DENTAL

Mercy Care members under age 21 are covered for comprehensive dental services. The use of preventive dental services is strongly encouraged. To support this, Mercy Care Plan contracts directly with dental providers and allows members to select a dentist from a published dental directory. No PCP referral or prior authorization is required for a member to see a contracted general dentist.

Dental services for adults are limited to emergency dental services, medically necessary dentures and pre-transplant dental services. Specific dental services covered under these limitations can be determined by the member's dentist. No prior authorization is needed for emergency services.

Mercy Care Advantage members are covered for additional limited services. Oral exams, cleaning and fluoride treatments are covered services up to two visits a year. Dental x-rays are covered once a year. No prior authorization is required.

Mercy Healthcare Group members are not covered for dental services.

REQUESTING A DENTAL PRIOR AUTHORIZATION

Mercy Care requires prior authorization for selected services. These services are outlined and summarized in the Benefit Matrix.

GENERAL INFORMATION

Prior authorization is required for the following:
  • Any treatment over $500
  • Services specified with a PA code on the Benefit Matrix
  • Referrals to a specialist

DENTAL OFFICE RESPONSIBILITY IN PRIOR AUTHORIZATION

The following is an outline of the role and responsibilities of the dental office in the Prior Authorization process.
  • Verify member eligibility before each appointment, particularly if multiple visits are authorized.
  • Determine if the service(s) requires prior authorization.
  • Submit a pre-treatment estimate by mail on an ADA form along with the Dental Prior Authorization Request Form to our Dental Prior Authorization unit. Include necessary supporting documentation of diagnostic quality (x-rays, narrative, charting).
  • For a referral to a specialist, submit the Dental Prior Authorization Request Form to the Dental Prior Authorization Unit. State the reason for the need to refer to a specialist on the form.
  • Refer only to MCP contracted dental specialists. If you need a Specialist List, please contact your Provider Representative or refer to the Mercy Care Plan Web site.
If a treatment plan changes, or if during the course of treatment an immediate procedure which is a covered service is required, do not interrupt a patient's care in order to obtain authorization. After the treatment, submit any changes to the original authorization that are needed, along with relevant documentation, and MCP will respond to the change request.

REQUESTING A ROUTINE DENTAL AUTHORIZATION BY MAIL

Complete requests will be processed within 14 working days from date of receipt (please allow for mailing time).

Mailing Address: Mercy Care Plan
Attn: Dental Prior Authorization Unit
2800 North Central Avenue, Suite 400
Phoenix, Arizona 85004


REQUESTING AN URGENT DENTAL AUTHORIZATION BY TELEPHONE

NOTE: Calling is reserved for urgent dental authorizations (when services are needed the same day or next day). Choose the Provider option. 

Call:  Phoenix (602) 263-3000
Outside the Phoenix Area (800) 624-3879

Please have the following information ready to give to the Prior Authorization staff:
  • Member identification number
  • Member name and date of birth
  • Diagnosis
  • Reason for referral or treatment proposed (including procedure codes)
  • For a referral, the specialty provider's name and phone number

REFERRAL OF MEMBERS WITH DEVELOPMENTAL DISABILITIES

Members with developmental disabilities (DD) require coordination of their medical and dental needs. If you need to refer a DD member to a dental provider who is equipped to accommodate special needs, please call the DD Liaison at (602) 263-3995 or (800) 624-3879 Ext. 3995 for assistance.


DENTAL BENEFIT MATRIX - CLICK HERE

DENTAL PA REQUIREMENTS NOTICE - CLICK HERE

PRIOR AUTHORIZATION FORM - CLICK HERE





August 20, 2008