Dental Prior Authorization (PA) Forms, CR 110373 

Jul 01, 2022

Effective July 1, 2022, we have updated the Prior Authorization (PA) process for dental services. We have updated some dental PA forms. Please see below for more information about the changes that are in effect on July 1, 2022.

Please discontinue use of these forms:

• Dentures PCP PA Form
• Supplemental Denture PA Form

Please use the following new forms:

• Removable Prosthodontics PA Form*
• Periodontic Services PA Form
• Pontics PA Form

*Please use the Removable Prosthodontics PA Form in place of the Dentures PCP PA Form and the Supplemental Denture PA Form.

Please use the updated version of the following PA forms:

• Handicapping Labiolingual Deviation Index Report
• Supplemental Dental Services PA Form
• Supplemental Orthodontia PA Form

Please discard older versions of PA forms that you downloaded or printed.

The PA forms are available by logging into your Trading Partner Account in the secure section of the Health PAS Online Portal  and by following this pathway: MaineCare Information>Prior Authorizations>Manual, Forms, and Criteria Sheets under Section 25.

See the Final Emergency Section 25 Billing Guidance document for more information. If you have questions, please email Provider Services or call 1-866-690-5585. TTY users dial 711.