3?years.? Yes? Pre?operative?X?rays,?
periodontal?charting,?
narrative?of?medical?
necessity,?photo?
(optional)?



Horizon?NJ?Health?Dental?Program?
Benefit?Plan?Details?&?Authorization?Requirements?

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151?

Horizon?NJ?Health?Dental?Program:?Non?Special?Needs?Plans?&?Special?Needs?Plans?
Code? Description? Age? Tooth?/?

Quad?/?Arch?
Limitations? Auth?

Req?
Requirement?

D4241? Gingival?flap?procedure,?
including?root?planing???one?
to?three?contiguous?teeth?or?
tooth?bounded?spaces?per?
quadrant?

18?999? Quadrants?
(LL,?LR,?UR,?
UL)?

One?per?3?years.? Yes? Pre?operative?X?rays,?
periodontal?charting,?
narrative?of?medical?
necessity,?photo?
(optional)?

D4245? Apically?positioned?flap? 18?999? Quadrants?
(LL,?LR,?UR,?
UL)?

One?per?floating?year.? Yes? Pre?operative?X?rays,?
periodontal?charting,?
narrative?of?medical?
necessity,?photo?
(optional)?

D4249? Clinical?crown?lengthening???
hard?tissue?

0?999? Permanent?
Teeth?1?32?

One?per?lifetime.? Yes? Pre?operative?X?rays,?
periodontal?charting,?
narrative?of?medical?
necessity,?photo?
(optional)?

D4260? Osseous?surgery?(including?
elevation?of?a?full?thickness?
flap?and?closure)???four?or?
more?contiguous?teeth?or?
tooth?bounded?spaces?per?
quadrant?

18?999? Quadrants?
(LL,?LR,?UR,?
UL)?

One?per?3?years.? Yes? Pre?operative?X?rays,?
periodontal?charting,?
narrative?of?medical?
necessity,?photos?



Horizon?NJ?Health?Dental?Program?
Benefit?Plan?Details?&?Authorization?Requirements?

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152?

Horizon?NJ?Health?Dental?Program:?Non?Special?Needs?Plans?&?Special?Needs?Plans?
Code? Description? Age? Tooth?/?

Quad?/?Arch?
Limitations? Auth?

Req?
Requirement?

D4261? Osseous?surgery?(including?
elevation?of?a?full?thickness?
flap?and?closure)???one?to?
three?contiguous?teeth?or?
tooth?bounded?spaces?per?
quadrant?

18?999? Quadrants?
(LL,?LR,?UR,?
UL)?

One?per?3?years.? Yes? Pre?operative?X?rays,?
periodontal?charting,?
narrative?of?medical?
necessity,?photos?

D4263? Bone?replacement?graft???first?
site?in?quadrant?

18?999? Permanent?
Teeth?1?32?

Once?per?lifetime.?
Not?allowed?on?same?date?of?service?as?D7140,?D7210,?
D7220,?D7230,?D7240,?or?D7241.?
Tooth?cannot?have?a?history?of?being?extracted.?

Yes? Pre?operative?X?rays,?
periodontal?charting,?
narrative?of?medical?
necessity,?photo?
(optional)?

D4264? Bone?replacement?graft???
each?additional?site?in?
quadrant?

18?999? Permanent?
Teeth?1?32?

Once?per?lifetime.?
Not?allowed?on?same?date?of?service?as?D7140,?D7210,?
D7220,?D7230,?D7240,?or?D7241.?
Tooth?cannot?have?a?history?of?being?extracted.?

Yes? Pre?operative?X?rays,?
periodontal?charting,?
narrative?of?medical?
necessity,?photo?
(optional)?

D4265? Biologic?materials?to?aid?in?
soft?and?osseous?tissue?
regeneration?

18?999? Permanent?
Teeth?1?32?

One?per?lifetime.? Yes? Pre?operative?X?rays,?
periodontal?charting,?
narrative?of?medical?
necessity,?photo?
(optional)?

D4266? Guided?tissue?regeneration???
resorbable?barrier,?per?site?

18?999? Permanent?
Teeth?1?32?

One?per?3?years.? Yes? Pre?operative?X?rays,?
periodontal?charting,?
narrative?of?medical?
necessity,?photo?
(optional)?



Horizon?NJ?Health?Dental?Program?
Benefit?Plan?Details?&?Authorization?Requirements?

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153?

Horizon?NJ?Health?Dental?Program:?Non?Special?Needs?Plans?&?Special?Needs?Plans?
Code? Description? Age? Tooth?/?

Quad?/?Arch?
Limitations? Auth?

Req?
Requirement?

D4267? Guided?tissue?regeneration???
non?resorbable?barrier,?per?
site?(includes?membrane?
removal)?

18?999? Permanent?
Teeth?1?32?

One?per?3?years.? Yes? Pre?operative?X?rays,?
periodontal?charting,?
narrative?of?medical?
necessity,?photo?
(optional)?

D4268? Surgical?revision?procedure,?
per?tooth?

18?999? Permanent?
Teeth?1?32?

One?per?3?years.? Yes? Pre?operative?X?rays,?
periodontal?charting,?
narrative?of?medical?
necessity,?photo?
(optional)?

D4270? Pedicle?soft?tissue?graft?
procedure?

18?999? Permanent?
Teeth?1?32?

One?per?3?years.? Yes? Pre?operative?X?rays,?
periodontal?charting,?
narrative?of?medical?
necessity,?photo?
(optional)?

D4273? Subepithelial?connective?
tissue?graft?procedures,?per?
tooth?

18?999? Permanent?
Teeth?1?32?

One?per?3?years.? Yes? Pre?operative?X?rays,?
periodontal?charting,?
narrative?of?medical?
necessity,?photo?
(optional)?

D4274? Distal?or?proximal?wedge?
procedure?(when?not?
performed?in?conjunction?
with?surgical?procedures?in?
the?same?anatomical?area)?

18?999? Permanent?
Teeth?1?32?

One?per?3?years.? Yes? Pre?operative?X?rays,?
periodontal?charting,?
narrative?of?medical?
necessity,?photo?
(optional)?



Horizon?NJ?Health?Dental?Program?
Benefit?Plan?Details?&?Authorization?Requirements?

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154?

Horizon?NJ?Health?Dental?Program:?Non?Special?Needs?Plans?&?Special?Needs?Plans?
Code? Description? Age? Tooth?/?

Quad?/?Arch?
Limitations? Auth?

Req?
Requirement?

D4275? Soft?tissue?allograft? 18?999? Permanent?
Teeth?1?32?

One?per?3?years.? Yes? Pre?operative?X?rays,?
periodontal?charting,?
narrative?of?medical?
necessity,?photo?
(optional)?

D4276? Combined?connective?tissue?
and?double?pedicle?graft,?per?
tooth?

18?999? Permanent?
Teeth?1?32?

One?per?3?years.? Yes? Pre?operative?X?rays,?
periodontal?charting,?
narrative?of?medical?
necessity,?photo?
(optional)?

D4277? Free?soft?tissue?graft?
procedure?(including?donor?
site?surgery),?first?tooth?or?
edentulous?tooth?position?in?
graft?

18?999? Permanent?
Teeth?1?32?

One?per?3?years.? Yes? Pre?operative?X?rays,?
periodontal?charting,?
narrative?of?medical?
necessity,?photo?
(optional)?

D4278? Free?soft?tissue?graft?
procedure?(including?donor?
site?surgery),?each?additional?
contiguous?tooth?or?
edentulous?tooth?position?in?
same?graft?site?

18?999? Permanent?
Teeth?1?32?

One?per?3?years.? Yes? Pre?operative?X?rays,?
periodontal?charting,?
narrative?of?medical?
necessity,?photo?
(optional)?



Horizon?NJ?Health?Dental?Program?
Benefit?Plan?Details?&?Authorization?Requirements?

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Horizon?NJ?Health?Dental?Program:?Non?Special?Needs?Plans?&?Special?Needs?Plans?
Code? Description? Age? Tooth?/?

Quad?/?Arch?
Limitations? Auth?

Req?
Requirement?

D4283? Autogenous?connective?tissue?
graft?procedure?(including?
donor?and?surgical?sites)???
each?additional?contiguous?
tooth,?implant?or?edentulous?
tooth?position?in?same?graft?
site?

18?999? Permanent?
Teeth?1?32?

One?per?3?years.? Yes? Pre?operative?X?rays,?
periodontal?charting,?
narrative?of?medical?
necessity,?photo?
(optional)?

D4285? Non?Autogenous?connective?
tissue?graft?procedure?
(including?donor?and?surgical?
sites)???each?additional?
contiguous?tooth,?implant?or?
edentulous?tooth?position?in?
same?graft?site?

18?999? Permanent?
Teeth?1?32?

One?per?3?years.? Yes? Pre?operative?X?rays,?
periodontal?charting,?
narrative?of?medical?
necessity,?photo?
(optional)?

D4320? Provisional?splinting???
intracoronal?

0?999? Arches?(UA,?
LA)?

?? Yes? Documentation?of?
medical?necessity?

D4321? Provisional?splinting???
extracoronal?

0?999? Arches?(UA,?
LA)?

?? Yes? Documentation?of?
medical?necessity?

D4341?
No?
Special?
Needs?

Periodontal?scaling?and?root?
planing???four?or?more?teeth?
per?quadrant?

0?999? Quadrants?
(LL,?LR,?UR,?
UL)?

One?per?floating?year.? Yes? Periodontal?charting?and?
pre?operative?X?rays?



Horizon?NJ?Health?Dental?Program?
Benefit?Plan?Details?&?Authorization?Requirements?

??SKYGEN?USA?|?CONFIDENTIAL?&?PROPRIETARY?|?Horizon?NJ?Health?Dental?Program?|?Effective:?1/1/20?
156?

Horizon?NJ?Health?Dental?Program:?Non?Special?Needs?Plans?&?Special?Needs?Plans?
Code? Description? Age? Tooth?/?

Quad?/?Arch?
Limitations? Auth?

Req?
Requirement?

D4341?
Special?
Needs?

Periodontal?scaling?and?root?
planing???four?or?more?teeth?
per?quadrant?

0?999? Quadrants?
(LL,?LR,?UR,?
UL)?

One?per?floating?year.? Yes? Periodontal?charting?and?
pre?operative?X?rays;?
letter?of?medical?
necessity?for?additional?
frequency?

D4342?
No?
Special?
Needs?

Periodontal?scaling?and?root?
planing???one?to?three?teeth?
per?quadrant?

0?999? Quadrants?
(LL,?LR,?UR,?
UL)?

One?per?floating?year.? Yes? Periodontal?charting?and?
pre?operative?X?rays?

D4342?
Special?
Needs?

Periodontal?scaling?and?root?
planing???one?to?three?teeth?
per?quadrant?

0?999? Quadrants?
(LL,?LR,?UR,?
UL)?

One?per?floating?year.? Yes? Periodontal?charting?and?
pre?operative?X?rays;?
letter?of?medical?
necessity?for?less?than?3?
years?

D4346? Scaling?in?presence?of?
generalized?moderate?or?
severe?gingival?inflammation?
??full?mouth,?after?oral?
evaluation?

0?999? ?? One?per?floating?year.?
Not?allowable?within?6?months?of?D1110,?D1120,?
D4341,?D4342,?D4260,?D4261?or?D4910.?

No? ??

D4355?
No?
Special?
Needs,?
MLTSS?

Full?mouth?debridement?to?
enable?comprehensive?
evaluation?and?diagnosis?

0?999? ?? One?per?three?floating?years.?
Not?allowable?within?6?months?of?D4341,?D4342,?
D4260,?D4261,?D4346,?or?D4910.?
Not?allowable?on?the?same?date?of?service?as?D0150,?
D0160,?D0180,?D1110,?D1120?or?any?other?D4000?
series?code.?

No? ??



Horizon?NJ?Health?Dental?Program?
Benefit?Plan?Details?&?Authorization?Requirements?

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157?

Horizon?NJ?Health?Dental?Program:?Non?Special?Needs?Plans?&?Special?Needs?Plans?
Code? Description? Age? Tooth?/?

Quad?/?Arch?
Limitations? Auth?

Req?
Requirement?

D4355?
Special?
Needs,?
MLTSS?

Full?mouth?debridement?to?
enable?comprehensive?
evaluation?and?diagnosis?

0?999? ?? One?per?floating?year.?
Not?allowable?within?6?months?of?D4341,?D4342,?
D4260,?D4261,?D4346,?or?D4910.?
Not?allowable?on?the?same?date?of?service?as?D0150,?
D0160,?D0180,?D1110,?D1120?or?any?other?D4000?
series?code.?

No? ??

D4381? Localized?delivery?of?
antimicrobial?agents?via?a?
controlled?release?vehicle?into?
diseased?crevicular?tissue,?per?
tooth?

0?999? Permanent?
Teeth?1?32?

One?per?2?years.? Yes? Description?of?procedure?
and?narrative?of?medical?
necessity?

D4910? Periodontal?maintenance? 0?999? ?? Allowable?twice?per?rolling?year?per?member.?
Requires?history?of?active?perio?treatment?(D4341,?
D4342,?D4260,?D4261,?or?D4910)?within?the?last?36?
months.??
Not?allowed?sooner?than?90?days?after?D1110,?D4210,?
D4211,?D4240,?D4241,?D4245,?D4260,?D4261,?D4263,?
D4264,?D4266,?D4267,?D4268,?D4270,?D4271,?D4273,?
D4274,?D4275,?D4276,?D4341,?or?D4342.?

No? ??

D4999? Unspecified?periodontal?
procedure,?by?report?

0?999? All?teeth;??
A?T;?1?32?

?? Yes? Description?of?procedure?
and?narrative?of?medical?
necessity?

D5110? Complete?denture???maxillary? 0?999? ?? One?per?90?months.? Yes? Full?mouth?X?rays?or?
panorex?



Horizon?NJ?Health?Dental?Program?
Benefit?Plan?Details?&?Authorization?Requirements?

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158?

Horizon?NJ?Health?Dental?Program:?Non?Special?Needs?Plans?&?Special?Needs?Plans?
Code? Description? Age? Tooth?/?

Quad?/?Arch?
Limitations? Auth?

Req?
Requirement?

D5120? Complete?denture???
mandibular?

0?999? ?? One?per?90?months.? Yes? Full?mouth?X?rays?or?
panorex?

D5130? Immediate?denture???
maxillary?

0?999? ?? One?per?lifetime;?allowed?within?14?days?of?D7140,?
D7210,?D7220,?D7230,?D7240,?D7241,?or?D7250.?
D5710,?D5711,?D5720,?D5721,?D5730,?D5731,?D5740,?
D5741,?D5750,?D5751,?D5760,?D5761,?D5850,?D5851?
not?payable?within?6?months?after?this?code.?

Yes? Full?mouth?X?rays?or?
panorex?

D5140? Immediate?denture???
mandibular?

0?999? ?? One?per?lifetime;?allowed?within?14?days?of?D7140,?
D7210,?D7220,?D7230,?D7240,?D7241,?or?D7250.?
D5710,?D5711,?D5720,?D5721,?D5730,?D5731,?D5740,?
D5741,?D5750,?D5751,?D5760,?D5761,?D5850,?D5851?
not?payable?within?6?months?after?this?code.?

Yes? Full?mouth?X?rays?or?
panorex?

D5211? Maxillary?partial?denture???
resin?base?(including?any?
conventional?clasps,?rests?and?
teeth)?

0?999? ?? One?per?90?months.? Yes? Full?mouth?X?rays?or?
panorex?

D5212? Mandibular?partial?denture???
resin?base?(including?any?
conventional?clasps,?rests?and?
teeth)?

0?999? ?? One?per?90?months.? Yes? Full?mouth?X?rays?or?
panorex?

D5213? Maxillary?partial?denture???
cast?metal?framework?with?
resin?denture?bases?

0?999? ?? One?per?90?months.? Yes? Full?mouth?X?rays?or?
panorex?



Horizon?NJ?Health?Dental?Program?
Benefit?Plan?Details?&?Authorization?Requirements?

??SKYGEN?USA?|?CONFIDENTIAL?&?PROPRIETARY?|?Horizon?NJ?Health?Dental?Program?|?Effective:?1/1/20?
159?

Horizon?NJ?Health?Dental?Program:?Non?Special?Needs?Plans?&?Special?Needs?Plans?
Code? Description? Age? Tooth?/?

Quad?/?Arch?
Limitations? Auth?

Req?
Requirement?

D5214? Mandibular?partial?denture???
cast?metal?framework?with?
resin?denture?bases?

0?999? ?? One?per?90?months.? Yes? Full?mouth?X?rays?or?
panorex?

D5221? Immediate?Maxillary?partial?
denture???resin?base?
(including?any?conventional?
clasps,?rests,?and?teeth)?

0?999? ?? One?per?90?months.? Yes? Full?mouth?X?rays?or?
panorex?

D5222? Immediate?Mandibular?partial?
denture???resin?base?
(including?any?conventional?
clasps,?rests,?and?teeth)?

0?999? ?? One?per?90?months.? Yes? Full?mouth?X?rays?or?
panorex?

D5223? Immediate?Maxillary?partial?
denture???cast?metal?base?
(including?any?conventional?
clasps,?rests,?and?teeth)?

0?999? ?? One?per?90?months.? Yes? Full?mouth?X?rays?or?
panorex?

D5224? Immediate?Mandibular?partial?
denture???cast?metal?base?
(including?any?conventional?
clasps,?rests,?and?teeth)?

0?999? ?? One?per?90?months.? Yes? Full?mouth?X?rays?or?
panorex?

D5225? Maxillary?partial?denture???
flexible?base?(including?any?
clasps,?rests,?and?teeth)?

0?999? ?? One?per?90?months.? Yes? Full?mouth?X?rays?or?
panorex?



Horizon?NJ?Health?Dental?Program?
Benefit?Plan?Details?&?Authorization?Requirements?

??SKYGEN?USA?|?CONFIDENTIAL?&?PROPRIETARY?|?Horizon?NJ?Health?Dental?Program?|?Effective:?1/1/20?
160?

Horizon?NJ?Health?Dental?Program:?Non?Special?Needs?Plans?&?Special?Needs?Plans?
Code? Description? Age? Tooth?/?

Quad?/?Arch?
Limitations? Auth?

Req?
Requirement?

D5226? Mandibular?partial?denture???
flexible?base?(including?any?
clasps,?rests,?and?teeth)?

0?999? ?? One?per?90?months.? Yes? Full?mouth?X?rays?or?
panorex?

D5410? Adjust?complete?denture???
maxillary?

0?999? ?? One?per?6?months.??
Not?within?6?months?of?reline/rebase?or?3?months?of?
D5510?or?D5610.?

No? ??

D5411? Adjust?complete?denture???
mandibular?

0?999? ?? One?per?6?months.?
Not?within?6?months?of?reline/rebase?or?3?months?of?
D5510?or?D5610.?

No? ??

D5421? Adjust?partial?denture???
maxillary?

0?999? ?? One?per?6?months.?
Not?within?6?months?of?reline/rebase?or?3?months?of?
D5510?or?D5610.?

No? ??

D5422? Adjust?partial?denture???
mandibular?

0?999? ?? One?per?6?months.?
Not?within?6?months?of?reline/rebase?or?3?months?of?
D5510?or?D5610.?

No? ??

D5511? Repair?broken?complete?
denture?base???Mandibular?

0?999? Lower?Arch? One?per?3?rolling?years.? No? ??

D5512? Repair?broken?complete?
denture?base???Maxillary?

0?999? Upper?Arch? One?per?3?rolling?years.? No? ?



Horizon?NJ?Health?Dental?Program?
Benefit?Plan?Details?&?Authorization?Requirements?

??SKYGEN?USA?|?CONFIDENTIAL?&?PROPRIETARY?|?Horizon?NJ?Health?Dental?Program?|?Effective:?1/1/20?
161?

Horizon?NJ?Health?Dental?Program:?Non?Special?Needs?Plans?&?Special?Needs?Plans?
Code? Description? Age? Tooth?/?

Quad?/?Arch?
Limitations? Auth?

Req?
Requirement?

D5520? Replace?missing?or?broken?
teeth???complete?denture?
(each?tooth)?

0?999? Permanent?
Teeth?1?32?

One?per?6?months.? No? ??

D5611? Repair?resin?partial?denture?
base???Mandibular?

0?999? Lower?Arch? One?per?3?rolling?years.? No? ??

D5612? Repair?resin?partial?denture?
base???Maxillary?

0?999? Upper?Arch? One?per?3?rolling?years.? No? ?

D5621? Repair?cast?partial?framework?
??Mandibular?

0?999? Lower?Arch? One?per?3?rolling?years.? No? ??

D5622? Repair?cast?partial?framework?
??Maxillary?

0?999? Upper?Arch? One?per?3?rolling?years.? No? ?

D5630? Repair?or?replace?broken?
clasp?

0?999? Permanent?
Teeth?1?32?

One?per?6?months.? No? ??

D5640? Replace?broken?teeth???per?
tooth?

0?999? Permanent?
Teeth?1?32?

One?per?6?months.? No? ??

D5650? Add?tooth?to?existing?partial?
denture?

0?999? Permanent?
Teeth?1?32?

One?per?6?months.? No? ??

D5660? Add?clasp?to?existing?partial?
denture?

0?999? Permanent?
Teeth?1?32?

One?per?6?months.? No? ??



Horizon?NJ?Health?Dental?Program?
Benefit?Plan?Details?&?Authorization?Requirements?

??SKYGEN?USA?|?CONFIDENTIAL?&?PROPRIETARY?|?Horizon?NJ?Health?Dental?Program?|?Effective:?1/1/20?
162?

Horizon?NJ?Health?Dental?Program:?Non?Special?Needs?Plans?&?Special?Needs?Plans?
Code? Description? Age? Tooth?/?

Quad?/?Arch?
Limitations? Auth?

Req?
Requirement?

D5710? Rebase?complete?maxillary?
denture?

0?999? ?? One?per?3?years.?
Not?allowed?within?6?months?after?D5110?or?D5130.?

No? ??

D5711? Rebase?complete?mandibular?
denture?

0?999? ?? One?per?3?years.?
Not?allowed?within?6?months?after?D5120?or?D5140.?

No? ??

D5720? Rebase?maxillary?partial?
denture?

0?999? ?? One?per?3?years.? No? ??

D5721? Rebase?mandibular?partial?
denture?

0?999? ?? One?per?3?years.? No? ??

D5730? Reline?complete?maxillary?
denture?(chairside)?

0?999? ?? One?per?12?months.? No? ??

D5731? Reline?complete?mandibular?
denture?(chairside)?

0?999? ?? One?per?12?months.? No? ??

D5740? Reline?maxillary?partial?
denture?(chairside)?

0?999? ?? One?per?12?months.? No? ??

D5741? Reline?mandibular?partial?
denture?(chairside)?

0?999? ?? One?per?12?months.? No? ??

D5750? Reline?complete?maxillary?
denture?(laboratory)?

0?999? ?? One?per?12?months.? No? ??

D5751? Reline?complete?mandibular?
denture?(laboratory)?

0?999? ?? One?per?12?months.? No? ??



Horizon?NJ?Health?Dental?Program?
Benefit?Plan?Details?&?Authorization?Requirements?

??SKYGEN?USA?|?CONFIDENTIAL?&?PROPRIETARY?|?Horizon?NJ?Health?Dental?Program?|?Effective:?1/1/20?
163?

Horizon?NJ?Health?Dental?Program:?Non?Special?Needs?Plans?&?Special?Needs?Plans?
Code? Description? Age? Tooth?/?

Quad?/?Arch?
Limitations? Auth?

Req?
Requirement?

D5760? Reline?maxillary?partial?
denture?(laboratory)?

0?999? ?? One?per?12?months.? No? ??

D5761? Reline?mandibular?partial?
denture?(laboratory)?

0?999? ?? One?per?12?months.? No? ??

D5850? Tissue?conditioning,?maxillary? 18?999? ?? One?per?12?months.? No? ??

D5851? Tissue?conditioning,?
mandibular?

18?999? ?? One?per?12?months.? No? ??

D5862? Precision?attachment,?by?
report?

18?999? Permanent?
Teeth?1?32?

?? Yes? Narrative?describing?
type?of?attachment?and?
the?medical?necessity?

D5863? Overdenture???complete?
maxillary?

18?999? Arches?(UA,?
LA)?

One?per?90?months.? Yes? Full?mouth?X?rays?or?
panorex?

D5864? Overdenture???partial?
maxillary?

18?999? Arches?(UA,?
LA)?

One?per?90?months.? Yes? Full?mouth?X?rays?or?
panorex?

D5865? Overdenture???complete?
mandibular?

18?999? Arches?(UA,?
LA)?

One?per?90?months.? Yes? Full?mouth?X?rays?or?
panorex?

D5866? Overdenture???partial?
mandibular?

18?999? Arches?(UA,?
LA)?

One?per?90?months.? Yes? Full?mouth?X?rays?or?
panorex?



Horizon?NJ?Health?Dental?Program?
Benefit?Plan?Details?&?Authorization?Requirements?

??SKYGEN?USA?|?CONFIDENTIAL?&?PROPRIETARY?|?Horizon?NJ?Health?Dental?Program?|?Effective:?1/1/20?
164?

Horizon?NJ?Health?Dental?Program:?Non?Special?Needs?Plans?&?Special?Needs?Plans?
Code? Description? Age? Tooth?/?

Quad?/?Arch?
Limitations? Auth?

Req?
Requirement?

D5867? Replacement?of?replaceable?
part?of?semi?precision?or?
precision?attachment?

18?999? Permanent?
Teeth?1?32?

?? Yes? Narrative?describing?
type?of?attachment?and?
the?medical?necessity?

D5875? Modification?of?removable?
prosthesis?following?implant?
surgery?

0?999? Arches?(UA,?
LA)?

?? Yes? Narrative?of?date?of?
implant?placement?with?
claim?

D5899? Unspecified?removable?
prosthodontic?procedure,?by?
report?

0?999? Arches?(UA,?
LA)?

?? Yes? Description?of?procedure?
and?narrative?of?medical?
necessity?

D5911? Facial?moulage?(sectional)? 0?999? ?? ?? Yes? Narrative?of?medical?
necessity?with?
preauthorization?

D5912? Facial?moulage?(complete)? 0?999? ?? ?? Yes? Narrative?of?medical?
necessity?with?
preauthorization?

D5913? Nasal?prosthesis? 0?999? ?? ?? Yes? Narrative?of?medical?
necessity?with?
preauthorization?

D5914? Auricular?prosthesis? 0?999? ?? ?? Yes? Narrative?of?medical?
necessity?with?
preauthorization?



Horizon?NJ?Health?Dental?Program?
Benefit?Plan?Details?&?Authorization?Requirements?

??SKYGEN?USA?|?CONFIDENTIAL?&?PROPRIETARY?|?Horizon?NJ?Health?Dental?Program?|?Effective:?1/1/20?
165?

Horizon?NJ?Health?Dental?Program:?Non?Special?Needs?Plans?&?Special?Needs?Plans?
Code? Description? Age? Tooth?/?

Quad?/?Arch?
Limitations? Auth?

Req?
Requirement?

D5915? Orbital?prosthesis? 0?999? ?? ?? Yes? Narrative?of?medical?
necessity?with?
preauthorization?

D5916? Ocular?prosthesis? 0?999? ?? ?? Yes? Narrative?of?medical?
necessity?with?
preauthorization?

D5919? Facial?prosthesis? 0?999? ?? ?? Yes? Narrative?of?medical?
necessity?with?
preauthorization?

D5922? Nasal?septal?prosthesis? 0?999? ?? ?? Yes? Narrative?of?medical?
necessity?with?
preauthorization?

D5923? Ocular?prosthesis,?interim? 0?999? ?? ?? Yes? Narrative?of?medical?
necessity?with?
preauthorization?

D5924? Cranial?prosthesis? 0?999? ?? ?? Yes? Narrative?of?medical?
necessity?with?
preauthorization?

D5925? Facial?augmentation?implant?
prosthesis?

0?999? ?? ?? Yes? Narrative?of?medical?
necessity?with?
preauthorization?



Horizon?NJ?Health?Dental?Program?
Benefit?Plan?Details?&?Authorization?Requirements?

??SKYGEN?USA?|?CONFIDENTIAL?&?PROPRIETARY?|?Horizon?NJ?Health?Dental?Program?|?Effective:?1/1/20?
166?

Horizon?NJ?Health?Dental?Program:?Non?Special?Needs?Plans?&?Special?Needs?Plans?
Code? Description? Age? Tooth?/?

Quad?/?Arch?
Limitations? Auth?

Req?
Requirement?

D5926? Nasal?prosthesis,?replacement? 0?999? ?? ?? Yes? Narrative?of?medical?
necessity?with?
preauthorization?

D5927? Auricular?prosthesis,?
replacement?

0?999? ?? ?? Yes? Narrative?of?medical?
necessity?with?
preauthorization?

D5928? Orbital?prosthesis,?
replacement?

0?999? ?? ?? Yes? Narrative?of?medical?
necessity?with?
preauthorization?

D5929? Facial?prosthesis,?
replacement?

0?999? ?? ?? Yes? Narrative?of?medical?
necessity?with?
preauthorization?

D5931? Obturator?prosthesis,?surgical? 0?999? ?? ?? Yes? Narrative?of?medical?
necessity?with?
preauthorization?

D5932? Obturator?prosthesis,?
definitive?

0?999? ?? ?? Yes? Narrative?of?medical?
necessity?with?
preauthorization?

D5933? Obturator?prosthesis,?
modification?

0?999? ?? ?? Yes? Narrative?of?medical?
necessity?with?
preauthorization?



Horizon?NJ?Health?Dental?Program?
Benefit?Plan?Details?&?Authorization?Requirements?

??SKYGEN?USA?|?CONFIDENTIAL?&?PROPRIETARY?|?Horizon?NJ?Health?Dental?Program?|?Effective:?1/1/20?
167?

Horizon?NJ?Health?Dental?Program:?Non?Special?Needs?Plans?&?Special?Needs?Plans?
Code? Description? Age? Tooth?/?

Quad?/?Arch?
Limitations? Auth?

Req?
Requirement?

D5935? Mandibular?resection?
prosthesis?without?guide?
flange?

0?999? ?? ?? Yes? Narrative?of?medical?
necessity?with?
preauthorization?

D5936? Obturator?prosthesis,?interim? 0?999? ?? ?? Yes? Narrative?of?medical?
necessity?with?
preauthorization?

D5937? Trismus?appliance?(not?for?
TMD?treatment)?

0?999? ?? ?? Yes? Narrative?of?medical?
necessity?with?
preauthorization?

D5951? Feeding?aid? 0?999? ?? ?? Yes? Narrative?of?medical?
necessity?with?
preauthorization?

D5952? Speech?aid?prosthesis,?
pediatric?

0?999? ?? ?? Yes? Narrative?of?medical?
necessity?with?
preauthorization?

D5953? Speech?aid?prosthesis,?adult? 0?999? ?? ?? Yes? Narrative?of?medical?
necessity?with?
preauthorization?

D5954? Palatal?augmentation?
prosthesis?

0?999? ?? ?? Yes? Narrative?of?medical?
necessity?with?
preauthorization?



Horizon?NJ?Health?Dental?Program?
Benefit?Plan?Details?&?Authorization?Requirements?

??SKYGEN?USA?|?CONFIDENTIAL?&?PROPRIETARY?|?Horizon?NJ?Health?Dental?Program?|?Effective:?1/1/20?
168?

Horizon?NJ?Health?Dental?Program:?Non?Special?Needs?Plans?&?Special?Needs?Plans?
Code? Description? Age? Tooth?/?

Quad?/?Arch?
Limitations? Auth?

Req?
Requirement?

D5955? Palatal?lift?prosthesis,?
definitive?

0?999? ?? ?? Yes? Narrative?of?medical?
necessity?with?
preauthorization?

D5958? Palatal?lift?prosthesis,?interim? 0?999? ?? ?? Yes? Narrative?of?medical?
necessity?with?
preauthorization?

D5959? Palatal?lift?prosthesis,?
modification?

0?999? ?? ?? Yes? Narrative?of?medical?
necessity?with?
preauthorization?

D5960? Speech?aid?prosthesis,?
modification?

0?999? ?? ?? Yes? Narrative?of?medical?
necessity?with?
preauthorization?

D5982? Surgical?stent? 0?999? ?? ?? Yes? Narrative?of?medical?
necessity?with?
preauthorization?

D5983? Radiation?carrier? 0?999? ?? ?? Yes? Narrative?of?medical?
necessity?with?
preauthorization?

D5984? Radiation?shield? 0?999? ?? ?? Yes? Narrative?of?medical?
necessity?with?
preauthorization?



Horizon?NJ?Health?Dental?Program?
Benefit?Plan?Details?&?Authorization?Requirements?

??SKYGEN?USA?|?CONFIDENTIAL?&?PROPRIETARY?|?Horizon?NJ?Health?Dental?Program?|?Effective:?1/1/20?
169?

Horizon?NJ?Health?Dental?Program:?Non?Special?Needs?Plans?&?Special?Needs?Plans?
Code? Description? Age? Tooth?/?

Quad?/?Arch?
Limitations? Auth?

Req?
Requirement?

D5985? Radiation?cone?locator? 0?999? ?? ?? Yes? Narrative?of?medical?
necessity?with?
preauthorization?

D5986? Fluoride?gel?carrier? 0?999? ?? ?? Yes? Narrative?of?medical?
necessity?with?
preauthorization?

D5987? Commissure?splint? 0?999? ?? ?? Yes? Narrative?of?medical?
necessity?with?
preauthorization?

D5988? Surgical?splint? 0?999? ?? ?? Yes? Narrative?of?medical?
necessity?with?
preauthorization?

D5991? Vesiculobullous?disease?
medicament?carrier?

0?999? ?? ?? Yes? Narrative?of?medical?
necessity?with?claim?

D5992? Adjust?maxillofacial?prosthetic?
appliance,?by?report?

0?999? ?? ?? Yes? Narrative?of?medical?
necessity?with?claim?

D5993? Maintenance?and?cleaning?of?
a?maxillofacial?prosthesis?
(extra??or?intra?oral)?other?
than?required?adjustments,?
by?report?

0?999? ?? One?per?floating?year.? Yes? Narrative?of?medical?
necessity?with?claim?



Horizon?NJ?Health?Dental?Program?
Benefit?Plan?Details?&?Authorization?Requirements?

??SKYGEN?USA?|?CONFIDENTIAL?&?PROPRIETARY?|?Horizon?NJ?Health?Dental?Program?|?Effective:?1/1/20?
170?

Horizon?NJ?Health?Dental?Program:?Non?Special?Needs?Plans?&?Special?Needs?Plans?
Code? Description? Age? Tooth?/?

Quad?/?Arch?
Limitations? Auth?

Req?
Requirement?

D5999? Unspecified?maxillofacial?
prosthesis,?by?report?

0?999? ?? ?? Yes? Description?of?procedure?
and?narrative?of?medical?
necessity?

D6010? Surgical?placement?of?implant?
body:?endosteal?implant?

0?999? Permanent?
Teeth?1?32?

One?per?tooth?per?lifetime.?
Four?teeth?per?arch.?

Yes? Full?mouth?X?rays?or?
panorex?

D6040? Surgical?placement:?epostial?
implant?

0?999? Arches?(UA,?
LA)?

One?per?90?months.? Yes? Full?mouth?X?rays?or?
panorex?

D6050? Surgical?placement?of?
transosteal?implant?

0?999? Permanent?
Teeth?1?32?

One?per?90?months.? Yes? Full?mouth?X?rays?or?
panorex?

D6052? Semi?precision?attachment?
abutment?(tooth)?

0?999? Permanent?
Teeth?1?32?

One?per?90?months.? Yes? Pre?operative?X?rays?

D6055? Dental?implant?supported?
connecting?bar?

0?999? Permanent?
Teeth?1?32?

One?per?90?months.? Yes? Pre?operative?X?rays?

D6056? Prefabricated?abutment?
includes?placement?

0?999? Permanent?
Teeth?1?32?

One?per?90?months.? Yes? Pre?operative?X?rays?

D6057? Custom?abutment?includes?
placement?

0?999? Permanent?
Teeth?1?32?

One?per?90?months.? Yes? Pre?operative?X?rays?



Horizon?NJ?Health?Dental?Program?
Benefit?Plan?Details?&?Authorization?Requirements?

??SKYGEN?USA?|?CONFIDENTIAL?&?PROPRIETARY?|?Horizon?NJ?Health?Dental?Program?|?Effective:?1/1/20?
171?

Horizon?NJ?Health?Dental?Program:?Non?Special?Needs?Plans?&?Special?Needs?Plans?
Code? Description? Age? Tooth?/?

Quad?/?Arch?
Limitations? Auth?

Req?
Requirement?

D6080? Implant?maintenance?
procedures?when?prostheses?
are?removed?and?reinserted,?
including?cleansing?of?
prostheses?

0?999? Permanent?
Teeth?1?32?

Twice?per?year.? Yes? Pre?operative?X?rays?

D6081? Scaling?and?debridement?in?
the?presence?of?inflammation?
or?mucositis?of?a?single?
implant,?including?cleaning?of?
the?implant?surfaces,?without?
flap?entry?and?closure?

21?999? Permanent?
Teeth?1?32?

Once?per?3?rolling?years.?
Not?in?conjunction?with?D1110,?D4346,?D4355,?D4910?
on?same?date?of?service?per?payee.?

Yes? Recent?full?mouth?perio?
charting?and?
radiographs;?narrative?
and?photos?if?bone?loss?
not?visible?on?x?rays?or?
for?Special?Health?Care?
Needs?Member?or?LTC?
resident?

D6090? Repair?implant?supported?
prosthesis,?by?report?

0?999? Permanent?
Teeth?1?32?

?? Yes? X?rays?

D6091? Replacement?of?semi?
precision?or?precision?
attachment?(male?or?female?
component)?of?
implant/abutment??

0?999? Permanent?
Teeth?1?32?

?? Yes? X?rays?

D6092? Re?cement?or?re?bond?
implant/abutment?supported?
crown?

0?999? Permanent?
Teeth?1?32?

?? Yes? X?rays?

D6095? Repair?implant?abutment,?by?
report?

0?999? Permanent?
Teeth?1?32?

?? Yes? X?rays?



Horizon?NJ?Health?Dental?Program?
Benefit?Plan?Details?&?Authorization?Requirements?

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172?

Horizon?NJ?Health?Dental?Program:?Non?Special?Needs?Plans?&?Special?Needs?Plans?
Code? Description? Age? Tooth?/?

Quad?/?Arch?
Limitations? Auth?

Req?
Requirement?

D6096? Remove?Broken?Implant?
Retaining?Screw?

0?999? Permanent?
Teeth?1?32?

? Yes? PA?x?ray?and?narrative?of?
medical?necessity?with?
complete?treatment?
plan?

D6100? Implant?Removal,?by?report? 0?999? Permanent?
Teeth?1?32?

?? Yes? X?rays?

D6101? Debridement?of?peri?implant?
defect?

0?999? Permanent?
Teeth?1?32?

?? Yes? Pre?operative?X?rays?and?
narrative?of?medical?
necessity?

D6102? Debridement?and?osseous?
contouring?of?a?peri?implant?
defect,?includes?surface?

0?999? Permanent?
Teeth?1?32?

?? Yes? Pre?operative?X?rays?and?
narrative?of?medical?
necessity?

D6103? Bone?graft?for?repair?of?peri?
implant?defect?not?including?
flap?entry??

0?999? Permanent?
Teeth?1?32?

?? Yes? Pre?operative?X?rays?and?
narrative?of?medical?
necessity?

D6104? Bone?graft?at?implant?
placement?

0?999? Permanent?
Teeth?1?32?

?? Yes? Pre?operative?X?rays?and?
narrative?of?medical?
necessity?

D6110? Implant/Abut?Removable?
Denture/Max?

0?999? Permanent?
Teeth?1?32?

?? Yes? Pre?operative?X?rays?and?
narrative?of?medical?
necessity?

D6111? Implant/Abut?Removable?
Denture/Mand?

0?999? Permanent?
Teeth?1?32?

?? Yes? Pre?operative?X?rays?and?
narrative?of?medical?
necessity?



Horizon?NJ?Health?Dental?Program?
Benefit?Plan?Details?&?Authorization?Requirements?

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Horizon?NJ?Health?Dental?Program:?Non?Special?Needs?Plans?&?Special?Needs?Plans?
Code? Description? Age? Tooth?/?

Quad?/?Arch?
Limitations? Auth?

Req?
Requirement?

D6190? Radiographic/surgical?implant?
index?

0?999? Permanent?
Teeth?1?32?

?? Yes? Pre?operative?X?rays?and?
narrative?of?medical?
necessity?

D6199? Unspecified?implant?
procedure?

0?999? Permanent?
Teeth?1?32?

?? Yes? Pre?operative?X?rays?and?
narrative?of?medical?
necessity?

D6210? Pontic???cast?high?noble?metal? 16?999? Permanent?
Teeth?1?32?

One?per?5?years.? Yes? Full?mouth?X?rays?or?
panorex?with?bitewings;?
narrative?of?medical?
necessity?for?members?
with?special?needs.?

D6211? Pontic???cast?predominantly?
base?metal?

16?999? Permanent?
Teeth?1?32?

One?per?5?years.? Yes? Full?mouth?X?rays?or?
panorex?

D6212? Pontic???cast?noble?metal? 16?999? Permanent?
Teeth?1?32?

One?per?5?years.? Yes? Full?mouth?X?rays?or?
panorex?

D6240? Pontic???porcelain?fused?to?
high?noble?metal?

16?999? Permanent?
Teeth?1?32?

One?per?5?years.? Yes? Full?mouth?X?rays?or?
panorex?

D6241? Pontic???porcelain?fused?to?
predominantly?base?metal?

16?999? Permanent?
Teeth?1?32?

One?per?5?years.? Yes? Full?mouth?X?rays?or?
panorex?

D6242? Pontic???porcelain?fused?to?
noble?metal?

16?999? Permanent?
Teeth?1?32?

One?per?5?years.? Yes? Full?mouth?X?rays?or?
panorex?



Horizon?NJ?Health?Dental?Program?
Benefit?Plan?Details?&?Authorization?Requirements?

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Code? Description? Age? Tooth?/?

Quad?/?Arch?
Limitations? Auth?

Req?
Requirement?

D6250? Pontic???resin?with?high?noble?
metal?

16?999? Permanent?
Teeth?1?32?

One?per?5?years.? Yes? Full?mouth?X?rays?or?
panorex?

D6251? Pontic???resin?with?
predominantly?base?metal?

16?999? Permanent?
Teeth?1?32?

One?per?5?years.? Yes? Full?mouth?X?rays?or?
panorex?

D6252 Pontic?resin?with?
predominantly?noble?metal?

16?999? Permanent?
Teeth?1?32?

One?per?5?years.? Yes? Full?mouth?X?rays?or?
panorex?

D6545? Retainer???cast?metal?for?resin?
bonded?fixed?prosthesis?

16?999? Permanent?
Teeth?1?32?

One?per?5?years.? Yes? Full?mouth?X?rays?or?
panorex?

D6720? Crown???resin?with?high?noble?
metal?

16?999? Permanent?
Teeth?1?32?

One?per?5?years.? Yes? Full?mouth?X?rays?or?
panorex?

D6721? Crown???resin?with?
predominantly?base?metal?

16?999? Permanent?
Teeth?1?32?

One?per?5?years.? Yes? Full?mouth?X?rays?or?
panorex?

D6722? Crown???resin?with?noble?
metal?

16?999? Permanent?
Teeth?1?32?

One?per?5?years.? Yes? Full?mouth?X?rays?or?
panorex?

D6750? Crown???porcelain?fused?to?
high?noble?metal?

16?999? Permanent?
Teeth?1?32?

One?per?5?years.? Yes? Full?mouth?X?rays?or?
panorex?

D6751? Crown???porcelain?fused?to?
predominantly?base?metal?

16?999? Permanent?
Teeth?1?32?

One?per?5?years.? Yes? Full?mouth?X?rays?or?
panorex?



Horizon?NJ?Health?Dental?Program?
Benefit?Plan?Details?&?Authorization?Requirements?

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Code? Description? Age? Tooth?/?

Quad?/?Arch?
Limitations? Auth?

Req?
Requirement?

D6752? Crown???porcelain?fused?to?
noble?metal?

16?999? Permanent?
Teeth?1?32?

One?per?5?years.? Yes? Full?mouth?X?rays?or?
panorex?

D6790? Crown???full?cast?high?noble?
metal?

16?999? Permanent?
Teeth?1?32?

One?per?5?years.? Yes? Full?mouth?X?rays?or?
panorex?

D6791? Crown???full?cast?
predominantly?base?metal?

16?999? Permanent?
Teeth?1?32?

One?per?5?years.? Yes? Full?mouth?X?rays?or?
panorex?

D6792? Crown???full?cast?noble?metal? 16?999? Permanent?
Teeth?1?32?

One?per?5?years.? Yes? Full?mouth?X?rays?or?
panorex?

D6920? Connector?bar? 16?999? Arches?(UA,?
LA)?

One?per?5?years.? Yes? Full?mouth?X?rays?or?
panorex?

D6930? Re?cement?or?re?bond?fixed?
partial?denture?

16?999? Permanent?
Teeth?1?32?

One?per?5?years.? Yes? Full?mouth?X?rays?or?
panorex?

D6940? Stress?breaker? 16?999? Permanent?
Teeth?1?32?

One?per?5?years.? Yes? Full?mouth?X?rays?or?
panorex?

D6950? Precision?attachment? 16?999? Permanent?
Teeth?1?32?

One?per?5?years.? Yes? Full?mouth?X?rays?or?
panorex?

D6980? Fixed?partial?denture?repair?
necessitated?by?restorative?
material?failure?

16?999? ?? One?per?5?years.? Yes? Full?mouth?X?rays?or?
panorex,?and?narrative?
of?medical?necessity?



Horizon?NJ?Health?Dental?Program?
Benefit?Plan?Details?&?Authorization?Requirements?

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Horizon?NJ?Health?Dental?Program:?Non?Special?Needs?Plans?&?Special?Needs?Plans?
Code? Description? Age? Tooth?/?

Quad?/?Arch?
Limitations? Auth?

Req?
Requirement?

D6985? Pediatric?partial?denture,?
fixed?

16?999? Upper?Arch? One?per?lifetime.? Yes? Full?mouth?X?rays?or?
panorex,?and?narrative?
of?medical?necessity?

D6999? Unspecified?fixed?
prosthodontic?procedure,?by?
report?

16?999? Permanent?
Teeth?1?32?

?? Yes? Full?mouth?X?rays?or?
panorex,?and?narrative?
of?medical?necessity?

D7111? Extraction,?coronal?remnants?
??deciduous?tooth?

0?999? Primary?
Teeth?A?T?

One?per?lifetime.? No? ??

D7140? Extraction,?erupted?tooth?or?
exposed?root?(elevation?
and/or?forceps?removal)?

0?999? All?teeth;??
A?T;?1?32?

One?per?lifetime.? No? ??

D7210? Surgical?removal?of?erupted?
tooth?requiring?removal?of?
bone?and/or?sectioning?of?
tooth,?and?including?elevation?
of?mucoperiosteal?flap?if?
indicated?

0?999? All?teeth;??
A?T;?1?32?

One?per?lifetime.? No? ??

D7220? Removal?of?impacted?tooth???
soft?tissue?

0?999? All?teeth;??
A?T;?1?32?

One?per?lifetime.? Yes? Pre?operative?X?rays?
(excluding?bitewings)?
and?narrative?of?medical?
necessity??

D7230? Removal?of?impacted?tooth???
partially?bony?

0?999? All?teeth;??
A?T;?1?32?

One?per?lifetime.? Yes? Pre?operative?X?rays?
(excluding?bitewings)?
and?narrative?of?medical?
necessity??



Horizon?NJ?Health?Dental?Program?
Benefit?Plan?Details?&?Authorization?Requirements?

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Horizon?NJ?Health?Dental?Program:?Non?Special?Needs?Plans?&?Special?Needs?Plans?
Code? Description? Age? Tooth?/?

Quad?/?Arch?
Limitations? Auth?

Req?
Requirement?

D7240? Removal?of?impacted?tooth???
completely?bony?

0?999? All?teeth;??
A?T;?1?32?

One?per?lifetime?combined?with?D7241.? Yes? Pre?operative?X?rays?
(excluding?bitewings)?
and?narrative?of?medical?
necessity??

D7241? Removal?of?impacted?tooth???
completely?bony,?with?
unusual?surgical?
complications?

0?999? All?teeth;??
A?T;?1?32?

One?per?lifetime?combined?with?D7240.? Yes? Pre?operative?X?rays?
(excluding?bitewings)?
and?narrative?of?medical?
necessity??

D7250? Surgical?removal?of?residual?
tooth?roots?(cutting?
procedure)?

0?999? All?teeth;??
A?T;?1?32?

One?per?lifetime.? Yes? Pre?operative?X?rays?
(excluding?bitewings)?
and?narrative?of?medical?
necessity??

D7260? Oro?antral?fistula?closure? 0?999? ?? ?? Yes? Pre?operative?X?rays?
(excluding?bitewings)?
and?narrative?of?medical?
necessity??

D7261? Primary?closure?of?a?sinus?
perforation?

0?999? ?? ?? Yes? Pre?operative?X?rays?
(excluding?bitewings)?
and?narrative?of?medical?
necessity??

D7270? Tooth?re?implantation?and/or?
stabilization?of?accidentally?
evulsed?or?displaced?tooth?

0?999? Permanent?
Teeth?1?32?

?? Yes? Narrative?of?medical?
necessity?and?treatment?
plan??



Horizon?NJ?Health?Dental?Program?
Benefit?Plan?Details?&?Authorization?Requirements?

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Horizon?NJ?Health?Dental?Program:?Non?Special?Needs?Plans?&?Special?Needs?Plans?
Code? Description? Age? Tooth?/?

Quad?/?Arch?
Limitations? Auth?

Req?
Requirement?

D7280? Surgical?access?of?an?
unerupted?tooth?

0?999? Teeth?2?15,?
18?31?

One?per?lifetime.? Yes? Narrative?of?medical?
necessity?and?treatment?
plan?

D7282? Mobilization?of?erupted?or?
malpositioned?tooth?to?aid?
eruption?

0?999? Permanent?
Teeth?1?32?

One?per?lifetime.? Yes? Narrative?of?medical?
necessity?and?treatment?
plan?

D7283? Placement?of?device?to?
facilitate?eruption?of?
impacted?tooth?

0?999? Teeth?2?15,?
18?31?

One?per?lifetime.? Yes? Narrative?of?medical?
necessity?and?treatment?
plan?

D7285? Incisional?biopsy?of?oral?tissue?
??hard?(bone,?tooth)?

0?999? ?? ?? Yes? Narrative?of?medical?
necessity?

D7286? Incisional?biopsy?of?oral?tissue?
??soft?

0?999? ?? ?? Yes? Narrative?of?medical?
necessity?

D7287? Exfoliative?cytological?sample?
collection?

0?999? ?? ?? Yes? Narrative?of?medical?
necessity?

D7288? Brush?biopsy???transepithelial?
sample?collection?

0?999? ?? ?? Yes? Narrative?of?medical?
necessity?

D7290? Surgical?repositioning?of?teeth? 0?20? Permanent?
Teeth?1?32?

?? Yes? Pre?operative?X?rays?and?
narrative?of?medical?
necessity?



Horizon?NJ?Health?Dental?Program?
Benefit?Plan?Details?&?Authorization?Requirements?

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Horizon?NJ?Health?Dental?Program:?Non?Special?Needs?Plans?&?Special?Needs?Plans?
Code? Description? Age? Tooth?/?

Quad?/?Arch?
Limitations? Auth?

Req?
Requirement?

D7291? Transseptal?
Fiberotomy/Supra?Crestal?
Fiberotomy,?By?Report?

0?20? Permanent?
Teeth?1?32?

Once?per?lifetime.? Yes? Narrative?of?medical?
necessity?

D7292? Surgical?placement?of?
temporary?anchorage?device?
[screw?retained?plate]?
requiring?flap;?includes?device?
removal?

0?999? ?? ?? Yes? Narrative?of?medical?
necessity?with?
preauthorization?

D7293? Surgical?placement?of?
temporary?anchorage?device?
requiring?flap;?includes?device?
removal?

0?999? ?? ?? Yes? Narrative?of?medical?
necessity?with?
preauthorization?

D7294? Surgical?placement?of?
temporary?anchorage?device?
without?flap;?includes?device?
removal?

0?999? ?? ?? Yes? Narrative?of?medical?
necessity?with?
preauthorization?

D7295? Harvest?of?bone?for?use?in?
autogenous?grafting?
procedure?

0?999? ?? ?? Yes? Narrative?of?medical?
necessity?with?
preauthorization?

D7310? Alveoloplasty?in?conjunction?
with?extractions???four?or?
more?teeth?or?tooth?spaces,?
per?quadrant?

0?999? Quadrants?
(LL,?LR,?UR,?
UL)?

?Only?payable?on?the?same?date?of?service?as?D7140.? Yes? Pre?operative?X?rays?and?
narrative?of?medical?
necessity?



Horizon?NJ?Health?Dental?Program?
Benefit?Plan?Details?&?Authorization?Requirements?

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Horizon?NJ?Health?Dental?Program:?Non?Special?Needs?Plans?&?Special?Needs?Plans?
Code? Description? Age? Tooth?/?

Quad?/?Arch?
Limitations? Auth?

Req?
Requirement?

D7311? Alveoloplasty?in?conjunction?
with?extractions???one?to?
three?teeth?or?tooth?spaces,?
per?quadrant?

0?999? Quadrants?
(LL,?LR,?UR,?
UL)?

?Only?payable?on?the?same?date?of?service?as?D7140.? Yes? Pre?operative?X?rays?and?
narrative?of?medical?
necessity?

D7320? Alveoloplasty?not?in?
conjunction?with?extractions?
??four?or?more?teeth?or?tooth?
spaces,?per?quadrant?

0?999? Quadrants?
(LL,?LR,?UR,?
UL)?

?? Yes? Pre?operative?X?rays?and?
narrative?of?medical?
necessity?

D7321? Alveoloplasty?not?in?
conjunction?with?extractions?
??one?to?three?teeth?or?tooth?
spaces,?per?quadrant?

0?999? Quadrants?
(LL,?LR,?UR,?
UL)?

?? Yes? Pre?operative?X?rays?and?
narrative?of?medical?
necessity?

D7340? Vestibuloplasty???ridge?
extension?(secondary?
epithelialization)?

0?999? Quadrants?
(LL,?LR,?UR,?
UL)?

?? Yes? Narrative?of?medical?
necessity?

D7350? Vestibuloplasty???ridge?
extension?(including?soft?
tissue?grafts,?muscle?
reattachment,?revision?of?soft?
tissue?attachment?and?
management?of?
hypertrophied?and?
hyperplastic?tissue)?

0?999? Quadrants?
(LL,?LR,?UR,?
UL)?

?? Yes? Narrative?of?medical?
necessity?

D7410? Excision?of?benign?lesion?up?
to?1.25?cm?

0?999? ?? ?? Yes? Copy?of?pathology?
report?with?claim?



Horizon?NJ?Health?Dental?Program?
Benefit?Plan?Details?&?Authorization?Requirements?

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Horizon?NJ?Health?Dental?Program:?Non?Special?Needs?Plans?&?Special?Needs?Plans?
Code? Description? Age? Tooth?/?

Quad?/?Arch?
Limitations? Auth?

Req?
Requirement?

D7411? Excision?of?benign?lesion?
greater?than?1.25?cm?

0?999? ?? ?? Yes? Copy?of?pathology?
report?with?claim?

D7412? Excision?of?benign?lesion,?
complicated?

0?999? ?? ?? Yes? Copy?of?pathology?
report?with?claim?

D7413? Excision?of?malignant?lesion?
up?to?1.25?cm?

0?999? ?? ?? Yes? Copy?of?pathology?
report?with?claim?

D7414? Excision?of?malignant?lesion?
greater?than?1.25?cm?

0?999? ?? ?? Yes? Copy?of?pathology?
report?with?claim?

D7415? Excision?of?malignant?lesion,?
complicated?

0?999? ?? ?? Yes? Copy?of?pathology?
report?with?claim?

D7440? Excision?of?malignant?tumor???
lesion?diameter?up?to?1.25?cm?

0?999? ?? ?? Yes? Copy?of?pathology?
report?with?claim?

D7441? Excision?of?malignant?tumor???
lesion?diameter?greater?than?
1.25?cm?

0?999? ?? ?? Yes? Copy?of?pathology?
report?with?claim?

D7450? Removal?of?benign?
odontogenic?cyst?or?tumor???
lesion?diameter?up?to?1.25?cm?

0?999? ?? ?? Yes? Copy?of?pathology?
report?with?claim?



Horizon?NJ?Health?Dental?Program?
Benefit?Plan?Details?&?Authorization?Requirements?

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Horizon?NJ?Health?Dental?Program:?Non?Special?Needs?Plans?&?Special?Needs?Plans?
Code? Description? Age? Tooth?/?

Quad?/?Arch?
Limitations? Auth?

Req?
Requirement?

D7451? Removal?of?benign?
odontogenic?cyst?or?tumor???
lesion?diameter?greater?than?
1.25?cm?

0?999? ?? ?? Yes? Copy?of?pathology?
report?with?claim?

D7460? Removal?of?benign?
nonodontogenic?cyst?or?
tumor???lesion?diameter?up?to?
1.25?cm?

0?999? ?? ?? Yes? Copy?of?pathology?
report?with?claim?

D7461? Removal?of?benign?
nonodontogenic?cyst?or?
tumor???lesion??diameter?
greater?than?1.25?cm?

0?999? ?? ?? Yes? Copy?of?pathology?
report?with?claim?

D7465? Destruction?of?lesion(s)?by?
physical?or?chemical?method,?
by?report?

0?999? ?? ?? Yes? Narrative?of?medical?
necessity?

D7471? Removal?of?lateral?exostosis?
(maxilla?or?mandible)?

0?999? Arches?(UA,?
LA)?

?? Yes? Narrative?of?medical?
necessity,?X?rays?or?
photos?optional?

D7472? Removal?of?torus?palatinus? 0?999? ?? ?? Yes? Narrative?of?medical?
necessity?with?claim,??
X?rays?or?photos?
optional?

D7473? Removal?of?torus?
mandibularis?

0?999? ?? ?? Yes? Narrative?of?medical?
necessity,?X?rays?or?
photos?optional?



Horizon?NJ?Health?Dental?Program?
Benefit?Plan?Details?&?Authorization?Requirements?

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Horizon?NJ?Health?Dental?Program:?Non?Special?Needs?Plans?&?Special?Needs?Plans?
Code? Description? Age? Tooth?/?

Quad?/?Arch?
Limitations? Auth?

Req?
Requirement?

D7485? Surgical?reduction?of?osseous?
tuberosity?

0?999? ?? ?? Yes? Narrative?of?medical?
necessity?with?claim,??
X?rays?or?photos?
optional?

D7490? Radical?resection?of?maxilla?or?
mandible?

0?999? ?? ?? Yes? Narrative?of?medical?
necessity?

D7510? Incision?and?drainage?of?
abscess???intraoral?soft?tissue?

0?999? ?? One?per?date?of?service.? Yes? Narrative?of?medical?
necessity?

D7511? Incision?and?drainage?of?
abscess???intraoral?soft?tissue?
??complicated?(includes?
drainage?of?multiple?fascial?
spaces)?

0?999? ?? ?? Yes? Narrative?of?medical?
necessity?

D7520? Incision?and?drainage?of?
abscess???extraoral?soft?tissue?

0?999? ?? ?? Yes? Narrative?of?medical?
necessity?

D7521? Incision?and?drainage?of?
abscess???extraoral?soft?tissue?
??complicated?(includes?
drainage?of?multiple?fascial?
spaces)?

0?999? ?? ?? Yes? Narrative?of?medical?
necessity?

D7530? Removal?of?foreign?body?from?
mucosa,?skin,?or?
subcutaneous?alveolar?tissue?

0?999? ?? ?? Yes? Narrative?of?medical?
necessity,?X?rays?or?
photos?optional?



Horizon?NJ?Health?Dental?Program?
Benefit?Plan?Details?&?Authorization?Requirements?

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Horizon?NJ?Health?Dental?Program:?Non?Special?Needs?Plans?&?Special?Needs?Plans?
Code? Description? Age? Tooth?/?

Quad?/?Arch?
Limitations? Auth?

Req?
Requirement?

D7540? Removal?of?reaction?
producing?foreign?bodies,?
musculoskeletal?system?

0?999? ?? ?? Yes? Narrative?of?medical?
necessity,?X?rays?or?
photos?optional?

D7550? Partial?ostectomy/?
sequestrectomy?for?removal?
of?non?vital?bone?

0?999? Quadrants?
(LL,?LR,?UR,?
UL)?

?? Yes? Pre?operative?X?rays?and?
narrative?of?medical?
necessity?

D7560? Maxillary?sinusotomy?for?
removal?of?tooth?fragment?or?
foreign?body?

0?999? ?? ?? Yes? Pre?operative?X?rays?and?
narrative?of?medical?
necessity?

D7610? Maxilla???open?reduction?
(teeth?immobilized,?if?
present)?

0?999? ?? ?? Yes? Pre?operative?X?rays?and?
narrative?of?medical?
necessity?

D7620? Maxilla???closed?reduction?
(teeth?immobilized,?if?
present)?

0?999? ?? ?? Yes? Pre?operative?X?rays?and?
narrative?of?medical?
necessity?

D7630? Mandible???open?reduction?
(teeth?immobilized,?if?
present)?

0?999? ?? ?? Yes? Pre?operative?X?rays?and?
narrative?of?medical?
necessity?

D7640? Mandible???closed?reduction?
(teeth?immobilized,?if?
present)?

0?999? ?? ?? Yes? Pre?operative?X?rays?and?
narrative?of?medical?
necessity?



Horizon?NJ?Health?Dental?Program?
Benefit?Plan?Details?&?Authorization?Requirements?

??SKYGEN?USA?|?CONFIDENTIAL?&?PROPRIETARY?|?Horizon?NJ?Health?Dental?Program?|?Effective:?1/1/20?
185?

Horizon?NJ?Health?Dental?Program:?Non?Special?Needs?Plans?&?Special?Needs?Plans?
Code? Description? Age? Tooth?/?

Quad?/?Arch?
Limitations? Auth?

Req?
Requirement?

D7650? Malar?and/or?zygomatic?arch?
??open?reduction?

0?999? ?? ?? Yes? Pre?operative?X?rays?and?
narrative?of?medical?
necessity?

D7660? Malar?and/or?zygomatic?arch?
??closed?reduction?

0?999? ?? ?? Yes? Pre?operative?X?rays?and?
narrative?of?medical?
necessity?

D7670? Alveolus???closed?reduction,?
may?include?stabilization?of?
teeth?

0?999? ?? ?? Yes? Pre?operative?X?rays?and?
narrative?of?medical?
necessity?

D7671? Alveolus???open?reduction,?
may?include?stabilization?of?
teeth?

0?999? ?? ?? Yes? Pre?operative?X?rays?and?
narrative?of?medical?
necessity?

D7680? Facial?bones???complicated?
reduction?with?fixation?and?
multiple?surgical?approaches?

0?999? ?? ?? Yes? Pre?operative?X?rays?and?
narrative?of?medical?
necessity?

D7710? Maxilla???open?reduction? 0?999? ?? ?? Yes? Pre?operative?X?rays?and?
narrative?of?medical?
necessity?

D7720? Maxilla???closed?reduction? 0?999? ?? ?? Yes? Pre?operative?X?rays?and?
narrative?of?medical?
necessity?



Horizon?NJ?Health?Dental?Program?
Benefit?Plan?Details?&?Authorization?Requirements?

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186?

Horizon?NJ?Health?Dental?Program:?Non?Special?Needs?Plans?&?Special?Needs?Plans?
Code? Description? Age? Tooth?/?

Quad?/?Arch?
Limitations? Auth?

Req?
Requirement?

D7730? Mandible???open?reduction? 0?999? ?? ?? Yes? Pre?operative?X?rays?and?
narrative?of?medical?
necessity?

D7740? Mandible???closed?reduction? 0?999? ?? ?? Yes? Pre?operative?X?rays?and?
narrative?of?medical?
necessity?

D7750? Malar?and/or?zygomatic?arch?
??open?reduction?

0?999? ?? ?? Yes? Pre?operative?X?rays?and?
narrative?of?medical?
necessity?

D7760? Malar?and/or?zygomatic?arch?
??closed?reduction?

0?999? ?? ?? Yes? Pre?operative?X?rays?and?
narrative?of?medical?
necessity?

D7770? Alveolus???open?reduction?
stabilization?of?teeth?

0?999? ?? ?? Yes? Pre?operative?X?rays?and?
narrative?of?medical?
necessity?

D7771? Alveolus,?closed?reduction?
stabilization?of?teeth?

0?999? ?? ?? Yes? Pre?operative?X?rays?and?
narrative?of?medical?
necessity?

D7780? Facial?bones???complicated?
reduction?with?fixation?and?
multiple?surgical?approaches?

0?999? ?? ?? Yes? Pre?operative?X?rays?and?
narrative?of?medical?
necessity?



Horizon?NJ?Health?Dental?Program?
Benefit?Plan?Details?&?Authorization?Requirements?

??SKYGEN?USA?|?CONFIDENTIAL?&?PROPRIETARY?|?Horizon?NJ?Health?Dental?Program?|?Effective:?1/1/20?
187?

Horizon?NJ?Health?Dental?Program:?Non?Special?Needs?Plans?&?Special?Needs?Plans?
Code? Description? Age? Tooth?/?

Quad?/?Arch?
Limitations? Auth?

Req?
Requirement?

D7810? Open?reduction?of?dislocation? 0?999? ?? ?? Yes? Narrative?of?medical?
necessity,?X?rays?or?
photos?optional?

D7820? Closed?reduction?of?
dislocation?

0?999? ?? ?? Yes? Narrative?of?medical?
necessity,?X?rays?or?
photos?optional?

D7830? Manipulation?under?
anesthesia?

0?999? ?? ?? Yes? Narrative?of?medical?
necessity,?X?rays?or?
photos?optional?

D7840? Condylectomy? 0?999? ?? ?? Yes? Narrative?of?medical?
necessity,?X?rays?or?
photos?optional?

D7850? Surgical?discectomy,?
with/without?implant?

0?999? ?? ?? Yes? Narrative?of?medical?
necessity,?X?rays?or?
photos?optional?

D7852? Disc?repair? 0?999? ?? ?? Yes? Narrative?of?medical?
necessity,?X?rays?or?
photos?optional?

D7854? Synovectomy? 0?999? ?? ?? Yes? Narrative?of?medical?
necessity,?X?rays?or?
photos?optional?



Horizon?NJ?Health?Dental?Program?
Benefit?Plan?Details?&?Authorization?Requirements?

??SKYGEN?USA?|?CONFIDENTIAL?&?PROPRIETARY?|?Horizon?NJ?Health?Dental?Program?|?Effective:?1/1/20?
188?

Horizon?NJ?Health?Dental?Program:?Non?Special?Needs?Plans?&?Special?Needs?Plans?
Code? Description? Age? Tooth?/?

Quad?/?Arch?
Limitations? Auth?

Req?
Requirement?

D7856? Myotomy? 0?999? ?? ?? Yes? Narrative?of?medical?
necessity,?X?rays?or?
photos?optional?

D7858? Joint?reconstruction? 0?999? ?? ?? Yes? Narrative?of?medical?
necessity,?X?rays?or?
photos?optional?

D7860? Arthrotomy? 0?999? ?? ?? Yes? Narrative?of?medical?
necessity,?X?rays?or?
photos?optional?

D7865? Arthroplasty? 0?999? ?? ?? Yes? Narrative?of?medical?
necessity,?X?rays?or?
photos?optional?

D7870? Arthrocentesis? 0?999? ?? ?? Yes? Narrative?of?medical?
necessity,?X?rays?or?
photos?optional?

D7871? Non?arthroscopic?lysis?and?
lavage?

0?999? ?? ?? Yes? Narrative?of?medical?
necessity,?X?rays?or?
photos?optional?

D7872? Arthroscopy???diagnosis,?with?
or?without?biopsy?

0?999? ?? ?? Yes? Narrative?of?medical?
necessity,?X?rays?or?
photos?optional?



Horizon?NJ?Health?Dental?Program?
Benefit?Plan?Details?&?Authorization?Requirements?

??SKYGEN?USA?|?CONFIDENTIAL?&?PROPRIETARY?|?Horizon?NJ?Health?Dental?Program?|?Effective:?1/1/20?
189?

Horizon?NJ?Health?Dental?Program:?Non?Special?Needs?Plans?&?Special?Needs?Plans?
Code? Description? Age? Tooth?/?

Quad?/?Arch?
Limitations? Auth?

Req?
Requirement?

D7873? Arthroscopy???surgical:?lavage?
and?lysis?of?adhesions?

0?999? ?? ?? Yes? Narrative?of?medical?
necessity,?X?rays?or?
photos?optional?

D7874? Arthroscopy???surgical:?disc?
repositioning?and?stabilization?

0?999? ?? ?? Yes? Narrative?of?medical?
necessity,?X?rays?or?
photos?optional?

D7875? Arthroscopy???surgical:?
synovectomy?

0?999? ?? ?? Yes? Narrative?of?medical?
necessity,?X?rays?or?
photos?optional?

D7876? Arthroscopy???surgical:?
discectomy?

0?999? ?? ?? Yes? Narrative?of?medical?
necessity,?X?rays?or?
photos?optional?

D7877? Arthroscopy???surgical:?
debridement?

0?999? ?? ?? Yes? Narrative?of?medical?
necessity,?X?rays?or?
photos?optional?

D7880? Occlusal?orthotic?device?to?
include?adjustments,?by?
report?

0?999? ?? ?? Yes? Narrative?of?medical?
necessity,?X?rays?or?
photos?optional?

D7881? Excision?of?salivary?gland,?by?
report?

0?999? ?? ?? Yes? Narrative?of?medical?
necessity,?X?rays?or?
photos?optional?



Horizon?NJ?Health?Dental?Program?
Benefit?Plan?Details?&?Authorization?Requirements?

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190?

Horizon?NJ?Health?Dental?Program:?Non?Special?Needs?Plans?&?Special?Needs?Plans?
Code? Description? Age? Tooth?/?

Quad?/?Arch?
Limitations? Auth?

Req?
Requirement?

D7899? Unspecified?TMD?therapy,?by?
report?

0?999? ?? ?? Yes? Pre?operative?X?rays?and?
narrative?of?medical?
necessity?

D7910? Suture?of?recent?small?
wounds?up?to?5?cm?

0?999? ?? ?? Yes? Narrative?of?medical?
necessity,?X?rays?or?
photos?optional?

D7911? Complicated?suture???up?to?5?
cm?

0?999? ?? ?? Yes? Narrative?of?medical?
necessity,?X?rays?or?
photos?optional?

D7912? Complicated?suture???greater?
than?5?cm?

0?999? ?? ?? Yes? Narrative?of?medical?
necessity,?X?rays?or?
photos?optional?

D7920? Skin?graft?(identify?defect?
covered,?location?and?type?of?
graft)?

0?999? ?? ?? Yes? Narrative?of?medical?
necessity,?X?rays?or?
photos?optional?

D7940? Osteoplasty???for?
orthognathic?deformities?

0?999? ?? ?? Yes? Narrative?of?medical?
necessity,?X?rays?or?
photos?optional?

D7941? Osteotomy???mandibular?rami? 0?999? ?? ?? Yes? Narrative?of?medical?
necessity,?X?rays?or?
photos?optional?



Horizon?NJ?Health?Dental?Program?
Benefit?Plan?Details?&?Authorization?Requirements?

??SKYGEN?USA?|?CONFIDENTIAL?&?PROPRIETARY?|?Horizon?NJ?Health?Dental?Program?|?Effective:?1/1/20?
191?

Horizon?NJ?Health?Dental?Program:?Non?Special?Needs?Plans?&?Special?Needs?Plans?
Code? Description? Age? Tooth?/?

Quad?/?Arch?
Limitations? Auth?

Req?
Requirement?

D7943? Osteotomy???mandibular?rami?
with?bone?graft;?includes?
obtaining?the?graft?

0?999? ?? ?? Yes? Narrative?of?medical?
necessity,?X?rays?or?
photos?optional?

D7944? Osteotomy???segmented?or?
subapical?

0?999? Quadrants?
(LL,?LR,?UR,?
UL)?

?? Yes? Narrative?of?medical?
necessity,?X?rays?or?
photos?optional?

D7945? Osteotomy???body?of?
mandible?

0?999? ?? ?? Yes? Narrative?of?medical?
necessity,?X?rays?or?
photos?optional?

D7946? LeFort?I?(maxilla???total)? 0?999? ?? ?? Yes? Narrative?of?medical?
necessity,?X?rays?or?
photos?optional?

D7947? LeFort?I?(maxilla???
segmented)?

0?999? ?? ?? Yes? Narrative?of?medical?
necessity,?X?rays?or?
photos?optional?

D7948? LeFort?II?or?LeFort?III?
(osteoplasty?of?facial?bones?
for?midface?hypoplasia?or?
retrusion)???without?bone?
graft?

0?999? ?? ?? Yes? Narrative?of?medical?
necessity,?X?rays?or?
photos?optional?

D7949? LeFort?II?or?LeFort?III???with?
bone?graft?

0?999? ?? ?? Yes? Narrative?of?medical?
necessity,?X?rays?or?
photos?optional?



Horizon?NJ?Health?Dental?Program?
Benefit?Plan?Details?&?Authorization?Requirements?

??SKYGEN?USA?|?CONFIDENTIAL?&?PROPRIETARY?|?Horizon?NJ?Health?Dental?Program?|?Effective:?1/1/20?
192?

Horizon?NJ?Health?Dental?Program:?Non?Special?Needs?Plans?&?Special?Needs?Plans?
Code? Description? Age? Tooth?/?

Quad?/?Arch?
Limitations? Auth?

Req?
Requirement?

D7950? Osseous,?osteoperiosteal,?or?
cartilage?graft?of?the?
mandible?or?maxilla???
autogenous?or?
nonautogenous,?by?report?

0?999? ?? ?? Yes? Narrative?of?medical?
necessity,?X?rays?or?
photos?optional?

D7951? Sinus?augmentation?with?
bone?or?bone?substitutes?via?
a?lateral?open?approach?

0?999? ?? ?? Yes? Narrative?of?medical?
necessity,?X?rays?or?
photos?optional?

D7952? Sinus?augmentation?via?a?
vertical?approach?

0?999? ?? ?? Yes? Narrative?of?medical?
necessity,?X?rays?or?
photos?optional?

D7955? Repair?of?maxillofacial?soft?
and/or?hard?tissue?defect?

0?999? ?? ?? Yes? Narrative?of?medical?
necessity,?X?rays?or?
photos?optional?

D7960? Frenulectomy???also?known?
as?frenectomy?or?frenotomy???
separate?procedure?not?
incidental?to?another?
procedure?

0?999? ?? ?? Yes? Narrative?of?medical?
necessity,?X?rays?or?
photos?optional?

D7963? Frenuloplasty? 0?999? ?? ?? Yes? Narrative?of?medical?
necessity,?X?rays?or?
photos?optional?



Horizon?NJ?Health?Dental?Program?
Benefit?Plan?Details?&?Authorization?Requirements?

??SKYGEN?USA?|?CONFIDENTIAL?&?PROPRIETARY?|?Horizon?NJ?Health?Dental?Program?|?Effective:?1/1/20?
193?

Horizon?NJ?Health?Dental?Program:?Non?Special?Needs?Plans?&?Special?Needs?Plans?
Code? Description? Age? Tooth?/?

Quad?/?Arch?
Limitations? Auth?

Req?
Requirement?

D7970? Excision?of?hyperplastic?tissue?
??per?arch?

0?999? Arches?(UA,?
LA)?

?? Yes? Narrative?of?medical?
necessity,?X?rays?or?
photos?optional?

D7971? Excision?of?pericoronal?
gingiva?

0?999? Permanent?
Teeth?1?32?

?? Yes? Narrative?of?medical?
necessity,?X?rays?or?
photos?optional?

D7972? Surgical?reduction?of?fibrous?
tuberosity?

0?999? ?? ?? Yes? Narrative?of?medical?
necessity,?X?rays?or?
photos?optional?

D7979? Non?Surgical?Sialolithotomy? 0?999? ? Once?per?lifetime.? Yes? Narrative?of?medical?
necessity?

D7980? Sialolithotomy? 0?999? ?? ?? Yes? Narrative?of?medical?
necessity,?X?rays?or?
photos?optional?

D7981? Excision?of?salivary?gland,?by?
report?

0?999? ?? ?? Yes? Narrative?of?medical?
necessity,?X?rays?or?
photos?optional?

D7982? Sialodochoplasty? 0?999? ?? ?? Yes? Narrative?of?medical?
necessity,?X?rays?or?
photos?optional?



Horizon?NJ?Health?Dental?Program?
Benefit?Plan?Details?&?Authorization?Requirements?

??SKYGEN?USA?|?CONFIDENTIAL?&?PROPRIETARY?|?Horizon?NJ?Health?Dental?Program?|?Effective:?1/1/20?
194?

Horizon?NJ?Health?Dental?Program:?Non?Special?Needs?Plans?&?Special?Needs?Plans?
Code? Description? Age? Tooth?/?

Quad?/?Arch?
Limitations? Auth?

Req?
Requirement?

D7983? Closure?of?salivary?fistula? 0?999? ?? ?? Yes? Narrative?of?medical?
necessity,?X?rays?or?
photos?optional?

D7990? Emergency?tracheotomy? 0?999? ?? ?? Yes? Narrative?of?medical?
necessity,?X?rays?or?
photos?optional?

D7991? Coronoidectomy? 0?999? ?? ?? Yes? Narrative?of?medical?
necessity,?X?rays?or?
photos?optional?

D7995? Synthetic?graft???mandible?or?
facial?bones,?by?report?

0?999? ?? ?? Yes? Narrative?of?medical?
necessity,?X?rays?or?
photos?optional?

D7996? Implant?mandible?for?
augmentation?purposes?
(excluding?alveolar?ridge),?by?
report?

0?999? ?? ?? Yes? Narrative?of?medical?
necessity,?X?rays?or?
photos?optional?

D7997? Appliance?removal?(not?by?
dentist?who?placed?
appliance),?includes?removal?
of?archbar?

0?999? ?? ?? Yes? Narrative?of?medical?
necessity,?X?rays?or?
photos?optional?

D7998? Intraoral?placement?of?a?
fixation?device?not?in?
conjunction?with?a?fracture?

0?999? ?? ?? Yes? Narrative?of?medical?
necessity,?X?rays?or?
photos?optional?



Horizon?NJ?Health?Dental?Program?
Benefit?Plan?Details?&?Authorization?Requirements?

??SKYGEN?USA?|?CONFIDENTIAL?&?PROPRIETARY?|?Horizon?NJ?Health?Dental?Program?|?Effective:?1/1/20?
195?

Horizon?NJ?Health?Dental?Program:?Non?Special?Needs?Plans?&?Special?Needs?Plans?
Code? Description? Age? Tooth?/?

Quad?/?Arch?
Limitations? Auth?

Req?
Requirement?

D7999? Unspecified?oral?surgery?
procedure,?by?report?

0?999? ?? ?? Yes? Narrative?of?medical?
necessity,?X?rays?or?
photos?optional?

D8010? Limited?orthodontic?
treatment?of?the?primary?
dentition?

0?20? ?? One?per?lifetime;?combined?frequency?with?D8010,?
D8020,?D8030,?D8040,?D8050,?or?D8060.?

Yes? Narrative,?general?
dentist?attestation,?
photos,?X?rays?

D8020? Limited?orthodontic?
treatment?of?the?transitional?
dentition?

0?20? ?? One?per?lifetime;?combined?frequency?with?D8010,?
D8020,?D8030,?D8040,?D8050,?or?D8060.?

Yes? Narrative,?general?
dentist?attestation,?
photos,?X?rays?

D8030? Limited?orthodontic?
treatment?of?the?adolescent?
dentition?

8?20? ?? One?per?lifetime;?combined?frequency?with?D8010,?
D8020,?D8030,?D8040,?D8050,?or?D8060.?

Yes? Narrative,?general?
dentist?attestation,?
photos,?X?rays?

D8040? Limited?orthodontic?
treatment?for?adult?dentition?

8?20? ?? One?per?lifetime;?combined?frequency?with?D8010,?
D8020,?D8030,?D8040,?D8050,?or?D8060?

Yes? Narrative,?general?
dentist?attestation,?
photos,?X?rays?



Horizon?NJ?Health?Dental?Program?
Benefit?Plan?Details?&?Authorization?Requirements?

??SKYGEN?USA?|?CONFIDENTIAL?&?PROPRIETARY?|?Horizon?NJ?Health?Dental?Program?|?Effective:?1/1/20?
196?

Horizon?NJ?Health?Dental?Program:?Non?Special?Needs?Plans?&?Special?Needs?Plans?
Code? Description? Age? Tooth?/?

Quad?/?Arch?
Limitations? Auth?

Req?
Requirement?

D8050? Interceptive?orthodontic?
treatment?of?the?primary?
dentition?

4?8? ?? One?per?lifetime;?combined?frequency?with?D8010,?
D8020,?D8030,?D8040,?D8050,?or?D8060.?

Yes? Narrative,?treatment?
plan,?general?dentist?
attestation,?photos,??
X?rays,?medical?narrative?
if?applicable?

D8060? Interceptive?orthodontic?
treatment?of?the?transitional?
dentition?

6?20? ?? One?per?lifetime;?combined?frequency?with?D8010,?
D8020,?D8030,?D8040,?D8050,?or?D8060.?

Yes? Narrative,?treatment?
plan,?general?dentist?
attestation,?photos,??
X?rays,?medical?narrative?
if?applicable?

D8080? Comprehensive?orthodontic?
treatment?of?the?adolescent?
dentition?

0?20? ?? One?per?lifetime.? Yes? HLD?score?sheet,?
narrative,?treatment?
plan,?general?dentist?
attestation,?photos,??
X?rays,?medical?narrative?
if?applicable?

D8210? Removable?appliance?therapy? 0?20? ?? One?per?lifetime.?
Not?on?the?same?date?of?service?as?D8010,?D8020,?
D8030,?D8040,?D8050,?D8060.?

Yes? Treatment?plan?and?
narrative?of?medical?
necessity?

D8220? Fixed?appliance?therapy? 0?20? ?? One?per?lifetime.?
Not?on?the?same?date?of?service?as?D8010,?D8020,?
D8030,?D8040,?D8050,?D8060.?

Yes? Treatment?plan?and?
narrative?of?medical?
necessity?



Horizon?NJ?Health?Dental?Program?
Benefit?Plan?Details?&?Authorization?Requirements?

??SKYGEN?USA?|?CONFIDENTIAL?&?PROPRIETARY?|?Horizon?NJ?Health?Dental?Program?|?Effective:?1/1/20?
197?

Horizon?NJ?Health?Dental?Program:?Non?Special?Needs?Plans?&?Special?Needs?Plans?
Code? Description? Age? Tooth?/?

Quad?/?Arch?
Limitations? Auth?

Req?
Requirement?

D8660? Pre?orthodontic?treatment?
examination?to?monitor?
growth?and?development?

0?20? ?? Once?per?rolling?year?per?provider.?? No? ??

D8670? Periodic?orthodontic?
treatment?visit?

0?20? ?? ?? Yes? Treatment?notes,?
documentation?of?
compliance,?general?
dentist?attestation,?
photos,?panorex,?copy?of?
initial?approval?if?
applicable?

D8680? Orthodontic?retention?
(removal?of?appliances,?
construction?and?placement?
of?retainer?or?retainers);?to?
include?adjustments?

0?20? ?? ?? Yes? Diagnostic?quality?
posttreatment?photos?

D8681? Removable?retainer?
adjustment?

0?20? ?? ?? No? ??

D8691? Repair?of?orthodontic?
appliance?

0?20? Arches?(UA,?
LA)?

?? Yes? Treatment?history,?
photos?optional?

D8692? Replacement?of?lost?or?
broken?retainer?

0?20? Arches?(UA,?
LA)?

One?per?lifetime.? Yes? Copy?of?approved?D8680?



Horizon?NJ?Health?Dental?Program?
Benefit?Plan?Details?&?Authorization?Requirements?

??SKYGEN?USA?|?CONFIDENTIAL?&?PROPRIETARY?|?Horizon?NJ?Health?Dental?Program?|?Effective:?1/1/20?
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Horizon?NJ?Health?Dental?Program:?Non?Special?Needs?Plans?&?Special?Needs?Plans?
Code? Description? Age? Tooth?/?

Quad?/?Arch?
Limitations? Auth?

Req?
Requirement?

D8693? Re?cement?or?re?bond?fixed?
retainer?

0?20? Arches?(UA,?
LA)?

?? No? ??

D8694? Repair?of?fixed?retainers,?
includes?reattachment?

0?20? Arches?(UA,?
LA)?

?? No? ??

D8695? Removal?Of?Fixed?
Orthodontic?Appliances?

0?999? ? Once?per?lifetime.? Yes? Narrative?of?medical?
necessity?

D8999? Unspecified?orthodontic?
procedure,?by?report?

0?20? ?? ?? Yes? Transfer?plan,?fee,?
reason?for?transfer,?orig?
rcds,?payment,?history,?
panorex,?ceph?x?ray,?HLD?
score?sheet?

D9110? Palliative?(emergency)?
treatment?of?dental?pain???
minor?procedure?

0?999? All?teeth;??
A?T;?1?32?

?Once?per?date?of?service?per?payee.? No? ??

D9210? Local?anesthesia?not?in?
conjunction?with?operative?or?
surgical?procedures?

0?999? ?? Twice?per?year?per?provider.?
Must?be?on?the?same?date?of?service?as?D0100?D0999.??
Not?allowed?on?the?same?date?of?service?as?any?other?
code.??

Yes? Radiographs?and/or?
photographs?and?
narrative?of?medical?
necessity?

D9211? Regional?block?anesthesia? 0?999? ?? Twice?per?year?per?provider.?
Must?be?on?the?same?date?of?service?as?D0100?D0999.??

Yes? Radiographs?and/or?
photographs?and?



Horizon?NJ?Health?Dental?Program?
Benefit?Plan?Details?&?Authorization?Requirements?

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Horizon?NJ?Health?Dental?Program:?Non?Special?Needs?Plans?&?Special?Needs?Plans?
Code? Description? Age? Tooth?/?

Quad?/?Arch?
Limitations? Auth?

Req?
Requirement?

Not?allowed?on?the?same?date?of?service?as?any?other?
code.??

narrative?of?medical?
necessity?

D9212? Trigeminal?division?block?
anesthesia?

0?999? ?? Twice?per?year?per?provider.?
Must?be?on?the?same?date?of?service?as?D0100?D0999.??
Not?allowed?on?the?same?date?of?service?as?any?other?
code.??

Yes? Radiographs?and/or?
photographs?and?
narrative?of?medical?
necessity?

D9222? Deep?Sedation/General?
Anesthesia???First?15?Minutes?

0?999? All?teeth;??
A?T;?1?32?

Once?per?date?of?service.?
Not?in?conjunction?with?D9230,?D9239,?D9243,?or?
D9248?on?same?date?of?service?

Yes? Narrative?of?medical?
necessity?

D9223? Deep?sedation/general?
anesthesia???each?subsequent?
15?minute?increment?

0?999? All?teeth;??
A?T;?1?32?

?Seven?per?date?of?service.?
Not?in?conjunction?with?D9230,?D9239,?D9243,?or?
D9248?on?same?date?of?service?

Yes? Narrative?of?medical?
necessity?

D9230? Inhalation?of?nitrous?
oxide/analgesia,?anxiolysis?

0?999? ?? One?per?date?of?service.?
Not?in?conjunction?with?D9222,?D9223,?D9239,?or?
D9243?on?same?date?of?service?per?payee.?

No? ??

D9239? Intravenous?Moderate?
(Conscious)?
Sedation/Analgesia???First?15?
Minutes?

0?999? ? One?per?date?of?service.?
Not?in?conjunction?with?D9222,?D9223,?D9230,?or?
D9248?on?same?date?of?service?

Yes? Documentation?of?
medical?necessity?

D9243? Intravenous?moderate?
(conscious)?
sedation/analgesia???each?
subsequent?15?minute?
increment?

0?999? ?? ?Seven?per?date?of?service.?
Not?in?conjunction?with?D9222,?D9223,?D9230,?or?
D9248?on?same?date?of?service?

Yes? Documentation?of?
medical?necessity?



Horizon?NJ?Health?Dental?Program?
Benefit?Plan?Details?&?Authorization?Requirements?

??SKYGEN?USA?|?CONFIDENTIAL?&?PROPRIETARY?|?Horizon?NJ?Health?Dental?Program?|?Effective:?1/1/20?
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Horizon?NJ?Health?Dental?Program:?Non?Special?Needs?Plans?&?Special?Needs?Plans?
Code? Description? Age? Tooth?/?

Quad?/?Arch?
Limitations? Auth?

Req?
Requirement?

D9248? Non?intravenous?moderate?
(conscious)?sedation??

0?999? ?? Not?in?conjunction?with?D9222,?D9223,?D9239,?or?
D9243?on?same?date?of?service.?

Yes? Documentation?of?
medical?necessity?

D9310? Consultation???diagnostic?
service?provided?by?dentist?or?
physician?other?than?
requesting?dentist?or?
physician?

0?999? ?? Will?not?be?paid?on?same?date?of?service?as?any?other?
service.?

No? ??

D9311? Treating?dentist?consults?with?
a?medical?health?care?
professional?concerning?
medical?issues?that?may?affect?
member?s?planned?dental?
treatment?

0?999? ?? ?? No? ??

D9410? House/extended?care?facility?
call?

0?999? ?? ?? Yes? Documentation?of?
medical?necessity?

D9420? Hospital?or?ambulatory?
surgical?center?call?

0?999? ?? One?per?date?of?service?per?patient.? Yes? Documentation?of?
medical?necessity?

D9430? Office?visit?for?observation?
(during?regularly?scheduled?
hours)???no?other?services?
performed?

0?999? ?? Not?allowable?on?the?same?date?of?service?as?any?
other?code.?
Only?payable?to?oral?surgeons.??

No?
?

D9610? Therapeutic?parenteral?drug,?
single?administration?

0?999? ?? Not?allowable?on?the?same?date?of?service?as?D9222,?
D9223,?D9239,?or?D9243.?

No? ??



Horizon?NJ?Health?Dental?Program?
Benefit?Plan?Details?&?Authorization?Requirements?

??SKYGEN?USA?|?CONFIDENTIAL?&?PROPRIETARY?|?Horizon?NJ?Health?Dental?Program?|?Effective:?1/1/20?
201?

Horizon?NJ?Health?Dental?Program:?Non?Special?Needs?Plans?&?Special?Needs?Plans?
Code? Description? Age? Tooth?/?

Quad?/?Arch?
Limitations? Auth?

Req?
Requirement?

D9612? Therapeutic?parenteral?drugs,?
two?or?more?administrations,?
different?medications?

0?999? ?? Not?allowable?on?the?same?date?of?service?as?D9222,?
D9223,?D9239,?or?D9243.?

Yes? Documentation?of?
medical?necessity?

D9630? Other?drugs?and/or?
medicaments,?by?report?

0?999? ?? ?Once?per?date?of?service.? Yes? Documentation?of?
medical?necessity?

D9910? Application?of?desensitizing?
medicament?

16?999? ?? Once?per?floating?year.?
Not?payable?on?the?same?date?of?service?as?D9911.?

No? ??

D9911? Application?of?desensitizing?
resin?for?cervical?and/or?root?
surface,?per?tooth?

16?999? Permanent?
Teeth?1?32?

Once?per?floating?year.?
Not?payable?on?the?same?date?of?service?as?D9910.?

No? ??

D9920?
Special?
Needs,?
Age?0?
999?

Behavior?management,?by?
report?

0?9? All?teeth;??
A?T;?1?32?

Two?per?date?of?service?per?patient?per?payee.?
Not?allowable?on?same?date?of?service?as?D9220,?
D9221,?D9223,?D9241,?D9243,?or?D9248.?

No?
?

D9930? Treatment?of?complications?
(post?surgical)???unusual?
circumstances,?by?report?

0?999? All?teeth;??
A?T;?1?32?

?Only?payable?to?oral?surgeons.? Yes? Documentation?of?
medical?necessity?

D9944? Occlusal?guard?? 16?999? ?? Once?per?3?years?combined?with?D9945.? Yes? Documentation?of?
medical?necessity?



Horizon?NJ?Health?Dental?Program?
Benefit?Plan?Details?&?Authorization?Requirements?

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Horizon?NJ?Health?Dental?Program:?Non?Special?Needs?Plans?&?Special?Needs?Plans?
Code? Description? Age? Tooth?/?

Quad?/?Arch?
Limitations? Auth?

Req?
Requirement?

D9945? Occlusal?guard? 16?999? ? Once?per?3?years?combined?with?D9944.? Yes? Documentation?of?
medical?necessity?

D9951? Occlusal?adjustment???limited? 16?999? ?? Not?in?conjunction?with?D9223,?D9243,?and?D9920?on?
same?date?of?service?per?payee.?
Once?per?1?rolling?year?per?payee.?
Not?allowable?on?the?same?DOS?as?D2140,?D2150,?
D2160,?D2161,?D2330,?D2331,?D2332,?D2335,?D2390,?
D2391,?D2392,?D2393,?D2394,?D2740,?D2750,?D2751,?
D2752,?D2790,?D2791,?D2792,?D2799,?D3310,?D3320,?
D3330,?D3346,?D3347,?or?D3348.?

No? ??

D9952? Occlusal?adjustment?
complete?

16?999? ?? Once?per?3?rolling?years?per?patient.?
Not?allowable?on?the?same?DOS?as?any?other?code.?

No? ??

D9971? Odontoplasty???1?2?teeth? 16?999? Permanent?
Teeth?1?32?

?? No? ??

D9974? Internal?Bleaching?per?tooth? 16?999? Permanent?
Teeth?1?32?

Once?per?lifetime?per?payee.? No? ??



Horizon?NJ?Health?Dental?Program?
Benefit?Plan?Details?&?Authorization?Requirements?

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Horizon?NJ?Health?Dental?Program:?Non?Special?Needs?Plans?&?Special?Needs?Plans?
Code? Description? Age? Tooth?/?

Quad?/?Arch?
Limitations? Auth?

Req?
Requirement?

D9999? Unspecified?adjunctive?
procedure,?by?report?

0?999? ?? Used?only?for?authorization?of?operating?room?/?
ambulatory?surgery?center.?
Not?to?be?billed.?

Yes? Description?of?
procedure,?narrative?of?
medical?necessity,?GA?
checklist,?hospital?/?
outpatient?name?(as?
needed)?



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SKYGEN?USA?
Provider?Manual??
Program?Effective:?January?1,?2012?
Revision?Effective:?January?1,?2020?