CurrentHealthPartnersPolicy 20-913603-913616

Authorization for Medical-Dental Procedures - Accidental Dental

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.

Policy Summary

PayerHealthPartners

PolicyAuthorization for Medical-Dental Procedures - Accidental Dental

Policy CodePolicy 20-913603-913616

Change TypeNo material changes

Effective DateSep 20, 2020

Next Review Date

Key ActionSubmit the completed authorization form with clinical documentation (including radiographs/photos) to Utilization Management by fax or secure email.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

fax & phoneUM contact methods listed

radiographs & injury detailsRequired documentation

authorization-onlyProcedure code scope

provider/member/procedureForm contents

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.

Policy Summary

PayerHealthPartners

PolicyAuthorization for Medical-Dental Procedures - Accidental Dental

Policy CodePolicy 20-913603-913616

Change TypeNo material changes

Effective DateSep 20, 2020

Next Review Date

Key ActionSubmit the completed authorization form with clinical documentation (including radiographs/photos) to Utilization Management by fax or secure email.

SourceLink

On This Page

Trek Health ingests and normalizes Transparency in Coverage data and payer policy updates to give provider organizations a clear view of how commercial reimbursement behaves across markets, payers, and services. Our platform transforms raw payer disclosures into structured intelligence that supports contract evaluation, payer negotiations, and service line strategy. By combining market benchmarks with ongoing policy visibility, Trek helps teams identify variability, risk, and opportunity in commercial reimbursement. The result is faster insight, stronger negotiating positions, and more informed financial decisions.

Submission Requirements and Provider Contacts

Prior Authorization

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.

Documentation Required

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.

Billing Rule

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.

OpenPayer

Authorization for Medical-Dental Procedures - Accidental Dental

Injury-related Coverage Criteria

Procedure Codes and Units

Submission Requirements and Provider Contacts

Supporting Documentation Definitions