Supplemental or amended prior authorization requirements that include additional and/or amended services found necessary after the original dental treatment plan has been prior authorized may be requested by recording such a need on the Horizon NJ Health Claim Form. This should then be submitted for supplemental authorization together with the original treatment plan or a photocopy thereof. Payment will not be made for such treatment without prior authorization.
Prior authorized (“nonroutine”) services shall be completed within one year of the date of authorization by the dental consultant. If physicians or health care
professionals are unable to complete the services within the prior authorized period, physicians may contact the dental consultant and request a change in the prior authorization request.
Post-Operative Review
Endodontics does not require prior authorization; however, pre- and post-operative periapical radiographs must be submitted, showing full apex of treated tooth before payment will be authorized. Failure to send necessary radiographs will result in the rejection of payment.
Radiograph Requirements
You must submit mounted full-mouth radiographs no older than 36 months and a recent periapical radiograph of the involved teeth. Radiographs must be clearly readable, free from defects, and have density and clarity so that interpretation can be made without difficulty by using the conventional view box, showing all clinical crowns and roots labeled with patient’s and dentist’s name. Date radiographs and mark left and right. Do not staple X-rays to form.
How to Submit Dental Claims Requiring Prior Authorization
Prior authorization request forms with applicable X-rays should be submitted to Horizon BCBSNJ. Do not staple X-rays to form. A copy of all dental prior authorization forms should be maintained by the dentist.
Prior authorization request forms received by Horizon BCBSNJ will be reviewed by the dental consultant. Upon completion of the review, the dentist will be notified of a decision in writing. All questions concerning prior authorizations may be
directed to: Horizon BCBSNJ P.O. Box 1938 Newark, NJ 07101-1938 Or call: 1-800-4DENTAL 27
Prior Authorization Requirements (continued)
Services Requiring Prior Authorization
The following procedures require prior authorization, except for dentists who submit claims electronically. All codes 8070 to 8999 require prior authorization regardless of the manner in which they are submitted.
Inlays/Onlays:
D2410 – Gold foil – 1 surface D2420 – Gold foil – 2 surfaces D2430 – Gold foil – 3 surfaces D2510 – Inlay – metallic – 1 surface D2520 – Inlay – metallic – 2 surfaces
D2530 – Inlay – metallic – 3 or more surfaces D2542 – Onlay – metallic – 2 surfaces
D2543 – Onlay – metallic – 3 surfaces
D2544 – Onlay – metallic – 4 or more surfaces D2642 – Onlay – porcelain/ceramic – 2 surfaces D2643 – Onlay – porcelain/ceramic – 3 surfaces
D2644 – Onlay – porcelain/ceramic – 4 or more surfaces D2662 – Onlay – resin-based composite – 2 surfaces D2663 – Onlay – resin-based composite – 3 surfaces
D2664 – Onlay – resin-based composite – 4 or more surfaces Single Crowns:
D2710 – Crown – resin D2712 – Crown – 3/4 resin
D2720 – Crown – resin with high noble metal
D2721 – Crown – resin with predominantly base metal D2722 – Crown – resin with noble metal
D2740 – Crown – porcelain/ceramic substrate
D2750 – Crown – porcelain fused to high noble metal
D2751 – Crown – porcelain fused to predominantly base metal D2752 – Crown – porcelain fused to noble metal
D2780 – Crown – 3/4 cast high noble metal
D2781 – Crown – 3/4 cast predominantly base metal D2782 – Crown – 3/4 cast noble metal
D2783 – Crown – 3/4 porcelain/ceramic D2790 – Crown – full cast high noble metal
D2791 – Crown – full cast predominantly base metal D2792 – Crown – full cast noble metal
Prior Authorization Requirements (continued)
Services Requiring Prior Authorization
Endodontics:
D3410 – Apicoectomy – anterior
D3421 – Apicoectomy – bicuspid (first root) D3425 – Apicoectomy – molar (first root) D3426 – Apicoectomy (each additional root) Periodontics:
D4210 – Gingivectomy or gingivoplasty – 4 or more contiguous teeth D4211 – Gingivectomy or gingivoplasty – 1 to 3 contiguous teeth D4240 – Gingival flap procedure – 4 or more contiguous teeth D4241 – Gingival flap procedure – 1 to 3 contiguous teeth D4245 – Apically positioned flap
D4249 – Clinical crown lengthening – hard tissue D4260 – Osseous surgery – 4 or more contiguous teeth D4261 – Osseous surgery – 1 to 3 contiguous teeth D4263 – Bone replacement graft – first site
D4264 – Bone replacement graft – each additional site in quadrant D4265 – Biologic material to aid in soft and osseous tissue regeneration D4266 – Guided tissue regeneration – resorbable barrier, per site
D4267 – Guided tissue regeneration – nonresorbable barrier, per site D4270 – Pedicle soft tissue graft
D4271 – Free soft tissue graft (including donor site)
D4273 – Subepithelial connective tissue graft procedures, per tooth D4275 – Soft tissue allograft
D4276 – Combined connective tissue and double pedicle graft, per tooth D4341 – Periodontal scaling and root planning – 4 or more teeth per quadrant D4342 – Periodontal scaling and root planning – 1 to 3 per quadrant
Fixed and Removable Partial Prostheses: D5110 – Complete denture – maxillary D5120 – Complete denture – mandibular D5130 – Immediate denture – maxillary D5140 – Immediate denture – mandibular D5211 – Maxillary partial denture – resin base D5212 – Mandibular partial denture – resin base
D5213 – Maxillary partial denture – cast metal framework D5214 – Mandibular partial denture – cast metal framework D5281 – Removable unilateral partial denture
Prior Authorization Requirements (continued)
Services Requiring Prior Authorization
Fixed and Removable Partial Prostheses (continued): D6210 – Pontic – cast high noble metal
D6211 – Pontic – cast predominantly base metal D6212 – Pontic – cast noble metal
D6214 – Pontic – titanium
D6240 – Pontic – porcelain fused to high noble metal
D6241 – Pontic – porcelain fused to predominantly base metal D6242 – Pontic – porcelain fused to noble metal
D6245 – Pontic – porcelain/ceramic
D6250 – Pontic – resin with high noble metal
D6251 – Pontic – resin with predominantly base metal D6252 – Pontic – resin with noble metal
D6545 – Retainer – cast metal for resin bonded fixed prosthesis
D6548 – Retainer – porcelain/ceramic for resin bonded fixed prosthesis D6720 – Crown – resin with high noble metal
D6721 – Crown – resin with predominantly base metal D6722 – Crown – resin with noble metal
D6750 – Crown – porcelain fused to high noble metal
D6751 – Crown – porcelain fused to predominantly base metal D6752 – Crown – porcelain fused to noble metal
D6781 – Crown – 3/4 cast with predominantly base metal D6782 – Crown – 3/4 cast with noble metal
D6783 – Crown – 3/4 porcelain/ceramic D6790 – Crown – full cast high noble metal
D6791 – Crown – full cast predominantly base metal D6792 – Crown – full cast noble metal
Prior Authorization Requirements (continued)
Services Requiring Prior Authorization
Oral Surgery:
D7260 – Oroantral fistula closure D7272 – Tooth transplantation
D7280 – Surgical access of an unerupted tooth
D7283 – Placement of device to facilitate eruption of impacted tooth
D7310 – Alveoloplasty in conjunction with extraction – 4 or more teeth or tooth spaces
D7320 – Alveoloplasty not in conjunction with extraction – 4 or more teeth or tooth spaces
D7340 – Vestibuloplasty – ridge extension (secondary epithelialization) D7350 – Vestibuloplasty – ridge extension (including soft tissue grafts) D7471 – Removal of lateral exostosis (maxilla or mandible)
D7472 – Removal of torus palatinus D7473 – Removal of torus mandibularis
D7530 – Removal of foreign body from mucosa, skin or subcutaneous alveolar tissue
D7540 – Removal of reaction producing foreign bodies
D7550 – Partial ostectomy/sequestrectomy for removal of non-vital bone D7560 – Maxillary sinusotomy for removal of tooth fragment or foreign body D7840 - Condylectomy D7850 – Surgical discectomy D7852 – Disc repair D7854 – Synovectomy D7856 – Myotomy D7858 – Joint reconstruction D7860 – Arthrotomy D7865 – Arthroplasty D7872 – Arthroscopy – diagnosis
D7873 – Arthroscopy – surgical: lavage and lysis of adhesions D7874 – Arthroscopy – surgical: disc repositioning and stabilization D7875 – Arthroscopy – surgical: synovectomy
D7876 – Arthroscopy – surgical: discectomy D7877 – Arthroscopy – surgical: debridement D7920 – Skin graft
D7940 – Osteoplasty – for orthognathic deformities D7941 – Osteotomy – mandibular rami
D7943 – Osteotomy – mandibular rami with bone graft D7944 – Osteotomy – segmented or subapical
D7945 – Osteotomy – body of mandible
Prior Authorization Requirements (continued)
Services Requiring Prior Authorization
Oral Surgery (continued):
D7950 – Osseous, osteoperiosteal or cartilage graft of mandible or maxilla D7955 – Repair of maxillofacial soft and/or hard tissue defect
D7960 – Frenulectomy – separate procedure D7963 – Frenuloplasty
D7970 – Excision of hyperplastic tissue – per arch D7980 – Sialolithotomy
D7981 – Excision of salivary gland, by report D7982 – Sialodochoplasty
D7983 – Closure of salivary fistula D7991 – Coronoidectomy
D7995 – Synthetic graft – mandible or facial bones, by report
D7996 – Implant – mandible for augmentation purposes (excluding alveolar ridge)
Orthodontics:
D8010 – Limited orthodontic treatment of the primary dentition D8020 – Limited orthodontic treatment of the transitional dentition D8030 – Limited orthodontic treatment of the adolescent dentition D8040 – Limited orthodontic treatment of the adult dentition
D8050 – Interceptive orthodontic treatment of the primary dentition D8060 – Interceptive orthodontic treatment of the transitional dentition D8070 – Comprehensive orthodontic treatment of the transitional dentition D8080 – Comprehensive orthodontic treatment of the adolescent dentition D8090 – Comprehensive orthodontic treatment of the adult dentition D8670 – Periodic orthodontic treatment visit
D8690 – Orthodontic treatment (alternative billing to a contract fee) D8691 – Repair of orthodontic appliance
D8692 – Replacement of lost or broken retainer
D8693 – Rebonding or recementing; and/or repair, as required of fixed retainers
Adjunctive General Services: D9940 – Occlusal guard, by report