Download First Smile - EarlyCare Plan

Schedule of Covered Services and Copayments
First Smile - EarlyCare Plan
Code Description Services when performed by a Dental Health
Services participating dentist or specialist
Code Description Copayment
D0350 Oral/facial photographic images obtained
intraorally or extraorally............................................................20
D0460 Pulp vitality tests - one test per visit.......................................20
D0470 Diagnostic casts.........................................................................20
D1110 Prophylaxis - adult - once every 6 months............................20
D1120 Prophylaxis - child - once every 6 months............................20
D1206 Topical application of fluoride varnish..................................20
D1208 Topical application of fluoride - frequency is based
on age of enrollee, see limitations..........................................20
D1330 Oral hygiene instructions - Available for enrollees 8
and younger. Available once every 6 months, up to
2 times in a 12-month period..................................................20
D1351 Sealant - per tooth - See limitations for details
about frequency.........................................................................20
D9543 Office Visit.................................................................................20
D9630 Other drugs and/or medicaments, by report........................20
D9930 Treatment of complications (post-surgical) - unusual
circumstances, by report...........................................................20
Copayment
Annual maximum.................................................................................None
Deductible.....................................................................................................0
*Out-of-pocket maximum - Individual................................................350
*Out-of-pocket maximum - Family......................................................700
According to
D9986 Missed appointment................................................ office policy
According to
D9987 Cancelled appointment........................................... office policy
Specialty services covered.......................................................................Yes
*For pediatric enrollees (18 years of age and under), all copayments for
essential health benefits listed under Covered Services and Copayments apply
to the member out-of-pocket maximum. Copayments for non-essential health
benefits services, listed as Other Covered Services do not apply to the member
out-of-pocket maximum.
Basic Dental Care - Child
Specialty services must be pre-authorized and are only available for children
18 and under.
D1510
D1515
D1550
D1555
D2140
D2150
D2160
D2161
Dental Check-up For Children
D0120 Periodic oral evaluation - established patient - once
every 6 months...........................................................................20
D0140 Limited oral evaluation - problem focused............................20
D0150 Comprehensive oral evaluation - new or
established patient.....................................................................20
D0190 Screening of a patient - limit of 2 per calendar year...........20
D0191 Assessment of a patient - limit of 2 per calendar year........20
D0210 Intraoral - complete series of radiographic images once in a 3-year period..............................................................20
D0220 Intraoral - periapical first radiographic image - once
in a two-year period...................................................................20
D0230 Intraoral - periapical each additional radiographic
image - once in a two-year period...........................................20
D0240 Intraoral - occlusal radiographic image..................................20
D0270 Bitewing - single radiographic image......................................20
D0272 Bitewings - two radiographic images......................................20
D0273 Bitewings - three radiographic images...................................20
D0274 Bitewings - four radiographic images - once every
12 months...................................................................................20
D0330 Panoramic radiographic image - once in a 3
year period..................................................................................20
D0340 Cephalometric radiographic image - once in a 2
year period..................................................................................20
D2330
D2331
D2332
D2335
D2390
D2391
D2392
D2393
D2394
D2710
D2910
D2915
D2920
D2929
D2930
Space maintainer - fixed - unilateral........................................30
Space maintainer - fixed - bilateral..........................................30
Re-cementation of space maintainer......................................30
Removal of fixed space maintainer.........................................30
Amalgam - one surface, primary or permanent....................30
Amalgam - two surfaces, primary or permanent..................30
Amalgam - three surfaces, primary or permanent................30
Amalgam - four or more surfaces, primary
or permanent..............................................................................30
Resin-based composite - one surface, anterior.....................30
Resin-based composite - two surfaces, anterior....................30
Resin-based composite - three surfaces, anterior.................30
Resin-based composite - four or more surfaces
or involving incisal angle (anterior).........................................30
Resin-based composite crown, anterior.................................30
Resin-based composite - one surface, posterior...................30
Resin-based composite - two surfaces, posterior..................30
Resin-based composite - three surfaces, posterior...............30
Resin-based composite - four or more
surfaces, posterior......................................................................30
Crown - resin-based composite (indirect)..............................30
Recement inlay, onlay, or partial coverage restoration.........30
Recement cast or prefabricated post and core......................30
Recement crown........................................................................30
Prefabricated porcelain/ceramic crown –
primary tooth.............................................................................30
Prefabricated stainless steel crown - primary tooth.............30
01.14WAFSECLX | Current Dental Terminology © 2015 American Dental Association. All rights reserved.
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Code Description D2931
D2932
D2933
D2934
D2950
D2952
D2954
D3120
D3220
D3221
D3230
D3240
D3351
D3352
D3430
D4211
D4341
D4342
D4355
D4910
D5410
D5411
D5421
D5422
D5510
D5520
D5620
D5650
D5660
D5850
D5851
Copayment
Code Description Prefabricated stainless steel crown - permanent tooth........30
Prefabricated resin crown.........................................................30
Prefabricated stainless steel crown with resin window........30
Prefabricated esthetic coated stainless steel
crown - primary tooth...............................................................30
Core buildup, including any pins when required..................30
Post and core in addition to crown,
indirectly fabricated...................................................................30
Prefabricated post and core in addition to crown................30
Pulp cap - indirect (excluding final restoration)....................30
Therapeutic pulpotomy (excluding final restoration)
- removal of pulp coronal to the dentinocemental
junction and application of medicament - Not offered
on permanent teeth...................................................................30
Pulpal debridement, primary and permanent teeth Not offered on primary teeth and excludes teeth 1,
16, 17, and 32.............................................................................30
Pulpal therapy (resorbable filling) - anterior, primary
tooth (excluding final restoration) - Only for
permanent anterior teeth..........................................................30
Pulpal therapy (resorbable filling) - posterior,
primary tooth (excluding final restoration)............................30
Apexification/recalcification – initial visit (apical
closure/calcific repair of perforations, root resorption,
pulp space disinfection, etc.) - Only for permanent
anterior teeth..............................................................................30
Apexification/recalcification - interim medication
replacement (apical closure/calcific repair of
perforations, root resorption, pulp space
disinfection, etc.)........................................................................30
Retrograde filling - per root.....................................................30
Gingivectomy or gingivoplasty - one to three
contiguous teeth or tooth bounded spaces
per quadrant...............................................................................30
Periodontal scaling and root planing - four or more
teeth per quadrant - Available for patients 13 and
older. Once per quadrant per two year period......................30
Periodontal scaling and root planing - one to three
teeth per quadrant - Available for patients 13 and
older. Once per quadrant per two year period......................30
Full mouth debridement to enable comprehensive
evaluation and diagnosis...........................................................30
Periodontal maintenance (limited to 1 per 3 months).........30
Adjust complete denture - maxillary.......................................30
Adjust complete denture - mandibular...................................30
Adjust partial denture - maxillary............................................30
Adjust partial denture - mandibular........................................30
Repair broken complete denture base....................................30
Replace missing or broken teeth - complete
denture (each tooth)..................................................................30
Repair cast framework..............................................................30
Add tooth to existing partial denture.....................................30
Add clasp to existing partial denture......................................30
Tissue conditioning, maxillary.................................................30
Tissue conditioning, mandibular.............................................30
Copayment
D5899 Unspecified removable prosthodontic procedure,
by report......................................................................................30
D6930 Recement fixed partial denture................................................30
D7111 Extraction, coronal remnants - deciduous tooth..................30
D7140 Extraction, erupted tooth or exposed root
(elevation and/or forceps removal)........................................30
D7210 Surgical removal of erupted tooth requiring removal
of bone and/or sectioning of tooth, and including
elevation of mucoperiosteal flap if indicated.......................30
D7250 Surgical removal of residual tooth roots
(cutting procedure)....................................................................30
D7283 Placement of device to facilitate eruption of
impacted tooth...........................................................................30
D7286 Biopsy of oral tissue - soft.......................................................30
D7288 Brush biopsy - transepithelial sample collection..................30
D7510 Incision and drainage of abscess - intraoral soft tissue.......30
D7971 Excision of pericoronal gingiva..............................................30
D9110 Palliative (emergency) treatment of dental pain
- minor procedure......................................................................30
D9221 Deep sedation/general anesthesia - each
additional 15 minutes................................................................30
D9230 Inhalation of nitrous oxide / anxiolysis, analgesia...............30
D9242 Intravenous conscious sedation/analgesia
- each additional 15 minutes....................................................30
D9248 Non-intravenous conscious sedation.....................................30
D9440 Office visit - after regularly scheduled hours........................30
D9610 Therapeutic parenteral drug, single administration..............30
D9612 Therapeutic parenteral drugs, two or more
administrations, different medications...................................30
D9920 Behavior management, by report............................................30
99201 Office/outpatient visit, new - When performed
by your participating general dentist or
contracted specialist..................................................................30
99211 Office/outpatient visit, established - When performed
by your participating general dentist or
contracted specialist..................................................................30
99231 Subsequent hospital care - When performed by
your participating general dentist or
contracted specialist..................................................................30
99241 Office consultation - When performed by your
participating general dentist or contracted specialist...........30
99251 Inpatient consultation - When performed by your
participating general dentist or contracted specialist...........30
Major Dental Care - Child
D2720
D2721
D2722
D2740
D2750
D2751
D2752
D3310
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Crown - resin with high noble metal....................................325
Crown - resin with predominantly base metal....................325
Crown - resin with noble metal.............................................325
Crown - porcelain/ceramic substrate...................................325
Crown - porcelain fused to high noble metal......................325
Crown - porcelain fused to predominantly base metal......325
Crown - porcelain fused to noble metal...............................325
Endodontic therapy, anterior tooth
(excluding final restoration)...................................................325
Code Description Copayment
Code Description D3320 Endodontic therapy, bicuspid tooth
(excluding final restoration)...................................................325
D3330 Endodontic therapy, molar (excluding
final restoration).......................................................................325
D3346 Retreatment of previous root canal therapy - anterior......325
D3347 Retreatment of previous root canal therapy - bicuspid.....325
D3348 Retreatment of previous root canal therapy - molar.........325
D3410 Apicoectomy - anterior - Only for anterior teeth...............325
D4210 Gingivectomy or gingivoplasty - four or more
contiguous teeth or tooth bounded spaces
per quadrant.............................................................................325
D5110 Complete denture - maxillary................................................325
D5120 Complete denture - mandibular............................................325
D5130 Immediate denture - maxillary...............................................325
D5140 Immediate denture - mandibular...........................................325
D5211 Maxillary partial denture - resin base (including
any conventional clasps, rests and teeth).............................325
D5212 Mandibular partial denture - resin base (including
any conventional clasps, rests and teeth).............................325
D5710 Rebase complete maxillary denture......................................325
D5711 Rebase complete mandibular denture..................................325
D5720 Rebase maxillary partial denture............................................325
D5721 Rebase mandibular partial denture........................................325
D5750 Reline complete maxillary denture (laboratory)..................325
D5751 Reline complete mandibular denture (laboratory)..............325
D5760 Reline maxillary partial denture (laboratory).......................325
D5761 Reline mandibular partial denture (laboratory)...................325
D5863 Overdenture – complete maxillary.......................................325
D5865 Overdenture – complete mandibular...................................325
D7220 Removal of impacted tooth - soft tissue.............................325
D7230 Removal of impacted tooth - partially bony.......................325
D7240 Removal of impacted tooth - completely bony..................325
D7241 Removal of impacted tooth - completely bony,
with unusual surgical complications.....................................325
D7270 Tooth reimplantation and/or stabilization of
accidentally evulsed or displaced tooth................................325
D7280 Surgical access of an unerupted tooth.................................325
D7285 Biopsy of oral tissue - hard (bone, tooth)...........................325
D7320 Alveoloplasty not in conjunction with extractions
- four or more teeth or tooth spaces, per quadrant............325
D7321 Alveoloplasty not in conjunction with extractions one to three teeth or tooth spaces, per quadrant................325
D7410 Excision of benign lesion up to 1.25 cm.............................325
D7471 Removal of lateral exostosis (maxilla or mandible)............325
D7472 Removal of torus palatinus....................................................325
D7473 Removal of torus mandibularis.............................................325
D7485 Surgical reduction of osseous tuberosity.............................325
D7520 Incision and drainage of abscess - extraoral
soft tissue..................................................................................325
D7530 Removal of foreign body from mucosa, skin, or
subcutaneous alveolar tissue..................................................325
D7880 Occlusal orthotic device, by report.......................................325
D7960 Frenulectomy - also known as frenectomy or
frenotomy - separate procedure not incidental to
another procedure - Pre-authorization is not needed
for members 6 and under.......................................................325
Copayment
D7963 Frenuloplasty - Pre-authorization is not needed for
members 6 and under.............................................................325
D7970 Excision of hyperplastic tissue - per arch............................325
D7972 Surgical reduction of fibrous tuberosity..............................325
D9220 Deep sedation/general anesthesia - first 30 minutes.........325
D9241 Intravenous conscious sedation/analgesia - first
30 minutes.................................................................................325
D9410 House/extended care facility call - Up to 2 calls
per facility per provider..........................................................325
D9420 Hospital or ambulatory surgical center call - Up to
1 call per provider, per day.....................................................325
D9940 Occlusal guard, by report.......................................................325
Medically Necessary Orthodontia
Copayments for medically necessary orthodontia apply to the member Out-of-Pocket Maximum.
Medically necessary orthodontia - member pays $350/year prorated
monthly starting with the first month of treatment, with a maximum
lifetime copayment of $700.
Orthodontic Services will only be approved for enrollees with a malocclusion associated with:
a. Cleft lip and palate, cleft palate, or cleft lip with alveolar process
involvement;
b. Craniofacial anomalies for:
• Hemifacial microsomia;
• Craniosynostosis syndromes;
• Arthrogryposis; or
• Marfan syndrome.
Must be prior approved.
Orthodontia (Non-Medically Necessary)
Copayments for non-essential health benefits services listed under Orthodontia
(Non-Medically Necessary) do not apply to the member out-of-pocket maximum.
D8210 Removable appliance therapy................................................250
D8220 Fixed appliance therapy..........................................................230
D8660 Pre-orthodontic treatment examination to
monitor growth and development..........................................40
D8670 Periodic orthodontic treatment visit.......................................10
D8680 Orthodontic retention (removal of appliances,
construction and placement of retainer(s)).........................315
D8690 Orthodontic treatment (alternative billing to a
contract fee)..................................................................................0
D8691 Repair of orthodontic appliance.............................................50
D8693 Re-cement or re-bond fixed retainer......................................45
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Code Description Copayment
Code Description Other Covered Services
Copayment
D3353 Apexification/recalcification - final visit (includes
completed root canal therapy - apical closure/calcific
repair of perforations, root resorption, etc.).......................300
D3355 Pulpal regeneration - initial visit............................................100
D3356 Pulpal regeneration - interim medication replacement......100
D3357 Pulpal regeneration - completion of treatment..................550
D4921 Gingival irrigation – per quadrant...........................................25
D5986 Fluoride gel carrier....................................................................30
D9210 Local anesthesia not in conjunction with operative or
surgical procedures....................................................................10
D9211 Regional block anesthesia.........................................................40
D9212 Trigeminal division block anesthesia......................................75
D9215 Local anesthesia in conjunction with operative or
surgical procedures......................................................................0
D9219 Evaluation for deep sedation or general anesthesia.............40
D9310 Consultation - diagnostic service provided by dentist
or physician other than requesting dentist or physician......20
D9430 Office visit for observation (during regularly scheduled
hours) - no other services performed....................................25
D9450 Case presentation, detailed and extensive
treatment planning.......................................................................0
D9910 Application of desensitizing medicament.............................15
D9911 Application of desensitizing resin for cervical and/or
root surface, per tooth..............................................................15
D9941 Fabrication of athletic mouthguard......................................125
D9942 Repair and/or reline of occlusal guard..................................75
D9951 Occlusal adjustment - limited..................................................35
D9952 Occlusal adjustment - complete............................................150
Copayments for non-essential health benefits services listed under, Other Covered
Services do not apply to the member out-of-pocket maximum.
D0145 Oral evaluation for a patient under three years of
age and counseling with primary caregiver............................20
D0160 Detailed and extensive oral evaluation - problem
focused, by report......................................................................40
D0170 Re-evaluation - limited, problem focused
(established patient; not post-operative visit)........................15
D0171 Re-evaluation – post-operative office visit............................10
D0180 Comprehensive periodontal evaluation - new or
established patient.....................................................................20
D0250 Extraoral - first radiographic image........................................10
D0260 Extraoral - each additional radiographic image......................6
D0277 Vertical bitewings - 7 to 8 radiographic images....................20
D0391 Interpretation of diagnostic image by a practitioner
not associated with capture of the image,
including report..........................................................................25
D0415 Collection of microorganisms for culture
and sensitivity.............................................................................35
D0425 Caries susceptibility tests..........................................................10
D0431 Adjunctive pre-diagnostic test that aids in detection of
mucosal abnormalities including premalignant and
malignant lesions, not to include cytology or
biopsy procedures......................................................................15
D0601 Caries risk assessment and documentation, with a
finding of low risk.....................................................................15
D0602 Caries risk assessment and documentation, with a
finding of moderate risk...........................................................15
D0603 Caries risk assessment and documentation, with a
finding of high risk....................................................................15
D1310 Nutritional counseling for control of dental disease.............0
D1320 Tobacco counseling for the control and prevention of
oral disease....................................................................................0
D1352 Preventive resin restoration in a moderate to high
caries risk patient – permanent tooth.....................................50
D1353 Sealant repair – per tooth...........................................................5
D1520 Space maintainer - removable - unilateral............................150
D1525 Space maintainer - removable - bilateral..............................250
D2940 Protective restoration................................................................35
D2941 Interim therapeutic restoration – primary dentition..............5
D2949 Restorative foundation for an indirect restoration...............30
D2951 Pin retention - per tooth, in addition to restoration............35
D2953 Each additional indirectly fabricated post - same tooth......90
D2955 Post removal.............................................................................140
D2957 Each additional prefabricated post - same tooth..................80
D3331 Treatment of root canal obstruction;
non-surgical access..................................................................175
D3332 Incomplete endodontic therapy; inoperable,
unrestorable or fractured tooth.............................................200
D3333 Internal root repair of perforation defects..........................150
Congenital Anomalies
Coverage for the treatment of congenital anomalies is available utilizing the services and copayments listed above.
For more detailed information on the terms of
your coverage, please consult your Exclusions and
Limitations document.
Please note: The listed procedures and copayments apply when
service is received at your participating general dentist. Not every
dentist will perform all services. If your dentist refers you to a
specialist, please contact your Member Service Specialist before
proceeding. All procedures are available from Dental Health
Services participating specialists. All specialty services must be preauthorized with Dental Health Services through a referral from your
participating dentist.
If you ever have questions about your dental
coverage, call your Member Service Specialist at
855-495-0906. We are happy to help you.
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Exclusions and Limitations
b. A maximum of five surfaces per tooth for permanent posterior
teeth, except for upper molars and a maximum of six surfaces per
tooth for teeth 1, 2, 3, 14, 15 and 16;
c. A maximum of six surfaces per tooth for resin-based composite
restorations for permanent anterior teeth;
d. An indirect crown once every 5 years, per tooth, for permanent
anterior teeth for enrollees from 12 through 18 years of age. Must
be pre-authorized;
e. All recementations of permanent indirect crowns for enrollees
from 12 through 18 years of age;
f. Prefabricated stainless steel crowns for primary posterior teeth
once every 3 years;
g. Prefabricated stainless steel crowns for permanent posterior teeth
excluding 1, 16, 17, and 32 once every 3 years;
h. Core buildup, including pins, only on permanent teeth, when
performed in conjunction with a crown;
i. Cast post and core or prefabricated post and core, on permanent
teeth when performed in conjunction with a crown.
Limitations:
Diagnostic Services are covered with the following limitations:
a. Intraoral complete series (D0210) is covered once in a threeyear period unless a panoramic radiograph (D0330) for the same
enrollee has been performed in the same three-year period.
Additional D0210 and D0330 are only covered if deemed by an
orthodontist or Oral Surgeon to be medically necessary (see e.);
b. Medically necessary periapical x-rays that are not included in a
complete series for diagnosis in conjunction with definitive
treatment;
c. An occlusal intraoral x-ray once in a two-year period;
d. A maximum of four bitewing x-rays (once per quadrant) once
every twelve months;
e. Panoramic radiograph (D0330) in conjunction with four bitewings
(D0274), once in a three-year period, only when an intraoral
complete series (D0210) for the same enrollee has not been paid
in the same three- year period.
f. Radiographs with no specific limitation are on a case-by-case basis
when medically necessary.
g. Oral and facial photographic images (D0350) on a case-by-case
basis.
Periodontal Services are covered with the following limitations:
a. Surgical periodontal services and post-operative care for
ginigivectomy/gingivoplasty.
b. Non-surgical periodontal scaling and root planing for teeth scaled
that are periodontically involved, once per quadrant for enrollees
aged 13 and older, per enrollee per two year period when preauthorized and evidenced by x-ray.
c. Periodontal maintenance for enrollees aged 13 and older, once per
enrollee, per 3 month period with pre-authorization.
Preventive Services are covered with the following limitations:
a. Dental Prophylaxis (D1110 & D1120) limited to once every 6
months for enrollees 18 and under;
b. Topical Fluoride Treatment (D1208) including fluoride rinse,
foam or gel, including disposable trays for enrollees:
i. 6 years of age and younger up to 3 times per 12-month period
per enrollee;
ii. 7 to 18 years of age, up to 2 times per 12 month period per
enrollee;
iii. Up to 3 times in a 12-month period per enrollee during
orthodontic treatment;
iv. Additional applications on a case-by-case basis.
c. Oral hygiene instruction for enrollees 8 and younger. The benefit
must inc lude individualized oral hygiene instructions, tooth
brushing techniques, flossing, and use of oral hygiene aids no
more than once every 6 months, up to 2 times in a 12 month
period.
d. Sealants (D1351) are for enrollees 18 years or younger when
used on mechanically and/or chemically prepared enamel surface
once per tooth in a 3-year period. For developmentally disabled
performed in a two-year period.
e. Space Maintainers (D1510, D1515, D1550, D1555) for enrollees
12 years of age and younger for fixed unilateral or bilateral space
maintenance subject to one space maintainer per quadrant, for
primary molars A, B, I, J, K, L, S and T.
i. Replacement space maintainers are covered on a case-by-case
basis.
ii. Removal of fixed space maintainers for enrollees 18 years of
age or younger.
Endodontic Services are covered with the following limitations:
a. Therapeutic pulpotomy on primary teeth and pulpal debridement
on permanent teeth only [excluding teeth 1, 16, 17, and 32];
b. Treatment with resorbable material for primary maxillary incisor
teeth D, E, F, and G, if the entire root is present at treatment;
c. Treatment for permanent anterior, bicuspid, and molar teeth
[excluding teeth 1, 16, 17, and 32].
d. Retreatment for the removal of post, pin, old root canal filing
material, and all procedures necessary to prepare the canal with
placement of new filing material.
Prosthodontic Services - Removable are covered with the following
limitations:
a. One resin based partial denture; replacement covered if provided
at least three years after the seat date;
b. One complete denture upper and lower and one replacement
denture per lifetime after at least 5 years from the seat date;
c. Rebasing and relining of complete or partial dentures once in a 3
year period, if performed at least 6 months from the seating date;
d. Partial, complete and immediate dentures must be pre-approved.
Other Limitations:
a. Authorized treatment is rendered only by your selected
participating dentist or participating specialist. Services provided
by a dentist other than the enrollee’s designated participating
dentist or participating specialist, except for emergency dental
conditions, are not covered.
b. All services performed must be medically necessary and consistent
with a diagnosis of dental disease or condition.
Restorative Services are covered with the following limitations:
a. Two occlusal restorations for the upper molars on teeth 1, 2, 3, 14,
15, and 16 if, the restorations are anatomically separated by sound
tooth structure;
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licensed dentist for the relief of pain, swelling or bleeding. This
does not include routine, extensive or postponable treatment.
Emergency dental care is limited to palliative treatment. Enrollee
must attempt to contact their plan dentist. When an enrollee’s
plan dentist is not able to be reached, emergency treatment can be
sought at any participating dentist. In cases where a participating
dentist cannot be reached, the treatment for the emergency dental
condition can be completed at any licensed dentist. Plan will
reimburse for procedures submitted on a Post Service Emergency
Dental Care Claim Form up to $150 per occurrence beyond all
applicable copayments.
m. Temporomandibular joint (TMJ) disorders and related disease
treatment are limited to coverage for occlusal orthotic device for
12-20 months on a case by case basis.
n. Medical necessity is defined under this plan as dental services and
supplies provided by a participating dentist appropriate to the
evaluation and treatment of disease, condition, illness or injury
and consistent with the applicable standard of care. This does not
include any service that is cosmetic in nature.
c. Specialty services require a referral from your participating dentist
and must be pre-authorized by Dental Health Services, including
a referral to a pediatric dentist.
d. Optional services (all cases in which the enrollee selects a plan
of treatment that is considered unnecessary by the dentist). The
enrollee is responsible for fee-for-service rates. This does not
apply to standard covered restorative procedures which offer a
choice of material.
e. Upgraded services (cases in which the enrollee selects a plan
of treatment that is considered an upgraded procedure) Dental
Health Services’ upgrade charges would apply.
f. Cosmetic dentistry – services for appearance only. This includes
such services as the replacement of clinically acceptable amalgam
fillings, veneers and bonding.
g. Unsatisfactory patient-doctor relationship: Dental Health Services
participating dentists reserve the right to limit or deny services to
an enrollee who fails to follow the prescribed course of treatment,
repeatedly fails to keep appointments, fails to pay applicable
copayments, is abusive to the participating dentist or their staff, or
obtains services by fraud or deception.
h. Denturists - Enrollees may elect to travel to the nearest participating
denturist for services. Enrollees may be able to receive services
from a participating denturist as long as the service performed
was within the lawful scope of the denturist’s license.
i. Dental procedure that cannot be performed in the dental office
due to the general health and/or physical limitations of the
enrollee are limited to covered services listed in this Schedule of
Covered Services and Copayments.
j. Not all participating dentists can perform all dental procedures,
please verify what services your selected dentist can perform for
you. Some complicated extractions, periodontal treatment, osseous
surgery and root canal treatment may be referred to a participating
specialist at the discretion of the participating general dentist.
k. Coverage for services are only available during period of
enrollment.
l. Emergency dental condition – is the emergent and acute onset
of a symptom or symptoms, including severe pain that would
lead a prudent layperson acting reasonably to believe that dental
condition exists that requires immediate, palliative care by a
Exclusions:
The following are not covered by your dental plan.
a. Services not specifically listed in the “Schedule of Covered
Services and Copayments.”
b. Work in progress: Dental work in progress (non-emergency/
temporary procedures started but not finished prior to the date
of eligibility) is not covered. This includes crown preps prepared
and temporized but not cemented, root canals in mid-treatment,
prosthetic cases post final impression stage (sent to the lab), etc.
This does not include teeth slated for root canal treatment and/or
canals filled during an emergency visit.
c. Benefits are only available if work is completed at the enrollee’s
participating dentist’s or participating specialist’s office.
d. This Plan does not provide benefits for services or supplies to the
extent that benefits are payable for them under any motor vehicle
medical, motor vehicle no-fault, uninsured motorist, underinsured
motorist, personal injury protection (PIP), commercial liability,
homeowner’s policy, or other similar type of coverage.
If you ever have questions about your dental coverage, call your Member Service Specialist. We are happy to help you.
Dental Health Services
A Great Reason to Smile sm
100 W. Harrison St., Suite S-440, South Tower, Seattle, WA 98119
855-495-0906
www.dentalhealthservices.com/WA
0415WM079
© 2015 Dental Health Services
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