Dental Preauthorization

Effective January 1, 2026

To ensure medical necessity and prevent service duplication, PA is required for certain procedures. Our new system is programmed to automatically detect and verify PA requirements during claim processing. Please update your processes and notify staff to ensure compliance.

This list shows dental codes that require preauthorization. Claims for these procedures without PA will be denied.

Note: We will no longer accept unspecified CDT codes (e.g., D9999) on submitted claims. All procedures must be reported using the most specific and appropriate CDT code available. Claims submitted with unspecified codes may be denied or delayed pending resubmission with proper coding.

Preauthorization (PA) Forms

DENTAL SERVICES (Excluding Single-Tooth Prosthodontic Restoration)

SINGLE-TOOTH PROSTHODONTIC RESTORATION (Peg Laterals, Restorative Labial Veneers, and Tooth Surface Loss)

Requesting Preauthorization (PA)

Submit the appropriate PA form above using one of the following methods:

• Fax: 801‑366‑7449 (Attn: Clinical Management)
• Mail: PEHP – Clinical Management, 560 E 200 S, SLC, UT 84102
• Provider Portal:
  1. Log in to the New Portal
  2. Submit via Message Center (Dental Pre-Authorization)
• Secure Email: Call 801‑366‑7555 or 801‑366‑7755 to request a secure email, then reply with your request and attachments to ensure transmission remains compliant with PHI security requirements.

Questions? Contact us via the Message Center in the New Portal or call us at 801-366-7555.