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PRIOR AUTHORIZATION DENTAL REQUEST FORM (PA/DRF) Providers may submit prior authorization (PA) requests by fax to Fresno PACE (855) 6296635 SECTION I PATIENT INFORMATION Patient Identification NumberDate

How to fill out prior authorization dental request

How to fill out prior authorization dental request

1. Obtain the prior authorization dental request form from the insurance company or dental office.
2. Fill out the patient's personal information such as name, date of birth, and insurance policy number.
3. Include the reason for the dental procedure that requires prior authorization.
4. Provide any relevant dental records or attachments that support the need for the procedure.
5. Submit the completed form and supporting documents to the insurance company for review.

Who needs prior authorization dental request?

1. Patients who are seeking coverage for a dental procedure that requires prior authorization.
2. Dentists or dental offices who want to ensure the procedure will be covered by insurance before performing it.

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What is prior authorization dental request?

A prior authorization dental request is a formal process through which a dental provider seeks approval from a patient's insurance company before performing specific dental procedures, ensuring that the proposed treatment is covered under the patient's insurance plan.

Who is required to file prior authorization dental request?

Typically, the dental provider or dentist performing the procedure is required to file a prior authorization dental request on behalf of the patient.

How to fill out prior authorization dental request?

To fill out a prior authorization dental request, the provider needs to complete the form with patient information, procedure codes, a detailed description of the services requested, and any necessary medical documentation to support the request.

What is the purpose of prior authorization dental request?

The purpose of a prior authorization dental request is to ensure that the proposed dental treatment is medically necessary and covered by the patient's insurance plan, preventing unexpected costs for the patient.

What information must be reported on prior authorization dental request?

The information that must be reported includes patient demographics (name, ID number, and contact info), provider information, treatment codes, a description of the dental procedure, and relevant clinical information or medical history that justifies the treatment.