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SD Medicaid orthodontic treatment process

Orthodontic treatment must be pre-approved and is covered by South Dakota Medicaid only when determined to be medically necessary, such as when a child has an extreme need due to difficulty eating, chewing, speaking, or breathing.

Treatment approval process 

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    The patient's general dentist begins the process by completing a Pre-orthodontic Certification Form (available below), attesting that the patient:
    * had at least 1 preventive exam and other recommended preventive services in the last 12 months;
    * exhibits good oral hygiene practices at home; and
    * is up-to-date with restorative work.

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    The patient gives the signed Pre-orthodontic Certification form to the orthodontic provider to be assessed for eligibility for orthodontic services coverage through SD Medicaid.

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    The orthodontic provider submits pre-determination to Delta Dental of South Dakota (DDSD) with:
    * Pre-orthodontic Certification form
    * Handicapping Labio-Lingual Deviations (HLD) Index form (available below)
    * All supporting diagnostic documentation 

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    DDSD conducts a review of documentation
    * If the patient meets criteria, a tentative approval letter explaining the next steps is sent to the patient
    * If the patient does not meet the criteria, a denial letter is sent 

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    The parent/guardian contacts a DDSD Dental Care Coordinator for an othodontic education session about patient responsibilities and barriers to treatment. A statement of orthodontic service agreement - a summary of the patient’s responsibilities - is mailed to the parent/guardian following the call. 

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    The parent/guardian returns the signed statement of orthodontic service agreement to DDSD 

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    A letter of approval is sent to the orthodontic service provider and patient to begin treatment 

Rating index

The treatment must be medically necessary as determined by a score of 30 or higher on the Handicapping Labio-Lingual Deviations (HLD) Index. The orthodontic provider completes the HLD index on a prescribed form (available below) and submits it with the treatment plan for review.

Payment structure

Orthodontic providers will be reimbursed 50% at the beginning of treatment, 25% at midpoint, and 25% at completion of treatment of patients covered by SD Medicaid.

 

Medicaid orthodontic process documents

Pre-orthodontic certification form

To be completed by the patient's dental home provider, this required form will be given to the orthodontic provider.

HLD Index form

To be completed by the orthodontic provider, this required form objectively measures malocclusion and must be submitted to DDSD with the predetermination.

At-risk referral form

Use this form to identify patients considered at-risk and who may benefit from Dental Care Coordination services. Submit the completed form to DDSD as noted in the form instructions.

Patient flyer

This informational flyer can help you explain the orthodontic benefit process to families and children who may be elegible.

The SD Medicaid ortho process explained 

This 40-minute video training presentation explains the process, including the HLD index scoring tool, oral hygiene and patient responsibility criteria, and resources for providers.

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