Download FAX FORM ORTHO Dental Services Prior

Medicaid Prior Authorization of Dental Services
Orthodontics
Fax – 1- 855-409-1521
Review Type:
Admission
Request Date: _________________
Modification (Extension of services)
Retrospective
RECIPIENT INFORMATION
Recipient Name: Last, First, Middle
Medicaid ID #:
_______________________________________________________
/
Date of Birth:
Sex:
/
Age:
/
Date of First Evaluation:
If Medicaid eligibility is retroactive,
/
Please enter start date of service:
/
/
REQUESTOR INFORMATION
REQUESTING ORTHODONTIST/PEDIODONTIST
Requestor’s Name:
Orthodontist/Pediodontist Name: Last, First, Middle
_____________________________________________________
___________________________________________________
(
Phone #:
)
-
Ext.
Fax # :
(
)
-
Phone #:
(
)
-
Fax # :
(
)
-
Medicaid #:
(Required)
email: _______________________________________________
NPI:
REFERRING DENTIST
DIAGNOSIS
Dentist’s Name: Last, First, Middle
Diagnosis Code: ______________________________
Description: __________________________________
___________________________________________________
/
/
Phone #:
(
)
-
Diagnosis Identified Date:
Fax # :
(
)
-
Diagnosis Code: ______________________________
Description: __________________________________
Medicaid #:
Diagnosis Identified Date:
/
/
NPI:
CDT™ CODE(S)
DESCRIPTION(S)
# UNITS
START DATE
THRU DATE
D8070
Comprehensive TX – trans dentition
/
/
/
/
D8080
Comprehensive TX- adolescent dentition
/
/
/
/
Effective: 12/01/12
Revised:
Page 1 of 5
Medicaid Prior Authorization of Dental Services
Orthodontics
Fax – 1- 855-409-1521
Medicaid ID Number:
CDT™ CODE(S)
Recipient Last/First/Middle Name:
DESCRIPTION(S)
# UNITS
START DATE
THRU DATE
D8090
Comprehensive TX – adult dentition
/
/
/
/
D8210
Removable appliance therapy
/
/
/
/
D8220
Fixed appliance therapy
/
/
/
/
D8670
Periodic orthodontic TX visit
/
/
/
/
D8692
Replacement – lost or broken retainer
/
/
/
/
D8999
Unspecified orthodontic procedure
/
/
/
/
Date Appliance Placed is required only for codes D8210 or D8220 for retrospective reviews or admission reviews when the recipient is retroactively eligible for
Medicaid, the appliance was placed prior to the request for authorization, and the recipient has not been discharged from care.
Date Appliance Placed, if applicable:
/
/
Please select the reason(s) for orthodontic request:
Cleft lip, cleft palate and other craniofacial anomalies
Upper anterior contact point displacements greater
than 4 mm
Overjet of 9 mm or more
Individual anterior tooth crossbites w/ greater than
2mm discrepancy between retruded contact position
and intercuspal position
Impinging overbite w/ evidence of gingival or palatal
trauma
Other: please explain:
Reverse overjet of 2mm or more
Extensive hypondontia w/ restorative implications
requiring pre-prosthetic orthodontics
Anterior open bites greater than 4mm
Impeded eruption of teeth (except third molars due to
overcrowding, displacement, presence of supermumerary
teeth, retained primary teeth, and any pathologic cause;
unless extraction of displaced teeth or adjacent teeth,
requiring no orthodontic treatment would be more
expedient
Effective: 12/01/12
Revised:
Page 2 of 5
Medicaid Prior Authorization of Dental Services
Orthodontics
Fax – 1- 855-409-1521
Medicaid ID Number:
Recipient Last/First/Middle Name:
Has the service already been provided:
Yes
No
Start date of treatment:
/
/
Orthodontic Initial Assessment Form score:
If this is a request to transfer a recipient in active treatment
provided by another orthodontist or pediodontitist, complete
the following.
Reason for transfer of treatment:
Treatment dates provided by other orthodontist or
pediodontitist:
From Date:
/
/
Thru Date:
/
/
Number of units provided:
Number of months remaining on PA:
When request is for extension of service limits (modification), explain why extension is needed:
Clinical Summary Information- prior treatment history, current treatment plan and other pertinent information, etc.
Effective: 12/01/12
Revised:
Page 3 of 5
Medicaid Prior Authorization of Dental Services
Orthodontics
Fax – 1- 855-409-1521
Medicaid ID Number:
Recipient Last/First/Middle Name:
Florida Agency for Health Care Administration Disclaimer Statement
eQHealth Solutions certification determination does not guarantee Medicaid payment for services. Eligibility for
and payment of Medicaid services are subject to all terms and conditions and limitations of the Medicaid
Program.
Requesting Provider Attestation Statement
I hereby attest that, as s dental services provider or provider representative, an order for dental services has
been received for the recipient. In addition, I attest that the treatment plan has been approved by the prescribing
(ordering) dentist. A dental provider who knowingly or willfully makes or causes to be made any false statement
or representation of a material fact in any application for Medicaid benefits or Medicaid payments, may be
subject to the application of sanctions, which include, but are not limited to, fines, suspensions, and
termination. In addition, the provider may be prosecuted under federal and/or state criminal laws and may be
subject to civil monetary penalties and/or fine.
Printed Name: ________________________________
Signature: ____________________________________
Date: _______________________________________
Effective: 12/01/12
Revised:
Page 4 of 5
Medicaid Prior Authorization of Dental Services
Orthodontics
Fax – 1- 855-409-1521
Remember to submit the required supporting documentation described in the following table. Only submit dental
models when specifically requested by eQHealth.
Type of Review Request
Initial Review Request (including
retrospective review)
Extension of Services
(modification review)


Required Documentation
Dental radiographs, photographs, images
Initial Assessment Form (IAF)
Note: If the request is for a recipient who is transferring from a different
dental provider the Initial Assessment Form (IAF) is not required.
Current radiographs/photographs/images showing progress to date
The following documentation is not required but may be submitted.
Type of Review Request
All Types of Review Request
Required Documentation
Documentation not included in the review request form that supports the
medically necessity of the requested services.
INSTRUCTIONS FOR COMPLETION OF CDT™ SERVICE CODES START AND THRU DATES:
ORTHODONTIC DENTAL INSTRUCTIONS
Admission Review
Recipient eligible for Medicaid on anticipated start date. Enter the anticipated start and thru date for orthodontic treatment
when treatment has not yet begun. A maximum of 24 visits (units) occurring over 36 months may be authorized for
medically necessary services.
Admission Review
Recipient not eligible for Medicaid on the start date of service, but received retroactive Medicaid eligibility and orthodontic
treatment has not been completed. Complete the actual start date and the anticipated thru date for orthodontic treatment.
A maximum of 24 (visits) units occurring over 36 months may be authorized for medically necessary services.
Modification
Extension of Service Limits: When a request for extension of services beyond 24 visits (units) for an existing authorization
is requested, submit the start date of the extended visits and the thru date of the existing authorization. Submit the total
number of additional units requested.
Transfer Cases
When the recipient is receiving active orthodontic treatment from a different dentist and is transferring to your care, submit
the anticipated start and thru date for the continuation of treatment. Submit the number of visits (units) and number of
months remaining on the previous prior authorization.
Retrospective Review
Recipient did not have Medicaid eligibility at the time to treatment and treatment has been completed. Submit the actual
dates of service and units. If an appliance was placed, submit the date in the applicable field.
Effective: 12/01/12
Revised:
Page 5 of 5