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Run: Dental Prior Authorization Submission and Tracking

Track dental prior authorization requests for restorative, orthodontic, and oral surgery procedures in one place. This template helps teams submit complete r...

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Submission Details

Request Type (required)

Select the type of prior authorization request.

Submission Date (required)

Date the request is being submitted.

Submitted By (required)

Name or role of the staff member submitting the request.

Internal Reference Number

Optional internal tracking number for audit trail and follow-up.

Priority (required)

Choose the urgency based on clinical or scheduling needs.

Patient and Coverage Information

Patient Initials (required)

Use initials instead of full name when possible to minimize PII.

Patient Date of Birth

Only collect if required by the payer for matching the member record.

Member ID (required)

Insurance member ID as shown on the payer card.

Payer Name (required)

Name of the insurance payer or dental plan.

Plan Type

Select the applicable coverage type if known.

Subscriber Relationship

Relationship to the subscriber, if needed for payer submission.

Procedure and Clinical Details

Procedure Category (required)

Select the procedure category to show the relevant follow-up fields.

Procedure Code (required)

Enter the CDT or payer-specific procedure code.

Procedure Description (required)

Short description of the requested procedure.

Tooth Numbers

List the tooth numbers involved, if applicable.

Quadrant or Arch

Select the affected quadrant or arch when relevant.

Clinical Justification (required)

Provide the minimum necessary clinical rationale supporting medical necessity.

Procedure-Specific Information

Restorative Procedure Details

Include materials, surfaces, or restoration specifics if the request is restorative.

Orthodontic Treatment Details

Include treatment phase, appliance type, and estimated duration if orthodontic.

Oral Surgery Details

Include procedure specifics, anesthesia needs, and any relevant surgical notes if oral surgery.

Estimated Date of Service

Planned service date, if known.

Supporting Attachments

Upload supporting documentation such as radiographs, treatment plans, narratives, or clinical notes.

Authorization Status and Follow-Up

Status (required)

Current status of the prior authorization request.

Authorization Number

Payer-issued authorization number, if approved.

Approval Date

Date the authorization was approved, if applicable.

Authorized Units

Number of units or visits authorized by the payer.

Expiration Date

Date the authorization expires, if provided by the payer.

Follow-Up Notes

Document payer communications, missing information, or next actions.

Submission and Audit Trail

Consent to Process PII (required)

Confirm that the information provided is limited to the minimum necessary for prior authorization processing and tracking.

Yes No N/A

Submitter Acknowledgement (required)

I confirm the information submitted is accurate to the best of my knowledge and will be used for authorization tracking and audit trail purposes.

Yes No N/A

Additional Comments

Optional notes for the billing or authorization team.

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