Submit prior authorization or retrospective review to UM/Delegate and verify member/provider status

Requests for prior authorization or retrospective review must be submitted electronically, by telephone, fax, or written request to the KF/ACP Utilization Management (UM) department or Delegate. UM/Delegate staff verify member eligibility and provider participation and will notify the provider if eligibility or participation cannot be verified; unresolved verification leads to denial in accordance with Policy UM.017P.

• Submit prior auth or retrospective review via electronic portal, phone, fax, or written request to KF/ACP UM or Delegate.
• Provide sufficient clinical documentation; UM/Delegate will request additional information if the submission is insufficient.
• Verify member eligibility and provider participation — lack of verification may result in denial per Policy UM.017P.

Obtain prior authorization for specified restorative, endodontic, orthodontic and sleep appliance codes

Certain restorative, endodontic, orthodontic and custom sleep apnea device codes require prior authorization and must include the specified supporting documentation and clinical criteria at time of request.

• Include required radiographs and narrative of medical necessity for restorative and endodontic codes (e.g., crowns, posts/cores, root canals) as listed in the grid.
• Submit panoramic/cephalometric radiographs, photos, and completed Salzmann form for comprehensive orthodontics (D8080) per criteria.
• For custom sleep appliance (D9947), include Lab Rx, physician Letter of Medical Necessity, and sleep study showing AHI/RDI ≥5.

Prior authorization required for many crowns, endodontics, and surgical procedures — include required docs

Many crown, endodontic, and related surgical codes are designated Auth Reqd = Yes or require a Benefit Limit Exception; providers must submit the required documentation (pre-op radiographs, narratives) with the prior authorization request.

• Crown codes (D2710, D2721, D2740, D2751) require pre-operative x‑rays of adjacent and opposing teeth and a narrative of medical necessity; many require BLE for members ≥21.
• Endodontic/surgical exposure codes (D3310–D3330, D3471–D3503) require pre‑operative radiographs and may be Auth Reqd = Yes with lifetime/per‑tooth limits.
• Follow code-specific auth status and documentation fields in the procedure grid when submitting requests.

Apicoectomy codes — check per-code auth status and limits before submission

Apicoectomy codes have mixed authorization requirements: some apicoectomy entries are Auth Reqd = No while related surgical endodontic and exposure codes may be Auth Reqd = YES and have per‑tooth limits and BLE requirements; submit authorization according to the specific code entry.

• D3410 (apicoectomy anterior) lists Auth Reqd = No and Max Count = 2 teeth but may require a Benefit Limit Exception for adults 21+.
• D3421, D3426 entries show Auth Reqd = No for certain apicoectomy-related items; verify the specific code's authorization and documentation requirements before submission.

Submit prior authorization for codes designated Auth Reqd = YES with required documentation

Procedure codes in the grid marked Auth Reqd = YES must have prior authorization submitted with the required documentation and meet any age, frequency, or BLE conditions listed for that code.

• Examples of Auth Reqd = YES codes include D3502, D3503, D3921, D4341, D4342 and many denture/appliance codes — follow the grid's 'Req Docs' and 'Period Type' fields.
• Obtain Benefit Limit Exception when indicated for adults age 21+ (unless in NF/ICF) as shown in the code entries.

Codes marked Auth Reqd in the grid must be submitted for prior authorization with listed documentation

Codes listed in the procedure grid that are designated Auth Reqd (marked in the grid) require prior authorization submission with the supporting documents specified in the grid prior to rendering services.

• Oral surgery impacted tooth codes (D7220–D7240, D7250) show Auth Reqd = Yes and require pre‑operative radiographs and narratives as listed.
• Orthodontic comprehensive (D8080) and retention/replacement codes (D8680, D8703, D8704, D8210, D8220) are marked Auth Reqd = YES and require the grid's specified documentation.

Step therapy — not specified in this extract

Step therapy is not specified in this extract; no step therapy requirements are defined in the available policy text.

• No step therapy rules are present in the provided sections.

For crowns and BLE requests submit periapical radiographs, panorex, and separate BLE request when required

For crowns, submit current periapical radiographs of the tooth/teeth to be crowned and a panorex or full‑mouth radiograph; for requests requiring a Benefit Limit Exception, submit numerical diagnosis reporting on a separate authorization request containing only BLE codes as instructed in the policy.

• Crowns (D2710, D2721, D2740, D2751, D2752, D2791): current periapical radiographs plus panorex/full mouth required.
• BLE requests must be submitted on a separate authorization request containing only codes requiring BLE to avoid denial.

Provide required radiographs, narratives, pathology reports, anesthesia logs, and LOMN/Lab Rx per code

Providers must submit the specified radiographs (periapical, panoramic/panorex, or cephalometric), narrative of medical necessity, pathology reports when indicated, anesthesia logs for retrospective reviews, and physician Letter of Medical Necessity plus Lab Rx for custom sleep apnea appliances.

• Pre‑operative radiographs: periapical, panoramic/panorex, or cephalometric as specified per code.
• Narrative of medical necessity is required for many procedures (e.g., dentures, oroantral fistula closure, periodontal and surgical procedures).
• Pathology reports are required for excision of lesions/tumors; anesthesia logs are required for retrospective anesthesia/sedation reviews.
• For D9947 (custom sleep appliance): Lab Rx and physician LOMN with sleep study data and AHI/RDI results.

Include pre‑operative x‑rays of adjacent/opposing teeth and medical necessity narrative for crown/restorative authorizations

Pre‑operative x‑rays of adjacent and opposing teeth and a narrative of medical necessity are required for many crown and restorative procedures and certain surgical codes; include these with authorization requests to avoid delays.

• Crown codes (D2710, D2721, D2740, D2751) list 'Pre‑operative x‑rays of adjacent teeth and opposing teeth' plus a narrative of medical necessity.
• Surgical exposure and repair codes require pre‑operative radiographs of adjacent and opposing teeth as noted in the code entries.

Submit post‑operative x‑rays or periodontal charting when required by the code

Certain procedures require post‑operative x‑rays or periodontal charting as part of the required documentation (for example, D3921 requires post‑operative x‑rays; gingivectomy entries require periodontal charting).

• D3921 (decoronation/submergence) requires post‑operative x‑rays (excluding bitewings) and a narrative.
• Gingivectomy/gingivoplasty entries cite pre‑op x‑rays and periodontal charting plus narrative of medical necessity.

Submit all code‑specific required supporting documentation listed in the procedure grid

Providers must submit the specific supporting documentation listed for each code — typically pre‑operative radiographs (excluding bitewings where noted), post‑operative x‑rays, panorex/full‑mouth films, periodontal charting, and a narrative of medical necessity where specified.

• Follow the 'Req Docs' field in the procedure grid for each code (e.g., D3502/D3503 require pre‑operative x‑rays excluding bitewings).
• Failure to include code‑specific required documentation may result in requests being returned for additional information or denied.

Examples: submit pre‑op x‑rays for impacted removal and narratives for oroantral closure/tooth re‑implantation

Examples of required documentation include pre‑operative x‑rays for impacted tooth removal (codes D7220–D7240), narratives of medical necessity for procedures such as oroantral fistula closure (D7260) and tooth re‑implantation (D7270); submit these as specified in the code entries.

• D7220–D7240: Pre‑operative radiographs required for impacted tooth removal authorizations.
• D7260 and D7270: Narrative of medical necessity required; D7270 also has an age maximum per grid.

For orthodontic authorizations submit panorex/cephalometric films, photos, Salzmann form, and evidence of completion as required

Orthodontic authorizations require panoramic and/or cephalometric radiographs; comprehensive orthodontics (D8080) additionally requires 5–7 diagnostic quality photos and a completed Salzmann Criteria Index form with a score ≥25. Retention/replacement codes require evidence of treatment completion.

• D8080: Panorex and/or cephalometric radiograph, 5–7 diagnostic photos, Salzmann form with score ≥25.
• D8680/D8703/D8704: Provide radiographs and evidence of successful treatment completion or case completion date and justification for continued retention.

Denial risk if eligibility, provider participation, or coverage under MA cannot be verified or documentation is insufficient

Denial can be triggered if member eligibility or provider participation cannot be verified; if the item/service is not covered under the MA Program; or if submitted documentation is insufficient to determine medical necessity.

• Verify member eligibility and provider participation before rendering services — lack of verification leads to denial per Policy UM.017P.
• Services not covered under the Medical Assistance program are forwarded for denial as non‑covered benefits.

Requests missing narratives, pathology reports, assistant surgeon info, or other required documents risk denial

Missing required documentation such as narrative of medical necessity, pathology report, assistant surgeon identification, or other code‑specified documents may result in denial of the authorization or claim.

• Excision of lesion/tumor (D7450/D7451/D7460/D7461) requires a copy of the pathology report — absence risks denial.
• Unspecified oral surgery (D7999) requires narrative plus assistant surgeon name/license/tax ID — missing this information may trigger denial.

Avoid disallowed same‑date code combinations — conflicting same‑DOS codes can trigger denial

Billing codes disallowed together on the same date of service may trigger denial; verify the procedure grid for not‑allowed same‑DOS combinations before billing.

• Example: D0190 is not allowed on the same date of service as D0120, D0140, D0145, or D0150 per the procedure grid.
• Review the grid 'Not allowed same DOS' notes prior to claim submission to avoid denials.

Missing pre‑op x‑rays and narrative for crown/restorative codes (e.g., D2710–D2751) may cause denial

Requests for specified crown and restorative codes (e.g., D2710, D2721, D2740, D2751) submitted without required pre‑operative x‑rays of adjacent/opposing teeth and a narrative of medical necessity may be denied.

• Include pre‑op radiographs of adjacent and opposing teeth and a narrative when requesting authorization for crown codes to reduce risk of denial.
• Ensure submissions meet the crown clinical criteria (e.g., minimum 50% bone support) as part of the documentation package.

Do not perform services requiring prior authorization (Auth Reqd = YES) without approved authorization — risk of denial

Failure to obtain prior authorization for codes marked Auth Reqd = YES (for example, D3502, D3503, D3921) may trigger denial of the claim or request.

• Check the grid for 'Auth Reqd' status for each code; do not perform services requiring prior authorization without an approved authorization or BLE when indicated.
• Codes with Auth Reqd = Yes also often require specific documentation (e.g., pre‑op x‑rays excluding bitewings for D3502/D3503).

Prior authorization required for selected oral surgery codes — submit pre‑op x‑rays/narratives as listed

Claims for oral surgery procedures marked Auth Reqd = Yes (examples: D7220, D7230, D7240, D7250, D7260, D7270, D7280, D7283) require prior authorization with required pre‑operative radiographs or narratives; lack of authorization/documentation may result in denial.

• D7220–D7240: Auth Reqd = Yes; pre‑operative radiographs required; Max Count and Period Type noted in grid.
• D7260/D7270/D7280/D7283: Auth Reqd = Yes; submit narrative or pre‑op films as specified and verify age limits in the grid.

Prior authorization required for comprehensive orthodontics and related codes — include required radiographs, photos, Salzmann form, and evidence of completion

Orthodontic comprehensive treatment (D8080) and related retention/replacement codes (D8680, D8703, D8704, D8210, D8220) are marked Auth Reqd = YES and require submission of the specified radiographs, photos, Salzmann form (for D8080), and evidence of treatment completion where applicable.

• D8080: Panorex and/or cephalometric radiograph, 5–7 diagnostic photos, completed Salzmann Criteria Index Form.
• Retention/replacement retainer codes require narrative with orthodontic case completion date and justification for continued retention.