Dental

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.

Dental Provider Manual

The dental provider manual is a resource for our dental providers and serves as a link between your office and CareSource. It provides important information on topics such as covered services, services that require prior authorization, claim submission and more.

• ODM State Dental Card

Forms

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.
• Navigate CareSource TMD Screening Examination Form – Use this screening form to determine evidence of a temporomandibular disorder (TMD) in a patient.
• Navigate Orthodontic Evaluation and Predetermination Form – Submit this form to request prior authorization for orthodontic services.
• Navigate Orthodontic Continuation of Care Form – Submit this form to request continuation of care for orthodontic services.
• Navigate Orthodontic Confirmation of Care Form – Submit this form to notify CareSource that a referred patient is not a candidate for comprehensive orthodontic treatment.
• Navigate 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.
• Navigate Evaluation Form for Comprehensive Orthodontic Treatment – Use this form to evaluate a patient for comprehensive orthodontic treatment options.
• Navigate 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.
• Navigate 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.