TO:  All Dental Providers

Effective:  July 15, 2013

Dental PA requests can be submitted either on paper via mail or electronically via Medicaid’s web portal.

 

Emergency PA Requests:

When there is a need for an emergency PA, providers must contact HPES/Dental PA Unit by calling 334-215-4144. If there is no answer, a voice mail message will be accepted. The voice mail message must include the following information:

·   Recipient’s name

·   Recipient’s Medicaid number (13 digits)

·   NPI of dentist

·   phone number of dentist including area code

·   nature of emergency

·   contact person if other than dentist for follow-up.

 

A paper or electronic PA request must be completed and received by HPES within ten business days of the telephone call/voice message request. If the paper or electronic request is not received within ten business days of the telephone call/voicemail message, the emergency PA request will be denied.

 

Paper PA Requests:

When submitting a paper PA request, the request must be submitted on a Prior Review and Authorization Dental Request Form (Form 343, revised 05/28/2013). All sections of the form must be completed. If the form is not completed in its entirety or if the PA request is submitted on any other form, the request will be denied.  

 

The completed form must be submitted with required documentation as referenced in the “Legible Documents Required for PA Requests” section of this Alert and must be mailed to HPES (address listed below in the “Mailing Address” section).  If required documents are not received with the paper PA request, the PA will be denied.  

 

Electronic PA Requests: 

When submitting an electronic request, select “Dental” if the service is being performed in the dentist office.  Select “Surgical” if the service is being performed in an outpatient hospital setting. 

 

Following submission of an Electronic PA Request, the required documentation as referenced in the “Legible Documents Required for PA Requests” section of this Alert must be mailed to HPES (address listed below in the “Mailing Address” section). 

 

The documentation must have the PA number written legibly in the upper right hand corner of each page of documentation so the documentation can be matched to the electronic PA request.  Documentation received without a PA number in the upper right hand corner will be shredded.

 

Electronic PA requests will be held for up to ten business days in order to allow sufficient time to receive the mailed documentation.  If the mailed documentation is not received in this time period, the PA request will be denied.  A new PA request must be submitted on paper with all the required documentation for the PA to be reconsidered. 
 

Discontinuance of Dental Mailbox:

The Dental Mailbox is being discontinued effective July 12, 2013 at 5 p.m., CST, all documents including radiographs must be mailed to the address below.

 

In the case of radiographs, the original may be mailed in lieu of a paper copy. If original radiographs are to be returned to the provider, please include a self-addressed, postage-paid envelope.

 

Legible Documents Required for PA Requests:

·         Radiographs are required with PA requests for CDT codes D7240 and D7241.  A post-surgical report by tooth number of actual unusual surgical complication(s) is also required for CDT code D7241.

 

·         Radiographs and medical documentation (clinical notes) are required with PA requests for CDT codes D3410 and D3430.

 

·         Radiographs are required with PA requests for CDT codes D1515, D1510, and D4355.

 

·         Complete periodontal charting, posterior bitewing radiographs and any involved anterior periapical or bitewing radiographs are required with PA requests for CDT codes D4341 and D4910.

 

·         Medical documentation (clinical notes) is required with PA requests for CDT codes: D7970 D9420, D9610, and D9612.

 

·         Radiographs, operative notes, and a completed ADA Dental claim form indicating procedures performed in the hospital setting are required with PA requests for hospital updates.  

 

·         Radiographs and clinical notes are required with PA requests for medical (CPT) codes  

 

Mailing Address:

The paper PA request form and all required documentation must be mailed to:

 

HPES

Dental PA Unit

P.O. Box 244032

Montgomery, AL 36124-4032

 

or

 

HPES

Dental PA Unit

 301 Technacenter Drive

Montgomery, AL 36117

 

Faxed copies will no longer be accepted.

If required documents are not received, the PA will be denied.

 

The Current Dental Terminology (CDT) codes are copyright © American Dental Association.