Authorization for Medical-Dental Procedures - Accidental Dental
Customize your policy alerts
Sign up for HealthPartners Policy 20-913603-913616 alerts
Get alerted when Policy 20-913603-913616 changes without checking for updates manually.
Monitor payer policy activity
This form and policy govern prior authorization requests for medical or dental procedures related to accidental dental injuries for HealthPartners members; it affects providers submitting authorization requests and Utilization Management reviewers.
No material clinical or coverage changes in this revision.
Injury-related Coverage Criteria
Injury-related authorization criteria
When services are required due to an injury that caused damage to teeth, the provider must submit the following with the authorization request:
ALL of the following must be submitted:
- Pre-injury radiographs.
- Post-injury radiographs.
- Date of injury.
- Details of the accident/how the injury occurred.
- Description of the tooth injury.
- Identification of which teeth were involved in the injury.
Procedure Codes and Units
| No codes listed |
Submission Requirements and Provider Contacts
Prior authorization submission requirements
Submit the completed authorization form with supporting clinical documentation (including radiographs/photos) to Utilization Management by fax or secure email. Include the proposed procedure date and indicate urgency if waiting the standard review time would seriously jeopardize the member's health, life, or ability to regain maximum functioning.
- Radiographs/photos must be mailed or emailed securely with the request form.
- Include proposed date of procedure and respond to the urgency question if applicable.
Contact and handling of incomplete forms
Fax completed forms to (952) 853-8713 and call Utilization Management at (952) 883-6333 with questions. Incomplete forms will be returned to the sender.
- Sign in at healthpartners.com/provider and use the Authorizations and referrals link to check authorization status.
Scope of procedure codes for this form
Only include procedure codes on the form that require authorization; any other codes will not be addressed on this form.
- Enter the Unit(s) field for procedure codes as required.
Supporting Documentation 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.