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The California DHS 4516 form serves a critical function within the California Children’s Services (CCS) program, specifically for dental and orthodontic services. This form is essential for healthcare providers seeking authorization for specific client services. It requires detailed information about the provider, including their name, contact information, and Denti-Cal provider number. Additionally, it collects comprehensive client information such as the client’s name, gender, date of birth, and residence address. Insurance details are also crucial, as the form asks whether the client is enrolled in Medi-Cal or other insurance plans. The requested services section allows providers to specify the type of services needed, whether for established CCS clients or for orthodontic procedures. Each service must be clearly detailed, including tooth numbers, descriptions, and associated fees. Lastly, the form mandates a signature from the dental provider, ensuring that all information provided is accurate and that the requested services are necessary for the client’s health. Understanding the nuances of this form is vital for providers to navigate the authorization process effectively.

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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)

 

City

 

 

 

State

ZIP code

 

 

 

 

 

 

 

 

 

 

 

 

14.

Mailing address (if different) (number, street, P.O. box number)

 

City

 

 

 

State

ZIP code

 

 

 

 

 

 

 

 

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

 

 

Yes

No

 

 

 

 

 

 

23.

Enrolled in commercial dental insurance plan?

If yes, name of plan

 

 

Yes

No

 

 

 

 

 

 

 

 

 

 

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

Yes

No

32.Other documentation attached

Yes

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.

Provider Information

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.

Client Information

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.

Insurance Information

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.

Requested Services

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.

DHS 4516 (7/04)

Page 2 of 2
➤ PDF File

Form Specifications

Fact Name Details
Form Title California Children's Services (CCS) Dental and Orthodontic Client Service Authorization Request (SAR)
Governing Law California Welfare and Institutions Code Section 14000 et seq.
Request Date The date on which the service request is made must be provided.
Provider Information Includes the provider's name, Denti-Cal provider number, and contact details.
Client Identification Requires the client's name, gender, date of birth, and CCS case number.
Insurance Verification Questions regarding enrollment in Medi-Cal, Healthy Families, or commercial dental plans are included.
Requested Services Providers must specify the type of service authorization requested, including CCS established clients or orthodontics.
Documentation Requirement Providers must certify that the information is true and may attach additional documentation.
Signature Requirement The form must be signed by the dental provider or an authorized designee to be valid.

California Dhs 4516: Usage Guidelines

Completing the California DHS 4516 form involves providing detailed information about the client, the requesting provider, and the specific services needed. Following these steps will ensure that all necessary information is accurately captured for processing.

  1. Date of request: Write the date when the request is being made.
  2. Provider name: Enter the full name of the provider requesting the services.
  3. Denti-Cal provider number: Fill in the Denti-Cal billing number (avoid using group numbers).
  4. Address: Provide the complete address of the requesting provider.
  5. Contact person: Indicate the name of the person who can be reached regarding the request.
  6. Contact telephone number: Enter the phone number for the contact person.
  7. Contact fax number: Provide the fax number for the provider’s office or contact person.
  8. Client name: Fill in the client's name, including last, first, and middle names.
  9. Gender: Check the appropriate box for the client's gender.
  10. Date of birth: Enter the client’s date of birth in the format mm/dd/yy.
  11. CCS case number: Input the client’s CCS case number; leave blank if unknown.
  12. Contact phone number: Provide a phone number where the client or their legal guardian can be reached.
  13. Residence address: Enter the client's home address (no P.O. Box).
  14. Mailing address: If different from the residence address, provide the mailing address.
  15. County of residence: Indicate the county where the client resides.
  16. Language spoken: Write the language that the client speaks.
  17. Name of parent/legal guardian: Enter the name of the client's parent or legal guardian.
  18. Mother’s first name: Fill in the first name of the client’s mother.
  19. Primary care physician: Provide the name of the client’s primary care physician, or enter "NK" if not known.
  20. Primary care physician telephone number: Enter the phone number for the primary care physician.
  21. Enrolled in Medi-Cal? Check yes or no. If yes, send TAR directly to Denti-Cal.
  22. If no, Client Index Number (CIN): If not enrolled in Medi-Cal, enter the CIN.
  23. Enrolled in Healthy Families? Mark yes or no. If yes, provide the name of the plan.
  24. Enrolled in commercial dental insurance plan? Check yes or no. If yes, enter the name of the plan.
  25. Service Authorization Request for: Check either "CCS established client" or "CCS orthodontics."
  26. Tooth Number or Description of Service: Enter the tooth number or description of the service requested.
  27. Arch: Specify the arch using codes (U for upper, L for lower).
  28. Surfaces: Use appropriate codes for tooth surfaces.
  29. Quantity: Indicate the number of occurrences for the procedure.
  30. Procedure numbers: Use the correct Denti-Cal codes for each service.
  31. Fee: Enter the usual and customary fee for the procedure.
  32. Is this a CCS supplemental services request? Check yes or no.
  33. Other documentation attached: Check yes if additional documents are included.
  34. Comments: Provide any additional comments or notes.
  35. Signature of dental provider: The form must be signed by the dentist, orthodontist, or an authorized representative.
  36. Date: Enter the date when the request is signed.

Your Questions, Answered

What is the California DHS 4516 form used for?

The California DHS 4516 form is a Service Authorization Request (SAR) specifically for dental and orthodontic services under the California Children’s Services (CCS) program. It is used by healthcare providers to request authorization for necessary dental procedures for eligible clients.

Who should fill out the DHS 4516 form?

The form should be completed by dental providers who are seeking approval for services on behalf of their clients. This includes orthodontists and general dentists who are part of the Denti-Cal network.

What information is required on the form?

Essential information includes the provider's details (name, Denti-Cal number, contact information), client information (name, date of birth, address, CCS case number), and insurance details. Additionally, the specific services requested and any relevant documentation must be provided.

How do I know if my client is eligible for services?

Eligibility is typically determined by whether the client is enrolled in Medi-Cal or another qualifying insurance plan. The form includes sections to indicate the client's insurance status, which helps establish eligibility for CCS services.

What should I do if the client is not enrolled in Medi-Cal?

If the client is not enrolled in Medi-Cal, you must provide their Client Index Number (CIN) on the form. This information is crucial for processing the authorization request through the appropriate channels.

Is there a deadline for submitting the DHS 4516 form?

While there is no specific deadline stated, it is advisable to submit the form as soon as possible to avoid delays in service authorization. Timely submission helps ensure that clients receive the necessary care without interruption.

What happens after the form is submitted?

Once submitted, the request will be reviewed by the appropriate authority. You will receive notification regarding the approval or denial of the requested services. Ensure that all information is accurate to facilitate a smooth review process.

Common mistakes

When filling out the California DHS 4516 form, it is crucial to be thorough and accurate. Here are nine common mistakes that people often make:

  1. Incorrect Date Entry: Failing to enter the correct date of the request can lead to delays. Always double-check the date to ensure it reflects when the request is made.
  2. Missing Provider Information: Leaving out details such as the provider's name, Denti-Cal provider number, or contact information can result in processing issues. Each field in the provider section is essential.
  3. Inaccurate Client Information: Errors in the client's name, date of birth, or gender can cause complications. It is important to ensure that all client details match official documents.
  4. Using P.O. Box for Residence Address: The form explicitly states not to use a P.O. Box for the residence address. Providing a physical address is necessary for accurate processing.
  5. Neglecting Insurance Information: Omitting information about Medi-Cal or other insurance plans can lead to confusion. Be sure to mark the appropriate boxes and provide any necessary details.
  6. Improper Service Request Selection: Not checking the correct box for the type of service authorization can result in the request being denied. Carefully review the options and select the appropriate service.
  7. Incomplete Service Details: Leaving out tooth numbers, descriptions, or procedure codes can delay the authorization process. Each service must be clearly detailed to avoid misunderstandings.
  8. Failure to Sign the Form: The form must be signed by the dental provider or authorized designee. A missing signature will render the request invalid.
  9. Not Providing Additional Documentation: If there are attachments or additional documents required, failing to check the box indicating their inclusion can lead to processing delays. Always ensure that all necessary documentation is included.

By avoiding these common mistakes, you can help ensure that the California DHS 4516 form is completed correctly and processed smoothly. Attention to detail is vital in this process.

Documents used along the form

The California DHS 4516 form is a crucial document used for requesting dental and orthodontic services for clients under the California Children's Services (CCS) program. Along with this form, several other documents may be necessary to ensure a smooth authorization process. Here are ten commonly used forms and documents that often accompany the DHS 4516:

  • CCS Eligibility Application: This form is used to determine if a child qualifies for services under the California Children's Services program. It gathers essential information about the child's medical condition and family income.
  • Treatment Authorization Request (TAR): A TAR is submitted to request approval for specific medical services. It is particularly important for clients enrolled in Medi-Cal and must be sent directly to Denti-Cal.
  • Denti-Cal Claim Form: This form is used to submit claims for reimbursement for dental services provided to Medi-Cal beneficiaries. It includes details about the services rendered and the associated costs.
  • Client Index Number (CIN) Verification: This document verifies the Client Index Number assigned to the client. It is essential for processing claims and ensuring proper billing.
  • Primary Care Physician Referral: A referral from the client's primary care physician may be required to confirm the need for dental or orthodontic services. This document provides additional support for the service request.
  • Consent for Treatment Form: This form is signed by the parent or legal guardian, giving permission for the dental provider to perform the necessary procedures. It is crucial for legal and ethical compliance.
  • Insurance Information Form: This document collects details about the client's dental insurance coverage, including any commercial plans. It helps determine the extent of coverage for requested services.
  • Medical History Form: A comprehensive medical history form provides the dental provider with important information about the client's past medical conditions, allergies, and current medications.
  • Dental Treatment Plan: This plan outlines the recommended dental procedures and the timeline for treatment. It serves as a guide for both the provider and the client regarding the expected services.
  • Progress Notes: These notes document the client's treatment history and any changes in their condition. They are important for ongoing care and may be required for future service requests.

Having these documents ready can facilitate a more efficient authorization process for dental and orthodontic services. Each form plays a specific role in ensuring that clients receive the necessary care while complying with program requirements.

Similar forms

  • California DHS 4500 Form: This form is used for the Service Authorization Request (SAR) in various healthcare services. Like the DHS 4516, it requires detailed client and provider information, ensuring that all necessary data is collected for service approval.
  • California Medi-Cal TAR (Treatment Authorization Request): Similar to the DHS 4516, the TAR is used to request prior authorization for specific medical services under Medi-Cal. Both forms require information about the client, provider, and requested services to facilitate approval.
  • CCS Program Application Form: This document is essential for enrolling clients in the California Children’s Services program. It shares similarities with the DHS 4516 in that it collects comprehensive client and guardian information, as well as details about medical needs.
  • Denti-Cal Claim Form: This form is utilized to submit claims for dental services provided to Medi-Cal beneficiaries. Like the DHS 4516, it requires specific service details, client identification, and provider information to process claims effectively.

Dos and Don'ts

When filling out the California DHS 4516 form, attention to detail is crucial. Here are five things you should and shouldn't do to ensure a smooth process:

  • Do provide accurate and complete information for each section of the form.
  • Do use the client's full name as it appears on official documents.
  • Do check the appropriate boxes for gender and insurance enrollment.
  • Do include the provider's Denti-Cal provider number correctly.
  • Do sign and date the form to validate the request.
  • Don't use a P.O. Box for the residence address; a physical address is required.
  • Don't leave any required fields blank; if unknown, indicate as such.
  • Don't mix different types of codes when entering procedure numbers.
  • Don't forget to attach any necessary supporting documentation.
  • Don't submit the form without verifying all information for accuracy.

Misconceptions

The California DHS 4516 form is a critical document used for requesting dental and orthodontic services for clients enrolled in California Children's Services (CCS). However, several misconceptions exist regarding this form. Below are five common misconceptions, along with clarifications.

  • The form is only for children. Many believe that the DHS 4516 form is exclusively for minors. While it primarily serves children under the CCS program, it can also apply to young adults who are still eligible for CCS services.
  • All dental services require this form. Some individuals think that every dental procedure needs a DHS 4516 form. In reality, this form is specifically for services covered under CCS. Other dental procedures outside this program may not require it.
  • The form guarantees service approval. There is a misconception that submitting the DHS 4516 form automatically guarantees that services will be approved. Approval is contingent upon the review of the request and the specific criteria set by CCS.
  • Only the dentist can submit the form. It is often assumed that only the dental provider can complete and submit the form. However, an authorized designee can also submit the form on behalf of the provider, provided they have the necessary permissions.
  • The form can be submitted without supporting documentation. Some people think that the DHS 4516 form can stand alone. In many cases, additional documentation is required to support the request for services, and failure to include this may result in delays or denials.

Key takeaways

Filling out the California DHS 4516 form correctly is essential for obtaining authorization for dental and orthodontic services under the California Children’s Services (CCS) program. Here are key takeaways to consider:

  • Accurate Information: Ensure that all fields are filled out accurately. This includes provider details, client information, and insurance data.
  • Service Selection: Clearly indicate the type of service being requested, whether it is for an established CCS client or orthodontic services.
  • Documentation: Attach any necessary documentation that supports the request. This may include previous treatment records or additional forms.
  • Signature Requirement: The form must be signed by the dental provider or an authorized designee. This confirms the accuracy of the information provided.
  • Timely Submission: Submit the form promptly to avoid delays in service authorization. Timeliness is crucial for ensuring that clients receive necessary care without interruption.

By adhering to these guidelines, providers can facilitate a smoother authorization process for their clients.