DraftclearhealthalliancePolicy 4B

NC Medicaid Orthodontic Services

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Defines coverage structure and sections for Clear Health Alliance's NC Medicaid orthodontic services policy; includes table of contents and headings for eligibility, EPSDT exceptions, prior approval, coverage criteria, limitations, documentation, transfers, extensions, and exclusions.

Policy Summary

Payerclearhealthalliance

PolicyNC Medicaid Orthodontic Services

Policy CodePolicy 4B

Change TypeNo material change

Effective Date

Next Review Date

Key ActionObtain prior approval and submit required orthodontic records via NCTracks Prior Approval Portal before initiating orthodontic services.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

≈20document chunks

Multiplesections listed

Includes EPSDTEPSDT

5.0-5.3Prior Approval section

Under 21

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DraftclearhealthalliancePolicy 4B

NC Medicaid Orthodontic Services

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Policy Summary

Payerclearhealthalliance

PolicyNC Medicaid Orthodontic Services

Policy CodePolicy 4B

Change TypeNo material change

Effective Date

Next Review Date

Key ActionObtain prior approval and submit required orthodontic records via NCTracks Prior Approval Portal before initiating orthodontic services.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

≈20document chunks

Multiplesections listed

Includes EPSDTEPSDT

5.0-5.3Prior Approval section

Under 21

Coverage — When Covered / Not Covered

Coverage criteria (structure only)

Document outlines future sections where coverage criteria will appear (General Criteria Covered; Specific Criteria Covered; Medicaid Additional Criteria).

TOC only: This excerpt only enumerates sections (e.g., 'When the Procedure, Product, or Service Is Covered', 'General Criteria Covered', 'Specific Criteria Covered', and 'Medicaid Additional Criteria Covered') and does not provide decision logic in this partition.

Full criteria are located in the referenced sections not included in this excerpt.

Coverage and Non-Coverage structure

Document contains distinct sections for Covered and Not Covered items (3.0 When Covered; 4.0 When Not Covered) and specific Medicaid criteria subsections.

Coverage and Non-Coverage Sections: Sections 3.0 (When Covered) and 4.0 (When Not Covered) are distinct; 3.2 contains specific covered criteria and Medicaid additional criteria (3.2.1, 3.2.2).

TOC references these sections but detailed criteria are in the full policy.

Coverage sections referenced

Document structure indicates coverage and criteria sections exist.

Coverage sections referenced: The table of contents enumerates sections governing coverage decisions including Prior Approval (5.1), Prior Approval Requirements (5.2), Limitations/Requirements (5.3) with subsections for Orthodontic Records (5.3.1), Comprehensive Orthodontic Treatment (5.3.2), and Combined Orthognathic Surgery and Orthodontic Treatment (5.3.3).

Detailed medical necessity logic resides in those sections.

High-level coverage organization

Coverage and limitations are organized under section 5.0 with specific subsections.

High-level organization: Section 5.0 contains requirements and limitations on coverage (5.1–5.9) including prior approval processes, ADA‑approved materials, Orthodontic Review Board, notifications, periodic maintenance visits, and reimbursement during ineligible periods.

Reference only; see sections 5.1–5.9 for operational rules.

Organizational criteria sections

Coverage organized into the following distinct groups (referenced in the TOC).

Prior Approval: Prior approval is required for orthodontic services (see 5.1) and prior approval requirements and voiding rules are described in 5.2 and 5.2.2.

TOC reference

Orthodontic Records: Submission of orthodontic records is required (see 5.3.1) as part of prior approval and case management processes.

TOC reference

Comprehensive Orthodontic Treatment: Comprehensive treatment criteria and limits are in 5.3.2; prior approval for comprehensive treatment is addressed in the policy.

TOC reference

Combined Orthognathic Surgery and Orthodontic Treatment: Criteria and record requirements for combined orthognathic surgery with orthodontics are in 5.3.3.

General Medical Necessity Criteria — Covered when ALL of the following are met

Covered when ALL of the following are met

Medically Necessary General Criteria: a. The procedure/product/service is individualized, specific, and consistent with symptoms or confirmed diagnosis and not in excess of the beneficiary's needs; b. It can be safely furnished and no equally effective, more conservative, or less costly treatment is available statewide; c. It is not primarily for the convenience of the beneficiary, caretaker, or provider.

From subsection 3.1

Specific Criteria Covered — 1 top-level node

Specific Criteria: No specific criteria defined in subsection 3.2.1 (None Apply).

From subsection 3.2.1

Medically Necessary Orthodontic Treatment Criteria — TWO OR MORE of the following severe criteria

Covered when ALL general coverage conditions are met and when TWO OR MORE of the following severe criteria are present:

General coverage conditions: Applicant meets the general medical necessity criteria: individualized/specific/consistent with diagnosis; safely furnished with no equally effective, more conservative or less costly alternative statewide; not primarily for convenience.

From 3.1

Specific severe occlusal or developmental criteria: Any of the following: a) severe skeletal condition possibly requiring orthodontics plus orthognathic surgery; b) severe Class II or Class III discrepancy; 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 of four or more teeth per arch; f) significant posterior open bite ≥ 2 mm of four or more teeth per arch (excluding primary/partially erupted or one/two teeth slightly out); g) impinging overbite causing soft‑tissue trauma; h) overjet ≥ 6 mm; i) crowding > 6 mm in either arch that is functionally intolerable; j) impactions with good prognosis for eruption into the arch; k) excessive spacing ≥ 10 mm in an arch or ≥ 8 mm cuspids‑to‑cuspids; l) two or more congenitally missing teeth (≥1 per quadrant, excluding third molars); m) occlusal condition from profound impact of craniofacial anomaly, severe trauma, or pathology; n) psychosocial inhibition with supporting licensed mental health documentation; o) potential for worsening of problems.2 or more

Non-covered and Exclusionary Criteria — Not covered when the following specific conditions apply

Not covered when the following specific conditions apply:

General not-covered conditions: Services not covered when Section 3.0 and 5.0 criteria are not met; duplicate services; experimental/investigational or clinical trial services are not covered.

From 4.1 and 4.2.1

Specific non-covered orthodontic services: Examples include: interceptive/Phase I treatment of primary/transitional dentition except for cleft/craniofacial/trauma cases; minor tooth movement <12 months; cuspid impactions with poor prognosis and no other problems; moderate posterior crossbites without mandibular shift/TMD or other problems; Class I with moderate crowding and normal overbite/overjet; simple space closure mild‑moderate; single‑arch simple treatment; localized short‑duration alignment; treatment begun prior to Medicaid eligibility; habit appliance therapy; occlusal guard/splint therapy for TMD; treatment started as private pay before Medicaid approval.

From 4.2.2

Comprehensive Orthodontic Treatment — Covered when ALL of the following are met

Covered when ALL of the following are met

Comprehensive treatment approval and limits: Prior approval for comprehensive orthodontic treatment is granted for up to 36 months; banding must occur after case approval and before maintenance billing; periodic orthodontic maintenance visits (D8670) are limited to once per calendar month, maximum 23 reimbursable visits; banding plus 23 maintenance visits constitute total reimbursement and provider must complete additional visits without further reimbursement; if banding is paid, Medicaid will continue to pay monthly maintenance visits regardless of eligibility for adolescent dentition only when the banding was paid and recorded in paid history.36 months; 23 visits; once per calendar month

From 5.3.2 and 5.7

Included appliances: When comprehensive treatment is approved, all fixed or removable appliances necessary to complete approved treatment (including broken or lost brackets) are included in Medicaid payment and beneficiaries must not be billed additional charges.

From 5.3.2 and 5.3.2 note

Combined Orthognathic Surgery and Comprehensive Orthodontic Treatment — Covered when ALL of the following are met

Covered when ALL of the following are met for combined orthognathic and comprehensive orthodontic treatment

Combined orthognathic surgery requirements: Initial consultation records (detailed problem‑focused evaluation D0160, extra‑oral 2D radiographs D0250, panoramic D0330, cephalometric D0340, diagnostic casts D0470 where applicable) are allowed; certain radiographs and models are limited (age or once‑in‑a‑lifetime limits) and prior approval is required for many of these records; interim records must be submitted with the prior approval for orthognathic surgery and NC Medicaid may override lifetime limits to allow payment for additional records required for surgery.Once‑in‑a‑lifetime for some records

From 5.3.3 and supporting subsections 5.3.3/131

Surgical procedure documentation: Prior approval for orthognathic procedures (D7940–D7955 series) is required and consultation notes from the surgeon agreeing with the treatment plan must be submitted as part of the prior approval package.

From 5.3.3 and 129–131

Retention and Transfer Cases — Covered when ALL of the following are met

Covered when ALL of the following are met

Retention and final payment: Orthodontic retention (debond, construction and placement of retainers D8680) is limited to beneficiaries under 21 and is a once‑in‑a‑lifetime service; when treatment is complete submit a prior approval with D8680 and the Orthodontic Post‑Treatment Summary for consideration of final payment.Once in a lifetime

From 5.3.2 and 7.5

Transfer cases: Continuation for transfer cases allowed only if prior treatment was approved by Medicaid or another state's CHIP; prior approval is required for in‑state and out‑of‑state transfers (submit D8670 as requested service), orthodontic records will not be reimbursed for transfer cases, and reimbursement is limited to the remaining number of periodic maintenance visits (D8670); submit prior approval for final payment (D8680) at case completion.N/A

From 7.2 and 5.3.2

Orthodontic continuation, termination, extension, and completion criteria

Covered continuation and final payment processes when documentation and prior approval requirements are met:

In‑state transfer continuation: Prior approval required with CDT D8670 entered as requested service; include narrative indicating in‑state transfer with initial provider name/address, current orthodontic status, and treatment plan with anticipated remaining length; attach AAO Transfer Form if banded or previous Medicaid approval marked 'VOID' if not banded. If submitting by mail use ADA claim form and mail to NCTracks Prior Approval Unit.

From 7.2.1

Out‑of‑state transfer continuation: Prior approval required with CDT D8670 entered as requested service; include narrative indicating out‑of‑state transfer with initial provider name/address, current status, treatment plan, AAO Transfer Form or prior provider records, proof of prior‑state Medicaid eligibility, and current photographs; confirm Medicaid eligibility on each date of service or no payment will be made.

From 7.2.2

Terminated treatment requirements: When treatment is terminated prior to completion due to circumstances beyond provider control, notify DHHS Utilization Review Contractor and submit prior approval with D8680, completed Termination Request Form, treatment notes from initial visit through termination, documentation of attempted contacts, and final photographic images if deband was rendered; Medicaid may require refund of a portion of banding fees in some cases.

The Table of Contents for this policy includes a dedicated "When the Procedure, Product, or Service Is Not Covered" section (Section 4.0) and subsections (e.g., 4.1 General Criteria Not Covered and 4.2 Specific Criteria Not Covered), indicating explicit non-covered/exclusion material is present elsewhere in the full policy document. The excerpted TOC entries show the presence of both general and Medicaid-specific not-covered subsections, but the TOC itself contains headings only and does not include the detailed exclusion language.

Administratively, the TOC distinguishes Not Covered content from the covered criteria and from the Requirements/Limitations sections (Section 5.0 and its subsections). This placement signals that providers should consult Section 4.0 for explicit exclusion rules when evaluating whether a requested orthodontic service qualifies for prior approval or payment.

Section headings listed in the Table of Contents show that Section 4.0 When the Procedure, Product, or Service Is Not Covered contains both 4.1 General Criteria Not Covered and 4.2 Specific Criteria Not Covered (with further subitems 4.2.1 and 4.2.2). The TOC indicates these subsections are separate from the coverage criteria (Section 3.0) and the requirements/limitations (Section 5.0), so providers must review 4.0 to identify explicit exclusions that could affect prior approval or claims adjudication.

Although the TOC confirms the structure and presence of the Not Covered subsections, the excerpt does not include the detailed non-coverage statements themselves; providers should open Section 4.0 for the full non-coverage rules when preparing prior approval requests or responding to denials.

The Table of Contents repeatedly references Not Covered sections (4.0, 4.1, 4.2) but the excerpted TOC does not reproduce the explicit exclusion text. In other words, the TOC signals that explicit non-covered items are part of the policy, but the specific NMN/exclusion statements must be read in the full text of Section 4.0 and its subitems rather than inferred from the TOC alone.

Because the TOC shows separate entries for "Specific Criteria Not Covered by Medicaid" and "Medicaid Additional Criteria Not Covered," providers should expect both general exclusions and Medicaid-specific exclusions to be spelled out in the policy body rather than in the TOC.

The policy includes Not Covered subsections as listed in the TOC: 4.0 When the Procedure, Product, or Service Is Not Covered, with subsections 4.1 General Criteria Not Covered and 4.2 Specific Criteria Not Covered (including 4.2.1 Specific Criteria Not Covered by Medicaid and 4.2.2 Medicaid Additional Criteria Not Covered). The full policy text for 4.2.2 enumerates multiple specific non-covered orthodontic case types (see Section 4.2.2

Providers should reference Section 4.2 for the detailed list of specific non-covered orthodontic services that may directly affect prior approval decisions and claims processing.

The Table of Contents lists a distinct subsection titled Medicaid Additional Criteria Not Covered (page reference in the TOC). This indicates there are Medicaid-specific exclusion criteria separate from general non-covered items—consult Section 4.2.2 for those details.

The TOC placement confirms that Medicaid additional not-covered criteria are part of the policy's exclusion framework and should be checked when assessing eligibility or preparing appeals for Medicaid beneficiaries.

Certain beneficiary groups are expressly excluded from orthodontic services under this policy. Examples listed in the policy limitations section include beneficiaries in the Medicaid for Pregnant Women program class MPW, Family Planning Waiver class MAFD, Medicare Qualified Beneficiaries class MQB, and beneficiaries enrolled in PACE. Providers must verify beneficiary program classification before submitting prior approval requests or claims, since these groups are not eligible for orthodontic services as described in this policy.

The Not Covered list specifically states that Interceptive or Phase I treatment of the primary and transitional dentition is not covered except when the malocclusion is functionally impairing due to cleft lip/palate, severe craniofacial developmental anomalies, or severe traumatic injuries. This exception is explicit in Section 4.2.2(a)

When comprehensive orthodontic treatment is approved, Medicaid payment is intended to include all fixed and removable appliances necessary to complete the approved treatment (this specifically includes broken or lost brackets). The policy states the beneficiary must not be billed additional charges for appliances included in an approved comprehensive case.

The comprehensive approval is administratively structured as a bundled payment where banding and the periodic maintenance visits (up to the allowed limit) represent total reimbursement for the approved case.

Payment eligibility for banding is contingent on the beneficiary's Medicaid eligibility on the date of banding. The policy states no payment will be issued if the beneficiary is not eligible on the banding date. However, if banding has been paid and the beneficiary subsequently becomes ineligible, Medicaid will reimburse periodic maintenance visits (D8670) for the adolescent dentition only if the beneficiary was eligible on the banding date and the payment appears in paid history.

Banding must occur prior to billing maintenance visits, and providers must confirm eligibility at the banding visit to preserve payment rights for the comprehensive case.

For transfer cases, the policy explicitly states that orthodontic records will not be reimbursed. Reimbursement for transfer cases is limited to the remaining number of periodic maintenance visits (D8670) for that beneficiary; at case completion a prior approval request for final payment (D8680) must be submitted for consideration of reimbursement of deband and retainer services.

Providers must therefore be prepared to supply prior approvals or prior-state Medicaid documentation as required for transfer continuity, but they cannot bill Medicaid for the previous provider's orthodontic records.

Claims are expected to be submitted electronically through NCTracks; the policy states paper claims are accepted only for the exceptions listed on the NCTracks website (such as time limit overrides, Medicare overrides, and certain adjustments). When paper submission is allowed, providers must use the 2019 ADA Dental Claim Form and follow the form instructions (including completing required fields and using black ink).

Providers should use the NCTracks Prior Approval Portal for prior approval uploads and reserve paper claims only for the limited exceptions identified by NCTracks.

If treatment is terminated before treatment objectives are achieved, the policy requires submission of an Orthodontic Treatment Termination Request and supporting documentation; final payment may be reduced or denied based on the circumstances. The policy explains that Medicaid may require partial refund of banding fees in some terminated-only-banded cases and that determinations about reduced final payment are made on a case-by-case basis.

Providers must upload termination documentation (including CDT D8680 as the requested service, termination form, treatment notes, attempts to contact, and final photographs when applicable) to the NCTracks Prior Approval Portal to support any claim for partial or final reimbursement after termination.

The Table of Contents includes both a Not Covered section (Section 4.0) and a separate General Criteria Not Covered listing, indicating that the policy maintains a distinct exclusion framework parallel to the coverage criteria. This confirms providers must consult the Not Covered sections separately from the coverage rules when evaluating services.

Because the TOC lists these elements distinctly, administrative staff should train to check both the coverage (Section 3.0) and non-coverage (Section 4.0) sections before submitting prior approval requests or claims to avoid preventable denials.

The TOC references Not Medically Necessary (NMN) or Not Covered conditions but the provided excerpt does not include the explicit NMN statements themselves. Section headings show where NMN language would appear (Section 4.0 and subitems), but the detailed criteria and examples of NMN conditions must be read in the policy body rather than the TOC.

Providers should not rely on the TOC alone for NMN guidance and must review Section 4.0 and its subsections for the full list of conditions and examples considered not medically necessary.

The Table of Contents references Not Covered sections and Medicaid-specific not-covered subsections but the excerpt does not show explicit NMN statements. The TOC serves as an index indicating the location of NMN content in the policy; the substantive NMN criteria are contained in the corresponding numbered sections.

When preparing prior approval requests or appeals, include full supporting documentation because NMN determinations are addressed in the full text of Section 4.0 rather than the TOC.

The TOC and the policy text reference both general and specific not-covered criteria: general exclusions (Section 4.1) and specific orthodontic not-covered examples (Section 4.2, including Medicaid Additional Criteria Not Covered under 4.2.2). The presence of both general and specific not-covered categories shows the policy distinguishes between broad exclusion principles and concrete case examples.

Providers should therefore consult both 4.1 and 4.2 when evaluating cases that might fall outside coverage or that may require a special Medicaid exception request.

The TOC contains entries for Not Covered material (Sections 4.0–4.2.2), confirming that these sections exist and are part of the policy structure, but the TOC itself provides only headings and page references and does not include the substantive exclusion text. Always open the corresponding sections to see the full non-coverage statements and any instructions for submitting a special approval request when appropriate.

Administrative staff should therefore use the TOC as a navigation tool and rely on Sections 4.0 and 5.0 for the operational rules that affect prior approval and claims.

The policy reiterates the EPSDT principle that services which are unsafe, ineffective, experimental, or not generally accepted as medical practice are not required to be covered under EPSDT. This policy-level principle supports exclusion of such services from coverage and is explicitly referenced in the EPSDT Special Provision subsection.

Providers should therefore be prepared to justify the medical necessity of unusual or novel orthodontic services, as experimental or investigational procedures are not required to be provided under EPSDT and may be excluded.

The policy states that cases not meeting the coverage criteria in Section 3.0 and the administrative requirements in Section 5.0 are considered not covered. Specifically, Section 4.2 lists examples such as minor or short-duration treatments (less than 12 months), simple one-arch or localized alignment problems, and treatments begun prior to Medicaid eligibility as not covered.

Providers should document when a case meets the Section 3.0 medical necessity thresholds and ensure prior approval and required records (Section 5.3.1) are submitted to avoid classification as not covered.

The policy explicitly states that repair or replacement of broken or missing brackets, bands, or wires is not allowed (no payment) when no other maintenance treatment is rendered. This limitation is part of the periodic maintenance visit rules for comprehensive orthodontic treatment and clarifies that such isolated appliance repairs are not separately reimbursable unless accompanied by an authorized maintenance visit.

When comprehensive treatment is approved, however, the policy also states that all fixed or removable appliances necessary to complete treatment (including broken or lost brackets) are included in the Medicaid payment, and beneficiaries must not be billed additionally. The distinction depends on whether the provider is operating within an approved comprehensive case or seeking separate payment for isolated repairs.

The policy describes final payment adjustment rules for cases that are terminated before objectives are achieved. If a case is judged to be "terminated before treatment objectives were achieved," Medicaid may reduce or deny the final payment based on the circumstances and individual case review. Providers must submit the Orthodontic Treatment Termination Request (including CDT D8680 as the requested service, treatment notes, documentation of contact attempts, and final photographs if deband occurred) to support any claim for partial reimbursement.

This administrative process ensures Medicaid can evaluate the degree of completed treatment and determine appropriate final payment adjustments when termination occurs.

Procedure and Diagnosis Codes

Covered CDT Codes (source)mixedCovered

CDT 2020 (various procedure codes)

NC Medicaid adopted procedure codes and descriptions as defined in CDT 2020; only codes listed in this policy are covered.

Referenced CDT codes and descriptionsCDT

D0150	Comprehensive oral evaluation - new or established patient
D0210	Intraoral - periapical first radiographic image (referenced as not allowed same date as D0330 in context)
D0330	Panoramic radiographic image
D0340	2D cephalometric radiographic image - acquisition, measurement and analysis
D0470	Diagnostic casts
D8070	Comprehensive orthodontic treatment of the transitional dentition
D8080	Comprehensive orthodontic treatment of the adolescent dentition
D8670	Periodic orthodontic treatment visit
D8680	Orthodontic retention (removal of appliances, construction and placement of retainer(s))

Orthodontic and orthognathic CPT/CDT codes referencedmixed

D8670	Periodic orthodontic treatment visit
D8680	Orthodontic retention (removal of appliances, construction and placement of retainer(s))
D0160	Detailed and extensive oral evaluation - problem focused, by report
D0250	Extra-oral - 2D projection radiographic image created using a stationary radiation source, and detector
D0330	Panoramic radiographic image
D0340	2D cephalometric radiographic image - acquisition, measurement and analysis
D0470	Diagnostic casts
D7940	Osteoplasty - for orthognathic deformities
D7941	Osteotomy - mandibular rami
D7943	Osteotomy - mandibular rami with bone graft; includes obtaining the graft

1–10 of 20
1/2

Prior approval and case management CDT codesCPTCovered

D8670	Periodic orthodontic treatment visit
D8680	Orthodontic retention
D0330	Panoramic radiographic image
D0340	2D cephalometric radiographic image - acquisition, measurement and analysis
D0470	Diagnostic casts
D8070	Comprehensive orthodontic treatment (diagnostic code referenced for prior approval)
D8080	Limited orthodontic treatment (diagnostic code referenced for prior approval)

Example procedure codes shown on example formsCPT

D8080	Orthodontic banding
D0330	Panoramic film
D0340	Cephalometric film
D0470	Diagnostic casts
D0150	Comprehensive oral evaluation

Diagnosis code qualifierICD-10

ICD-10 = AB

Diagnosis Code List Qualifier shown on form

Termination/Post-treatment code (D8680)CDTCovered

D8680

Orthodontic retention (used for termination and final review submissions)

Extension code (D8670)CDTCovered

D8670

Periodic orthodontic treatment visit (used for prior approval extension requests)

inv-50: Anterior open bite — measurement threshold

Anterior open bite thresholdTrue anterior open bite: 2 mm or more involving four or more teeth per arch

Exclusions/notesMeasurement excludes single-tooth minor issues; must be of four or more teeth per arch

Source contextUsed as one of the Medicaid additional criteria increasing probability of approval when combined with other criteria

inv-51: Posterior open bite — measurement threshold

Posterior open bite threshold

Prior Approval, Submission & Billing Requirements

Prior Authorization
Obtain Prior Approval and Upload Records via NCTracks
Obtain prior approval before rendering orthodontic services; prior approval does not guarantee payment and eligibility must be verified prior to treatment. Upload all records except models to the NCTracks Prior Approval Portal; mail models with the NC DHHS Prior Approval Health Services Attachment Review Cover Sheet when required. Failure to obtain prior approval will result in denial of payment.
Prior approval is required for orthodontic services and must be submitted to the DHHS Utilization Review Contractor (5.1, 5.2).
Upload all records except models to NCTracks Prior Approval Portal; mail models with the DHHS cover sheet for mailed submissions.
Prior approval does not guarantee payment and claims without required prior approval will be denied (EOB 00023 for expired approvals).

Prior Authorization
Indicate Predetermination/Preauthorization on ADA Form
Enter a predetermination/preauthorization request on the ADA claim form (Field 1) and include the predetermination/preauthorization number (Field 2) when applicable; complete required form fields as shown in Attachment A.

Definitions and Terminology

inv-108: EPSDT Special Provision — exception for beneficiaries under 21

EPSDT exception referencedException to policy limitations for Medicaid beneficiaries under 21 years of age (EPSDT) is referenced in the Table of Contents and special provisions sections

Prior approval still requiredEPSDT beneficiaries under 21 still require prior approval when the service requires it (policy references EPSDT and Prior Approval)

Where detailedReferenced in Eligibility Requirements > Special Provisions (see EPSDT Special Provision in Table of Contents)

inv-110: Comprehensive Orthodontic Treatment referenced as a defined category (placeholder)

Defined category referenceComprehensive Orthodontic Treatment is listed as a major subsection (5.3.2) addressing criteria and limitations for full-course orthodontic care

Approval period note

Policy Background and Scope

Background: This policy is the NC Medicaid Orthodontic Services policy adopted for Clear Health Alliance and sets out the organization of eligibility, EPSDT exception, coverage criteria, limitations, exclusions, prior approval requirements, documentation and oversight elements (e.g., Orthodontic Review Board). The provided TOC and excerpts identify where full clinical and administrative rules are located.

Revision History

2023-12-15amendmentLatest

Policy posted with Amended Date December 15, 2023; policy noted as posted 12/15/2023 with an effective date of 2023-04-01

2002-07-01original_effective_date

Original effective date of the policy established as July 1, 2002

2019-07-01update

Policy Summary

Payerclearhealthalliance

PolicyNC Medicaid Orthodontic Services

Policy CodePolicy 4B

Change TypeNo material change

Effective Date

Next Review Date

Key ActionObtain prior approval and submit required orthodontic records via NCTracks Prior Approval Portal before initiating orthodontic services.

SourceLink

On This Page

From Subsection 3.2.2

Prior approval extension: If treatment exceeds 36 months and paid maintenance visits have not exceeded 23, provider must submit Prior Approval Extension Request with CDT D8670 and completed Extension Request Form; claims submitted after prior approval expiration will deny with EOB 00023 until extension submitted.36 months; paid visits <= 23

From 7.4

Case completion and final payment: Upon case completion submit prior approval with CDT D8680 and completed Orthodontic Post‑Treatment Summary Form and final photographic images; if fewer than 12 maintenance visits were paid, attach treatment notes to substantiate the final claim; requests will be manually priced and reimbursed based on remaining visits if case is determined completed.12 maintenance visits

From 7.5

Significant posterior open bite: 2 mm or more involving four or more teeth per arch

ExclusionsDoes not include primary teeth, partially erupted teeth, or one or two teeth slightly out of occlusion

ContextListed among Medicaid additional criteria that increase probability for orthodontic approval

inv-52: Overjet — measurement threshold

Overjet thresholdOverjet (excessive protrusion) of 6 mm or greater

Clinical impactListed as a functionally impairing criterion that may increase probability of approval when present with other criteria

Assessment noteMeasured as protrusion; included in Medicaid Additional Criteria Covered

inv-53: Crowding — measurement threshold

Crowding thresholdCrowding greater than 6 mm in either arch (moderate to severe and functionally intolerable)

Clinical requirementMust be functionally intolerable over a long period (e.g., occlusal disharmony or gingival recession secondary to severe crowding)

Role in approvalOne of the Medicaid additional criteria used to increase likelihood of approval when two or more criteria are present

inv-54: Excessive spacing — measurement threshold

Excessive spacing thresholdExcessive spacing of 10 mm or more in an arch, or 8 mm or greater from mesial of cuspid to mesial of cuspid

Exclusion for prosthetic spacesAny space that will remain for prosthodontic or implant replacement cannot be included in the measurements for meeting spacing criteria

ContextListed among Medicaid additional criteria that increase probability of orthodontic approval

Mark 'Request for Predetermination/Preauthorization' in Field 1 on the ADA form.
Include the predetermination/preauthorization number in Field 2 when required.

Prior Authorization
Follow Sections 5.1–5.2 for Prior Approval Rules
Reference prior approval instructions in sections 5.1 and 5.2 when preparing requests; the Table of Contents identifies these subsections as the location for prior approval and requirement details.
See 5.1 Prior Approval and 5.2 Prior Approval Requirements (including 5.2.2 Voiding a Prior Approval) for submission and voiding rules.

Prior Authorization
Submit Prior Approval Request and Supporting Records
When prior approval is required, submit the prior approval request and all supporting health records to the DHHS Utilization Review Contractor as specified in 5.2.1 General.
Include the prior approval request and all health records that support meeting the specific criteria in Subsection 3.2.

Prior Authorization
Prior Approval Must Be Obtained; Verify Eligibility
Prior approval is required for orthodontic services (see 5.1); obtain prior approval before rendering treatment and verify beneficiary eligibility on each date of service.
Failure to obtain required prior approval before rendering a service will result in denial of payment.
Confirm Medicaid eligibility on the date of banding and on each service date as required.

Prior Authorization
EPSDT Cases Still Require Prior Approval
EPSDT (beneficiaries under 21) does not remove the requirement for prior approval; if prior approval is required by the policy the provider must obtain it even for EPSDT cases.
EPSDT beneficiaries still require prior approval when the service requires it; see NCTracks Provider Claims and Billing Assistance Guide for additional EPSDT/prior approval details.

Prior Authorization
Submit Complete Orthodontic Records with Prior Approval
Prior approval submissions for orthodontic services must include required orthodontic records; submission of records does not guarantee payment and cases must be functionally impairing to be considered.
Orthodontic records (radiographs, intraoral/extraoral photos, models, pretreatment narrative, ADA forms) must be diagnostic quality or the case will be returned.
Prior approval for comprehensive treatment is granted for 36 months; submission of full records is required with the request.

Prior Authorization
Prior Approval Required for Comprehensive and Orthognathic Care (36 Months)
Prior approval is required for comprehensive orthodontic treatment and combined orthognathic-related services; approvals for comprehensive treatment are granted for up to 36 months.
Comprehensive orthodontic approvals are granted for 36 months and include appliances necessary to complete approved treatment.
Additional interim records are required for orthognathic surgery requests; NC Medicaid may override lifetime limits for surgical records.

Prior Authorization
Use D8670/D8680 and NCTracks for Transfers, Extensions, and Completion
Submit prior approval requests for transfers, extensions, and case completion electronically via NCTracks using CDT code D8670 for transfer/extension requests and D8680 for termination/case completion; include the required narratives and supporting records.
In-state transfers: enter D8670 as requested service, include narrative with initial provider info, current status, treatment plan; attach AAO Transfer Form if banded or previous Medicaid approval marked 'VOID' if not banded.
Out-of-state transfers: enter D8670, attach AAO Transfer Form or prior-state records, proof of prior-state Medicaid eligibility, and current photographic images.
Extensions: enter D8670 and include completed Orthodontic Prior Approval Extension Request Form.
Case completion/termination: enter D8680 and include Termination or Post-Treatment Summary Form and required documentation.

Prior Authorization
Indicate Predetermination/Preauthorization on ADA Claim (Field 1)
When submitting predetermination/preauthorization on the ADA claim form, mark the request type and provide the predetermination/preauthorization number as required in Attachment A's header instructions.
Field 1 on the ADA form must indicate the Type of Transaction (Request for Predetermination/Preauthorization).
Include predetermination/preauthorization number in Field 2 when available.

Prior Authorization
Submit D8670 for Prior Approval Extension When >36 Months
If treatment extends beyond the original 36-month approval period and paid maintenance visits have not exceeded 23, submit a Prior Approval Extension Request with CDT code D8670 and the completed extension form; claims after approval expiry will deny until extension is submitted.
Submit D8670 as the requested service and include a completed Orthodontic Prior Approval Extension Request Form in NCTracks.
Claims submitted after prior approval expiration will deny with EOB 00023 until an extension request is submitted.

Billing Rule
Included Appliances Are Covered with Comprehensive Approval
When comprehensive orthodontic treatment is approved, payment includes any fixed or removable appliances necessary to complete treatment; providers may not bill the beneficiary for included appliances.
Included appliances include functional appliances, palatal expanders, bite plates, holding arches, retainers, etc.
Included appliances are part of the comprehensive approval and cannot be billed separately to the beneficiary.

Billing Rule
Banding Required Prior to Billing Maintenance Visits
Banding must occur before billing maintenance visits; cases must be approved prior to initial banding and records must confirm banding status for subsequent maintenance billing.
The case must be approved before the initial banding takes place.
Banding payment is prerequisite to billing periodic maintenance visits (D8670).

Billing Rule
Payment Sequencing: Banding then Incremental Maintenance (up to 23 visits)
Banding payment constitutes about one-third of the maximum allowed; the remainder is paid incrementally across up to 23 maintenance visits (D8670) and providers must complete any additional visits without further reimbursement.
Payment received for banding is approximately one-third of total reimbursement; up to 23 reimbursable maintenance visits comprise the remainder.
Providers are expected to complete additional maintenance visits beyond paid visits without further reimbursement.

Prior Authorization
Submit D8680 and Termination Form for Case Termination
Submit an Orthodontic Treatment Termination Request with CDT code D8680 when a case is terminated; include the completed termination form, treatment notes through the date of termination, documentation of attempted contacts, and final photos if deband occurred.
Enter D8680 as requested service and upload the Orthodontic Treatment Termination Request in NCTracks.
Include treatment notes, attempted contact documentation, and final photographic images if deband was rendered.

Documentation Required
Maintain and Furnish Records for Minimum Six-Year Retention
Provider must retain financial, medical, and other records for at least six years and furnish records on request; diagnostic-quality records must be provided on transfer or upon Medicaid request and providers cannot charge for records requested by Medicaid.
Retain records for a minimum of six years unless a longer period is required by law or board rule.
Provide diagnostic-quality radiographs and treatment records when transferring cases or upon request by Medicaid; do not charge Medicaid for requested records.

Documentation Required
Required Orthodontic Records for Prior Approval and Submission Method
Orthodontic records (radiographs, photos, diagnostic casts, narratives, ADA forms) are required for prior approval and must be diagnostic quality; when submitting electronically upload all records except models which must be mailed with the DHHS cover sheet.
Required records include panoramic (D0330), cephalometric (D0340) with tracing/analysis, intraoral/extraoral photos, diagnostic casts (D0470) trimmed to centric occlusion with bite registration, and a detailed treatment plan.
Electronic submissions: upload all records except models to NCTracks; mail models with the Prior Approval Health Services Attachment Review Cover Sheet.

Documentation Required
Submit Orthodontic Records with Approval; Verify Eligibility at Record Date
Providers must submit orthodontic records as part of any prior approval request; records taken when the beneficiary is not Medicaid-eligible will not be paid.
Confirm Medicaid eligibility on the date orthodontic records are taken; if not eligible, no payment will be issued.
Orthodontic records are a once-in-a-lifetime service and must be requested on the same prior approval as treatment.

Billing Rule
Use Adopted CDT 2020 Codes; Enter 'D.' Codes on Claims
Use CDT 2020 procedure codes adopted by NC Medicaid; only procedure codes listed in this policy are covered and all CDT codes on forms must begin with 'D.' when submitted.
NC Medicaid has adopted CDT 2020 codes; providers must use the policy-listed CDT codes (e.g., D8070, D8080, D0330, D0340, D0470, D8670, D8680).
On ADA claim forms enter five-digit procedure codes beginning with 'D.'

Documentation Required
Include Diagnostic Casts, Photos, Radiographs, Treatment Plan in Prior Approval
Prior approval submissions must include diagnostic casts trimmed to centric occlusion with markings, required extraoral and intraoral photographs, radiographs, a detailed treatment plan, and consultation notes for orthognathic cases.
Diagnostic casts must be trimmed to centric occlusion with markings and include a bite registration.
Photographic set: three extraoral and five intraoral images as specified; radiographs include panoramic and lateral cephalometric with tracing; include treatment plan details and surgeon consultation notes for orthognathic cases.

Prior Authorization
Upload Transfer Requests with D8670 and Required Documentation via NCTracks
For transfer prior approval requests upload materials to NCTracks using CDT code D8670 and include the narrative, provider information, current orthodontic status, treatment plan with anticipated remaining length, and required radiographs/photographs; attach AAO Transfer Form or prior approvals as specified.
Enter D8670 as the requested service and indicate transfer type in Documentation of Medical Necessity.
Include AAO Transfer Form if banded or previous Medicaid approval marked 'VOID' if not banded; for out-of-state transfers include proof of prior-state Medicaid eligibility.

Prior Authorization
Include D8680 and Required Termination/Post-Treatment Documents
When submitting termination or case-completion requests include CDT code D8680 and the completed termination or post-treatment summary forms, treatment notes, attempted contact documentation, and final photographic images when deband was rendered.
Enter D8680 as the requested service for termination or final review.
Attach the Orthodontic Treatment Termination Request or Orthodontic Post-Treatment Summary Form, treatment notes, contact attempt documentation, and final photos if applicable.

Documentation Required
Retain and Transfer Records; Furnish on Request
Maintain health records for at least six years and provide diagnostic-quality records on transfer or upon Medicaid request; comply with applicable NC State Board rules for record transfer and retention.
Retain financial and clinical records for a minimum of six years; NC State Board rule recommends ten years for complete treatment records.
Provide original or diagnostic copies of radiographs and treatment records within 30 days upon request; providers may charge a duplication fee consistent with private-pay patients.

Billing Rule
Complete ADA 2019 Claim Fields; Submit Electronically Except for NCTracks Exceptions
Complete required ADA 2019 claim form fields when submitting paper claims and use black ink; electronic submission via NCTracks is required for most claims except specified exceptions.
Paper claims must use the 2019 ADA Dental Claim Form completed in black ink and include required fields (subscriber name, DOB, 10-digit ID, procedure date/code, place of treatment '11', NPI, signature).
Claims are expected to be submitted electronically via NCTracks unless they meet NCTracks exceptions (time limit overrides, Medicare overrides, certain adjustments).

Documentation Required
Upload Termination/Extension/Post-Treatment Documents to NCTracks
Upload required documents for termination, extension, and post-treatment submissions to the NCTracks Prior Approval Portal, including completed request forms and supporting treatment documentation as specified in subsections 7.3–7.5.
Terminate: upload D8680 request, termination form, treatment notes, attempted contact documentation, and final photos if deband performed.
Extend: upload D8670 request and completed Prior Approval Extension Request Form.
Post-treatment: upload D8680 request, Post-Treatment Summary Form, final photos, and treatment notes if fewer than 12 maintenance visits were paid.

Documentation Required
Provide D8680 and Complete Termination Package; Possible Refunds
Termination requests must include CDT code D8680 and a completed Orthodontic Treatment Termination Request Form plus supporting treatment notes and contact documentation; Medicaid may require refund of banding fees in some cases.
Enter D8680 as requested service and attach the completed termination request form and treatment notes.
Provide documentation of attempted contacts and final photographic images if deband was rendered; be aware Medicaid may seek partial refund of banding fees where applicable.

Prior Authorization
Submit D8670 and Extension Form for Prior Approval Extension
Extension requests require CDT code D8670 and a completed Orthodontic Prior Approval Extension Request Form; submit via NCTracks and note that claims after prior approval expiration will deny with EOB 00023 until the extension is submitted.
Enter D8670 as the requested service and include the completed extension request form.
Claims submitted after prior approval expiration will deny with EOB 00023 until an extension request is filed.

Documentation Required
Include D8680 and Post-Treatment Summary with Final Photos and Notes
Post-treatment summary submissions must include CDT code D8680, the completed Orthodontic Post-Treatment Summary Form, final photographic images, and treatment notes when fewer than 12 maintenance visits were paid.
Enter D8680 as the requested service and upload the Post-Treatment Summary Form and final photos.
If fewer than 12 maintenance visits were paid, attach complete treatment notes from initial visit through retainers to substantiate final claim payment.

Denial Risk
Services That Meet 'Not Covered' or Limitations May Be Denied
Refer to the Table of Contents and Limitations/Not Covered sections as implied denial triggers; services meeting 'Not Covered' or limitation criteria may be denied when submitted.
The TOC references 'When the Procedure... Is Not Covered' and 'Limitations,' which indicate conditions that may trigger denials if met.
Providers should review sections 4.0 and 5.3 to avoid submitting non-covered services.

Denial Risk
Be Aware Prior Approvals May Be Voided per 5.2.2
Prior approvals can be voided under the conditions described in subsection 5.2.2; providers must follow the voiding rules in 5.2.2 to prevent unexpected denials or voided approvals.
See 5.2.2 Voiding a Prior Approval for rules that may result in a prior approval being voided.
Ensure submitted information matches requirements to avoid voiding.

Denial Risk
Claims Deny When Required Prior Approval Is Missing
Claims may be denied if prior approval is not obtained where required; failure to secure prior approval before rendering services will result in denial of payment.
Obtain prior approval before rendering any service designated as requiring prior approval.
Denials for lack of prior approval will be enforced as stated in Section 5.1.

Documentation Required
Verify Medicaid Eligibility for Each Date of Service
Verify each beneficiary's Medicaid eligibility at every service date; records or services provided when the beneficiary is not eligible will not be paid.
Confirm eligibility on the date orthodontic records are taken and on the date of banding; if not eligible, no payment will be issued.
For adolescent dentition, maintenance visits may be reimbursed during later ineligible visits only if the beneficiary was eligible on the date of banding and payment is in paid history.

Denial Risk
Do Not Submit Records Taken When Beneficiary Was Ineligible
If orthodontic records are taken when the beneficiary is not Medicaid-eligible, no payment will be issued; submit records only when eligibility is confirmed and request covers the record date.
Orthodontic records must be requested with the date the records were taken used as the requested begin date in NCTracks.
Confirm eligibility on the date records are taken because orthodontic records are reimbursed only if taken while beneficiary is eligible.

Denial Risk
No Payment if Not Eligible on Date of Banding
If the beneficiary is not Medicaid eligible on the date of banding, no payment will be issued; banding must occur while beneficiary is eligible under the same health plan that was approved in NCTracks.
Confirm eligibility and that the health plan matches the approval in NCTracks on the date of banding.
Only periodic orthodontic visits for adolescent dentition may be reimbursed during later ineligible visits if banding was paid while eligible and payment is in paid history.

Denial Risk
Claims Deny with EOB 00023 After Prior Approval Expiration
Claims submitted after the prior approval expiration date will deny with EOB 00023 'SERVICE REQUIRES PRIOR APPROVAL' until an extension request (D8670) has been submitted and approved.
Submit a Prior Approval Extension Request with D8670 when treatment exceeds the original 36-month approval and paid maintenance visits have not exceeded 23.
Claims after approval expiration will deny with EOB 00023 until extension is submitted.

Billing Rule
Submit Claims Electronically via NCTracks; Paper Only for Exceptions
Submit claims electronically via NCTracks except for allowed exceptions listed on the NCTracks website; paper claims are accepted only for specified exceptions and must be completed in black ink using the 2019 ADA Dental Claim Form.
Most claims must be submitted electronically; paper submissions allowed only for NCTracks-listed exceptions (time limit overrides, Medicare overrides, certain adjustments).
Paper ADA 2019 dental claim forms must be completed in black ink and include all required fields.

Denial Risk
Expired Prior Approval Causes EOB 00023 Denial — Submit D8670 to Extend
Claims submitted after prior approval expiration will be denied with EOB 00023 'SERVICE REQUIRES PRIOR APPROVAL'; providers must file an extension request (D8670) to restore claim payment eligibility.
EOB 00023 will be used to deny claims submitted after prior approval expiration.
An extension request must be submitted via NCTracks with D8670 and the completed extension form to resume payment processing.

When approved, comprehensive treatment prior approval is granted for up to 36 months (referenced elsewhere in policy sections)

Included appliancesWhen comprehensive treatment is approved, necessary fixed or removable appliances are included and providers may not bill beneficiaries additional charges

inv-111: Orthodontic Review Board referenced in section 5.5

Orthodontic Review Board referenceOrthodontic Review Board is identified in section 5.5 as the body that reviews cases and determines coverage

Board actionsMay physically examine the beneficiary before approval and evaluates functional need and other factors (attendance, cooperation, oral hygiene)

Case-by-case determinationsBoard determines authorization on a case-by-case basis

inv-114: Orthodontics definition — corrective procedure for functionally impairing occlusal conditions

Orthodontics definitionOrthodontics: corrective procedure for functionally impairing occlusal conditions (including craniofacial abnormalities and traumatic or pathologic anatomical deviations) that cause pain, deformity, significant malfunction, aggravate a condition, or result in further injury or infirmity

Quality and scopeSuch services must maintain a high standard of quality and be within reasonable limits of services customarily available

Coding noteOnly the procedure codes listed in this policy are covered (CDT 2020)

inv-116: Functionally impairing occlusal conditions — examples referenced

Examples of functionally impairing conditionsIncludes severe skeletal anomalies requiring orthognathic surgery; severe Class II/III discrepancies; posterior or anterior crossbites of three or more teeth per arch; anterior or significant posterior open bites ≥2 mm of four or more teeth per arch; impinging overbite causing soft tissue trauma; overjet ≥6 mm; crowding >6 mm; impactions with good prognosis; excessive spacing ≥10 mm or ≥8 mm cuspids-to-cuspids; two or more congenitally missing teeth; occlusal impact from craniofacial anomaly, trauma, or pathology; psychosocial inhibition with documentation; potential for worsening

Role in approvalThese examples are the Medicaid Additional Criteria Covered used to increase probability of approval when two or more are present

Measurement specificsSeveral items include explicit measurement thresholds (e.g., open bite ≥2 mm, overjet ≥6 mm, spacing thresholds) used during review

inv-117: Orthodontic Review Board — role and authority (case-by-case determinations)

Board role and authorityOrthodontic Review Board determines on a case-by-case basis whether to authorize coverage; may examine beneficiary physically and evaluate functional need and patient factors

Factors consideredBoard considers beneficiary's attitude, appointment compliance, ability to follow instructions, and oral hygiene maintenance

Final decisionBoard has authority to authorize coverage based on comprehensive assessment

inv-118: Functionally impairing — screening and record collection note

Screening and record collection noteOnce a case has been screened and orthodontic records obtained and it is certain the case is functionally impairing, the provider shall request prior approval

Action requiredSubmit prior approval electronically to NCTracks Prior Approval Portal with specified radiographs, photos, models, narrative and procedure codes

Definition useThe term 'functionally impairing' is used as the threshold in Attachment A for when to request prior approval

inv-109: No clinical definitions present in this excerpt (placeholder)

No clinical definitions presentThe Definitions subsection in this excerpt states 'None Apply.' — no additional clinical definitions are provided in this part of the document

Reference locationDefinitions heading appears in the Table of Contents but contains no definitions in this excerpt

ImplicationOther sections of the policy contain definitions and examples; this excerpt's Definitions section is empty

inv-115: Definitions section has no additional definitions in this excerpt (placeholder)

Definitions section contentThe Definitions subsection in this excerpt contains no additional definitions (stated as 'None Apply.')

Placeholder noteAdditional definitions are provided elsewhere in the policy; not present in this excerpt

LocationAppears under 1.1 Definitions in the Description section

inv-112: Comprehensive Orthodontic Treatment listed as subsection 5.3.2 (placeholder)

Subsection listingComprehensive Orthodontic Treatment is listed as subsection 5.3.2 in the Table of Contents

Content locationDetails and criteria for comprehensive treatment are found in 5.3.2 (not included in this excerpt)

Related sectionsSee 5.1 Prior Approval and 5.2 Prior Approval Requirements for submission and approval context

inv-113: Combined Orthognathic Surgery and Comprehensive Orthodontic Treatment listed as subsection 5.3.3 (placeholder)

Combined orthognathic subsectionCombined Orthognathic Surgery and Comprehensive Orthodontic Treatment is listed as subsection 5.3.3 in the Table of Contents

Content expectationSubsection 5.3.3 addresses combined surgical/orthodontic care considerations; full criteria are located in that subsection

Related attachmentsPrior approval and specific radiographic/diagnostic cast requirements for orthognathic cases are referenced elsewhere in the policy attachments

Policy updated for CDT additions and billing guide revisions effective with multiple CDT updates through 2020; Orthodontic Billing Guide and forms updated