PA3 Dental

Dental
Prior Authorization Level 3 (PA-3) Request Form

Submission Instructions: Please complete this form when requesting Dental and send it to the World Trade Center
Health Program by posting it to the secure SFTP server and then sending an email to [email protected]
indicating the secure server posting of this request. Incomplete forms will be sent back for more information. Please
note each dental procedure per tooth, separately. DO NOT FILL OUT NIOSH DECISION OR NIOSH DECISION
RATIONALE.

General and Member Information

Request Date

Member Type
Responder

Member Name

Member Date of Birth

Survivor

Choose a CCE/NPN

Member 911#

Relevant Certified Condition

ICD Code

Relevant Certified Condition

ICD Code

Relevant Certified Condition

ICD Code

CCE/NPN Requester Information

Requester Name

Requester Credentials

Requester E-mail

Requester Phone

Clinical Director Name (if not requester)

Clinical Director Concurrence Signature

Pre-Dental workup/testing is documented properly (PA2) in members record.
YES

NO

Dental Request

Procedure/Service

NIOSH Decision

Procedure/Service

NIOSH Decision

Procedure/Service

NIOSH Decision

Procedure/Service

NIOSH Decision

Procedure/Service

NIOSH Decision

Tooth/Area

CDT Code

NIOSH Decision Rationale

Tooth/Area

Approved Charge

CDT Code

NIOSH Decision Rationale

Tooth/Area

CDT Code

NIOSH Decision Rationale

Estimated
Charge

Approved Charge

CDT Code

NIOSH Decision Rationale

Tooth/Area

Estimated
Charge

Approved Charge

NIOSH Decision Rationale

Tooth/Area

Estimated
Charge

Estimated
Charge

Approved Charge

CDT Code

Estimated
Charge

Approved Charge

Clinical Summary: Please describe the type of procedure(s)/service(s) requested. Provide medical necessity
rationale for requested procedures, in particular noting how it relates to the treatment or management of the
certified WTC-related condition or medically associated condition. Treatment must be non-experimental and
non-investigational . Document or attach other required criteria noted in the WTCHP Codebook guidelines,
WTCHP Policy and Procedures Manual or other relevant supporting information.

Dental Provider Information (Used for Pricing)

Provider Name

Credentials and Specialty

Clinic/Office Address

Clinic/Office Phone

Provider E-mail

TO BE FILLED OUT BY NIOSH
Name

NIOSH Decision

NIOSH Decision Comments

Credentials

Signature