National Association of Dental Plans Clarifies How to Obtain Medically Necessary Treatment Criteria

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In response to the many AAO members who have found it challenging to obtain the criteria defining medically necessary care for orthodontic cases, AAO leadership reached out to our industry partner, the National Association of Dental Plans (NADP) in hopes of collecting information helpful in qualifying cases in question.  The AAO requested state-by-state breakdowns on how to qualify cases and streamline the claims process.*
 
The AAO learned that an agreement between the NADP and member payers prohibits the distribution of proprietary information. The response noted the information sought by the AAO can often be found on respective payer websites. NADP Deputy Executive Director Tim Brown also noted that in some cases, the qualifying criteria can be found in the provider’s network participation agreement. 
 
Dr. Steve Robirds, AAO code consultant and the AAO Council on Orthodontic Health Care (COHC) are continuing to work toward gaining payer acceptance of the AAO’s proposed auto-qualifiers to determine eligibility/approval to receive medically necessary orthodontic care. 
 
* An excerpt from the AAO’s letter to the NADP: “As you know, various states and even various payers within those states define 'medically necessary orthodontic care' differently.  Many of the carriers and administrators have not communicated to providers what index or qualifying mechanism is being used.  Our members are having a difficult time determining what information they need to submit with patient claims in order to satisfy payer requirements. We would like to request that NADP provide us with a state-by-state listing of all qualifying criteria needed to establish medically necessary care for orthodontics as required by your member insurance payers.”
 
Jun. 1, 2017

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