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SD Medicaid orthodontic review process


The South Dakota Medicaid program is implementing a new review process for orthodontic benefits on July 1, 2020.


The goals of these changes are a more efficient process, better patient compliance with treatment plans, and increased access to care for patients covered by Medicaid.

The changes are detailed below, followed by the forms and instructions for download and use.

A new rating index

The Salzmann Index will be replaced by the Handicapping Labio-Lingual Deviations Form (HLD Index) for more objective scoring based on condition.

Beginning July 1, 2020, the treatment must be medically necessary as determined by a score of 30 or higher on the HLD Index. The treating provider will complete the HLD index and submit with the orthodontic treatment plan for review.

3 new pre-determination criteria:

1. Completion of a new Pre-Orthodontic Certification Form by the patient’s general dentist, attesting that the patient:

* is up to date with preventative care;
* exhibits good oral hygiene practices at home; and
* is up-to-date with restorative work.

The form will be presented by the patient to the orthodontic provider for the patient to be assessed for orthodontic services covered by SD Medicaid. The form must be submitted with the orthodontic treatment plan.

Delta Dental of South Dakota can help patients currently scheduled for upcoming orthodontic assessments to get the form through the remainder of the year.

2. The parent/legal guardian of the patient must complete an orthodontic education session with a Medicaid Dental Care Coordinator prior to being approved for treatment; and

3. The parent/legal guardian of the patient must sign a summary of the patient’s responsibilities discussed in the orthodontic education session.

A new payment structure

Beginning July 1, 2020, orthodontic providers will be rembursed 50% at the beginning of treatment, 25% at midpoint, and 25% at completion of treatment of patients covered by SD Medicaid.

New ortho process explained

Video

New ortho process explained

How do the changes to the Medicaid orthodontic benefit impact your practice? This 40-minute video presentation explains the new process, including the new scoring tool, oral hygiene and patient responsibility criteria, and resources for providers.   

Watch on YouTube

New orthodontic process steps

Medicaid orthodontic process forms

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.

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