Tip for State-specific

Adult dental coverage under Medicaid varies significantly by state — some states cover only emergency extractions

Tip for State-specific

Children's dental services are mandatory under Medicaid EPSDT

Tip for State-specific

If denied, the treating dentist can submit a peer-to-peer review or formal appeal

Dental, Vision & HearingmoderateDoctor signature required

Medicaid Dental Authorization / Claim Form

State-specific · State Medicaid agencies / dental MCOs

Prior authorization or claim form for Medicaid dental services. Coverage varies significantly by state; some states limit adults to emergency dental only.

Form Details

Total fields: 35
Auto-fillable: 22 (63%)
Time without BeneFill: 20 minutes
Time with BeneFill: 6 minutes
Time saved: 14 minutes
Filled by: doctor
Frequency: as needed
State-specific: Yes — form may vary by state

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Where to Submit This Form

🌐

Submit through the state Medicaid provider portal

The dental provider typically submits this on behalf of the patient.

📠

Fax to the state Medicaid dental program or managed care plan

Fax number varies by state and managed care plan.

🌐

Call the state Medicaid dental benefits administrator

Provider services line for prior authorization requests.

Filing Deadline

Must be submitted and approved before the dental procedure is performed. Submit at least 10-14 business days before the planned procedure.

Required Attachments

📎 Completed prior authorization request form
📎 Dental radiographs (X-rays) showing the condition requiring treatment
📎 Narrative justification from the treating dentist
📎 Periodontal charting (for periodontal procedures)
📎 Clinical photographs (if applicable)

Processing Time

Standard: 10-15 business days. Expedited: 3-5 business days for urgent conditions.

What Happens Next

The Medicaid dental program will approve, deny, or request additional information. If approved, the authorization number must be included on the claim.

Tips for This Form

✓ Adult dental coverage under Medicaid varies significantly by state — some states cover only emergency extractions
✓ Children's dental services are mandatory under Medicaid EPSDT
✓ If denied, the treating dentist can submit a peer-to-peer review or formal appeal
✓ Emergency dental procedures may not require prior authorization — check your state's policy

More Dental, Vision & Hearing Forms

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J400/J430/J432 · American Dental Association

Standard dental claim form used for billing all dental insurance plans. Includes pre-treatment estimates and procedure codes.

Donated Dental Services Application

DDS Application · Dental Lifeline Network / ADA

Application for free comprehensive dental treatment through volunteer dentists for people who cannot afford treatment due to disability, age (65+), or medical condition.

Medicaid Vision Benefit Authorization

State-specific · State Medicaid agencies

Authorization for Medicaid-covered vision services. Coverage varies widely by state, with some limiting to one exam every two years or glasses only after cataract surgery.

New Eyes Voucher Application

New Eyes Application · New Eyes (nonprofit)

Application for vouchers for prescription glasses for individuals with low income. Must be submitted by a social worker or case manager on behalf of the client.

Lions Club Hearing Aid Program Application

Local club application · Local Lions Clubs

Local program distributing refurbished or low-cost hearing aids to those in need.

Medicaid Hearing Aid Authorization

State-specific · State Medicaid agencies

Authorization for Medicaid-covered hearing aids and audiology services. Not all states cover hearing aids for adults.

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Disclaimer: BeneFill™ provides form-filling assistance and informational guidance only. It is not affiliated with, endorsed by, or sponsored by the State Medicaid agencies / dental MCOs or any government agency. The information provided is for general informational purposes and does not constitute legal, medical, financial, or tax advice. Always verify form requirements and submission details directly with the issuing agency.