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December 2016 Texas Medicaid Provider Procedures Manual

Medical and Nursing Specialists, Physicians, and Physician Assistants Handbook : 9 Physician : 9.3 Doctor of Dentistry Practicing as a Limited Physician : 9.3.1 Prior Authorization for General Dental Services Due to Life-Threatening Medical Condition : Guidelines for Requesting Mandatory Prior Authorization
The limited physician dentist must request the mandatory prior authorization, and the request must include:
The limited physician dentist’s provider identifier.
The limited physician dentist’s signature.
All supporting documentation must be included with the request for authorization. Providers are to send requests and documentation to the following address:
Texas Medicaid & Healthcare Partnership
Special Medical Prior Authorization
12357-B Riata Trace Parkway, Suite 100
Austin, TX 78727
Fax: 1-512-514-4213

Texas Medicaid & Healthcare Partnership
CPT only copyright 2014 American Medical Association. All rights reserved.