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Part B, Dental Services Handbook - Commonly Used Appendices List

Appendix

Description

Appendix 1

Wisconsin Medicaid - Quick Access Guide to Wisconsin Medicaid Information

Appendix 2

Wisconsin Medicaid - Dental Certification Form

Appendix 3

Wisconsin Medicaid - Covered Drugs

Appendix 4

Wisconsin Medicaid - Noncovered Drugs

Appendix 5

Wisconsin Medicaid - Covered Dental Services

Appendix 6

Multidisciplinary Temporomandibular Joint Evaluation Programs Approved By the Wisconsin Department of Health and Family Services Medicaid Program

Appendix 7

Example of Prescription for Specialized Medical Vehicle Trips That Exceed Upper Mileage Limits

Appendix 8

Place of Service Codes

Appendix 9

Diagnostic Services

Appendix 10

Preventive Services

Appendix 11

Restorative Services

Appendix 12

Endodontic Services

Appendix 13

Periodontic Services

Appendix 14

Removable Prosthodontic Services

Appendix 15

Fixed Prosthodontic Services

Appendix 16

Oral and Maxillofacial Surgery Services

Appendix 17

Orthodontic Services

Appendix 18

Adjunctive/General Services

Appendix 19

Current Procedural Terminology Codes for Dentists Billing as Oral Surgeons

Appendix 20

Sample Prior Authorization Dental Attachment Request Form (PA/DRF)

Appendix 21

Prior Authorization Dental Request Form (PA/DRF) Completion Guidelines

Appendix 22

Sample Prior Authorization Dental Attachment Request Form (PA/DA)

Appendix 23

Prior Authorization Dental Attachment Request Form (PA/DA) Completion Guidelines

Appendix 24

Wisconsin Medicaid Information Needed for Prior Authorization Requests

Appendix 25

Provision of Upgraded Partial Denture and Crowns to Medicaid Recipients

Appendix 26

American Dental Association Claim Form Example
Current ADA 2002 and 2000 claim form examples and instructions, Update 2004-19.

Appendix 27

American Dental Association Claim Form Completion Instructions
Current ADA 2002 and 2000 claim form examples and instructions, Update 2004-19.

Appendix 28

HCFA1500 Claim Form Example

Appendix 29

HCFA 1500 Claim Form Instructions for Dental Services

Appendix 30

Wisconsin Medicaid Allowable Place of Services Table and Allowable Type of Service Table

Appendix 31

Wisconsin Medicaid Dental Billing Requiring Additional Documentation

Appendix 32

Sample Electronic Claims Questionnaire

Appendix 33

Electronic Media Claims Questionnaire

Appendix 34

Understanding Explanation of Benefits Messages on the American Dental Association Claim Form

Appendix 35

HealthCheck Screening Information Chart

Appendix 36

Dental Coverage Limits for Special Recipient Eligibility Categories