Get Thsteps Dental Mandatory Prior Authorization Request Form

Completing the THSteps Dental Mandatory Prior Authorization Request Form online is essential for obtaining necessary dental services. This guide provides a step-by-step approach to help you successfully fill out the form, ensuring you provide all required information accurately.

Follow the steps to complete your prior authorization request form online.

1. Click ‘Get Form’ button to obtain the form and open it for editing.
2. Begin by entering the client’s name in the designated field, including the last name, first name, and middle initial.
3. Input the Medicaid number (PCN) for the client in the specified section.
4. Fill in the client's date of birth in the appropriate format.
5. Select the appropriate documentation that you are submitting for review for either restorative or orthodontic services.
6. For orthodontic services, indicate the documentation being submitted, such as plaster cast models, X-rays, photos, or others.
7. Specify the date of service diagnostic tools were produced, ensuring accuracy.
8. Complete the proposed treatment plan section by entering the procedure code, tooth number or letter, surface involved, and charge.
9. The performing dentist must then review and check the relevant certification statements provided in the form.
10. Finally, the performing dentist should sign and date the form, along with providing their printed name, telephone number, address, fax number, TPI, NPI, and taxonomy.
11. After completing all sections, you can save your changes, download, print, or share the form as necessary.

Start completing your THSteps Dental Mandatory Prior Authorization Request Form online now for efficient processing.