PM 20-14-02

  1. (Provider) Submits request for prior approval for a client by sending ADA Dental Claim Form J510 to:

    revised textDentaQuest Prior Authorizations
    12121 N. Corporate Parkway
    Mequon, WI 53092 

  2. (Provider) Checks client's eligibility on date service is given.

    NOTE: Prior approval does not mean client is eligible for medical aid. 

  3. (Approving Authority) Decides if prior approval is given. Prior approval does not include an amount to be paid, unless the amount is specified in the request.
  4. (Orthodontist) Requests prior approval for comprehensive orthodontic treatment. Request must include:
    • orthodontic exam and records;
    • X-rays, facial photos, and diagnostic models;
    • specific treatment plan including diagnosis, prognosis, and length of time needed for service; and
    • fee for service.