Dental Record Authorization And Invoice For Outpatient Services
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3NOTE: INSTRUCTIONS ARE WRITTEN FOR A MULTI-PART FORM. PRINT ADDITIONAL COPIES AS NECESSARY
DENTAL RECORD AUTHORIZATION AND
INVOICE FOR OUTPATIENT SERVICES
PART I - EXAMINATION PROCEDURE INSTRUCTIONS FOR THE PARTICIPATING FEE DENTIST
1. Examination Authorization. The Department of Veterans Affairs (VA) has authorized this veteran to choose a general practitioner
who will complete a thorough oral examination and treatment plan. The VA must be apprised of the veteran's current dental needs so as to
make a determination of the extent and type of treatment to be authorized. The allowable fees for radiographs and examination have been
indicated in Item 14 on page 3 of this form. The fee for radiographs is based on a full mouth series. This is a basic requirement when no
diagnostically usable radiograph record exists relating to a complete dentition. In a circumstance where depleted dentition or edentulous
status exists, the requirement for radiographs should be modified by the examining dentist. Any modification from a full mouth series
should be annotated by specifying the radiographs actually exposed. The fee will be adjusted, accordingly, by the VA. On subsequent
examinations, only radiographs necessary for proper diagnosis and treatment should be taken. Where pre-existing radiographs will serve to
satisfactorily augment a thorough clinical evaluation, the pre-printed entry in Item 9 should be crossed out and initiated by the examining
dentist.
WHEN IS ITEM 11 COMPLETED? WHICH ITEM AUTHORIZES TREATMENT?
2. Inappropriate selection of fee dentist. If you are a specialist, your practice is restricted to a specialty, or you are currently on active
military duty and engaged in part-time private practice, the veteran has made an inappropriate selection of a fee dentist. (VA is prohibited
from making payment of fees to a member of the military services.) Return this authorization and allied papers to the veteran and clarify
that a Civilian General Practice Dentist must be chosen for examination and treatment plan purposes. If the veteran needs assistance, the
Chief of Dental Service at the VA issuing office may be contacted.
3. Use of form. VA Form 10-2570d will serve for examination record, treatment recommendations, record of treatment and invoice for
services provided. When you receive the carbon-interleafed VA Form 10-2570d, please keep all copies together. Entries must be made
with a typewriter or ball point pen only. Use heavy pressure with a ball point pen. Inspect the last copy to see if all entries have been
recorded legibly. Supply all data requested in Items 2 through 5. Be certain to include your telephone number (including area code) in
Item 2A.
4. Examination authorized. The examination authorization is your authority to proceed with radiographs and examination only. You
may not proceed with definitive dental care for your veteran patient. Payment will not be made for unauthorized treatment. The only
exception is for limited EMERGENCY dental care. To obviate an emergency situation, care which is needed at the time of the
examination (relief of pain, etc.) can be provided. However, the VA office (shown in Item 1) issuing this authorization must be notified of
the details and treatment within 15 days or there is no authority to make payment for these emergency services.
5. Dental examination. Chart all missing teeth in Item 6. Enter the date examination was conducted and radiographs were taken in Item
10 opposite the appropriate pre-printed entries in Item 9. During the examination, take care to discuss options and not commit to any
specific treatment plan.
If there are significant differences between what VA considers reasonable and appropriate and the proposed
treatment plan, VA may reexamine the veteran prior to treatment authorization to determine a treatment plan that provides a satisfactory
resolution of needs and is compatible with cost containment measures. List all treatment recommendations under Items 7, 8 and 9. Types
of abutments and pontics for fixed partial dentures must be stipulated and teeth to be clasped for removable partial dentures must be
specified. Enter your usual and customary fee for each line entry under Item 12. Enter statements in Item 13 (Remarks) which will further
clarify data under Item 9. Please identify specific teeth which the veteran states were extracted while he was in active military service.
Details as to appropriate dates and places of extractions are necessary to determine if replacements can be authorized. When all appropriate
entries have been completed, return the packet along with the patient's radiographs to the issuing office (shown in Item 1) for treatment
authorization.
6. Requirement to review radiographs. The VA outpatient dental care program operates under legal restriction and, with few exceptions,
only those dental conditions determined to be "service-incurred" may be corrected at Government expense. Therefore, it is necessary that
treatment recommendations and radiographs be returned to the issuing office (Item 1) for determination of the extent of allowable treatment
at VA expense and establishment of authorized fees for these services. Radiographs will be returned to you with the treatment authorization
and may be retained by you for your records.
7. Time limitation. There is a time limitation indicated in Item 19. Examination should be completed and findings returned by this date.
If veteran does not respond for examination, return the authorization to the issuing office. If there is a good reason an extension of time is
required, contact the issuing office (Item 1) for an extension of the time limitation.
8. Payment for Services. Payment for examination and treatment will be made following completion or termination of treatment.
9.
Precaution. There may be instances in which recently discharged veterans will report directly to your office requesting that certain
dental treatment initiated by the Military during service be completed at Government expense. While it is possible that such veterans, after
making application, may be determined eligible for treatment, VA will not be responsible for dental services provided prior to the date
treatment is appropriately authorized.
VA FORM
10-2570d
DENTIST: NO PAYMENT WILL BE MADE UNLESS PRE-AUTHORIZED BY VA
Instructions
MAR 2008 (R)
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