Does NC Medicaid Cover Braces?

North Carolina Medicaid can provide coverage for orthodontic treatment, but this coverage is available only under specific circumstances. It is generally offered to individuals under the age of 21 when the treatment is determined to be medically necessary. This means that coverage is not typically provided for cosmetic purposes, but rather for conditions that affect a person’s health and function.

Eligibility for Coverage

For orthodontic treatment to be covered by NC Medicaid, it must be medically necessary. The criteria focus on functional impairments rather than aesthetic concerns, ensuring that treatment addresses conditions that negatively impact a person’s ability to speak, chew, or maintain oral health.

Conditions that may qualify for coverage include severe malocclusion, significant skeletal discrepancies, or severe Class II or Class III dental malocclusions. Other qualifying issues are multiple teeth in crossbite with a functional shift, a deep, complete, and traumatic overbite, or an excessive overjet of 6 millimeters or greater. Severe crowding exceeding 6 millimeters may also meet the criteria. Coverage is extended to individuals under 21 years old through the Early and Periodic Screening, Diagnostic, and Treatment (EPSDT) benefit.

The Prior Authorization Process

Obtaining coverage for orthodontic services through NC Medicaid requires a mandatory prior authorization before any treatment begins. The dental professional, typically an orthodontist, initiates this process by submitting a request to Medicaid. This step is essential because an approved prior authorization does not guarantee payment, nor does it ensure beneficiary eligibility on the date the service is rendered.

The preferred method for submitting prior authorization requests is through the NCTracks Provider Portal, an online system designed to streamline the submission. However, providers also have the option to submit paper forms via mail or fax. The submission must include comprehensive documentation, such as diagnostic records, X-rays, and photographs, along with a detailed treatment plan and a justification for medical necessity. Specific forms, such as the “Supplement to Dental Prior Approval Form (DMA-6602),” are often required to support the request.

Medicaid aims to make a decision on most prior authorization requests within 15 business days. However, this timeframe may be extended if additional information or clarification is needed from the provider. It is the responsibility of the provider to clearly document that the beneficiary meets all clinical coverage criteria. If the request is approved, an authorization number is issued; if denied, there is typically an appeal process available.

Finding a Provider

Locating an orthodontist who accepts NC Medicaid is an important step after understanding the eligibility and prior authorization requirements. A primary resource for this search is the official NC Medicaid website, which provides a provider search tool. This tool allows individuals to look for participating orthodontists within their area.

It is also advisable to directly contact orthodontic offices to confirm if they are currently accepting NC Medicaid and if they are taking on new Medicaid patients for orthodontic treatment. Some local county Department of Social Services (DSS) offices or health departments may also provide lists of participating providers. Finding an orthodontist who is experienced with the NC Medicaid prior authorization process can be beneficial, as their familiarity with the requirements may help navigate the approval process more effectively.