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Pre-Authorization Process

/Pre-Authorization Process
Pre-Authorization Process2021-07-26T09:06:45+00:00

The following table provides information about pre-authorization and claims submission requirements by CDT code for Children’s Medicaid Dental Services. An asterisk (*) indicates that the item should be submitted only if available. Please note, some services do not require pre-authorization, but do require supporting documentation such as medical necessity rationale, x-rays, color photos, pathology reports, and tooth ID numbers with claim submission.

Pre-authorization of care should be requested electronically through the MCNA Provider Portal at http://portal.mcna.net. MCNA will process pre-authorization requests within three (3) business days. Within 24 hours of when the determination is made, the pre-authorization approval will be available to view on the Provider Portal. For providers not utilizing the Portal, the UM staff will mail a hard copy of the pre-authorization approval to both the member and the provider within three (3) business days of the determination for standard requests and within 72 hours for emergency requests. The written notice will provide information on whether the requested service was approved or denied, including the criteria used to make the decision. If the pre-authorization request is denied, the adverse determination notice will include information on how the member can request more information or file an appeal. Within three (3) business days of the provider referral to MCNA for review, but no later than the 10th business day after date the pre-authorization was received, MCNA will make a final decision on the request.

Incomplete Pre-Authorization Requests

MCNA is unable to process pre-authorizations with missing essential information.  Essential information includes: member name, member number or Medicaid number, member date of birth, requesting provider name, requesting provider’s National Provider Identifier (NPI), service requested – Current Dental Terminology (CDT), rendering provider’s name, and rendering provider’s NPI.  If a pre-authorization is submitted with missing essential information, that request will be returned to the office submitting a request with a letter describing the essential information that is missing.

If the pre-authorization request is incomplete (missing, incorrect or illegible documentation, illegible photographs, etc.), MCNA will notify the provider (via phone call if possible) and member no later than three (3) days after receiving it to request the missing or incomplete information. While MCNA is waiting for the requested information, the pre-authorization request will be assigned a “pending” status. MCNA must receive the necessary information to complete the pre-authorization request within 10 business days of the request’s original submission. Upon receipt of the documentation, the pre-authorization request will be removed from pending status and processed according to required time frames. If MCNA does not receive the requested information by the end of the 3rd business day (and the PA will be denied), the PA will be referred to a clinician for review with all information received with the request no later than the 7th business day after the PA was received. If MCNA receives the information after the tenth business day, UM staff will duplicate the request and send it through the review process.

Approved Pre-Authorization Requests

Approved pre-authorization requests are valid for 90 days from the date of approval. Both the member and provider will receive notification of which services were approved, as well as the expiration date of the authorization for the approved services.  If orthodontic treatment does not begin within the valid 180-day period, the provider must submit a new pre-authorization request for approval. All approvals for services are assigned a unique authorization number, which must be submitted with the claim after services are rendered.

Prior Authorization Annual Review Report

The Prior Authorization Annual Review Report provides the history of all changes after September 1, 2019, for the reporting period.

More Information

Faxed pre-authorization requests will not be accepted. MCNA will not return x-rays, periodontal charting, or other related documents. Please submit duplicate sets of these documents when required to be submitted with a pre-authorization request.

Please review the MCNA Texas Provider Manual at http://manuals.mcna.net/texas for additional information by CDT code including frequency limitations and other specifications. Providers may contact the Provider Hotline Monday – Friday, 7 a.m. – 7 p.m. at 1-855-776-6262 with requests for assistance with the prior authorization process. Members may contact the Member Hotline Monday – Friday, 8 a.m. – 7 p.m. at 1-855-691-6262 to inquire about the status of prior authorization requests and for assistance understanding the prior authorization process.

CDT Description Prior Authorization Rationale X-ray Other Documentation
D0367 Cone beam CT capture and interpretation with field of view of both jaws, with or without cranium X X
D0470 Diagnostic casts X X
D0999 Unspecified diagnostic procedure X X X
D1351 Sealant – per tooth X (anterior teeth) Tooth number and surface(s). Color diagnostic photos for anterior teeth.
D2510 Inlay – metallic – one (1) surface X X X
D2520 Inlay – metallic – two (2) surfaces X X X
D2530 Inlay – metallic – three (3) or more surfaces X X X
D2542 Onlay –metallic – two (2) surfaces X X X
D2543 Onlay – metallic – three (3) surfaces X X X
D2544 Onlay – metallic – four (4) or more surfaces X X X
D2650 Inlay – resin-based composite – one (1) surface X X X
D2651 Inlay – resin-based composite – two (2) surfaces X X X
D2652 Inlay – resin-based composite – three (3) or more surfaces X X X
D2662 Onlay – resin-based composite – two (2) surfaces X X X
D2663 Onlay – resin-based composite – three (3) surfaces X X X
D2664 Onlay – resin-based composite – four (4) or more surfaces X X X
D2710 crown – resin based composite (indirect) X X X
D2720 crown – resin with high noble metal X X X
D2721 crown – resin based with predominantly base metal X X X
D2722 Crown – resin with noble metal X X X
D2740 crown – porcelain/ceramic substrate X X X
D2750 crown – porcelain fused to high noble metal X X X
D2751 crown – porcelain fused to predominantly base metal X X X
D2752 crown – porcelain fused to noble metal X X X
D2780 Crown – ¾ cast high noble metal X X X
D2781 crown – ¾ cast predominantly base metal X X X
D2782 Crown – ¾ cast noble metal X X X
D2783 Crown – ¾ porcelain/ceramic X X X
D2790 crown – full cast high noble metal X X X
D2791 crown – full cast predominantly base metal X X X
D2792 crown – full cast noble metal X X X
D2794 Crown – titanium X X X
D2960 Labial veneer (resin laminate) – chairside X X X
D2961 Labial veneer (resin laminate) – laboratory X X X
D2962 Labial veneer (porcelain laminate) – laboratory X X X
D2971 Additional procedures to construct new crown under existing partial denture framework X X X
D2980 Crown repair necessitated by restorative material failure X X X
D2999 Unspecified restorative procedure, by report X X X
D3110 Pulp cap – direct (excluding final restoration) X (Added requirement 4/7/21) X
D3120 Pulp cap – indirect (excluding final restoration) X (Added requirement 4/7/21) X
D3346 Retreatment of root canal – anterior X X X
D3347 Retreatment of root canal – bicuspid X X X
D3348 Retreatment of root canal – molar X X X
D3351 Apexification/recalcification – initial visit (apical closure/calcific repair) X X X
D3352 Apexification/recalcification – interim medication replacement (apical closure/calcific repair of perforations, root resorption, pulp space disinfection, etc) X X X
D3353 Apexification/recalcification – final visit (includes completed root canal therapy – apical closure/calcific repair of perforations, root resorption, etc) X X X
D3410 Apicoectomy – anterior X X X
D3421 Apicoectomy – bicuspid (first root) X X X
D3425 Apicoectomy – molar (first root) X X X
D3426 Apicoectomy – (each additional root) X X X
D3430 Retrograde filling – per root X X X
D3450 Root amputation – per root X X X
D3460 Endodontic endosseous implant X X X
D3470 Intentional re-implantation X X X
D3910 Isolation of tooth with rubber dam (surgical procedures only) X X X
D3920 Hemisection (tooth splitting) X X X
D3950 Canal preparation and fitting of dowel or post X X X
D3999 Unspecified endodontic procedure, by report X X X
D4210 Gingivectomy or gingivoplasty – four (4) or more contiguous teeth or tooth bounded spaces per quadrant X X X Medical necessity, pre-operative color Photos
D4211 Gingivectomy or gingivoplasty – one (1) to three (3) contiguous teeth or tooth bounded spaces per quadrant X X X Medical necessity, pre-operative color Photos
D4230 Anatomical crown exposure – four (4) or more contiguous teeth or bounded tooth spaces per quadrant X X X Medical necessity, pre-operative color Photos
D4231 Anatomical crown exposure – one (1)to three (3) teeth per quadrant X X X Medical necessity, pre-operative color Photos
D4240 Gingival flap procedure, including root planning – four (4) or more contiguous teeth or tooth bounded spaces per quadrant X X X Medical necessity, pre-operative color Photos
D4241 Gingival flap procedure, including root planning – one (1) to three (3) contiguous teeth or tooth bounded spaces per quadrant X X X Medical necessity, pre-operative color Photos
D4245 Apically positioned flap X X X Medical necessity, pre-operative color Photos
D4249 Clinical crown lengthening – hard tissue X X X Medical necessity, pre-operative color Photos
D4260 Osseous surgery (including elevation of a full thickness flap and closure) – four (4) or more contiguous teeth or tooth bounded spaces per quadrant X X X Medical necessity, pre-operative color Photos
D4261 Osseous surgery (including elevation of a full thickness flap and closure) – one (1) to three (3) contiguous teeth or tooth bounded spaces per quadrant X X X Medical necessity, pre-operative color Photos
D4266 Guided tissue regeneration  – resorbable barrier, per site X X X Medical necessity, pre-operative color Photos
D4267 Guided tissue regeneration – non resorbable barrier, per site (includes membrane removal) X X X Medical necessity, pre-operative color Photos
D4270 Pedicle soft tissue graft procedure X X X Medical necessity, pre-operative color Photos
D4273 Autogenous connective tissue graft procedure (including donor and recipient surgical sites) first tooth, implant, or edentulous tooth position in graft X X X Medical necessity, pre-operative color Photos
D4274 Distal or proximal  wedge procedure X X X Medical necessity, pre-operative color Photos
D4275 Non-autogenous connective tissue graft (including recipient site and donor material) first tooth, implant, or edentulous tooth position in graft X X X Medical necessity, pre-operative color Photos
D4276 Combined connective tissue and double pedicle graft, per tooth X X X Medical necessity, pre-operative color Photos
D4283 Autogenous connective tissue graft procedure (including donor and recipient surgical sites), each additional contiguous tooth, implant or edentulous tooth position in same graft site X X X Medical necessity, pre-operative color Photos
D4285 Non-autogenous connective tissue graft procedure (including recipient surgical site and donor material), each additional contiguous tooth, implant or edentulous tooth position in same graft site X X X Medical necessity, pre- and post-operative color Photos
D4320 Provisional splinting – intracoronal X X X Periodontal charting
D4321 Provisional splinting – extracoronal X X X Periodontal charting
D4341 Periodontal scaling and root planning – four (4) or more teeth per quadrant X X X Periodontal charting
D4342 Periodontal scaling and root planning – one (1) to three (3) teeth per quadrant X X X Periodontal charting
D4355 Full mouth debridement to enable comprehensive periodontal evaluation and diagnosis on a subsequent visit X X X Color photos
D4381 Localized delivery of antimicrobial agents via a controlled release vehicle into diseased crevicular tissue, per tooth X X X Periodontal charting
D4910 Preventive periodontal maintenance X X X
D4920 Unscheduled dressing change (by someone other than treating dentist or their staff) X X X
D4999 Unspecified periodontal procedure X X X
D5110 Complete denture – maxillary X X X
D5120 Complete denture – mandibular X X X
D5130 Immediate denture – maxillary X X X
D5140 Immediate denture – mandibular X X X
D5211 Maxillary partial denture – resin base (including any conventional clasps, rests and teeth) X X X
D5212 Mandibular partial denture – resin base (including any conventional clasps, rests and teeth) X X X
D5213 Maxillary partial denture – cast metal framework with resin denture bases (including any conventional clasps, rests and teeth) X X X
D5214 Mandibular partial denture – cast metal framework with resin denture bases (including any conventional clasps, rests and teeth) X X X
D5282 Removable unilateral partial denture – one piece cast metal (including clasps and teeth), maxillary X X X
D5283 Removable unilateral partial denture – one piece cast metal (including clasps and teeth), mandibular X X X
D5226 mandibular partial denture – flexible base (including any clasps, rests and teeth) X X X
D5410 Adjust complete denture – maxillary X X
D5411 Adjust complete denture – mandibular X X
D5421 Adjust partial denture – maxillary X X
D5422 Adjust partial denture – mandibular X X
D5511 Repair broken complete denture base, mandibular X X
D5512 Repair broken complete denture base, maxillary X X
D5520 Replace missing or broken teeth – complete denture (each tooth) X X X
D5611 Repair resin partial denture base, mandibular X X
D5612 Repair resin partial denture base, maxillary X X
D5630 Repair or replace broken clasp – per tooth X X
D5640 Replace broken teeth – per tooth X X
D5650 Add tooth to existing partial denture X X
D5660 Add clasp to existing partial denture X X
D5670 Replace all teeth and acrylic on metal framework (maxillary) X X
D5671 Replace all teeth and acrylic on cast metal framework (mandibular) X X
D5710 Rebase complete maxillary denture X X X
D5711 Rebase complete mandibular denture X X X
D5720 Rebase partial maxillary denture X X X
D5721 Rebase partial mandibular denture X X X
D5730 Reline complete maxillary denture (chair side) X X X
D5731 Reline complete mandibular denture (chair side) X X X
D5740 Reline partial maxillary denture (chair side) X X X
D5741 Reline partial mandibular denture (chair side) X X X
D5750 Reline complete maxillary denture (laboratory) X X X
D5751 Reline complete mandibular denture (laboratory) X X X
D5760 Reline maxillary partial denture (laboratory) X X X
D5761 Reline mandibular partial denture (laboratory) X X X
D5810 Interim complete denture (maxillary) X X X
D5811 Interim complete denture (mandibular) X X X
D5820 Interim partial denture (maxillary) X X X
D5821 Interim partial denture (mandibular) X X X
D5850 Tissue conditioning, maxillary X X X
D5851 Tissue conditioning, mandibular X X X
D5862 Precision attachment, by report X X X
D5863 Overdenture – complete maxillary X X X
D5864 Overdenture – partial maxillary X X X
D5865 Overdenture – complete mandibular X X X
D5866 Overdenture – partial mandibular X X X
D5899 Unspecified removable prosthodontic procedure, by report X X X
D5911 Facial moulage sectional X X X
D5912 Facial moulage complete X X X
D5913 Nasal prosthesis X X X
D5914 Auricular prosthesis X X X
D5915 Orbital prosthesis X X X
D5916 Ocular prosthesis X X X
D5919 Facial prosthesis X X X
D5922 Nasal septal prosthesis X X X
D5923 Occular prosthesis interim X X X
D5924 Cranial prosthesis X X X
D5925 Facial augmentation implant X X X
D5926 Replacement nasal prosthesis X X X
D5927 Auricular prosthesis replacement X X X
D5928 Orbital prosthesis replacement X X X
D5929 Facial prosthesis replacement X X X
D5931 Obturator prosthesis, surgical X X X
D5932 Obturator prosthesis, definitive X X X
D5933 Obturator prosthesis, modification X X X
D5934 Mandibular resection prosthesis with guide flange X X X
D5935 Mandibular resection prosthesis without guide flange X X X
D5936 Temporary obturator prosthesis X X X
D5937 Trismus appliance X X X
D5951 Feeding aid X X X
D5952 Pediatric speech aid X X X
D5953 Adult speech aid X X X
D5954 Palatal augmentation prosthesis X X X
D5955 Palatal lift prosthesis, definitive X X X
D5958 Palatal lift prosthesis, interim X X X
D5959 Palatal lift prosthesis, modification X X X
D5960 Speech aid prosthesis modification X X X
D5982 Surgical stent X X X
D5983 Radiation applicator X X X
D5984 Radiation shield X X X
D5985 Radiation cone locator X X X
D5986 Fluoride applicator X X X
D5987 Commissure splint X X X
D5988 Surgical splint X X X
D5992 Adjust maxillofacial prosthetic appliance, by report X X X
D5999 Unspecified maxillofacial prosthesis, by report X X X
D6210 Pontic – cast high noble metal X X X
D6211 Pontic – cast predominantly base metal X X X
D6212 Pontic – cast noble metal X X X
D6240 Pontic – porcelain fused to high noble metal X X X
D6241 Pontic – porcelain fused to predominantly base metal X X X
D6242 Pontic – porcelain fused to noble metal X X X
D6245 Pontic – porcelain/ceramic X X X
D6250 Pontic – resin with high noble metal X X X
D6251 Pontic – resin with predominantly base metal X X X
D6252 Pontic – resin with noble metal X X X
D6545 Retainer – cast metal for resin bonded fixed prosthesis X X X
D6548 Retainer – porcelain/ceramic for resin bonded fixed prosthesis X X X
D6720 Crown – resin with high noble metal X X X
D6721 Crown – resin with predominantly base metal X X X
D6722 Crown – resin with noble metal X X X
D6740 Crown – porcelain/ceramic X X X
D6750 Crown – porcelain fused to high noble metal X X X
D6751 Crown – porcelain fused to predominantly base metal X X X
D6752 Crown –  porcelain fused to noble metal X X X
D6780 Retainer crown – ¾ cast high noble metal X X X
D6781 Retainer crown – ¾ cast based metal X X X
D6782 Retainer crown – ¾ cast noble metal X X X
D6783 Retainer crown – ¾ porcelain/ceramic X X X
D6790 Retainer crown – full cast high noble metal X X X
D6791 Retainer crown  full cast predominantly base metal X X X
D6792 Retainer crown – full cast noble metal X X X
D6920 Connector bar X X X
D6930 Re-cement or re-bond fixed partial denture X X X
D6940 Stress breaker X X X
D6950 Precision attachment X X X
D6980 Fixed partial denture repair necessitated by restorative material failure X X X
D6999 Unspecified fixed prosthodontic procedure, by report X X X
D7111 Extraction, coronal remnants – primary tooth X X X Color photos
D7140 Extraction, erupted tooth or exposed root (elevation and/or forceps removal) X X X Color photos
D7210 Extraction, erupted tooth requiring removal of bone and/or sectioning of tooth, and including elevation of mucoperiosteal flap if indicated X X X
D7220 Removal of impacted tooth – soft tissue X X X
D7230 Removal of impacted tooth – partially bony X X X
D7240 Removal of impacted tooth – completely bony X X X
D7241 Removal of impacted tooth – completely bony, with unusual surgical complications X X X Unusual circumstance
D7250 Removal of residual tooth roots (cutting procedure) X X X
D7260 Oroantral fistula closure X X X
D7272 Tooth transplantation X X X
D7280 Surgical access of unerupted tooth X X X
D7282 Mobilization of erupted or malpositioned tooth to aid eruption X X X
D7283 Placement of device to facilitate eruption of impacted tooth X X X
D7285 Incisional biopsy of oral tissue – hard (bone, tooth) X X X
D7286 Incisional biopsy of oral tissue – soft X X X
D7290 Surgical repositioning of teeth X X X
D7291 Transseptal fiberotomy – by report X X X
D7310 Alveoplasty in conjunction with extractions – four (4) or more teeth or tooth spaces, per quadrant X X X
D7320 Alveoplasty not in conjunction with extractions – four (4) or more teeth or tooth space , per quadrant X X X
D7340 Vestibuloplasty – ridge extension (secondary epithelialization) X X X
D7350 Vestibuloplasty – ridge extension (including soft tissue grafts, muscle reattachment, revision of soft tissue attachment and management of hypertrophied and hyperplastic tissue) X X X
D7410 Vestibuloplasty – ridge extension (secondary eepithelialization) X Color photos
D7411 Excision of benign lesion greater than 1.25 cm X X Color photos
D7413 Excision of malignant lesion about to 1.25 cm X X Color photos
D7414 Excision of malignant lesion greater than 1.25 cm X X Color photos
D7440 Excision of malignant tumor – lesion diameter up to 1.25 cm X X X Pathology report
D7441 Excision of malignant tumor – lesion diameter greater than 1.25 cm X X X Pathology report
D7450 Removal of benign odontogenic cyst or tumor – lesion diameter up to 1.25 cm X X X Pathology report
D7451 Removal of benign odontogenic cyst or tumor – lesion diameter of greater than 1.25 cm X X X Pathology report
D7460 Removal of a benign nonodontogenic cyst or tumor – lesion diameter up to 1.25 cm X X X Pathology report
D7461 Removal of a benign nonodontogenic cyst or tumor – lesion diameter greater than 1.25 cm X X X Pathology report
D7465 Destruction of lesion(s) by physical or chemical method, by report X X X Pathology report
D7472 Removal of torus palatinus X X
D7530 Removal of a foreign body from mucosa, skin, or subcutaneous alveolar tissue X X X
D7540 Removal of reaction producing foreign bodies, musculoskeletal system X X X
D7550 Partial ostectomy/sequestrectomy for removal of non-vital bone X X X
D7560 Maxillary sinusotomy for removal of tooth fragment or foreign body X X X
D7670 Alveolus – closed reduction, may include stabilization of teeth X X X
D7820 Closed reduction of dislocation X X X
D7880 Occlusal orthotic applicance X X X
D7899 Unspecified TMD therapy – by report X X X
D7955 Repair of maxillofacial soft and/or hard tissue defect X X
D7960 Frenulectomy – also known as frenectomy or frenotomy – separate procedure not incidental to another procedure X X Color photos
D7970 Excision of hyperplastic tissue – per arch X X Color photos
D7971 Excision of pericoronal gingiva X X Color photos
D7972 Surgical reduction of fibrous tuberosity X
D7980 Surgical sialolithotomy X X X
D7983 Closure of salivary fistula X X X
D7997 Appliance removal X X X
D7999 Unspecified oral surgery procedure X X X
D8050 Interceptive orthodontic treatment of the primary dentition X X X
D8060 Interceptive orthodontic treatment of the transitional dentition X X X
D8070 Comprehensive orthodontic treatment of the transitional dentition (one (1) of D8070, D8080, or D8090 per lifetime) X X X
D8080 Comprehensive orthodontic treatment of the adolescent dentition (one (1) of D8070, D8080, or D8090 per lifetime) X X X
D8090 Comprehensive orthodontic treatment of the adult dentition (one (1) of D8070, D8080, or D8090 per lifetime) X X X
D8210 Removable appliance therapy X X X Arch
D8220 Fixed appliance therapy X X X Arch
D8670 Periodic orthodontic treatment visit – the number of visits will vary based on which level was approved X X X
D8680 Orthodontic retention (removal of appliances, construction and placement of retainer(s) X X X
D8690 Bracket replacement X X X
D8691 Repair of orthodontic appliance – one (1) per arch per lifetime X X X
D8692 Replacement of lost or broken retainer X X X Medical necessity, a signed “non-covered services form”
D8693 Rebonding or recementing, and/or repair, as required, of fixed retainers. X X X Medical necessity, a signed “non-covered services form”
D8999 Unspecified orthodontic procedure, by report X X X Transfer cases only
D9222 Deep sedation/general anesthesia – first 15 minutes X X X
D9223 Deep sedation/general anesthesia – each subsequent 15-minute increment X X X
D9239 Intravenous moderate (conscious) sedation/analgesia – first 15 minutes X X X
D9243 Intravenous moderate (conscious) sedation/analgesia – each subsequent 15 minute increment X X X
D9248 Non-intravenous conscious sedation X X X
D9930 Treatment of complications (post-surgical) unusual circumstances, by report X X
D9950 Occlusal analysis – mounted case X X
D9952 Occlusal adjustment – complete X X
D9970 Enamel microabrasion X X
D9974 Internal bleaching per tooth X Medical necessity
D9999 Unspecified adjunctive procedure, by report X X X