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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 : 9.3.1.1 Guidelines for Requesting Mandatory Prior Authorization

9.3.1.1
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.
Note:
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.