SD Medicaid orthodontic process

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

Pre-ortho form [.pdf]

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.

HLD index form [.pdf]

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.

At-risk referral