Download Orthodontic Request Form - eQHealth Solutions Mississippi Division

Orthodontic Services for EPSDT Eligible
Beneficiaries
Precertification Request Form
460 Briarwood, Suite 300
Jackson, MS 39206
Fax: 888.204.0377
Beneficiary Information
Guardian Name and Address
Name: _________________________________
Guardian Name: _______________________________________
Guardian Address:______________________________________
City, State, Zip Code:____________________________________
Medicaid #:
/
Date of Birth:
/
Guardian Phone Number:
Age:
Sex:
-
-
(M or F)
Provider Information
Request Date:
/
Servicing Provider Medicaid#:
/20
Referring MD/NP/PA Name: _______________________
MS Medicaid #:
Telephone #: (____) ______-________ Ext. ___________
Provider/Facility:
______________________________
Contact/Requestor:____________________________________
Telephone #:(_____) _________ -___________ Ext._________
Fax #: (_____) _________ -_________________
Request Type - Select one
Start Date of Service
Date of Assessment
/
/
Has service already been provided?
Is request the result of an emergency?
Please use ICD-10-CM to complete the below information:
/20
/20
Yes
Yes
Primary diagnosis code:
Secondary diagnosis code:
No
(only use if needed)
No
Is request follow-up from an EPSDT screening?
Yes
Is this request for Phase I treatment?
Yes
No
Is this request for Phase 2 treatment?
Yes
No
Effective:
Revised:
12/1/13
April 2016
No
Tertiary diagnosis code:
(only use if needed)
A list of common codes can be found at ms.eqhs.org or
call (866) 740-2221 for assistance.
Orthodontic Services for EPSDT Eligible Beneficiaries Precertification Request Form
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Please select the MS Medicaid Prior Authorized Orthodontic CDT Procedure Code(s) for your request.
I am requesting the following:
Make a
Selection
Code and Code Description
FULL ORTHODONTIC TREATMENT
D8080 - Comprehensive Orthodontic Treatment of Adolescent Dentition
Units Requested
D8670 - Periodic Orthodontic Treatment Visit (as part of contract) include number of units
requested.
_____
PHASE 1 ORTHODONTIC TREATMENT
D8050 – Interceptive Orthodontic Treatment (Primary Dentition)
D8060 – Interceptive Orthodontic Treatment (Transitional Dentition)
Units Requested
D8670 - Periodic Orthodontic Treatment Visit, include number of units requested.
_____
TRANSFER OF ORTHODONTIC TREATMENT
D8080 - Comprehensive Orthodontic Treatment of Adolescent Dentition
Units Requested
D8670 - Periodic Orthodontic Treatment Visit, include number of units requested.
_____
OTHER ORTHODONTIC TREATMENT
D8999 Unspecified Orthodontic Procedure - by Report
(Do not use this code for transfer from practice or for requests for Full, Phase I, or Phase II treatment ,
unless instructed otherwise by eQHealth)
Other: Please specify_________________________________________________________
THE FOLLOWING QUESTION MUST BE ANSWERED
Is this a request to transfer services to another orthodontist/dental practice? Y
or N
If Yes, please list the name of the previous treating dentist/orthodontist_________________________
If Yes, please complete the month and year treatment was started with the other dental practice and reason for
transfer:
/20
Effective:
Revised:
Reason for transfer: ______________________________________________________
12/1/13
April 2016
Orthodontic Services for EPSDT Eligible Beneficiaries Precertification Request Form
Page 2 of 4
Beneficiary Name: _______________________
Medicaid I.D.:
Additional Instructions and Documentation Requirements
If submitting request via eQSuite ™(online):
If submitting request via fax:
•
•
•
Intraoral pictures AND radiographs are
required
Digital files can quickly be uploaded
DO NOT send dental mold or model unless
requested by eQHealth
•
•
•
•
Precertification request form must be included
Intraoral pictures and radiographs must be mailed
to:
eQHealth Solutions
460 Briarwood Dr, Suite 300
Jackson, MS 39206
DO NOT send dental mold or model unless
requested by eQHealth
All items will be returned upon conclusion of
review.
FULL ORTHODONTIC TREATMENT DOCUMENT REQUIREMENTS
• Intraoral photographs (IOPs)
• Radiographs
• Brief Clinical Summary/Treatment Plan to include clinical goals
PHASE 1 ORTHODONTIC TREATMENT DOCUMENT REQUIREMENTS
• Pre-Phase 1 Intraoral photographs (IOPs)
• Radiographs
• Brief Clinical Summary/Treatment Plan to include clinical goals
PHASE 2 ORTHODONTIC TREATMENT DOCUMENT REQUIREMENTS
• Pre-Phase 1 Intraoral photographs (IOPs) if not previously submitted to eQHealth
• Post-Phase 1 Intraoral photographs
• Updated radiographs (if applicable)
• Brief Clinical Update and Phase 2 Treatment Plan to include
• Measurement of Phase 1 clinical goals
• Beneficiary compliance with Phase 1 treatment plan
• Detail Phase 2 goals
TRANSFER ORTHODONTIC TREATMENT DOCUMENT REQUIREMENTS
• Intraoral photographs (IOPs)
• Updated radiographs (if applicable)
• Brief Clinical Update and Treatment Plan to include clinical goals
• Beneficiary/Parent Freedom of Choice Form available on website ms.eqhs.org
Effective:
Revised:
12/1/13
April 2016
Orthodontic Services for EPSDT Eligible Beneficiaries Precertification Request Form
Page 3 of 4
Beneficiary Name: ________________________
Medicaid I.D.:
CLINICAL TREATMENT PLAN/SUMMARY
Mississippi Medicaid Disclaimer Statement
eQHEALTH SOLUTIONS’ CERTIFICATION DETERMINATION DOES NOT GUARANTEE MEDICAID
PAYMENT FOR SERVICES OR THE AMOUNT OF PAYMENT FOR MEDICAID SERVICES. ELIGIBILITY
FOR AND PAYMENT OF MEDICAID SERVICES ARE SUBJECT TO ALL TERMS AND CONDITIONS AND
LIMITIATIONS OF THE MEDICAID PROGRAM.
I certify the requested items for the above beneficiary are the exact items ordered and certified as medically
necessary by the ordering dentist/physician/nurse practitioner/physician assistant or other Medicaid approved
professional; and the items have been and/or will be delivered to the above beneficiary. Proof of this information is
contained onsite and readily available if needed. A provider who knowingly or willingly makes, or causes to be
made, false statement or representation of a material fact in any application for Medicaid benefits or Medicaid
payments may be prosecuted under Federal and State criminal laws. A false attestation can result in civil monetary
penalties as well as fines, and may automatically disqualify the provider as a provider of Medicaid services
Signature of Provider: _________________________ Date: __________________
Effective:
Revised:
12/1/13
April 2016
Orthodontic Services for EPSDT Eligible Beneficiaries Precertification Request Form
Page 4 of 4