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American Dental Association (ADA) Request for Authorization Claim Form Instructions

Revised: 11-16-2016

Authorization Instructions

If you choose not to use MN–ITS Authorization Request or upload your information in the KEPRO portal, you may submit a paper authorization request using these authorization instructions. Address all boxes unless not used by Minnesota Health Care Programs (MHCP) for dental providers to submit fee-for-service paper ADA authorization claim forms. Submit all authorization requests (except for enrollees of managed care organizations [MCOs]) to the medical review agent mailing address.

You must attach adequate and detailed documentation to the authorization request or your request will be denied for lack of clinical information. Refer to Authorization Requirement Tables for Children and Pregnant Women and Authorization Requirement Tables for Non Pregnant Adults.

Do not submit authorization requests for services that do not require authorization or are noncovered services; they incur unnecessary costs and will not be approved.

To ensure that your forms are properly processed, follow these guidelines:

  • • Paper claims must be typed
  • • Use upper case lettering (capital letters)
  • • Use black or blue ink
  • • Use a 10 or 12 point font, preferably using Times or Arial print face; not dot matrix
  • • Do not use bold or italics
  • • Do not use red ink or write notes in any space other than box 35

  • Box 1:


    Enter an X in the “Request for Predetermination/Preauthorization” box.

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    Box 2:

    Leave blank when submitting an authorization.

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    Box 3:


    Enter the company/plan name, address, city, state and ZIP code as follows:

    PO Box 64166
    St. Paul, MN 55164

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    Boxes 4 through 11:

    If the recipient/subscriber has other coverage enter information as follows:

  • • Dental coverage; complete each of the fields even if the service is not covered on their plan or if the other coverage will pay or had paid zero.
  • • Medical coverage; complete each of the fields only if the dental CDT codes are covered on the plan.
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    Box 12:


    Enter policyholder/subscriber’s (MHCP recipient) name, address, city, state and ZIP code.

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    Box 13:


    Enter subscriber’s (MHCP recipient) date of birth using eight-digit format date MM/DD/YYYY.

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    Box 14:


    Enter an X in the appropriate box to indicate the subscriber’s (MHCP recipient) gender.

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    Box 15:


    Enter policyholder/subscriber’s (MHCP recipient) eight-digit MHCP ID number.

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    Boxes 16 through 17:

    Not used by MHCP.

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    Box 18:


    Enter an X in self box.

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    Box 19:

    Reserved for future use.

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    Boxes 20 through 22:

    Not used by MHCP.

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    Box 23:


    Enter patient ID/account # assigned by the dentist’s office to uniquely identify the patient. This is a HIPAA required field.

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    Box 24:

    Enter the most current and appropriate CDT code (example: D7240).

    Reminder: All service lines on an approved authorization must be billed exactly as approved on the authorization.

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    Box 25:


    Used only for periodontal services. Enter code of the oral cavity code that identifies the quadrant to be worked on.

    00 Whole of the Oral Cavity
    01 Maxillary Area
    02 Mandibular Area
    10 Upper Right Quadrant
    20 Upper Left Quadrant
    30 Lower Right Quadrant
    40 Lower Left Quadrant

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    Box 26:


    Following the MN Uniform Companion guide enter the tooth system as follows:

  • • JP – Tooth number (not used on authorizations)
  • • JO – Oral cavity designation (used only on periodontal services)
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    Box 27:


    Enter the appropriate tooth number, if applicable.

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    Box 28:


    Services that require a tooth surface do not require an authorization. The tooth surface codes are informational only:

    Buccal – B
    Distal – D

    Facial or Labial – F
    Incisal – I

    Lingual – L
    Mesial – M
    Occlusal – O

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    Box 29:


    Enter the most current and appropriate CDT code for the service to be provided.

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    Box 30:


    Required for authorizations. Enter current CDT description of the service requiring authorization.

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    Box 31:


    Enter your usual and customary charge for the procedure.

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    Box 31a:


    Not used by MHCP

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    Box 32:

    Enter the total charge from all requested authorization service lines.

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    Box 33:


    On the most current ADA claim form or on supporting clinical documentation identify all:

    Missing teeth with a “X”

    Tooth numbers of the teeth to be replaced by the prosthesis.

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    Boxes 34 and 34a:

    34 Enter the appropriate diagnosis code qualifier:

    Do not use B=ICD-9; ICD-9 is no longer valid

    Use AB only – ICD-10 code

    34a. Enter the primary diagnosis code in field A. Additional diagnosis codes may be entered in fields B, C, and D; up to a maximum of four diagnoses per authorization request.

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    Box 35:


    Enter additional information. Example: narrative description related to services requiring authorization.

    Additional supporting documentation is required for all MHCP services that require authorization; refer to the authorization links above for each services specific clinical documentation requirements.

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    Boxes 36 and 37:

    Not used by MHCP.

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    Box 38:


    Enter the appropriate CMS compliant place of service code that identifies where the service is to be provided.

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    Box 39:

    Enter a “Y” to indicate if there are any type of radiographs, images, periodontal charting or other clinical documentation that will be submitted with the authorization request.

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    Boxes 40 through 42:

    Not used for MHCP authorization of initial orthodontic care. Used for additional phases of orthodontic care.

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    Box 43:


    Enter X in the appropriate box.

    If no, skip 44.
    If yes, complete 44.

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    Box 44:


    Enter date of prior placement of prosthesis.

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    Box 45:


    If claim is related to an accident, enter X in the appropriate box and complete 46 or 47 or both.

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    Box 46:


    Enter date of accident.

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    Box 47:


    If auto accident related, enter state where auto accident occurred.

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    Box 48:


    Enter the billing dentist’s or dental entity’s name.

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    Box 49:


    Enter the enrolled MHCP billing provider or individual dentists NPI number.

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    Box 50:


    Not used by MHCP.

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    Box 51:


    Enter the billing dentist’s or dental entity’s federal tax identification number of social security number.

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    Box 52:


    Enter the phone number of the dentist or dental entity.

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    Box 52A:


    This box is situational unless the pay-to-provider was enumerated as a Type II consolidated provider through the National Plan and Provider Enumeration System (NPPES) and the zip code is the same for multiple locations.

    Enter the taxonomy or contract code that indicates the specialty type of the pay-to-provider.

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    Box 53:


    Enter the individual treating provider or assigned representative’s signature and date. The signature may be typed, stamped, or handwritten.

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    Box 54:


    Enter the individual treating provider’s NPI.

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    Box 55:

    Not used for MHCP.

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    Box 56:


    Enter the address for the individual treating provider.

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    Box 56A:


    This box is situational unless the treating provider has a specialty taxonomy code.

    Enter the taxonomy or contract code that indicates the specialty type of the dental professional who will deliver the treatment.

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    Refer to the HIPAA compliant Heath Care Provider Taxonomy Code Set for Individual or Groups for the appropriate code for Dental Providers.

    Box 57:

    Enter the phone number for the individual treating provider.

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    Box 58:

    Not used by MHCP.

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    These instructions must be used in conjunction with the current requirements maintained in the MHCP Provider Manual.

    For more information, call the MHCP Provider Call Center at 651-431-2700 or 800-366-5411.

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    © 2018 Minnesota Department of Human Services Updated: 11/16/16 1:39 PM | Accessibility | Terms/Policy | Contact DHS | Top of Page | Updated: 11/16/16 1:39 PM