DENTAL PRIOR AUTHORIZATION REQUEST AND NOTOFICATION OF BENEFITS

Please allow 48 hours for your request to be completed. This response will include the coverage for each code, the plan's UCR, and allowable fees for the service being rendered.

Requesting provider NPI (or IHCP Provider ID)

Requesting provider

Requesting Provider Tax ID

Requesting Provider Tax ID :Requesting provider

Dentist Name

Name :Requesting provider(Required)

Provider’s Address

Taxonomy :Requesting provider

Telephone

Telephone :Requesting provider

Member name

Member address

Member ID/ Policy

Member date of birth

Dates of service		Requested service		Place of service	Units	Billed Charges
Start MMDDYYYY	Stop MMDDYYYY	Procedure code REQUIRED	Description	Place of service	Units	Billed Charges
Date MM slash DD slash YYYY Date MM slash DD slash YYYY Date MM slash DD slash YYYY Date MM slash DD slash YYYY Date MM slash DD slash YYYY Date MM slash DD slash YYYY Date MM slash DD slash YYYY	Date MM slash DD slash YYYY Date MM slash DD slash YYYY Date MM slash DD slash YYYY Date MM slash DD slash YYYY Date MM slash DD slash YYYY Date MM slash DD slash YYYY Date MM slash DD slash YYYY	Procedure code 1 Procedure code 2 Procedure code 3 Procedure code 4 Procedure code 5 Procedure code 6 Procedure code 7	Description 1 Description 2 Description 3 Description 4 Description 5 Description 6 Description 7	Place of service 1 Place of service 2 Place of service 3 Place of service 4 Place of service 5 Place of service 6 Place of service 7	Units 1 Units 2 Units 3 Units 4 Units 5 Units 6 Units 7	Dollars 1 Dollars 2 Dollars 3 Dollars 4 Dollars 5 Dollars 6 Dollars 7

*Notification of Benefits is not a guarantee of payment, verification of eligibility or treatment decision. All treatment decisions are made between the member and the treating dentist. Payment of benefits is based on eligibility and the terms of the dental rider at the time of service. The insurer will only pay for services that it determines to be medically necessary based on usual, reasonable and customary charges. If the insurer determines that a particular service is not medically necessary, the member is not eligible or that a particular service is not covered under the dental rider, the insurer will deny payment for that service. All unauthorized treatment in excess of $500 will be subjected to a review and may be subject to a penalty or denial of the claim(s).

DENTAL PRIOR AUTHORIZATION REQUEST AND NOTOFICATION OF BENEFITS

Dental treatment plan