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Preauthorization list

While not required, we encourage preauthorization for the services listed below. The list is not comprehensive.

To request authorization for these services, you may use the ADA Dental Claim Form and mark the "Request for pre-determination/preauthorization" box.

Please include clinical documentation sufficient to determine eligibility and medical necessity. We appreciate your help.

If you have questions, please contact our Dental Customer Service team at (866) 373-7053 or dental@pacificsource.com.

Multiple Crowns

Codes D2710 through D2794

Requested Documentation: 

  • Chart notes 

  • Diagnosis and clinical findings
  • Current radiographs

Implants

Code D6010 

Requested Documentation: 

  • Chart notes 
  • Diagnosis and clinical findings
  • Current radiographs

Periodontics

Codes D4210 through D4342

Requested Documentation: 

  • Chart notes 

  • Diagnosis and clinical findings
  • Clinical photos 
  • Current periodontal charting
  • Current radiographs

Oral and Maxillofacial Surgery

Codes D7220 through D7953

Requested Documentation: 

  • Chart notes 
  • Diagnosis and clinical findings
  • Current radiographs

Questions? We're here to help.

Contact PacificSource Dental Customer Service for questions concerning:
- Member benefits or eligibility
- Status of a specific claim or EOP


Email: dental@pacificsource.com 
Phone: (541) 225-1981 (Eugene) or (866) 373-7053 (all other areas) 
Fax: (541) 225-3655