Survey
* Your assessment is very important for improving the work of artificial intelligence, which forms the content of this project
Download Mercy Care Plan External
Document related concepts
no text concepts found
Transcript
All claims should be mailed to: Post Office Box 61235 Phoenix, AZ 85082-1235 All prior authorization requests should be mailed to: 4350 E. Cotton Center Blvd. Bldg. D Phoenix, AZ 85040 e-mail: [email protected] Fax: 602-431-7155 Mercy Care Plan External - Dental Benefits Matrix *****SEE - Electronic claims: Please contact your provider rep if you are interested in submitting electronically. LAST PAGE***** All treatment plans in excess of $1,000 require Prior Authorization. X-rays must accompany your request for Prior Authorization. Emergency dental services do not require Prior Authorization. All NON-PAR providers require Prior Authorization for any services, except emergency services. - Referrals and treatment for TMJ are NOT a covered benefit unless medically necessary and will continue to require Prior Authorization for evaluation. - Replacement of restorations and other services within a 2 year period at the same office is not billable. - Post-op treatment for services rendered within 3 months of original service is not billable. MEMBERS AGE 21 AND OVER ARE NO LONGER ELIGIBLE FOR EMERGENT DENTAL SERVICES Prior Authorization is not a guarantee of payment Effective 07/01/2014 CDT 2014 Procedure Code Coverage Category (0 -20 yrs) Procedure Description Additional Documentation Required for Prior Authorization (0-20 yrs) Coverage Category 21 yrs & older) Additional Documentation Required for Prior Authorization (21 yrs and +) Clinical Oral Examinations D0120 D0140 D0145 D0150 D0160 D0170 D0180 D0190 D0191 Periodic oral examination (2 per year; 6 months plus 1 day apart) Limited oral evaluation-problem focused ** May not be billed with D9110 on same date of service Oral evaluation for patient under three years of age /counseling with primary caregiver (2 per year; 6 months plus 1 day apart) Comprehensive oral evaluation – new or established patient (only billable one time per member / per provider) Detailed and extensive oral evaluation - problem based ** Narrative required with claims submission Re-evaluation limited, problem focused (Established patient; not post-operative visit) ** Narrative required with claims submission Comprehensive periodontal evaluation – new or established patient ** Narrative required with claims submission Screening of a patient Assessment of a patient C C N/PT C C N C N/PT C N/PT N N C N/PT N N N N C N/PT C C C C C C C C C C C N/PT Radiographs D0210 D0220 D0230 D0240 D0250 D0260 D0270 Intraoral - complete series (including bitewings) (1 series in a 3 year period) Not covered for children under 6 years old Intraoral - periapical - first film Intraoral - periapical - each additional film Intraoral - occlusal film Extraoral - first film Extraoral - each additional film Bitewing - single film (2 per year; 6 months plus 1 day apart) C- Covered Service N-Non-covered Service C-PA - Covered only with prior authorization Page 1 of 18 PT - covered only with PreTransplant auth CDT 2014 Procedure Code Coverage Category (0 -20 yrs) Procedure Description D0272 D0273 D0274 D0277 D0290 D0310 D0320 D0321 D0322 D0330 D0340 D0350 D0364-0391 D0393 D0394 D0395 Bitewings - two films (2 per year; 6 months plus 1 day apart) Not covered for children under 2 years old Bitewings – three films Not covered for children under 10 years old Bitewings - four films (2 per year; 6 months plus 1 day apart) Not covered for children under 10 years old Vertical bitewings 7 – 8 films Posterior - anterior or lateral skull and facial bone survey film Sialography Temporomandibular joint arthrogram, including injection Other temporomandibular joint films, by report Tomographic survey Panoramic film (1 in a 3 year period) Not covered for children under 5 years old Cephalometric film Oral/facial images (includes intra and extraoral images) Cone beam, CT, MRI imaging Treatment simulation using 3D image volume Digital subtraction of two or more images or image volumes of the same modality Fusion of two or more 3D image volumes of one or more modalities Additional Documentation Required for Prior Authorization (0-20 yrs) Coverage Category 21 yrs & older) C N/PT C N/PT C N/PT C C-PA C-PA C-PA C-PA N C N/PT C-PA N C-PA C-PA N C C-PA C-PA N C/PA N N Include Narrative Include Narrative Additional Documentation Required for Prior Authorization (21 yrs and +) N N N N N N Test and Laboratory Examinations D0415-D0431 D0460 D0470 D0472 D0473 D0474 D0475-D0479 D0480 D0481-D0486 D0502 D0601-0603 D0999 Testing Procedures Pulp vitality tests Diagnostic casts Accession of tissue, gross exam, preparation and transmission of written report Accession of tissue, gross and microscopic exam, prep and transmission of written report Accession of tissue, gross and microscopic exam, including assessment of surgical margins for presence of disease, preparation and transmission of report Pathology lab procedures Accession of exfoliative cytologic smears, microscopic examination, preparation and transmission of written report Pathology lab procedures Other oral pathology procedures, by report Carries Risk Assessment and documentation—low to high risk Unspecified diagnostic procedure, by report N N C-PA N N Include Narrative N N N N N N N N N N N N C-PA N C-PA N N/PT N N/PT Include narrative Include narrative Dental Procedures – Preventive D1110 D1120 D1206 D1208 Prophylaxis - adult (ages 14+) (2 per year; 6 months plus 1 day apart) Prophylaxis - child (ages 0-13) (2 per year; 6 months plus 1 day apart) Topical Application of Fluoride Varnish/Moderate to High Caries Risk Patients (2 per year; 6 months plus 1 day apart) Topical Application of Fluoride (2 per year; 6 months plus 1 day apart) C- Covered Service N-Non-covered Service C C C N/PT N N C N C-PA - Covered only with prior authorization Page 2 of 18 PT - covered only with PreTransplant auth CDT 2014 Procedure Code Coverage Category (0 -20 yrs) Procedure Description Additional Documentation Required for Prior Authorization (0-20 yrs) Coverage Category 21 yrs & older) D1310 D1320 D1330 Nutritional counseling for the control of dental disease** Tobacco counseling for the control of oral disease** Oral Hygiene Instruction** **Oral hygiene instruction, nutritional counseling, and tobacco counseling are considered to be included in the fee for the exam and/or prophy. N N N N N N D1351 Sealant - per tooth (permanent first and second molars )- #2, 3, 14, 15, 18, 19, 30, 31, only) Not covered for children over 15 years old (only covered every 36 months) C N D1352 Preventive resin restoration in a moderate to high caries risk patient-- per tooth (permanent first and second molars )- #2, 3, 14, 15, 18, 19, 30, 31, only) Not covered for children over 15 years old (only covered every 36 months) Space Maintainer - fixed unilateral – for posterior primary teeth only, which have been lost prematurely. C N D1510 C – PA Posterior teeth only. X-ray showing evidence of bone coronal to erupting permanent tooth. N D1515 Space Maintainer - fixed bilateral – for posterior primary teeth only, which have been lost prematurely. C - PA Posterior teeth only X-ray showing evidence of bone coronal to erupting permanent tooth. N D1520 Space Maintainer - removable unilateral – for posterior primary teeth only C-PA Posterior teeth only N D1525 Space Maintainer - removable bilateral – for posterior primary teeth only C-PA Posterior teeth only X-ray showing evidence of bone coronal to erupting permanent tooth. X-ray showing evidence of bone coronal to erupting permanent tooth. D1550 Re-cementation of Space Maintainer ** Narrative required with claims submission Removal of fixed Space maintainer – Not by dentist who placed appliance ** Narrative required with claims submission Unspecified preventive procedure, by report C N C N D1555 D1999 C/PA Include Narrative Additional Documentation Required for Prior Authorization (21 yrs and +) N N/PT Include Narrative Dental Procedures – Restorative D2140 D2150 D2160 D2161 D2330 **Multiple surface restorations on a tooth (whether connecting surfaces or not) on the same date of service is reimbursed by the total number of surfaces restored. Amalgam - one surface, primary or permanent Amalgam - two surfaces, primary or permanent Amalgam - three surfaces, primary or permanent Amalgam - four or more surfaces, primary or permanent Resin - one surface, anterior C- Covered Service N-Non-covered Service C C C C C C-PA - Covered only with prior authorization Page 3 of 18 N/PT N/PT N/PT N/PT N/PT PT - covered only with PreTransplant auth CDT 2014 Procedure Code Coverage Category (0 -20 yrs) Procedure Description D2331 Resin - two surfaces, anterior D2332 Resin - three surfaces, anterior Ages 1-4 Covered Ages 5 and over---Covered with PA C C/PA Resin - four or more surfaces OR involving the incisal angle, anterior Ages 1-4 Covered Ages 5 and over---Covered with PA C C/PA D2335 D2390 D2391 D2392 D2393 D2394 Additional Documentation Required for Prior Authorization (0-20 yrs) C Coverage Category 21 yrs & older) Additional Documentation Required for Prior Authorization (21 yrs and +) N/PT N/PT N/PT Resin – based composite crown, anterior Resin – based composite – 1 surface, posterior Resin – based composite – 2 surfaces, posterior Resin – based composite – 3 surfaces, posterior Resin – based composite – 4 or more surfaces, posterior C C C C C N/PT N/PT N/PT N/PT N/PT N N N Cast Fixed Restorations D2410-D2722 D2740 Gold Foil Restorations, Inlay/Onlay Restorations, Resin and High Noble Crowns Crown---porcelain/ceramic substrate D2750 Crown – porcelain fused to high noble metal **Documentation of seated crown required with claim D2751 Crown – porcelain fused to predominantly base metal **Documentation of seated crown required with claim D2752 Crown – porcelain fused to noble metal **Documentation of seated crown required with claim D2780 D2781 D2782 D2783 D2790 Crown – ¾ cast high noble metal Crown – ¾ cast predominately base metal Crown – ¾ cast noble metal Crown – ¾ porcelain/ceramic (NOT including facial veneers) Crown – full cast high noble metal **Documentation of seated crown required with claim C- Covered Service N-Non-covered Service C-PA Ages 18-20 Endo Tx Teeth Only C-PA Ages 18-20 Endo Tx Teeth Only C-PA Ages 18-20 Endo Tx Teeth Only C-PA Ages 18-20 Endo Tx Teeth Only N N N N C-PA Ages 18-20 Endo Tx Teeth Only C-PA - Covered only with prior authorization Page 4 of 18 N N N N N N N N PT - covered only with PreTransplant auth CDT 2014 Procedure Code Coverage Category (0 -20 yrs) Procedure Description Additional Documentation Required for Prior Authorization (0-20 yrs) Coverage Category 21 yrs & older) D2791 Crown – full cast predominantly base metal **Documentation of seated crown required with claim C-PA Ages 18-20 Endo Tx Teeth Only N D2792 Crown – Full cast noble metal **Documentation of seated crown required with claim N D2794 Crown- titanium **Documentation of seated crown required with claim D2799 Provisional crown C-PA Ages 18-20 Endo Tx Teeth Only C-PA Ages 18-20 Endo Tx Teeth Only N N/PT D2910 Re-cement inlay, onlay, or partial coverage restoration ** Narrative required with claims submission Re-cement cast or prefabricated post and core ** Narrative required with claims submission Re-cement crown ** Narrative required with claims submission Reattachment of tooth fragment, incisal edge or cusp ** Narrative required with claims submission Prefabricated porcelain/ceramic crown-primary tooth Prefabricated stainless steel crown - primary tooth Prefabricated stainless steel crown - permanent tooth Prefabricated resin crown Ages 1-4 Covered Ages 5 and over---Covered with PA C N/PT C N/PT C N/PT C N C C C N N N/PT N/PT Additional Documentation Required for Prior Authorization (21 yrs and +) N Other Restorative Services D2915 D2920 D2921 D2929 D2930 D2931 D2932 D2933 C C/PA Prefabricated stainless steel crown with resin window Ages 1-4 Covered Ages 5 and over---Covered with PA N D2934 Prefabricated esthetic coated stainless steel crown – primary tooth D2940 Protective restoration –Sedative filling **Sedative fillings and permanent restorations on the same tooth may not be billed on the same date of service. **Sedative fillings and pulpotomy or RCT may not be billed on the same tooth (primary or permanent) for the same date of service. **Sedative fillings not covered on primary teeth without narrative. Interim therapeutic restoration---primary dentition D2941 C- Covered Service N-Non-covered Service C C/PA Anterior teeth only C Anterior teeth only C N/PT C N C-PA - Covered only with prior authorization Page 5 of 18 N PT - covered only with PreTransplant auth CDT 2014 Procedure Code Coverage Category (0 -20 yrs) Procedure Description Additional Documentation Required for Prior Authorization (0-20 yrs) Coverage Category 21 yrs & older) D2949 D2950 Restorative foundation for an indirect restoration Core build-up, including any pins N C N N/PT Anterior teeth only D2951 **Claims for core build-ups must be accompanied by a narrative describing that greater than ½ of the tooth structure is absent. **Not covered on primary teeth. Pin retention - per tooth, in addition to restoration C D2952 Post and core in addition to crown C D2953 D2954 Each additional cast post-same tooth Prefabricated post and core in addition to crown N C Post removal Each additional prefabricated post –same tooth Labial veneers, crown repairs, and additional procedures for crowns under existing partials Temporary crown (fractured tooth) Inlay repair necessitated by restorative material failure Onlay repair necessitated by restorative material failure Veneer repair necessitated by restorative material failure Resin infiltration of incipient smooth surface lesions Unspecified restorative procedure, by report N N N N/PT Anterior teeth only N/PT Anterior teeth only N N/PT Anterior teeth only N N N C N N N N C-PA N N N N N N/PT D2955 D2957 D2960-D2962 & 2971-D2980 D2970 D2981 D2982 D2983 D2990 D2999 Include Narrative Additional Documentation Required for Prior Authorization (21 yrs and +) Include X-ray Include X-ray Include X-ray Include Narrative Dental Procedures - Endodontics D3110 D3120 D3220 D3221 D3222 D3230 D3240 Pulp cap – direct (excluding final restoration) **Direct pulp caps are covered only on permanent teeth. **Direct pulp caps and permanent fillings may not be billed on the same tooth on the same date of service. This is considered part of the restoration fee. Pulp cap - indirect (excluding final restoration) **Indirect pulp caps are covered only on permanent teeth. **Indirect pulp caps and permanent fillings may not be billed on the same tooth on the same date of service. This is considered part of the restoration fee. Therapeutic pulpotomy (excluding final restoration), primary and permanent teeth (not to be used for apexogenesis) Pulpal debridement, primary and permanent teeth Partial Pulpotomy for apexogenesis--permanent tooth with incomplete root development Pulpal therapy (resorbable filling) - anterior, primary tooth (excluding restoration) Pulpal therapy (resorbable filling) - posterior, primary tooth (excluding restoration) C N C N C N C C-PA Include X-ray Will be paid as palliative treatment (D9110) N/PT N C C N N C C N/PT N Root Canal Therapy (Including Follow-up Care) **Initial x-ray for root canal therapy (RCT) is a covered benefit. Subsequent xrays are considered included in the fee for RCT and are not billable. D3310 D3320 Anterior (excluding final restoration) Bicuspid (excluding final restoration) C- Covered Service N-Non-covered Service C-PA - Covered only with prior authorization Page 6 of 18 Include x-ray PT - covered only with PreTransplant auth CDT 2014 Procedure Code Coverage Category (0 -20 yrs) Procedure Description Additional Documentation Required for Prior Authorization (0-20 yrs) D3330 D3331 Molar (excluding final restoration) Treatment of root canal obstruction; non-surgical access C C-PA D3332 Incomplete endodontic therapy; inoperable or fractured. C-PA D3333 Internal root repair or perforation defects. C-PA D3346 D3347 D3348 D3351 Retreatment of previous root canal therapy - anterior Retreatment of previous root canal therapy – bicuspid Retreatment of previous root canal therapy - molar Apexification/recalcification - initial visit (apical closure/calcific repair of perforations, root resorption, etc.) Apexification/recalcification - interim medication (apical closure/calcific repair of perforations, root resorption, etc.) Apexification/recalcification - final visit (includes completed root canal therapy) C-PA C-PA C-PA C-PA Pulpal regeneration—initial visit Pulpal regeneration—interim medication replacement Pulpal regeneration—completion of treatment Apicoectomy/periradicular surgery - anterior Apicoectomy/periradicular surgery - bicuspid (first root) Apicoectomy/periradicular surgery - molar (first root) Apicoectomy/periradicular surgery - each additional root Periradicular surgery without apicoectomy Bone graft in conjunction with periradicular surgery---per tooth, single site Bone graft in conjunction with periradicular surgery---each additional tooth-same site Retrograde filling - per root N N N C-PA C-PA C-PA C-PA N N N Include x-ray Include x-ray Include x-ray Include x-ray C-PA Include x-ray Biologic materials to aid in soft and osseous tissue regeneration/with periradicular surgery Guided tissue regeneration, resorbable barrier, per site, with periradicular surgery Root amputation - per root Endodontic endosseous implant Intentional replantation (including necessary splinting) Surgical procedure for isolation of tooth with rubber dam Hemisection (including any root removal), not including root canal therapy Canal preparation and fitting of performed dowel or post Unspecified endodontic procedure, by report N D3352 D3353 D3355 D3356 D3357 D3410 D3421 D3425 D3426 D3427 D3428 D3429 D3430 D3431 D3432 D3450 D3460 D3470 D3910 D3920 D3950 D3999 C-PA C-PA N C-PA N N N C-PA N C-PA Include x-ray & Narrative Include x-ray & Narrative Include x-ray & Narrative Include x-ray Include x-ray Include x-ray Include x-ray & narrative Include x-ray & narrative Include x-ray & narrative Coverage Category 21 yrs & older) N N N N N/PT N N N N N/PT Anterior teeth only N Include x-ray Include Narrative Include x-ray N N N N N/PT N N N N N N Include x-ray Additional Documentation Required for Prior Authorization (21 yrs and +) N N N N N N N N/PT Include x-ray Include x-ray Include Narrative Dental Procedures - Periodontics D4210 D4211 Gingivectomy or gingivoplasty – 4 or more contiguous teeth or tooth bounded spaces per quadrant Gingivectomy or gingivoplasty – 1 to 3 contiguous teeth or tooth bounded spaces per quadrant C- Covered Service N-Non-covered Service C-PA C-PA Include Narrative, Perio Chart Include Narrative, Perio Chart C-PA - Covered only with prior authorization Page 7 of 18 N/PT N/PT PT - covered only with PreTransplant auth CDT 2014 Procedure Code Coverage Category (0 -20 yrs) Procedure Description D4212 Additional Documentation Required for Prior Authorization (0-20 yrs) Coverage Category 21 yrs & older) Additional Documentation Required for Prior Authorization (21 yrs and +) D4261 Gingivectomy or gingivoplasty to allow access for restorative procedure, per tooth Anatomical Crown Exposure – Four or more contiguous teeth per quadrant Anatomical Crown Exposure – 1 to 3 teeth per quadrant Gingival flap procedure, including root planing – 4 or more contiguous teeth or tooth bounded spaces per quadrant Gingival flap procedure, including root planing – 1 to 3 contiguous teeth or tooth bounded spaces per quadrant Apically positioned flap Clinical crown lengthening – hard tissue Osseous surgery (including flap entry and closure) - 4 or more contiguous teeth or bounded teeth spaces per quadrant Osseous surgery (including flap entry and closure) – 1 to 3 teeth per quadrant D4263 Bone replacement graft---first site in quadrant C-PA Include Narrative, Perio Chart Include Narrative, Perio Chart Include Narrative D4264 D4265 D4266 D4267 D4270 D4273 D4274 C-PA C-PA C-PA C-PA C-PA C-PA C-PA Include Narrative Include Narrative Include Narrative Include Narrative Include Narrative Include Narrative Include Narrative N N N N N N N D4275 D4276 D4277 D4278 D4320 D4321 D4341 Bone replacement graft—each additional site in quadrant Biologic materials to aid in soft and osseous tissue regeneration Guided tissue regeneration—restorable barrier—per site Guided tissue regeneration—Non-restorable barrier—per site Pedicle soft tissue graft procedure Sub-epithelial connective tissue graft procedures, per tooth Distal or proximal wedge procedure (when not performed in conjunction with surgical procedures in the same anatomical area Soft tissue allograft Combined connective tissue and double pedicle graft----per tooth Free soft tissue graft procedure (including donor site surgery) first tooth Free soft tissue graft procedure (including donor site surgery) each additional tooth Provisional splinting---intra-coronal Provisional splinting---extra-coronal Periodontal scaling and root planing – 4 or more teeth per quadrant C-PA C-PA N N C-PA C-PA C-PA Include Narrative Include Narrative N N N N N N N/PT Include Narrative, Perio Chart D4342 Periodontal scaling and root planing – 1 to 3 teeth, per quadrant C-PA N/PT Include Narrative, Perio Chart D4355 Full mouth debridement to enable comprehensive evaluation and diagnosis C-PA N/PT Include Narrative, Perio Chart D4381 D4910 Localized delivery of chemotherapeutic agent via a controlled release vehicle into diseased crevicular tissue, per tooth, by report Periodontal maintenance procedures -following active periodontal therapy— C-PA D4920 D4921 Unscheduled dressing change (by someone other than the treating dentist) Gingival irrigation –per quadrant C/PA N D4230 D4231 D4240 D4241 D4245 D4249 D4260 C- Covered Service N-Non-covered Service N N N N C-PA N N N/PT Include Narrative, Perio Chart N/PT Include Narrative, Perio Chart C-PA N C-PA C-PA C-PA Include Narrative, Perio Chart Include Narrative, Perio Chart Include Narrative Include Narrative Include Narrative, Perio Chart, Xrays Include Narrative, Perio Chart, Xrays Include Narrative, Perio chart N N/PT N N Include Narrative & Perio chart C-PA - Covered only with prior authorization Page 8 of 18 N N N/PT N/PT N/PT N PT - covered only with PreTransplant auth CDT 2014 Procedure Code Procedure Description D4999 Coverage Category 21 yrs & older) C-PA Additional Documentation Required for Prior Authorization (0-20 yrs) Include Narrative C-PA C-PA C-PA C-PA C-PA Include Narrative Include Narrative Include Narrative Include Narrative Include Narrative N N N N N C-PA Include Narrative N C-PA Include Narrative N C-PA Include Narrative N Include Narrative N N N Coverage Category (0 -20 yrs) Unspecified periodontal procedure, by report N/PT Additional Documentation Required for Prior Authorization (21 yrs and +) Include Narrative Dental Procedures – Prosthodontics (When Medically Necessary) D5110 D5120 D5130 D5140 D5211 D5212 D5213 D5214 D5225 D5226 D5281 D5410 D5411 D5421 D5422 D5510 D5520 D5610 D5620 D5630 D5640 D5650 D5660 D5670 D5671 D5710 D5711 D5720 D5721 D5730 D5731 D5740 D5741 D5750 D5751 D5760 Complete denture maxillary Complete denture mandibular Immediate denture maxillary Immediate denture mandibular Maxillary partial denture - resin base (including any conventional clasps, rests and teeth) Mandibular partial denture - resin base (including any conventional clasps, rests and teeth) Maxillary partial denture - cast metal framework with resin denture bases (including any conventional clasps, rests and teeth Mandibular partial denture - cast metal framework with resin denture bases (including any conventional clasps, rests and teeth) Maxillary partial denture – flexible base (including any clasps, rests, and teeth) Mandibular partial denture – flexible base (including any clasps, rests, and teeth) Removable unilateral partial denture - one piece cast metal (including clasps and teeth) Adjust complete denture - maxillary Adjust complete denture - mandibular Adjust partial denture - maxillary Adjust partial denture - mandibular Repair broken complete denture base Replace missing or broken teeth - complete denture (each tooth) Repair resin denture base Repair cast framework Repair or replace broken clasp Replace broken teeth Add tooth to existing partial denture Add clasp to existing partial denture Replace all teeth and acrylic on cast metal framework (maxillary) Replace all teeth and acrylic on cast metal framework (mandibular) Rebase complete maxillary denture Rebase complete mandibular +C224 denture Rebase maxillary partial denture Rebase mandibular partial denture Reline maxillary complete denture (chairside) Reline mandibular complete denture (chairside) Reline maxillary partial denture (chairside) Reline mandibular partial denture (chairside) Reline maxillary complete denture (laboratory) Reline mandibular complete denture (laboratory) Reline maxillary partial denture (laboratory) C- Covered Service N-Non-covered Service N N C-PA C-PA C-PA C-PA C-PA C-PA C-PA C-PA C-PA C-PA C-PA C-PA C-PA N N C-PA C-PA C-PA C-PA C-PA C-PA C-PA C-PA C-PA C-PA C-PA Include Narrative Include Narrative Include Narrative Include Narrative Include Narrative Include Narrative Include Narrative Include Narrative Include Narrative Include Narrative Include Narrative Include Narrative Include Narrative Include Narrative Include Narrative Include Narrative Include Narrative Include Narrative Include Narrative Include Narrative Include Narrative Include Narrative Include Narrative C-PA - Covered only with prior authorization Page 9 of 18 N N N N N N N N N N N N N N N N N N N N N N N N N PT - covered only with PreTransplant auth CDT 2014 Procedure Code Coverage Category (0 -20 yrs) Procedure Description D5761 D5820 Reline mandibular partial denture (laboratory) Interim Partial Denture (use for anterior flipper) (maxillary) C-PA C-PA D5821 Interim Partial Denture (use for anterior flipper) (mandibular) C-PA Tissue conditioning---maxillary Tissue conditioning---mandibular Other removable prosthetic services Overdentures Replacement of replaceable part of semi-precision attachment (male or female component) Modification of removable prosthesis following implant surgery Unspecified removable prosthodontic procedure C-PA C-PA N N N D5850 D5851 D5860-5862 D5863-5866 D5867 D5875 D5899 N C-PA Additional Documentation Required for Prior Authorization (0-20 yrs) Include Narrative Include Narrative & x-ray Include Narrative & x-ray Include Narrative Include Narrative Include Narrative Coverage Category 21 yrs & older) Additional Documentation Required for Prior Authorization (21 yrs and +) N N N N N N N N N N Dental Procedures – Maxillofacial Prosthetics (When Medically Necessary) D5911 D5912 D5913 D5914 D5915 D5916 D5919 D5922 D5923 D5924 D5925 D5926 D5927 D5828 D5929 D5931 D5932 D5933 D5934 D5935 D5936 D5937 D5951 D5952 D5953 D5954 D5955 D5958 D5959 Facial moulage (sectional) Facial moulage (complete) Nasal prosthesis Auricular prosthesis Orbital prosthesis Ocular prosthesis Facial prosthesis Nasal septal prosthesis Ocular prosthesis, interim Cranial prosthesis Facial augmentation implant prosthesis Nasal prosthesis, replacement Auricular prosthesis, replacement Orbital prosthesis, replacement Facial prosthesis, replacement Obturator prosthesis, surgical Obturator prosthesis, definitive Obturator prosthesis, modification Mandibular resection prosthesis with guide flange Mandibular resection prosthesis without guide flange Obturator/prothesis, interim Trismus appliance (not for TMD treatment) Feeding aid Speech aid prosthesis, pediatric Speech aid prosthesis, adult Palatal augmentation prosthesis Palatal life prothesis, definitive Palatal lift prothesis, interim Palatal lift prothesis, modification C- Covered Service N-Non-covered Service C-PA Include Narrative N C-PA Include Narrative N C-PA Include Narrative N C-PA Include Narrative N C-PA Include Narrative N C-PA Include Narrative N C-PA Include Narrative N C-PA Include Narrative N C-PA Include Narrative N C-PA Include Narrative N C-PA Include Narrative N C-PA Include Narrative N C-PA Include Narrative N C-PA Include Narrative N C-PA Include Narrative N C-PA Include Narrative N C-PA Include Narrative N C-PA Include Narrative N C-PA Include Narrative N C-PA Include Narrative N C-PA Include Narrative N C-PA Include Narrative N C-PA Include Narrative N C-PA Include Narrative N C-PA Include Narrative N C-PA Include Narrative N C-PA Include Narrative N C-PA Include Narrative N C-PA Include Narrative N C-PA - Covered only with prior authorization PT - covered only with PreTransplant auth Page 10 of 18 CDT 2014 Procedure Code Coverage Category (0 -20 yrs) Procedure Description D5960 D5982 D5983 D5984 D5985 D5986 D5987 D5988 D5991 D5992 D5994 D5999 Speech aid prosthesis, modification Surgical stent Radiation carrier Radiation shield Radiation cone locator Fluoride gel carrier Commissure splint Surgical splint Vesiculobullous disease medicament carrier Adjust maxillofacial prosthetic appliance, by report Periodontal medicament carrier with peripheral seal—lab processed Unspecified maxillofacial prosthesis, by report C-PA C-PA C-PA C-PA C-PA C-PA C-PA C-PA C-PA C-PA N C-PA Additional Documentation Required for Prior Authorization (0-20 yrs) Include Narrative Include Narrative Include Narrative Include Narrative Include Narrative Include Narrative Include Narrative Include Narrative Include Narrative Include Narrative Include Narrative Coverage Category 21 yrs & older) Additional Documentation Required for Prior Authorization (21 yrs and +) N N N N N N N N N N N N Dental Procedures - Implant Services D6010-D6199 Surgical Implants N N Pontics Inlays/Onlays Crowns - cast (resin/porcelain) N N N N N N Re-cement fixed partial denture ** Narrative required with claims submission Other Fixed Partial Denture Procedures Unspecified fixed prosthodontic procedure, by report C N/PT Dental Procedures – Prosthodontics - Fixed D6205-D6253 D6545-D6634 D6710-D6920 D6930 D6940-D6985 D6999 N C-PA Include narrative N N Oral and Maxillofacial Surgery (Symptomatic Teeth Only) **Extractions of naturally exfoliating teeth are not a covered benefit. **Extractions are covered ONLY for ages 0-20 if: 1. Tooth (teeth) is symptomatic and/or exhibits pathology. 2. Extraction (s) in NOT for orthodontic purposes 3. Extraction (s) is NOT for the prophylactic extraction of 3 rd molars 4. Prior Authorization is submitted for ALL 3 rd molar extractions **Claims for ALL extractions must be accompanied by x-ray and/or treatment notes. D7111 D7140 D7210 D7220 D7230 Coronal remnants – deciduous tooth Extraction, erupted tooth or exposed root (elevation and/or forceps removal) Surgical removal of erupted tooth requiring elevation of mucoperiosteal flap and removal of bone and/or section of tooth including cutting of gingiva and bone, removal of tooth structure, minor smoothing of socket bone and closure Removal of impacted tooth - soft tissue – occlusal surface of tooth covered by soft tissue; requires mucoperiosteal flap elevation Removal of impacted tooth - partially bony – part of crown covered by bone; requires mucoperiosteal flap elevation and bone removal C- Covered Service N-Non-covered Service C C C C-PA C-PA N N/PT N/PT Include x-ray, Narrative Include x-ray, Narrative C-PA - Covered only with prior authorization Page 11 of 18 N/PT N/PT PT - covered only with PreTransplant auth CDT 2014 Procedure Code Coverage Category (0 -20 yrs) Procedure Description C-PA D7280 Removal of impacted tooth - completely bony – most or all of crown covered by bone; requires mucoperiosteal flap elevation and bone removal Removal of impacted tooth - completely bony, with unusual surgical complications – most or all of crown covered by bone; unusually difficult or complicated due to factors such as nerve dissection required, separate closure of maxillary sinus required or aberrant tooth position Surgical removal of residual tooth roots (cutting procedure) includes cutting of soft tissue and bone, removal of tooth surface and closure (completely submerged in bone) ** Narrative required with claims submission Coronectomy—intentional partial tooth removal Oral antral fistula closure Primary closure of a sinus perforation Tooth reimplantation and/or stabilization of accidentally evulsed or displaced tooth ** Narrative required with claims submission Tooth transplantation (includes from one site to another and splinting and/or stabilization Surgical access of an unerupted tooth D7282 Mobilization of erupted or malpositioned tooth to aid eruption C-PA D7283 Placement of device to facilitate eruption of impacted tooth C-PA D7285 D7286 D7287 D7288 Biopsy of oral tissue – hard Biopsy of oral tissue – soft Cytology sample collection Brush biopsy – trans epithelial sample collection ** Include narrative and pathology report with claim Surgical repositioning of teeth Transseptal fiberotomy – supra crestal fiberotomy, by report Surgical placement: Temporary anchorage device (screw retained plate requiring surgical flap) C-PA C-PA N N D7293 Surgical placement: Temporary anchorage device requiring surgical flap C-PA D7294 Surgical placement: Temporary anchorage device without surgical flap C-PA D7310 Alveoloplasty in conjunction with extractions – four or more teeth or tooth spaces per quadrant Alveoloplasty in conjunction with extractions – 1 to 3 teeth or tooth spaces per quadrant Alveoloplasty not in conjunction with extractions – four or more teeth or tooth spaces per quadrant Alveoloplasty not in conjunction with extractions – 1 to 3 teeth or tooth spaces per quadrant C-PA D7240 D7241 D7250 D7251 D7260 D7261 D7270 D7272 D7290 D7291 D7292 D7311 D7320 D7321 C- Covered Service N-Non-covered Service C-PA Additional Documentation Required for Prior Authorization (0-20 yrs) Include x-ray, Narrative Include x-ray, Narrative C C/PA C C C N N C-PA C-PA C-PA C-PA Include Narrative N/PT N C C N N Include x-ray, Narrative Include x-ray, Narrative N Include x-ray, Narrative Include Narrative Include Narrative N Include x-ray , Narrative Include x-ray, Narrative Include x-ray, Narrative Include x-ray, Narrative Include x-ray, Narrative Include x-ray, Narrative Include x-ray, Narrative C-PA - Covered only with prior authorization Page 12 of 18 N/PT N/PT N C-PA Coverage Category 21 yrs & older) Additional Documentation Required for Prior Authorization (21 yrs and +) N C-PA C-PA N N Include Narrative Include Narrative N N C-PA Include x-ray, Narrative C-PA Include x-ray, Narrative C-PA Include x-ray, Narrative N N N N PT - covered only with PreTransplant auth CDT 2014 Procedure Code Coverage Category (0 -20 yrs) Procedure Description D7340 D7350 D7410 D7411 D7412 D7413 D7414 D7415 D7440 D7441 D7450 D7451 D7460 D7461 D7465 D7471 D7472 D7473 D7485 D7490 D7510 D7511 D7520 D7521 D7530 D7540 D7550 D7560 Vestibuloplasty - ridge extension (second epithelialization) Vestibuloplasty - ridge extension (including soft tissue grafts, muscle reattachments, revision of soft tissue attachment and management of hypertrophied and hyperplastic tissue.) Excision of benign lesion up to 1.25 cm Excision of benign lesion greater than 1.25 cm Excision of benign lesion – complicated Excision of malignant lesion up to 1.25 cm Excision of malignant lesion greater than 1.25 cm Excision of malignant lesion, complicated Excision of malignant tumor - lesion diameter up to 1.25 cm Excision of malignant tumor - lesion diameter greater than 1.25 cm Removal of benign odontogenic cyst or tumor - lesion diameter up to 1.25 cm Removal of benign odontogenic cyst or tumor - lesion diameter greater than 1.25 cm Removal of benign nonodontogenic cyst or tumor - lesion diameter up to 1.25 cm Removal of benign nonodontogenic cyst or tumor - lesion diameter greater than 1.25 cm Destruction of lesion(s) by physical or chemical methods, by report Removal of lateral exostosis (maxilla or mandible) Removal of torus palatinus Removal of torus mandibularis Surgical reduction of osseous tuberosity Radical resection of mandible with bone graft Incision and drainage of abscess - intraoral soft tissue ** Narrative required with claims submission Incision and drainage of abscesses – intraoral soft tissue – complicated (multiple fascial spaces) ** Narrative required with claims submission Incision and drainage of abscess - extraoral soft tissue ** Narrative required with claims submission Incision and drainage of abscesses – extraoral soft tissue – complicated (multiple fascial spaces) ** Narrative required with claims submission **Incision and drainage of abscesses and extractions may not be billed on the same date of service for the same tooth unless a narrative accompanying claim documents use of drain/stent placement. Removal of foreign body from mucosa, skin, or subcutaneous areolar tissue Removal of reaction-producing foreign bodies - musculoskeletal system Partial ostectomy - sequestrectomy for removal of non-vital bone Maxillary sinusotomy for removal of tooth fragment or foreign body Additional Documentation Required for Prior Authorization (0-20 yrs) N N Coverage Category 21 yrs & older) Additional Documentation Required for Prior Authorization (21 yrs and +) N N C-PA C-PA C-PA C-PA C-PA C-PA C-PA C-PA C-PA C-PA Include Narrative Include Narrative Include Narrative Include Narrative Include Narrative Include Narrative Include Narrative Include Narrative Include Narrative Include Narrative C-PA C-PA C-PA C-PA C-PA C-PA C-PA C-PA C-PA C-PA Include Narrative Include Narrative Include Narrative Include Narrative Include Narrative Include Narrative Include Narrative Include Narrative Include Narrative Include Narrative C-PA C-PA Include Narrative Include Narrative C-PA C-PA Include Narrative Include Narrative C-PA C-PA C-PA C-PA C-PA C-PA C Include Narrative Include Narrative Include Narrative Include Narrative Include Narrative Include Narrative C-PA N N N N C-PA C Include Narrative C C C C C C C-PA C C-PA C-PA Include Narrative Include Narrative Include Narrative C-PA C C-PA C-PA Include Narrative Include Narrative Include Narrative Include Narrative Treatment of Fractures (When Medically Necessary) D7610 ** Treatment notes and x-rays must accompany claim Maxilla - open reduction (teeth immobilized if present) C- Covered Service N-Non-covered Service C C-PA - Covered only with prior authorization Page 13 of 18 C PT - covered only with PreTransplant auth CDT 2014 Procedure Code Coverage Category (0 -20 yrs) Procedure Description D7620 D7630 D7640 D7650 D7660 D7670 D7671 D7680 D7710 D7720 D7730 D7740 D7750 D7760 D7770 D7771 D7780 Maxilla - closed reduction (teeth immobilized if present) Mandible - open reduction (teeth immobilized if present) Mandible - closed reduction (teeth immobilized if present) Malar and/or zygomatic arch – open reduction Malar and/or zygomatic arch – closed reduction Alveolus – closed reduction, may include stabilization of teeth Alveolus – open reduction, may include stabilization of teeth Facial bones - complicated reduction with fixation and multiple surgical approaches Maxilla – open reduction Maxilla - closed reduction Mandible - open reduction Mandible - closed reduction Malar and/or zygomatic arch - open reduction Malar and/or zygomatic arch - closed reduction Alveolus – open reduction stabilization of teeth Alveolus – closed reduction stabilization of teeth Facial bones - complicated reduction with fixation and multiple surgical approaches Additional Documentation Required for Prior Authorization (0-20 yrs) Coverage Category 21 yrs & older) C C C C C C C C C C C C C C C C C C C C C C C C C C C C C C C C C C Additional Documentation Required for Prior Authorization (21 yrs and +) Reduction of Dislocation and Management of Other Temporomandibular Joint Dysfunctions (When Medically Necessary) D7810 D7820 D7830 D7840 D7850 D7852 D7854 D7856 D7858 D7860 D7865 D7870 D7871 D7872 D7873 D7874 D7875 D7876 D7877 D7880 D7899 Open Reduction of dislocation Closed Reduction of dislocation Manipulation under anesthesia Condylectomy Surgical discectomy with/without implant Disc repair Synovectomy Myotomy Joint reconstruction Arthrotomy Arthroplasty Arthrocentesis Non-arthroscopy lysis and lavage Arthroscopy - diagnosis, with or without biopsy Arthroscopy - surgical: lavage and lysis of adhesions Arthroscopy - surgical - disc repositioning and stabilization Arthroscopy – surgical: synovectomy Arthroscopy - surgical - synovectomy Arthroscopy - surgical - debridement Occlusal orthotic appliance Unspecified TMD therapy, by report C- Covered Service N-Non-covered Service C-PA C-PA C-PA C-PA C-PA C-PA C-PA C-PA C-PA C-PA C-PA C-PA C-PA C-PA C-PA C-PA C-PA C-PA C-PA C-PA C-PA Include Narrative Include Narrative Include Narrative Include Narrative Include Narrative Include Narrative Include Narrative Include Narrative Include Narrative Include Narrative Include Narrative Include Narrative Include Narrative Include Narrative Include Narrative Include Narrative Include Narrative Include Narrative Include Narrative Include Narrative Include Narrative C-PA - Covered only with prior authorization Page 14 of 18 C-PA C-PA C-PA C-PA C-PA C-PA C-PA C-PA C-PA C-PA C-PA C-PA C-PA C-PA C-PA C-PA C-PA C-PA C-PA C-PA C-PA Include Narrative Include Narrative Include Narrative Include Narrative Include Narrative Include Narrative Include Narrative Include Narrative Include Narrative Include Narrative Include Narrative Include Narrative Include Narrative Include Narrative Include Narrative Include Narrative Include Narrative Include Narrative Include Narrative Include Narrative Include Narrative PT - covered only with PreTransplant auth CDT 2014 Procedure Code Coverage Category (0 -20 yrs) Procedure Description Additional Documentation Required for Prior Authorization (0-20 yrs) Coverage Category 21 yrs & older) Additional Documentation Required for Prior Authorization (21 yrs and +) Repair of Traumatic Wounds D7910 D7911 D7912 D7920 D7921 D7940 D7941 D7943 D7944 D7945 D7946 D7947 D7948 D7949 D7950 D7951 D7952 D7953 D7955 D7960 D7963 D7970 D7971 D7972 D7980 D7981 D7982 D7983 D7990 D7991 D7995 D7996 D7997 D7998 D7999 ** Narrative required with claims submission Suture of recent small wounds - up to 5 cm ** Complicated suture - up to 5 cm ** Complicated suture - greater than 5 cm ** Skin graft (identify defect covered, location, and type of graft) Collection and application of autologous blood concentrate product Osteoplasty - for orthognathic deformities Osteotomy - ramus, closed Osteotomy - ramus, open with bone graft Osteotomy - segmented or subapical (report by range of tooth numbers within segment) Osteotomy - body of mandible LeFort I (maxilla - total) LeFort I (maxilla - segmented) LeFort II or LeFort III (osteoplasty of facial bones for midface hypoplasia or retrusion) - without bone graft LeFort II or LeFort III - with bone graft Osseous, osteoperiosteal, or cartilage graft of the mandible or maxilla- autogenous or non-autogenous, by report Sinus augmentation with bone or bone substitutes via a lateral open approach Sinus augmentation via a vertical approach Bone replacement graft for ridge preservation – per site Repair of maxillofacial soft and hard tissue defect Frenulectomy (frenectomy or frenotomy) - separate procedure Frenuloplasty Excision of hyperplastic tissue - per arch Excision of pericoronal gingiva Surgical reduction of fibrous tuberosity Sialolithotomy Excision of salivary gland, by report Sialodochoplasty Closure of salivary fistula Emergency tracheotomy Coronoidectomy Synthetic graft - mandible or facial bones, by report Implant - mandible for augmentation purposes (excluding alveolar + C8 ridge), by report Appliance removal (not by dentist who placed the appliance), includes removal of archbar Intraoral placement of a fixation device not in conjunction with a fracture Unspecified oral surgery procedure, by report C C C C-PA N C-PA C-PA C-PA C-PA Include Narrative Include Narrative Include Narrative Include Narrative C C C C-PA N C-PA C-PA C-PA C-PA C-PA C-PA C-PA C-PA Include Narrative Include Narrative Include Narrative Include Narrative C-PA C-PA C-PA C-PA Include Narrative Include Narrative Include Narrative Include Narrative C-PA C-PA Include Narrative Include Narrative C-PA C-PA Include Narrative Include Narrative C-PA N C-PA C-PA C-PA C-PA C-PA C-PA C-PA C-PA C-PA C-PA C-PA C C-PA C-PA C-PA Include Narrative Include Narrative Include Narrative Include Narrative Include Narrative C-PA N C-PA C-PA N N N/PT N/PT N/PT C-PA C-PA C-PA C-PA C C-PA C-PA C-PA C-PA Include Narrative C-PA Include Narrative C-PA C-PA Include Narrative Include Narrative C-PA C-PA Include Narrative Include Narrative Include Narrative Include Narrative Include Narrative Include Narrative Include Narrative Include Narrative Include Narrative Include Narrative Include Narrative Include Narrative Include Narrative Include Narrative Include Narrative Include Narrative Include Narrative Include Narrative Include Narrative Include Narrative Include Narrative Include Narrative Include Narrative Include Narrative Include Narrative Include Narrative Include Narrative Include Narrative Include Narrative Include Narrative Include Narrative Orthodontics (When Medically Necessary) C- Covered Service N-Non-covered Service C-PA - Covered only with prior authorization Page 15 of 18 PT - covered only with PreTransplant auth CDT 2014 Procedure Code Procedure Description D8010 D8020 D8030 D8040 D8050 D8060 D8070 D8080 D8090 D8210 D8220 D8660 D8670 D8680 D8690 D8691 D8692 D8693 D8694 D8999 C-PA C-PA C-PA C-PA C-PA C-PA C-PA C-PA C-PA C-PA C-PA C-PA C-PA C-PA Additional Documentation Required for Prior Authorization (0-20 yrs) Include Narrative Include Narrative Include Narrative Include Narrative Include Narrative Include Narrative Include Narrative Include Narrative Include Narrative Include Narrative Include Narrative Include Narrative Include Narrative Include Narrative C-PA Include Narrative N C-PA C-PA C-PA C/PA C-PA Include Narrative Include Narrative Include Narrative Include Narrative Include Narrative N N N N N Coverage Category (0 -20 yrs) Limited orthodontic treatment of the primary dentition Limited orthodontic treatment of the transitional dentition Limited orthodontic treatment of the adolescent dentition Limited orthodontic treatment of the adult dentition Interceptive orthodontic treatment of the primary dentition Interceptive orthodontic treatment of the transitional dentition Comprehensive orthodontic treatment of the transitional dentition Comprehensive orthodontic treatment of adolescent dentition Comprehensive orthodontic treatment of the adult dentition Removable appliance therapy Fixed appliance therapy Pre-orthodontic treatment visit Periodic orthodontic treatment visit (as part of contract) Orthodontic retention (removal of appliances, construction and placement of retainer(s)) Orthodontic treatment (alternative billing to a contract fee, services provided by dentists other than original treating dentist) Repair of orthodontic appliance. Replace lost or broken retainer. Re-bonding or re-cementing of fixed retainers Repair of fixed retainers, includes reattachment Unspecified orthodontic procedure, by report Coverage Category 21 yrs & older) Additional Documentation Required for Prior Authorization (21 yrs and +) N N N N N N N N N N N N N N Adjunctive General Services D9110 D9120 Palliative (emergency) treatment of dental pain - minor procedure ** May not be billed with D0140 on same date of service. Claim must be accompanied by narrative describing treatment provided. Fixed Partial Denture Sectioning C N C N Anesthesia D9210 D9211 D9212 D9215 D9220 D9221 D9230 D9241 D9242 D9248 Local anesthesia not in conjunction with operative or surgical procedures Regional block anesthesia Trigeminal division block anesthesia Local anesthesia Deep sedation/general anesthesia - first 30 minutes **May not be billed with behavior management, D9920, D9248 or D9230 Deep sedation/general anesthesia - each additional 15 minutes Analgesia Intravenous conscious sedation/analgesia – first 30 minutes **May not be billed with behavior management, D9920, D9248 or D9230. Intravenous conscious sedation/analgesia – each additional 15 minutes Non-intravenous conscious sedation C-PA N N N C-PA Include Narrative Include Narrative N N N N C-PA Include Narrative C-PA C-PA >10 years of age C for 10 years and younger C-PA Include Narrative Include Narrative C-PA C-PA Include Narrative Include Narrative Include Narrative C-PA Include Narrative C-PA C Include Narrative C-PA C-PA Include Narrative Include Narrative Professional Consultation C- Covered Service N-Non-covered Service C-PA - Covered only with prior authorization Page 16 of 18 PT - covered only with PreTransplant auth CDT 2014 Procedure Code Coverage Category 21 yrs & older) C-PA Additional Documentation Required for Prior Authorization (0-20 yrs) Include Narrative N/PT Additional Documentation Required for Prior Authorization (21 yrs and +) Include Narrative Coverage Category (0 -20 yrs) Procedure Description D9310 Consultation (diagnostic service provided by dentist or physician other than requesting dentist or physician D9410 House/Extended care facility call C-PA Include Narrative C-PA Include Narrative D9420 Hospital call C-PA Include Narrative C-PA Include Narrative D9430 Office visit for observation (during regularly scheduled hours), no other services performed Office visit - after regularly scheduled hours ** Narrative required with claims submission Case presentation, detailed and extensive treatment planning Therapeutic parenteral drug, single administration Therapeutic parenteral drugs, two or more administrations, different medications **Therapeutic parenteral drug codes should not be used to report administration of sedatives, anesthetic or reversal agents Other drugs Application of desensitizing medicament Application of desensitizing resin for cervical and/or root surface, per tooth Behavior management Not a covered benefit Professional Visits D9440 D9450 D9610 D9612 D9630 D9910 D9911 D9920 D9930 C N C N N C-PA C-PA N N/PT N N N N N N N N N C N/PT D9940 Treatment of complications (post surgical) ** Narrative required with claims submission Occlusal guard, includes adjustments for 24 months D9941 D9942 Fabrication of athletic mouth guard Repair and/or reline of occlusal guard D9950 D9951 Occlusion analysis – mounted case Occlusal adjustment – limited N C-PA Occlusal adjustment – complete Enamel microabrasion Odontoplasty and bleaching procedures Sales tax Unspecified adjunctive procedure, by report N N N N C-PA D9952 D9970 D9971 -D9975 D9985 D9999 Include Narrative Include Narrative C-PA N N Include Narrative, X-ray Include Narrative, X-ray Include Narrative Include Narrative, X-ray Include Narrative Include Narrative N N N N N/PT Include Narrative, X-ray N N N N N PRIOR AUTHORIZATIONS All Prior authorization requests should be mailed to: 4350 E. Cotton Center Blvd. Phoenix, AZ 85040 or C- Covered Service N-Non-covered Service Bldg. D C-PA - Covered only with prior authorization Page 17 of 18 PT - covered only with PreTransplant auth e-mail: [email protected] Fax: 602-431-7155 CLAIMS Mercy Care is now able to accept electronic claim submissions for dental claims through Emdeon. Most dental claims will not require x-rays with submission. However, if your claim requires additional attachments and you need to submit x-rays, chart notes, etc., the claim must be mailed to Mercy Care Plan. These claims cannot be submitted electronically to us. Please mail these claims to: Mercy Care Plan Dental Claims Department P. O. Box 61235 Phoenix, Az. 85082-1235 If you are interested in submitting your claims electronically, please contact your Provider Relations Representative for further information. C- Covered Service N-Non-covered Service C-PA - Covered only with prior authorization Page 18 of 18 PT - covered only with PreTransplant auth
Related documents