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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