Download Summary of Benefits

Delta Dental® Individual
DeltaCare USA
Pediatric Basic Plan
Dental plan administered and
underwritten by Delta Dental
Insurance Company
Available together with select
medical plans offered through
Health First Health Plans & Insurance
Delta Dental Individual
Pediatric Basic Plan
W
ith DeltaCare USA, there
are no claim forms to submit.
Select a
DeltaCare USA
dentist
Receive your
welcome kit
Schedule an
appointment
Receive dental
care
Pay only your
copayment
directly to
dentist
Thank you for considering DeltaCare® USA for your dental
coverage. When it comes to dental benefits, making the
right choice doesn’t have to be complicated. DeltaCare
USA plans are easy to use, and offer a great combination
of affordability and dentist choice. Learn how DeltaCare
USA plans work, and how to keep you healthy.
About DeltaCare USA
When new enrollees initially subscribe, they receive a list of dental
procedures that show their share of the cost for covered services when
provided by their selected DeltaCare USA network dentist. This share of
the costs is called a copayment. When enrollees visit their DeltaCare USA
dentist, they are only responsible for the copayment for each procedure
at the time of treatment; but they must visit their selected DeltaCare USA
dentist in order to receive benefits.
In addition to knowing procedure costs up front, DeltaCare USA plans
also provide other advantages. The plans do not require enrollees to
satisfy a deductible, so they can start saving on out-of-pocket costs
immediately. And with no annual maximum limitations, enrollees can
use their DeltaCare USA benefits all year long.
Plan features
• DeltaCare USA plans include a copayment schedule when you
enroll, so they’ll know their share of the cost for covered services
before visiting the dentist.
• DeltaCare USA plans include no deductibles and no annual benefit
maximums for covered services.
Underwritten by
Delta Dental Insurance Company
P.O. Box 1803
Alpharetta, GA 30023
Administered by
Delta Dental Insurance Company
P.O. Box 1803
Alpharetta, GA 30023
Customer Service
800-471-8148
deltadentalins.com
• Low
copayments or no copayments for many services such as
cleanings and exams help keep smiles healthy by encouraging
regular checkups and cleanings.
• No claim forms to fill out – patients just pay their DeltaCare USA
dentist the copayment amount at the time of service.
• Easy-to-use DeltaCare USA dental plans provide a great balance of
network dentist choice and affordability.
Delta Dental Insurance Company provides benefits as a Prepaid
Limited Health Services Organization as described in Chapter 636
of the Florida Statutes.
HLT-DCU-O-I-FL-C70
Dentists you can trust
• A network of private practice dental facilities that have been carefully screened for
quality care and best practices
• A large choice of dentists and low network turnover so that patients can enjoy a long-term
relationship with their network dentist
• Easy access to specialty care – DeltaCare USA network dentists will coordinate care if
enrollees require treatment from a specialist for services covered under the plan
DeltaCare USA plans offer many advantages
Select a DeltaCare USA plan for these great features:
• Coverage
that can provide peace of mind. Our plans include no restrictions on pre-existing
conditions (except for work in progress), and out-of-area dental emergency coverage.
• Online services that make getting information quick and easy. Wherever you are - work,
home or on the go - you can access account information and view benefits and eligibility,
find a dentist and print ID cards. And our online tools are a snap to use on a smart phone, so
we’re there when you need us.
• T he SmileWay® Wellness Program provides resources such as dental health information,
newsletters, risk quizzes and MySmileKids to help keep smiles healthy.
• It’s easy to change DeltaCare USA dentists. Enrollees may change their selected network
dentist at deltadentalins.com or by notifying us by phone or in writing. Requests made by the
21st of the month will become effective the first of the following month.
This benefit information is only a summary and not intended or designed
to replace or serve as a plan Contract or Policy. Please consult the
Evidence of Coverage or Plan Policy for a complete description of plan
benefits, limitations and exclusions. In the event of any inconsistency
between this document and the Evidence of Coverage or Plan Policy, the
terms of the Evidence of Coverage or Plan Policy will prevail.
Read your Policy carefully. This brochure provides a brief description of
the important features of your Policy. This is not the insurance Policy and
only the Policy provisions will control. The Policy itself sets forth in detail
the rights and obligations of both you and your insurance company. It is
therefore important that you read your policy carefully.
If you are not satisfied with the Policy for any reason, you may return the
Policy within 10 days after you receive it. Mail or deliver it to Delta Dental
Insurance Company. Any premium paid will be refunded. The Policy will
then be void from its start.
deltadentalins.com
E INDIVIDUAL #74655 (9/13)
Delta Dental Individual
DeltaCare® USA
Pediatric Basic Plan
Plan Highlights
DeltaCare USA provides great dental benefits and predictable costs. The plan provides a full list
of copayments1 so the cost for covered services is never a surprise. Copayments for some of
the most common services are listed below.
Sample of Covered Services2
Category
Procedure Code and Description3
Copayment Amount1
Pediatric Enrollees
(up to age 19)
Diagnostic &
Preventive
Services (D & P)
Basic Services
D0999 - Office visit
No cost
D0120 - Periodic oral exam – established patient
No cost
D0150 - Comprehensive oral evaluation – new or established
patient
No cost
D0210 - Complete series of x-rays
No cost
D0220 - Periapical x-ray of tooth's root
No cost
D0230 - Periapical x-ray of tooth’s root, each additional image
No cost
D0272 - Bitewing x-rays (2 images)
No cost
D0274 - Bitewing x-rays (4 images)
No cost
D0330 - Panoramic x-ray
No cost
D1110 - Prophylaxis (cleaning) – adult
No cost
D1120 - Prophylaxis (cleaning) – child
No cost
D1208 - Fluoride treatment
No cost
D1351 - Sealant – per tooth
No cost
D2140 - Amalgam (silver-colored) filling – 1 surface
No cost
D2150 - Amalgam (silver-colored) filling – 2 surfaces
No cost
D2160 - Amalgam (silver-colored) filling – 3 surfaces
No cost
D2330 - Resin (tooth-colored) filling, front tooth, 1 surface
No cost
D2331 - Resin (tooth-colored) filling, front tooth, 2 surfaces
No cost
D2332 - Resin (tooth-colored) filling, front tooth, 3 surfaces
No cost
D2391 - Resin (tooth-colored) filling, back tooth, 1 surface
No cost
D2392 - Resin (tooth-colored) filling, back tooth, 2 surfaces
No cost
D2393 - Resin (tooth-colored) filling, back tooth, 3 surfaces
No cost
Category
Procedure Code and Description3
Copayment Amount1
Pediatric Enrollees
(up to age 19)
Endodontics
Periodontics
Oral Surgery
Major Services
Orthodontics
D3310 - Root canal, front tooth
No cost
D3320 - Root canal, bicuspid tooth
No cost
D3330 - Root canal, molar tooth
No cost
D4260 - Periodontal surgery, per quadrant
D4341 - Periodontal scaling and root planing – four or more teeth
per quadrant
D4910 - Periodontal maintenance
No cost
D7140 - Extraction (removal) of a fully exposed tooth
D7210 - Surgical extraction or erupted (exposed) tooth
D7240 - Extraction (removal) of fully impacted tooth, completely
bony
No cost
D2750 - Crown, porcelain and precious metal
No cost
D2790 - Crown, precious metal
No cost
D5110 – Full upper denture
No cost
D6240 - Bridge pontic, porcelain and precious metal
No cost
D6750 - Bridge crown, porcelain and precious metal
No cost
D8080 - Pediatric services – Medically necessary only
No cost
No cost
No cost
No cost
No cost
1
A copayment is the amount the enrollee pays for covered services at the time of treatment.
2
Benefits featured above represent the most frequently used services covered under your plan; other services
are also covered. After enrollment, the DeltaCare USA plan will make available a complete list of covered
services and copayments, along with any limitations and exclusions that apply.
3
Copayments and procedure descriptions referenced above are intended to clarify the delivery of benefits under
the DeltaCare USA plan and are not to be interpreted as CDT-2014 descriptors or nomenclature, which are
under copyright by the American Dental Association. The American Dental Association may periodically
change CDT codes or definitions. Such updated codes, descriptors and nomenclature may be used to
describe these covered procedures in compliance with federal legislation.
HL_DCU_FL_O_I_PED_BSC_HEALTH_FIRST
Description of Benefits and Copayments
Delta Dental Individual
DeltaCare® USA
The Benefits shown below are performed as needed and deemed appropriate by the attending Contract Dentist
subject to the limitations and exclusions of the plan. Please refer to Schedule B for further clarification of
Benefits. Enrollees should discuss all treatment options with their Contract Dentist prior to services being
rendered.
Text that appears in italics below is specifically intended to clarify the delivery of Benefits under the
DeltaCare® USA plan and is not to be interpreted as CDT-2014 procedure codes, descriptors or nomenclature
which is under copyright by the American Dental Association. The American Dental Association may
periodically change CDT codes or definitions. Such updated codes, descriptors and nomenclature may be
used to describe these covered procedures in compliance with federal legislation.
OOPM applies only to Essential Health Benefits (EHB) for Pediatric Enrollee(s). OOPM means the maximum
amount of money that a Pediatric Enrollee must pay for covered dental services. Payment for Premiums and
payment for services that are Optional, that are upgraded treatment (such as precious or semi-precious metals and
material upgrades) or that are not covered under the Policy will not count toward the OOPM. Payment for such
services will continue to apply even after the OOPM is met. Delta Dental recommends that the Pediatric Enrollee or
other party responsible keep a record of payment for Benefits. Please refer to the medical portion of your benefits booklet
for more information on the OOPM.
Code
Description
D0100–D0999 I. DIAGNOSTIC
D0999 Unspecified diagnostic procedure, by
report
D0120 Periodic oral evaluation - established
patient (14)
D0140 Limited oral evaluation - problem focused
Pediatric
Enrollee
Pays
No cost
No cost
No cost
Clarifications/Limitations
Includes office visit, per visit (in addition to
other services)
Limited to 2 of (D0120, D0150, D0180) per
12 month period
Limited to 1 of per dentist per 12 month
period
D0145
Oral evaluation for a patient under three
years of age and counseling with primary
caregiver
No cost
D0150
Comprehensive oral evaluation - new or
established patient
No cost
D0160
Detailed and extensive oral evaluation problem focused, by report
Comprehensive periodontal evaluation new or established patient
No cost
No cost
Limited to 2 of (D0120, D0150, D0180) per
12 month period; limited to 1 of (D0180) per
12 month period
No cost
Limited to 1 series every 36 months
D0240
Intraoral - complete series of
radiographic images
Intraoral - periapical first radiographic
image
Intraoral - periapical each additional
radiographic image
Intraoral - occlusal radiographic image
D0250
Extraoral - first radiographic image
No cost
D0260
Extraoral - each additional radiographic
image
No cost
D0180
D0210
D0220
D0230
Limited to 2 of (D0120, D0150, D0180) per
12 month period; limited to 1 of (D0150) per
12 month period
No cost
No cost
No cost
V14
Code
Description
D0270
Bitewing - single radiographic image
Pediatric
Enrollee
Pays
No cost
D0272
Bitewings - two radiographic images
No cost
D0273
Bitewings - three radiographic images
No cost
D0274
Bitewings - four radiographic images
No cost
D0277
No cost
D0330
Vertical bitewings - 7 to 8 radiographic
images
Panoramic radiographic image
D0425
Caries susceptibility tests
No cost
D0460
Pulp vitality tests
No cost
D0470
Diagnostic casts
No cost
D0601
Caries risk assessment and
documentation, with a finding of low risk
No cost
Limited to age 3 to 18; limited to 1 per 36
month period when performed the same
Contract Dentist or office.
D0602
Caries risk assessment and
documentation, with a finding of
moderate risk
No cost
Limited to age 3 to 18; limited to 1 per 36
month period when performed the same
Contract Dentist or office.
D0603
Caries risk assessment and
documentation, with a finding of high risk
No cost
Limited to age 3 to 18; limited to 1 per 36
month period when performed the same
Contract Dentist or office.
D1000-D1999 II. PREVENTIVE
D1110 Prophylaxis - adult
No cost
Cleaning; limited to 2 of (D1110, D1120) per
12 month period
D1120
Prophylaxis - child
No cost
D1206
D1208
D1351
Topical application of fluoride varnish
Topical application of fluoride
Sealant - per tooth
No cost
No cost
No cost
Cleaning; limited to 2 of (D1110, D1120) per
12 month period
Limited to 2 per 12 month period
Limited to 2 per 12 month period
Limited to permanent molars without
restorations or decay; limited to 1 of (D1351,
D1352) per tooth every 36 months
D1352
Preventive resin restoration in a
moderate to high caries risk patient –
permanent tooth
No cost
D1510
D1515
Space maintainer - fixed - unilateral
Space maintainer - fixed - bilateral
D1520
D1525
D1550
Space maintainer - removable - unilateral
Space maintainer - removable - bilateral
Re-cementation of space maintainer
No cost
Clarifications/Limitations
Limited to 1 series every 6 months
Limited to 1 every 36 months
Limited to permanent molars without
restorations or decay; limited to 1 of (D1351,
D1352) per tooth every 36 months
No cost
$ No cost
No cost
No cost
No cost
D2000-D2999 III. RESTORATIVE
- Includes polishing, all adhesives and bonding agents, indirect pulp capping, bases, liners and acid etch
procedures.
- Replacement of crowns, inlays and onlays requires the existing restoration to be 60+ months old.
D2140
Amalgam - one surface, primary or
permanent
No cost
D2150
Amalgam - two surfaces, primary or
permanent
No cost
D2160
Amalgam - three surfaces, primary or
permanent
No cost
V14
Code
Description
D2161
Amalgam - four or more surfaces,
primary or permanent
D2330
Resin-based composite - one surface,
anterior
No cost
D2331
Resin-based composite - two surfaces,
anterior
No cost
D2332
Resin-based composite - three surfaces,
anterior
No cost
D2335
Resin-based composite - four or more
surfaces or involving incisal angle
(anterior)
No cost
D2391
Resin-based composite - one surface,
posterior
No cost
D2392
Resin-based composite - two surfaces,
posterior
No cost
D2393
Resin-based composite - three surfaces,
posterior
No cost
D2394
Resin-based composite - four or more
surfaces, posterior
No cost
D2510
D2520
Inlay - metallic - one surface
Inlay - metallic - two surfaces
No cost
No cost
D2530
D2542
D2543
D2544
D2740
D2750
Inlay - metallic - three or more surfaces
Onlay - metallic - two surfaces
Onlay - metallic - three surfaces
Onlay - metallic - four or more surfaces
Crown - porcelain/ceramic substrate
Crown - porcelain fused to high noble
metal
No cost
No cost
No cost
No cost
No cost
No cost
D2751
Crown - porcelain fused to predominantly
base metal
No cost
D2752
D2780
D2781
Crown - porcelain fused to noble metal
Crown - 3/4 cast high noble metal
Crown - 3/4 cast predominantly base
metal
No cost
No cost
No cost
D2782
D2783
Crown - 3/4 cast noble metal
Crown - 3/4 porcelain/ceramic
No cost
No cost
D2790
D2791
Crown - full cast high noble metal
Crown - full cast predominantly base
metal
Crown - full cast noble metal
Crown - titanium
Recement inlay, onlay, or partial
coverage restoration
No cost
No cost
D2920
D2930
Recement crown
Prefabricated stainless steel crown primary tooth
No cost
No cost
D2931
Prefabricated stainless steel crown permanent tooth
No cost
D2792
D2794
D2910
Pediatric
Enrollee
Pays
No cost
Clarifications/Limitations
No cost
No cost
No cost
Limited to one per Enrollee, per tooth, per
lifetime through age 14
Limited to one per Enrollee, per tooth, per
lifetime through age 14
V14
Code
Description
Pediatric
Enrollee
Pays
No cost
D2950
Core buildup, including any pins when
required
D2951
Pin retention - per tooth, in addition to
restoration
No cost
D2954
Prefabricated post and core in addition to
crown
No cost
D2980
Crown repair necessitated by restorative
material failure
No cost
D2981
Inlay repair necessitated by restorative
material failure
No cost
D2982
Onlay repair necessitated by restorative
material failure
No cost
D2983
Veneer repair necessitated by restorative
material failure
No cost
D2990
Resin infiltration of incipient smooth
surface lesions
No cost
Clarifications/Limitations
Includes canal preparation
D3000-D3999 IV. ENDODONTICS
D3110 Pulp cap - direct (excluding final
restoration)
No cost
D3120
Pulp cap - indirect (excluding final
restoration)
No cost
D3220
Therapeutic pulpotomy (excluding final
restoration) - removal of pulp coronal to
the dentinocemental junction and
application of medicament
No cost
D3221
Pulpal debridement, primary and
permanent teeth
No cost
D3222
Partial pulpotomy for apexogenesis permanent tooth with incomplete root
development
No cost
D3230
Pulpal therapy (resorbable filling) anterior, primary tooth (excluding final
restoration)
No cost
D3240
Pulpal therapy (resorbable filling) posterior, primary tooth (excluding final
restoration)
No cost
D3310
Endodontic therapy, anterior tooth
(excluding final restoration)
No cost
Root canal
D3320
Endodontic therapy, bicuspid tooth
(excluding final restoration)
No cost
Root canal
D3330
Endodontic therapy, molar (excluding
final restoration)
No cost
Root canal
D3331
Treatment of root canal obstruction; nonsurgical access
No cost
D3332
Incomplete endodontic therapy;
inoperable, unrestorable or fractured
tooth
Retreatment of previous root canal
therapy - anterior
No cost
D3346
No cost
V14
Code
Description
D3347
Retreatment of previous root canal
therapy - bicuspid
D3348
Retreatment of previous root canal
therapy - molar
No cost
D3351
Apexification/recalcification – initial visit
(apical closure/calcific repair of
perforations, root resorption, pulp space
disinfection, etc.)
No cost
D3352
Apexification/recalcification - interim
medication replacement (apical
closure/calcific repair of perforations, root
resorption, pulp space disinfection, etc.)
No cost
D3353
Apexification/recalcification - final visit
(includes completed root canal therapy apical closure/calcific repair of
perforations, root resorption, etc.)
No cost
D3355
D3356
Pulpal regeneration - initial visit
Pulpal regeneration - interim medication
replacement
No cost
No cost
D3357
Pulpal regeneration - completion of
treatment
No cost
D3410
D3421
D3425
Apicoectomy - anterior
Apicoectomy - bicuspid (first root)
Apicoectomy - molar (first root)
No cost
No cost
No cost
D3426
D3427
Apicoectomy (each additional root)
Periradicular surgery without
apicoectomy
Retrograde filling - per root
Root amputation - per root
Hemisection (including any root removal),
not including root canal therapy
No cost
No cost
D3430
D3450
D3920
Pediatric
Enrollee
Pays
No cost
Clarifications/Limitations
No cost
No cost
No cost
D4000-D4999 V. PERIODONTICS
- Includes preoperative and postoperative evaluations and treatment under a local anesthetic.
D4210
Gingivectomy or gingivoplasty - four or
more contiguous teeth or tooth bounded
spaces per quadrant
No cost
D4211
Gingivectomy or gingivoplasty - one to
three contiguous teeth or tooth bounded
spaces per quadrant
No cost
D4212
Gingivectomy or gingivoplasty to allow
access for restorative procedure, per
tooth
No cost
D4240
Gingival flap procedure, including root
planing - four or more contiguous teeth or
tooth bounded spaces per quadrant
No cost
D4241
Gingival flap procedure, including root
planing - one to three contiguous teeth or
tooth bounded spaces per quadrant
No cost
D4249
Clinical crown lengthening - hard tissue
No cost
V14
Code
Description
Pediatric
Enrollee
Pays
No cost
Clarifications/Limitations
D4260
Osseous surgery (including flap entry
and closure) - four or more contiguous
teeth or tooth bounded spaces per
quadrant
D4261
Osseous surgery (including flap entry
and closure) - one to three contiguous
teeth or tooth bounded spaces per
quadrant
No cost
D4268
D4270
D4273
Surgical revision procedure, per tooth
Pedicle soft tissue graft procedure
Subepithelial connective tissue graft
procedures, per tooth
No cost
No cost
No cost
D4275
D4276
Soft tissue allograft
Combined connective tissue and double
pedicle graft, per tooth
No cost
No cost
D4277
Free soft tissue graft procedure
(including donor site surgery), first tooth
or edentulous tooth position in graft
No cost
D4278
Free soft tissue graft procedure
(including donor site surgery), each
additional contiguous tooth or edentulous
tooth position in same graft site
No cost
D4341
Periodontal scaling and root planing four or more teeth per quadrant
No cost
Limited to 4 quadrants during any 24
consecutive months
D4342
Periodontal scaling and root planing one to three teeth per quadrant
No cost
Limited to 4 quadrants during any 24
consecutive months
D4355
Full mouth debridement to enable
comprehensive evaluation and diagnosis
No cost
Limited to 1 of per Enrollee per lifetime
D4381
Localized delivery of antimicrobial agents
via controlled release vehicle into
diseased crevicular tissue, per tooth
No cost
For each of the first two teeth treated within a
quadrant following root planing or periodontal
maintenance
D4381
Localized delivery of antimicrobial agents
via controlled release vehicle into
diseased crevicular tissue, per tooth
No cost
For an additional tooth treated in the same
quadrant following root planing or periodontal
maintenance
D4910
Periodontal maintenance
No cost
Limited to 4 treatments each 12 month
period
D5000-D5899 VI. PROSTHODONTICS (removable)
- For all listed dentures and partial dentures, Copayment includes after delivery adjustments and tissue
conditioning, if needed, for the first six months after placement. The Enrollee must continue to be eligible, and the
service must be provided at the Contract Dentist or office where the denture was originally delivered.
- Replacement of a denture or a partial denture requires the existing denture to be 60+ months old.
D5110
D5120
D5130
D5140
D5211
Complete denture - maxillary
Complete denture - mandibular
Immediate denture - maxillary
Immediate denture - mandibular
Maxillary partial denture - resin base
(including any conventional clasps, rests
and teeth)
No cost
No cost
No cost
No cost
No cost
V14
Code
Description
D5212
Mandibular partial denture - resin base
(including any conventional clasps, rests
and teeth)
D5213
Maxillary partial denture - cast metal
framework with resin denture bases
(including any conventional clasps, rests
and teeth)
No cost
D5214
Mandibular partial denture - cast metal
framework with resin denture bases
(including any conventional clasps, rests
and teeth)
No cost
D5281
Removable unilateral partial denture one piece cast metal (including clasps
and teeth)
No cost
D5410
Adjust complete denture - maxillary
No cost
D5411
D5421
D5422
D5510
D5520
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)
No cost
No cost
No cost
No cost
No cost
D5610
Repair resin denture base
No cost
D5620
D5630
D5640
D5650
D5660
D5670
Repair cast framework
Repair or replace broken clasp
Replace broken teeth - per tooth
Add tooth to existing partial denture
Add clasp to existing partial denture
Replace all teeth and acrylic on cast
metal framework (maxillary)
No cost
No cost
No cost
No cost
No cost
No cost
D5671
Replace all teeth and acrylic on cast
metal framework (mandibular)
No cost
D5710
D5711
D5720
D5721
D5730
Rebase complete maxillary denture
Rebase complete mandibular denture
Rebase maxillary partial denture
Rebase mandibular partial denture
Reline complete maxillary denture
(chairside)
No cost
No cost
No cost
No cost
No cost
D5731
Reline complete mandibular denture
(chairside)
No cost
D5740
Reline maxillary partial denture
(chairside)
Reline mandibular partial denture
(chairside)
No cost
D5750
Reline complete maxillary denture
(laboratory)
No cost
D5751
Reline complete mandibular denture
(laboratory)
No cost
D5741
Pediatric
Enrollee
Pays
No cost
Clarifications/Limitations
No cost
V14
Code
Description
Pediatric
Enrollee
Pays
No cost
D5760
Reline maxillary partial denture
(laboratory)
D5761
Reline mandibular partial denture
(laboratory)
No cost
D5850
D5851
Tissue conditioning, maxillary
Tissue conditioning, mandibular
No cost
No cost
Clarifications/Limitations
D5900-D5999 VII. MAXILLOFACIAL PROSTHETICS - Not Covered
D6000-D6199 VIII. IMPLANT SERVICES
- Includes adjustments, if needed, for the first six months after placement, if the Enrollee continues to be eligible
and the service is provided at the Contract Dentist’s facility where the implant was originally delivered.
- Replacement of a retainer, pontic, or stress breaker requires the existing bridge to be 60+ months old.
- FPD, as referenced below, stands for fixed partial denture.
D6010
Surgical placement of implant body:
endosteal implant
No cost
D6053
Implant/abutment supported removable
denture for completely edentulous arch
No cost
D6054
Implant/abutment supported removable
denture for partially edentulous arch
No cost
D6055
Connecting bar – implant supported or
abutment supported
No cost
D6056
Prefabricated abutment – includes
modification and placement
No cost
D6057
Custom fabricated abutment – includes
placement
No cost
D6058
Abutment supported porcelain/ceramic
crown
No cost
D6059
Abutment supported porcelain fused to
metal crown (high noble metal)
No cost
D6060
Abutment supported porcelain fused to
metal crown (predominantly base metal)
No cost
D6061
Abutment supported porcelain fused to
metal crown (noble metal)
No cost
D6062
Abutment supported cast metal crown
(high noble metal)
No cost
D6063
Abutment supported cast metal crown
(predominantly base metal)
No cost
D6064
Abutment supported cast metal crown
(noble metal)
No cost
D6065
Implant supported porcelain/ceramic
crown
No cost
D6066
Implant supported porcelain fused to
metal crown (titanium, titanium alloy, high
noble metal)
No cost
D6067
Implant supported metal crown (titanium,
titanium alloy, high noble metal)
No cost
D6068
Abutment supported retainer for
porcelain/ceramic FPD
No cost
D6069
Abutment supported retainer for
porcelain fused to metal FPD (high noble
No cost
V14
Code
Description
Pediatric
Enrollee
Pays
Clarifications/Limitations
metal)
D6070
Abutment supported retainer for
porcelain fused to metal FPD
(predominantly base metal)
No cost
D6071
Abutment supported retainer for
porcelain fused to metal FPD (noble
metal)
Abutment supported retainer for cast
metal FPD (high noble metal)
No cost
D6073
Abutment supported retainer for cast
metal FPD (predominantly base metal)
No cost
D6074
Abutment supported retainer for cast
metal FPD (noble metal)
No cost
D6075
Implant supported retainer for ceramic
FPD
No cost
D6076
Implant supported retainer for porcelain
fused to metal FPD (titanium, titanium
alloy, or high noble metal)
No cost
D6077
Implant supported retainer for cast metal
FPD (titanium, titanium alloy, or high
noble metal)
No cost
D6078
Implant/abutment supported fixed
denture for completely edentulous arch
No cost
D6079
Implant/abutment supported fixed
denture for partially edentulous arch
No cost
D6080
Implant maintenance procedures when
prostheses are removed and reinserted,
including cleansing of prostheses and
abutments
No cost
D6090
Repair implant supported prosthesis, by
report
No cost
D6091
Replacement of semi-precision or
precision attachment (male or female
component) of implant/abutment
supported prosthesis, per attachment
No cost
D6094
D6095
D6100
D6194
Abutment supported crown - (titanium)
Repair implant abutment, by report
Implant removal, by report
Abutment supported retainer crown for
FPD (titanium)
No cost
No cost
No cost
No cost
D6072
No cost
D6200-D6999 IX. PROSTHODONTICS, fixed
- Each retainer and each pontic constitutes a unit in a fixed partial denture (bridge).
- Replacement of a crown, pontic, inlay, onlay or stress breaker requires the existing bridge to be 60+ months old.
D6210
D6211
D6212
D6214
Pontic - cast high noble metal
Pontic - cast predominantly base metal
Pontic - cast noble metal
Pontic - titanium
No cost
No cost
No cost
No cost
V14
Code
Description
D6240
Pontic - porcelain fused to high noble
metal
D6241
Pontic - porcelain fused to predominantly
base metal
No cost
D6242
D6245
D6545
Pontic - porcelain fused to noble metal
Pontic - porcelain/ceramic
Retainer - cast metal for resin bonded
fixed prosthesis
No cost
No cost
No cost
D6548
Retainer - porcelain/ceramic for resin
bonded fixed prosthesis
No cost
D6601
Inlay - porcelain/ceramic, three or more
surfaces
No cost
D6604
Inlay - cast predominantly base metal,
two surfaces
No cost
D6605
Inlay - cast predominantly base metal,
three or more surfaces
No cost
D6613
Onlay - cast predominantly base metal,
three or more surfaces
No cost
D6740
Crown - porcelain/ceramic
No cost
D6750
Crown - porcelain fused to high noble
metal
No cost
D6751
Crown - porcelain fused to predominantly
base metal
No cost
D6752
D6780
D6781
Crown - porcelain fused to noble metal
Crown - 3/4 cast high noble metal
Crown - 3/4 cast predominantly base
metal
No cost
No cost
No cost
D6782
Crown - 3/4 cast noble metal
No cost
D6783
D6790
D6791
Crown - 3/4 porcelain/ceramic
Crown - full cast high noble metal
Crown - full cast predominantly base
metal
Crown - full cast noble metal
Crown - titanium
Recement fixed partial denture
Fixed partial denture repair necessitated
by restorative material failure
No cost
No cost
No cost
D6792
D6794
D6930
D6980
Pediatric
Enrollee
Pays
No cost
Clarifications/Limitations
No cost
No cost
No cost
No cost
D7000-D7999 X. ORAL AND MAXILLOFACIAL SURGERY
- Includes preoperative and postoperative evaluations and treatment under a local anesthetic.
D7111
Extraction, coronal remnants - deciduous
tooth
No cost
D7140
Extraction, erupted tooth or exposed root
(elevation and/or forceps removal)
No cost
D7210
Surgical removal of erupted tooth
requiring removal of bone and/or
sectioning of tooth, and including
elevation of mucoperiosteal flap if
indicated
Removal of impacted tooth - soft tissue
No cost
D7220
No cost
V14
Code
Description
D7230
Removal of impacted tooth - partially
bony
Removal of impacted tooth - completely
bony
D7240
Pediatric
Enrollee
Pays
No cost
Clarifications/Limitations
No cost
D7241
Removal of impacted tooth - completely
bony, with unusual surgical complications
No cost
D7250
Surgical removal of residual tooth roots
(cutting procedure)
No cost
D7251
Coronectomy – intentional partial tooth
removal
No cost
D7270
Tooth reimplantation and/or stabilization
of accidentally evulsed or displaced tooth
No cost
D7280
Surgical access of an unerupted tooth
No cost
D7310
Alveoloplasty in conjunction with
extractions - four or more teeth or tooth
spaces, per quadrant
No cost
D7311
Alveoloplasty in conjunction with
extractions - one to three teeth or tooth
spaces, per quadrant
No cost
D7320
Alveoloplasty not in conjunction with
extractions - four or more teeth or tooth
spaces, per quadrant
No cost
D7321
Alveoloplasty not in conjunction with
extractions - one to three teeth or tooth
spaces, per quadrant
No cost
D7471
Removal of lateral exostosis (maxilla or
mandible)
No cost
D7510
Incision and drainage of abscess intraoral soft tissue
No cost
D7910
D7921
Suture of recent small wounds up to 5 cm
Collection and application of autologous
blood concentrate product
No cost
No cost
D7971
Excision of pericoronal gingiva
No cost
V14
Code
Description
Pediatric
Clarification/Limitations
Enrollee
Pays
D8000-D8999 XI. ORTHODONTICS - Medically Necessary for Pediatric Enrollees ONLY
- Orthodontic Services must meet medical necessity as determined by a dentist. Orthodontic treatment is a benefit
only when medically necessary as evidenced by a severe handicapping malocclusion and when a prior
authorization is obtained. Severe handicapping malocclusion is not a cosmetic condition. Teeth must be severely
misaligned causing functional problems that compromise oral and/or general health.
- Medically necessary Orthodontic Services are limited to Pediatric Enrollees who have been enrolled in the Policy
for 24 consecutive months. Benefits are not provided for orthodontic treatment including all services related to
orthodontic treatment (such as diagnostic and pre-treatment records) until the 24 month Waiting Period is satisfied.
Prior coverage for Pediatric Enrollees under a Delta Dental exchange certified pediatric essential dental plan will be
credited towards the Pediatric Waiting Period under this dental plan. In order for prior coverage to be credited, such
prior coverage must occur immediately preceding the election of this plan.
- Pediatric Enrollee must continue to be eligible, benefits for medically necessary orthodontics will be provided in
periodic payments to the Contract Dentist.
- Comprehensive orthodontic treatment procedures (D8080, D8090) include all appliances, adjustments, insertion,
removal and post treatment stabilization (retention). No additional charge to the Enrollee is permitted except for
services provided by an orthodontist other than the original treating dentist or dental office.
- Refer to Schedule B for Limitations and Exclusions for Medically Necessary Orthodontics for additional
information.
D8080 Comprehensive orthodontic treatment of
No cost
the adolescent dentition
D8090 Comprehensive orthodontic treatment of
No cost
the adult dentition
D8660 Pre-orthodontic treatment visit
No cost
Included in comprehensive case fee; a
D8670 Periodic orthodontic treatment visit (as
No cost
separate fee applies for services provided by
part of contract)
an orthodontist other than the original
treating orthodontist or dental office
Included in comprehensive case fee; a
D8680 Orthodontic retention (removal of
No cost
separate fee applies for services provided by
appliances, construction and placement
an orthodontist other than the original
of retainer(s))
treating orthodontist or dental office who was
paid for banding
Included in comprehensive case fee; a
D8693 Rebonding or recementing of fixed
No cost
separate fee applies for services provided by
retainers
an orthodontist other than the original
treating orthodontist or dental office
D8694
Repair of fixed retainers, includes
reattachment
No cost
D9000-D9999 XII. ADJUNCTIVE GENERAL SERVICES
D9110 Palliative (emergency) treatment of
No cost
dental pain - minor procedure
D9220 Deep sedation/general anesthesia - first
No cost
30 minutes
Included in comprehensive case fee; a
separate fee applies for services provided by
an orthodontist other than the original
treating orthodontist or dental office
Covered only when given by a Contract
Dentist for covered oral surgery
D9221
Deep sedation/general anesthesia - each
additional 15 minutes
No cost
Covered only when given by a Contract
Dentist for covered oral surgery
D9241
Intravenous conscious
sedation/analgesia - first 30 minutes
No cost
Covered only when given by a Contract
Dentist for covered oral surgery
D9242
Intravenous conscious
sedation/analgesia - each additional 15
minutes
No cost
Covered only when given by a Contract
Dentist for covered oral surgery; limited to 3
per day
V14
Code
Description
D9310
Consultation - diagnostic service
provided by dentist or physician other
than requesting dentist or physician
Office visit - after regularly scheduled
hours
D9440
Pediatric
Enrollee
Pays
No cost
Clarification/Limitations
No cost
D9610
Therapeutic parenteral drug, single
administration
No cost
D9612
No cost
D9940
Therapeutic parenteral drugs, two or
more administrations, different
medications
Treatment of complications (postsurgical) - unusual circumstances, by
report
Occlusal guard, by report
No cost
Age 13 and up; limited to 1 per 12 month
period
D9941
D9974
Fabrication of athletic mouthguard
Internal bleaching - per tooth
No cost
No cost
Limited to 1 per 12 month period
Limited to 1 per tooth per 36 month period
D9999
Unspecified adjunctive procedure, by
report
No cost
Includes failed appointment without 24 hour
notice
D9930
No cost
Endnotes:
Base metal is the benefit. If noble or high noble metal (precious) is used for a crown, bridge, indirectly fabricated post
and core, inlay or onlay, the Enrollee will be charged the additional laboratory cost of the noble or high noble metal. If
covered, an additional laboratory charge also applies to a titanium crown.
Porcelain/ceramic crown, pontic and fixed bridge retainer on molars is considered a material upgrade with a maximum
additional charge to the Enrollee of $150 per unit.
For a covered porcelain-fused-to-metal crown, a porcelain margin is considered a material upgrade with a maximum
additional charge to the Enrollee of $75 per unit.
When there are more than six crowns, retainers and/or pontics in the same treatment plan, an Enrollee may be
charged an additional $125 per unit, beyond the 6th unit.
Name brand, laboratory processed or in-office processed crowns/pontics produced through specialized technique or
materials are material upgrades. The Contract Dentist may charge an additional fee not to exceed $325 in addition to
the listed Copayment. Refer to Schedule B for Limitations and Exclusions for additional information.
If services for a listed procedure are performed by the assigned Contract Dentist, the Enrollee pays the specified
Copayment. Listed procedures which require a Dentist to provide Specialist Services, and are referred by the assigned
Contract Dentist, must be authorized in writing by the plan. The Enrollee pays the Copayment specified for such
services.
Procedures not listed above are not covered, however, may be available at the Contract Dentist’s “filed fees”. “Filed
fees” mean the Contract Dentist’s fees on file with the plan. Questions regarding these fees should be directed to the
Customer Service department at 800-471-9925.
Optional is defined as any alternative procedure presented by the DeltaCare USA dentist that satisfies the same dental
need as a covered procedure, is chosen by the Enrollee and is subject to the limitations and exclusions of the plan.
The applicable charge to the Enrollee is the difference between the DeltaCare USA dentist's usual and customary fee
for the Optional procedure and the usual and customary fee for the covered procedure, plus any applicable Copayment for the covered procedure.
V14
Limitations and Exclusions of Benefits for Pediatric Benefits
Delta Dental Individual
DeltaCare® USA
Limitations and Exclusions of Benefits for Pediatric Enrollees (Under age 19)
Benefits and Limitations for Diagnostic Services:
1. Two oral evaluations (D0120, D0150 and D0180) are covered in a 12 consecutive month period.
2. Only one (1) comprehensive evaluation (D0150, D0180) will be allowed in a 12 consecutive month period.
3. Only one limited oral evaluation, problem-focused (D0140) will be allowed per Enrollee per dentist in a 12
consecutive month period.
4. Detailed and extensive oral evaluations (problem-focused) (D0160) are limited to once per Enrollee per
dentist, per life of the contract.
5. Bitewing x-rays in conjunction with periodic examinations are limited to one (1) series of four (4) films in
any six (6) consecutive month period. Isolated bitewing or periapical films are allowed on an emergency
or episodic basis.
6. Full mouth x-rays in conjunction with periodic examinations are limited to once every thirty-six (36)
consecutive months.
7. Panoramic x-rays are limited to once every thirty-six (36) consecutive months.
Benefits and Limitations for Preventive Services:
1. Two routine prophylaxes (D1110, D1120) are covered in a 12 consecutive month period.
2. Two topical fluoride applications are covered in a 12 consecutive month period.
3. Sealants (D1351, D1352) are covered only on permanent molars. The teeth must be caries free with no
restorations on the mesial, distal or occlusal surfaces. One sealant per tooth is once every thirty-six (36)
consecutive months.
Benefits and Limitations for Restorative Services:
1. Repair or replacement of restorations by the same dentist and involving the same tooth surfaces,
performed within 24 months of the original restoration are included, and a separate fee is not chargeable
to the Enrollee by a Contract Dentist. However, coverage may be allowed if the repair or replacement is
due to fracture of the tooth or the restoration involves the occlusal surface of a posterior tooth or the
lingual surface of an anterior tooth and is placed following root canal therapy.
2. The covered restorations includes all related services including, but not limited to, etching, bases, liners,
dentinal adhesives, local anesthesia, polishing, caries removal, preparation of gingival tissue,
occlusal/contact adjustments, and detection agents.
3. Prefabricated stainless steel crowns (D2930, D2931) are covered only on primary teeth, permanent teeth
through age 14, or when placed as a result of accidental injury. They are limited to one per Enrollee, per
tooth, per lifetime.
4. Name brand, laboratory processed or in-office processed crowns/pontics produced through specialized
technique or materials are material upgrades. Contract Dentists may offer services that utilize brand or
trade names at an additional fee. The Enrollee must be offered the plan benefits of a high quality
laboratory processed crown/pontic that may include: porcelain/ceramic; porcelain with base, noble or
high-noble metal. If the Enrollee chooses the alternative of a material upgrade (name brand laboratory
processed or in-office processed crowns/pontics produced through specialized technique or materials,
including but not limited to: Captek, Procera, Lava, Empress and Cerec) the Contract Dentist may charge
an additional fee not to exceed $325.00 in addition to the listed Copayment. Contact the Customer
Service department at 800-471-9925 if you have questions regarding the additional fee or name brand
services.
5. Onlays, permanent single crown restorations, and posts and cores for Enrollees 12 years of age or
younger are excluded from coverage, unless specific rationale is provided indicating the reason for such
treatment (e.g., fracture, endodontic therapy, etc.) and is approved by the plan.
6. Core buildups (D2950) can be considered for benefits only when there is insufficient retention for a crown.
A buildup should not be reported when the procedure only involves a filler used to eliminate undercuts,
box forms or concave irregularities in the preparation.
7. Replacement of crowns, onlays, buildups, and posts and cores is covered only if the existing crown,
onlay, buildup, or post and core was inserted at least sixty (60) months prior to the replacement and
satisfactory evidence is presented that the existing crown, onlay, buildup, or post and core is not and
cannot be made serviceable. Satisfactory evidence must show that the existing crown, onlay, buildup, or
PIScBhi-FL-dc-15
1
V14
post and core is not and cannot be made serviceable. The sixty (60) month service date is measured
based on the actual date (day and month) of the initial service versus the first day of the initial service
month.
8. Onlays, crowns, and posts and cores are covered only when necessary due to decay or tooth fracture.
However, if the tooth can be adequately restored with amalgam or composite (resin) filling material,
coverage is for that service. Crowns, inlays, onlays, buildups, or posts and cores, begun prior to the
effective date of coverage or cemented after the cancellation date of coverage, are not eligible for
coverage.
9. Recementation of prefabricated and cast crowns, bridges, onlays, inlays, and posts is eligible once per 6
month period. Recementation provided within 12 months of placement by the same dentist is included at
no additional cost to the Enrollee.
Benefits and Limitations for Endodontic Services:
1. Pulpotomies are included when performed by the same dentist within a 45-day period prior to the
completion of root canal therapy.
2. A pulpotomy is covered when performed as a final endodontic procedure and is covered generally on
primary teeth only. Pulpotomies performed on permanent teeth are included to root canal therapy and are
not reimbursable unless specific rationale is provided and root canal therapy is not and will not be
provided on the same tooth.
3. Pulpal therapy (resorbable filling) is limited to primary teeth only. It is a benefit for primary incisor teeth for
Enrollees up to age six and for primary molars and cuspids to age 11 and is limited to once per tooth per
lifetime.
4. Incomplete endodontic therapy is not a covered benefit when due to the patient discontinuing treatment.
5. For reporting and benefit purposes, the completion date for endodontic therapy is the date the tooth is
sealed.
Benefits and Limitations for Periodontal Services:
1. Gingivectomy or gingivoplasty, gingival flap procedure, guided tissue regeneration, soft tissue grafts, bone
replacement grafts and osseous surgery provided within 24 months of the same surgical periodontal
procedure, in the same area of the mouth are not covered.
2. Surgical periodontal procedures or scaling and root planing in the same area of the mouth within 24
months of a gingival flap procedure are not covered.
3. Subepithelial connective tissue grafts and combined connective tissue and double pedicle grafts are
covered at the level of free soft tissue grafts.
4. A single site for reporting osseous grafts consists of one contiguous area, regardless of the number of
teeth (e.g., crater) or surfaces involved. Another site on the same tooth is included to the first site
reported. Non-contiguous areas involving different teeth may be reported as additional sites.
5. Osseous surgery is not covered when provided within 24 months of osseous surgery in the same area of
the mouth.
6. Guided tissue regeneration is covered only when provided to treat Class II furcation involvement or
intrabony defects. It is not covered when provided to obtain root coverage, or when provided in
conjunction with extractions, cyst removal or procedures involving the removal of a portion of a tooth, e.g.,
apicoectomy or hemisection.
7. One crown lengthening per tooth, per lifetime, is covered.
8. Periodontal scaling and root planing provided within 24 months of periodontal scaling and root planing or
periodontal surgical procedures, in the same area of the mouth is not covered.
9. Up to four periodontal maintenance procedures and up to two routine prophylaxes may be covered within
a 12 consecutive month period, but the total of periodontal maintenance and routine prophylaxes may not
exceed four procedures in a 12 month period.
10. Periodontal maintenance is only covered when performed following active periodontal treatment.
11. An oral evaluation reported in addition to periodontal maintenance will be covered as a separate
procedure subject to the policy and limitations applicable to oral evaluations.
12. Coverage for multiple periodontal surgical procedures (except soft tissue grafts, osseous grafts, and
guided tissue regeneration) provided in the same area of the mouth during the same course of treatment
is based on the fee for the greater surgical procedure.
13. Full mouth debridement to enable comprehensive evaluation and diagnosis (code D4355) is covered once
per lifetime.
Benefits and Limitations for Oral Surgery Services:
2
V14
1. Charges for related services such as necessary wires and splints, adjustments, and follow up visits are
included to the fee for reimplantation and/or stabilization.
2. Routine postoperative care such as suture removal is included to the fee for the surgery.
3. The removal of impacted teeth is covered based on the anatomical position as determined from a review
of x-rays. If the degree of impaction is determined to be less than the reported degree, coverage will be
based on the allowance for the lesser level.
4. Removal of impacted third molars in Enrollees under age 15 is not covered unless specific documentation
is provided that substantiates the need for removal and is approved by the plan.
Benefits and Limitations for Prosthodontic Services:
1. Services or treatment for the provision of an initial prosthodontic appliance (i.e., fixed bridge restoration,
implants, removable partial or complete denture, etc.) when it replaces natural teeth extracted or missing,
including congenital defects, prior to Effective Date of Coverage may not be eligible for coverage.
2. For reporting and benefit purposes, the completion date for crowns and fixed partial dentures is the
cementation date. The completion date is the insertion date for removable prosthodontic appliances. For
immediate dentures, however, the dentist who fabricated the dentures may be reimbursed for the
dentures after insertion if another dentist, typically an oral surgeon, inserted the dentures.
3. Removable cast base partial dentures for Enrollees under 12 years of age are excluded from coverage
unless specific rationale is provided indicating the necessity for that treatment and is approved by the
plan.
4. Name brand, laboratory processed or in-office processed crowns/pontics produced through specialized
technique or materials are material upgrades. Contract Dentists may offer services that utilize brand or
trade names at an additional fee. The Enrollee must be offered the plan benefits of a high quality
laboratory processed crown/pontic that may include: porcelain/ceramic; porcelain with base, noble or
high-noble metal. If the Enrollee chooses the alternative of a material upgrade (name brand laboratory
processed or in-office processed crowns/pontics produced through specialized technique or materials,
including but not limited to: Captek, Procera, Lava, Empress and Cerec) the Contract Dentist may charge
an additional fee not to exceed $325.00 in addition to the listed Copayment. Contact the Customer
Service department at 800-471-9925 if you have questions regarding the additional fee or name brand
services
5. Re-cementation of prefabricated and cast crowns, bridges, onlays, inlays, and posts is eligible once per 6month period. Recementation provided within 12 months of placement by the same dentist is included at
no additional cost to the Enrollee. Adjustments provided within six months of the insertion of an initial or
replacement denture or implant are included at no additional cost to the Enrollee when made by the same
dentist.
6. With the exception of a new immediate denture, relining or rebasing is covered at no additional cost to the
Enrollee within six months of a denture’s initial delivery.
7. A reline/rebase is covered once in any 36 months.
8. Fixed partial dentures, buildups, and posts and cores for Enrollees under 16 years of age are not covered
unless specific rationale is provided indicating the necessity for such treatment and is approved by the
plan.
9. Coverage for a denture or an overdenture made with precious metals is based on the allowance for a
conventional denture. Specialized procedures performed in conjunction with an overdenture are not
covered.
10. A fixed partial denture and removable partial denture are not covered benefits in the same arch.
Coverage is for a removable partial denture to replace all missing teeth in the arch.
11. Precision attachments, personalization, precious metal bases, and other specialized techniques are not
covered benefits.
12. Implants and related prosthetics may be covered and may be reimbursed as an alternative benefit as a
three unit fixed partial denture.
13. Replacement of removable prostheses (D5110 through D5214) and fixed prostheses (D6210 through
D6792) is covered only if the existing removable and/or fixed prostheses was inserted at least sixty (60)
months prior to the replacement and satisfactory evidence is presented that the existing removable and/or
fixed prostheses cannot be made serviceable. Satisfactory evidence must show that the existing
removable prostheses and/or fixed prostheses cannot be made serviceable. The sixty (60) month service
date is measured based on the actual date (day and month) of the initial service versus the first day of the
initial service month.
14. Replacement of dentures that have been lost, stolen, or misplaced is not a covered service.
15. Removable or fixed prostheses initiated prior to the effective date of coverage or inserted/cemented after
3
V14
the cancellation date of coverage are not eligible for coverage.
Policies, Limitations, and Exclusions for Orthodontic Services - Medically Necessary:
1. Services are limited to medically necessary orthodontics when provided by a Contract Dentist and when
necessary and customary under generally accepted dental practice standards. Orthodontic treatment is a
benefit of this plan only when medically necessary as evidenced by a severe handicapping malocclusion
for Pediatric Enrollees and shall be prior authorized by the plan.
2. Orthodontic procedures are a benefit only when the diagnostic casts verify a minimum score of 26 points
on the Handicapping Labio-Lingual Deviation (HLD) Index or one of the automatic qualifying conditions
below exist.
3. The automatic qualifying conditions are:
a. Cleft palate deformity. If the cleft palate is not visible on the diagnostic casts written
documentation from a credentialed specialist shall be submitted, on their professional
letterhead, with the prior authorization request,
b. A deep impinging overbite in which the lower incisors are destroying the soft tissue of the
palate,
c. A crossbite of individual anterior teeth causing destruction of soft tissue,
d. Severe traumatic deviation.
4. The following documentation must be submitted to the plan with the request for prior authorization of
services by the Contract Dentist:
• ADA 2006 or newer claim form with service code(s) requested;
• Diagnostic study models (trimmed) with bite registration; or OrthoCad equivalent;
• Cephalometric radiographic image or panoramic radiographic image;
• HLD score sheet completed and signed by the Orthodontist; and
• Treatment plan.
5. The allowances for comprehensive orthodontic treatment procedures (D8080, D8090) include all
appliances, adjustments, insertion, removal and post treatment stabilization (retention). No additional
charge to the Enrollee is permitted.
6. Comprehensive orthodontic treatment includes the replacement, repair and removal of brackets, bands
and arch wires by the original treating orthodontist.
7. Orthodontic procedures are benefits for medically necessary handicapping malocclusion, cleft palate and
facial growth management cases for Pediatric Enrollees and shall be prior authorized.
8. Only those cases with permanent dentition shall be considered for medically necessary handicapping
malocclusion, unless the Enrollee is age 13 or older with primary teeth remaining. Cleft palate and
craniofacial anomaly cases are a benefit for primary, mixed and permanent dentitions. Craniofacial
anomalies are treated using facial growth management.
9. All necessary procedures that may affect orthodontic treatment shall be completed before orthodontic
treatment is considered.
10. When specialized orthodontic appliances or procedures chosen for aesthetic considerations are provided,
the plan will make an allowance for the cost of a standard orthodontic treatment.
11. Repair and replacement of an orthodontic appliance inserted under the Plan that has been damaged, lost,
stolen, or misplaced is not a covered service.
12. Should an Enrollee’s coverage be canceled or terminated for any reason, and at the time of
cancellation or termination be receiving any orthodontic treatment, the Enrollee will be solely responsible
for payment for treatment provided after cancellation or termination, except:
If an Enrollee is receiving ongoing orthodontic treatment at the time of termination, the plan will continue
to provide orthodontic Benefits for:
4
V14
a. For 60 days if the Enrollee is making monthly payments to the Contract Orthodontist; or
b. Until the later of 60 days after the date coverage terminates or the end of the quarter in progress, if
the Enrollee is making quarterly payments to the Contract Orthodontist.
At the end of 60 days (or at the end of the Quarter), the Enrollee’s obligation shall be based on the
Contract Orthodontist’s usual fee at the beginning of treatment. The Contract Orthodontist will prorate the
amount over the number of months to completion of the treatment. The Enrollee will make payments
based on an arrangement with the Contract Orthodontist.
Benefits, Limitations and Exclusions for Medically Necessary Orthodontics by Procedure Code:
Comprehensive Orthodontic Services
Procedure D8080 Comprehensive orthodontic treatment of the adolescent dentition
The allowances for comprehensive orthodontic treatment procedures include all appliances,
adjustments, insertion, removal and post treatment stabilization (retention). No additional charge
to the Enrollee is permitted.
Procedure D8090 Comprehensive orthodontic treatment of the adult dentition
The allowances for comprehensive orthodontic treatment procedures include all appliances,
adjustments, insertion, removal and post treatment stabilization (retention). No additional charge
to the Enrollee is permitted.
Other Orthodontic Services
Procedure D8660 Pre-orthodontic treatment visit
Under the plan processing policies, this procedure is considered to be equivalent to procedure
D0150, and is a benefit only for Enrollees with orthodontic coverage.
Procedure D8670 Periodic orthodontic treatment visit (as part of contract)
Periodic treatment visits are part of, and included in the case fee for comprehensive orthodontic
treatment.
Procedure D8680 Orthodontic retention (removal of appliances, construction and placement of
retainer(s))
1. Under the plan processing policies, the removal of orthodontic appliances is considered part
of, and included in the comprehensive case fees for, orthodontic treatment when performed
by the same dentist or dental office.
2. When this service is provided by a dentist or dental office other than the original treating
orthodontist, please submit a narrative report.
Procedure D8690 Orthodontic treatment (alternative billing to a contract fee)
1. The plan considers this procedure to be included in the orthodontic case fee. A separate fee
may not be charged to the Enrollee when submitted by the same dentist or dental office as
the orthodontic treatment. A separate fee applies for services provided by an orthodontist
other than the original treating orthodontist. This is limited to transfer of care and removal of
appliances.
Procedure D8693 Rebonding or recementing; and/or repair, as required, of fixed retainers
1. The plan considers this procedure to be included in the comprehensive case fee. A separate
fee may not be charged to the Enrollee when submitted by the original treating dentist or
dental office.
2. This procedure may be benefitted if performed by a dentist or dental office other than the
original treating dentist or dental office. Fees for subsequent procedures attributable to lack of
Enrollee compliance are the Enrollee’s financial responsibility.
5
V14
Procedure D8694 Repair of fixed retainers, includes reattachment
1. The plan considers this procedure to be included in the orthodontic case fee. A separate fee
may not be charged to the Enrollee when submitted by the same dentist or dental office as
the orthodontic treatment.
This procedure may be benefitted if performed by a different dentist or dental office other than
the original treating orthodontist/dental office. Fees for subsequent procedures attributable to
lack of Enrollee compliance are the Enrollee’s financial responsibility.
Benefits and Limitations for General Services:
1. Deep sedation/general anesthesia and intravenous conscious sedation are covered (by report) only when
provided in connection with a covered procedure(s) and when rendered by a dentist or other professional
licensed dentist and approved to provide anesthesia in the state where the service is rendered.
2. Deep sedation/general anesthesia and intravenous conscious sedation are covered only by report when
determined to be medically or dentally necessary for documented handicapped or uncontrollable
Enrollees or justifiable medical or dental conditions.
3. In order for deep sedation/general anesthesia and intravenous conscious sedation to be covered, the
procedure for which it was provided must be submitted.
4. Deep sedation/general anesthesia and intravenous conscious sedation submitted without a report will be
denied as a non-covered benefit.
5. For palliative (emergency) treatment to be covered; it must involve a problem or symptom that occurred
suddenly and unexpectedly that requires immediate attention.
6. In order for palliative (emergency) treatment to be covered, the dentist must provide treatment to alleviate
the Enrollee’s problem. If the only service provided is to evaluate the Enrollee and refer to another dentist
and/or prescribe medication, it would be considered a limited oral evaluation - problem focused.
7. Consultations are covered only when provided by a dentist other than the practitioner providing the
treatment.
8. Consultations reported for a non-covered benefit, such as Temporomandibular Joint Dysfunction (TMJD),
are not covered.
9. After hours visits are covered only when the dentist must return to the office after regularly scheduled
hours to treat the Enrollee in an emergency situation.
10. Therapeutic drug injections are only covered in unusual circumstances, which must be documented by
report. They are not benefits if performed routinely or in conjunction with, or for the purposes of, general
anesthesia, analgesia, sedation or premedication.
11. Preparations that can be used at home, such as fluoride gels, special mouth rinses (including
antimicrobials), etc., are not covered benefits.
12. Occlusal guards are covered by report for Enrollee 13 years of age or older when the purpose of the
occlusal guard is the treatment of bruxism. Occlusal guards are limited to one per 12 consecutive month
period.
13. Athletic mouth guards are limited to one per 12 consecutive month period.
14. Internal bleaching of discolored teeth (D9974) is covered by report for endodontically treated anterior
teeth.
15. Internal bleaching of discolored teeth (D9974) is eligible once per tooth per thirty-six (36) month period.
Non-Covered Services
Except as specifically provided, the following services, supplies, or charges are not covered:
1. Any dental service or treatment not specifically listed as a covered service.
2. Those not prescribed by or under the direct supervision of a dentist, except in those states where dental
hygienists are permitted to practice without supervision by a dentist. In these states, the plan will pay for
eligible covered services provided by an authorized dental hygienist performing within the scope of his or
her license and applicable state law.
3. Services or treatment provided by a member of the Enrollee’s immediate family.
4. Those services submitted by a dentist which are for the same services performed on the same date for
the same Enrollee by another dentist.
5. Those which are experimental or investigative (deemed unproven).
6. Those which are for any illness or bodily injury which occurs in the course of employment if benefits or
compensation is available, in whole or in part, under the provision of any legislation of any governmental
unit. This exclusion applies whether or not the member claims the benefits or compensation.
6
V14
7. Those which are later recovered in a lawsuit or in a compromise or settlement of any claim, except where
prohibited by law.
8. Those provided free of charge by any governmental unit, except where this exclusion is prohibited by law.
9. Those for which the member would have no obligation to pay in the absence of this or any similar
coverage.
10. Those received from a dental or medical department maintained by or on behalf of an employer, mutual
benefit association, labor union, trust, or similar person or group.
11. Those performed prior to the Enrollee’s effective coverage date.
12. Those incurred after the termination date of the member’s coverage unless otherwise indicated.
13. Those which are not medically or dentally necessary, or which are not recommended or approved by the
treating dentist. (Services determined to be unnecessary or which do not meet accepted standards of
dental practice are not billable to the Enrollee by a Contract Dentist unless the dentist notifies the Enrollee
of his/her liability prior to treatment and the Enrollee chooses to receive the treatment. Contract Dentists
should document such notification in their records.)
14. Those not meeting accepted standards of dental practice.
15. Those which are for unusual procedures and techniques and may not be considered generally accepted
practices by the American Dental Association.
16. Those performed by a dentist who is compensated by a facility for similar covered services performed for
members.
17. Those resulting from the Enrollee’s failure to comply with professionally prescribed treatment.
18. Telephone consultations.
19. Any charges for failure to keep a scheduled appointment.
20. Duplicate and temporary devices, appliances, and services.
21. Services related to the diagnosis and treatment of Temporomandibular Joint Dysfunction (TMJD).
22. Services to alter vertical dimension and/or restore or maintain the occlusion. Such procedures include,
but are not limited to, equilibration, periodontal splinting, full mouth rehabilitation, and restoration for
misalignment of teeth.
23. Treatment or services for injuries resulting from the maintenance or use of a motor vehicle if such
treatment or service is covered under a plan or policy of motor vehicle insurance, including a certified selfinsurance plan.
24. Treatment of services for injuries resulting from war or act of war, whether declared or undeclared, or from
police or military service for any country or organization.
25. Services or treatment provided as a result of intentionally self-inflicted injury or illness.
26. Services or treatment provided as a result of injuries suffered while committing or attempting to commit a
felony, engaging in an illegal occupation, or participating in a riot, rebellion or insurrection.
27. Hospital costs or any additional fees that the dentist or hospital charges for treatment at the hospital
(inpatient or outpatient).
28. Adjunctive dental services as defined by applicable federal regulations.
29. Charges for copies of Enrollees’ records, charts or x-rays, or any costs associated with forwarding/mailing
copies of Enrollees’ records, charts or x-rays.
30. State or territorial taxes on dental services performed.
Adjunctive Services
1. Adjunctive dental care is dental care that is:
a. Medically necessary in the treatment of an otherwise covered medical (not dental) condition.
b. An integral part of the treatment of such medical condition.
c. Essential to the control of the primary medical condition.
d. Required in preparation for or as the result of dental trauma, which may be or is caused by
medically necessary treatment of an injury or disease (iatrogenic).
2. The plan does not cover adjunctive dental care services. These are medical services that may be covered
under a medical policy even when provided by a general dentist or oral surgeon. The following diagnoses
or conditions may fall under this category:
a. Treatment for relief of Myofascial Pain Dysfunction Syndrome (MFPS) or Temporomandibular
Joint Dysfunction (TMJD).
b. Orthodontic treatment for cleft lip or cleft palate, or when required in preparation for, or as a result
of, trauma to teeth and supporting structures caused by medically necessary treatment of an
injury or disease.
c. Procedures associated with preventive and restorative dental care when associated with
radiation therapy to the head or neck unless otherwise covered as a routine preventive procedure
7
V14
under this plan.
d. Treatment of total or complete ankyloglossia.
e. Treatment of an extraoral abscess or intraoral abscess that extends beyond the dental alveolus,
f. Treatment of cellulitis and osteitis, which is clearly exacerbating and directly affecting a medical
condition currently under treatment.
g. Removal of teeth and tooth fragments in order to treat and repair facial trauma resulting from an
accidental injury.
h. Prosthetic replacement of either the maxilla or mandible due to reduction of body tissues
associated with traumatic injury (such as a gunshot wound) in addition to services related to
treating neoplasms or iatrogenic dental trauma.)
8
V14