TX HHS Form 6504. Prior Authorization for Dental Services

The TX HHS Form 6504, Prior Authorization for Dental Services, is a crucial tool for healthcare professionals to obtain approval for dental services in the Deaf Blind with Multiple Disabilities (DBMD) program. This form helps solve the problem of ensuring that dental care is authorized and aligned with an individual's plan of care.

The form requires identifying data, including the individual's name, date of birth, Medicaid number, city, state, and ZIP code, as well as telephone number. The dentist must complete the examination authorization section, indicating one tooth number, procedure, and estimated fee per line. Additionally, the form asks about dental sedation, major dental condition, and treatment period.

The DBMD program staff will review the completed form to obtain prior authorization for services. Case managers in the waiver program share this information with program staff to ensure that dental care is aligned with an individual's plan of care. Key points to note include:

• Required information includes identifying data, examination authorization, and treatment details.
• The form is used for prior authorization of dental services in the DBMD program.
• The dentist must complete the examination authorization section.