Indiana caresource provider manual 2018

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CareSource offers Medicaid, children's health care. People who actually take advantage of their dental benefits and. Its a credit card for health-related expenses. CareSource is a not-for-profit organization serving Medicaid members and it is the second largest Medicaid plan in the United States. Immigrants came to America for many reasons, but most came for the possibilities of a free society which would allow them to better their lives and to practice their religion freely.

Our employees curated a Spotify playlist to share what it feels. Sofmed Breathables Monthly 6 Pack. To try out the new solution, CareSource identified two large are on the path to automation and take them to the next step — or beyond.

Billboard Hot chart and sold 11 million copies worldwide. CareSource offers Medicaid, children's health care programs, Marketplace plans, and Medicare Advantage plans. Updated Jan 2, , am EST. Policymakers should not give America's creditors, present and future, any reason to. CareSource remains committed to our members and the communities we serve.

That is to say, you will only income a copay. Visit us online or call your local store to find. For Practitioner Selection - CareSource verifies licensure and ensures the highest level of training and board certification, and also verifies all credentials through the National Practitioner Data Bank for information about the practitioner.

Sediments settle in different densities and structures, depending on the local wave. America's Best does, however, accept the following national vision insurance plans: Advantica. Reimbursement is based on the prevailing state Medicaid or Medicare fee schedule. How much does America's best really cost? CareSource is a nonprofit that began as a managed health care plan serving Medicaid members in Ohio. If you do not see your plan listed here, please give us a call and we.

In order to have your health care services covered by your CareSource plan, you must get them from a network provider. Find a Doctor. Order same-day delivery or pickup from more than retailers and grocers. Does walmart vision accept united health care duel. Enrollment in CareSource Medicare Advantage plans depends on. CareSource Employee Reviews. This best method is far simpler than you think.

Find the best mobile homes deals on the market in santa clara county, ca and buy a property up to 50 percent below market value. Dec 31, The United States of America formed after the colonies decided to revolt against th.

Each year two contact lens exams are included. Helpful 82 Video is ever-growing because it's the best way to quickly and concisely relay information to your audience.

In fact, whatever the insurances, they doesn't cover for eyeglasses. The best option, of course, would be for Congress to engage in an intentional, bipartisan deficit reduction effort, and such an effort - if substantial enough - could avoid the across-the-board cuts under Statutory PAYGO or even the BCA sequester.

The entire surgical center staff is awesome. What Does the Vote Mean? Now a Subsidiary of Patient Infosystems Inc. Ambetter vs CareSource: What's the difference?. This includes name, email address, mailing address, phone number, employment details including dates and position titles, and licensure and certification information such as number, issuing date and expiration date.

Carrying on the quality of dentistry standards that we set for ourselves and serving the community is our bottom line. Your Target Optical vision insurance coverage can vary depending on your plan.

Storing them in some refrigerators with a sealed bag covering appears to be the best option. Even if you cannot utilize Medicaid at Americas Best, there are alternative vision clinics, like Walmart Vision Center and Visionworks, that take Medicaid. Working at CareSource: What to know before applying. America's Best isn't among places that accept Medicaid for glasses but it accepts most vision insurance plans.

Existing Users Enter passcode to edit information:. We recommend you confirm coverage and restrictions with your insurance provider before seeking services. Teeth cleaning by dental hygienists. Meghan Elizabeth Trainor born December 22, is an American singer-songwriter and television personality.

CareSource is a nonprofit, multi-state health plan recognized as a national leader in managed care. CareSource tied for the No. Do America's best accept Medicaid?. Sofmed breathables 1 day 90 Pack. Although the firm does not take Medicaid, it does provide inexpensive eye tests and savings on eyeglasses and contacts. In response to the growing public health concerns related to the Coronavirus COVID , we have created a resource page to identify your benefit coverage and services offered during this time of need.

Dr Gilbert is passionate about helping patients achieve their best vision, through LASIK or cataract surgery for vision impairment, or by treating chronic dry eye or other medical conditions. Check your local Visionworks for top plans in your area, or call to see if your plan is. Book an appointment or eye exam today!. The best way to find out if you have Amwell's services as a covered benefit.

A beach is a landform alongside a body of water which consists of loose particles. CareSource is one of a few options that lower-income, underserved communities have for a managed health plan.

Talk to our friendly LEGO experts online. The answer to this question is yes, America's Best Price does include lenses. Vast magnificence elevated the Erectile dysfunction reddit Impotence medical definition mind Does Caresource Cover Viagra of the beholder to Face with her robe I receive Rhino 12 pill reviews it, Does Caresource Cover Viagra cried he, as the pledge of Escape the dreadful destiny awaiting her, but must, perhaps Made several attempts to speak.

Health Insurance Information. The metatarsal-phalangeal joint at the base of the big toe is affected most often, accounting for half of cases. He came to the United States in Today, CareSource serves more than 1. This means the country turned years old in Cancel anytime without penalties. Vaccination is the best form of protection against COVID and new variants, but boosting rates across Ohio may require new strategies to reach families.

America's Best Contacts and Eyeglasses Review for The particles composing a beach are typically made from rock, such as sand, gravel, shingle, pebbles, etc. Sofmed breathables advanced 6 Pack. Having a clear idea about the components becomes necessary to ensure that you get the one that suits your needs and.

For order and payment issues, it's best to call us as we can't take payment info over chat. Shop All Sofmed Contacts. If you think you will travel out of our service area, be sure to fill your. Provider Manual The CareSource Dental Provider Manual provides information on topics such as covered services, claims submissions and prior authorization requirements and processes. Most plans cover eye exams, glasses or contact lenses, and. In some cases, MCEs may have more lenient requirements for paying emergency services, but according to the new policy, MCEs may not enact more stringent requirements.

Managed Health Services does not appear to have an autopay list in place but would also be subject to these new policies if they implement one. Lists of these kinds have been used for several years as a way for payers to quantify the prudent layperson guideline for determining emergencies.

Physicians, however, have balked at using final diagnoses as a way to evaluate the prudent layperson standard. They insist that presenting symptoms offer a much more compelling picture of what patients are thinking when they present to the ER.

And even then, both mild and severe conditions can share presenting symptoms. Other resources highlighted in this article include:.

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Gracias por su visita. Qr Code Generator. Hola, necesitas tener JavaScript habilitado para usar esta red. Por favor verifica la configuracion de tu navegador o contacta a el administrador de tu sistema. Blood pressure. Recommended b. Soft tissue examination. Periodontal assessment. Occlusal classification. Dentition charting. Identified by patient name. Mounted if intraoral films.

Adequate documentation of the treatment plan including any alternate treatment options that specifically describes all the services planned for the patient by entry of these items:. An Adequate documentation of the periodontal status, if necessary, which is dated and requires charting of the location and severity of these items:. Periodontal pocket depth. Furcation involvement. Adequacy of attached gingiva. Missing teeth. Gingival status. Amount of plaque. Amount of calculus.

Education provided to the patient. Recall interval. An adequate documentation of medical and dental consultations within and outside the practice which requires entry of these items:. Provider to whom consultation is directed. Description of service, procedure, and observation. Documentation in treatment record must contain documentation to support the level of American Dental Association Current Dental Terminology code billed as detailed in the nomenclature and descriptors.

Documentation must be written on a tooth by tooth basis for a per tooth code, on a quadrant basis for a quadrant code and on a per arch basis for an arch code. Type and dosage of anesthetics and medications given or prescribed. The patient record has one explicitly defined format that is currently in use. There is consistent use of each component of the patient record by all staff. Entries in the records are legible. Entries of symbols and abbreviations in the records are uniform, easily interpreted and are commonly understood in the practice.

Each participating DentaQuest office is required to maintain and document a formal system for patient recall. The system can utilize either written or phone contact. Any system should encompass routine patient check-ups, cleaning appointments, follow-up treatment appointments, and missed appointments for any Health Plan member that has sought dental treatment.

Regular check-ups are needed to keep your teeth healthy. Call us ahead of time if you cannot keep the appointment. Missed appointments are very costly to us. Thank you for your help.

Dental offices indicate that Medicaid patients sometimes fail to show up for appointments. Follow-up appointments must be scheduled within 30 days of the present treatment date, as appropriate.

These guidelines were developed in conjunction with the Food and Drug Administration. The Panel recommends posterior bitewing radiographs for a new patient, with a primary dentition and closed proximal contacts.

The Panel recommends an individualized radiographic examination consisting of selected periapicals with posterior bitewings for a new adolescent patient. The Panel recommends an individualized radiographic examination consisting of selected periapicals with posterior bitewings for a new dentulous adult patient. The Panel recommends a full-mouth intraoral radiographic survey OR a panoramic radiograph for the new edentulous adult patient. The Panel recommends that posterior bitewings be performed at a month interval for those children with clinical caries or who are at increased risk for the development of caries in either the primary or transitional dentition.

The Panel recommends that posterior bitewings be performed at a month interval for adolescents with clinical caries or who are at increased risk for the development of caries.

The Panel recommends that posterior bitewings be performed at a month interval for adults with clinical caries or who are at increased risk for the development of caries.

The Panel found that an examination for occult disease in this group cannot be justified on the basis of prevalence, morbidity, mortality, radiation dose and cost. Therefore, the Panel recommends that no radiographs be performed for edentulous recall patients without clinical signs or symptoms.

The Panel recommends that posterior bitewings be performed at an interval of months for children with a primary dentition with closed posterior contacts that show no clinical caries and are not at increased risk for the development of caries. The Panel recommends that posterior bitewings be performed at intervals of months for patients with a transitional dentition who show no clinical caries and are not at an increased risk for the development of caries.

The Panel recommends that posterior bitewings be performed at intervals of months for dentulous adult patients who show no clinical caries and are not at an increased risk for the development of caries. Patients with periodontal disease, or a history of periodontal treatment for Child — primary and transitional dentition, Adolescent and Dentulous Adult.

The panel recommends that prior to the eruption of the first permanent tooth, no radiographs be performed to assess growth and development at recall visits in the absence of clinical signs or symptoms. The Panel recommends that for the adolescent age years of age recall patient, a single set of periapicals of the wisdom teeth OR a panoramic radiograph. The Panel recommends that no radiographs be performed on adults to assess growth and development in the absence of clinical signs or symptoms.

First examination at the eruption of the first tooth and no later than 12 months. Includes assessment of pathology and injuries. By clinical examination. Must be repeated regularly and frequently to maximize effectiveness. Consider when systemic fluoride exposure is suboptimal.

Up to at least 16 years. Appropriate discussion and counseling should be an integral part of each visit for care. Initially, responsibility of parent, as child matures, jointly with parent, then, when indicated, only child. At every appointment; initially discuss appropriate feeding practices, then the role of refined carbohydrates and frequency of snacking in caries development and childhood obesity.

Initially play objects, pacifiers, car seats; when learning to walk; then with sports and routine playing, including the importance of mouthguards.

At first, discuss the need for additional sucking: digits vs pacifiers; then the need to wean from the habit before malocclusion or skeletal dysplasia occurs. For school-aged children and adolescent patients, counsel regarding any existing habits such as fingernail biting, clenching, or bruxism.

For caries-susceptible primary molars, permanent molars, premolars, and anterior teeth with deep pits and fissures; placed as soon as possible after eruption. Documentation requests for information regarding treatment using these codes are determined by generally accepted dental standards for authorization, such as radiographs, periodontal charting, treatment plans, or descriptive narratives.

In some instances, the State legislature will define the requirements for dental procedures. These criteria were formulated from information gathered from practicing dentists, dental schools, ADA clinical articles and guidelines, insurance companies, as well as other dental related organizations. These criteria and policies must meet and satisfy specific State and Health Plan requirements as well. They are designed as guidelines for authorization and payment decisions and are not intended to be all-inclusive or absolute.

Additional narrative information is appreciated when there may be a special situation. We hope that the enclosed criteria will provide a better understanding of the decision-making process for reviews. Your feedback and input regarding the constant evolution of these criteria is both essential and welcome.

DentaQuest shares your commitment and belief to provide quality care to Members and we appreciate your participation in the program. Please remember these are generalized criteria. Services described may not be covered in your particular program. In addition, there may be additional program specific criteria regarding treatment. Therefore, it is essential you review the Benefits Covered Section before providing any treatment.

These clinical criteria will be used for making medical necessity determinations for prior authorizations, post payment review and retrospective review. For all procedures, every Provider in the DentaQuest program is subject to random chart audits.

Providers are required to comply with any request for records. The Provider will be notified in writing of the results and findings of the audit. DentaQuest providers are required to maintain comprehensive treatment records that meet professional standards for risk management. Documentation in the treatment record must justify the need for the procedure performed due to medical necessity, for all procedures rendered.

Post-operative radiographs are required for endodontic procedures and permanent crown placement to confirm quality of care. In the event that radiographs are not available or cannot be obtained, diagnostic quality intraoral photographs must substantiate the need for procedures rendered.

Multistage procedures are reported and may be reimbursed upon completion. The completion date is the date of insertion for removable prosthetic appliances. The completion date for immediate dentures is the date that the remaining teeth are removed, and the denture is inserted. The completion date for fixed partial dentures and crowns, onlays, and inlays is the cementation.

The completion date for endodontic treatment is the date the canals are permanently filled. The prophylactic removal of asymptomatic teeth i. Filling material does not extend excessively beyond the apex. To meet criteria, a crown must be opposed by a tooth or denture in the opposite arch or be an abutment for a partial denture.

A dated post-operative radiograph must be submitted for review for payment. In cases where pathology is not apparent, a written narrative justifying treatment is required. Root canal therapy is performed in order to maintain teeth that have been damaged through trauma or carious exposure. Sargenti filling material is used. Any reimbursement already made for an inadequate service may be recouped after DentaQuest reviews the circumstances.

In most cases, authorization is not required. Where authorization is required for primary or permanent teeth, the following criteria apply:. An authorization for a crown on a permanent tooth following root canal therapy must meet the following criteria:. Prosthetic services are intended to restore oral form and function due to premature loss of permanent teeth that would result in significant occlusal dysfunction.

This does not refer to just the time a patient has been receiving treatment from a certain Provider. Gag reflex, potential for swallowing the prosthesis, severely handicapped. Please review Exhibits of this ORM for any benefit limitations on subsequent adjustments, repairs and relines.

Recipients must be eligible on that date in order for the denture service to be covered. To ensure the proper seating of a removable prosthetic partial or full denture some treatment plans may require the removal of excess bone tissue prior to the fabrication of the prosthesis. Clinical guidelines have been formulated for the dental consultant to ensure that the removal of tori mandibular and palatal is an appropriate course of treatment prior to prosthetic treatment.

Code D CDT—4 is related to the removal of the lateral exostosis. This code is subject to authorization and may be reimbursed for when submitted in conjunction with a treatment plan that includes removable prosthetics.

In the application of clinical criteria for benefit determination, dental consultants must consider the overall dental health. A tooth that is determined to be non-restorable may be subject to an alternative treatment plan. Requests for general anesthesia or IV sedation will be authorized for procedures Covered by Health Plan if any of the following criteria are met:. Periodontal scaling and root planing, per quadrant involves instrumentation of the crown and root surfaces of the teeth to remove plaque and calculus from these surfaces.

It is indicated for patients with periodontal disease and is therapeutic, not prophylactic in nature. Some soft tissue removal occurs. This procedure may be used as a definitive treatment in some stages of periodontal disease and as a part of pre-surgical procedures in others. It is anticipated that this procedure would be requested in cases of severe periodontal conditions i.

It is performed on patients with periodontal disease and is therapeutic, not prophylactic, in nature. Periodontal scaling and root planing are arduous and time consuming. They may need to be repeated and may require local anesthetic. Comprehensive orthodontic treatment is considered medically necessary when adequate corrective treatment is not achievable with less extensive means, and one of the following criteria is met:. Implants will only be considered when a single tooth is missing in an arch excluding third molars or as support for an implant supported full denture maximum allowance is 4 implants on the maxillary arch and 2 implants on the mandibular arch.

Services rendered beyond benefit limits will not be considered covered services. If there is a concern that one of the plans benefit limits may be non-complaint, please notify us immediately.

In order to be Medically Necessary, the service or supply for medical illness or injury must be determined by Plan or its designee in its judgment to be a Covered Service which is required and appropriate in accordance with the law, regulations, guidelines and accepted standards of medical practice in the community.

Amounts members pay for plan premiums, balance-billed charges from non-network services, and health care services this plan does not cover are not included in the maximum out-of-pocket limit. Each Provider shall have its own distinct tax identification number. The document linked below is a comprehensive list of covered services with corresponding Cost Share Categories.

Welcome to the DentaQuest provider forms and attachment resource page. The link below provides methods to access and acquire both electronic and printable forms addressed within this document. To view copies please visit our website at www.

You will then be able to log in using your password and User ID. If you do not have internet access, to have a copy mailed, you may also contact DentaQuest Provider Services Coverage of comprehensive orthodontics is limited to the most severe handicapping orthodontic conditions.

Coverage is further limited to children under age 21 in Kentucky and children under 19 in Georgia, Indiana, Ohio, and West Virginia. Only one course of orthodontic treatment per recipient, per lifetime is covered. Prior authorization is required for all comprehensive orthodontic treatment. A patient must demonstrate a minimum of five 5 symptoms, with at least two 2 of the symptoms appearing under dentofacial abnormality before the provider considers submitting a request for consideration.

DentaQuest is not mandating the use of this form. Please refer to State statutes for specific State requirements and guidelines. I hereby authorize Dr. I am informed and fully understand that there are inherent risks involved in the administration of any drug, medicament, antibiotic, or local anesthetic. I am informed and fully understand that there are inherent risks involved in any dental treatment and extractions tooth removal.

The most common risks can include, but are not limited to:. Bleeding, swelling, bruising, discomfort, stiff jaws, infection, aspiration, paresthesia, nerve disturbance or damage either temporary or permanent, adverse drug response, allergic reaction, cardiac arrest. Alternative treatment options, including no treatment, have been discussed and understood.

No guarantees have been made as to the results of treatment. A full explanation of all complications is available to me upon request from the dentist. Note: The above form is intended to be a sample. Complete all parts of this form. Execute all signatures where indicated. If account requires counter signatures, both signatures must appear on this form. As a convenience to me, for payment of services or goods due me, I hereby request and authorize DentaQuest, LLC to credit my bank account via Direct Deposit for the agreed upon dollar amounts and dates.

I also agree to accept my remittance statements online and understand paper remittance statements will no longer be processed. This authorization will remain in effect until revoked by me in writing.

I agree you shall be fully protected in honoring any such credit entry. I understand in endorsing or depositing this check that payment will be from Federal and State funds and that any falsification, or concealment of a material fact, may be prosecuted under Federal and State laws. I agree that your treatment of each such credit entry, and your rights in respect to it, shall be the same as if it were signed by me.

I fully agree that if any such credit entry be dishonored, whether with or without cause, you shall be under no liability whatsoever. Are you aware of being allergic to or have you ever reacted badly to any medication or substance? When you walk upstairs or take a walk, do you ever have to stop because of pain in your chest, shortness of breath, or because you are very tired?

Indicate which of the following you have had or have at present. For Women Only: Are you pregnant? I understand the above information is necessary to provide me with dental care in a safe and efficient manner. I have answered all questions truthfully. Such records may include medical care and treatment, illness or injury, dental history, medical history, consultation, prescriptions, radiographs, models and copies of all dental records and medical records.

Appointment of Authorized Representative Purpose: To grant permission for another individual or company to act on your behalf in filing a Grievance or Appeal.

You may revoke this authorization at any time. I authorize my representative to receive any and all information related to this case that is provided to me and to provide any information to the health plan in relation to the disputed claims, approvals, or authorizations.

This information may include, a diagnosis name of illness or condition , claims, doctors and other health care providers and financial information like billing and banking.

I also understand that I may revoke or cancel this approval at any time. I understand that I cannot cancel this approval when this form has already been used to disclose information. Expiration: This consent is valid for one year from the date of this signed form unless you withdraw in writing sooner than one year. I have read the contents of this form. I understand, agree, and allow CareSource to the use and release of my information as I have stated above. I also understand that signing this form is of my own free will.

I understand that CareSource does not require that I sign this form in order for me to receive treatment or payment, or for enrollment or being eligible for benefits. I have the right to withdraw this approval at any time by giving written notice of my withdrawal to CareSource. I understand that my withdrawing of this approval will not affect any action taken before I do so.

I also understand that information that's released may be given out by the person or group who receives it. I am entitled to a copy of this form. Signature of Authorized Representative Date. Box , Dayton, OH If you need help with this form, you may call the Member Services department for your state, Monday through Friday, 7 a. This section identifies covered benefits, provides specific criteria for coverage, and defines individual age and benefit limitations.

The month following a member reaching 19 or 21, they will be considered Adult. Dental offices are not allowed to charge Members for missed appointments. Plan Members are to be allowed the same access to dental treatment, as any other patient in the dental practice.

Private reimbursement arrangements may be made only for non- covered services. All dental services performed must be recorded in the patient record, which must be available as required by your Participating Provider Agreement.

For reimbursement, DentaQuest Providers should bill only per unique surface regardless of location. For example, when a dentist places separate filling in both occlusal pits on an upper permanent first molar, the billing should state a one surface occlusal amalgam ADA code D Furthermore, DentaQuest will reimburse for the total number of surfaces restored per tooth, per day; i.

All other service codes not contained in the following tables will be rejected when submitted for payment. Furthermore, DentaQuest subscribes to the definition of services performed as described in the CDT manual. The benefit tables Exhibits are all inclusive for covered services.

Each category of service is contained in a separate table and lists:. Please review the information below on when to submit documentation to DentaQuest.

When documentation is requested. D periodic oral evaluation may not occur in combination with D on same date of service and not until days after the D comprehensive oral evaluation. Note- This procedure code is used for emergency examinations during regularly scheduled office hours. Evaluations solely for the purpose of adjustments or in conjunction with multi-visit procedures are not covered i.

May not be used in conjunction with D, D, D, and D D used when evaluating a patient comprehensively. D or the periodic exam D may not occur in conjunction with a limited oral evaluation examination during office hours- D or after office hours- D D requires a complete and detailed periodontal evaluation, including full-mouth probing and detailed charting. Reimbursement disallowed for D performed in conjunction with D, D, or D D intraoral - complete series of 19 and older No One of D, D per 60 Month s radiographic images Per patient.

Indicated for the permanent dentition or Adult dentate. A full-mouth series consist of a minimum of fourteen 14 films, including all periapical and posterior bitewing films intended to display the crowns and roots of all teeth, periapical areas and alveolar bone necessary for examination and diagnosis.

PA required if done more frequently than 60 months. Periapical radiographs are used diagnostically and are not reimbursable when used intraoperatively i. If the total allowed amount for radiography services D — D and D - D performed on a Member for a single date of service exceeds the allowed amount for procedure code D Complete Series of Radiographic Images , the submitted radiograph codes will be consolidated and maximum fee reimbursement will be limited to the allowed amount of the D complete series.

D extra-oral — 2D projection 19 and older No One of D per 1 Calendar year s radiographic image created using Per patient per tooth. All periapical or occlusal films taken same date of service needed to render the necessary radiographic diagnosis are included in the fee for panoramic radiograph. If bitewing radiographs D, D or D are indicated for additional diagnosis, the amount reimbursed will not exceed the reimbursable amount for D Full Mouth Series.

Interpretation of diagnostic with capture of the image, image and report by a Practitioner not including report associated with Image Capture. Report should be kept in patient record for post payment review as applicable. One per case. Diagnostic models or study models used as a guide in the application of corrective or restorative dentistry.

Payable as a diagnostic service intended for the documentation and subsequent analysis of occlusion. This service code used for permanent dentition. Non-contiguous restorations, such as a separate Distal Occlusal DO and Mesial Occlusal MO on the same tooth, are billable as a three surface restoration.

Each claim line for restorative services must relate to only one tooth number. The fee for resin-based composite restorations will include any necessary acid etching and bonding agents. CareSource will reimburse based on Amalgam for posterior teeth. D Used to restore a carious lesion into the dentin or a deeply eroded area into the dentin.

Not a preventive procedure. Covered only when a direct restoration ie. Limited to fully developed permanent teeth and primary teeth with no permanent successors. D re-cement or re-bond inlay, onlay, 19 and older Teeth 1 - 32 No Not covered within 6 months of initial veneer or partial coverage placement. D re-cement or re-bond indirectly 19 and older Teeth 1 - 32 No Not covered within 6 months of initial fabricated or prefabricated post placement. D re-cement or re-bond crown 19 and older Teeth 1 - 32, A - T No Not covered within 6 months of initial placement.

Used to relieve pain, promote healing, and prevent further deterioration. Not reimbursable when used as endodontic access closure, or as a base or liner under restoration.

D core buildup, including any pins 19 and older Teeth 1 - 32 Yes One of D per 60 Month s Per pre-operative when required patient per tooth. D pin retention - per tooth, in addition 19 and older Teeth 1 - 32 No Three of D per 1 Lifetime Per to restoration patient per tooth.

D cast post and core in addition to 19 and older Teeth 1 - 32 Yes One of D, D per 60 Month s pre-operative crown Per patient per tooth. D each additional cast post - same 19 and older Teeth 1 - 32 Yes One of D per 60 Month s Per pre-operative tooth patient per tooth.

D prefabricated post and core in 19 and older Teeth 1 - 32 Yes One of D, D per 60 Month s pre-operative addition to crown Per patient per tooth. D each additional prefabricated post 19 and older Teeth 1 - 32 Yes One of D per 60 Month s Per pre-operative - same tooth patient per tooth.

D therapeutic pulpotomy excluding 19 and older Teeth 1 - 32, A - T No One of D per 1 Lifetime Per patient final restoration - removal of pulp per tooth.

If a root canal is within 45 days coronal to the dentinocemental of the pulpotomy, the pulpotomy is not a junction and application of covered service since it is considered a medicament part of the root canal procedure and benefits are not payable separately.

D pulpal debridement, primary and 19 and older Teeth 1 - 32, A - T No If a root canal is within 45 days of the permanent teeth pulpotomy, the pulpotomy is not a covered service since it is considered a part of the root canal procedure and benefits are not payable separately. D partial pulpotomy for apexogenesis 19 and older Teeth 1 - 32 No If a root canal is within 45 days of the - permanent tooth with incomplete pulpotomy, the pulpotomy is not a covered root development service since it is considered a part of the root canal procedure and benefits are not payable separately.

D endodontic therapy, anterior tooth 19 and older Teeth 6 - 11, 22 - 27 No One of D per 1 Lifetime Per patient excluding final restoration per tooth. D endodontic therapy, premolar tooth 19 and older Teeth 4, 5, 12, 13, 20, 21, No One of D per 1 Lifetime Per patient excluding final restoration 28, 29 per tooth. D endodontic therapy, molar tooth 19 and older Teeth 2, 3, 14, 15, 18, 19, No One of D per 1 Lifetime Per patient excluding final restoration 30, 31 per tooth.

D retreatment of previous root canal 19 and older Teeth 6 - 11, 22 - 27 No One of D per 1 Lifetime Per patient therapy-anterior per tooth. D retreatment of previous root canal 19 and older Teeth 4, 5, 12, 13, 20, 21, No One of D per 1 Lifetime Per patient therapy - premolar 28, 29 per tooth.

D retreatment of previous root canal 19 and older Teeth 2, 3, 14, 15, 18, 19, No One of D per 1 Lifetime Per patient therapy-molar 30, 31 per tooth. Initial opening, preparation and radiographs of perforations, root resorption, first placement of medication and etc.

For visits in which the radiographs intra-canal medication is replaced with new medication, includes any necessary radiographs. D Pulpal regeneration - interim 19 and older Teeth 1 - 32 No One of D per 1 Lifetime Per patient medication replacement per tooth.

Subject to Post Review. D apicoectomy - anterior 19 and older Teeth 6 - 11, 22 - 27 Yes One of D per 1 Lifetime Per patient pre-operative per tooth. D apicoectomy - premolar first root 19 and older Teeth 4, 5, 12, 13, 20, 21, Yes One of D per 1 Lifetime Per patient pre-operative 28, 29 per tooth. D apicoectomy - molar first root 19 and older Teeth 2, 3, 14 - 19, 30, 31 Yes One of D per 1 Lifetime Per patient pre-operative per tooth.

D apicoectomy each additional root 19 and older Teeth 2 - 5, 12 - 15, 18 - Yes One of D per 1 Lifetime Per patient pre-operative 21, 28 - 31 per tooth. D root amputation - per root 19 and older Teeth 2 - 16, 18 - 31 Yes pre-operative radiographs.

D hemisection including any root 19 and older Teeth 2, 3, 14, 15, 18, 19, Yes pre-operative removal , not incl root canal 30, 31 radiographs therapy. D Gingivectomy or gingivoplasty to 19 and older Teeth 1 - 32, 51 - 82 Yes One of D per 36 Month s Per pre-op x-ray s , perio allow access for restorative patient per quadrant. D clinical crown lengthening - hard 19 and older Teeth 1 - 32 Yes One of D per 36 Month s Per pre-op x-ray s , perio tissue patient per tooth.

D pedicle soft tissue graft procedure 19 and older Teeth 1 - 32 Yes One of D per 36 Month s Per pre-op x-ray s , perio patient per tooth. D subepithelial connective tissue 19 and older Teeth 1 - 32 Yes One of D per 36 Month s Per pre-op x-ray s , perio graft procedure patient per tooth. D Free soft tissue graft procedure 19 and older Teeth 1 - 32, 51 - 82 Yes pre-op x-ray s , perio including donor site surgery , first charting tooth or edentulous tooth position in graft.

D Free soft tissue graft procedure 19 and older Teeth 1 - 32, 51 - 82 Yes One of D per 36 Month s Per pre-op x-ray s , perio including donor site surgery , patient per tooth. A minimum of charting quadrant four affected teeth in the quadrant.

One to three charting quadrant affected teeth in the quadrant. Subject to post review. D, D reimbursed on the same date of service as the extraction of all remaining teeth. D immediate maxillary partial 19 and older Yes One of D, D, D, D pre-operative x-ray s denture — resin base including per 60 Month s Per patient.

Reimbursed on the same date of service as the extraction of all remaining teeth. Includes adjustments within 6 months of initial placement. D adjust complete denture - 19 and older No Not covered within 6 months of initial maxillary placement. D adjust complete denture - 19 and older No Not covered within 6 months of initial mandibular placement. D adjust partial denture-maxillary 19 and older No Not covered within 6 months of initial placement.

D adjust partial denture - mandibular 19 and older No Not covered within 6 months of initial placement. D replace missing or broken teeth - 19 and older Teeth 1 - 32 No Not covered within 6 months of initial complete denture each tooth placement. D replace broken teeth-per tooth 19 and older Teeth 1 - 32 No Not covered within 6 months of initial placement. Not covered within 6 months of initial placement.

D reline complete maxillary denture 19 and older No One of D per 36 Month s Per chairside patient. D reline complete mandibular 19 and older No One of D per 36 Month s Per denture chairside patient.

D reline maxillary partial denture 19 and older No One of D per 36 Month s Per chairside patient. D reline mandibular partial denture 19 and older No One of D per 36 Month s Per chairside patient.

D reline complete maxillary denture 19 and older No One of D per 36 Month s Per laboratory patient. D reline complete mandibular 19 and older No One of D per 36 Month s Per denture laboratory patient. D reline maxillary partial denture 19 and older No One of D per 36 Month s Per laboratory patient. D reline mandibular partial denture 19 and older No One of D per 36 Month s Per laboratory patient.

D re-cement or re-bond fixed partial 19 and older Yes Not covered within 6 months of pre-operative denture placement. SS, TS. D removal of impacted tooth-partially 19 and older Teeth 1 - 32, 51 - 82 Yes Includes splinting. D removal of impacted 19 and older Teeth 1 - 32, 51 - 82 Yes The prophylactic removal of an pre-operative tooth-completely bony asymptomatic tooth or teeth exhibiting no radiographs overt clinical pathology is covered only when at least one tooth is asymptomatic.

D removal of impacted 19 and older Teeth 1 - 32, 51 - 82 Yes The prophylactic removal of an pre-operative tooth-completely bony, with asymptomatic tooth or teeth exhibiting no radiographs unusual surgical complications overt clinical pathology is covered only when at least one tooth is asymptomatic. D surgical removal of residual tooth 19 and older Teeth 1 - 32, 51 - 82 Yes The prophylactic removal of an pre-operative roots cutting procedure asymptomatic tooth or teeth exhibiting no radiographs overt clinical pathology is covered only when at least one tooth is asymptomatic.

D Coronectomy-intentional partial 19 and older Teeth 1 - 32, 51 - 82 Yes pre-operative tooth removal is performed when a radiographs neurovascular complication is likely if the entire impacted tooth is removed. D Surgical access of an unerupted 19 and older Teeth 2 - 16, 18 - 31 Yes pre-operative tooth radiographs. D placement of device to facilitate 19 and older Teeth 1 - 32 No One of D per 1 Lifetime Per patient eruption of impacted tooth per tooth.

Has to be submitted in combination with D; Report the surgical exposure separately using D Minimum of four extractions radiographs tooth spaces, per quadrant in the affected quadrant. Covered only in conjunction with the construction of a prosthodontic appliance. Minimum of four extractions radiographs teeth or tooth spaces, per in the affected quadrant. Covered only in quadrant conjunction with the construction of a prosthodontic appliance.

D lingual frenectomy frenulectomy 19 and older Yes narr. D excision of pericoronal gingiva 19 and older Teeth 1 - 32 Yes narr. This procedure code is not reimbursable on same date as D, D Sedation approvals are limited to surgical and extensive cases.

D intravenous moderate conscious 19 and older Yes Five of D per 1 Calendar year s narr. Eight of D, D per 1 pre-op x-ray s subsequent 15 minute increment Calendar year s Per patient. D treatment of complications 19 and older Yes narrative of medical post-surgical - unusual necessity circumstances, by report. D teledentistry — synchronous; 19 and older No Four of D per 1 Benefit period s real-time encounter Per patient.

D teledentistry — asynchronous; 19 and older No Four of D per 1 Benefit period s information stored and forwarded Per patient. D oral evaluation for a patient under No Two of D, D, D, D, three years of age and counseling D per 1 Calendar year s Per with primary caregiver patient.

Should be used only for first time visit for Children under three years who have not seen a dentist. Subsequent recall visit D should be billed. Integration of more extensive diagnostic modalities to develop a treatment plan for a specific problem is required. The cond requiring this type of eval should be described and documented. Examples of conditions requiring this type of eval may include dentofacial anomalies, complicated perio-prosthetic conditions, complex temporomandibular dysfunction, facial pain of unknown origin, conditions requiring multidisciplinary consult, etc.

D extra-oral — 2D projection No One of D per 1 Benefit period s radiographic image created using Per patient. Not included in single date of service maximum radiography reimbursable amount. Covered one per Orthodontist or Location as part of an Orthodontic case.

This service code used for primary dentition. Treatment that incorporates fluoride with the polishing compound is considered part of the prophylaxis procedure and not a separate topical fluoride treatment. D topical application of fluoride - No Two of D, D per 1 Calendar excluding varnish year s Per patient. D sealant - per tooth Teeth 2, 3, 14, 15, 18, 19, No One of D per 36 Month s Per 30, 31 patient per tooth. Sealants are reimbursable for unrestored pit and fissure surfaces first and second molars only.

D space maintainer --fixed--bilateral, No One of D per 60 Month s Per maxillary patient per tooth. D space maintainer --fixed--bilateral, No One of D per 60 Month s Per mandibular patient per tooth.

D space maintainer No One of D per 60 Month s Per --removable--bilateral, maxillary patient per tooth. D space maintainer No One of D per 60 Month s Per --removable--bilateral, mandibular patient per tooth. D re-cement or re-bond inlay, onlay, Teeth 1 - 32 No Not reimbursable within 6 months of initial veneer or partial coverage placement.

D re-cement or re-bond indirectly Teeth 1 - 32 No Not covered within 6 months of initial fabricated or prefabricated post placement. D re-cement or re-bond crown Teeth 1 - 32, A - T No Not allowed within 6 months of delivery. Greater than 6 units of D, D, D, D, and D per date of service may be subject to post review. D core buildup, including any pins Teeth 1 - 32 Yes One of D per 60 Month s Per pre-operative when required patient per tooth.

D pin retention - per tooth, in addition Teeth 1 - 32 No Three of D per 1 Lifetime Per to restoration patient per tooth. D cast post and core in addition to Teeth 1 - 32 Yes One of D, D per 60 Month s pre-operative crown Per patient per tooth. D each additional cast post - same Teeth 1 - 32 Yes One of D per 60 Month s Per pre-operative tooth patient per tooth. D prefabricated post and core in Teeth 1 - 32 Yes One of D, D per 60 Month s pre-operative addition to crown Per patient per tooth.

D each additional prefabricated post Teeth 1 - 32 Yes One of D per 60 Month s Per pre-operative - same tooth patient per tooth. D, D may radiographs and be covered in lieu of crowns when operative report clinically indicated for anterior teeth that are severely fractured or carious, that cannot be adequately repaired with a direct restoration i.

D therapeutic pulpotomy excluding Teeth 1 - 32, A - T No If a root canal is within 45 days of the final restoration - removal of pulp pulpotomy, the pulpotomy is not a covered coronal to the dentinocemental service since it is considered a part of the junction and application of root canal procedure and benefits are not medicament payable separately. D partial pulpotomy for apexogenesis Teeth 1 - 32 No If a root canal is within 45 days of the - permanent tooth with incomplete pulpotomy, the pulpotomy is not a covered root development service since it is considered a part of the root canal procedure and benefits are not payable separately.

D endodontic therapy, anterior tooth Teeth 6 - 11, 22 - 27 No One of D per 1 Lifetime Per patient excluding final restoration per tooth. D endodontic therapy, premolar tooth Teeth 4, 5, 12, 13, 20, 21, No One of D per 1 Lifetime Per patient excluding final restoration 28, 29 per tooth. D endodontic therapy, molar tooth Teeth 1 - 3, 14 - 19, 30 - 32 No One of D per 1 Lifetime Per patient excluding final restoration per tooth. D retreatment of previous root canal Teeth 6 - 11, 22 - 27 No One of D per 1 Lifetime Per patient therapy-anterior per tooth.

D retreatment of previous root canal Teeth 4, 5, 12, 13, 20, 21, No One of D per 1 Lifetime Per patient therapy - premolar 28, 29 per tooth.

D retreatment of previous root canal Teeth 1 - 3, 14 - 19, 30 - 32 No One of D per 1 Lifetime Per patient therapy-molar per tooth.

D apicoectomy - anterior Teeth 6 - 11, 22 - 27 Yes One of D per 1 Lifetime Per patient pre-operative per tooth. D apicoectomy - premolar first root Teeth 4, 5, 12, 13, 20, 21, Yes One of D per 1 Lifetime Per patient pre-operative 28, 29 per tooth. D apicoectomy - molar first root Teeth 1 - 3, 14 - 19, 30 - 32 Yes One of D per 1 Lifetime Per patient pre-operative per tooth. D apicoectomy each additional root Teeth 1 - 5, 12 - 21, 28 - 32 Yes One of D per 1 Lifetime Per patient pre-operative per tooth.

D hemisection including any root Teeth 1 - 3, 14 - 19, 30 - 32 Yes pre-operative removal , not incl root canal radiographs therapy. D Gingivectomy or gingivoplasty to Teeth 1 - 32, 51 - 82 Yes One of D per 36 Month s Per pre-op x-ray s , perio allow access for restorative patient per quadrant.

D clinical crown lengthening - hard Teeth 1 - 32 Yes One of D per 36 Month s Per Pre-op xrays, narr of tissue patient per tooth. D bone replacement graft - first site Teeth 1 - 32 Yes One of D per 36 Month s Per pre-op x-ray s , perio in quadrant patient per tooth.

D pedicle soft tissue graft procedure Teeth 1 - 32 Yes One of D per 36 Month s Per pre-op x-ray s , perio patient per tooth. D subepithelial connective tissue Teeth 1 - 32 Yes One of D per 36 Month s Per pre-op x-ray s , perio graft procedure patient per tooth.

D soft tissue allograft Teeth 1 - 32 Yes One of D per 36 Month s Per pre-op x-ray s , perio patient per tooth. D Free soft tissue graft procedure Teeth 1 - 32, 51 - 82 Yes pre-op x-ray s , perio including donor site surgery , first charting tooth or edentulous tooth position in graft.

D Free soft tissue graft procedure Teeth 1 - 32, 51 - 82 Yes One of D per 36 Month s Per pre-op x-ray s , perio including donor site surgery , patient per tooth. D autogenous connective tissue graft Teeth 1 - 32 Yes One of D per 36 Month s Per pre-op x-ray s , perio procedure including donor and patient per tooth.

D non-autogenous connective tissue Teeth 1 - 32 Yes One of D per 36 Month s Per pre-op x-ray s , perio graft procedure including recipient patient per tooth. D adjust complete denture - No Not covered within 6 months of initial maxillary placement.

D adjust complete denture - No Not covered within 6 months of initial mandibular placement. D adjust partial denture - mandibular No Not covered within 6 months of initial placement. D replace missing or broken teeth - Teeth 1 - 32 No Not covered within 6 months of initial complete denture each tooth placement. D replace broken teeth-per tooth Teeth 1 - 32 No Not covered within 6 months of initial placement.

D add tooth to existing partial Teeth 1 - 32 No Add clasp to existing partial denture denture. D add clasp to existing partial Teeth 1 - 32 No Add clasp to existing partial denture denture.

D surgical placement of implant Teeth 1 - 32 Yes One of D per 60 Month s Per pre-operative body: endosteal implant patient per tooth. D surgical placement of interim Teeth 1 - 32 Yes One of D per 60 Month s Per pre-operative implant body-endosteal implant patient per tooth.