Form 4116-Dental, Dental Summary Sheet

Instructions

Updated: 7/2012

Purpose

Providers must submit Form 4116-Dental to HHSC to request reimbursement authorization for payment for dental services.

Procedure

The same authorization for payment form may be used for more than one individual.

Multiple requests for authorization for payment on the same form must have the same service month and year.

An authorization for payment form for dental treatment also must include the cost of the dental treatment.

Transmittal

Mail all claims to:

Authorization for Payment
Claims Management, Mail Code W-400
P.O. Box 149030
Austin, TX 78714-9030

Detailed Instructions

The following information must be included on an authorization for payment form:

Service Month and Year — For dental treatment, state the calendar month and year in which the individual received the service component.

Component Code — State the component code for the program provider that provided the service component.

Contract No. — Self explanatory.

Contact Person — Enter the name of the staff member completing the form.

Area Code and Telephone No. — Enter the telephone number for the contact person during normal business hours.

Name (Last, First, Initial) — Enter the name of the individual receiving the service.

Client CARE ID No. — Enter the CARE ID number for the individual receiving the service.

Service Date (MM/DD/YY) — For dental treatment, enter the calendar day, month and year in which the individual received the service component.

Service Description — Self explanatory.

Service Code — Self explanatory.

Dollars Spent — Self explanatory.

Requisition Fee — Self explanatory.

Attestation — Signature and date of submitter certifying that all requirements of Billing Guidelines have been met. Signature must be original.