To ensure timely processing and avoid delays, please follow the guidelines below when submitting cases:
Tooth Numbers & Codes
• Use the plus (+) sign to add additional tooth numbers for the same code.
Workflow: Add code → add tooth → click the plus (+) sign → select additional teeth → submit.
This will add all additional teeth at once.
• List tooth numbers in numerical order.
• If additional codes are needed, please add them directly within the same case.
Case Submission Best Practices
• Submit all treatment in one case whenever possible.
• Submit all units for D9245 in a single case (do not submit separate cases for additional units).
• D9245, D9222, and D9223 are the only codes eligible for multiple units (quantities).
• Leave the “Requested Rate” field blank on all submissions. (Note: Pricing is not set by Acentra Health and is not considered as a part of the review process)
• Set the requested duration to 365 days, as eligibility allows.
Reconsiderations, Revisions & Additional Information
• Reconsiderations (Recons) must be submitted correctly and should not be used for additional information or authorization revisions.
• Authorization Revision:
Used to update the servicing provider. Please provide all information for the change; Name, NPI number and address.
(Note: The requesting provider cannot be changed.)
• Additional Information:
When Acentra Health requests more documentation, submit it as Additional Information, not as a reconsideration.
Reconsiderations have a 30 day determination period and may delay your case if used incorrectly.
• Reconsideration Definition:
Used when a code is DENIED (not rejected or voided). A recon allows for a second review by a different reviewer.
Documentation Requirements
• Submit all required and updated documentation with each D4910 request, even if previously submitted.
• For multiple radiographs or intraoral images:
o Submit one single attachment in FMX format
o Clearly label with:
 Member name
 Left (L) and Right (R) markers
 Date of service
Retrospective Documentation Requests & Prior Authorization Reminder
To ensure timely and accurate review of retrospective requests, please include the following required documentation:
• Dated progress notes
• Dated and clearly labeled radiographs
• Dated treatment plan
• Explanation for retrospective request and why a prior authorization was not obtained prior to services rendered
Providing complete, clearly labeled, and dated records helps prevent delays and allows for efficient processing.
!!!Important Reminder!!!
Prior authorization (PA) requests—must be submitted prior to providing the service. There are limited exceptions for retroactive eligibility, emergencies, and child sedation for retrospective review.
Following these guidelines will help prevent delays and ensure your submissions are processed efficiently. Thank you for your continued cooperation.