Dental Benefits Matrix
Dental Benefits Matrix Important information X‐rays and chart notes must accompany your request for Prior Authorization. Emergency dental services do not requirePrior Authorization. Please refer to the AHCCCS Uniform Warranty List located under AHCCCS’ Guides and Manuals to determine the frequency a restoration or other services can be replaced. All NON‐PAR providers require Prior Authorizationfor any services, except emergency services. Post‐op treatment for services rendered within3 months of original service is not billable. Members age 21 and older have a 1k emergent benefit and prior authorization is not needed ifit meets AHCCCS criteria. Members age 21 and older that qualify for an emergent root canal may have a crown placed to complete the care. Otherwise, permanent crowns are not a covered benefit. Prior authorization is not a guarantee of payment. C‐ Covered Service Mercy Care RBHA Dental Benefits Matrix 1/2020 Proprietary N‐Non‐covered Service Mail Prior Authorization to: Mercy Care RBHA Dental Prior Authorization 4755 S. 44th Place Phoenix, AZ 85040 Email Prior Authorizations: dental@mercycareaz.org Fax: 602‐431‐7155 Most dental claims will not require X‐rays with submission. However, if your claim requires additional attachments and you need to submit X‐rays, chart notes, etc., the claimmust be mailed to Mercy Care RBHA. These claims cannot be submitted electronically to us. Please mail these claims to the address below: DENTAL CLAIMS – MAIL TO: Mercy Care RBHA dental claims PO Box 62978 Phoenix, AZ 85082‐2979 C‐PA ‐ Covered only with prior authorization 1 of 21
MERCY CARE – REGIONAL BEHAVIORAL HEALTH AUTHORITY (MC RBHA) CDT 2020 Procedure Code D0120 Procedure Description Coverage Category (0 ‐20 years) Additional Documentation Required for Prior Authorization (0‐20 years) Emergent Benefit‐Policy 310‐D1‐ covered if it meet AHCCCS criteria (21 years & older) Periodic oral examination (2 per year; 6 months plus 1 day apart) Limited oral evaluation‐problem focused ** May not be billed with D0120,D0150,D0160 or D0170 C C C‐policy 310‐D1‐covered if it meets criteria C N D0160 Comprehensive oral evaluation – new or established patient (only billable one time per member/per provider) Detailed and extensive oral evaluation ‐ problem based D0171 Re‐evaluation post‐operative office visit C D0180 Comprehensive periodontal evaluation – new or established patient C‐PA Include Narrative N D0190 Screening of a patient C‐ One of (D0190, Include Narrative N D0191 Assessment of a patient C ‐‐One of (D0190, Include Narrative C‐ policy 310‐D1‐covered if it meets criteria D0210 Intraoral ‐ complete series (including bitewings) C 1 series in a 3 year period N D0220 Intraoral ‐ periapical ‐ first film C D0230 Intraoral ‐ periapical ‐ each additional film C D0240 Intraoral ‐ occlusal film C D0140 D0150 Include Narrative D0191) per 12 Month(s) Mercy Care RBHA Dental Benefits Matrix 1/2020 N‐Non‐covered Service N N D0191) per 12 Month(s) C‐ Covered Service Proprietary C N C policy 310‐D1‐covered if it meets criteria C‐ policy 310‐D1‐covered if it meets criteria N C‐PA ‐ Covered only with prior authorization 2 of 21
D0250 C‐PA N C N D0270 Extra‐oral – 2D projection radiographic image created using a stationary radiation source, and detector Extra‐oral posterior dental radiographic Bitewing ‐ single film C 2 per year; 6 months plus 1 day apart D0272 Bitewings ‐ two films C 2 per year; 6 months plus 1 day apart D0273 Bitewings – three films C D0274 Bitewings ‐ four films C 2 per year; 6 months plus 1 day apart D0277 Vertical bitewings 7 – 8 films C 1 per 36 month(s) D0310 D0320 D0321 D0330 Sialography Temporomandibular joint arthrogram, including injection Other temporomandibular joint films, by report Panoramic film C‐PA C‐PA C‐PA C Include Narrative Include Narrative Include Narrative 1 in a 3 year period D0340 D0350 D0367 Cephalometric film Oral/facial images (includes intra and extra oral images) Cone beam CT capture and interpretation with field of view of both jaws; with or without cranium Treatment simulation using 3D image volume Diagnostic casts Other oral pathology procedures, by report C‐PA C‐PA C‐PA Include Narrative C‐PA C‐PA C‐PA Include Narrative Include Narrative Include Narrative N N N C‐PA C Include Narrative 2 per year; 6 months plus 1 day apart N N C 2 per year; 6 months plus 1 day apart N D0251 D0393 D0470 D0502 D0999 D1110 D1206 Unspecified diagnostic procedure, by report Prophylaxis ‐ adult (ages 14 ) (2 per year; 6 months plus 1 day apart) Topical Application of Fluoride Varnish C‐ Covered Service Mercy Care RBHA Dental Benefits Matrix 1/2020 Proprietary N‐Non‐covered Service C‐ policy 310‐D1‐covered if it meets criteria C‐ policy 310‐D1‐covered if it meets criteria C‐ policy 310‐D1‐covered if it meets criteria C‐ policy 310‐D1‐covered if it meets criteria C‐ policy 310‐D1‐covered if it meets criteria N N N C‐ policy 310‐D1‐covered if it meets criteria N N N C‐PA ‐ Covered only with prior authorization 3 of 21
D1208 Topical Application of Fluoride C D1354 D1510 D1516 D1517 D1520 D1526 D1527 D1551 Interim caries arresting medicament application‐ per tooth Space maintainer‐fixed‐unilateral Space maintainer‐ fixed‐bilateral, maxillary Space maintainer‐ fixed‐bilateral, mandibular Space maintainer‐ removable‐ unilateral Space maintainer‐ removable‐bilateral, maxillary Space maintainer‐ removable‐bilateral, mandibular Re‐cementation of bilateral space maintainer, maxillary C C‐PA C‐PA C‐PA C‐PA C‐PA C‐PA C D1552 Re‐cement of bilateral space maintainer, mandibular C D1553 Re‐cement unilateral space maintainer‐per quadrant C D1556 Removal of fixed unilateral space maintainer‐per quadrant C 2 per year; 6 months plus 1 day apart Include Narrative Include Narrative Include Narrative Include Narrative Include Narrative Include Narrative Include Narrative‐ with claims submission Include Narrative‐ with claims submission Include Narrative‐ with claims submission Include Narrative‐ with claims submission N N N N N N N N N N N N D1557 Removal of fixed bilateral space maintainer, maxillary (done by dentist or practice that did not place appliance) C Include Narrative‐ with claims submission N D1558 Removal of fixed bilateral space maintainer, mandibular (done by dentist or practice that did not place appliance) C Include Narrative‐ with claims submission N Include Narrative Include Narrative N N N N N N C‐ policy 310‐D1‐covered if it meets criteria D1575 D1999 D2140 D2150 D2160 D2161 D2330 Distal shoe space maintainer‐fixed‐unilateral Unspecified preventive procedure, by report Amalgam ‐ one surface, primary or permanent Amalgam ‐ two surfaces, primary or permanent Amalgam ‐ three surfaces, primary or permanent Amalgam ‐ four or more surfaces, primary or permanent Resin ‐ one surface, anterior C‐PA C‐PA C C C C C D2331 Resin ‐ two surfaces, anterior C D2332 Resin ‐ three surfaces, anterior C C‐ Covered Service Mercy Care RBHA Dental Benefits Matrix 1/2020 Proprietary N‐Non‐covered Service C‐ policy 310‐D1‐covered if it meets criteria C‐ policy 310‐D1‐covered if it meets criteria C‐PA ‐ Covered only with prior authorization 4 of 21
D2335 C D2390 Resin ‐ four or more surfaces OR involving the incisal angle, anterior Resin – based composite crown, anterior C‐PA Include Narrative D2391 D2392 D2393 D2394 D2740 Resin – based composite – 1 surface, posterior Resin – based composite – 2 surfaces, posterior Resin – based composite – 3 surfaces, posterior Resin – based composite – 4 or more surfaces, posterior Crown‐‐‐porcelain/ceramic substrate C C C C C‐PA ‐ Ages 18‐20 Endo Tx Teeth Only Documentation of seated crown and x‐ ray required with claim D2750 Crown – porcelain fused to high noble metal C‐PA ‐ Ages 18‐20 Endo Tx Teeth Only Documentation of seated crown and x‐ ray required with claim D2751 Crown – porcelain fused to predominantly base metal C‐PA ‐ Ages 18‐20 Endo Tx Teeth Only Documentation of seated crown and x‐ ray required with claim D2752 Crown – porcelain fused to noble metal C‐PA ‐ Ages 18‐20 Endo Tx Teeth Only Documentation of seated crown and x‐ ray required with claim D2753 Crown‐porcelain fused to titanium and titanium alloys C‐PA ‐ Ages 18‐20 Endo Tx Teeth Only Documentation of seated crown and x‐ ray required with claim D2790 Crown – full cast high noble metal C‐PA ‐ Ages 18‐20 Endo Tx Teeth Only Documentation of seated crown and x‐ ray required with claim D2791 Crown – full cast predominantly base metal C‐PA ‐ Ages 18‐20 Endo Tx Teeth Only Documentation of seated crown and x‐ ray required with claim D2792 Crown – Full cast noble metal C‐PA ‐ Ages 18‐20 Endo Tx Teeth Only Documentation of seated crown and x‐ ray required with claim D2794 Crown‐ titanium C‐PA ‐ Ages 18‐20 Endo Tx Teeth Only Documentation of seated crown and x‐ ray required with claim D2910 Re‐cement inlay, onlay, or partial coverage restoration C Include Narrative D2915 Re‐cement cast or prefabricated post and core C Include Narrative C‐ Covered Service Mercy Care RBHA Dental Benefits Matrix 1/2020 Proprietary N‐Non‐covered Service C‐ policy 310‐D1‐covered if it meets criteria C‐ policy 310‐D1‐covered if it meets criteria N N N N C‐ policy 310‐D1‐covered if it meets criteria‐narrative with pre and post op x‐rays C‐ policy 310‐D1‐covered if it meets criteria‐narrative with pre and post op x‐rays C‐ policy 310‐D1‐covered if it meets criteria‐narrative with pre and post op x‐rays C‐ policy 310‐D1‐covered if it meets criteria‐narrative with pre and post op x‐rays C‐ policy 310‐D1‐covered if it meets criteria‐narrative with pre and post op x‐rays C‐ policy 310‐D1‐covered if it meets criteria‐narrative with pre and post op x‐rays C‐ policy 310‐D1‐covered if it meets criteria‐narrative with pre and post op x‐rays C‐ policy 310‐D1‐covered if it meets criteria‐narrative with pre and post op x‐rays C‐ policy 310‐D1‐covered if it meets criteria‐narrative with pre and post op x‐rays C‐ Policy 310‐D1‐covered if it meets criteria C‐ policy 310‐D1‐covered if it meets criteria C‐PA ‐ Covered only with prior authorization 5 of 21
D2920 Re‐cement crown C Include Narrative D2921 Reattachment of tooth fragment, incisial edge or cusp C Include Narrative D2929 D2930 D2931 Prefabricated porcelain/ceramic crown‐primary tooth Prefabricated stainless steel crown ‐ primary tooth Prefabricated stainless steel crown ‐ permanent tooth C‐PA C‐PA C‐PA Include Narrative Include Narrative Include Narrative D2932 Prefabricated resin crown C‐PA Include Narrative D2933 Prefabricated stainless steel crown with resin window Include Narrative D2934 D2940 Prefabricated esthetic coated stainless steel crown – primary tooth Protective restoration –Sedative filling C‐PA Anterior teeth only C‐PA Anterior teeth only C‐PA D2941 D2950 Interim therapeutic restoration‐‐‐primary dentition Core build‐up, including any pins C‐PA C‐PA D2951 D2952 Pin retention ‐ per tooth, in addition to restoration Post and core in addition to crown D2954 D2999 N N C‐ policy 310‐D1‐covered if it meets criteria C‐ policy 310‐D1‐covered if it meets criteria C‐ policy 310‐D1‐covered if it meets criteria N C‐ policy 310‐D1‐covered if it meets criteria C‐PA C‐PA Sedative fillings and permanent restorations on the same tooth may not be billed on the same date of service. Sedative fillings and pulpotomy or RCT may not be billed on the same tooth (primary or permanent) for the same date of service. Sedative fillings not covered on primary teeth without narrative. Include Narrative Claims for core build‐ups must be accompanied by a narrative describing that greater than ½ of the tooth structure is absent. Not covered on primary teeth. Include Narrative Include Narrative Prefabricated post and core in addition to crown C‐PA Include Narrative Unspecified restorative procedure, by report C‐PA Include Narrative C‐ policy 310‐D1‐covered if it meets criteria N C‐ Covered Service Mercy Care RBHA Dental Benefits Matrix 1/2020 Proprietary Include Narrative C‐ policy 310‐D1‐covered if it meets criteria N N‐Non‐covered Service N C‐ policy 310‐D1‐covered if it meets criteria N C‐ policy 310‐D1‐covered if it meets criteria C‐PA ‐ Covered only with prior authorization 6 of 21
D3110 Pulp cap – direct (excluding final restoration) C D3120 Pulp cap ‐ indirect (excluding final restoration) C D3220 Therapeutic pulpotomy (excluding final restoration), primary and permanent teeth Pulpal debridement, primary and permanent teeth C‐PA D3222 Partial Pulpotomy for apexogenesis‐‐permanent tooth with incomplete root development C‐PA Include X‐ray & narrative D3230 D3240 D3310 Pulpal therapy (restorable filling)‐anterior, primary tooth Pulpal therapy (restorable filling)‐posterior, primary tooth Anterior C‐PA C‐PA C‐PA Excluding final restoration Excluding final restoration Excluding final restoration D3320 Bicuspid C‐PA Excluding final restoration D3330 Molar C‐PA Excluding final restoration D3331 Treatment of root canal obstruction; non‐surgical access C‐PA Include X‐ray & Narrative D3332 D3333 D3346 Incomplete endodontic therapy; inoperable or fractured. Internal root repair or perforation defects. Retreatment of previous root canal therapy ‐ anterior C‐PA C‐PA C‐PA Include X‐ray & narrative Include X‐ray & narrative Include X‐ray & narrative D3347 Retreatment of previous root canal therapy – bicuspid C‐PA Include X‐ray & narrative D3348 Retreatment of previous root canal therapy ‐ molar C‐PA Include X‐ray & narrative D3221 C‐ Covered Service Mercy Care RBHA Dental Benefits Matrix 1/2020 Proprietary Direct pulp caps are covered only on permanent teeth. Direct pulp caps and permanent fillings may not be billed on the same tooth on the same date of service. This is considered part of the restoration fee. Indirect pulp caps are covered only on permanent teeth. Indirect pulp caps and permanent fillings may not be billed on the same tooth on the same date of service. This is considered part of the restoration fee. not to be used for apexogenesis C N‐Non‐covered Service C‐ policy 310‐D1‐covered if it meets criteria C‐ policy 310‐D1‐covered if it meets criteria C‐ policy 310‐D1‐covered if it meets criteria C‐ policy 310‐D1‐covered if it meets criteria N N N C‐ policy 310‐D1‐covered if it meets criteria C‐ policy 310‐D1‐covered if it meets criteria C‐ policy 310‐D1‐covered if it meets criteria C‐ policy 310‐D1‐covered if it meets criteria N N C‐ policy 310‐D1‐covered if it meets criteria C‐ policy 310‐D1‐covered if it meets criteria C‐ policy 310‐D1‐covered if it meets criteria C‐PA ‐ Covered only with prior authorization 7 of 21
D3351 D3410 Apexification/recalcification ‐ initial visit (apical closure/calcific repair of perforations, root resorption, etc.) Apexification/recalcification ‐ interim medication (apical closure/calcific repair of perforations, root resorption, etc.) Apexification/recalcification ‐ final visit (includes completed root canal therapy) Apicoectomy/periradicular surgery ‐ anterior D3421 Apicoectomy/periradicular surgery ‐ bicuspid (first root) C‐PA Include X‐ray D3425 Apicoectomy/periradicular surgery ‐ molar (first root) C‐PA Include X‐ray D3426 Apicoectomy/periradicular surgery ‐ each additional root C‐PA Include X‐ray D3430 Retrograde filling ‐ per root C‐PA Include X‐ray & narrative D3450 D3920 Root amputation ‐ per root Hemisection (including any root removal), not including root canal therapy Unspecified endodontic procedure, by report Gingivectomy or gingivoplasty – 4 or more contiguous teeth or tooth bounded spaces per quadrant C‐PA C‐PA Include X‐ray Include X‐ray C‐ policy 310‐D1‐covered if it meets criteria C‐ policy 310‐D1‐covered if it meets criteria C‐ policy 310‐D1‐covered if it meets criteria C‐ policy 310‐D1‐covered if it meets criteria C‐ policy 310‐D1‐covered if it meets criteria N N C‐PA C‐PA Include Narrative Include Narrative, Perio Chart N N C‐PA Include Narrative, Perio Chart Include Narrative, Perio Chart, medical necessity Include Narrative, Perio Chart N C‐PA C‐PA Include Narrative, Perio Chart Include Narrative, Perio Chart N N C‐PA C‐PA Include Narrative, Perio Chart Include Narrative N D4263 Gingivectomy or gingivoplasty – 1 to 3 contiguous teeth or tooth bounded spaces per quadrant Gingival flap procedure, including root planing – 4 or more contiguous teeth or tooth bounded spaces per quadrant Gingival flap procedure, including root planing – 1 to 3 contiguous teeth or tooth bounded spaces per quadrant Clinical crown lengthening – hard tissue Osseous surgery (including flap entry and closure) ‐ 4 or more contiguous teeth or bounded teeth spaces per quadrant Osseous surgery (including flap entry and closure) – 1 to 3 teeth per quadrant Bone replacement graft‐‐‐first site in quadrant D4264 Bone replacement graft—each additional site in quadrant C‐PA Include Narrative N D3352 D3353 D3999 D4210 D4211 D4240 D4241 D4249 D4260 D4261 C‐ Covered Service Mercy Care RBHA Dental Benefits Matrix 1/2020 Proprietary C‐PA Include X‐ray & narrative N C‐PA Include X‐ray & narrative N C‐PA Include X‐ray & narrative N C‐PA Include X‐ray C‐PA C‐PA N‐Non‐covered Service N N N C‐PA ‐ Covered only with prior authorization 8 of 21
D4265 D4266 D4267 D4270 D4273 D4274 D4275 D4276 D4320 D4321 D4341 D4342 D4346 D4355 D4910 D4920 D4999 D5110 D5120 D5130 D5140 D5211 D5212 Biologic materials to aid in soft and osseous tissue regeneration Guided tissue regeneration—restorable barrier—per site Guided tissue regeneration—Non‐restorable barrier—per site Pedicle soft tissue graft procedure Sub‐epithelial connective tissue graft procedures, per tooth Distal or proximal wedge procedure (when not performed in conjunction with surgical procedures in the same anatomical area Soft tissue allograft Combined connective tissue and double pedicle graft‐‐‐ per tooth Provisional splinting‐‐‐intra‐coronal Provisional splinting‐‐‐extra‐coronal Periodontal scaling and root planing – 4 or more teeth per quadrant Periodontal scaling and root planing – 1 to 3 teeth, per quadrant Scaling in the presence of generalized moderate or severe gingival inflammation – full mouth after evaluation Full mouth debridement to enable comprehensive evaluation and diagnosis Periodontal maintenance procedures ‐following active periodontal therapy— Unscheduled dressing change (by someone other than the treating dentist) Unspecified periodontal procedure, by report 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) C‐ Covered Service Mercy Care RBHA Dental Benefits Matrix 1/2020 Proprietary C‐PA Include Narrative N C‐PA C‐PA Include Narrative Include Narrative N N C‐PA C‐PA Include Narrative Include Narrative N N C‐PA Include Narrative N C‐PA C‐PA Include Narrative Include Narrative N N C‐PA C‐PA C‐PA Include Narrative Include Narrative Include Narrative, Perio Chart, X‐rays N N N C‐PA Include Narrative, Perio Chart, X‐rays N C‐PA Include Narrative, Perio Chart, X‐rays N C‐PA Include Narrative, Perio chart N C‐PA Include Narrative & Perio chart N C‐PA N C‐PA C‐PA C‐PA C‐PA C‐PA C‐PA Include Narrative Include Narrative Include Narrative Include Narrative Include Narrative Include Narrative N N N N N N C‐PA Include Narrative N N‐Non‐covered Service C‐PA ‐ Covered only with prior authorization 9 of 21
D5213 D5214 D5221 D5222 D5223 D5224 D5282 D5283 D5284 D5286 D5410 D5411 D5421 D5422 D5511 D5512 D5520 D5611 D5612 D5620 D5621 D5622 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) Immediate maxillary partial denture‐resin base(including any conventional clasps, rests and teeth) Immediate mandibular partial denture‐ resin base(including any conventional clasps, rests and teeth) Immediate maxillary partial denture‐ cast metal framework with resin denture bases (including any conventional clasps, rests and teeth) Immediate mandibular partial denture‐cast metal framework with resin dentures bases (including any conventional clasps, rests and teeth) Removable unilateral partial denture, one‐piece cast metal, (including clasp and teeth), maxillary Removable unilateral partial denture, one‐piece cast metal, (including clasp and teeth), mandibular Removable unilateral partial denture‐one‐piece flexible base (including clasps and teeth) ‐per quadrant Removable unilateral partial denture‐one‐piece resin (including clasps and teeth)‐per quadrant Include Narrative N C‐PA Include Narrative N C‐PA Include Narrative N C‐PA Include Narrative N C‐PA Include Narrative N C‐PA Include Narrative N C‐PA Include Narrative N C‐PA Include Narrative N C‐PA Include Narrative N C‐PA Include Narrative N Include Narrative Include Narrative Include Narrative Include Narrative Include Narrative Include Narrative Include Narrative N N N N N N N Adjust complete denture ‐ maxillary C‐PA Adjust complete denture ‐ mandibular C‐PA Adjust partial denture ‐ maxillary C‐PA Adjust partial denture ‐ mandibular C‐PA Repair broken complete denture base, mandibular C‐PA Repair broken complete denture base, maxillary C‐PA Replace missing or broken teeth ‐ complete denture (each C‐PA tooth) Repair resin denture base, mandibular C‐PA Repair resin denture base, maxillary C‐PA Repair cast framework C‐PA Repair cast metal framework, mandibular C‐PA Repair cast metal framework, maxillary C‐PA C‐ Covered Service N‐Non‐covered Service Mercy Care RBHA Dental Benefits Matrix 1/2020 Proprietary C‐PA Include Narrative Include narrative Include Narrative Include Narrative Include Narrative C‐PA ‐ Covered only with prior authorization N N N N N 10 of 21
D5630 D5640 D5650 D5660 D5710 D5711 D5720 D5721 D5730 D5731 D5740 D5741 D5750 D5751 D5760 D5761 D5820 D5821 C‐PA C‐PA C‐PA C‐PA C‐PA C‐PA C‐PA C‐PA C‐PA C‐PA C‐PA C‐PA C‐PA C‐PA C‐PA C‐PA C‐PA C‐PA Include Narrative Include Narrative Include Narrative Include Narrative Include Narrative Include Narrative Include Narrative Include Narrative Include Narrative Include Narrative Include Narrative Include Narrative Include Narrative Include Narrative Include Narrative Include Narrative Include Narrative & X‐ray Include Narrative & X‐ray N N N N N N N N N N N N N N N N N N D5850 D5851 D5876 Repair or replace broken clasp Replace broken teeth Add tooth to existing partial denture Add clasp to existing partial denture Rebase complete maxillary denture Rebase complete mandibular C224 denture Rebase maxillary partial denture Rebase mandibular partial denture Reline maxillary complete denture (chairside) Reline mandibular complete denture (chairside) Reline maxillary partial denture (chairside) Reline mandibular partial denture (chairside) Reline maxillary complete denture (laboratory) Reline mandibular complete denture (laboratory) Reline maxillary partial denture (laboratory) Reline mandibular partial denture (laboratory) Maxillary Interim Partial Denture (use for anterior flipper) Mandibular Interim Partial Denture (use for anterior flipper) Maxillary Tissue conditioning Mandibular Tissue conditioning Add metal substructure to acrylic full denture (per arch) C‐PA C‐PA C‐PA Include Narrative Include Narrative Include Narrative N N N D5899 Unspecified removable prosthodontic procedure C‐PA Include narrative N D5911 D5912 D5913 D5914 D5915 D5916 D5919 D5922 D5923 D5924 D5925 D5926 D5927 Facial moulage (sectional) Facial moulage (complete) Nasal prosthesis Auricular prosthesis Orbital prosthesis Ocular prosthesis Facial prosthesis Nasal septal prosthesis Ocular prosthesis, interim Cranial prosthesis Facial augmentation implant prosthesis Nasal prosthesis, replacement Auricular prosthesis, replacement C‐PA C‐PA C‐PA C‐PA C‐PA C‐PA C‐PA C‐PA C‐PA C‐PA C‐PA C‐PA C‐PA Include Narrative Include Narrative Include Narrative Include Narrative Include Narrative Include Narrative Include Narrative Include Narrative Include Narrative Include Narrative Include Narrative Include Narrative Include Narrative N N N N N N N N N N N N N C‐ Covered Service Mercy Care RBHA Dental Benefits Matrix 1/2020 Proprietary N‐Non‐covered Service C‐PA ‐ Covered only with prior authorization 11 of 21
D5828 D5929 D5931 D5932 D5933 D5934 D5935 D5936 D5937 D5951 D5952 D5953 D5954 D5955 D5958 D5959 D5960 D5982 D5983 D5984 D5985 D5986 D5987 D5988 D5991 D5999 D6081 Orbital prosthesis, replacement Facial prosthesis, replacement Obturator prosthesis, surgical Obturator prosthesis, definitive Obturator prosthesis, modification Mandibular resection prosthesis with guide flange Mandibular resection prosthesis without guide flange Obturator/prosthesis, interim Trismus appliance (not for TMD treatment) Feeding aid Speech aid prosthesis, pediatric Speech aid prosthesis, adult Palatal augmentation prosthesis Palatal life prosthesis, definitive Palatal lift prosthesis, interim Palatal lift prosthesis, modification Speech aid prosthesis, modification Surgical stent Radiation carrier Radiation shield Radiation cone locator Fluoride gel carrier Commissure splint Surgical splint Vesiculobullous disease medicament carrier Unspecified maxillofacial prosthesis, by report Scaling and debridement in the presence of inflammation or mucositis of a single implant, including cleaning of the implant surfaces, without flap entry and closure C‐PA C‐PA C‐PA C‐PA C‐PA C‐PA C‐PA C‐PA C‐PA C‐PA C‐PA C‐PA C‐PA C‐PA C‐PA C‐PA C‐PA C‐PA C‐PA C‐PA C‐PA C‐PA C‐PA C‐PA C‐PA C‐PA C‐PA D6930 Re‐cement fixed partial denture C‐PA D6999 Unspecified fixed prosthodontic procedure, by report C‐PA C‐ Covered Service Mercy Care RBHA Dental Benefits Matrix 1/2020 Proprietary N‐Non‐covered Service Include Narrative Include Narrative Include Narrative Include Narrative Include Narrative Include Narrative Include Narrative Include Narrative Include Narrative Include Narrative Include Narrative Include Narrative Include Narrative Include Narrative Include Narrative Include Narrative Include Narrative Include Narrative Include Narrative Include Narrative Include Narrative Include Narrative Include Narrative Include Narrative Include Narrative Include Narrative Include narrative, pre‐op x‐ray(s), perio charting (Not to be performed in conjunction of D1110, D4910, D4346) Narrative required with claims submission Include narrative N N N N N N N N N N N N N N N N N N N N N N N N N N N N N C‐PA ‐ Covered only with prior authorization 12 of 21
*Extractions of naturally exfoliating teeth are not a covered benefit. **Extractions are covered for ages 0‐20 if: 1. Tooth (teeth) is symptomatic and/or exhibits pathology. 2. Extraction (s) in NOT for orthodontic purposes 3. Extraction (s) is NOT for the prophylactic extraction of 3rd molars 4. Prior Authorization is submitted for ALL 3rd molar extractions **Claims for ALL extractions must be accompanied by X‐ray and/or treatment notes. D7111 Coronal remnants – deciduous tooth C‐PA C‐ policy 310‐D1‐covered if it meets criteria D7140 Extraction, erupted tooth or exposed root (elevation and/or forceps removal) Surgical removal of erupted tooth requiring elevation of mucoperiosteal flap and removal of bone and/or section of tooth including cutting of gingiva and bone, removal of tooth structure, minor smoothing of socket bone and closure Removal of impacted tooth ‐ soft tissue – occlusal surface of tooth covered by soft tissue; requires mucoperiosteal flap elevation Removal of impacted tooth ‐ partially bony – part of crown covered by bone; requires mucoperiosteal flap elevation and bone removal Removal of impacted tooth ‐ completely bony – most or all of crown covered by bone; requires mucoperiosteal flap elevation and bone removal Removal of impacted tooth ‐ completely bony, with unusual surgical complications – most or all of crown covered by bone; unusually difficult or complicated due to factors such as nerve dissection required, separate closure of maxillary sinus required or aberrant tooth position Surgical removal of residual tooth roots (cutting procedure) includes cutting of soft tissue and bone, removal of tooth surface and closure (completely submerged in bone) C‐PA C‐ policy 310‐D1‐covered if it meets criteria C‐ policy 310‐D1‐covered if it meets criteria Coronectomy—intentional partial tooth removal D7210 D7220 D7230 D7240 D7241 D7250 D7251 C‐ Covered Service Mercy Care RBHA Dental Benefits Matrix 1/2020 Proprietary C‐PA C‐PA Include X‐ray, Narrative C‐ policy 310‐D1‐covered if it meets criteria C‐PA Include X‐ray, Narrative C‐ policy 310‐D1‐covered if it meets criteria C‐PA Include X‐ray, Narrative C‐ policy 310‐D1‐covered if it meets criteria C‐PA Include X‐ray, Narrative C‐ policy 310‐D1‐covered if it meets criteria C‐PA Include X‐ray, Narrative C‐ policy 310‐D1‐covered if it meets criteria C‐PA Include Narrative C‐ policy 310‐D1‐covered if it meets criteria N‐Non‐covered Service C‐PA ‐ Covered only with prior authorization 13 of 21
D7260 Oral antral fistula closure C‐PA D7261 Primary closure of a sinus perforation C‐PA D7270 Tooth reimplantation and/or stabilization of accidentally evulsed or displaced tooth C‐PA Narrative required with claims submission C‐ policy 310‐D1‐covered if it meets criteria C‐ policy 310‐D1‐covered if it meets criteria C‐ policy 310‐D1‐covered if it meets criteria D7280 D7282 C‐PA C‐PA Include X‐ray, Narrative Include X‐ray, Narrative N N C‐PA Include X‐ray, Narrative N D7285 Surgical access of an unerupted tooth Mobilization of erupted or malpositioned tooth to aid eruption Placement of device to facilitate eruption of impacted tooth Biopsy of oral tissue – hard C‐PA Include Narrative D7286 Biopsy of oral tissue – soft C‐PA Include Narrative D7292 Surgical placement: Temporary anchorage devic
meets AHCCCS criteria. Members age 21 and older that qualify for an emergent root canal may have a crown placed to complete the care. Otherwise, permanent crown sare not a covered benefit. Prior authorization is not a guarantee of payment. Mail Prior Authorization to: Mercy Care RBHA Dental Prior Authorization 4755 S. 44. th . Place
CONTENTS CONTENTS Notation and Nomenclature A Matrix A ij Matrix indexed for some purpose A i Matrix indexed for some purpose Aij Matrix indexed for some purpose An Matrix indexed for some purpose or The n.th power of a square matrix A 1 The inverse matrix of the matrix A A The pseudo inverse matrix of the matrix A (see Sec. 3.6) A1 2 The square root of a matrix (if unique), not elementwise
A Matrix A ij Matrix indexed for some purpose A i Matrix indexed for some purpose Aij Matrix indexed for some purpose An Matrix indexed for some purpose or The n.th power of a square matrix A 1 The inverse matrix of the matrix A A The pseudo inverse matrix of the matrix A (see Sec. 3.6) A1/2 The square root of a matrix (if unique), not .
CONTENTS CONTENTS Notation and Nomenclature A Matrix Aij Matrix indexed for some purpose Ai Matrix indexed for some purpose Aij Matrix indexed for some purpose An Matrix indexed for some purpose or The n.th power of a square matrix A 1 The inverse matrix of the matrix A A The pseudo inverse matrix of the matrix A (see Sec. 3.6) A1/2 The square root of a matrix (if unique), not elementwise
CONTENTS CONTENTS Notation and Nomenclature A Matrix A ij Matrix indexed for some purpose A i Matrix indexed for some purpose Aij Matrix indexed for some purpose An Matrix indexed for some purpose or The n.th power of a square matrix A 1 The inverse matrix of the matrix A A The pseudo inverse matrix of the matrix A (see Sec. 3.6) A1 2 The sq
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DENTAL SCIENCES 1 Chapter 1 I Dental Assisting— The Profession 3 The Career of Dental Assisting 4 Employment for the Dental Assistant 4 The Dental Team 6 Dental Jurisprudence and Ethics 12 Dental Practice Act 12 State Board of Dentistry 12 The Dentist, the Dental Assistant, and the Law 13 Standard of Care 13 Dental Records 14 Ethics 14
Cigna Dental Care DMO Patient Charge Schedules 887394 09/15 CDT 2016 Covered under Procedure Code1 Dental Description and Nomenclature Cigna Dental 01 and 02 PCS Cigna Dental 03 PCS Cigna Dental 04 PCS Cigna Dental 05 PCS Cigna Dental 06 PCS Cigna Dental 07 PCS Cigna Dental 08 PCS Chair Time Per Y/N Minutes Code # (if different) Y/N Code # (if .
is a detailed list of dental services provided by a dental office and given to Delta Dental for payment. Delta Dental means Delta Dental Plan of Michigan, Inc., a service provider for dental benefits under the Michigan Dental Program. Delta Dental ID Card is a permanent (not monthly) card. We send
