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Arkansas Department of Human Services Division of Medical Services DATE: / / BENEFICIARY NAME: PROVIDER: D.D.S. MEDICAL ASSISTANCE DENTAL DISPOSITION REASON FOR DENIAL X-rays do not substantiate need.

How to fill out medical assistance dental disposition

Point by point instructions on how to fill out a medical assistance dental disposition:

1. Gather necessary information: Before filling out the form, make sure you have all the required details. These may include your personal information, medical assistance program information, information about the dental provider, and any relevant dental treatment details.
2. Identify the form: Locate the specific medical assistance dental disposition form required by your state or program. It is essential to use the correct form to ensure accurate documentation.
3. Start with personal information: Begin by providing your personal details, including your full name, address, contact information, date of birth, and social security number. Ensure all information is accurate and up to date.
4. Provide medical assistance program information: Enter the necessary details related to your medical assistance program, such as your program ID number or any other identifying information specific to your program.
5. Fill out dental provider information: Enter the dentist's or dental clinic's information, including their name, address, contact details, and any identification numbers required by the medical assistance program.
6. Describe the dental treatment: Provide a detailed description of the dental treatment you received or are seeking. Include information such as the dates of service, specific procedures performed, treatment codes, and any accompanying diagnostic or procedural codes if applicable.
7. Attach supporting documents: Depending on the requirements of the form, you may need to attach supporting documents such as itemized dental bills, receipts, or any other relevant paperwork. Ensure you follow the guidelines provided on the form regarding document submission.
8. Review and sign the form: Carefully review all the information you provided to ensure accuracy and completeness. Once you are satisfied, sign and date the form as required. Consider making copies of the completed form for your records.

Who needs a medical assistance dental disposition?

1. Individuals who have received dental treatment covered under their medical assistance program.
2. Those seeking reimbursement for dental services or verifying treatment for insurance purposes.
3. Dental care providers who need to report treatment details and receive reimbursement from the medical assistance program.
4. Depending on the specific program or state requirements, the need for a medical assistance dental disposition may vary.

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What is medical assistance dental disposition?

Medical assistance dental disposition is a form that details the dental services provided to patients covered by Medicaid.

Who is required to file medical assistance dental disposition?

Dentists who provide services to patients covered by Medicaid are required to file medical assistance dental disposition.

How to fill out medical assistance dental disposition?

To fill out medical assistance dental disposition, dentists must include the patient's information, the services provided, and any other required details.

What is the purpose of medical assistance dental disposition?

The purpose of medical assistance dental disposition is to document the dental services provided to patients covered by Medicaid for reimbursement purposes.

What information must be reported on medical assistance dental disposition?

Information such as the patient's name, Medicaid ID, services provided, dates of service, and provider information must be reported on medical assistance dental disposition.