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Prior authorization list

While not required, we encourage prior authorization 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 dental or medical necessity.

To determine if we recommend or require prior authorization for a particular service, search our Authorization Grid.

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

Providers of Medicaid patients

Please contact the patient's dental care organization for services other than hospital dentistry.

Questions about dental prior authorization?

 

Call us

Commercial
866-373-7053

Medicare
888-863-3637

Fax us

541-225-3655