How to Obtain Prior Authorization for Dental Procedures?

Suppose a patient visits your practice for a dental implant. You treat the patient, submit a dental claim, and start waiting for the payment.

But, guess what? It comes back as a denial.

Reason? Your payer required prior authorization for the claim, but you didn’t get it before submitting the claim.

If you run a dental practice, this scenario probably stings a little. It’s one of the most frustrating and completely avoidable revenue leaks in the industry.

The good news? Once you understand exactly how prior authorization works and where most practices go wrong, it becomes a manageable, even predictable, part of your billing workflow.

So, let’s discuss steps and best practices to obtain pre-authorization for dental claims, and learn how professional dental RCM services improve the process and prevent claim denials.

What is Prior Authorization for Dental Claims?

Prior authorization (sometimes called pre-authorization or pre-approval) is essentially a green light from an insurance carrier before you perform a specific dental procedure. The payer reviews the clinical justification for the planned treatment and decides if it qualifies for coverage under the patient’s benefits plan.

To make it simple, prior authorization is a step in the front-end revenue cycle process, in which the payer requires you to request approval for these procedures, and when the payer approves them, you get the pre-authorization number and submit the dental claims.

But make sure that pre-authorization doesn’t guarantee payment. Your reimbursement depends on your entire claim submission.

Which Dental Procedures Require Pre-Authorization?

Not every procedure needs pre-approval, but some complex or high-cost treatments almost always trigger the requirement. These include:

• Crowns, bridges, and major restorative work
• Orthodontic treatment (braces, clear aligners)
• Dental implants and bone grafting
• Oral surgery, including complex extractions and jaw procedures
• Periodontal treatments beyond standard maintenance
• Sleep apnea oral appliances (especially when billed through medical insurance)

However, each payer has its own requirements for pre-authorization, and these also vary by procedure. One payer might require pre-approval for a three-unit bridge; another might not. Due to the difference, you need a systematic approach to submit pre-authorization requests that get approved fast.

How Does Prior Authorization Impact Your Revenue Cycle?

Getting prior authorization from the payer is very important to manage a smooth dental revenue cycle.

If you don’t obtain pre-authorization from the payer for certain treatments and submit your claims without it, the payer may not approve your claims, resulting in claim denials and payment delays. Due to that, it’s difficult to maintain a consistent cash flow in a dental practice.

Reworking on managing denials and sending appeals to recover payment consumes a lot of time for your staff. Plus, in most cases, if you don’t obtain pre-authorization from the payer, it’s most likely that the payer doesn’t accept it after the treatment (except for emergency cases).

As a result, the payer doesn’t reimburse. Either you need to charge the patient for the treatment costs, or accept the revenue loss as a write-off.

But, if you obtain prior authorization the right way, you get:

• Fewer claim denials
• Faster reimbursements
• Fewer billing disputes with patients
• Reduced staff burden in denial management

Step-by-Step Process for Dental Prior Authorization

Here’s the process to obtain prior authorization.

Verify Insurance Benefits Before the Appointment

Before anything else, know the patient’s plan inside and out with real-time insurance eligibility verification services. 

Contact the payer or log into their provider portal to confirm whether prior authorization is required for the planned treatment. Check frequency limitations, waiting periods, and coverage percentages simultaneously. This single step prevents most surprises related to authorizations.

Gather Solid Clinical Documentation

Insurance companies don’t take your word for it. They want clinical proof. 

So, compile these records before submitting:

• Detailed treatment plan with accurate CDT procedure codes
• Current X-rays, intraoral photographs, or periodontal charting
• Written treatment narrative explaining medical/dental necessity
• Patient dental history and documentation of existing restorations

The narrative is where many practices get confused. Think of it like telling a story. Walk the reviewer through why this treatment is clinically necessary, not just what you plan to do. If you specify details, you’re likely to win authorizations.

Submit the Prior Authorization Request

Submit your prior authorization request through the payer’s preferred channel: web portal, fax, or phone. 

The request can be via a pre-authorization form issued by the payer, which includes details like the patient’s full name, date of birth, enrollee’s name (which may be different if the patient is not the main subscriber), and subscriber ID number.

You also need to add procedure details like CDT code, procedure description, tooth number, tooth surfaces, and any patient responsibilities like coinsurance.

Also, double-check submission deadlines; most plans require requests 5-10 business days before the procedure date. Incomplete submissions are the number one cause of delays, so include all required documents.

Follow up with the Payer

Reach out to the payer within a couple of days after you send in your claim. Verify they have received it and ask when you might expect a decision. 

Keep a record of everything: the name of the person you spoke with, the date, and a summary of what was said. This kind of thorough documentation is helpful if you ever have to appeal a decision.

Plus, keep tracking your authorization record in the payer portal or by contacting the payer.

Explain to the Patient

Once you receive the payer’s decision on your prior authorization request, whether it’s approved, modified, or denied, immediately contact the patient.

If the payer approves the request, be sure to record the authorization number and its expiration date; these are typically valid for a period of 90 days in most plans. If the authorization is denied, inform the patient of their available options before proceeding with the treatment.

The thing to note is that most practices may find it difficult to explain that to the patient. Professional front office management services help with that, making it easy to manage patient conversations.

Appeal Denials Strategically

Denials don’t mean the end. According to the Kaiser Family Foundation, a huge number of initially denied claims are reversed on appeal when strong documentation is submitted. Write a compelling appeal letter and attach updated clinical evidence. These practices help you win appeals.

What are the Common Mistakes in Dental Prior Authorization?

Prior authorization is a detailed process, where even experienced billing teams can make mistakes. However, you can avoid these errors. 

Want to know how? Let’s discuss the common errors in dental pre-authorization with practical solutions.

Submitting incomplete documentation

Payers can deny your prior authorization requests if you don’t submit sufficient documents to prove your treatment.

Fix: Attach all the required documents, such as clinical narratives, dental radiographs, periodontal charts, and other treatment details that prove that the treatment is important for the patient’s health. If you can prove these details, it’s likely that the payer approves it for claim submission.

Using wrong or mismatched CDT codes

When you use an outdated or wrong CDT code for a dental procedure in your pre-authorization form, payers straight away deny the request.

Fix: Follow the American Dental Association’s updates and use the latest CDT codes. Also, check your payer manuals to use the codes that they reimburse. It helps you with CDT coding accuracy for pre-authorizations.

Missing submission deadlines

Each payer has its own deadline to submit prior authorization, and if you miss it, you can’t get approval.

Fix: Make sure that you obtain pre-authorization a certain number of days before the treatment. It can be found in the payer manuals or by contacting the payer directly. Your payer may require you to get the approval 7-14 days before standard procedures and at least 30 days before complex procedures. 

So, follow your payer guidelines and submit pre-authorizations, because your payer may not allow retro authorization.

Letting authorizations expire

After the payer gives pre-authorization, they require providers to treat the patient soon. Authorizations have deadlines, which are 90 days in most cases, but may vary by each payer plan. 

According to a study by Harvard, if these authorizations expire and you don’t treat the patient within the deadline, you need to submit a new request for authorizations, which means starting the pre-authorization process all over again. And if you submit claims without valid pre-authorizations, it results in denials.

Fix: Don’t delay the dental service after receiving pre-authorization from the payer. Schedule the procedure for the earliest and best possible date and treat the patient soon, so your pre-authorization is valid, and it makes your claim submission clean and compliant.

And in case your authorization expires without treating the patient, request an extension for it or submit a new pre-authorization request. Keep information updated in your systems, and also maintain transparency by guiding the patient about it.

How to Manage Prior Authorization for Emergency Treatments?

While in common situations, you need to request pre-authorizations a couple of days before treating a patient, there are some cases when you can’t get enough time to request payer approval and perform an emergency treatment. These cases include:

• Abscess or infection
• Broken tooth
• Severe pain in a tooth
• Swelling that affects breathing

In any of these emergency cases, most payers allow you to perform emergency treatment first, without waiting for approval. And, after treating the patient, you must immediately submit a retro-authorization request to the payer.

Make sure you mention that it’s an emergency case, and also attach documentation to prove why you needed to urgently treat a patient. 

Documentation includes clinical notes, dental X-rays, and a written note containing other symptoms that show that delaying care could be harmful for the patient’s health.

Use emergency CDT codes for these situations, such as CDT D0140 for a problem-focused and limited oral evaluation.

What are the Best Practices to Obtain Prior Authorization?

Check Payer Policies for Pre-Authorization

Each payer has its own requirements for pre-authorization requests. They have pre-authorization request forms, which contain fields like CDT codes, patient name, policyholder name (if separate from the patient), dentist’s NPI number, procedure details, and brief notes on why the treatment is required.

Make sure to complete these forms and consult with your payer to check their pre-authorization request. Their payer manuals also contain a list of procedures that require pre-authorization.

And, note that each payer has their own policies for prior authorization.

Submit Electronic Authorization Requests

Send prior authorization electronically by using the payer portal. It’s an easier and quicker process. Plus, it’s easy to track the progress of your authorization request by entering the authorization number in the payer portal. It reduces the need to contact payer representatives.

Build Narrative Templates for Most Common Procedures

Treatment narratives are very helpful in pre-authorization requests, so build some narrative templates for the most commonly billed procedures in your dental practice. These templates help you easily customize and prepare narratives, which you can attach to your requests. It’s a better and faster approach than building new narratives from scratch every time.

Narratives help explain a patient’s dental history and why a treatment is needed. Strong documentation makes these narratives complete and solid.

Automate Prior Authorization Requests

Consider using software with artificial intelligence and robotic process automation for accurate and fast prior authorization requests.

These systems can perform the following tasks, doing more than half of your job:

• Check payer requirements by integrating with payer portals to check if a procedure needs pre-authorization
• Collect and attach required documents like clinical notes, narratives, and X-rays
• Fill all the pre-authorization forms automatically by adding details, like patient info, CDT codes, and provider NPI.
• Submit pre-authorization requests to the payer portals
• Track authorization requests to monitor their status, whether they’re approved, denied, or pending
• Generate alerts when the payer approves or denies the pre-authorization request
• Update your software automatically with the latest details

However, prior authorization may require manual intervention for expert tasks like communicating with the payer on clinical disputes, managing complex denials, and writing detailed clinical narratives.

Outsource Revenue Cycle

Pre-authorization must be requested and handled very carefully; an incomplete or incorrect request can lead to the payer denying it.

And that may not be possible when your practice staff is already occupied scheduling patient appointments, providing quality care to patients, and managing other day-to-day tasks.

Even if you have a dedicated in-house billing team, managing pre-authorizations might still be difficult, as billers have to also manage other billing tasks.

Solution? Partner with an RCM services provider, like TransDental, that assigns dedicated resources solely to request and manage pre-authorizations with insurance companies. These RCM companies work with multiple payers and know their requirements very well. Plus, their staff are trained in professionally coordinating with payers for insurance-related queries.

All that expertise comes into play when you outsource your revenue cycle to these reliable companies.

Final Thoughts

Prior authorizations don’t guarantee payments, but make your dental claims strong. The reason is that payers require pre-authorization requests for expensive treatments to prevent fraud and control costs. Make sure your pre-authorization forms are complete with updated information, accurate CDT codes, and supporting documentation. 

A detailed pre-authorization request that explains the necessity for a treatment is more likely to win approvals and get payer approvals for claim reimbursements.

Frequently Asked Questions (FAQs)