Dental Application Dental Policies Dental Coordinator Dental Fees
Dental Prior Authorization Dental Payment Dental Claims Inquiries Dental Eligibility

Dental Application

Currently, all dental services are provided under the fee-for-service program, which covers dental services for Hawaii Medicaid recipients. (Previously dental services were part of the managed care program.) If you would like to be a dental provider or if you are already a provider and want to report changes you can use the Medicaid Provider Application/Change Request Form (DHS1139) and appropriate attachment forms (DHS 1139A, 1139B, 1139C, 1139D, 1139E, 1139F, 1139G and 1139H).  

   New Applicants:  

You should submit a new application if you:

    • 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.,

Dental Policies

Medicaid policy information for dentists can be found in:

Dental Memos:
  • 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. .

Dental Coordinator

CCMC (Community Case Management Corporation) is contracted by HDS to help recipients find a dentist.

Dentists may call CCMC at:
Oahu: (808) 792-1070 or Toll-free (888) 792-1070

Dental Fees

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

Dental Prior Authorization

Some dental procedures require prior authorization. All hospital prior authorizations must be submitted to HDS on paper using the Request for Dental Authorization form.

All non-hospital prior authorizations (including orthodontic prior authorizations) can be submitted electronically or on the standard ADA claim form. For further information, please contact HDS Medicaid at:

HDS Medicaid Customer Service
Oahu: 529-9345; Neighbor Islands: 1-855-819-9117

Dental Payment

Effective January 16, 2013 HDS is the Third Party Administrator (TPA) for Hawaii Medicaid�s dental program. HDS has partnered with Community Case Management Corp. (CCMC), who will continue to handle the outreach services to Medicaid patients.

HDS Medicaid has a dedicated mailing address, customer service number and website for eligibility and electronic claims processing.

HDS Medicaid Customer Service:
Tel: (808) 529-9345, or Toll-free (855) 819-9117
Fax: (808) 529-9333, or Toll-free (855) 819-9118

HDS Medicaid DenTel Automated Voice Response System (for eligibility and fax back only):
(808) 529-9346 or Toll-free (855) 819-9119

Mail Medicaid Claims to:
HDS Medicaid
700 Bishop St Ste 750
Honolulu, HI 96813

HDS Medicaid Web Portal (eligibility, claims submission, claim information):

Professional Relations Department:
(808) 529-9222 or Toll-free (800) 232-2533 ext. 222

Dental Claims Inquiries

HDS Medicaid Customer Service. Oahu: 529-9345; Neighbor Islands: 1-855-819-9117
HDS Medicaid: 700 Bishop Street Suite 750, Honolulu, HI 96813

Dental Eligibility

To check a patient�s Medicaid eligibility providers may use any of the following resources:

  • HDS Medicaid Customer Service.
    Oahu: 529-9345; Neighbor Islands: 1-855-819-9117

  • HDS DenTel Automated Voice Response System.
    Oahu: 529-9346; Neighbor Islands: 1-855-819-9119

  • HDS Medicaid Web Portal at https://hdsmedicaid.org

  • Call AVRS (Automated Voice Response System) 1-800-882-4608

  • Log on to Medicaid On-line:https://hiweb.statemedicaid.us

  • Call Med-QUEST Customer Service Section.
    Oahu: 524-3370; Neighbor Islands: 1-800-316-8005

© Hawaii State Med-QUEST Division 2003-2007