Dental Anesthesia Prior Authorization Requirements

Date: 10/03/18

As a reminder, when requesting prior authorization for Dental Anesthesia for Superior Medicaid (STAR, STAR+PLUS, STAR Health, STAR Kids) and CHIP members, please follow the requirements listed below:

Dental office  

• General anesthesia provided in a dentist office will require prior authorization through Superior for CHIP and Medicaid members, regardless of the member’s age. 
• For services provided to Medicaid members under the age of 7, the dental provider must include a copy of the Dental Maintenance Organization (DMO) authorization form with the request for prior authorization for general anesthesia in the office. Dental providers are being notified of this change in a separate communication through the Medicaid DMOs.

Facility (ASC or hospital)

• Superior will continue to require prior authorization for facilities for all dental procedures, regardless of the member’s age. 
• For services provided to Medicaid members under the age of 7, the facility will be required to provide the DMO authorization for at the time of their prior authorization request.
  • Anesthesiologists’ claims will be denied if the dentist or facility fail to obtain prior authorization for dental anesthesia services provided to members under 7 years of age.

Dental Anesthesia Claim Submissions

• Consistent with this guidance, DMO forms must be included with prior authorization requests for Medicaid members under 7 years of age, but are no longer required as attachment to dental anesthesia claims for all Superior Medicaid members under 7 years of age. 

• As a reminder, effective February 1, 2018, the required modifier was changed from EP to U3 for the following procedure codes:
  • Procedure code 00170 when submitted for dental general anesthesia
  • Procedure code 41899 when submitted by a freestanding or hospital-based ambulatory surgical center for dental therapy under general anesthesia in the outpatient hospital setting
• Providers may currently bill the U3 modifier for CHIP dental general anesthesia member claims.  
• Beginning on January 1, 2019, Superior HealthPlan will require the U3 modifier for dental general anesthesia for CHIP members. For dates of service on and after January 1, 2019, dental anesthesia claims for CHIP members will be denied if the U3 modifier is not billed for those services. 

The Texas Medicaid Program’s communication can be found by visiting Texas Health Steps Prior Authorization Requirements for Dental Anesthesia (PDF).

For additional questions or information, please contact your Superior HealthPlan Account Manager.