Download 2014 Dental Evidence of Coverage for

2014 Dental Evidence of Coverage for
Care1st Health Plan Kern Choice Plan (HMO) Members
In general, preventive dental services (such as cleaning, routine dental exams, and dental x-rays) are not
covered by Original Medicare.
For more information, refer to the Covered Dental Procedures following this benefit chart. Services
must be provided by your selected participating
dental provider in order to be covered. Not all participating dentists perform all of the covered dental
procedures. The covered dental procedures will not
be covered if performed by someone other than a
participating general dentist. If your selected dentist
does not perform a necessary covered dental procedure you may wish to contact Dental Health Services
about selecting an alternative provider.
Listed copayments apply when services are provided
by participating network dentists who are not specialists. The dental plan covers the listed services when
those services are provided by contracted network
general dentists. The copayments listed apply only to
services provided by your selected participating general dentist.
During the course of treatment, your selected general
dentist may determine that the services of a dental
specialist are required. You will be responsible for any
services provided by the dental specialist.
H5928_14_348_MK_Approved
Members, particularly those who have not kept up
with their routine dental appointments - at least once
every six (6) months - or have been diagnosed with
periodontal disease, may find that they require services
involving periodontal scaling and root planing or fullmouth debridement before routine care such as regular
cleanings can or will be provided. Please see the benefit
scheduled below for copayments for these procedures.
Routine dental care is provided by a participating provider of Dental Health Services. A referral by a plan
physician is not required for routine dental services.
For information on participating dentists in your
area, please contact Dental Health Services Monday
through Friday, from 7:30 a.m. through 5 p.m. PST, at
1-888-645-1261. TTY/TDD 1-888-645-1257.
*Routine dental care copays do not apply to your maximum
out-of-pocket amount.
Covered Dental Procedures
& Member Copayments
The covered dental procedures chart lists copayments
based upon the Current Dental Terminology (CDT)
procedure codes approved by the American Dental
Association (ADA).
Not all benefits may be suitable for you. Your selected
Dental Health Services dentist will determine the appropriate care you need and review a treatment plan
with you prior to beginning any procedure.
The copayments listed in the chart apply for services
only when the services are prescribed by a contracted
dentist as necessary, adequate and appropriate for
your condition. Please discuss your treatment plan
and financial responsibility with your Dental Health
Services dentist prior to beginning any dental treatment. Copayments are due and payable at the time
services are rendered or when you begin treatment.
If you require assistance in getting information about
your treatment plan or have any questions regarding
the copayments you are charged, you may contact
Dental Health Services Member Services at (888)
645-1261, Monday-Friday, 8am-5pm. TTY/TDD users (888) 645-1267.
Emergency Dental Care
Emergency dental care is any dental service to evaluate and stabilize dental conditions of a recent onset
and severity accompanied by excessive bleeding, severe pain, or acute infection that would lead a reasonably prudent lay person possessing average knowledge of dentistry to believe that immediate care is
needed.
If you have a dental emergency and need to seek immediate care, first call your Dental Health Services
dentist. Participating offices maintain 24-hour emergency communication accessibility and are expected
to see you within 24-hours or less, as your condition
requires. If your dentist is not available, please call
Dental Health Services Member Services at (800)
645-1261. TTY/TDD users (888) 645-1267. If both
the dental office and Dental Health Services cannot
be reached, you are covered for emergency care at
another participating dentist, or from any dentist. If
you pay for emergency palliative treatment, you can
submit your request for reimbursement to Dental
Health Services Member Services. If your request is
approved, Dental Health Services will reimburse you
for the cost of palliative treatment less any copay that
applies to the services rendered. Contact your Dental
Health Services contracted dentist for follow-up care
as soon as possible.
Out-of-Area Emergency
Dental Care
Out-of-area emergency dental care is emergency palliative dental treatment required by an enrollee when
more than 50 miles from any Dental Health Services
dental office. Your benefit includes up to $50 maximum per incident, after copayments are deducted.
You must submit an itemized receipt from the dental office that provided the emergency service and a
brief explanation. Make sure to include your Dental
Health Services and member numbers and submit directly to Dental Health Services.
Mailing Address:
Dental Health Services
Attention: Member Services
3833 Atlantic Avenue
Long Beach, CA90807-3505
Decisions relating to payment or denial of the reimbursement request will be made within thirty (30)
business days of the date that all information reasonably required to render the decision is received by
Dental Health Services.
To request a review of the denial or partial denial,
submit a written notice to Dental Health Services
within sixty (60) days of receiving the denial notice.
See Chapter 9 of your Care1st Kern Choice Plan
Evidence of Coverage booklet for additional information regarding appeals and grievances.
2014 Evidence of Coverage for Care1st Health Plan Members | Page 2
Obtaining a Second
Opinion for Dental Care
Second dental opinions are a covered dental benefit.
It may be requested if you have unanswered questions about diagnosis, treatment plans, and/or the
results achieved by such dental treatment. Contact
Dental Health Services’ Member Service Department
at (888) 645-1261, Monday-Friday, 8am-5pm. TTY/
TDD users (888) 645-1267. You may also send a written request to the following address:
Dental Health Services
Attention: Member Services
3833 Atlantic Avenue
Long Beach, CA 90807-3505
All requests for a second opinion are processed
within 5 business days of receipt by Dental Health
Services except when an expedited second opinion
is warranted; in which case a decision will be made
and conveyed to you within 72 hours. Upon approval, Dental Health Services will contact the consulting dentist and make arrangements to enable you to
schedule an appointment. All second opinion consultations will be completed by a Dental Health Services
Contracting Dentist with qualifications in the same
area of expertise as the referring dentist or dentist
who provided the initial examination or services.
Transferring to Another Dentist
Second dental opinions are a covered benefit with a
$20.00 copayment. If a second opinion is at the request of Dental Health Services, the copayment will
be waived. Reasons for a second opinion to be provided or authorized shall include, but are not limited to:
• If you question the reasonableness or necessity
of recommended surgical procedures;
• If you question a diagnosis or plan of care for a
condition that threatens loss of life, loss of limb,
loss of bodily function, or substantial impairment
including, but not limited to, a serious chronic
condition;
• If the clinical indications are not clear or are complex and confusing, a diagnosis is in doubt due to
conflicting test results, or the treating dentist is
unable to diagnose the condition, and the member requests a second opinion.
• If the treatment plan in progress is not improving
your dental condition within an appropriate period of time given the diagnosis and plan of care,
and you request a second opinion regarding the
diagnosis and continuation of treatment.
You may transfer to another dentist if you are not
satisfied with the dentist you selected. You may contact Dental Health Services Member Services at (888)
645-1261, Monday-Friday, 8am-5pm. TTY/TDD users (888) 645-1267.
If you owe your dentist money at the time you want
to transfer to another dentist, you will still be financially responsible for the monies owed to your dentist.
If you transfer dentists, you may have to pay a fee for
the cost of duplicating your x-rays and dental records.
Members may not usually transfer dentists while in
the middle of a multi-visit procedure where a final
impression for fabrication has occurred, unless exception cause can be shown. These procedures include
crowns, inlays and onlays, removable partial dentures,
complete dentures and components of bridges.
If Your Participating Dentist
no Longer Contracts with
Dental Health Services
If the relationship ends between Dental Health
Services and your selected dentist, your dentist is
obligated to complete any and all treatment in progress.
Dental Health Services will arrange a transfer for you
to another dentist to provide continued care under
the plan.
2014 Evidence of Coverage for Care1st Health Plan Members | Page 3
Resolving Disagreements
If you have concerns regarding any aspects Dental
Health Services benefits, contact Kern Choice Plan’s
Member Services for assistance at 1-800-544-0088
(TTY/TDD users, please call 711. You need special
telephone equipment to use this number), calls to
these numbers are free. We are available to receive
your calls between the hours of 8:00 a.m. and 8:00
p.m., seven days a week.
If you have concerns that are not fully resolved, you
have the right to file an appeal or a grievance with
Dental Health Services. For additional information
on these procedures, refer to Chapter 9 of your
Care1st Kern Choice Plan Evidence of Coverage
booklet for additional information regarding appeals
and grievances.
Limitations and Exclusions
to Dental Health Services
Dental Health Services Exclusions
The following services are not covered by your
dental plan.
• Services that are not consistent with professionally recognized standards of practice.
• Services related to implants or attachments to implants.
• Cosmetic services, for appearance only, unless
specifically listed.
• Myofunctional therapy-procedures for training,
treating or developing muscles in and around the
jaw or mouth including TMJ and related diseases,
except for an occlusal guard.
• Treatment for malignancies, neoplasms (tumors)
and cysts as well as hereditary, congenital and/or
developmental malformations.
• Dispensing of drugs not normally supplied in a
dental office.
• Hospitalization charges, dental procedures or services rendered while a patient is hospitalized.
• Procedures, appliances or restorations (other
than fillings) that are necessary for full mouth rehabilitation or crown/bridgework requiring more
than 10 crowns/pontics. Procedures performed
by a prosthodontist. Fixed bridges replacing second bicuspid and molar teeth are covered except
when there are posterior, bilateral, non-restored
missing teeth in the same arch.
• General anesthesia, including intravenous and inhalation sedation.
• Dental procedures that cannot be performed in
the dental office due to the general health and/or
physical limitations of the member.
• Expenses incurred for dental procedures initiated
prior to member’s eligibility with Dental Health
Services, or after termination of eligibility.
• Services that are reimbursed by a third party (such
as the medical portion of an insurance/health
plan or any other third party indemnification).
• Extractions of non-pathologic, asymptomatic
teeth, including extractions and/or surgical procedures for orthodontic reasons.
• Setting of a fracture or dislocation, surgical procedures related to cleft palate, micrognathia or
macrognathia, and surgical grafting procedures.
• Coordination of benefits with another prepaid
managed care dental plan.
• Orthodontic treatment of a case in progress and/
or retreatment of orthodontic cases.
2014 Evidence of Coverage for Care1st Health Plan Members | Page 4
• Cephalometric x-rays, tracings, photographs and
orthodontic study models.
• Replacement of lost or broken orthodontic appliances.
• Implant services and implant-supported dental
appliances and attachments, implant placement,
maintenance, removal and all other services associated with a dental implant.
• Changes in orthodontic treatment necessitated by
an accident of any kind.
• Services solely for cosmetic purposes, or for conditions that are a result of hereditary or developmental defects, such as cleft palate, upper and lower jaw malformations, congenitally missing teeth
and teeth that are discolored or lacking enamel.
• Malocclusions so severe or mutilated that they are
not amenable to ideal orthodontic therapy.
• Services not specifically covered on the Schedule
of Covered Services and Copayments.
• Hospitalization services: not covered.
• Prescription drug coverage: not covered.
• Emergency health services: not covered.
• Ambulance services: not covered.
• Durable medical equipment: not covered.
• Mental health Services: not covered.
• Chemical dependency services: not covered.
• Home health services: not covered.
• This dental plan does not provide general anesthesia. Members requiring general anesthesia should
inquire with their medical plan for coverage.
• Any procedure that is not specifically listed in
the Dental Benefits Chart, or in the professional
opinion of the Dental Health Services dentist (a)
has poor prognosis for a successful result and reasonable longevity based on the condition of the
tooth or teeth and/or surrounding structures, or
(b) is inconsistent with generally accepted standards for dentistry.
• Consultations for non-covered benefits.
Dental Health Services Limitations
Restrictions on benefits are applied to the following services.
• Treatment of dental emergencies is limited to
treatment that will alleviate acute symptoms and
does not cover definitive restorative treatment including, but not limited to root canal treatment
and crowns.
• Optional services: when the patient selects a plan
of treatment that is considered optional or unnecessary by the attending dentist, the additional
cost is the responsibility of the patient.
• Routine teeth cleaning (prophylaxis) is limited to
once every six months and full mouth x-rays are
limited to one set every three years if needed.
• Periodontal surgical procedures are limited to
four quadrants every two years.
• There are additional charges for precious/noble
metals (gold).
• Replacement will be made of any existing appliance (denture, etc.) only if it is unsatisfactory and
cannot be made satisfactory. Prosthetic appliances
will be replaced only after five years have elapsed
from the time of delivery. Lost or stolen removable
appliances are the responsibility of the enrollee.
• Relines are limited to once per twelve months, per
appliance.
2014 Evidence of Coverage for Care1st Health Plan Members | Page 5
• Single unit inlays and crowns are a benefit as provided above only when the teeth cannot be adequately restored with other restorative materials.
• Services provided by a dental specialist are not
covered. The dental procedures listed in this
EOC are covered only when performed by your
Dental Health Services general dentist.
• Restorative, crowns, endodontics and oral surgery
services: Copayments for fillings, caps, root canals and extractions vary by procedure.
2014 Evidence of Coverage for Care1st Health Plan Members | Page 6
Schedule of Covered Services and Copayments
Care1st H ealth Plan - Kern Choice Plan
(H MO)
Code
Description
Failed/no-show general dentist
appointment without 24-hour
notice
Office Visit
Copayment
Code
Description
20
D0391
Interpretation of diagnostic image
by a practitioner not associated
with capture of the image,
including report
Pulp vitality tests
Diagnostic casts
0
Diagnostic
D0120
D0140
D0150
D0160
D0170
D0180
D0210
D0220
D0230
D0240
D0250
D0260
D0270
D0272
D0273
D0274
D0277
D0330
Periodic oral evaluation established patient
Limited oral evaluation - problem
focused
Comprehensive oral evaluation new or established patient
Detailed and extensive oral
evaluation - problem focused, by
report
Re-evaluation - limited, problem
focused (established patient; not
post-operative visit)
Comprehensive periodontal
evaluation - new or established
patient
Intraoral - complete series of
radiographic images
Intraoral - periapical first
radiographic image
Intraoral - periapical each
additional radiographic image
Intraoral - occlusal radiographic
image
Extraoral - first radiographic image
Extraoral - each additional
radiographic image
Bitewing - single radiographic image
Bitewings - two radiographic images
Bitewings - three radiographic
images
Bitewings - four radiographic
images
Vertical bitewings - 7 to 8
radiographic images
Panoramic radiographic image
0913M566
D0460
D0470
0
Preventive
0
D1110
0
0
D1208
D1310
D1320
0
0
D1330
0
0
D1525
0
D1550
D1555
0
0
0
0
0
0
0
5
0
0
0
0
0
Space maintainer - fixed - unilateral
Space maintainer - fixed - bilateral
Space maintainer - removable unilateral
Space maintainer - removable bilateral
Re-cementation of space maintainer
Removal of fixed space maintainer
50
70
40
50
0
0
Amalgam Restorations - Primary or Permanent
D2140
D2150
D2160
D2161
0
0
Prophylaxis - adult (limited to 1 per
6 months & additional at higher
copayments)
Topical application of fluoride
Nutritional counseling for control
of dental disease
Tobacco counseling for the control
and prevention of oral disease
Oral hygiene instructions
5
Space Maintainers
D1510
D1515
D1520
0
Copayment
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
25
30
35
40
Resin-Based Composite Restorations
D2330
D2331
Resin-based composite - one
surface, anterior
Resin-based composite - two
surfaces, anterior
Current Dental Terminology © 2013 American Dental Association. All rights reserved
30
40
Code
Description
D2332
Resin-based composite - three
surfaces, anterior
Resin-based composite - four or
more surfaces or involving incisal
angle (anterior)
Resin-based composite crown,
anterior
Resin-based composite - one
surface, posterior
Resin-based composite - two
surfaces, posterior
Resin-based composite - three
surfaces, posterior
Resin-based composite - four or
more surfaces, posterior
D2335
D2390
D2391
D2392
D2393
D2394
Copayment
Code
Description
45
D2663
50
D2664
Onlay - resin-based composite three surfaces
Onlay - resin-based composite four or more surfaces
Crown - resin-based composite
(indirect)
Crown - ¾ resin-based composite
(indirect)
Crown - resin with high noble metal
Crown - resin with predominantly
base metal
Crown - resin with noble metal
Crown - porcelain/ceramic
substrate
Crown - porcelain fused to high
noble metal
Crown - porcelain fused to
predominantly base metal
Crown - porcelain fused to noble
metal
Crown - 3/4 cast high noble metal
Crown - 3/4 cast predominantly
base metal
Crown - 3/4 cast noble metal
Crown - 3/4 porcelain/ceramic
Crown - full cast high noble metal
Crown - full cast predominantly
base metal
Crown - full cast noble metal
Crown - titanium
120
110
130
150
180
0913M566
D2712
D2720 *
D2721
D2722 *
D2740 *
D2750 *
Crowns - Single Restoration Only
*Additional charges of $125 for noble metal, $150 for high noble
metal. Add $100 for porcelain on molars, $50 for porcelain butt
margin, $200 for specialized crowns such as Lava, Captek,
Empress, Procera, etc.
D2510 * Inlay - metallic - one surface
D2520 * Inlay - metallic - two surfaces
D2530 * Inlay - metallic - three or more
surfaces
D2542 * Onlay - metallic - two surfaces
D2543 * Onlay - metallic - three surfaces
D2544 * Onlay - metallic - four or more
surfaces
D2610 Inlay - porcelain/ceramic - one
surface
D2620 Inlay - porcelain/ceramic - two
surfaces
D2630 Inlay - porcelain/ceramic - three or
more surfaces
D2642 Onlay - porcelain/ceramic - two
surfaces
D2643 Onlay - porcelain/ceramic - three
surfaces
D2644 Onlay - porcelain/ceramic - four or
more surfaces
D2650 Inlay - resin-based composite - one
surface
D2651 Inlay - resin-based composite - two
surfaces
D2652 Inlay - resin-based composite three or more surfaces
D2662 Onlay - resin-based composite two surfaces
D2710
230
230
230
230
230
230
D2751
D2752 *
D2780 *
D2781
D2782 *
D2783 *
D2790 *
D2791
310
D2792 *
D2794 *
330
Other Restorative Services
Recement inlay, onlay, or partial
coverage restoration
D2915 Recement cast or prefabricated
330
post and core
D2920 Recement crown
330
D2930 Prefabricated stainless steel crown primary tooth
330
D2931 Prefabricated stainless steel crown permanent tooth
230
D2932 Prefabricated resin crown
D2933 Prefabricated stainless steel crown
250
with resin window
D2934 Prefabricated esthetic coated
250
stainless steel crown - primary tooth
D2940 Protective restoration
250
D2950 Core buildup, including any pins
when required
Current Dental Terminology © 2013 American Dental Association. All rights reserved
330
D2910
Copayment
250
250
150
150
150
150
150
280
280
280
280
230
230
230
280
230
230
230
230
20
20
20
60
60
60
80
80
0
30
Code
Description
D2951
Pin retention - per tooth, in
addition to restoration
Post and core in addition to crown,
indirectly fabricated
Each additional indirectly
fabricated post - same tooth
Prefabricated post and core in
addition to crown
Post removal
Each additional prefabricated
post - same tooth
Labial veneer (resin laminate) chairside
Labial veneer (resin laminate) laboratory
Labial veneer (porcelain laminate) laboratory
Additional procedures to construct
new crown under existing partial
denture framework
Coping
D2952
D2953
D2954
D2955
D2957
D2960
D2961
D2962
D2971
D2975
Copayment
Code
Description
20
D3332
Incomplete endodontic therapy;
inoperable, unrestorable or
fractured tooth
Internal root repair of perforation
defects
Retreatment of previous root canal
therapy - anterior
Retreatment of previous root canal
therapy - bicuspid
Apexification/recalcification –
initial visit (apical closure/calcific
repair of perforations, root
resorption, pulp space disinfection,
etc.)
Apexification/recalcification interim medication replacement
(apical closure/calcific repair of
perforations, root resorption, pulp
space disinfection, etc.)
Apexification/recalcification - final
visit (includes completed root canal
therapy - apical closure/calcific
repair of perforations, root
resorption, etc.)
Canal preparation and fitting of
preformed dowel or post
70
0
55
55
0
D3333
D3346
D3347
D3351
240
280
D3352
360
25
D3353
230
Endodontics
D3110
D3120
D3220
D3221
D3230
D3240
D3310
D3320
D3330
D3331
Pulp cap - direct (excluding final
restoration)
Pulp cap - indirect (excluding final
restoration)
Therapeutic pulpotomy (excluding
final restoration) - removal of pulp
coronal to the dentinocemental
junction and application of
medicament
Pulpal debridement, primary and
permanent teeth
Pulpal therapy (resorbable filling) anterior, primary tooth (excluding
final restoration)
Pulpal therapy (resorbable filling) posterior, primary tooth (excluding
final restoration)
Endodontic therapy, anterior tooth
(excluding final restoration)
Endodontic therapy, bicuspid
tooth (excluding final restoration)
Endodontic therapy, molar
(excluding final restoration)
Treatment of root canal
obstruction; non-surgical access
0913M566
12
6
17
D3950
D4211
17
D4241
70
D4277
150
220
D4341
325
D4342
50
80
50
200
320
35
35
35
55
Periodontics
D4240
60
Copayment
Gingivectomy or gingivoplasty one to three contiguous teeth or
tooth bounded spaces per quadrant
Gingival flap procedure, including
root planing - four or more
contiguous teeth or tooth bounded
spaces per quadrant
Gingival flap procedure, including
root planing - one to three
contiguous teeth or tooth bounded
spaces per quadrant
Free soft tissue graft procedure
(including donor site surgery), first
tooth or edentulous tooth position
in graft
Periodontal scaling and root
planing - four or more teeth per
quadrant
Periodontal scaling and root
planing - one to three teeth per
quadrant
Current Dental Terminology © 2013 American Dental Association. All rights reserved
60
250
200
320
50
25
Code
Description
D4355
Full mouth debridement to enable
comprehensive evaluation and
diagnosis
Localized delivery of antimicrobial
agents via controlled release vehicle
into diseased crevicular tissue, per
tooth
Periodontal maintenance (limited
to 1 per 6 months & additional at
higher copayments)
Unspecified periodontal procedure,
by report
D4381
D4910
D4999
Copayment
Code
Description
50
D5510
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 - per tooth
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
denture
Rebase maxillary partial denture
Rebase mandibular partial denture
Reline complete maxillary denture
(chairside)
Reline complete mandibular
denture (chairside)
Reline maxillary partial denture
(chairside)
Reline mandibular partial denture
(chairside)
Reline complete maxillary denture
(laboratory)
Reline complete mandibular
denture (laboratory)
Reline maxillary partial denture
(laboratory)
Reline mandibular partial denture
(laboratory)
Interim complete denture
(maxillary)
Interim complete denture
(mandibular)
Interim partial denture (maxillary)
Interim partial denture (mandibular)
Tissue conditioning, maxillary
Tissue conditioning, mandibular
50
50
0
Dentures
Dentures and partials include four months free adjustments. Add
lab cost of any gold.
D5110
D5120
D5130
D5140
D5211
D5212
D5213
D5214
D5225
D5226
D5281
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)
D5421
D5422
Adjust complete denture - maxillary
Adjust complete denture mandibular
Adjust partial denture - maxillary
Adjust partial denture - mandibular
0913M566
D5610
D5620
D5630
D5640
D5650
D5660
D5670
D5671
350
350
360
360
200
D5710
D5711
200
D5731
D5720
D5721
D5730
D5740
380
D5741
D5750
380
D5751
580
D5760
D5761
580
150
Denture Adjustments & Repairs
D5410
D5411
D5520
0
0
D5810
D5811
D5820
D5821
D5850
D5851
0
0
Current Dental Terminology © 2013 American Dental Association. All rights reserved
Copayment
30
20
30
50
40
20
20
30
220
220
140
140
140
140
80
80
80
80
140
140
140
140
140
140
140
140
40
40
Code
Description
Copayment
Bridges
*Additional charges of $125 for noble metal, $150 for high noble
metal. Add $100 for porcelain on molars, $50 for porcelain butt
margin, $200 for specialized crowns such as Lava, Captek,
Empress, Procera, etc.
D6205
Code
Description
D6611 * Onlay - cast high noble metal, three
or more surfaces
D6612 Onlay - cast predominantly base
metal, two surfaces
D6613 Onlay - cast predominantly base
metal, three or more surfaces
D6614 * Onlay - cast noble metal, two
surfaces
D6615 * Onlay - cast noble metal, three or
more surfaces
D6624 * Inlay - titanium
D6634 * Onlay - titanium
D6710 Crown - indirect resin based
composite
D6720 * Crown - resin with high noble metal
D6721 Crown - resin with predominantly
base metal
D6722 * Crown - resin with noble metal
D6740 * Crown - porcelain/ceramic
D6750 * Crown - porcelain fused to high
noble metal
D6751 Crown - porcelain fused to
predominantly base metal
D6752 * Crown - porcelain fused to noble
metal
D6780 * Crown - 3/4 cast high noble metal
D6781 Crown - 3/4 cast predominantly
base metal
D6782 * Crown - 3/4 cast noble metal
D6783 * Crown - 3/4 porcelain/ceramic
D6790 * Crown - full cast high noble metal
D6791 Crown - full cast predominantly
base metal
D6792 * Crown - full cast noble metal
D6794 * Crown - titanium
D6930 Recement fixed partial denture
D6975 Coping
Pontic - indirect resin based
130
composite
D6210 * Pontic - cast high noble metal
230
D6211 Pontic - cast predominantly base
230
metal
D6212 * Pontic - cast noble metal
230
D6214 * Pontic - titanium
230
D6240 * Pontic - porcelain fused to high
280
noble metal
D6241 Pontic - porcelain fused to
280
predominantly base metal
D6242 * Pontic - porcelain fused to noble
280
metal
D6245 * Pontic - porcelain/ceramic
280
D6250 * Pontic - resin with high noble metal
130
D6251 Pontic - resin with predominantly
130
base metal
D6252 * Pontic - resin with noble metal
130
D6545 Retainer - cast metal for resin
180
bonded fixed prosthesis
D6548 Retainer - porcelain/ceramic for
180
resin bonded fixed prosthesis
D6600 Inlay - porcelain/ceramic, two
280
surfaces
D6601 Inlay - porcelain/ceramic, three or
280
more surfaces
D6602 * Inlay - cast high noble metal, two
230
surfaces
D6603 * Inlay - cast high noble metal, three
230
or more surfaces
D6604 Inlay - cast predominantly base
230
metal, two surfaces
D6605 Inlay - cast predominantly base
230
Oral Surgery
metal, three or more surfaces
D6606 * Inlay - cast noble metal, two
230
D7111 Extraction, coronal remnants surfaces
deciduous tooth
D6607 * Inlay - cast noble metal, three or
230
D7140 Extraction, erupted tooth or
more surfaces
exposed root (elevation and/or
forceps removal)
D6608 * Onlay - porcelain/ceramic, two
280
surfaces
D7210 Surgical removal of erupted tooth
requiring removal of bone and/or
D6609 * Onlay - porcelain/ceramic, three or
280
sectioning of tooth, and including
more surfaces
elevation of mucoperiosteal flap if
D6610 * Onlay - cast high noble metal, two
230
indicated
surfaces
Current Dental Terminology © 2013 American Dental Association. All rights reserved
0913M566
Copayment
230
230
230
230
230
230
230
130
130
130
130
280
280
280
280
230
230
280
280
230
230
230
230
20
70
30
35
100
Code
Description
D7270
Tooth reimplantation and/or
stabilization of accidentally evulsed
or displaced tooth
Alveoloplasty in conjunction with
extractions - four or more teeth or
tooth spaces, per quadrant
Alveoloplasty in conjunction with
extractions - one to three 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 - one to three
teeth or tooth spaces, per quadrant
Incision and drainage of abscess intraoral soft tissue
Incision and drainage of abscess intraoral soft tissue - complicated
(includes drainage of multiple
fascial spaces)
D7310
D7311
D7320
D7321
D7510
D7511
Copayment
250
80
80
80
80
10
100
Other Services
D9110
D9215
D9310
D9440
D9450
D9630
D9940
D9941
D9942
D9972
D9973
D9974
Palliative (emergency) treatment of
dental pain - minor procedure
Local anesthesia in conjunction
with operative or surgical
procedures
Consultation - diagnostic service
provided by dentist or physician
other than requesting dentist or
physician
Office visit - after regularly
scheduled hours
Case presentation, detailed and
extensive treatment planning
Other drugs and/or medicaments,
by report
Occlusal guard, by report
Fabrication of athletic mouthguard
Repair and/or reline of occlusal
guard
External bleaching - per arch performed in office
External bleaching - per tooth
Internal bleaching - per tooth
0913M566
10
0
20
50
Code
Description
Copayment
Orthodontics
Please call your Dental Health Services Member Service Specialist at
800-637-6453 (TTY Users call 888-645-1257) from 7:30am 5:00pm Monday - Friday PST, for a referral to a conveniently located
affiliated orthodontist. Orthodontic models, x-rays, photographs and
records are not covered. There may be additional copayments depending
on treatment needs.
Consultation
Failed/no-show appointment
without 24-hour notice
Full banded - child, up to age 19
Full banded - adult
Partial banded - child, up to age 19
Partial banded - adult
Mixed dentition - phase 1
Palatal expansion
Rapid palatal expansion
Retention appliance - after
orthodontic treatment
Functional appliance (BionatorFrankel)
Headgear
Simple crossbite
Copying records
25
25
1775
1975
1250
1450
450
350
550
180
550
350
275
40
Care1st is a Medicare Advantage HMO plan with a Federal
Government contract and State Medicaid contract in Arizona and
California. Enrollment in Care1st Health Plan depends on contract
renewal. The benefit information provided is a brief summary, not a
complete description of benefits. For more information contact the
plan. Benefits and/or copayments/coinsurance may change on
January 1 of each year. Limitations, copayments, and restrictions
may apply.
0
25
180
100
90
200
This information is available for free in other langu-ages. Please
contact Member Services: 1-800-544-0088 (TTY /TDD users
call 711), 8am – 8pm, 7 days a week.
Esta información está disponible gratuitamente en otros idiomas.
Comuníquese con Servicios para los Miembros: 1-800-544-0088
(TTY/TDD 711), de 8am a 8pm, los 7 días de la semana.
100
100
Current Dental Terminology © 2013 American Dental Association. All rights reserved