Medicaid Pre-Authorization

• Medicaid now requires that we fax or mail pre-authorization requests for work to be covered.
• Forms have to be filled out entirely for them to be accepted.
  (click for example form for help)
• Before treatment begins: pre-authorization must be approved and approval number written on claim for payment.
• Fax forms to 1-801-536-0958

Medicaid procedures that must be pre-authorized before beginning treatment:

Periodontics
Codes	Description	Limitations
D4355	Full Mouth Debridement	If patient is UNDER the age of 18. 18 and older not required.
D4341	SCRP - Periodontal scaling and root planing-four or more teeth	Only maybe covered if under the age of 18
D4342	SCRP - Periodontal scaling and root planing-one to three teeth	Only maybe covered if under the age of 18

Crowns & Prosthodontics
Codes	Description	Limitations
D2751	Crown - PFM	Anterior teeth only Children to the age of 20 *Does not cross over because they are pregnant
D5110-D5800	Dentures & Partials

If ever in question about a code and the limitations click here for link to more info.

Related Documents

• Blank form
• Sample Pre filled form

Related Pages

• Medicaid Policies