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 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