Submitting Dental Service Authorization Requests

When requesting authorization for a procedure, adequate and detailed documentation must be attached to the authorization request. Use the ADA claim form when requesting Service Authorization and current CDT procedure codes.

You must submit adequate case information and appropriate diagnostic materials when you request a Service Authorization. This information must be legible, clearly visible, and computer-generated, when possible. 

Dental Service Authorizations must be submitted via mail or email.

Secure email is PrimeWest Health's preferred method of receiving Service Authorization requests. Please email requests to dental@primewest.org. Because many X-rays and pictures are now scanned digitally and do not use actual film, this secure email address offers you an opportunity to reduce postage costs.

To begin using this service, send an email request to the address above (do not include Protected Health Information [PHI]). PrimeWest Health will respond with an email guiding you through the steps of setting up secure email. Also included will be a secure email user guide for your reference. Due to PHI requirements, a secure route must be used.

You will still need to use postal mail if actual film X-rays are being submitted.

Please mail Service Authorization requests to:

Attn: Dental Utilization Management
PrimeWest Health
3905 Dakota St
Alexandria, MN 56308

Regardless of how requests are made, they must include all information required by PrimeWest Health for the service requested and X-rays/photos should be of diagnostic quality. If you are submitting a Service Authorization for a denture replacement prior to the three-year time frame, also include a completed Denture Replacement Request Form. If you have any questions, please call the Provider Contact Center at 1-866-431-0802 (toll free).

If submitting a Service Authorization for periodontal scaling and root planing (D4341, D4342), also include a completed Periodontal Scaling and Root Planing (SRP) Service Authorization Request Supplemental Document.

PrimeWest Health contracts with independent dental reviewers (licensed DDS) to review requests for Service Authorization. Dental providers are notified promptly of Service Authorization decisions according to Minnesota Rules. Providers may contact PrimeWest Health Utilization Management (UM) at 1-866-431-0803 (toll free) for assistance with Service Authorization or benefit determination questions.

Please review the following general tips and guidelines for all dental Service Authorization submissions:

• The Minnesota Board of Dentistry has adopted the philosophy that “if it is not written down, it did not happen.” Keep this in mind while transcribing clinical notes.
• Common recordkeeping errors include not updating the medical history, not interpreting radiographs, and not getting informed consent. Pay special attention to these areas.
• Do not handwrite notes in the “remarks” section of the ADA claim form. Notes must be typed.
• X-rays must include the member’s name, date of birth, and the date the X-ray was taken.
• If a member was given a Service Authorization by the Minnesota Department of Human Services (DHS) or another health plan for a dental service he/she is currently receiving or will receive, please include the approval from DHS or the other health plan along with the ADA claim form.
• If you receive a Service Authorization denial from PrimeWest Health and you have new or additional information that you would like considered, resubmit the request to PrimeWest Health. If you receive a Service Authorization denial, but you do not have additional or new information, you have the option to Appeal the denial. Review the Appeal rights included with your denial for more information.
• Sign up to receive emails about important PrimeWest Health benefit and process changes by subscribing to dental provider updates on our website.

PW_11-19_607
Updated_05/10/2024