OAR 410-123-1160
Prior Authorization

(1) Health Services Division (Division) prior authorization (PA) requirements:
(a) For fee-for-service (FFS) dental clients, the following services require PA:
(A) Crowns (porcelain fused to metal);
(B) Crown repair;
(C) Retreatment of previous root canal therapy – anterior;
(D) Complete dentures;
(E) Immediate dentures;
(F) Partial dentures;
(G) Prefabricated post and core in addition to fixed partial denture retainer;
(H) Fixed partial denture repairs;
(I) Skin graft; and
(J) Orthodontics (when covered pursuant to OAR 410-123-1260 (OHP Dental Benefits));
(b) Hospital dentistry always requires PA, regardless of the client’s enrollment status. Refer to OAR 410-123-1490 (Hospital Dentistry) for more information;
(c) Oral surgical services require PA when performed in an ambulatory surgical center (ASC) or an outpatient or inpatient hospital setting and related anesthesia. Refer to OAR 410-123-1260 (OHP Dental Benefits) (Oral Surgery Services), and the current Medical Surgical Services administrative rule OAR 410-130-0200 (Prior Authorization) for information;
(d) Maxillofacial surgeries may require PA in some instances. Refer to the current Medical Surgical Services administrative rule 410-130-0200 (Prior Authorization), for information.
(2) The Division does not require PA for outpatient or inpatient services related to a “Dental Emergency Condition” which means determination based on the presenting symptoms (not the final diagnosis) as perceived by a prudent layperson (rather than a Health Care Professional) and includes cases in which the absence of immediate medical attention would not in fact have had the adverse results. Dental Emergency Condition may include but is not limited to severe tooth pain, unusual swelling, or an avulsed tooth. The client’s clinical record must document any appropriate clinical information that supports the need for the hospitalization.
(3) How to request PA:
(a) Submit the request to the Division in writing. Refer to the Dental Services Provider Guide for specific instructions and forms to use. Telephone calls requesting PA will not be accepted;
(b) Documentation submitted when requesting authorization must support the medical justification for the service. The authorization request must contain:
(A) A cover sheet detailing relevant provider and recipient Medicaid numbers;
(B) Requested dates of service;
(C) HCPCS or Current Dental Terminology (CDT) Procedure code requested;
(D) Amount of service or units requested; and
(E) Any additional clinical information supporting medical justification for the services requested;
(c) Treatment justification: The Division may request the treating dentist to submit appropriate radiographs or other clinical information that justifies the treatment:
(A) When radiographs are required, they must be:
(i) Readable copies;
(ii) Mounted or loose;
(iii) In an envelope, stapled to the PA form;
(iv) Clearly labeled with the dentist’s name and address and the client’s name; and
(v) If digital x-ray, they must be of photo quality;
(B) Do not submit radiographs unless it is required by the Dental Services administrative rules or they are requested during the PA process.
(4) The Division will issue a decision on PA requests within 30 days of receipt of the request. The Division will provide PA for services when:
(a) The prognosis is favorable;
(b) The treatment is practical;
(c) The services are dentally appropriate; and
(d) A lesser-cost procedure would not achieve the same ultimate results.
(5) PA does not guarantee client eligibility or reimbursement. It is the responsibility of the provider to check the client’s eligibility on each date of service.
(6) For certain services and billings, the Division will seek a general practice consultant or an oral surgery consultant for professional review to determine if a PA will be approved. The Division will deny PA if the consultant decides that the clinical information furnished does not support the treatment of services.
(7) MCE PA requirements:
(a) For services other than hospital dentistry, contact the client’s Dental Care Organization (DCO) for PA requirements for individual services and/or supplies listed in the Dental Services administrative rules. DCOs may not have the same PA requirements for dental services as listed in this administrative rule;
(b) For hospital dentistry, refer to OAR 410-123-1490 (Hospital Dentistry) for details regarding PA requirements.

Source: Rule 410-123-1160 — Prior Authorization, https://secure.­sos.­state.­or.­us/oard/view.­action?ruleNumber=410-123-1160.

Last Updated

Jun. 8, 2021

Rule 410-123-1160’s source at or​.us