Find policies, billing codes, payers, states, and providers
Dental Service Authorization (SA) request form and submission process
Customize your policy alerts
Sign up for all Alaska Medicaid policy alerts
Know when Alaska Medicaid releases new policies or updates existing guidance.
Monitor payer policy activity
Governs completion and submission of Alaska Medicaid Dental Service Authorization (SA) requests by dental providers to the Alaska Medicaid Fiscal Agent; affects dental providers requesting prior authorization for services for Alaska Medicaid recipients.
No material clinical or coverage changes in this revision.
Dental Service Authorization Form Criteria
Dental SA form criteria
Form completion and submission criteria
ALL of the following
- Provider Contact Phone Number entered (box 1).
- Provider Alaska Medicaid Group ID or Individual ID entered (box 3).
- Provider organization, name, address, and fax number entered (box 5).
- Recipient name, date of birth, age, and Alaska Medicaid Recipient ID entered (boxes 6, 7, 9, 8).
- Date of Service provided (box 4) and indication if request is retroactive (box 2) when applicable.
ALL of the following
- Procedure/Drug Code entered in box 12 (enter the corresponding procedure or drug code for the requested service).
- Specific services description entered (box 13).
- Requested quantity entered (box 14).
- Tooth number entered when applicable (box 15).
- Surface code entered when applicable (box 16).
ALL of the following
Anesthesia indication
- If using anesthesia, box 10b must be completed and indicate General or IV.
- If not using anesthesia, leave box 10b blank.
- Additional information may be provided in box 10a when needed for approval.
ALL of the following
- Authorized signature, title, and date provided (box 17/Authorized Signature) — signature must be the professional attesting to accuracy and medical necessity.
- Provider attestation: signer attests the form is accurate and meets Alaska Medicaid program requirements.
ALL of the following
- Include any radiographs required for processing; radiographs must be mailed to: ATTN: DENTAL Service Authorization, PO Box 240807, Anchorage, AK 99524-0807.
ALL of the following
- Submission method: submit completed form to Alaska Medicaid Fiscal Agent by fax to 866.780.2219, DSM email, or mail as directed by the Fiscal Agent.
ALL of the following
- To update an approved Service Authorization, submit a Dental SA Update Request as specified by the Fiscal Agent.
ALL of the following
- Note: Authorization does not guarantee payment; payment is subject to the recipient's eligibility and current identification card status.
Procedure Codes and Required Documentation
| Procedure/Drug Code — enter corresponding procedure or drug code for requested service in box 12 |
Submission, Form Processing, and Payment Notes
Submission and update instructions
Complete and sign the Dental Service Authorization form and submit to Alaska Medicaid Fiscal Agent (FA) via Fax to 866.780.2219, via DSM to DentalSA@hms.fa.directak.net, or via Mail to P.O. Box 240808 Anchorage, AK 99524-0808. To request an update to an approved SA, complete a Dental SA Update Request. The form must bear the signature of the professional who attests that the content is accurate and meets Alaska Medicaid program requirements.
- Fax: 866.780.2219
- DSM email: DentalSA@hms.fa.directak.net
- Mail: P.O. Box 240808, Anchorage, AK 99524-0808
- Use Dental SA Update Request to modify an approved SA
Form fields and processing
The form includes fields for provider and recipient identification and contact information and detailed service data. Complete all applicable fields: provider contact phone number; retroactive request indicator (and if Yes, enter actual date of service in Date of Service); provider Alaska Medicaid Group or Individual ID; date of service; provider organization/name/address/fax; recipient name, date of birth, Alaska Medicaid recipient ID, age, and sex; additional information; anesthesia indicator (General or IV) if applicable; procedure/drug code; specific services requested; requested quantity; tooth number; surface code; and authorized signature, title, and date. Mail any required radiographs with the SA form to: ATTN: DENTAL Service Authorization, PO Box 240807, Anchorage, AK 99524-0807.
- Provider Contact Phone Number
- Is Request Retroactive? (if Yes, enter actual date in Date of Service)
- Provider Alaska Medicaid Group ID (or Individual ID)
- Date of Service
- Provider Organization, Name, Address, and Fax Number
- Recipient Name, DOB, Alaska Medicaid Recipient ID, Age, Sex
- Additional Information (box 10a)
- Anesthesia indicator (box 10b) — check and specify General or IV if using anesthesia
- Procedure/Drug Code (box 12)
- Specific Services Requested (box 13)
- Requested Qty (box 14)
- Tooth Number (box 15)
- Surface Code (box 16)
- Authorized Signature, Title, Date (box 17)
- Radiographs (if required) — mail to PO Box 240807, Anchorage, AK 99524-0807
Payment caveat
Authorization does not guarantee payment. Payment is subject to the recipient's eligibility at the time of service; verify the recipient's current identification card before rendering service.
- Payment contingent on recipient eligibility and current ID card
- For AK Medicaid FA use only fields (boxes 18–26) — information entered by FA may affect validity of the request
Key Definitions
OpenPayer is powered by Trek Health's payer performance platform. Trek continuously ingests, validates, and normalizes Transparency in Coverage data alongside payer policies and other commercial payer data to create a structured payer intelligence foundation. OpenPayer uses this foundation to deliver personalized search results, dynamically generated policy pages, and tailored policy monitoring based on each user's payers, specialties, billing codes, and areas of interest. The same intelligence powers broader payer performance workflows, including reimbursement benchmarking, contract evaluation, payer negotiations, and financial decision-making.