LIBERTY Dental Plan (Florida SMMC) form, verified 2026-09-29

Florida Medicaid HLD index worksheet

Enter the measurements from the Florida Medicaid orthodontic initial assessment (FL-Medicaid-HLD_2019.09.23) and get each item's points, the total against the form's 26-point threshold, and whether an automatic qualifying condition is marked. Copy the narrative into your note or print the worksheet. The plan makes the coverage decision; this page reports what the form's arithmetic shows.

Built from the score sheet and scoring instructions published by LIBERTY Dental Plan (Florida SMMC). Florida's SMMC dental plans are LIBERTY and DentaQuest; DentaQuest's form was not found publicly, so DentaQuest members should confirm their plan's form. Sources and the transcription notes are at the bottom of the page.

Measurements only. This page has no name, date of birth or ID field, keeps everything in this browser tab, and sends nothing. The printout has blank lines for the office to fill in by hand.

Items 1 to 6A: automatic qualifying conditions

Mark any that apply. Per the form, a marked condition ends scoring ("score no further"); attach the documentation the form asks for.

1Cleft Palate DeformityAt least one of: diagnostic casts; intraoral photograph of the palate; written consultation report by a qualified specialist or Craniofacial Panel2Cranio-Facial AnomalyDescription of the condition from a credentialed specialist3Deep Impinging OverbiteLower incisors are destroying the soft tissue of the palate; tissue laceration and/or clinical attachment loss must be present4Crossbite of Individual Anterior TeethClinical attachment loss and recession of the gingival margin are present5Severe Traumatic DeviationDescription of the condition; examples: loss of a premaxilla segment by burns or by accident, the result of osteomyelitis, or other gross pathology

6A (overjet over 9 mm with incompetent lips; mandibular protrusion over 3.5 mm with masticatory and speech difficulties) is asked below when the measurement calls for it.

Items 6B to 13: measurements

Position the enrollee's teeth in centric occlusion. Enter the measured value in mm; the worksheet rounds to the nearest mm for the points. Enter 0 when a condition is absent.

Overjet (1 per mm)

Over 9 mm: the form asks whether the lips are incompetent (6A). A measured value over 9 is treated as over 9; the points use the rounded value.

Overbite (1 per mm)

A pencil mark on the tooth showing the extent of overlap helps. The form notes a reverse overbite should be measured and recorded; it gives it no score, and anterior open bite is item 9. Above 15 mm the worksheet asks you to confirm the value.

Mandibular protrusion (reverse overjet) (x5)

Reverse overjet. x5. Over 3.5 mm: the form asks about masticatory and speech difficulties (6A). A measured value over 3.5 is treated as over 3.5; the points use the rounded value.

Open bite (x4)

Absence of anterior occlusal contact, incisal edge of a maxillary central incisor to the corresponding mandibular incisor. x4. With pronounced protrusion a close approximation is acceptable per the form. Above 15 mm the worksheet asks you to confirm the value.

Ectopic eruption (x3 per tooth)

Count each tooth more than 50% blocked out of the arch, excluding third molars. Mutually blocked-out teeth count once. Split by arch and region: the form scores only the higher of anterior ectopic eruption and anterior crowding in the same arch, while posterior ectopic teeth always count.

Maxilla, anteriorMaxilla, posteriorMandible, anteriorMandible, posterior

Anterior crowding (x5 per arch)

Arch length insufficiency must exceed 3.5 mm. Mild rotations that may respond to stripping or mild expansion are not crowding.

Maxilla crowdedMandible crowded

Labio-lingual spread (1 per mm)

One displaced anterior tooth: incisal edge to the normal arch line. Otherwise the distance between the most protruded and the most lingually displaced adjacent anterior tooth. With multiple crowding, enter only the most severe single measurement. Above 15 mm the worksheet asks you to confirm the value.

Posterior crossbite (unilateral = 4)

Two or more adjacent teeth, one a molar; the maxillary teeth involved both palatal or both completely buccal. Bilateral posterior crossbite scores 0.

NoneUnilateralBilateral (scores 0)

Result on this worksheet

Incomplete: no total yet

Still needed (5):

Overjet (item 6B)
Overbite (item 7)
Mandibular protrusion (item 8)
Open bite (item 9)
Labio-lingual spread (item 12)

A total is shown only when every item has a value; enter 0 for an absent condition.

The plan decides. This is a worksheet against the LIBERTY Dental Plan (Florida SMMC) form (FL-Medicaid-HLD_2019.09.23); DentaQuest members should confirm their plan's form.

Narrative to paste

Florida Medicaid HLD index worksheet (FL-Medicaid-HLD_2019.09.23). Worksheet, not the plan's form.
Incomplete: 5 input(s) still needed: Overjet (item 6B); Overbite (item 7); Mandibular protrusion (item 8); Open bite (item 9); Labio-lingual spread (item 12). No total.
Measurements entered so far: Ectopic eruption 0 teeth; Anterior crowding none; Posterior unilateral crossbite none.

Include my measurements, this result and the data version in a “wrong score” report. No identifiers are included. The contact page opens in a new tab; this worksheet stays as it is.

Worksheet, not the plan's form. Florida Medicaid HLD index, FL-Medicaid-HLD_2019.09.23.

Florida Medicaid HLD worksheet

Patient:
Date of birth:
Medicaid ID:
Assessment date:

Items in the plan's form order; copy each score across line by line. Rounded to the nearest mm. The plan decides.

#	Condition	Recorded
1	Cleft Palate Deformity
2	Cranio-Facial Anomaly
3	Deep Impinging Overbite
4	Crossbite of Individual Anterior Teeth
5	Severe Traumatic Deviation
6A	Overjet over 9 mm with incompetent lips, or mandibular protrusion over 3.5 mm with masticatory and speech difficulties
6B	Overjet
7	Overbite
8	Mandibular protrusion (reverse overjet)
9	Open bite
10	Ectopic eruption	0 teeth
11	Anterior crowding	none
12	Labio-lingual spread
13	Posterior unilateral crossbite	none
	Total (this form: 26 or more)

Incomplete: no total yet

Florida Medicaid HLD index worksheet (FL-Medicaid-HLD_2019.09.23). Worksheet, not the plan's form.
Incomplete: 5 input(s) still needed: Overjet (item 6B); Overbite (item 7); Mandibular protrusion (item 8); Open bite (item 9); Labio-lingual spread (item 12). No total.
Measurements entered so far: Ectopic eruption 0 teeth; Anterior crowding none; Posterior unilateral crossbite none.

Sources and transcription notes

form and scoring instructions (2 pages) (LIBERTY Dental Plan (Florida SMMC), retrieved 2026-09-29; SHA-256 5eba5abe9926)
plan provider reference guide (eligibility: score of 26 or higher or an automatically qualifying condition) (LIBERTY Dental Plan (Florida SMMC), retrieved 2026-09-29; SHA-256 2408e3de5217)

LIBERTY Florida Medicaid Provider Reference Guide, revised 10/1/2025, p. 69: “Have a Handicapping Labio-Lingual Deviations (HLD) Index score of 26 or higher or one of the automatically qualifying conditions”.

Where the form is silent, and what this worksheet does

On page 2 (scoring instructions) the instruction text for conditions 3 to 6A is shifted by one row against page 1: row 4 carries the palate-tissue text that belongs to condition 3, row 5 carries the attachment-loss text that belongs to condition 4, and row 6A carries the traumatic-deviation examples that belong to condition 5. Page 1 (the score sheet) is authoritative for the auto-qualifier definitions.
Items 6B, 7 and 12 have no printed multiplier and no 'x' in the score column; they are treated as 1 point per mm (the HLD convention).
The form says to round measurements to the nearest mm but does not say whether the 9 mm overjet and 3.5 mm mandibular protrusion cutoffs compare the raw or the rounded value. This worksheet compares the cutoffs on the raw entered value (a measured 3.51 mm is treated as over 3.5) and rounds only the points.
Item 6B covers overjet of 9 mm or less; 6A covers overjet over 9 mm only with incompetent lips. An overjet over 9 mm without incompetent lips fits neither; the form does not say how to score it and the worksheet reports it as outside the form.
Item 8 covers mandibular protrusion of 3.5 mm or less; 6A covers over 3.5 mm only with masticatory and speech difficulties. Over 3.5 mm without both difficulties fits neither; the worksheet reports it as outside the form.
The overbite instruction says a reverse overbite should be measured and recorded but gives it no score; anterior open bite is item 9. The worksheet takes overbite as a non-negative mm value.

The Florida form lists no review route other than the automatic qualifying conditions (items 1 to 6A) and the 26-point threshold. The state coverage policy (Rule 59G-4.060) names no index or threshold; the plan's guide adds cephalometric and panoramic images to the prior-authorization packet.

Data verified 2026-09-29; re-verification due by 2027-03-28. After that date this page shows the state as not yet supported until the form is checked again. Another state? Request your state.

Orthodontic documentation

The exam note and the letter to the referring dentist from one recording

14 days of full Pro. No sales call.

Start free trial Scribeable for orthodontics

14-day Pro trial with a card on file. $79/month starts 14 days after your trial begins unless you cancel first. Cancel any time from Settings > Billing.