Download TennCare Inpatient and Outpatient Hospital

TennCare Inpatient and Outpatient Hospital Readiness
Pre-admission Form
This form is required to be submitted with documentation as outlined in Section 15.00, Criteria for
Provision of Dental Treatment in a Inpatient/Outpatient Hospital (“Hospital”) Facility or in an Ambulatory
Surgical Center (ASC)
Date ________________________________________________________________
Patient Name ________________________________________________________
Patient Address _______________________________________________________
Patient ID # __________________________________________________________
A. I certify that I have examined this patient
YES
NO
Date of exam ______________________________________________________
B. There is pathology or injury requiring extensive dental treatment (restorative or
surgical)
YES
NO
C. I certify that I have attempted to treat this patient in my office
YES
NO
If yes, date of visit___________________________________________________
D. If a general dentist, I have attempted to refer this patient to a dental specialist (oral
surgeon or pediatric dentist)?
YES
NO
E. If no, why was a referral not made?
F. Were x-rays taken to determine diagnosis?
YES
NO
G. I have submitted all of the documentation required to submit a request for prior
authorization as described in the TennFDUHOffice Reference Manual?
NO
YES
H. If answer to “F” or “G” is no, please explain why the aforementioned documentation
is not being submitted:
________________________________________________________________
CERTIFY THAT THE ABOVE INFORMATION IS CORRECT:
Name of provider ______________________________________________________
Provider’s signature ___________________________________________________
Date ________________________________________________________________
Submit to:
DentaQuest - TennCare
Attn: Pre-authorizations
12121 N. Corporate Pkwy
Mequon, WI 50392
FAX: 262.834.3575 or 888.313.2883
TennCare Dental Provider ORM Oct 2013