• Opened a new private practice
• Were a Managed Care Provider
• Are reactivating a Medicaid Provider number which was terminated more than one year ago.
• If you are establishing a payee (pay to) other than your own social security number . A separate application must be submitted on behalf of the payee entity (e.g. XYZ, Inc or LLC).

    Instructions are provided for form DHS1139; however, here are some additional “pointers” to get you started:

• Parts A, B, C & E. should be completed:
• If you are providing regular services to individuals under age 21, please complete Part D also.
• Submit the following documents with your application:
• Copy of dentists current Hawaii dental license card;
• IRS Form W-9.
• For dental specialists (i.e. Pediatric, Endodontic, Oral Surgery) - documents certifying completion of specialty training.

   Current Applicants:

To modify Information on existing Applications:

You should submit an application if you need to add a location, close a location, change ownership or make any other adjustments on your existing application:

• If you are adding or closing service locations, check the appropriate boxes and complete Part A.
• The "Instructions for Existing Providers" outlines requirements for all other changes.
• Please refer to the “Instructions for Existing Providers” for additional information that you may be required to submit such as your current Hawaii license, W-9, Federal DEA, etc.,
Back To Top

Dental Policies

Medicaid policy information for dentists can be found in:

• Medicaid Provider Manual Dental Services, chapter 14

• DENTAL M09-01 Dental Program Amendments
• DENTAL M09-02 Updated Neighbor Island Fee Schedule
• DENTAL 09-03 Changes to Adult Dental Benefits Eff 08/10/09
• CYRCA 0901 Non-Emergency Transportation Policy Adherence
• DENTAL M09-04 Foreign Language and Sign Language Interpreter Services
• DENTAL M09-05 Children's Health Insurance Program Reauthorization Act (CHIPRA) "Insured Kids Now" Website
  

  To view the ACS Provider memos listed below, click here.

Policy #	Description	Issue Date
ACS M09-14	Drugs Prescribed by Dentists for QUEST or QExA Recipients	06-16-09
ACS M07-16	Dental Procedures Codes	08/27/07
ACS M07-15	Transition of Dental Claims Processing and all the attachments (1-4)	08/27/07
ACS M07-04	Adult Dental Benefits (Preventive/Restorative and Dentures) rendered in a Federally Qualified Health Center (FQHC)	Effective December 1, 2006
ACS M06-20	Adult Dental Benefits (Preventive/Restorative and Dentures)	Effective December 1, 2006
ACS M06-06	National Provider Identifier (NPI) Information	05/8/06
ACS M04-14	Acceptance of Claim Form ADA 2002	12/22/04
ACS M04-08	Dental Coverage for Adults	08/16/04
ACS M03-22	Claims Filing Instructions for Dental Procedure Codes D0230, D4210, D240, D7310, D7320	11/20/03
ACS M03-12	Clarification of Coverage of Dental Sedation	10/1/03
M02-16	Sign Language Interpreter Services	08/12/02
M02-14	Coverage of Elective Tooth Extractions	07/3/02

• Hawaii Revised Statutes
  • 17-1735: General Provisions For Fee For Service Medical Assistance
• 17-1737: Scope and Contents of the Fee for Service Medicaid Assistance Program
• 17-1739: Authorization, Payment and Claims in the Fee-For-Service Medical Assistance Program
• 17-1739.1: Authorization, Payment and Claims in the Fee-For-Service Medical Assistance Program for Non-Institutional Services. .
Back To Top

• CCMC (Community Case Management Corp.) is contracted by the State to help recipients find a dentist.
• Dentists may call CCMC at 486-8030 (Oahu) or 866-486-8030 ( Neighbor Islands). Find out how they can help you and your Medicaid patients.

Dental Fees

Click here for the Oahu Dental Fee Schedule. Click here for the new increased Neighbor Island Dental Fee Schedule.

Dental Prior Authorization

AVRS Quick Reference Sheet