The California DHS 4516 form is a request for service authorization related to dental and orthodontic services under the California Children’s Services (CCS) program. This form is essential for healthcare providers to secure approval for necessary treatments for eligible children. To ensure proper processing, fill out the form accurately and completely by clicking the button below.
The California DHS 4516 form serves as a crucial tool for healthcare providers seeking authorization for dental and orthodontic services under the California Children’s Services (CCS) program. This form captures essential information about both the provider and the client, ensuring that all necessary details are submitted for service requests. Key sections include provider identification, which requires the provider's name, Denti-Cal number, and contact information, as well as client information that covers the client's name, date of birth, and residence address. Additionally, the form inquires about the client's insurance status, including enrollment in Medi-Cal or any commercial dental insurance plans. The requested services section allows providers to specify the type of service needed, whether for an established CCS client or orthodontic services, along with detailed descriptions of the procedures, tooth numbers, and associated fees. By requiring signatures and affirmations of accuracy, the DHS 4516 ensures accountability and compliance with the program's standards, ultimately facilitating necessary dental care for eligible children.
State of California—Health and Human Services Agency
Department of Health Services
California Children’s Services (CCS)
CCS DENTAL AND ORTHODONTIC CLIENT SERVICE AUTHORIZATION REQUEST (SAR)
Provider Information
1.
Date of request
2. Provider name
3.
Denti-Cal provider number
4.
Address (number, street)
City
State
ZIP code
5.
Contact person
6.
Contact telephone number
7. Contact fax number
(
)
Client Information
8.
Client name—last
first
middle
9.
Gender
10. Date of birth (mm/dd/yy)
11. CCS case number
12. Contact phone number
Male
Female
13.
Residence address (number, street) (DO NOT USE P.O. BOX)
14.
Mailing address (if different) (number, street, P.O. box number)
15.
County of residence
16.
Language spoken
17. Name of parent/legal guardian
18.
Mother’s first name
19.
Primary care physician (if known)
20. Primary care physician telephone number
Insurance Information
21. a. Enrolled in Medi-Cal?
Yes
No
If yes, send TAR directly to Denti-Cal
21. b. If no, Client Index Number (CIN)
22.
Enrolled in Healthy Families?
If yes, name of plan
23.
Enrolled in commercial dental insurance plan?
Requested Services
24.
Service Authorization Request for (CHECK ONE)
a. CCS established client
b. CCS orthodontics
25.
26.
27.
28.
29.
30.
Tooth Number or
Description of Service
Procedure
Letter Arch
Surfaces
(Including X-rays, prophylaxis, etc.)
Quantity
Number
Fee
31. Is this a CCS supplemental services request
32.Other documentation attached
33. Comments
This is to certify that to the best of my knowledge, the information contained above and any attachments provided is true, accurate, and complete and the requested services are necessary to the health of the patient. The provider has read, understands, and agrees to be bound by and comply with the statements and conditions contained on page two of this form.
34. Signature of dental provider or authorized designee
35. Date
DHS 4516 (7/04)
Page 1 of 2
Instructions
1.Date of the request: Date the request is being made.
2.Provider’s name: Enter the name of the provider who is requesting services.
3.Denti-Cal provider number: Enter Denti-Cal billing number (no group numbers).
4.Address: Enter the requesting provider’s address.
5.Contact person: Enter the name of the person who can be contacted regarding the request; all authorizations should be addressed to the contact person.
6.Contact telephone number: Enter the phone number of the contact person.
7.Contact fax number: Enter the fax number for the provider’s office or contact person.
8.Client name: Enter the client’s name—last, first, and middle.
9.Gender: Check the appropriate box.
10.Date of birth: Enter the client’s date of birth.
11.CCS case number: Enter the client’s CCS number. If not known, leave blank.
12.Contact phone number: Enter the phone number where the client or client’s legal guardian can be reached.
13.Residence address: Enter the address of the client. Do not use a P.O. Box number.
14.Mailing address: Enter the mailing address if it is different than number 13.
15.County of residence: Enter residential county of the client.
16.Language spoken: Enter the client’s language spoken.
17.Name of parent/legal guardian: Enter the name of client’s parent/legal guardian.
18.Mother’s first name: Enter the client’s mother’s first name.
19.Primary care physician: Enter the client’s primary care physician’s name. If it is not known, enter NK (not known).
20.Primary care physician telephone number: Enter the client’s primary care physician phone number.
21.a. Enrolled in Medi-Cal? Mark the appropriate box. If the answer is yes, do not send this SAR to CCS, send a TAR directly to Denti-Cal.
b. If the answer is no, enter the Client Index Number (CIN).
22.Enrolled in Healthy Families? Mark the appropriate box. If the answer is yes, enter the name of the plan.
23.Enrolled in a commercial dental insurance plan? Mark the appropriate box. If the answer is yes, enter the name of the commercial dental insurance plan.
24.a. CCS established client: Check if requesting approval for an established CCS client.
b. CCS Orthodontics: Check if requesting approval for orthodontic services.
25.Tooth number or letter; arch; quadrant: Enter the universal tooth code numbers 1 thru 32 or letters A thru T for tooth reference. Use arch codes U (upper), L (lower). Use quadrant codes UR (upper right), UL (upper left), LR (lower right), and LL (lower left).
26.Tooth surfaces: Use M (mesial), D (distal), O (occlusal), I (incisal), L (lingual or palatal), B (buccal), and F (facial).
27.Description of service: Furnish a brief description for each service. Standard abbreviations are acceptable.
28.Quantity: For the procedures having multiple occurrences, indicate the number of occurrences of the procedure, e.g., multiple radiographs (procedure 111), units for prosthetic procedures (procedure 716), or number of pins (procedure 648).
29.Procedure numbers: Use a Denti-Cal three-digit, state-approved four-digit, or state-approved five-digit code for each service.
NOTE: Do not mix different types of codes when completing a claim or TAR form.
30.Fee: Enter your usual and customary fee for the procedure rather than the Denti-Cal Schedule of Maximum Allowances fee.
31.Check yes or no box if this is a CCS Supplemental Services Request.
32.Check the box if there is other documentation attached.
33.Comments. Enter any additional comments.
Signature
34.Signature of dental provider: Form must be signed by the dentist, orthodontist, or authorized representative.
35.Date: Enter the date the request is signed.
Page 2 of 2
Completing the California DHS 4516 form is an important step in seeking dental and orthodontic services authorization. After filling out this form, it will be submitted to the appropriate authorities for processing. Ensure all information is accurate and complete to avoid delays in your request.
What is the purpose of the California DHS 4516 form?
The California DHS 4516 form is used to request service authorization for dental and orthodontic services under the California Children’s Services (CCS) program. It is specifically designed for providers to obtain approval for services that are deemed necessary for the health of eligible clients. This form ensures that the requested services align with the guidelines set by the CCS program.
Who should fill out the California DHS 4516 form?
The form should be completed by dental providers who are seeking authorization for services for their clients. This includes dentists, orthodontists, or authorized representatives of the provider. Accurate completion of the form is essential to facilitate the authorization process and to ensure that all necessary information is provided for review.
What information is required on the California DHS 4516 form?
The form requires various pieces of information, including provider details, client information, insurance status, and requested services. Key sections include the provider's name and contact information, the client's name, gender, date of birth, and residence address. Additionally, the form asks about the client's insurance coverage and specifics regarding the requested dental or orthodontic services, including procedure codes and fees.
What happens after submitting the California DHS 4516 form?
Once the form is submitted, it will be reviewed by the appropriate authorities within the CCS program. They will assess the request based on the information provided and determine whether the requested services are authorized. If approved, the provider will receive confirmation, allowing them to proceed with the necessary treatments. If additional information is needed or if the request is denied, the provider will be notified accordingly.
When filling out the California DHS 4516 form, many people make mistakes that can delay the authorization process. One common error is not providing the correct client information. This includes missing or incorrect names, dates of birth, or contact numbers. If the client’s name is not entered in the correct order—last name, first name, and middle name—it can lead to confusion and potential denial of services.
Another frequent mistake involves the insurance information section. Some applicants either forget to check whether the client is enrolled in Medi-Cal or Healthy Families or mistakenly select the wrong option. This can result in the request being sent to the wrong place, which causes unnecessary delays. Always double-check that the correct boxes are marked and that the Client Index Number (CIN) is provided if the client is not enrolled in Medi-Cal.
People often overlook the importance of accurate service descriptions. When detailing the requested services, using vague terms or abbreviations that are not widely recognized can lead to misunderstandings. Each service should be clearly described, and proper codes should be used. This ensures that the reviewer understands exactly what is being requested and can process the form efficiently.
Lastly, many individuals forget to sign the form or provide the date of the signature. This is a crucial step, as the form will not be considered valid without it. A missing signature can halt the process entirely, requiring the form to be resubmitted. Always remember to review the entire form before submission to ensure all necessary sections are completed accurately.
The California DHS 4516 form is a critical document used for requesting authorization for dental and orthodontic services under the California Children’s Services (CCS) program. In addition to this form, several other documents and forms are often required to ensure comprehensive processing of service requests. Here is a list of related forms and documents that may accompany the DHS 4516.
These accompanying documents play an essential role in the authorization process, facilitating effective communication between providers, clients, and insurance entities. Properly completing and submitting these forms can significantly enhance the likelihood of timely approvals and successful treatment outcomes.
When filling out the California DHS 4516 form, it’s essential to approach the process with care. Here are five key things to do and avoid to ensure your submission is accurate and complete.
By following these guidelines, you can help ensure a smoother process and reduce the likelihood of delays in service authorization. Taking the time to fill out the form correctly is crucial for the health and well-being of the client.
Misconception 1: The DHS 4516 form is only for emergency dental services.
This form is designed for a range of dental and orthodontic services, not just emergencies. It allows providers to request authorization for various treatments under the California Children's Services program.
Misconception 2: Only certain dental providers can use the DHS 4516 form.
While the form is specifically for providers enrolled in Denti-Cal, it is available to all eligible dental professionals who meet the necessary requirements. This includes both general dentists and specialists.
Misconception 3: Submitting the DHS 4516 guarantees approval for services.
Submitting the form does not guarantee that services will be authorized. Approval depends on the medical necessity of the requested services and compliance with program guidelines.
Misconception 4: The form can be submitted without complete client information.
Incomplete forms may lead to delays or denials of service requests. It is crucial to provide all required information accurately to ensure timely processing.
Misconception 5: The DHS 4516 form is not necessary for clients already enrolled in Medi-Cal.
Even if a client is enrolled in Medi-Cal, the DHS 4516 form may still be required for specific dental services. In such cases, providers must send a Treatment Authorization Request (TAR) directly to Denti-Cal instead.
Filling out the California DHS 4516 form is a crucial step in ensuring that your child receives necessary dental and orthodontic services through the California Children’s Services (CCS) program. Here are some key takeaways to keep in mind:
By following these guidelines, you can enhance the likelihood of a smooth and efficient process in obtaining the necessary dental and orthodontic services for your child.