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Orthodontic referral oral health and hygiene assessment form
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Specifies the required completed form and oral health criteria that a referring dentist must provide and sign before an orthodontic referral and that the orthodontist must include with the authorization request. Applies to Alaska Medicaid recipients and their dental providers.
No material clinical or coverage changes in this revision.
Orthodontic Referral Coverage Criteria
Pre-referral oral health criteria
Referral to an orthodontist is appropriate when AT LEAST ONE of the following conditions is met:
Referral criteria
- Cleft palate: Recipient referred for treatment of cleft palate.
- Caries-free with adequate hygiene: Recipient presented for a caries-free initial visit OR has had all decayed teeth restored AND has remained caries free for at least six months; and demonstrates oral hygiene adequate to begin and successfully complete orthodontic services.caries-free >= 6 months
Both caries-free status and adequate oral hygiene required for this branch.
No other explicit exclusions are listed on the form. The form’s coverage criteria require that at least one of the listed conditions be met before referral; it does not specify additional exclusions beyond those criteria.
Referrals for orthodontic evaluation should only be made when at least one of the listed conditions is met. Specifically, the form requires either referral for treatment of cleft palate or that the patient presented for a caries-free initial visit or has had all decayed teeth restored and has remained caries-free for at least six months and demonstrates oral hygiene adequate to begin and complete orthodontic services. Referrals submitted without meeting one of these conditions are not supported by the form and may lead to incomplete authorization or denial if the completed, signed assessment is not provided.
Key Coding / Clinical Thresholds
Required Forms, Documentation, and Submission Rules
Required form and submission
Prior authorization for orthodontic services requires a completed and signed Oral Health and Hygiene Assessment form. The referring dentist must complete the form, sign it, and forward it to the evaluating orthodontist as part of the authorization request.
- Referring dentist must complete and sign the Oral Health and Hygiene Assessment form.
- The completed form must be submitted by the requesting orthodontist with the authorization request.
Pre-referral oral health requirement
At least one oral health condition must be met before referring a recipient for orthodontic evaluation. Specifically, referrals are permitted when the recipient is being referred for cleft palate treatment, or the recipient presented for a caries-free initial visit or has had all decayed teeth restored and has remained caries free for at least six months and demonstrates oral hygiene adequate to begin and successfully complete orthodontic services.
- Referral allowed for treatment of cleft palate.
- Referral allowed if caries-free initial visit OR all decayed teeth restored and caries-free for ≥ 6 months plus adequate oral hygiene.
Missing required form — denial risk
Failure to submit the completed and signed Oral Health and Hygiene Assessment form with the authorization request may result in denial of the authorization or an incomplete authorization that delays services.
- Missing form may lead to denial or delay of authorization.
Background and Rationale
Orthodontic treatment outcomes are influenced by the patient’s current oral health. The form explicitly requires that active caries be managed before referral: either the patient is caries-free at the initial visit or all decayed teeth have been restored and the patient has remained caries-free for at least six months. In addition, the referring dentist must attest that the patient demonstrates adequate oral hygiene to begin and successfully complete orthodontic services. These steps are intended to reduce treatment complications and improve the likelihood of successful orthodontic care.
Definitions
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