Prior Authorization Documents

Prior Authorization Guidance

UHC Dental will process prior-authorization requests within three (3) business days. Once a determination has been made, the prior-authorization approval will be available to view on the Provider Portal as well as written notices issued. Our Utilization Management team will mail a hard copy of the prior- authorization approval within three (3) business days of the determination for standard requests and within one (1) business day for emergency requests. If the prior-authorization request is denied, the member and provider will receive an adverse determination notice. Approved prior-authorization requests are valid for 90 days from the date of approval. Both the member and provider will receive notification of which services were approved, as well as the expiration date of the authorization for the approved services. If orthodontic treatment does not begin within the valid 180-day period, the provider must submit a new pre-authorization request for approval.

What is a “complete” Prior Authorization request?

A request for a service that includes all information/documents required to make and establish a medical necessity determination. The prior authorization (PA) requirements to consider a PA request complete are listed on our website for the requested service.

What are the “essential” information requirements needed to initiate a PA review?

Member name
Member number or Medicaid number
Member date of birth
Requesting provider name
Requesting provider’s National Provider Identifier (NPI)
Service requested - Current Dental Terminology (CDT), Current Procedural Terminology (CPT), or Healthcare Common Procedure Coding System (HCPCS)
Service requested start and end date(s)
Quantity of service units requested based on the CDT, CPT, HCPCS
CDT coded procedures requested

What is an Incomplete PA Request?

A request for a service that is missing information to establish medical necessity as listed in the Prior Authorization.

If an incomplete PA Request is received, UHC Dental with take the following actions:

Notify the requesting provider and Member, in writing, that the PA contained missing information and provide a notice of extension (NOE) no later than 3 Business Days after the PA Received Date.
UHC Dental may also contact the provider by telephone and obtain the information necessary to resolve the Incomplete PA Request.
The MCO’s written request for additional information must include the following: o A statement that the request has received but we are unable to decide about the requested services without the submission of additional information.
- A clear and specific list and description of missing/incomplete/incorrect information or documentation that must be submitted in order to consider the request complete.
- A due date for which the incomplete information must be received and how the provider may contact UHC Dental.
If the information requested in not received by the end of the 3rd Business Day from the date of the notice to the provider, then the PA request may result in an Adverse Benefit Determination.
Within 3 Business Days of the referral for Clinical review, but no later than the 10th Business Day after the PA Receive Date, UHC Dental will make a final decision on the PA request.
A peer-to-peer consultation can occur at any time during the PA request process after a Clinical review.
Final determinations must be made within 3 Business Days after the date missing information is provided to an MCO.

This document provides information about UnitedHealthcare Dental’s Prior Authorization Guidance requirements by CDT code for Children’s Dental Services.

Annual Prior Authorization Report

UnitedHealthcare Dental annually reviews our dental plan Annual Prior Authorization Report in accordance with Texas Government Code Section §533.00283. The policies are normally reviewed annually for the previous Texas Health and Human Services fiscal year (Sept. 1 through Aug. 31).

Other Prior Authorization Information

UnitedHealthcare Dental annually reviews our dental plan UHC Dental TX Criteria for Dental Therapy Under General Anesthesia .

Prior Authorization Metrics

Prior Authorization Assistance

Members may contact the Member Hotline at 1-877-901-7321 TTY 7-1-1 to inquire about the status of prior authorization requests and for assistance understanding the prior authorization process. Our standard Hotline Hours of Operation is 8am to 5pm Monday-Friday.