Provider Alert! Prior Authorization of Texas Health Steps (THSteps) dental therapy under general anesthesia for members who are six years of age or younger

Effective July 1, 2017, Texas Children’s Health Plan will be required to implement prior authorization for Level 4 deep sedation and general anesthesia provided in conjunction with therapeutic dental treatment for Medicaid dental clients from ages 0 through six years. All Level 4 services must be authorized prior to rendering services. Anesthesia services provided by a dentist should use procedure code D9223. Any anesthesia services provided by an anesthesiologist (M.D./D.O.) or certified registered nurse anesthetist (CRNA), should use procedure code 00170, with an EP modifier. Texas Children’s Health Plan will also require prior authorization for facility fees associated with dental therapy under general anesthesia billed with code 41899.

Requests for prior authorization for anesthesiologist/CRNA and facility charges must include:

• Location where the procedure will be performed.
• Narrative detailing the reason for the proposed level of anesthesia.
• Proof of authorization for the dental services from the dental maintenance organization (DMO).

The current process of scoring 22 points on the Criteria for Dental Therapy Under General Anesthesia form does not guarantee authorization or reimbursement for clients who are six years of age and younger.

Emergency Treatment

In cases of an emergency medical condition, accident or trauma, prior authorization is not necessary. A narrative and appropriate pre- and post-treatment radiographs/photographs must be submitted with the claim. These will be reviewed by the MCO for appropriateness prior to payment.

If you have any questions, please call Provider Relations at 1-800-731-8527.