Ortho Score Sheet Medicaid 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
ATTACH MEDICAL EVIDENCE AND APPROPRIATE DOCUMENTATION FOR EACH OF THE FOLLOWING EIGHT AREAS ON A SEPARATE PIECE OF PAPER IN ADDITION TO COMPLETING THE HLD SCORE SHEET ABOVE Any other relevant documentation available which may assist the DOH in making a determination 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
Ortho Score Sheet Medicaid
Ortho Score Sheet Medicaid
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Ortho Nurse Report Sheet SBAR Patient Handoff Download Now Etsy
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Fillable Online ACA HLD Orthodontic Treatment Score Sheet ACA HLD
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Providers should be conservative in scoring Liberal scoring will not be helpful in the evaluation and approval of the case The case must be considered dysfunctional and have a minimum of 26 points on the IAF to qualify for any orthodontic care other than crossbite correction Enter a score of zero 0 if the condition is absent Start by measuring overjet of the most protruding incisor Measure overbite from the labio incisal edge of the overlapped front tooth teeth to point of maximum coverage Ectopic eruption and Anterior crowding should not be doubled scored Record only the more serious condition not both
The Handicapping Labio Lingual Deviations Form HLD is a quantitative objective method for measuring malocclusion The HLD provides a single score based on a series of measurements that represent the degree to which a case deviates from normal alignment and occlusion You will need this form and a scaled millimeter ruler or a Boley Gauge 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
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Current Medicaid guidelines are outdated and do not reflect current standards of orthodontic treatment The HLD Index is simple to use and the results are reproducible The HLD Index provides an objective and standardized measurement methodology to determine Medicaid coverage for the treatment of a severe physically handicapping malocclusion The treating dentist orthodontist must submit a written detailed explanation of the medical necessity of the orthodontia services along with the completed HLD Index PA request form and treatment plan
Please be advised that Healthcare and Family Services HFS has implemented a new orthodontia scoring tool effective January 1 2017 This new tool will be used to assess all orthodontic cases for LIBERTY Dental Plan LIBERTY members beginning January 1 2017 Assessment of HLDI Scoring Methods and Their Effect on Orthodontic Medicaid Approval Denial Rates In 2017 the state of Illinois implements Handicapping Labio Lingual Deviation Index HLD as a system to determine severe malocclusion of children they will cover for orthodontic treatment
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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
https://www.emedny.org/ProviderManuals/Dental/PDFS/H…
ATTACH MEDICAL EVIDENCE AND APPROPRIATE DOCUMENTATION FOR EACH OF THE FOLLOWING EIGHT AREAS ON A SEPARATE PIECE OF PAPER IN ADDITION TO COMPLETING THE HLD SCORE SHEET ABOVE Any other relevant documentation available which may assist the DOH in making a determination
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Fillable Online ACA HLD Orthodontic Treatment Score Sheet Fax Email
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Ortho Score Sheet Medicaid - Providers should be conservative in scoring Liberal scoring will not be helpful in the evaluation and approval of the case The case must be considered dysfunctional and have a minimum of 26 points on the IAF to qualify for any orthodontic care other than crossbite correction
