CSHCN Services Program 2010 > Dental > Benefits, Limitations, and Authorization Requirements

14.2.1 Prior Authorization Requirements

Prior authorization is required for all orthodontia services and selected dental services.

All requests for prior authorization must be submitted using the CSHCN Services Program Prior Authorization Request for Dental or Orthodontia Services form. The TMHP-CSHCN Services Program may require the submission of X-rays, models, etc., for specific prior authorized services. All prior authorization requests must include specific rationale for the requested service, including documentation of medical necessity and appropriateness of the recommended treatment. Additional documentation, including current periapical radiographs, must be maintained in the client's medical or dental record and submitted to the CSHCN Services Program on request.

Authorization and prior authorization request forms submitted to TMHP must be signed and dated by the dental provider treating the client. If indicated on the form, an authorized representative's signature is acceptable. All signatures and dates must be hand-written and current. Computerized or stamped signatures are not permitted. Alterations to dates and signatures, such as cross-outs or white-outs, are not allowed. Submitted forms without an original hand-written signature and date will be rejected. Providers must keep the original, signed forms in the client's medical record as documentation.

Important: Refer to each individual section under Benefits and Limitations for specific information about prior authorization requirements.

Refer to: Section 4.3, "Prior Authorizations" for detailed information about prior authorization requirements.

Appendix B, "CSHCN Services Program Prior Authorization Request for Dental or Orthodontia Services" for an example of this form.

Tip: Photocopy this form and retain the original for future use.

Note: Fax transmittal confirmations are not accepted as proof of timely prior authorization submission.