NC Medicaid
Orthodontic Services

Medicaid and Health Choice
Clinical Coverage Policy No: 4B
Amended Date: July 1, 2020

To all beneficiaries enrolled in a Prepaid Health Plan (PHP): for questions about benefits andservices available on or after implementation, please contact your PHP.

Table of Contents
1.0

Description of the Procedure, Product, or Service ........................................................................... 1
1.1
Definitions .......................................................................................................................... 1

2.0

Eligibility Requirements .................................................................................................................. 1
2.1
Provisions............................................................................................................................ 1
2.1.1 General ................................................................................................................... 1
2.1.2 Specific .................................................................................................................. 1
2.2
Special Provisions ............................................................................................................... 2
2.2.1 EPSDT Special Provision: Exception to Policy Limitations for a Medicaid
Beneficiary under 21 Years of Age ....................................................................... 2
2.2.2 EPSDT does not apply to NCHC beneficiaries ..................................................... 3
2.2.3 Health Choice Special Provision for a Health Choice Beneficiary age 6 through18 years of age ....................................................................................................... 3
2.3
Limitations .......................................................................................................................... 3

3.0

When the Procedure, Product, or Service Is Covered ...................................................................... 3
3.1
General Criteria Covered .................................................................................................... 3
3.2
Specific Criteria Covered.................................................................................................... 3
3.2.1 Specific criteria covered by both Medicaid and NCHC ........................................ 3
3.2.2 Medicaid Additional Criteria Covered................................................................... 4
3.2.3 NCHC Additional Criteria Covered ...................................................................... 4

4.0

When the Procedure, Product, or Service Is Not Covered ............................................................... 4
4.1
General Criteria Not Covered ............................................................................................. 5
4.2
Specific Criteria Not Covered............................................................................................. 5
4.2.1 Specific Criteria Not Covered by both Medicaid and NCHC................................ 5
4.2.2 Medicaid Additional Criteria Not Covered............................................................ 5
4.2.3 NCHC Additional Criteria Not Covered................................................................ 6

5.0

Requirements for and Limitations on Coverage .............................................................................. 6
5.1
Prior Approval .................................................................................................................... 6
5.2
Prior Approval Requirements ............................................................................................. 6
5.2.1 General ................................................................................................................... 6
5.2.2 Voiding a Prior Approval ...................................................................................... 7
5.3
Limitations or Requirements............................................................................................... 7
5.3.1 Orthodontic Records .............................................................................................. 7
5.3.2 Comprehensive Orthodontic Treatment................................................................. 9
5.3.3 Combined Orthognathic Surgery and Comprehensive Orthodontic Treatment... 11
5.4
ADA-Approved Materials ................................................................................................ 13
5.5
Orthodontic Review Board ............................................................................................... 13
5.6
Notifications to the Provider ............................................................................................. 13
5.7
Periodic Orthodontic Treatment (Maintenance) Visits ..................................................... 13
5.8
Reimbursement of Orthodontic Maintenance Visits During Ineligible Periods ............... 14

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NC Medicaid
Orthodontic Services
5.9

Medicaid and Health Choice
Clinical Coverage Policy No: 4B
Amended Date: July 1, 2020

Request for Medicaid Special Approval of a Non-Covered Service or Service Outside the
Policy Limitations ............................................................................................................. 14

6.0

Provider(s) Eligible to Bill for the Procedure, Product, or Service ............................................... 15
6.1
Provider Qualifications and Occupational Licensing Entity Regulations......................... 15
6.2
Provider Certifications ...................................................................................................... 15

7.0

Additional Requirements ............................................................................................................... 15
7.1
Compliance ....................................................................................................................... 15
7.2
Orthodontic Transfer Cases .............................................................................................. 15
7.2.1 In-State Transfer Cases ........................................................................................ 16
7.2.2 Out-of-State Transfer Cases................................................................................. 16
7.3
Terminated Orthodontic Treatment .................................................................................. 17
7.4
Orthodontic Prior Approval Extension Request (when paid maintenance visits have notexceeded the 23 allowed) .................................................................................................. 18
7.5
Orthodontic Case Completion........................................................................................... 18
7.6
Health Record Documentation.......................................................................................... 19
7.7
Transfer of Beneficiary Dental Records ........................................................................... 20

8.0

Policy Implementation and History ............................................................................................... 21

Attachment A: Orthodontic Billing Guide .................................................................................................. 24
A1:
Instructions for Requesting Orthodontic Prior Approval .................................................. 24
A2:
Example of a Completed Orthodontic Prior Approval Request........................................ 26
A3:
Instructions for Filing an Orthodontic Claim.................................................................... 27
A4:
Example of a Completed Claim for Orthodontic Records ................................................ 30
A5:
Orthodontic Treatment Termination Request ................................................................... 31
A6:
Orthodontic Prior Approval Extension Request ............................................................... 33
A7:
Orthodontic Post-Treatment Summary ............................................................................. 35

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NC Medicaid
Orthodontic Services

Medicaid and Health Choice
Clinical Coverage Policy No.: 4B
Amended Date: July 1, 2020

Related Clinical Coverage Policies
Refer to https://medicaid.ncdhhs.gov/ for the related coverage policy listed below:
4A Dental Services

1.0

Description of the Procedure, Product, or Service
Orthodontics is defined as a corrective procedure for functionally impairing occlusal conditions(including craniofacial abnormalities and traumatic or pathologic anatomical deviations) thatcause pain or suffering, physical deformity, significant malfunction, aggravates a condition, or
results in further injury or infirmity. Such services must maintain a high standard of quality andmust be within the reasonable limits of services customarily available and provided to most
persons in the community with the limitations and exclusions specified in this policy. Only theprocedure codes listed in this policy are covered under the North Carolina (NC) Medicaid(Title XIX) and Health Choice (Title XXI) Dental Programs.
NC Medicaid has adopted procedure codes and descriptions as defined in Section 1, Code on
Dental Procedures and Nomenclature (CDT Code), of the CDT 2020 Dental Procedure Codes
published by the American Dental Association (ADA).

1.1

2.0

Definitions

None Apply.

Eligibility Requirements
2.1

Provisions
2.1.1

General(The term “General” found throughout this policy applies to all Medicaid andNCHC policies)a. An eligible beneficiary shall be enrolled in either:
1. the NC Medicaid Program (Medicaid is NC Medicaid program, unlesscontext clearly indicates otherwise); or
2. the NC Health Choice (NCHC is NC Health Choice program, unlesscontext clearly indicates otherwise) Program on the date of service andshall meet the criteria in Section 3.0 of this policy.
b. Provider(s) shall verify each Medicaid or NCHC beneficiary’s eligibility
each time a service is rendered.
c. The Medicaid beneficiary may have service restrictions due to theireligibility category that would make them ineligible for this service.
d. Following is only one of the eligibility and other requirements forparticipation in the NCHC Program under GS 108A-70.21(a): Children must
be between the ages of 6 through 18.

2.1.2

Specific(The term “Specific” found throughout this policy only applies to this policy)
a. Medicaid_____________________________________________________________________________________CDT 2020 Dental Procedure Codes (including procedure codes, nomenclature, descriptions, and otherdata) is copyrighted by the American Dental Association. © 2020 American Dental Association. All
rights reserved. Applicable FARS/DFARS apply.
1
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Orthodontic Services

Medicaid and Health Choice
Clinical Coverage Policy No.: 4B
Amended Date: July 1, 2020

None Apply.
b. NCHC
None Apply.

2.2

Special Provisions
2.2.1

EPSDT Special Provision: Exception to Policy Limitations for a
Medicaid Beneficiary under 21 Years of Agea. 42 U.S.C. § 1396d(r) [1905(r) of the Social Security Act]
Early and Periodic Screening, Diagnostic, and Treatment (EPSDT) is afederal Medicaid requirement that requires the state Medicaid agency tocover services, products, or procedures for Medicaid beneficiary under 21
years of age if the service is medically necessary health care to correct orameliorate a defect, physical or mental illness, or a condition [healthproblem] identified through a screening examination (includes any
evaluation by a physician or other licensed practitioner).
This means EPSDT covers most of the medical or remedial care a childneeds to improve or maintain his or her health in the best condition possible,
compensate for a health problem, prevent it from worsening, or prevent thedevelopment of additional health problems.
Medically necessary services will be provided in the most economic mode,
as long as the treatment made available is similarly efficacious to the service
requested by the beneficiary’s physician, therapist, or other licensed
practitioner; the determination process does not delay the delivery of theneeded service; and the determination does not limit the beneficiary’s right toa free choice of providers.
EPSDT does not require the state Medicaid agency to provide any service,product or procedure:
1. that is unsafe, ineffective, or experimental or investigational.
2. that is not medical in nature or not generally recognized as an accepted
method of medical practice or treatment.
Service limitations on scope, amount, duration, frequency, location ofservice, and other specific criteria described in clinical coverage policies may
be exceeded or may not apply as long as the provider’s documentation showsthat the requested service is medically necessary “to correct or ameliorate adefect, physical or mental illness, or a condition” [health problem]; that is,provider documentation shows how the service, product, or procedure meets
all EPSDT criteria, including to correct or improve or maintain thebeneficiary’s health in the best condition possible, compensate for a healthproblem, prevent it from worsening, or prevent the development of additional
health problems.
b. EPSDT and Prior Approval Requirements
1. If the service, product, or procedure requires prior approval, the fact thatthe beneficiary is under 21 years of age does NOT eliminate therequirement for prior approval.
2. IMPORTANT ADDITIONAL INFORMATION about EPSDT andprior approval is found in the NCTracks Provider Claims and Billing

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NC Medicaid
Orthodontic Services

Medicaid and Health Choice
Clinical Coverage Policy No.: 4B
Amended Date: July 1, 2020

Assistance Guide, and on the EPSDT provider page. The Web addresses
are specified below.
NCTracks Provider Claims and Billing Assistance Guide:
https://www.nctracks.nc.gov/content/public/providers/providermanuals.html
EPSDT provider page: https://medicaid.ncdhhs.gov/

2.2.2

EPSDT does not apply to NCHC beneficiaries

2.2.3

Health Choice Special Provision for a Health Choice Beneficiary age 6through 18 years of age
NC Medicaid shall deny the claim for coverage for an NCHC beneficiary whodoes not meet the criteria within Section 3.0 of this policy. Only services
included under the NCHC State Plan and the NC Medicaid clinical coveragepolicies, service definitions, or billing codes are covered for an NCHC
beneficiary.

2.3

3.0

Limitations

Pregnant Medicaid eligible beneficiaries covered under the Medicaid for Pregnant
Women program class “MPW” and beneficiaries covered under the Family Planning
Waiver program class “MAFD” are not eligible for orthodontic services as described inthis policy. Beneficiaries covered under the Medicare Qualified Beneficiaries program
class “MQB” do not receive a Medicaid card and the only benefit that the beneficiary
receives from Medicaid is the payment of the Medicare premium. The beneficiary is not
eligible for any orthodontic services as described in this policy. Beneficiaries enrolledwith the Program of All-Inclusive Care for the Elderly (PACE) are not covered fororthodontic services as described in this policy. Providers shall ask beneficiaries for their
PACE card and contact the PACE program for information regarding benefits. Refer to
Subsection 5.3, Limitations or Requirements for eligibility limitations for individual
procedure codes.

When the Procedure, Product, or Service Is Covered
Note: Refer to Subsection 2.2.1 regarding EPSDT Exception to Policy Limitations for a
Medicaid Beneficiary under 21 Years of Age.

3.1

General Criteria Covered

3.2

Specific Criteria Covered

Medicaid and NCHC shall cover the procedure, product, or service related to this policy
when medically necessary, and:a. the procedure, product, or service is individualized, specific, and consistent withsymptoms or confirmed diagnosis of the illness or injury under treatment, and not inexcess of the beneficiary’s needs;b. the procedure, product, or service can be safely furnished, and no equally effective
and more conservative or less costly treatment is available statewide; andc. the procedure, product, or service is furnished in a manner not primarily intended forthe convenience of the beneficiary, the beneficiary’s caretaker, or the provider.

3.2.1

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Specific criteria covered by both Medicaid and NCHC
None Apply.

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Orthodontic Services

3.2.2

3.2.3

4.0

Medicaid and Health Choice
Clinical Coverage Policy No.: 4B
Amended Date: July 1, 2020

Medicaid Additional Criteria Covered

The following criteria for functionally impairing occlusal conditions apply whencases are reviewed for Medicaid orthodontic approval. The probability for
approval is increased when two or more of the following criteria exist:
a. Severe skeletal condition that may require a combination of orthodontic
treatment and orthognathic surgery to correct (beneficiary’s age and the
direction of growth are also considered);b. Severe anterior-posterior occlusal discrepancy (severe Class II or Class III
dental malocclusion);c. Posterior crossbite of three or more teeth per arch;d. Anterior crossbite of three or more teeth per arch;e. True anterior open bite: 2 mm or more; of four or more teeth per arch;f. Significant posterior open bite: 2 mm or more; of four or more teeth per arch(not involving primary teeth, partially erupted teeth, or one or two teeth
slightly out of occlusion);g. Impinging overbite with evidence of occlusal contact into the opposing soft
tissue (lower incisors must be causing tissue trauma);h. Overjet (excessive protrusion 6 mm or greater);i. Crowding greater than 6 mm in either arch that must be moderate to severe
and functionally intolerable over a long period of time (such as occlusal
disharmony or gingival recession secondary to severe crowding);
j. Impactions where eruption is impeded with a good prognosis of beingbrought into the arch;k. Excessive spacing of 10 mm or more, in either the maxillary or mandibular
arch (excluding third molars), or 8 mm or greater from mesial of cuspid tomesial of cuspid. Any space that will remain for prosthodontic or implant
replacement cannot be included in the measurements for meeting spacing
criteria;l. Two or more congenitally missing teeth (excluding third molars) of at least
one tooth per quadrant;
m. Occlusal condition that exhibits a profound impact from a congenital ordevelopmental disorder (craniofacial anomaly), severe trauma, or pathology;
n. Psychological and emotional factors causing psychosocial inhibition to thenormal pursuits of life (requires supporting documentation of pre-existing
condition from a licensed mental health professional specializing in childpsychology or child psychiatry); oro. Potential that all problems will worsen.

NCHC Additional Criteria Covered

NCHC shall cover orthodontic services only for functionally impairing
malocclusions caused by an occlusal condition that exhibits a profound impact
from a congenital or developmental disorder (craniofacial anomaly such as cleft
lip and palate or other conditions caused by a syndrome), severe trauma, or
pathology which effect the function of speech, chewing, or swallowing.

When the Procedure, Product, or Service Is Not Covered
Note: Refer to Subsection 2.2.1 regarding EPSDT Exception to Policy Limitations for a
Medicaid Beneficiary under 21 Years of Age.

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Orthodontic Services

Medicaid and Health Choice
Clinical Coverage Policy No.: 4B
Amended Date: July 1, 2020

4.1

General Criteria Not Covered

4.2

Specific Criteria Not Covered

Medicaid and NCHC shall not cover the procedure, product, or service related to thispolicy when:a. the beneficiary does not meet the eligibility requirements listed in Section 2.0;
b. the beneficiary does not meet the criteria listed in Section 3.0;c. the procedure, product, or service duplicates another provider’s procedure, product,or service; ord. the procedure, product, or service is experimental, investigational, or part of a clinical
trial.

4.2.1
4.2.2

Specific Criteria Not Covered by both Medicaid and NCHC

Orthodontic services are not covered when the criteria specified in Section 3.0
and Section 5.0 of this policy have not been met.

Medicaid Additional Criteria Not Covered

Orthodontic services are not covered when the above medical criteria are notmet. Additionally, the following types of cases are not eligible for approval:a. Interceptive or Phase I treatment cases of the primary and transitional
dentition except for cases involving functionally impairing malocclusions
caused by cleft lip and palate or other severe craniofacial developmental
anomalies or severe traumatic injuries;
b. Minor tooth movement cases requiring a relatively short treatment period(less than 12 months);c. Cuspid impactions with a poor prognosis of being brought down into
occlusion in the presence of no other significant problems;d. Bilateral or unilateral posterior crossbites of moderate severity without asignificant mandibular shift or history of temporomandibular dysfunction anda lack of other significant problems;
e. Class I malocclusions with moderate crowding, no crossbites, overbite andoverjet within normal limits;f. Simple space closure of mild to moderate anterior spacing;g. Simple one arch treatment;
h. Localized tooth alignment problems requiring a relatively short period oftreatment (such as simple anterior or posterior crossbites, diastema closure,rotations);i. Orthodontic treatment begun prior to the patient becoming eligible for
Medicaid;
j. Habit appliance therapy;k. Occlusal guard (including splint therapy for the treatment of
temporomandibular dysfunction); andl. Orthodontic treatment started as a private pay arrangement before Medicaid
approval is requested.
If a non-covered orthodontic service is deemed medically necessary and warrants
consideration of approval, the provider shall submit a prior approval request
along with a letter describing the special circumstances of the case andappropriate orthodontic records. (Refer to Subsection 5.9, Request for
Medicaid Special Approval of a Non-Covered Service or Service Outside the

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Orthodontic Services

Medicaid and Health Choice
Clinical Coverage Policy No.: 4B
Amended Date: July 1, 2020

Policy Limitations, for specific instructions on submitting a prior approval
request.)

4.2.3

5.0

NCHC Additional Criteria Not Covereda. In addition to the specific criteria not covered in Subsection 4.2.1 of thispolicy, NCHC shall not cover orthodontic services when the NCHC
beneficiary does not have a functionally impairing malocclusion caused byan occlusal condition that exhibits a profound impact from a congenital ordevelopmental disorder (craniofacial anomaly such as cleft lip and palate orother conditions caused by a syndrome), severe trauma, or pathology which
effect the function of speech, chewing, or swallowing.
b. NCGS § 108A-70.21(b) “Except as otherwise provided for eligibility, fees,
deductibles, copayments, and other cost sharing charges, health benefits
coverage provided to children eligible under the Program shall be equivalent
to coverage provided for dependents under North Carolina Medicaid
Program except for the following:
1. No services for long-term care.
2. No nonemergency medical transportation.
3. No EPSDT.
4. Dental services shall be provided on a restricted basis in accordance with
criteria adopted by the Department to implement this subsection.”

Requirements for and Limitations on Coverage
Note: Refer to Subsection 2.2.1 regarding EPSDT Exception to Policy Limitations for
Medicaid Beneficiaries under 21 Years of Age.

5.1

Prior Approval

Orthodontic services require prior approval. Prior approval does not guarantee payment.
Beneficiary eligibility for the date of service must be verified before rendering treatment.
Failure to obtain required prior approval before rendering a service shall result in denialof payment for that service. The orthodontic records must be obtained for each case andscreened to determine that the case is functionally impairing. All radiographic images,
photographic images and models must be of acceptable diagnostic quality or the case will
be returned. When submitting a prior approval request for orthodontic treatment
electronically, upload all records except for the models to the NCTracks Prior Approval
Portal. The models must be mailed with the NC DHHS Prior Approval Health Services
Attachment Review Cover Sheet. When submitting by mail, all orthodontic priorapproval information (ADA Dental Claim Forms, pretreatment narrative, radiographic
images, photographic images and models) must be received in the same package for eachbeneficiary. Multiple cases can be sent in the same package. If all the information is notreceived in the same package, the case will be returned to the provider requesting theadditional information.
Refer to Attachment A – Orthodontic Billing Guide, for additional information.

5.2

Prior Approval Requirements
5.2.1

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GeneralThe provider(s) shall submit to the Department of Health and Human Services(DHHS) Utilization Review Contractor the following:6

NC Medicaid
Orthodontic Services

Medicaid and Health Choice
Clinical Coverage Policy No.: 4B
Amended Date: July 1, 2020a. the prior approval request; andb. all health records and any other records that support the beneficiary has met
the specific criteria in Subsection 3.2 of this policy.

5.2.2

Voiding a Prior Approval

The provider may void an orthodontic prior approval within a four-year period of
the effective date for one of the following reasons:a. the beneficiary’s treatment plan has changed significantly;
b. the prior approval period has expired before the service could be rendered; orc. the beneficiary wishes to have the service rendered by another provider.
In such cases, the provider shall choose one of the following methods toaccomplish the process:a. Submit electronically in the NCTracks Prior Approval Portal by clicking on
the “Void PA Request” button to void the entire request; orb. Submit by mailing a printed copy of the approved prior approval requestfrom NCTracks and marking “VOID” on specific detail lines to be voided.
Send this copy to NCTracks or to the beneficiary’s new dentist if requested.
Note: Do not void any detail lines in which payment has been received for that
service.

5.3

Limitations or Requirements

By State legislative authority, NC Medicaid applies service limitations to CDT Codes as
they relate to individual beneficiaries. These service limitations are applied without
modification of the CDT procedure nomenclature. Limitations that apply to an entire
category of service are described at the beginning of the appropriate subsection.
Limitations that apply to an individual procedure code are indicated by an asterisk (*)
beneath the description of that code. Claims for services that fall outside these limitations
will be denied unless special approval is granted for services deemed medically necessary
for a Medicaid beneficiary under 21 years of age. Refer to Subsection 5.9, Request for
Medicaid Special Approval of a Non-Covered Service or Service Outside the Policy
Limitations.
NC Medicaid has adopted procedure codes and descriptions as defined in Section 1, Codeon Dental Procedures and Nomenclature (CDT Code), of the CDT 2020 Dental
Procedure Codes published by the American Dental Association (ADA). CDT 2020
Dental Procedure Codes (including procedure codes, nomenclature, descriptions, andother data) is copyrighted by the American Dental Association. © 2020 American Dental
Association. All rights reserved. Applicable FARS/DFARS apply.

5.3.1

Orthodontic Records
It is essential that Medicaid or NCHC eligibility be confirmed on the date that theorthodontic records are taken. If the beneficiary is not eligible, no payment will
be issued.
Note: Orthodontic records must only be taken for NCHC beneficiaries if thebeneficiary has an occlusal condition that exhibits a profound impact from acongenital or developmental disorder (craniofacial anomaly such as cleft lip andpalate or other conditions caused by a syndrome), severe trauma, or pathology.

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NC Medicaid
Orthodontic Services

Medicaid and Health Choice
Clinical Coverage Policy No.: 4B
Amended Date: July 1, 2020

Records are not reimbursed for NCHC beneficiaries who do not meet thesecriteria.
Medicaid and NCHC shall not cover interceptive orthodontics. Therefore,
professional judgment must be used to determine at what stage orthodontic
records are taken.
Orthodontic records are a once in a lifetime service. Orthodontic records must be
submitted for prior approval using the date the records were taken as therequested begin date in the NCTracks Prior Approval Portal. The orthodontic
records must be requested on the same request as the request for prior approval of
orthodontic treatment. Once approval is granted, the provider shall submit theclaim for payment of the orthodontic records electronically to NCTracks. No
prior approval is required for the comprehensive oral evaluation (D0150). The
provider may file a claim for payment once the evaluation has been rendered.
Code
D0150
D0330

D0340
D0470

Description
Comprehensive oral evaluation – new or established patient* Use as the initial exam for a beneficiary* Allowed as an initial exam once per billing provider per beneficiary
Panoramic radiographic image* Limited to beneficiaries age six and older* Allowed as part of the orthodontic records if the previous panoramic
radiographic image is more than one year old* Once in a lifetime service as part of the orthodontic records* Not allowed on the same date of service as D0210
2D cephalometric radiographic image – acquisition, measurement and analysis* Limited to beneficiaries under 21 years of age* Once in a lifetime service
Diagnostic casts* Limited to beneficiaries under 21 years of age* Once in a lifetime service* Study models must be properly occluded and trimmed with markings that
identify the beneficiary’s accurate occlusion* Print the NC DHHS Prior Approval Health Services Attachment Review
Cover Sheet to include in the mailing package with the study models

PA Needed?
No
Yes

Yes
Yes

Note: Diagnostic intraoral and extraoral photographic images are required as acomponent of the orthodontic records submitted for orthodontic prior approval.
These images are deemed a standard of care by the American Association of
Orthodontics (AAO) Committee on Medically Necessary Orthodontic Care.
Refer to Attachment A – Orthodontic Billing Guide, for additional informationand examples of a prior approval request and a claim for orthodontic records.

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Orthodontic Services

5.3.2

Code
D8070

D8080

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Medicaid and Health Choice
Clinical Coverage Policy No.: 4B
Amended Date: July 1, 2020

Comprehensive Orthodontic Treatment

Medicaid or NCHC approval and reimbursement for comprehensive orthodontic
treatment also includes any fixed or removable appliances necessary to complete
the approved treatment including functional appliances (such as a Herbst
appliance), palatal expanders, bite plates, holding arches, retainers, etc.

Description
Comprehensive orthodontic treatment of the transitional dentition* Limited to Medicaid beneficiaries under 21 years of age* Limited to NCHC beneficiaries under 19 years of age* Limited to functionally impairing malocclusions caused by an occlusal
condition that exhibits a profound impact from a congenital ordevelopmental disorder (craniofacial anomaly such as cleft lip and palate
or other conditions caused by a syndrome), severe trauma, or pathology
which effect the function of speech, chewing, or swallowing* Includes placement and monitoring of fixed or removable appliances suchas a functional appliance necessary to initiate active treatment* Use for full banding including the placement of bands, brackets, andappliances necessary to initiate active treatment of the upper and lower
arches* Once in a lifetime service* Prior approval of orthodontic services is granted for 36 months* Essential to confirm on each date of service that the beneficiary is still
eligible under the same health plan (Medicaid or NCHC) in which theapproval was granted in NCTracks. If the beneficiary is not eligible andthe health plan is not the same as approved, no payment will be issued* Once the banding has been paid, use for the maintenance visits forcomprehensive orthodontic treatment of the transitional dentition* Allowed once per calendar month (for example, a patient seen for acomprehensive orthodontic treatment of the transitional dentition visit on
any date in January would be eligible for the next visit on any date in
February)* Not allowed for repair or replacement of broken or missing brackets,bands, or wires when no other maintenance treatment is rendered* Limited to 23 reimbursable maintenance visits* The banding and 23 maintenance visits constitute the total reimbursement
for comprehensive orthodontic treatment and the provider is expected tocomplete any additional maintenance visits necessary to achieve an
acceptable treatment outcome without further reimbursement
Comprehensive orthodontic treatment of the adolescent dentition* Limited to Medicaid beneficiaries under 21 years of age* Limited to NCHC beneficiaries under 19 years of age* Limited to functionally impairing malocclusions for Medicaid
beneficiaries* Limited to functionally impairing malocclusions caused by an occlusal
condition that exhibits a profound impact from a congenital ordevelopmental disorder (craniofacial anomaly such as cleft lip and palate
or other conditions caused by a syndrome), severe trauma, or pathology

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PA Needed?
Yes

Yes

NC Medicaid
Orthodontic Services

Code

D8670

D8680

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Medicaid and Health Choice
Clinical Coverage Policy No.: 4B
Amended Date: July 1, 2020

Description
which effect the function of speech, chewing, or swallowing for NCHC
beneficiaries* Includes placement and monitoring of fixed or removable appliances suchas a functional appliance necessary to initiate active treatment* Use for full banding including the placement of bands, brackets, andappliances necessary to initiate active treatment of the upper and lower
arches* Once in a lifetime service* Prior approval of orthodontic services is granted for 36 months* Essential to confirm on the date of banding that the beneficiary is still
eligible under the same health plan (Medicaid or NCHC) in which theapproval was granted in NCTracks. If the beneficiary is not eligible andthe health plan is not the same as approved, no payment will be issued
Periodic orthodontic treatment visit* Limited to Medicaid beneficiaries under 21 years of age* Limited to NCHC beneficiaries under 19 years of age* Use for the maintenance visits for comprehensive orthodontic treatment of
the adolescent dentition* Limited to functionally impairing malocclusions for Medicaid
beneficiaries* Limited to functionally impairing malocclusions caused by an occlusal
condition that exhibits a profound impact from a congenital ordevelopmental disorder (craniofacial anomaly such as cleft lip and palate
or other conditions caused by a syndrome), severe trauma, or pathology
which effect the function of speech, chewing, or swallowing for NCHC
beneficiaries* Prior approval of orthodontic services is granted for 36 months* Allowed once per calendar month (for example, a patient seen for aperiodic orthodontic treatment visit on any date in January would be
eligible for the next visit on any date in February)* Not allowed for repair or replacement of broken or missing brackets,bands, or wires when no other maintenance treatment is rendered* Limited to 23 reimbursable maintenance visits* The banding and 23 maintenance visits constitute the total reimbursement
for comprehensive orthodontic treatment and the provider is expected tocomplete any additional maintenance visits necessary to achieve an
acceptable treatment outcome without further reimbursement* If the case is approved and the banding is paid, Medicaid or NCHC willcontinue to pay for monthly maintenance visits regardless of eligibility
Orthodontic retention (removal of appliances, construction and placement ofretainer(s))* Limited to Medicaid beneficiaries under 21 years of age* Limited to NCHC beneficiaries under 19 years of age* Once in a lifetime service* When comprehensive orthodontic treatment is complete, refer to
Subsection 7.5 - Orthodontic Case Completion, for specific instructions

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PA Needed?

Yes

Yes

NC Medicaid
Orthodontic Services

Code

*

Medicaid and Health Choice
Clinical Coverage Policy No.: 4B
Amended Date: July 1, 2020

Description
When comprehensive orthodontic treatment is terminated, refer to
Subsection 7.3 – Terminated Orthodontic Treatment, for specificinstructions

PA Needed?

Note: When a case is approved for comprehensive orthodontic treatment, allfixed or removable appliances (including broken or lost brackets) necessary tocomplete the approved treatment are included in the Medicaid or NCHC payment
and the beneficiary must not be billed any additional charges.
Refer to Attachment A – Orthodontic Billing Guide, for additional
information.

5.3.3

Combined Orthognathic Surgery and Comprehensive Orthodontic
Treatment
The following orthodontic records are allowed for the initial consultation visit for
combined orthognathic surgery and comprehensive orthodontic treatment.

Code
D0160
D0250

D0330

D0340
D0470

Description
Detailed and extensive oral evaluation – problem focused, by report* Allowed for the initial consultation visit for combined comprehensive
orthodontic treatment and orthognathic surgery
Extra-oral – 2D projection radiographic image created using a stationary
radiation source, and detector* These images include, but are not limited to: Lateral Skull; PosteriorAnterior Skull; Submentovertex; Waters; Reverse Tomes; Oblique
Mandibular Body; Lateral Ramus
Panoramic radiographic image* Limited to beneficiaries age six and older* Allowed as part of the orthodontic records if the previous panoramic
radiographic image is more than one year old* Once in a lifetime service as part of the orthodontic records* Not allowed on the same date of service as D0210
2D cephalometric radiographic image – acquisition, measurement and analysis* Limited to beneficiaries under 21 years of age* Once in a lifetime service
Diagnostic casts* Limited to beneficiaries under 21 years of age* Once in a lifetime service* Study models must be properly occluded and trimmed with markings that
identify the beneficiary’s accurate occlusion* Print the NC DHHS Prior Approval Health Services Attachment Review
Cover Sheet to include in the mailing package with the study models

PA Needed?
No
No

Yes

Yes
Yes

When the patient is ready for surgery, additional records are needed as the interim
records. These records must be submitted with the prior approval request fororthognathic surgery. NC Medicaid shall grant an override of the lifetime limit toallow payment for the additional records required for the surgery request.

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NC Medicaid
Orthodontic Services

Medicaid and Health Choice
Clinical Coverage Policy No.: 4B
Amended Date: July 1, 2020

Note: The same records are required for orthognathic surgery requests submitted onbehalf of a beneficiary who initiated their orthodontic treatment through a privatepay arrangement.
Certain second surgeries (such as bilateral procedures) performed on the same dateof service may be reimbursed at 50 percent of the maximum allowed rate.
Code
D7940
D7941
D7943
D7944
D7945
D7946
D7947
D7948
D7949
D7950
D7955

Description
Osteoplasty – for orthognathic deformities
Osteotomy – mandibular rami
Osteotomy – mandibular rami with bone graft; includes obtaining the graft
Osteotomy – segmented or subapical
Osteotomy – body of mandible
LeFort I (maxilla – total)
LeFort I (maxilla – segmented)
LeFort II or LeFort III (osteoplasty of facial bones for midface hypoplasia or
retrusion) – without bone graft
LeFort II or LeFort III – with bone graft
Osseous, osteoperiosteal, or cartilage graft of the mandible or maxilla –
autogenous or nonautogenous, by report
Repair of maxillofacial soft and/or hard tissue defectPA Needed?
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes

Refer to Attachment A – Orthodontic Billing Guide, for additional
information.
The following records are required when submitting a prior approval request for
combined comprehensive orthodontic treatment of the adolescent dentition (D8080)
and orthognathic surgery to correct a skeletal imbalance:
a. Diagnostic Casts;
1. Trimmed to centric occlusion with markings that identify the beneficiary’s
accurate occlusion
2. Bite registration required
3. Description of centric relation-centric occlusion shifts greater than 2mm
b. Three Extraoral Photographic Images;
1. Full face with patient at rest
2. Right profile with patient at rest
3. Full face with patient smiling as fully as possiblec. Five Intraoral Photographic Images;
1. Maxillary occlusal view
2. Mandibular occlusal view
3. Right lateral view in centric occlusion
4. Left lateral view in centric occlusion
5. Frontal view in centric occlusiond. Radiographic Images;
1. Panoramic (labeled right and left)

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Orthodontic Services

Medicaid and Health Choice
Clinical Coverage Policy No.: 4B
Amended Date: July 1, 2020

2. Lateral cephalometric with tracing and analysis (right lateral with teeth inocclusion and the patient in a relaxed lip posture)
3. Posterior-anterior cephalometric if asymmetry is present
4. Individual periapical films as needed for special diagnostic concernse. Treatment Plan; and1. Necessary extractions
2. Pre-surgical orthodontic treatment goals with specific measurements in all
three dimensions
3. Pre-treatment lateral cephalometric predictions showing anticipatedorthodontic and surgical movements and resulting soft tissue profile
4. Estimated time to complete pre-surgical orthodontics
5. Post-surgical orthodontic treatment goals and estimated time to complete
treatment
6. Retention planf. Consultation notes from the provider who will be rendering the orthognathic
surgery services indicating agreement with the proposed treatment plan.

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5.4

ADA-Approved Materials

5.5

Orthodontic Review Board

5.6

Notifications to the Provider

5.7

Periodic Orthodontic Treatment (Maintenance) Visits

Only dental materials accepted by the ADA Council on Scientific Affairs shall be
accepted for use in the dental care of Medicaid and NCHC beneficiaries. Specific use of
these materials must follow the guidelines of the ADA Council on Scientific Affairs.
The Orthodontic Review Board shall determine on a case-by-case basis whether toauthorize coverage. If necessary, members of the review board shall physically examine
the beneficiary before approval of the case. In reaching a decision, the functional needmust be examined as well as other factors such as:a. The beneficiary’s attitude and ability to meet appointments.
b. The beneficiary’s ability to follow instructions and cooperate through a lengthy
treatment period.
c. The beneficiary’s ability to maintain an acceptable level of oral hygiene vital to thesuccess of treatment.
Once a decision is made regarding the request for orthodontic services, written
notification is sent to the provider.
a. If the case is approved, the DHHS Utilization Review Contractor will send anelectronic Notice of Decision to the provider through NCTracks and return allorthodontic records.
b. If the case is denied, the DHHS Utilization Review Contractor will send an electronic
Notice of Decision to the provider through NCTracks and return all orthodontic
records. A letter of notification of denial, along with appeal rights, is mailed to thebeneficiary. A copy of the denial letter is also mailed to the provider.
It is anticipated that the treatment period will be completed in 24 to 36 months after
initial banding. Periodic orthodontic treatment (maintenance) visits are paid only once percalendar month with a total of 23 visits allowed (for example, a patient seen for aperiodic orthodontic treatment visit on any date in January would be eligible for the next
visit on any date in February).

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Orthodontic Services

Medicaid and Health Choice
Clinical Coverage Policy No.: 4B
Amended Date: July 1, 2020

Refer to Attachment A – Orthodontic Billing Guide, for additional information.

5.8

Reimbursement of Orthodontic Maintenance Visits During Ineligible Periods
It is essential that Medicaid or NCHC eligibility be confirmed on the date of banding. If
the beneficiary is not eligible, no payment will be made. Only orthodontic periodic
maintenance visits (D8670) for the comprehensive orthodontic treatment of theadolescent dentition (D8080) are reimbursed regardless of the beneficiary’s eligibility
status at that visit if the beneficiary was eligible on the date of banding and the payment
is in paid history. The case must be approved before the initial banding takes place.
Banding must occur before maintenance visits are billed.
Note: The beneficiary must be Medicaid or NCHC eligible for reimbursement of theperiodic maintenance visits for comprehensive orthodontic treatment of the transitional
dentition (D8070) on each date of service.
No other services are covered during ineligible periods. Providers shall make thebeneficiary aware that Medicaid or NCHC will not pay for any routine care, restorative
care, extractions, or orthognathic surgery needed during orthodontic treatment if renderedduring ineligible periods.

5.9

Request for Medicaid Special Approval of a Non-Covered Service or Service
Outside the Policy Limitations

Dental providers may request special approval for a service that is non-covered by the
NC Medicaid program or falls outside the limitations stated in this policy, if that service
is deemed medically necessary for a Medicaid beneficiary under 21 years of age as
described in Subsection 2.2.1 of this policy. All such requests must be submitted andapproved prior to delivery of the service. Submit electronically by uploading the request
to the NCTracks Prior Approval Portal with the following information:a. CDT Code of service being requested entered and indicate that the request is for
special approval of a non-covered service in the “Documentation of Medical
Necessity” field;b. any materials needed to document medical necessity (such as radiographic andphotographic images, dental and periodontal charting, a letter from the beneficiary’s
medical care provider); andc. the completed Non-Covered State Medicaid Plan Services Request Form for
Beneficiaries Under 21 Years of Age or a cover letter that documents how the service
will correct or ameliorate a defect, physical or mental illness, or a condition [healthproblem]. This includes documentation about how the service, product, or procedure
will correct or ameliorate (improve or maintain the beneficiary’s health in the best
condition possible, compensate for a health problem, prevent it from worsening, orprevent the development of additional health problems) as well as the effectivenessand safety of the service, product, or procedure.
If submitting by mail, submit a completed ADA Dental Claim Form with the above listed
information. Mail to:
NCTracks Prior Approval Unit
PO Box 31188
Raleigh, NC 27622

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Orthodontic Services

Medicaid and Health Choice
Clinical Coverage Policy No.: 4B
Amended Date: July 1, 2020

If the procedure(s) receives special approval and the beneficiary is Medicaid eligible on
the date the service is rendered, the dentist then can file for reimbursement.
Note: A copy of the Non-Covered State Medicaid Plan Services Request Form for
Beneficiaries Under 21 Years of Age can be found on the NCTracks Prior Approval pageat https://www.nctracks.nc.gov/content/public/providers/prior-approval.html.

6.0

Provider(s) Eligible to Bill for the Procedure, Product, or Service
To be eligible to bill for the procedure, product, or service related to this policy, the provider(s)shall:
a. meet Medicaid or NCHC qualifications for participation;b. have a current and signed Department of Health and Human Services (DHHS) Provider
Administrative Participation Agreement; andc. bill only for procedures, products, and services that are within the scope of their clinicalpractice, as defined by the appropriate licensing entity.
Note: All dental providers participating in the Medicaid and NCHC programs shall provide
services according to the rules and regulations detailed in this policy.

7.0

6.1

Provider Qualifications and Occupational Licensing Entity Regulations

6.2

Provider Certifications

None Apply.

To obtain a dental specialty taxonomy, the provider shall submit proof of the residency
program completion and a copy of the specialty certification to NC Medicaid with theinitial enrollment application or through a Managed Change Request in the NCTracks
Provider Portal.

Additional Requirements
Note: Refer to Subsection 2.2.1 regarding EPSDT Exception to Policy Limitations for a
Medicaid Beneficiary under 21 Years of Age.

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7.1

Compliance7.2

Orthodontic Transfer Cases

Provider(s) shall comply with the following in effect at the time the service is rendered:a. All applicable agreements, federal, state and local laws and regulations including the
Health Insurance Portability and Accountability Act (HIPAA) and record retention
requirements; andb. All NC Medicaid’s clinical (medical) coverage policies, guidelines, policies, provider
manuals, implementation updates, and bulletins published by the Centers for
Medicare and Medicaid Services (CMS), DHHS, DHHS division(s) or fiscal
contractor(s).
The beneficiary must be receiving orthodontic treatment that was approved by Medicaid,
NCHC, or another state’s NCHC equivalent medical assistance program to be considered
for continuation of treatment. Orthodontic records will not be reimbursed for transfer
cases. Providers are reminded that reimbursement for transfer cases is limited to theremaining number of periodic maintenance visits (D8670) for that beneficiary. At case15

NC Medicaid
Orthodontic Services

Medicaid and Health Choice
Clinical Coverage Policy No.: 4B
Amended Date: July 1, 2020

completion, submit a prior approval request for final orthodontic payment (D8680) for
consideration of reimbursement for the deband and retainers.
Refer to Subsection 7.5 – Orthodontic Case Completion, for additional informationthat is required when submitting a case for final orthodontic payment.

7.2.1

In-State Transfer Cases

Prior approval of in-state transfer cases is required. Submit electronically by
uploading the request to the NCTracks Prior Approval Portal with the following
information:a. CDT Code D8670 (periodic orthodontic treatment visit) entered as therequested service and indicate that the request is for in-state transfer in the“Documentation of Medical Necessity” field.
b. A narrative indicating that the case is an “in-state transfer.” The narrative
must include:
1. the initial provider’s name and address;
2. the beneficiary’s current orthodontic status; and3. the treatment plan with the anticipated length of the remaining treatment.
c. If the beneficiary has been banded, submit an American Association of
Orthodontists (AAO) Transfer Form.
d. If the beneficiary has not been banded, attach a copy of the Medicaid or
NCHC orthodontic approval from the previous orthodontic provider with thespecific detail lines marked “VOID.”
If submitting by mail, submit a completed ADA Dental Claim Form with theabove listed information. Mail to NCTracks Prior Approval Unit, Orthodontic
Review Board.
Refer to Attachment A – Orthodontic Billing Guide, for additional instructions
for requesting orthodontic prior approval.

7.2.2

Out-of-State Transfer Cases

The beneficiary must have been approved and receiving comprehensive
orthodontic treatment under Medicaid or other NCHC equivalent medical
assistance program in their previous state of residence to be considered forcontinuation of treatment in North Carolina.
Prior approval for out-of-state transfer cases is required. Submit electronically by
uploading the request to the NCTracks Prior Approval Portal with the following
information:a. CDT Code D8670 (periodic orthodontic treatment visit) entered as therequested service and indicate that the request is for out-of-state transfer inthe “Documentation of Medical Necessity” field.
b. A narrative indicating that the case is an “out-of-state transfer.” The narrative
must include:
1. the initial provider’s name and address;
2. the beneficiary’s current orthodontic status; and3. the treatment plan with the anticipated length of the remaining treatment.
c. A copy of the American Association of Orthodontists (AAO) Transfer Formor a copy of the orthodontic treatment records from the previous provider.

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Orthodontic Services

Medicaid and Health Choice
Clinical Coverage Policy No.: 4B
Amended Date: July 1, 2020

d. Attach some proof of Medicaid eligibility in the previous state of residence(copy of the Medicaid card from the previous state or records from theprevious provider that indicate Medicaid as the payer).
e. Current photographic images (required). Current orthodontic models arehelpful but not required.

If submitting by mail, submit a completed ADA Dental Claim Form with theabove listed information. Mail to NCTracks Prior Approval Unit, Orthodontic
Review Board.
Once approved, it is essential that Medicaid or NCHC eligibility be confirmed oneach date of service. If the beneficiary is not eligible, no payment will be made.
Refer to Attachment A – Orthodontic Billing Guide, for additional instructions
for requesting orthodontic prior approval.

7.3

Terminated Orthodontic Treatment

Case termination prior to completion of treatment should rarely take place. All efforts
should be made to complete the active phase of treatment. If circumstances occur beyond
the control of the dentist (such as beneficiary death or moving out-of-state) that prevents
the completion of orthodontic treatment, the provider shall notify the DHHS Utilization
Review Contractor.
Submit electronically by uploading the request to the NCTracks Prior Approval Portal
with the following information:a. CDT Code D8680 (orthodontic retention) entered as the requested service andindicate that the request is for termination of treatment in the “Documentation of
Medical Necessity” field.
b. A completed Orthodontic Treatment Termination Request Form.
c. A copy of the beneficiary’s treatment notes from the initial visit through the date of
termination.
d. Supporting documentation of when and how attempted contacts were made (such as
information indicating telephone calls made, messages left with county social
worker, relatives, neighbors or friends, letters mailed).
e. Final photographic images are required for consideration of final reimbursement, if
deband was rendered.
If submitting by mail, submit a completed ADA Dental Claim Form with the above listed
information. Mail to NCTracks Prior Approval Unit, Orthodontic Review Board.
If the beneficiary was only banded, Medicaid or NCHC may require that a percentage ofthe banding fee be refunded to the program. This is based on individual caseconsideration and the circumstances surrounding case termination. In these cases,
Medicaid or NCHC shall contact the provider to arrange for the refund.
If a beneficiary has been terminated but presents back to the provider for treatmentcompletion, either:a. Submit a prior approval request to re-establish the remaining maintenance visits(D8670); or

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Orthodontic Services

Medicaid and Health Choice
Clinical Coverage Policy No.: 4B
Amended Date: July 1, 2020

b. Render the deband and retainers (D8680) and submit the prior approval request as
described in Subsection 7.5, Orthodontic Case Completion.
Refer to Attachment A – Orthodontic Billing Guide, for additional information and a
copy of the Orthodontic Treatment Termination Request.

7.4

Orthodontic Prior Approval Extension Request (when paid maintenancevisits have not exceeded the 23 allowed)

It is anticipated that the orthodontic treatment will be completed within 36 months. Whenthe orthodontic treatment exceeds this three-year approval period and the provider has notreceived payment for the 23 maintenance visits, the provider shall notify the DHHS
Utilization Review Contractor.
Submit electronically by uploading the request to the NCTracks Prior Approval Portal
with the following information:a. CDT Code D8670 (periodic orthodontic treatment visit) entered as the requested
service and indicate that the request is for a prior approval extension in the“Documentation of Medical Necessity” field.
b. A completed Orthodontic Prior Approval Extension Request Form.
If submitting by mail, submit a completed ADA Dental Claim Form with the above listed
information. Mail to NCTracks Prior Approval Unit, Orthodontic Review Board.
Claims submitted after the prior approval expiration date will deny with EOB 00023“SERVICE REQUIRES PRIOR APPROVAL.” Until an extension request has been
submitted in such cases, Medicaid or NCHC claims will deny.
Refer to Attachment A – Orthodontic Billing Guide, for additional information and a
copy of the Orthodontic Prior Approval Extension Request.

7.5

Orthodontic Case Completion

Providers are allowed payment for the banding and 23 maintenance visits. Payment
received for banding constitutes about one-third of the maximum allowed for the entire
treatment. The balance is paid incrementally with each periodic maintenance visit. The
banding and 23 maintenance visits constitute the total reimbursement for comprehensive
orthodontic treatment. The provider shall complete any additional maintenance visits
necessary to achieve an acceptable treatment outcome without further reimbursement.
In rare instances, it may take fewer than 23 visits to complete treatment. In such cases, aprovider may submit a final request for payment of the balance of remaining visits. The
request will be considered based on the number of remaining visits and the outcome of
the case.
Providers shall notify the DHHS Utilization Review Contractor upon case completion. It
is important that Medicaid and NCHC receive a post-treatment summary so that caserecords are complete.

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Orthodontic Services

Medicaid and Health Choice
Clinical Coverage Policy No.: 4B
Amended Date: July 1, 2020

Submit electronically by uploading the request to the NCTracks Prior Approval Portal
with the following information:a. CDT Code D8680 (orthodontic retention) entered as the requested service andindicate that the request is for the final orthodontic review in the “Documentation of
Medical Necessity” field.
b. Submit a completed Orthodontic Post-Treatment Summary Form.
c. Final photographic images (required).
d. If fewer than 12 maintenance visits were paid, record review is required to
substantiate the final claim payment. Attach a copy of the beneficiary’s treatment
notes from the initial visit through the delivery of retainers, if applicable. If it isdetermined that treatment was not “completed” but rather “terminated before
treatment objectives were achieved,” the final payment may be reduced or notallowed. This is based on individual case consideration and the circumstances
surrounding the case.
If submitting by mail, submit a completed ADA Dental Claim Form with the above listed
information. Mail to NCTracks Prior Approval Unit, Orthodontic Review Board.
Once the required documentation has been submitted, the request will be manually priced
and Medicaid or NCHC will allow reimbursement based on the number of remaining
visits if the case is determined to be a completed case. The post-treatment summary
includes the results of the treatment and assessment of the beneficiary’s cooperation. The
final orthodontic claim will not be paid unless a post-treatment summary is submitted andprocedure code D8680 is approved. After approval has been granted, the provider shallsubmit the claim for payment to receive the approved reimbursement.
Refer to Attachment A – Orthodontic Billing Guide, for additional information and a
copy of the Orthodontic Post-Treatment Summary.

7.6

Health Record Documentation

Providers are responsible for maintaining all financial, medical, and other records
necessary to fully disclose the nature and extent of services billed to Medicaid or NCHC.
These records must be retained for a period of at least six years from the date of service,unless a longer retention period is required by federal or state law, regulations, oragreements. The provider shall furnish upon request appropriate documentation—
including beneficiary records, supporting material, and any information regarding
payments claimed by the provider—for review by NC Medicaid, its agents, the Centers
for Medicare and Medicaid Services (CMS), the Medicaid Investigations Division of the
NC Attorney General’s Office, and other entities as required by law. Providers cannot
charge for records requested by Medicaid or NCHC.
The NC State Board of Dental Examiners applicable rule regarding patient records [21
NCAC 16T. 0101(a)] states that a dentist shall maintain complete treatment records on all
patients treated for a period of at least ten years. The complete rule is available for review
at http://reports.oah.state.nc.us/ncac.asp?folderName=\Title%2021%20%20Occupational%20Licensing%20Boards%20and%20Commissions\Chapter%2016%2
0-%20Dental%20Examiners.

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Orthodontic Services

Medicaid and Health Choice
Clinical Coverage Policy No.: 4B
Amended Date: July 1, 2020

The Health Insurance Portability and Accountability Act (HIPAA) does not prohibit therelease of records to Medicaid or NCHC (45 CFR 164.502).

7.7

Transfer of Beneficiary Dental Records

Providers are reminded to provide records of diagnostic quality when transferring dental
records to another provider or directly to a beneficiary. Since bitewing radiographic
images are allowed once a year and panoramic radiographic images and intraoral
complete series of radiographic images are allowed once every five years, it is imperativethat the images that are transferred are of diagnostic quality so the provider receiving theimages can make a proper diagnosis regarding treatment.
The provider shall comply with 21 NCAC 16T.0102, Transfer of Records Upon Request,
which states: “A dentist shall, upon request by the patient of record, provide all
information required by the Health Insurance Portability and Accountability Act(HIPAA) and this Rule, including original or diagnostic copies of radiographs and alegible copy of all treatment records to the patient or to a licensed dentist identified by
the patient. The dentist may charge a fee not exceeding the actual cost of duplicating therecords. The records shall be provided within 30 days of the request and production shallnot be contingent upon current, past or future dental treatment or payment of services.”
Medicaid and NCHC policy does not prohibit a dentist from charging a record
duplication fee to a beneficiary, provided the same fee is charged to private-pay patients.
Board rules do not set a maximum level for this duplication fee. When NC Medicaid or
the DHHS Utilization Review Contractor requests records to verify medical necessity or
accuracy of billing, providers do not receive compensation.

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Orthodontic Services
8.0

Medicaid and Health Choice
Clinical Coverage Policy No.: 4B
Amended Date: July 1, 2020

Policy Implementation and History
Original Effective Date: July 1, 2002

History:
Date
Section Revised
10/01/2003
All Sections
10/01/2004
09/01/2005
12/01/2005

All Sections
Section 2.3; 5.2; and 5.7
Section 2.3

120/1/2006
12/01/2006
05/01/2007

Section 2.3
Sections 3.0; 4.0; and 5.0
Sections 2.0; 3.0; 4.0; and 5.0

06/01/2007

Section 5.6

06/01/2007

Section 1.0; 5.2; andAttachment A (Orthodontic
Billing Guide)
1.0; 2.2; 2.3; 5.1; 5.3; 5.7;
5.8; 5.9; 6.0; 7.3; 7.4; 7.5;
7.6; 7.7; 8.0; and Attachment
A

04/01/2010

08/01/2011

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1.0; 3.0; 3.1; 3.2; 4.0; 4.1;
4.2; 5.0; 5.1; 5.3, 5.3.1; 5.8;
6.0; 7.0; 7.1; 7.2, 7.2.1; 7.2.2;
7.3; 7.4; 7.5; 7.6; andAttachment A

ChangeImplementation of CDT-4 Procedure Codes andstyle/grammar revisions.
Implementation of the 2002 ADA Dental Claim Form.
A special provision related to EPSDT was added.
The web address for DMA’s EPSDT policy instructions
was added to this section.
The special provision related to EPSDT was revised.
A note regarding EPSDT was added to these sections.
EPSDT information was revised to clarify exceptions topolicy limitations for beneficiaries under 21 years ofage.
Revised to include the Non-Covered State Medicaid
Plan Services Request Form (for recipients under 21
years of age).
Updated CDT 2006 Copyright disclaimer and revised
the Orthodontic Billing Guide to include the 2006 ADA
Dental Claim Form.
Updated CDT 2009/2010 Copyright disclaimer;changed EDS company name to HP throughout the
document; removed “pink” regarding the Medicaid forPregnant Women Medicaid card; removed “blue”
regarding the Family Planning Waiver Medicaid card;
added statements regarding beneficiaries covered under
the Medicare Qualified Beneficiaries program; added
statements regarding beneficiaries covered under the
Program of All-Inclusive Care for the Elderly (PACE)
program; added heading for ADA-Approved Materials;
added section on Medical Record Documentation; added
section on Compliance; added section on Transfer ofRecipient Dental Records; moved the information in
Section 8 (Billing Guidelines) to Sections 5 and 7;
removed field 58 as a required field on the ADA Dental
Claim Form; updated orthodontic forms; made generalrevisions throughout the policy to improve clarity,
grammar, and style; and incorporated standard
statements where appropriate.
Updated policy to standard DMA language; changed“functionally handicapping” to “functionally
impairing”; updated CDT 2011/2012 copyright
disclaimer; clarification of existing criteria and included
additional criteria to document covered and non-covered
orthodontic treatment; addition of procedure code21NC Medicaid
Orthodontic Services

Date

Section Revised

10/01/2011

Throughout

03/12/2012

Throughout

10/01/2015

All Sections and Attachments

10/01/2015

All Sections and Attachments

03/15/2019

Table of Contents

7/1/2020

All Sections and Attachments

7/1/2020

Table of Contents

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Medicaid and Health Choice
Clinical Coverage Policy No.: 4B
Amended Date: July 1, 2020

ChangeD8070; clarification of existing procedure codes; andclarification of orthodontic transfer cases, terminatedcases, and completed cases.
Session Law 2011-145 “Except as otherwise provided
for eligibility, fees, deductibles, copayments, and othercost sharing charges, health benefits coverage provided
to children eligible under the NC Health Choice
Program shall be equivalent to coverage provided for
dependents under the North Carolina Medicaid
Program.” DMA was given the timeframe October 1,
2011 to March 12, 2012 to fully implement the NCHC
transition to a Medicaid look-alike program.
Technical changes to merge Medicaid and NCHC
current coverage into one policy.
Changed fiscal agent references from HP to CSC
throughout the document; Updated CDT-2015
procedure code descriptions effective with date ofservice 1/1/2015; Updated place of service references to
HIPAA standards; and updated instructions related to
CSC processing.
Updated policy template language and added ICD-10
codes to comply with federally mandated 10/1/2015
implementation where applicable.
Added, “To all beneficiaries enrolled in a Prepaid
Health Plan (PHP): for questions about benefits andservices available on or after November 1, 2019, pleasecontact your PHP.”
Updated policy template language; Updated due to CDT
2016, 2017, 2018, 2019 and 2020 additions, deletions
and revisions; Included covered
orthodontic/orthognathic surgery codes as listed in the
Dental Clinical Coverage Policy 4A; Removed optional
for photographic images for orthodontic records thatmust be submitted for prior approval; Added requiredfor photographic images for out-of-state transfer
requests, terminated cases that were debanded, andorthodontic case completions; Revised orthodontic
criteria based on recommendations from the AAO
Committee on Medically Necessary Orthodontic Care;
Updated CDT 2020 Copyright disclaimer; Revised the
Orthodontic Billing Guide to include the 2019 ADA
Dental Claim Form and updated the Orthodontic
Treatment Termination Request Form, Orthodontic
Prior Approval Extension Request Form, and the
Orthodontic Post-Treatment Summary Form.
Updated policy template language, “To all beneficiaries
enrolled in a Prepaid Health Plan (PHP): for questions

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Orthodontic Services

Date

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Section Revised

Medicaid and Health Choice
Clinical Coverage Policy No.: 4B
Amended Date: July 1, 2020

Changeabout benefits and services available on or after
implementation, please contact your PHP.”

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Orthodontic Services

Medicaid and Health Choice
Clinical Coverage Policy No.: 4B
Amended Date: July 1, 2020

Attachment A: Orthodontic Billing Guide
Provider(s) shall comply with the, NCTracks Provider Claims and Billing Assistance Guide, Medicaid
bulletins, fee schedules, NC Medicaid’s clinical coverage policies and any other relevant documents for
specific coverage and reimbursement for Medicaid and NCHC:

A1:

Instructions for Requesting Orthodontic Prior Approval

Once a case has been screened, the orthodontic records obtained, and it is certain the case isfunctionally impairing, the provider shall request prior approval.
Submit electronically by uploading the request to the NCTracks Prior Approval Portal with thefollowing information:a.
Enter the procedure code for the orthodontic treatment (D8070 or D8080) and the procedurecodes for the orthodontic records being requested (D0330, D0340 and D0470) with the daterendered as the requested begin date.
b.
Attach the panoramic radiographic image (D0330).
c.
Attach the 2D cephalometric radiographic image – acquisition, measurement and analysis(D0340).
d.
Attach intraoral and facial photographic images (required).
e.
Attach a narrative which contains:
1. the provider’s assessment of the beneficiary’s motivation, ability to cooperate fororthodontic care, and ability to maintain oral hygiene;
2. the provider’s assessment of the beneficiary’s oral condition and the need for treatment;
3. the provider’s assessment of the beneficiary’s history of compliance with previous
dental care;
4. the estimated fee for the orthodontic treatment;
5. the estimated treatment period;
6. the proposed treatment plan (such as reduce overjet, extract premolars, extract
supernumerary teeth, expose impacted teeth, remove cysts, restorations, orthognathic
surgery); and7. the measures taken to restore decayed teeth and the dates restorations were completed.
f.
Print the NC DHHS Prior Approval Health Services Attachment Review Cover Sheet toinclude in the package of the properly occluded and trimmed dental models with markingsthat identify the beneficiary’s accurate occlusion.
Mail the models with the cover sheet. If submitting the entire case by mail, include a completed
ADA Dental Claim Form with all the above listed information. If all the information is notreceived in the same package, the case will be returned to the provider requesting the additional
information. Multiple cases can be sent in the same package. Mail to:
If using: United States Postal Service (USPS)
NCTracks Prior Approval Unit
ATTN: Orthodontic Review Board
PO Box 31188
Raleigh, NC 27622

If using: UPS, FedEx, and DHL
NCTracks Prior Approval Unit
ATTN: Orthodontic Review Board
2610 Wycliff Road, Suite 102
Raleigh, NC 27607

When the records are being prepared, be sure that all items are clearly labeled with the date taken,
the provider's name, and the beneficiary’s name for proper handling and return. All radiographic
images, photographic images, and models must be of acceptable diagnostic quality or the case will
be returned.

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Orthodontic Services

Medicaid and Health Choice
Clinical Coverage Policy No.: 4B
Amended Date: July 1, 2020

Each arch of the model and wax bite (if included) must be wrapped separately in foam, bubbleplastic or a similar padding, and packed in a sturdy corrugated reusable shipping box. Boxes must
be sealed with heavy, reinforced paper tape or strapping tape.
Refer to Subsection 5.1, Prior Approval, for additional information.

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Orthodontic Services

A2:

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Medicaid and Health Choice
Clinical Coverage Policy No.: 4B
Amended Date: July 1, 2020

Example of a Completed Orthodontic Prior Approval Request

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A3:

Medicaid and Health Choice
Clinical Coverage Policy No.: 4B
Amended Date: July 1, 2020

Instructions for Filing an Orthodontic Claim

Prior to submitting electronic claims, providers shall enroll with NC Medicaid. The enrollment
application is completed online via the NCTracks provider portal. To login to the provider portal
you will need a North Carolina Identity (NCID). Reference the “Getting Started” page of the portal
located at https://www.nctracks.nc.gov/content/public/providers/getting-started.html for step bystep instructions.
Claims are expected to be submitted electronically. Only claims that comply with the exceptions
on the NCTracks website at https://www.nctracks.nc.gov/content/public/providers/claims.html
may be submitted on paper. Exceptions include time limit overrides, Medicare overrides, andcertain adjustment requests.
For those claims that are required to be billed on paper, Medicaid and NCHC accepts dental claimson the 2019 ADA Dental Claim Form. The following instructions are specific to that form. Paper
dental claims must be completed in black ink only (do not highlight any portion of the claim) toallow the DHHS Utilization Review Contractor to image all dental claim forms electronically.
The following fields must be completed as described to allow proper processing of dental claimson the 2019 ADA Dental Claim Form.

Field No.

Field Name

1

Type of Transaction

12

Policyholder/Subscriber Name

13

Date of Birth14

Gender15

Policyholder/Subscriber ID

23

Patient ID/Account #24

Procedure Date

29

Procedure Code30
31

Description
Fee

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Explanation
Check the appropriate box:
• Statement of Actual Services (claim)• Request for Predetermination/Preauthorization(prior approval request)• EPSDT/Title XIX
Enter the beneficiary’s full name (Last, First, Middle
Initial) as it appears on the Medicaid or NCHC card.
Enter the beneficiary’s date of birth using eight digits(example: May 7, 2005 – 05/07/2005).
Check the appropriate box: M=male, F=female, or
U=unknown.
Enter the beneficiary’s 10-digit identification number
listed on the Medicaid or NCHC card.
Enter the beneficiary’s medical record number if used byyour office. It will appear on your Remittance and Status
Report (RA), if entered.
Enter the date the procedure was completed using eight
digits (example: November 1, 2019 – 11/01/2019).
Enter the five digit dental procedure code rendered.
Note: All procedure codes must begin with the letter“D.”Enter the description of the procedure.
Enter your usual and customary charge for theprocedure, not the established Medicaid and NCHC
fee. For a schedule of rates, refer to:https://medicaid.ncdhhs.gov/.

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Orthodontic Services

Field No. Field Name
31a
Other Fee(s)32Total Fee

33

Missing Teeth Information

35
38

Remarks
Place of Treatment

40
48
49

Is Treatment for Orthodontics?
Name, Address, City, State, Zip
Code
NPI

52

Phone Number

53

Signed (Treating Dentist), Date

54

NPI

56

Address, City, State, Zip Code

56a

Provider Specialty Code

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Medicaid and Health Choice
Clinical Coverage Policy No.: 4B
Amended Date: July 1, 2020

Explanation
If applicable, enter the amount of payment received
from third party insurance plan(s). Do not include any
payments from Medicare Part B or allowable Medicaid
or NCHC copayments.
Enter the total charges for all procedures listed on theclaim form. Do not deduct Medicaid or NCHC
copayments or third-party insurance payments listed infield 31a. The fiscal agent will calculate the maximum
amount payable by taking into account any copaymentsor third-party payments.
Cross out (X) missing teeth, slash (/) teeth to be
extracted, circle impacted teeth, and show space closure
with arrows (, ).
Enter the billing provider’s taxonomy.
Enter “11” as the place of treatment. Orthodontic
services are covered only if delivered in a provider’s
office.
Check Yes.
Enter the name, address, city, state and zip code + 4
code of the dentist or practice that is to receive payment.
Enter the billing provider’s NPI number of the dentist
or practice that is to receive payment.
• If payment is to be made to a group practice, thenenter the group NPI number.
• If payment is to be made to an individual dentist,
then enter the individual dentist NPI number.
Enter the area code and phone number of the billing
dentist or practice.
Signature of the provider rendering service. The
signature certifies that: “Services for which payment isrequested are medically necessary and indicated in thebest interest of the beneficiary’s oral health. The
provider’s signature on Medicaid and NCHC documents
and claims shall be binding and shall certify that all
information is accurate and complete.” Enter thesignature date using eight digits (example: December 1,
2019 – 12/01/2019).
Enter the attending provider’s NPI number for theindividual dentist rendering service. This number should
correspond to the signature in field 53.
Enter the treating dentist’s name, address, city, state, andzip code + 4 code.
Enter the attending provider’s taxonomy.

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Orthodontic Services

Medicaid and Health Choice
Clinical Coverage Policy No.: 4B
Amended Date: July 1, 2020

If exceptions apply, mail claims to:
NCTracks Claims Unit
PO Box 30968
Raleigh, NC 27622
ADA Dental Claim Forms may be ordered directly from the ADA.
Website: http://ebusiness.ada.org/productcatalog
Address:
American Dental Association
211 E. Chicago Avenue
Chicago, IL 60611-2678

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Orthodontic Services

A4:

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Medicaid and Health Choice
Clinical Coverage Policy No.: 4B
Amended Date: July 1, 2020

Example of a Completed Claim for Orthodontic Records

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Orthodontic Services

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Medicaid and Health Choice
Clinical Coverage Policy No.: 4B
Amended Date: July 1, 2020

Orthodontic Treatment Termination Request

Providers shall submit an Orthodontic Treatment Termination Request when a case is terminated.
Case termination prior to completion of treatment should rarely take place. All efforts should bemade to complete the active phase of treatment. If circumstances occur beyond control of thedentist (such as beneficiary death or moving out-of-state) that prevent orthodontic treatmentcompletion, the provider shall notify the DHHS Utilization Review Contractor.
Submit electronically by uploading the request to the NCTracks Prior Approval Portal with thefollowing information:a. CDT Code D8680 (orthodontic retention) entered as the requested service and indicate that therequest is for termination of treatment in the “Documentation of Medical Necessity” field.
b. A completed Orthodontic Treatment Termination Request Form (refer to a copy of this formon the next page). This form is available in NCTracks athttps://www.nctracks.nc.gov/content/public/providers/prior-approval.html.
c. A copy of the beneficiary’s treatment notes from the initial visit through the date of
termination.
d. Supporting documentation of when and how attempted contacts were made (such as
information indicating telephone calls made, messages left with county social worker,
relatives, neighbors or friends, letters mailed).
e. Final photographic images are required for consideration of final reimbursement, if deband
was rendered.
If the beneficiary was only banded, Medicaid or NCHC may require that a percentage of the
banding fee be refunded to the program. This is based on individual case consideration and thecircumstances surrounding case termination. In these cases, Medicaid or NCHC shall contact theprovider to make arrangements for the refund.
If submitting by mail, submit a completed ADA Dental Claim Form with the above listed
information. Mail to:
NCTracks Prior Approval Unit
ATTN: Orthodontic Review Board
PO Box 31188
Raleigh, NC 27622
Refer to Subsection 7.3, Terminated Orthodontic Treatment, for additional information.

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Orthodontic Services

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Medicaid and Health Choice
Clinical Coverage Policy No.: 4B
Amended Date: July 1, 2020

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Medicaid and Health Choice
Clinical Coverage Policy No.: 4B
Amended Date: July 1, 2020

Orthodontic Prior Approval Extension Request

It is anticipated that the orthodontic treatment will be completed within 36 months. Providers shallsubmit an Orthodontic Prior Approval Extension Request whenever treatment extends beyond theoriginal 36-month approval period. Claims submitted after the prior approval expiration date will
deny with EOB 00023 “SERVICE REQUIRES PRIOR APPROVAL.” Until an extension request
has been submitted in such cases, Medicaid or NCHC claims will deny.
Submit electronically by uploading the request to the NCTracks Prior Approval Portal with thefollowing information:a. CDT Code D8670 (periodic orthodontic treatment visit) entered as the requested service andindicate that the request is for a prior approval extension in the “Documentation of Medical
Necessity” field.
b. A completed Orthodontic Prior Approval Extension Request Form (refer to a copy of this formon the next page). This form is available in NCTracks athttps://www.nctracks.nc.gov/content/public/providers/prior-approval.html.
If submitting by mail, submit a completed ADA Dental Claim Form with the above listed
information. Mail to:
NCTracks Prior Approval Unit
ATTN: Orthodontic Review Board
PO Box 31188
Raleigh, NC 27622
Refer to Subsection 7.4, Orthodontic Prior Approval Extension Request, for additional
information.

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Orthodontic Services

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Medicaid and Health Choice
Clinical Coverage Policy No.: 4B
Amended Date: July 1, 2020

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Orthodontic Services

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Medicaid and Health Choice
Clinical Coverage Policy No.: 4B
Amended Date: July 1, 2020

Orthodontic Post-Treatment Summary

Providers shall notify the DHHS Utilization Review Contractor upon case completion. It is
important that Medicaid and NCHC receive a post-treatment summary so that case records arecomplete.
Submit electronically by uploading the request to the NCTracks Prior Approval Portal with thefollowing information:a. CDT Code D8680 (orthodontic retention) entered as the requested service and indicate that therequest is for the final orthodontic review in the “Documentation of Medical Necessity” field.
b. Submit a completed Orthodontic Post-Treatment Summary Form (refer to a copy of this formon the next page). This form is available in NCTracks athttps://www.nctracks.nc.gov/content/public/providers/prior-approval.html.
c. Final photographic images (required).
d. If fewer than 12 maintenance visits were paid, record review is required to substantiate thefinal claim payment. Attach a copy of the beneficiary’s treatment notes from the initial visit
through the delivery of retainers, if applicable. If it is determined that treatment was not“completed” but rather “terminated before treatment objectives were achieved,” the final
payment may be reduced or not allowed. This is based on individual case consideration andthe circumstances surrounding the case.
If submitting by mail, submit a completed ADA Dental Claim Form with the above listed
information. Mail to:
NCTracks Prior Approval Unit
ATTN: Orthodontic Review Board
PO Box 31188
Raleigh, NC 27622
Refer to Subsection 7.5, Orthodontic Case Completion, for additional information.

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Orthodontic Services

Medicaid and Health Choice
Clinical Coverage Policy No.: 4B
Amended Date: July 1, 2020

NORTH CAROLINA MEDICAID PROGRAM
ORTHODONTIC POST-TREATMENT SUMMARY
Note: Submit electronically by uploading the request to the NCTracks Prior Approval Portal withthe procedure code D8680 as the requested service and indicate that the request is for the final
orthodontic review and payment, if applicable. Attach this completed Orthodontic Post-Treatment
Summary Form and final photographic images. If fewer than 12 maintenance visits were paid,
attach a copy of the recipient’s complete treatment notes from the initial visit through the deliveryof retainers.
Date: _______
Recipient name: ___________________________

Medicaid ID:_________________________________________

Date of debanding: _____________________
Number of paid maintenance visits: _______
Date retainers delivered: __________________

Retainers delivered:
Upper:
Yes
No
Lower:Yes
No

Results obtained:
Excellent
Good
Fair
Poor

Assessment of recipient cooperation:
Excellent
Good
Fair
Poor

Comments:_________________________________________________________________________________________________________________________________________________________________________________________________________________________________
If it is determined that treatment was not “complete” but rather “terminated before treatment
objectives were achieved,” the final payment may be reduced or not allowed. This is based on
individual case consideration and the circumstances surrounding the case.
Billing provider NPI:
Billing provider name:Service location address:
Service location phone:* If submitting by mail, submit a completed ADA Dental Claim Form with procedure code D8680
along with the required documentation as stated above. Mail to:
NCTracks Prior Approval Unit
ATTN: Orthodontic Review Board
PO Box 31188
Raleigh, NC 27622

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