Download First Smile - EarlyCare Plan

Schedule of Covered Procedures and Copayments
First Smile - EarlyCare Plan
Services when performed by a
Dental Health Services participating dentist
Code
Description Copayment
Deductible...................................................................................................................0
Individual out-of-pocket maximum................................................................... 350
Family out-of-pocket maximum......................................................................... 700
According to
assigned Dental
Failed (no show) appointment w/o notice.......................................Office Policy
All copayments paid by, or on behalf of the enrollee, apply
towards the enrollee’s annual out-of-pocket maximum.
Dental Check-up For Children
D0120
D0140
D0150
D0190
D0191
D0210
D0220
D0230
D0240
D0270
D0272
D0273
D0274
D0330
D0340
D0350
D0460
D0470
D1110
D1120
D1206
D1208
D1330
D1351
D9543
D9630
D9930
Periodic oral evaluation - established patient - once every 6 months.... 10
Limited oral evaluation - problem focused......................................... 10
Comprehensive oral evaluation - new or established patient........... 10
Screening of a patient - limit of 2 per calendar year................................ 10
Assessment of a patient - limit of 2 per calendar year............................ 10
Intraoral - complete series of radiographic images - once in
a 3-year period............................................................................................. 10
Intraoral - periapical first radiographic image - once in a
two-year period............................................................................................. 10
Intraoral - periapical each additional radiographic image - once
in a two-year period...................................................................................... 10
Intraoral - occlusal radiographic image................................................ 10
Bitewing - single radiographic image................................................... 10
Bitewings - two radiographic images.................................................... 10
Bitewings - three radiographic images................................................. 10
Bitewings - four radiographic images - once every 12 months............... 10
Panoramic radiographic image - once in a 3 year period......................... 10
Cephalometric radiographic image - once in a 2 year period................. 10
Oral/facial photographic images obtained
intraorally or extraorally......................................................................... 10
Pulp vitality tests - one test per visit.......................................................... 10
Diagnostic casts....................................................................................... 10
Prophylaxis - adult - once every 6 months................................................. 10
Prophylaxis - child - once every 6 months................................................. 10
Topical application of fluoride varnish................................................ 10
Topical application of fluoride - frequency is based on age
of enrollee, see limitations............................................................................. 10
Oral hygiene instructions - Available for enrollees 8 and
younger. Available once every 6 months, up to 2 times
in a 12-month period................................................................................... 10
Sealant - per tooth - See limitations for details about frequency................. 10
Office Visit............................................................................................... 10
Other drugs and/or medicaments, by report..................................... 10
Treatment of complications (post-surgical) - unusual
circumstances, by report......................................................................... 10
Code
Description D1550
D1555
D2140
D2150
D2160
D2161
D2330
D2331
D2332
D2335
Re-cementation of space maintainer.................................................... 20
Removal of fixed space maintainer...................................................... 20
Amalgam - one surface, primary or permanent................................. 20
Amalgam - two surfaces, primary or permanent................................ 20
Amalgam - three surfaces, primary or permanent............................. 20
Amalgam - four or more surfaces, primary or permanent............... 20
Resin-based composite - one surface, anterior................................... 20
Resin-based composite - two surfaces, anterior.................................. 20
Resin-based composite - three surfaces, anterior............................... 20
Resin-based composite - four or more surfaces
or involving incisal angle (anterior)...................................................... 20
Resin-based composite crown, anterior............................................... 20
Resin-based composite - one surface, posterior................................. 20
Resin-based composite - two surfaces, posterior............................... 20
Resin-based composite - three surfaces, posterior............................. 20
Resin-based composite - four or more surfaces, posterior............... 20
Crown - resin-based composite (indirect)........................................... 20
Recement inlay, onlay, or partial coverage restoration....................... 20
Recement cast or prefabricated post and core.................................... 20
Recement crown...................................................................................... 20
Prefabricated porcelain/ceramic crown – primary tooth................. 20
Prefabricated stainless steel crown - primary tooth........................... 20
Prefabricated stainless steel crown - permanent tooth...................... 20
Prefabricated resin crown...................................................................... 20
Prefabricated stainless steel crown with resin window...................... 20
Prefabricated esthetic coated stainless steel
crown - primary tooth............................................................................ 20
Core buildup, including any pins when required................................ 20
Post and core in addition to crown, indirectly fabricated................. 20
Prefabricated post and core in addition to crown.............................. 20
pulp cap - indirect (excluding final restoration).................................. 20
Therapeutic pulpotomy (excluding final restoration)
- removal of pulp coronal to the dentinocemental
junction and application of medicament - Not offered on
permanent teeth............................................................................................ 20
Pulpal debridement, primary and permanent teeth - Not
offered on primary teeth and excludes teeth 1, 16, 17, and 32...................... 20
Pulpal therapy (resorbable filling) - anterior,
primary tooth (excluding final restoration) - Only for permanent
anterior teeth................................................................................................ 20
Pulpal therapy (resorbable filling) - posterior,
primary tooth (excluding final restoration)......................................... 20
Apexification/recalcification – initial visit (apical
closure/calcific repair of perforations, root resorption,
pulp space disinfection, etc.) - Only for permanent anterior teeth............ 20
Apexification/recalcification - interim medication
replacement (apical closure/calcific repair of perforations,
root resorption, pulp space disinfection, etc.).................................... 20
Retrograde filling - per root................................................................... 20
Gingivectomy or gingivoplasty - one to three contiguous
teeth or tooth bounded spaces per quadrant...................................... 20
Periodontal scaling and root planing - four
or more teeth per quadrant - Available for patients 13 and older.
Once per quadrant per two year period.......................................................... 20
Periodontal scaling and root planing - one
to three teeth per quadrant - Available for patients 13 and older.
Once per quadrant per two year period.......................................................... 20
Periodontal maintenance (limited to 1 per 6 months)....................... 20
D2390
D2391
D2392
D2393
D2394
D2710
D2910
D2915
D2920
D2929
D2930
D2931
D2932
D2933
D2934
D2950
D2952
D2954
D3120
D3220
D3221
D3230
D3240
D3351
D3352
D3430
D4211
D4341
Basic Dental Care - Child
D4342
D1510 Space maintainer - fixed - unilateral..................................................... 20
D1515 Space maintainer - fixed - bilateral........................................................ 20
D4910
01.14WAFSECLX | Current Dental Terminology © 2013 American Dental Association. All rights reserved.
Copayment
Code
Description D5410
D5411
D5421
D5422
D5510
D5520
Adjust complete denture - maxillary.................................................... 20
Adjust complete denture - mandibular................................................ 20
Adjust partial denture - maxillary......................................................... 20
Adjust partial denture - mandibular..................................................... 20
Repair broken complete denture base.................................................. 20
Replace missing or broken teeth - complete
denture (each tooth)................................................................................ 20
Repair cast framework............................................................................ 20
Add tooth to existing partial denture................................................... 20
Add clasp to existing partial denture.................................................... 20
Tissue conditioning, maxillary............................................................... 20
Tissue conditioning, mandibular........................................................... 20
Unspecified removable prosthodontic procedure, by report........... 20
Recement fixed partial denture............................................................. 20
Extraction, coronal remnants - deciduous tooth............................... 20
Extraction, erupted tooth or exposed root
(elevation and/or forceps removal)...................................................... 20
Surgical removal of erupted tooth requiring removal
of bone and/or sectioning of tooth, and including
elevation of mucoperiosteal flap if indicated..................................... 20
Surgical removal of residual tooth roots (cutting procedure).......... 20
Placement of device to facilitate eruption of impacted tooth......... 20
Biopsy of oral tissue - soft..................................................................... 20
Brush biopsy - transepithelial sample collection................................ 20
Incision and drainage of abscess - intraoral soft tissue..................... 20
Removal of foreign body from mucosa, skin,
or subcutaneous alveolar tissue............................................................. 20
Excision of pericoronal gingiva............................................................ 20
Palliative (emergency) treatment of dental pain
- minor procedure................................................................................... 20
Deep sedation/general anesthesia - each
additional 15 minutes.............................................................................. 20
Inhalation of nitrous oxide / anxiolysis, analgesia............................. 20
Intravenous conscious sedation/analgesia
- each additional 15 minutes.................................................................. 20
Non-intravenous conscious sedation................................................... 20
Office visit - after regularly scheduled hours...................................... 20
Therapeutic parenteral drug, single administration............................ 20
Therapeutic parenteral drugs, two or more
administrations, different medications................................................. 20
Behavior management, by report......................................................... 20
Office/outpatient visit, new - When performed by your
participating general dentist or contracted specialist........................................ 20
Office/outpatient visit, established - When performed by your
participating general dentist or contracted specialist........................................ 20
Subsequent hospital care - When performed by your participating
general dentist or contracted specialist............................................................ 20
Office consultation - When performed by your participating
general dentist or contracted specialist............................................................ 20
Inpatient consultation - When performed by your participating
general dentist or contracted specialist............................................................ 20
D5620
D5650
D5660
D5850
D5851
D5899
D6930
D7111
D7140
D7210
D7250
D7283
D7286
D7288
D7510
D7530
D7971
D9110
D9221
D9230
D9242
D9248
D9440
D9610
D9612
D9920
99201
99211
99231
99241
99251
Copayment
Major Dental Care - Child
D2720
D2721
D2722
D2740
D2750
D2751
D2752
D3310
Crown - resin with high noble metal.................................................. 275
Crown - resin with predominantly base metal.................................. 275
Crown - resin with noble metal........................................................... 275
Crown - porcelain/ceramic substrate................................................. 275
Crown - porcelain fused to high noble metal................................... 275
Crown - porcelain fused to predominantly base metal.................... 275
Crown - porcelain fused to noble metal............................................ 275
Endodontic therapy, anterior tooth
(excluding final restoration)................................................................. 275
D3320 Endodontic therapy, bicuspid tooth
(excluding final restoration)................................................................. 275
D3330 Endodontic therapy, molar (excluding final restoration)................ 275
Code
Description Copayment
D3346
D3347
D3348
D3410
D4210
Retreatment of previous root canal therapy - anterior................... 275
Retreatment of previous root canal therapy - bicuspid.................. 275
Retreatment of previous root canal therapy - molar....................... 275
Apicoectomy - anterior - Only for anterior teeth.................................... 275
Gingivectomy or gingivoplasty - four or more
contiguous teeth or tooth bounded spaces per quadrant............... 275
D5110 Complete denture - maxillary.............................................................. 275
D5120 Complete denture - mandibular.......................................................... 275
D5211 Maxillary partial denture - resin base (including
any conventional clasps, rests and teeth)........................................... 275
D5212 Mandibular partial denture - resin base (including
any conventional clasps, rests and teeth)........................................... 275
D5710 Rebase complete maxillary denture.................................................... 275
D5711 Rebase complete mandibular denture................................................ 275
D5720 Rebase maxillary partial denture......................................................... 275
D5721 Rebase mandibular partial denture..................................................... 275
D5750 Reline complete maxillary denture (laboratory)................................ 275
D5751 Reline complete mandibular denture (laboratory)............................ 275
D5760 Reline maxillary partial denture (laboratory)..................................... 275
D5761 Reline mandibular partial denture (laboratory)................................. 275
D5863 overdenture – complete maxillary...................................................... 275
D5864 overdenture – partial maxillary............................................................ 275
D7220 Removal of impacted tooth - soft tissue........................................... 275
D7230 Removal of impacted tooth - partially bony..................................... 275
D7240 Removal of impacted tooth - completely bony................................ 275
D7241 Removal of impacted tooth - completely bony,
with unusual surgical complications................................................... 275
D7270 Tooth reimplantation and/or stabilization of
accidentally evulsed or displaced tooth.............................................. 275
D7280 Surgical access of an unerupted tooth............................................... 275
D7285 Biopsy of oral tissue - hard (bone, tooth)......................................... 275
D7320 Alveoloplasty not in conjunction with extractions
- four or more teeth or tooth spaces, per quadrant......................... 275
D7410 Excision of benign lesion up to 1.25 cm........................................... 275
D7471 Removal of lateral exostosis (maxilla or mandible)......................... 275
D7472 Removal of torus palatinus.................................................................. 275
D7473 Removal of torus mandibularis........................................................... 275
D7485 Surgical reduction of osseous tuberosity........................................... 275
D7520 Incision and drainage of abscess - extraoral soft tissue.................. 275
D7880 Occlusal orthotic device, by report.................................................... 275
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............................ 275
D7963Frenuloplasty - Pre-authorization is not needed for members
6 and under............................................................................................... 275
D7970 Excision of hyperplastic tissue - per arch......................................... 275
D7972 Surgical reduction of fibrous tuberosity............................................ 275
D9220 Deep sedation/general anesthesia - first 30 minutes....................... 275
D9241 Intravenous conscious sedation/analgesia - first 30 minutes......... 275
D9410 House/extended care facility call - Up to 2 calls per facility
per provider................................................................................................ 275
D9420 Hospital or ambulatory surgical center call - Up to 1 call
per provider, per day................................................................................... 275
D9940 Occlusal guard, by report..................................................................... 275
Congenital Anomalies
Coverage for the treatment of congenital anomalies is available utilizing the
services and copayments listed above.
Orthodontia - Child
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.
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 pre-authorized 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
[800-637-6453]. We are happy to help you.
Exclusions and Limitations
Limitations:
Diagnostic Services are covered with the following limitations:
a. Intraoral complete series (D0210) is covered once in a three-year period
unless a panoramic radiograph (D0330) for the same enrollee has been
performed in the same three-year period. Additional D0210 and D0330
Intraoral complete series films or a panoramic film are only covered if
deemed by an orthodontist or Oral Surgeon to be medically necessary;
b. Periapical radiograph that are not included in a complete series for
diagnosis in conjunction with definitive treatment are only covered when
medically necessary;
c. 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 threeyear period.
d. Radiographs with no specific limitation are on a case-by-case basis when
medically necessary.
e. Oral and facial photographic images (D0350) on a case-by-case basis.
Preventive Services are covered with the following limitations:
a. Dental Prophylaxis (D1110 & D1120) limited to once every 6 months for
enrollees 18 and under, and once every 12 months for 19 years olds.
b. Topical Fluoride Treatment (D1208) including fluoride rinse, foam or gel,
including disposable trays for enrollees:
a. 6 years of age and younger up to 3 times per 12-month period per
enrollee;
b. 7 to 18 years of age, up to 2 times per 12 month period per enrollee;
c. Up to 3 times in a 12-month period per enrollee during orthodontic
treatment;
d. 19 years of age, once in a 12 month period.
e. Additional applications on a case-by-case basis
c. Sealants (D1351) is for enrollees 18 years or younger or up to 19 years
old for developmentally disabled when used on mechanically and/or
chemically prepared enamel surface once per tooth in a 3-year period for
enrollees 18 and younger. For developmentally disabled performed in a
two-year period.
d. 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.
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;
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 19 years of age. Must be preauthorized;
e. All recementations of permanent indirect crowns for enrollees from 12
through 19 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. Case post and core or prefabricated post and core, on permanent teeth
when performed in conjunction with a crown.
Periodontal Services are covered with the following limitations:
a. Surgical periodontal services and postoperative care for ginigivectomy/
gingivoplasty.
b. Non-surgical periodontal scaling and root planning for the teeth scaled
that are periodontically involved once per quadrant for enrollees aged
13 and older per enrollee per two year period when pre-authorized and
evidenced by X-ray.
c. Periodontal maintenance for enrollees aged 13 and older, once per
enrollee per 12 month period with pre-authorization.
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 (prior authorization is required for
services provided by a participating specialist). Services provided by a
dentist other than the enrollee’s designated participating provider or
authorized 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.
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 provider). 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. Cosmetic dentistry – services for appearance only. This includes such
services as the replacement of clinically acceptable amalgam fillings,
Veneers and Bonding.
f. Unsatisfactory patient-doctor relationship: Dental Health Services
providers 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 provider or their staff, or obtains services by fraud or
deception.
g. Submit claims within 60 days. Dental Health Services shall not be liable
to pay a claim for emergency care or for any Dental Health services
authorized treatment provided by a dentist other than a participating
provider unless the enrollee submits the claim to Dental Health Services
within 60 days after treatment.
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 service performed was within the lawful
scope of the denturist’s license.
i. Benefits are only available if work is completed at enrollee’s participating
dentist’s office, a pre-authorized specialist or in the event of dental
emergency at a non-network dentist. See your Evidence of Coverage
pamphlet for more information.
j. Not all participating dentists can perform all dental procedures, please
verify what services your selected provider 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 general dentist.
k. Coverage for services 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 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 standard claim form up to $150 after member has fulfilled
any of their cost sharing requirements.
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. 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.
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 midtreatment, 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. 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.
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 pre-authorized 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. We are happy to help you.
Dental Health Services
A Great Reason to Smile
sm
100 W Harrison St., S-440, South Tower, Seattle, WA 98119
[800-637-6453]
www.dentalhealthservices.com/WA
0714WM078
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