CareSource® covers dental services for our MyCare Ohio (Medicare-Medicaid Plan) members. Our dental providers can access the following tools to help them provide efficient and quality care.
The CareSource Dental Provider Handbook provides information on topics such as covered services, claims submissions and prior authorization requirements and processes.
Use the following forms for prior authorization requests, claim submissions and more:
- ODJFS Dental Services Prior Authorization Form – Submit this form to the Ohio Department of Job and Family Services (ODJFS) to request prior authorization for dental services.
- ADA Dental Claim Form Instructions – Follow the instructions to fill out the American Dental Association’s (ADA) dental claim form.
- Dental EFT Enrollment Authorization Agreement Form – Follow the instructions to enroll in Scion Dental’s EFT program.
- CareSource TMD Screening Examination Form – Use this screening form to determine evidence of a temporomandibular disorder (TMD) in a patient.
- Orthodontic Evaluation and Predetermination Form – Submit this form to request prior authorization for orthodontic services.
- Orthodontic Continuation of Care Form – Submit this form to request continuation of care for orthodontic services.
- Orthodontic Confirmation of Care Form – Submit this form to notify CareSource that a referred patient is not a candidate for comprehensive orthodontic treatment.
- Orthodontic Treatment Plan Acknowledgements Form for Comprehensive Orthodontic Treatment – Submit this form along with a prior authorization request to acknowledge a comprehensive treatment plan for a dental patient.
- Evaluation Form for Comprehensive Orthodontic Treatment – Use this form to evaluate a patient for comprehensive orthodontic treatment options.
- Orthodontic Form for Non-Compliance/Termination with Comprehensive or Interceptive Orthodontic Treatment – Submit this form to notify CareSource of a patient’s noncompliance/termination during orthodontic treatment.
- Evaluation Form to Scaling and Root Planning
Updates & Announcements
Our goal is to keep you informed with timely information about our plan and services. As changes occur and as needs arise, we issue network notifications to our providers via the Updates & Announcements webpage. Please check this page often to learn about updates and changes than impact your practice.