To request preauthorized approval for treatment:

• Submit a pre-treatment estimate on an approved American Dental Association Claim Form.
• Email (preferred) the form to preauthorizationrequest@victims.ca.gov.
• Fax the form to 866-902-8669.

CalVCB will review the estimate to determine if the treatment is both medically necessary and crime-related. CalVCB may request additional information, such as previous dental records.

The Board may only make payment after the authorized services were provided.

An applicant does not have the right to appeal the denial of a pre-treatment estimate because they have not incurred the pecuniary loss. However, the claimant may still undergo the dental treatment and submit the incurred expenses to CalVCB with the understanding CalVCB may not reimburse these expenses. If the expense is recommended for denial, the applicant may appeal the recommendation.

Dentists must submit bills on an American Dental Association (ADA) Dental Claim Form that must include:

• Patient’s name and address
• Date(s) of service
• Type(s) of service(s) provided (diagnosis and procedure)
• CDT (Current Dental Terminology) code(s)
• Tooth number (if applicable)
• Any missing teeth
• Charges for each procedure
• Total charges
• Provider’s name, license number, federal tax identification number (FEIN or SSN), business address, telephone number, signature or signature stamp, and billing date