Download Reminder About Orthodontic Prior Authorization

Reminder About Orthodontic Prior Authorization
Information posted July 15, 2011
Prior authorization is required for all Texas Health Steps (THSteps) orthodontic services
except for procedure code D8660. The THSteps Dental Mandatory Prior Authorization
Request Form must contain the date of service on which the orthodontic diagnostic tools
were produced. If the request is approved, the date that the records were produced is
considered to be the start date of the orthodontic authorized period.
Note: For group providers, if the Texas Provider Identifier (TPI) of the group is included
as the performing provider on the THSteps Dental Mandatory Prior Authorization
Request Form, any performing provider within the group who is skilled in the authorized
service can see the client. If the TPI of an individual performing provider is included on
the form, only that provider can see the client.
The client must be eligible for Medicaid and THSteps when authorization is requested
and also when the orthodontic treatment plan is initiated. If banding is initiated after the
loss of eligibility, claims will be denied, and the treatment will not be considered by
Medicaid. Banding must have been initiated before loss of eligibility for the treatment to
be considered to completion.
It is the provider’s responsibility to determine whether the client is eligible by checking
one of the following:

The client’s Your Texas Benefits Medicaid Card

The client’s current Medicaid Identification Form (Form H3087) or Medicaid Eligibility
Verification Form (Forms H1027 and H1027-A-C), and the date of birth on the form
must indicate that the client is 20 years of age or younger and that no limitations are
indicated
Prior authorization is a condition for reimbursement; it is not a guarantee of payment.
For more information, call the TMHP Contact Center at 1-800-925-9126.