Dental Prior Authorization Forms

• Dental Services (9/28/17)
• Dentures (<21 years old) (9/28/17)
• Limited Orthodontic Treatment (9/28/17)
• Interceptive Orthodontic Treatment (9/28/17)
• Interceptive Orthodontic Treatment Type-In (9/28/17)
• Treatment to Control Harmful Habits (10/05/17)
• Comprehensive Orthodontic Treatment TYPE-IN / Write-In (4/18/18)
• Procedure codes that require reporting for Area of Oral Cavity (01/22/2016)   
• Dental Claim Submission –  ICD 10 Dental Diagnosis update Communication (02/17/2015)