Dentaquest Ortho Score Sheet Score exactly as measured from the labial of the lower incisor to the labial of the upper incisor The measurement in millimeters is entered on the score sheet and multiplied by five 5 A reverse overbite if present should
PROCEDURE use this score sheet and a Boley Gauge or disposable ruler Indicate by checkmark next to A or B which criteria you are submitting for review Position the patient s teeth in centric occlusion HANDICAPPING LABIO LINGUAL DEVIATION HLD INDEX SCORE SHEET Instructions Complete this score sheet and submit along with a completed prior authorization request A Boley Gauge or disposable
Dentaquest Ortho Score Sheet
Dentaquest Ortho Score Sheet
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DentaQuest Recommended As Preferred Vendor By The Association For
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Orthodontic Criteria Salzmann Index Author DentaQuest Created Date 12 27 2022 11 08 50 AM PDF 1 7 4 0 obj Filter FlateDecode Length 26004 stream x Ov 8 S I 1g 3 b 22 lK O rG o O
all dental work must be completed and oral hygiene must be good BEFORE orthodontic treatment is approved PROCEDURE use this score sheet and a Boley Gauge or disposable ruler Indicate by checkmark next to A B and or C which criteria you are submitting for review Position the patient s teeth in centric occlusion orthodontic index to assess severity of malocclusion and to help identify and prioritize treatment needs New York State will establish a total score of 26 on the HDL Index as a threshold score This is consistent with determinations made in NYS following the existing guidelines as well as with other states such as California Nevada and Alaska
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Enter total on the score sheet and multiply by five 5 If ectopic eruption exists in the anterior region of the same arch count the condition that scores the most points All orthodontic services included in ACA qualified dental products require prior authorization by a CareFirst dental consultant The member must present with a fully erupted set of permanent teeth
The Orthodontic Qualifying Score In order to qualify for orthodontic coverage in the HUSKY Health Program the minimum scoring for medical necessity will be 26 points and greater which will make Connecticut consistent with other states minimum scoring requirement The purpose of this study was to compare subjects who were submitted for coverage under either the DentaQuest Orthodontic Criteria Index or the HLD index to see if a difference exists in the number of subjects who received coverage and the type of malocclusions that were covered
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Score exactly as measured from the labial of the lower incisor to the labial of the upper incisor The measurement in millimeters is entered on the score sheet and multiplied by five 5 A reverse overbite if present should
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PROCEDURE use this score sheet and a Boley Gauge or disposable ruler Indicate by checkmark next to A or B which criteria you are submitting for review Position the patient s teeth in centric occlusion
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Dentaquest Ortho Score Sheet - Insurance claim submission process for DentaQuest insurance company required patient digital records and scored HLDI sheet by orthodontist A board of case assessors at DentaQuest Medicaid insurance company will assess the cases provide the result
