2017 Provider Quick Reference Guide for Medicare Advantage ...€¦ · xNational UnitedHealthcare...

2017 Provider Quick Reference Guide for Medicare Advantage Plans

UnitedHealthcareAttn: Provider Quick Reference Guidec/o PCA15 W. Aylesbury Road, Suite 200Timonium, MD 21093

Presorted StandardUS Postage

PaidWaldorf, MD

Permit No. 144

SAMPLE

September 22, 2016 Dear Valued Provider: UnitedHealthcare thanks you for your participation in the UnitedHealthcare (UHC) Medicare dental network. We are pleased to provide you with our new 2017 Provider Quick Reference Guide for Medicare Advantage plans, which includes the state specific Quick Reference Guides (QRGs) for all Medicare products, and a Frequently Asked Questions (FAQ) reference sheet. As a reminder, members will be referencing or showing their medical ID card as they do not have a separate dental ID card. A sample card, showing the format, is below. Many of the medical cards may display the acronym “HMO” (example 1). However, the dental plan for this member is not an HMO plan, but rather it is our UHC Medicare plan in which you participate. On the back of the card, please use the Dental Provider phone number that is located in the lower right hand corner.

While the above is just a sample, please refer to the state specific QRG which reflects a copy of the ID card that corresponds to the member’s plan. This copy will display the actual plan name and dental provider phone number. Should you have any questions, please contact us by dialing our dedicated toll free customer service number found on the Quick Reference Guide for your state. We look forward to continuing a long and mutually rewarding relationship. Sincerely,

Vice President, Network Development UnitedHealthcare Dental

Example 1 Dental Provider Phone Number

1

2017 Provider Quick Reference Guide For Medicare Advantage Plans

UnitedHealthcare FAQ

Q. What is a Quick Reference Guide (QRG)? A. QRG is a 2 to 3 page reference document that shows the following:

Plan name A sample member ID card that is plan name specific. Phone numbers for eligibility/benefit verification and claims questions. Addresses for claims/prior authorization submission. Summary of covered ADA codes/services and corresponding frequency. Web site for online services

Q. How do I use this book?

A. The book will include an index showing QRGs in alphabetical order by state.

Q. How will I know which QRG goes with what member? A. The members ID card will reflect the name of their Plan. Refer to the Index; locate the state and the Plan name.

Q. Are the Quick Reference Guides for all Medicare Advantage products in this book?

A. Yes, all Medicare Advantage Plans are included in this booklet. QRGs for Medicaid lines of business are not included except for some Medicaid plans in Florida.

Q. What fee schedule is used for covered services?

A. Covered services will be reimbursed according to your contracted commercial PPO fee schedule.

Q. Who can help me with questions about my participation? A. To obtain a copy of your fee schedule, contractual questions, dentist changes or office updates; please call provider Services at (800) 822-5353.

2017 M&R FAQ

3

2017 Provider Quick Reference Guide (QRG) Index for Medicare Advantage Plans Sectioned by State & National Level Plans

State Plans Alabama

AARP MedicareComplete Plan ( $1,000 Annual Max/ Product D0015896) UnitedHealthcare Community Plan Dual Complete ($2,500 Annual Max/Product 409) National AARP MedicareComplete & UnitedHealthcare MedicareComplete Plans (See national plan section) National UnitedHealthcare Dental Platinum Rider (See national plan section) National UnitedHealthcare Nursing Home & Assisted Living Plans (See national plan section)

Arkansas

National AARP MedicareComplete & UnitedHealthcare MedicareComplete Plans (See national plan section) National AARP MedicareComplete Plans (See national plan section) National UnitedHealthcare Care Improvement Plus Gold Rx (See national plan section) National UnitedHealthcare Care Improvement Plus Silver Rx, Dual Advantage (See national plan section) National UnitedHealthcare Dental Platinum Rider (See national plan section)

Arizona UnitedHealthcare Community Plan Dual Complete ($2,500 Annual Max/Products 67 & 365) UnitedHealthcare Medicare Nursing Home Plan ($2,400 Annual Max/D0018585) National UnitedHealthcare Dental Platinum Rider (See national plan section) National UnitedHealthcare Nursing Home & Assisted Living Plan (See national plan section)

California

AARP MedicareComplete DHMO (No Annual Max/Product D0012660) High Option Rider-DHMO ($1,000 Annual Max/Product D0012025) Optional Rider-DHMO (No Annual Max/Product D00012024) National UnitedHealthcare Dental Platinum Rider (See national plan section)

Colorado High Option Rider 260 DHMO ($1,000 Annual Max/Product D0012026) UnitedHealthcare Medicare Nursing Home Plan ($2,400 Annual Max/D0018585) National AARP MedicareComplete & UnitedHealthcare MedicareComplete Plans (See national plan section) National Erickson Advantage Medicare (See national plan section) National UnitedHealthcare Nursing Home & Assisted Living Plan (See national plan section) National UnitedHealthcare Nursing Home & Assisted Living Plans (See national plan section)

5


Connecticut

UnitedHealthcare AARP MedicareComplete Plans (formally Oxford DHMO) (No Annual Max/Product 143) National AARP MedicareComplete & UnitedHealthcare MedicareComplete Plans (See national plan section) National UnitedHealthcare Dental Platinum Rider (See national plan section) National UnitedHealthcare Nursing Home & Assisted Living Plans (See national plan section)

District of Columbia UnitedHealthcare Community Plan Dual Complete ($1,000 Annual Max/Product 193) National UnitedHealthcare Nursing Home & Assisted Living Plans (See national plan section)

Delaware UnitedHealthcare Community Plan Dual Complete ($1,000 Annual Max/Product 400) National UnitedHealthcare Nursing Home & Assisted Living Plans (See national plan section)

Florida AARP MedicareComplete Choice Plan (No Annual Max/Product D0007383) UnitedHealthcare Community Plan/UnitedHealthcare of Florida Dual Complete LP ($1,500 Annual Max/Product 364) UnitedHealthcare Community Plan/UnitedHealthcare of Florida Dual Complete Medicaid Wrap (No Annual Max/Product 289) UnitedHealthcare Community Plan/UnitedHealthcare of Florida Dual Complete RP ($1,500 Annual Max/Product 288) UnitedHealthcare the Villages MedicareComplete, AARP MedicareComplete Focus, AARP MedicareComplete Plus, AARP MedicareComplete Plans (No Annual Max/Product D0007381) National UnitedHealthcare Nursing Home & Assisted Living Plan (See national plan section) National UnitedHealthcare Nursing Home & Assisted Living Plans (See national plan section)

Georgia

AARP MedicareComplete Plans ($500 Annual Max/Product D0015895) UnitedHealthcare Care Improvement Plus Medicare Advantage ($500 Annual Max/Product 402) UnitedHealthcare Care Improvement Plus Silver Rx ($1,000 Annual Max/Product 367) UnitedHealthcare Community Plan Dual Complete ($1,000 Annual Max/Product 168) UnitedHealthcare Community Plan Dual Complete ($1,000 Annual Max/Product 169) National AARP MedicareComplete & UnitedHealthcare MedicareComplete Plans (See national plan section) National UnitedHealthcare Care Improvement Plus Gold Rx (See national plan section) National UnitedHealthcare Care Improvement Plus Silver Rx (See national plan section) National UnitedHealthcare Dental Platinum Rider (See national plan section)

66


Hawaii

UnitedHealthcare Community Plan Dual Complete ($2,000 Annual Max/Product 170) UnitedHealthcare Community Plan Medicare Dual SNP ($1,000 Annual Max/Product 357) National UnitedHealthcare Dental Platinum Rider (See national plan section)

Idaho AARP MedicareComplete Choice Plan 2 (No Annual Max/Product D0013571)

Illinois

AARP MedicareComplete Plan ($1,000 Annual Max/Product D0010299) National AARP MedicareComplete & UnitedHealthcare MedicareComplete Plans (See national plan section) National AARP MedicareComplete Choice Plans (See national plan section) National UnitedHealthcare Dental Platinum Rider (See national plan section)

Indiana

AARP MedicareComplete Plan 2 ($1,000 Annual Max/Product D0018539) National AARP MedicareComplete & UnitedHealthcare MedicareComplete Plans (See national plan section) National AARP MedicareComplete Choice Plans (See national plan section) National UnitedHealthcare Dental Platinum Rider (See national plan section)

Iowa

National AARP MedicareComplete & UnitedHealthcare MedicareComplete Plans (See national plan section)

Kansas

AARP MedicareComplete Plans & UnitedHealthcare Chronic Complete ($1000 Annual Max/Product D0018548) UnitedHealthcare Community Plan Dual Complete ($2,000 Annual Max/Product 398) National AARP MedicareComplete & UnitedHealthcare MedicareComplete Plans (See national plan section) National AARP MedicareComplete Choice Plans (See national plan section) National UnitedHealthcare Dental Platinum Rider (See national plan section)

Kentucky

National AARP MedicareComplete & UnitedHealthcare MedicareComplete Plans (See national plan section) National AARP MedicareComplete Plans (See national plan section) National UnitedHealthcare Dental Platinum Rider (See national plan section)

7


Louisiana

UnitedHealthcare Community Plan Dual Complete ($2,000 Annual Max/Product 399) Massachusetts

National AARP MedicareComplete & UnitedHealthcare MedicareComplete Plans (See national plan section) National Erickson Advantage Medicare (See national plan section)

Maryland

National Erickson Advantage Medicare (See national plan section) National UnitedHealthcare Nursing Home & Assisted Living Plans (See national plan section)

Maine

National AARP MedicareComplete Choice Plans (See national plan section) National UnitedHealthcare Nursing Home & Assisted Living Plans (See national plan section)

Michigan

National AARP MedicareComplete Choice Plans (See national plan section) Missouri

National AARP MedicareComplete & UnitedHealthcare MedicareComplete Plans (See national plan section) National AARP MedicareComplete Choice Plans (See national plan section) National UnitedHealthcare Care Improvement Plus Gold Rx (See national plan section) National UnitedHealthcare Care Improvement Plus Silver Rx, Dual Advantage (See national plan section) National UnitedHealthcare Dental Platinum Rider (See national plan section)

Mississippi UnitedHealthcare Community Plan Dual Complete ($2,000 Annual Max/Product 401)

Nebraska

National AARP MedicareComplete & UnitedHealthcare MedicareComplete Plans (See national plan section)

New Hampshire

National AARP MedicareComplete & UnitedHealthcare MedicareComplete Plans (See national plan section) National AARP MedicareComplete Choice Plans (See national plan section) National UnitedHealthcare Nursing Home & Assisted Living Plans (See national plan section)

88


New Jersey

UnitedHealthcare AARP MedicareComplete Plans (formally Oxford DHMO) (No Annual Max/Product 143) National Erickson Advantage Medicare (See national plan section)

New Mexico UnitedHealthcare Community Plan Dual Complete ($2,000 Annual Max/Product 172) UnitedHealthcare Community Plan Dual Complete ($2,000 Annual Max/Product 403) National UnitedHealthcare Dental Platinum Rider (See national plan section)

New York UnitedHealthcare AARP MedicareComplete Plans (formally Oxford DHMO) (No Annual Max/Product 143) UnitedHealthcare Community Plan Dual Complete ($2,500 Annual Max/Product 20) UnitedHealthcare MedicareComplete Choice Plans ($1,000 Annual Max/Product D0015893) National AARP MedicareComplete & UnitedHealthcare MedicareComplete Plans (See national plan section) National UnitedHealthcare Dental Platinum Rider (See national plan section)

Nevada AARP MedicareComplete & AARP MedicareComplete SecureHorizons (No Annual Max/Product D0011527) National AARP MedicareComplete & UnitedHealthcare MedicareComplete Plans (See national plan section)

North Carolina

UnitedHealthcare Community Plan Dual Complete ($2,500 Annual Max/Product 408) National AARP MedicareComplete & UnitedHealthcare MedicareComplete Plans (See national plan section) National UnitedHealthcare Dental Platinum Rider (See national plan section) National UnitedHealthcare Nursing Home & Assisted Living Plans (See national plan section)

Ohio UnitedHealthcare Community Plan Dual Complete ($2,000 Annual Max/Product 369) National AARP MedicareComplete & UnitedHealthcare MedicareComplete Plans (See national plan section) National AARP MedicareComplete Plans (See national plan section) National UnitedHealthcare Dental Platinum Rider (See national plan section) National UnitedHealthcare Nursing Home & Assisted Living Plans (See national plan section) National UnitedHealthcare Nursing Home Plan (See national plan section)

9


Oklahoma

AARP MedicareComplete & AARP MedicareComplete SecureHorizons (No Annual Max/Product D0011527) National AARP MedicareComplete & UnitedHealthcare MedicareComplete Plans (See national plan section) National UnitedHealthcare Dental Platinum Rider (See national plan section)

Oregon

UnitedHealthcare Nursing Home and Assisted Living Plans ($1,000 Annual Max/Product D0012657) National AARP MedicareComplete & UnitedHealthcare MedicareComplete Plans (See national plan section) National UnitedHealthcare Dental Platinum Rider (See national plan section) National UnitedHealthcare Nursing Home & Assisted Living Plans (See national plan section)

Pennsylvania

UnitedHealthcare Community Plan Dual Complete ($2,500 Annual Max/Product 368) National AARP MedicareComplete & UnitedHealthcare MedicareComplete Plans (See national plan section) National AARP MedicareComplete Choice Plans (See national plan section) National Erickson Advantage Medicare (See national plan section) National UnitedHealthcare Nursing Home & Assisted Living Plans (See national plan section)

Rhode Island

UnitedHealthcare Community Plan Dual Complete ($2,000 Annual Max/Product 397) National AARP MedicareComplete & UnitedHealthcare MedicareComplete Plans (See national plan section) National UnitedHealthcare Dental Platinum Rider (See national plan section)

South Carolina UnitedHealthcare Care Improvement Plus Silver Rx ($1,000 Annual Max/Product 367) National AARP MedicareComplete & UnitedHealthcare MedicareComplete Plans (See national plan section) National UnitedHealthcare Care Improvement Plus Gold Rx (See national plan section) National UnitedHealthcare Care Improvement Plus Silver Rx (See national plan section) National UnitedHealthcare Dental Platinum Rider (See national plan section)

Tennessee UnitedHealthcare Community Plan Dual Complete ($1,000 Annual Max/Product 23) National AARP MedicareComplete & UnitedHealthcare MedicareComplete Plans (See national plan section) National UnitedHealthcare Nursing Home & Assisted Living Plans (See national plan section)

1010


Texas

AARP MedicareComplete Focus ($500 Annual Max/Product D0012666) AARP MedicareComplete Focus Essential (No Annual Max/Product D0012703) AARP MedicareComplete Plans & UnitedHealthcare Chronic Complete ($1000 Annual Max/Product D0018551) AARP MedicareComplete SecureHorizons Essential (No Annual Max/Product D1000068) UnitedHealthcare Community Plan Dual Complete ($1,000 Annual Max/Product 173) UnitedHealthcare Community Plan Dual Complete ($1,250 Annual Max/Product 396) UnitedHealthcare Community Plan Dual Complete ($2,000 Annual Max/Product 191) UnitedHealthcare Community Plan Dual Complete ($2,000 Annual Max/Product 394) UnitedHealthcare Community Plan Dual Complete ($2,500 Annual Max/Product 192) UnitedHealthcare Community Plan Dual Complete ($2,500 Annual Max/Product 395) National AARP MedicareComplete & UnitedHealthcare MedicareComplete Plans (See national plan section) National Erickson Advantage Medicare (See national plan section) National UnitedHealthcare Care Improvement Plus Gold Rx (See national plan section) National UnitedHealthcare Care Improvement Plus Silver Rx (See national plan section) National UnitedHealthcare Dental Platinum Rider (See national plan section)

Utah AARP MedicareComplete Plan 2 (No Annual Max/Product D0018584) National AARP MedicareComplete & UnitedHealthcare MedicareComplete Plans (See national plan section)

Virginia

National AARP MedicareComplete & UnitedHealthcare MedicareComplete Plans (See national plan section) National UnitedHealthcare Dental Platinum Rider (See national plan section) National Erickson Advantage Medicare (See national plan section) National UnitedHealthcare Nursing Home & Assisted Living Plans (See national plan section)

Washington

UnitedHealthcare Community Plan Dual Complete ($1,250 Annual Max/Product 194) UnitedHealthcare Nursing Home and Assisted Living Plans ($1,000 Annual Max/ Product D0012657) National AARP MedicareComplete & UnitedHealthcare MedicareComplete Plans (See national plan section) National UnitedHealthcare Dental Platinum Rider (See national plan section) National UnitedHealthcare Nursing Home & Assisted Living Plans (See national plan section)

11


Wisconsin

UnitedHealthcare Community Plan Dual Complete ($1,500 Annual Max/Product 363) UnitedHealthcare Nursing Home Plan ($1,000 Annual Max/Product D0013573) National AARP MedicareComplete & UnitedHealthcare MedicareComplete Plans (See national plan section) National UnitedHealthcare Care Improvement Plus Gold Rx (See national plan section) National UnitedHealthcare Dental Platinum Rider (See national plan section) National UnitedHealthcare Nursing Home & Assisted Living Plans (See national plan section)

National Plans

AARP MedicareComplete & UnitedHealthcare MedicareComplete Plans (No Annual Max/Products D0011451 & D0015219) AARP MedicareComplete Choice Plans 1 & 2 (No Annual Max/Product D0011530) AARP MedicareComplete Plans ($1,000 Annual Max/Product D0015894) Erickson Advantage Medicare (No Annual Max/Product D0005183) UnitedHealthcare Care Improvement Plus Gold Rx (No Annual Max/Product 283) UnitedHealthcare Care Improvement Plus Silver Rx (No Annual Max/Product 284) UnitedHealthcare Care Improvement Plus Silver Rx, Dual Advantage ($500 Annual Max/Product 366) UnitedHealthcare Dental Platinum Rider ($1,000 Annual Max/Products D001337 & D0015067) UnitedHealthcare Nursing Home & Assisted Living Plans ($250 Annual Max/Product D0003398) UnitedHealthcare Nursing Home & Assisted Living Plans ($500 Annual Max/Product D0007296) UnitedHealthcare Nursing Home & Assisted Living Plans ($500 Annual Max/Product D0012658) UnitedHealthcare Nursing Home & Assisted Living Plan ($1,800 Annual Max/Product D0014777) UnitedHealthcare Nursing Home Plan ($250 Annual Max/Product D0011452)

1212

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h no

ble

met

alcr

own

- por

cela

in fu

sed

to p

redo

min

antly

bas

e m

etal

crow

n - p

orce

lain

fuse

d to

nob

le m

etal

crow

n, 3

/4 c

ast h

igh

nobl

e m

etal

crow

n, 3

/4 c

ast p

redo

min

atel

y ba

se m

etal

crow

n - 3

/4 re

sin-

base

d co

mpo

site

(ind

irect

)cr

own

- res

in w

ith h

igh

nobl

e m

etal

crow

n - r

esin

with

pre

dom

inan

tly b

ase

met

alcr

own

- res

in w

ith n

oble

met

alcr

own

- por

cela

in/c

eram

ic su

bstr

ate

resi

n-ba

sed

com

posi

te -

one

surf

ace,

pos

terio

rre

sin-

base

d co

mpo

site

- tw

o su

rfac

es, p

oste

rior

resi

n-ba

sed

com

posi

te -

thre

e su

rfac

es, p

oste

rior

resi

n-ba

sed

com

posi

te -

four

or m

ore

surf

aces

, pos

terio

rcr

own,

resi

n-ba

sed

com

posi

te (i

ndire

ct)

pulp

vita

lity

test

s

amal

gam

- fo

ur o

r mor

e su

rfac

es, p

rimar

y or

per

man

ent

resi

n-ba

sed

com

posi

te -

one

surf

ace,

ant

erio

rre

sin-

base

d co

mpo

site

- tw

o su

rfac

es, a

nter

ior

resi

n-ba

sed

com

posi

te -

thre

e su

rfac

es, a

nter

ior

resi

n-ba

sed

com

posi

te -

four

or m

ore

surf

aces

or i

nvol

ving

inci

sal a

ngle

(ant

erio

r)

Topi

cal a

pplic

atio

n of

fluo

ride

- exc

ludi

ng v

arni

shor

al h

ygie

ne in

stru

ctio

nsam

alga

m -

one

surf

ace,

prim

ary

or p

erm

anen

tam

alga

m -

two

surf

aces

, prim

ary

or p

erm

anen

tam

alga

m -

thre

e su

rfac

es, p

rimar

y or

per

man

ent

intr

aora

l - o

cclu

sal r

adio

grap

hic

imag

ebi

tew

ing

- sin

gle

radi

ogra

phic

imag

ebi

tew

ings

- tw

o ra

diog

raph

ic im

ages

deta

iled

and

exte

nsiv

e or

al e

valu

atio

n - p

robl

em-fo

cuse

d, b

y re

port

re-e

valu

atio

n, li

mite

d, p

robl

em fo

cuse

dre

-eva

luat

ion

- pos

t-op

erat

ive

offic

e vi

sit

com

preh

ensi

ve p

erio

dont

al e

valu

atio

n - n

ew o

r est

ablis

hed

patie

ntin

trao

ral -

com

plet

e se

ries o

f rad

iogr

aphi

c im

ages

intr

aora

l - p

eria

pica

l firs

t rad

iogr

aphi

c im

age

intr

aora

l - p

eria

pica

l eac

h ad

ditio

nal r

adio

grap

hic

imag

e

prop

hyla

xis -

adu

lt

bite

win

gs -

four

radi

ogra

phic

imag

espa

nora

mic

radi

ogra

phic

imag

e

D279

1D2

792

D279

4D2

915

D292

0

D278

0D2

781

D278

2D2

783

D279

0

D272

2D2

740

D275

0D2

751

D275

2

D239

4D2

710

D271

2D2

720

D272

1

D233

2D2

335

D239

1D2

392

D239

3

D215

0D2

160

D216

1D2

330

D233

1

D111

0D1

208

D133

0D2

140

D046

0

D027

0D0

272

D027

4D0

330

D021

0D0

220

D023

0D0

240

D016

0D0

170

D017

1D0

180

No

Freq

uenc

y/Li

mita

tions

unlim

ited

perio

dic

oral

eva

luat

ion

No

limite

d or

al e

valu

atio

n - p

robl

em fo

cuse

d

unlim

ited

No

No

unlim

ited

Cove

red

Den

tal S

ervi

ces:

Proc

edur

e Co

dePr

oced

ure

Des

crip

tion

Prio

r Aut

horiz

atio

n Re

quire

d?D0

120

D014

0

D014

5D0

150

oral

eva

luat

ion

for a

pat

ient

und

er th

ree

year

s of a

ge a

nd c

ouns

elin

g w

ith p

rimar

y ca

regi

ver

com

preh

ensi

ve o

ral e

valu

atio

n - n

ew o

r est

ablis

hed

patie

nt

unlim

ited

unlim

ited

3232

unlim

ited

unlim

ited

unlim

ited

unlim

ited

unlim

ited

unlim

ited

unlim

ited

unlim

ited

unlim

ited

unlim

ited

unlim

ited

unlim

ited

unlim

ited

unlim

ited

unlim

ited

unlim

ited

unlim

ited

unlim

ited

unlim

ited

unlim

ited

unlim

ited

unlim

ited

unlim

ited

unlim

ited

unlim

ited

unlim

ited

unlim

ited

unlim

ited

unlim

ited

unlim

ited

unlim

ited

unlim

ited

unlim

ited

unlim

ited

unlim

ited

4 ev

ery

year

unlim

ited

unlim

ited

unlim

ited

unlim

ited

unlim

ited

unlim

ited

unlim

ited

unlim

ited

unlim

ited

unlim

ited

unlim

ited

unlim

ited

unlim

ited

unlim

ited

unlim

ited

No

No

No

No

No

No

No

No

No

No

No

No

No

No

No

No

No

No

No

No

No

No

No

No

No

No

No

No

No

No

No

No

Yes

Yes

Yes

No

No

No

No

No

No

No

Yes

Yes

Yes

Yes

Yes

No

No

No

No

repl

ace

all t

eeth

and

acr

ylic

on

cast

met

al fr

amew

ork

(max

illar

y)re

plac

e al

l tee

th a

nd a

cryl

ic o

n ca

st m

etal

fram

ewor

k (m

andi

bula

r)re

line

com

plet

e m

axill

ary

dent

ure

(cha

irsid

e)re

line

com

plet

e m

andi

bula

r den

ture

(cha

irsid

e)

repa

ir ca

st fr

amew

ork

repa

ir or

repl

ace

brok

en c

lasp

- pe

r too

thre

plac

e br

oken

teet

h - p

er to

oth

add

toot

h to

exi

stin

g pa

rtia

l den

ture

add

clas

p to

exi

stin

g pa

rtia

l den

ture

- pe

r too

th

adju

st p

artia

l den

ture

- m

axill

ary

adju

st p

artia

l den

ture

- m

andi

bula

rre

pair

brok

en c

ompl

ete

dent

ure

base

repl

ace

mis

sing

or b

roke

n te

eth

- com

plet

e de

ntur

e (e

ach

toot

h)re

pair

resi

n de

ntur

e ba

se

max

illar

y pa

rtia

l den

ture

- fle

xibl

e ba

se (i

nclu

ding

any

cla

sps,

rest

s and

teet

h)m

andi

bula

r par

tial d

entu

re -

flexi

ble

base

(inc

ludi

ng a

ny c

lasp

s, re

sts a

nd te

eth)

rem

ovab

le u

nila

tera

l par

tial d

entu

re -

one

piec

e ca

st m

etal

(inc

ludi

ng c

lasp

s and

teet

h)ad

just

com

plet

e de

ntur

e - m

axill

ary

adju

st c

ompl

ete

dent

ure

- man

dibu

lar

imm

edia

te d

entu

re -

man

dibu

lar

max

illar

y pa

rtia

l den

ture

- re

sin b

ase

(incl

udin

g an

y co

nven

tiona

l cla

sps,

rest

s and

teet

h)

man

dibu

lar p

artia

l den

ture

- re

sin

base

(inc

ludi

ng a

ny c

onve

ntio

nal c

lasp

s, re

sts a

nd te

eth)

max

illar

y pa

rtia

l den

ture

- ca

st m

etal

fram

ewor

k w

ith re

sin d

entu

re b

ases

(inc

ludi

ng a

ny c

onve

ntio

nal

clas

ps, r

ests

and

man

dibu

lar p

artia

l den

ture

- ca

st m

etal

fram

ewor

k w

ith re

sin

dent

ure

base

s (in

clud

ing

any

conv

entio

nal c

lasp

s, re

sts a

nd

perio

dont

al m

aint

enan

cegi

ngiv

al ir

rigat

ion

- per

qua

dran

tco

mpl

ete

dent

ure

- max

illar

yco

mpl

ete

dent

ure

- man

dibu

lar

imm

edia

te d

entu

re -

max

illar

y

inco

mpl

ete

endo

dont

ic th

erap

y; in

oper

able

, unr

esto

rabl

e or

frac

ture

d to

oth

cana

l pre

para

tion

and

fittin

g of

pre

form

ed d

owel

or p

ost

perio

dont

al sc

alin

g an

d ro

ot p

lann

ing

- fou

r or m

ore

teet

h pe

r qua

dran

tpe

riodo

ntal

scal

ing

and

root

pla

nnin

g - o

ne -

thre

e te

eth,

per

qua

dran

tfu

ll m

outh

deb

ridem

ent t

o en

able

com

preh

ensi

ve e

valu

atio

n an

d di

agno

sis

pulp

cap

- in

dire

ct (e

xclu

ding

fina

l res

tora

tion)

ther

apeu

tic p

ulpo

tom

y (e

xclu

ding

fina

l res

tora

tion)

endo

dont

ic th

erap

y, a

nter

ior t

ooth

(exc

ludi

ng fi

nal r

esto

ratio

n)en

dodo

ntic

ther

apy,

bic

uspi

d to

oth

(exc

ludi

ng fi

nal r

esto

ratio

n)en

dodo

ntic

ther

apy,

mol

ar (e

xclu

ding

fina

l res

tora

tion)

pref

abric

ated

pos

t and

cor

e in

add

ition

to c

row

nea

ch a

dditi

onal

pre

fabr

icat

ed p

ost,

sam

e to

oth

addi

tiona

l pro

cedu

res t

o co

nstr

uct n

ew c

row

n un

der e

xist

ing

part

ial d

entu

re fr

amew

ork

(to

be

repo

rted

in a

dditi

on to

cro

wn

resi

n in

filtr

atio

n of

inci

pien

t sm

ooth

surf

ace

lesi

ons

pulp

cap

- di

rect

(exc

ludi

ng fi

nal r

esto

ratio

n)

prot

ectiv

e re

stor

atio

nin

terim

ther

apeu

tic re

stor

atio

n-pr

imar

y de

ntiti

onpi

n re

tent

ion

- per

toot

h, in

add

ition

to re

stor

atio

nca

st p

ost a

nd c

ore

in a

dditi

on to

cro

wn

each

add

ition

al in

dire

ctly

fabr

icat

ed p

ost,

sam

e to

oth

pref

abric

ated

stai

nles

s ste

el c

row

n - p

erm

anen

t too

thpr

efab

ricat

ed re

sin

crow

n

D573

1

D565

0D5

660

D567

0D5

671

D573

0

D552

0D5

610

D562

0D5

630

D564

0

D541

0D5

411

D542

1D5

422

D551

0

D521

3

D521

4D5

225

D522

6

D528

1

D512

0D5

130

D514

0

D521

1

D521

2

D434

2D4

355

D491

0D4

921

D511

0

D332

0D3

330

D333

2D3

950

D434

1

D299

0D3

110

D312

0D3

220

D331

0

D295

2D2

953

D295

4D2

957

D297

1

D293

1D2

932

D294

0D2

941

D295

1

33

unlim

ited

unlim

ited

unlim

ited

unlim

ited

4 ev

ery

24 m

onth

s fro

m la

st d

ate

of se

rvic

e

unlim

ited

unlim

ited

unlim

ited

unlim

ited

unlim

ited

unlim

ited

unlim

ited

1 pe

r life

time

per t

ooth

1 pe

r life

time

per t

ooth

unlim

ited

unlim

ited

unlim

ited

unlim

ited

unlim

ited

unlim

ited

unlim

ited

unlim

ited

unlim

ited

unlim

ited

unlim

ited

unlim

ited

unlim

ited

unlim

ited

unlim

ited

unlim

ited

unlim

ited

unlim

ited

unlim

ited

unlim

ited

unlim

ited

unlim

ited

unlim

ited

unlim

ited

unlim

ited

unlim

ited

unlim

ited

unlim

ited

unlim

ited

unlim

ited

unlim

ited

unlim

ited

unlim

ited

unlim

ited

No

No

No

No

No

No

No

No

No

No

Yes

Yes

No

No

No

Yes

Yes

Yes

Yes

Yes

Yes

Yes

Yes

Yes

Yes

Yes

Yes

No

Yes

Yes

No

Yes

Yes

Yes

No

No

No

Yes

Yes

Yes

No

No

No

No

No

No

No

No

case

pre

sent

atio

n, d

etai

led

and

exte

nsiv

e tr

eatm

ent p

lann

ing

occl

usal

adj

ustm

ent

occl

usal

adj

ustm

ent -

lim

ited

palli

ativ

e (e

mer

genc

y) tr

eatm

ent o

f den

tal p

ain

- min

or p

roce

dure

loca

l ane

sthe

sia

in c

onju

nctio

n w

ith o

pera

tive

or su

rgic

al p

roce

dure

s

offic

e vi

sit f

or o

bser

vatio

n (d

urin

g re

gula

rly sc

hedu

led

hour

s) -

no o

ther

serv

ices

per

form

edof

fice

visi

t - a

fter

regu

larly

sche

dule

d ho

urs

rece

men

t or r

e-bo

nd fi

xed

part

ial d

entu

reex

trac

tion,

cor

onal

rem

nant

s - d

ecid

uous

toot

hex

trac

tion,

eru

pted

toot

h or

exp

osed

root

(ele

vatio

n an

d/or

forc

eps r

emov

al)

inci

sion

and

dra

inag

e of

abs

cess

- in

trao

ral s

oft t

issu

e

inci

sion

and

dra

inag

e of

abs

cess

- in

trao

ral s

oft t

issu

e - c

ompl

icat

ed (i

nclu

des d

rain

age

of m

ultip

le

fasc

ial s

pace

s)

reta

iner

cro

wn-

3/4

porc

elai

n/ce

ram

icre

tain

er c

row

n - f

ull c

ast h

igh

nobl

e m

etal

reta

iner

cro

wn

- ful

l cas

t pre

dom

inan

tly b

ase

met

alre

tain

er c

row

n - f

ull c

ast n

oble

met

alre

tain

er c

row

n - t

itani

um

reta

iner

cro

wn

- por

cela

in fu

sed

to p

redo

min

antly

bas

e m

etal

reta

iner

cro

wn

- por

cela

in fu

sed

to n

oble

met

alre

tain

er c

row

n - 3

/4 c

ast h

igh

nobl

e m

etal

reta

iner

cro

wn-

3/4

cast

pre

dom

inat

ely

base

d m

etal

reta

iner

cro

wn-

3/4

cast

nob

le m

etal

reta

iner

cro

wn

- res

in w

ith h

igh

nobl

e m

etal

reta

iner

cro

wn

- res

in w

ith p

redo

min

antly

bas

e m

etal

reta

iner

cro

wn

- res

in w

ith n

oble

met

alre

tain

er c

row

n-po

rcel

ain/

cera

mic

reta

iner

cro

wn

- por

cela

in fu

sed

to h

igh

nobl

e m

etal

pont

ic -

porc

elai

n fu

sed

to n

oble

met

alpo

ntic

-por

cela

in/c

eram

icpo

ntic

- re

sin

with

hig

h no

ble

met

alpo

ntic

- re

sin

with

pre

dom

inan

tly b

ase

met

alpo

ntic

- re

sin

with

nob

le m

etal

pont

ic -

cast

pre

dom

inan

tly b

ase

met

alpo

ntic

- ca

st n

oble

met

alpo

ntic

- tit

aniu

mpo

ntic

- po

rcel

ain

fuse

d to

hig

h no

ble

met

alpo

ntic

- po

rcel

ain

fuse

d to

pre

dom

inan

tly b

ase

met

al

Ove

rden

ture

-com

plet

e m

axill

ary

Ove

rden

ture

-par

tial m

axill

ary

Ove

rden

ture

- co

mpl

ete

man

dibu

lar

Ove

rden

ture

-par

tial m

andi

bula

rpo

ntic

- ca

st h

igh

nobl

e m

etal

relin

e m

andi

bula

r par

tial d

entu

re (c

hairs

ide)

relin

e co

mpl

ete

max

illar

y de

ntur

e (la

bora

tory

)re

line

com

plet

e m

andi

bula

r den

ture

(lab

orat

ory)

relin

e m

axill

ary

part

ial d

entu

re (l

abor

ator

y)re

line

man

dibu

lar p

artia

l den

ture

(lab

orat

ory)

relin

e m

axill

ary

part

ial d

entu

re (c

hairs

ide)

D943

0D9

440

D945

0D9

943

D995

1

D751

0

D751

1D9

110

D921

5

D679

2D6

794

D693

0D7

111

D714

0

D678

1D6

782

D678

3D6

790

D679

1

D674

0D6

750

D675

1D6

752

D678

0

D625

1D6

252

D672

0D6

721

D672

2

D624

0D6

241

D624

2D6

245

D625

0

D586

6D6

210

D621

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212

D621

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D576

0D5

761

D586

3D5

864

D586

5

D574

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741

D575

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751

3434

Prov

ider

Cla

im D

ispu

tes

Mem

ber A

ppea

ls &

Grie

vanc

es

In a

n ef

fort

to c

ompl

y w

ith th

e Ce

nter

s for

Med

icar

e an

d M

edic

aid

(CM

S) st

ate

man

date

d re

quire

men

ts, p

leas

e be

adv

ised

that

DHM

O E

ncou

nter

Dat

a Su

bmis

sion

s are

now

requ

ired.

CM

S no

w re

quire

s tha

t w

e re

port

100

% o

f util

izatio

n da

ta fo

r our

AAR

P M

edic

are

Com

plet

e DH

MO

mem

bers

. To

ens

ure

that

we

mee

t CM

S re

quire

men

t of r

epor

ting

100%

util

izatio

n, w

e ar

e ha

ppy

to re

-intr

oduc

e ou

r Den

tal

Ince

ntiv

e Pr

ogra

m e

ffect

ive

imm

edia

tely

. De

ntal

Ben

efit

Prov

ider

s will

reim

burs

e ou

r pro

vide

rs $

2.00

for e

ach

enco

unte

r cla

im su

bmitt

ed fo

r AAR

P M

edic

are

Com

plet

e D

HM

O m

embe

rs o

nly

for a

ll pr

oced

ures

(cov

ered

und

er th

e m

embe

r's p

lan)

per

form

ed o

n th

ose

mem

bers

, for

eac

h da

te o

f ser

vice

. Al

l pro

cedu

res p

erfo

rmed

MU

ST b

e re

port

ed in

clud

ing

proc

edur

es w

heth

er o

r not

the

mem

ber h

as a

co

paym

ent.

Thi

s is a

requ

irem

ent f

or a

ll co

ntra

cted

pro

vide

rs to

subm

it ut

iliza

tion

for e

ach

patie

nt tr

eate

d.

Her

e ar

e a

few

way

s the

Enc

ount

er In

form

atio

n ca

n be

subm

itted

:

1)

Electronically

- As

you

wou

ld a

PPO

or I

ndem

nity

Cla

im

2)

Web

Site

- Cl

aim

s can

be

subm

itted

indi

vidu

ally

on

our w

ebsi

te a

t ww

w.u

hcpr

ovid

ers.

com

3)

By

Mai

l - A

s you

wou

ld a

PPO

or I

ndem

nity

Cla

im

4)

Util

izat

ion

Repo

rts -

Mus

t con

tain

ALL

requ

ired

info

rmat

ion:

• Su

bscr

iber

ID•

Subs

crib

er D

ate

of B

irth

• G

roup

Nam

e or

Num

ber

• Pa

tient

’s F

ull N

ame

• Pa

tient

’s D

ate

of B

irth

• Re

latio

nshi

p to

Sub

scrib

er•

Phys

ical

Add

ress

• AD

A Co

de P

erfo

rmed

• To

oth#

/ Q

uadr

ant

• Su

rfac

e•

Trea

ting

Dent

ist N

ame

• De

ntist

Tax

I.D.

for B

illin

g

Enco

unte

r/U

tiliza

tion

Repo

rtin

g - W

hen

subm

ittin

g En

coun

ter/

Util

izat

ion

clai

ms,

you

mus

t inc

lude

Cod

e D0

999

alon

g w

ith a

ll co

vere

d se

rvic

e pr

oced

ure

code

s you

per

form

on

each

AAR

P M

edic

are

Com

plet

e DH

MO

mem

ber.

Plea

se n

ote

the

follo

win

g:

1)

If y

ou su

bmit

D099

9 al

one

no a

dditi

onal

$2.

00 re

imbu

rsem

ent w

ill n

ot b

e pa

id.

Addi

tiona

lly, c

laim

subm

issio

n w

ould

be

cons

ider

ed n

on-c

ompl

iant

.

2) If

you

subm

it al

l ser

vice

pro

cedu

re se

rvic

e co

des b

ut d

on't

incl

ude

D099

9 as

wel

l as y

ou w

on't

be re

imbu

rsed

the

addi

tiona

l $2.

00.

In a

dditi

on, t

he c

laim

will

be

cons

ider

ed n

on-c

ompl

iant

.

Mai

l mem

ber a

ppea

ls to

: Uni

tedH

ealth

care

, Att

n: A

ppea

ls a

nd G

rieva

nce

Depa

rtm

ent,

PO B

ox 6

106,

MS

CA12

4-01

57, C

ypre

ss, C

A 90

630

AARP

Med

icar

e Co

mpl

ete

San

Dieg

o DH

MO

Pla

n co

ver t

he d

enta

l cod

es li

sted

abo

ve. P

rovi

der p

aym

ent i

s mad

e on

a F

ee-fo

r-Se

rvic

e ba

sis.

Mem

bers

hav

e In

-Net

wor

k on

ly b

enef

its a

nd th

ere

is n

o an

nual

be

nefit

max

imum

, coi

nsur

ance

or d

educ

tible

. The

mem

ber c

opay

s var

y fo

r cov

ered

serv

ices

from

$3

- $65

0. S

ome

serv

ices

requ

ire p

rior a

utho

rizat

ion.

Dent

al P

rovi

ders

with

com

plai

nts a

re to

con

tact

Uni

tedH

ealth

care

Den

tal’s

Pro

vide

r Ser

vice

dep

artm

ent a

t 877

-816

-359

6. N

etw

ork

Prov

ider

con

trac

tual

dis

pute

s, O

ut-o

f-Net

wor

k pr

ovid

er d

ispu

tes,

and

re

proc

essi

ng re

ques

ts w

ill b

e lo

gged

into

the

appe

als d

atab

ase.

Ple

ase

mai

l to

the

Appe

als &

Grie

vanc

es P

O B

ox li

sted

abo

ve. R

esea

rch

and

reso

lutio

n w

ill b

e co

mpl

eted

with

in 3

0 ca

lend

ar d

ays.

Mem

ber a

ppea

ls a

re re

view

ed b

y th

e he

alth

pla

n, a

nd a

re n

ot d

eleg

ated

to U

HC D

enta

l. Al

l Mem

ber a

ppea

ls (i

nclu

des P

re-S

ervi

ce a

ppea

ls, I

n N

etw

ork

Prov

ider

app

eals

, and

Out

of N

etw

ork

prov

ider

app

eals

) re

ceiv

ed b

y U

HC D

enta

l will

be

forw

arde

d to

the

heal

th p

lan

via

over

nigh

t mai

l, w

ithin

7 d

ays o

f rec

eipt

of t

he a

ppea

l.

35

CA_F

ACET

S D0

0126

60_P

kg D

T035

_DT0

35-H

0000

a-DM

O75

09/2

016

“Prio

r Aut

horiz

atio

n re

quire

d” m

eans

the

prac

titio

ner m

ust s

ubm

it th

ose

proc

edur

es fo

r app

rova

l with

clin

ical

doc

umen

tatio

n su

ppor

ting

nece

ssity

bef

ore

perf

orm

ing

thos

e pr

oced

ures

. To

do th

is c

ompl

ete

a st

anda

rd A

DA c

laim

form

and

che

ck th

e bo

x m

arke

d “P

re-T

reat

men

t EST

IMAT

E.”

Prio

r aut

horiz

atio

n re

ques

t can

be

subm

itted

via

the

prov

ider

web

por

tal (

at w

ww

.myu

hcpr

ovid

ers.

com

), su

bmitt

ed

elec

tron

ical

ly v

ia y

our c

lear

ingh

ouse

, or s

impl

y m

ail t

he fo

rm, t

o th

e be

low

add

ress

, alo

ng w

ith a

ny re

quire

d su

pple

men

tal i

nfor

mat

ion

(film

s, n

arra

tive,

per

io-c

hart

ing,

etc

.). Y

our o

ffice

will

then

rece

ive

an

Expl

anat

ion

of B

enef

its (E

OB)

out

linin

g th

e de

nial

or a

ppro

val o

f req

uest

ed tr

eatm

ent a

nd p

lan

paym

ent a

mou

nts w

hen

appl

icab

le.

Prio

r Aut

horiz

atio

n Re

ques

ts

3636

Iden

tific

atio

n Ca

rds

Sam

ple

Mem

ber I

D C

ard*

Fron

t of c

ard

Back

of c

ard

Fron

t of c

ard

Back

of c

ard

Impo

rtan

t Tel

epho

ne N

umbe

rs &

Web

site

s

Prov

ider

Qui

ck R

efer

ence

Gui

de -

Effe

ctiv

e 1/

1/20

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lifor

nia

Hig

h O

ptio

n Ri

der -

DH

MO

- $1

000

Annu

al M

axim

umAA

RP M

edic

areC

ompl

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Secu

re H

oriz

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lans

1, 2

, 4 a

nd V

alue

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ns

*Ple

ase

note

that

the

Med

ical

ID C

ard

is un

iver

sal a

nd in

clud

es a

ll lin

es o

f cov

erag

e. T

he M

edic

al p

lan

can

be H

MO

or P

PO a

nd th

is d

oes n

ot re

flect

the

Dent

al P

lan

Bene

fits.

Ple

ase

flip

the

ID C

ard

over

to se

e th

e De

ntal

Pro

vide

r in

form

atio

n on

the

back

(i.e

. car

rier w

ebsi

te a

nd to

ll-fr

ee n

umbe

r). T

his i

nfor

mat

ion

can

be u

sed

to c

onfir

m p

rovi

der p

artic

ipat

ion,

mem

ber e

ligib

ility

and

ben

efits

. Thi

s is a

SAM

PLE

ID C

ard

and

may

diff

er fr

om th

e m

embe

r's ID

Ca

rd.

Elig

ibili

ty,

Bene

fits,

Cla

im(s

) and

Aut

horiz

atio

ns87

7-81

6-35

96Li

ve A

gent

: Mon

day

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:00A

M -

6:00

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STIV

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day

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to In

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Num

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bout

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0-82

2-53

53Li

ve A

gent

: Mon

day

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ay, 8

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M -

11:0

0PM

, EST

37

Impo

rtan

t Add

ress

es

Impo

rtan

t Ele

ctro

nic

Clai

ms &

Prio

r Aut

horiz

atio

n Su

bmis

sion

Info

rmat

ion

unlim

ited

unlim

ited

unlim

ited

unlim

ited

unlim

ited

unlim

ited

unlim

ited

unlim

ited

unlim

ited

unlim

ited

unlim

ited

unlim

ited

unlim

ited

unlim

ited

unlim

ited

unlim

ited

unlim

ited

unlim

ited

unlim

ited

unlim

ited

unlim

ited

unlim

ited

unlim

ited

unlim

ited

unlim

ited

unlim

ited

unlim

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No

D046

0pu

lp v

italit

y te

sts

No

D111

0pr

ophy

laxi

s - a

dult

No

D099

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spec

ified

dia

gnos

tic p

roce

dure

, by

repo

rtN

o

No

D214

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alga

m -

one

surf

ace,

prim

ary

or p

erm

anen

tN

oD2

150

D023

0in

trao

ral -

per

iapi

cal e

ach

addi

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l rad

iogr

aphi

c im

age

No

D024

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trao

ral -

occ

lusa

l rad

iogr

aphi

c im

age

No

D021

0D0

220

5213

3

D012

0D0

140

D014

5D0

150

perio

dic

oral

eva

luat

ion

limite

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al e

valu

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robl

em fo

cuse

d

oral

eva

luat

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for a

pat

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und

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year

s of a

ge a

nd c

ouns

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rimar

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regi

ver

com

preh

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ve o

ral e

valu

atio

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ew o

r est

ablis

hed

patie

ntN

o

Cove

red

Den

tal S

ervi

ces:

Prio

r Aut

horiz

atio

n Re

quire

d?Pr

oced

ure

Code

Freq

uenc

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mita

tions

24 h

ours

a d

ay

Proc

edur

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escr

iptio

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24 h

ours

a d

ay

Clai

ms

D017

0D0

171

D018

0

deta

iled

and

exte

nsiv

e or

al e

valu

atio

n - p

robl

em-fo

cuse

d, b

y re

port

unlim

ited

2 ev

ery

year

No

No

No

No

No

re-e

valu

atio

n, li

mite

d, p

robl

em fo

cuse

dre

-eva

luat

ion

- pos

t-op

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offic

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sit

com

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D016

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intr

aora

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ompl

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adio

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imag

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unlim

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unlim

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Med

icar

ew

ww

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icar

e.go

v24

hou

rs a

day

Elig

ibili

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Bene

fits,

Cla

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Aut

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ww

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Cent

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or M

edic

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Prov

ider

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son

for M

ailin

g

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Num

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laim

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D027

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D033

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radi

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tedH

ealth

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Den

tal,

PO B

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t Lak

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ty, U

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tedH

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nite

dHea

lthca

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enta

l, Ap

peal

s Disp

utes

, PO

Box

305

69, S

alt L

ake

City

, UT

8413

0-05

69

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amal

gam

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o su

rfac

es, p

rimar

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per

man

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No

D120

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pica

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licat

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of fl

uorid

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xclu

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var

nish

No

D133

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al h

ygie

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stru

ctio

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o

No

D252

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lay

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allic

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o su

rfac

esN

o

D239

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sin-

base

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site

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terio

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oD2

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com

posi

te -

four

or m

ore

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terio

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oun

limite

dun

limite

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D233

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sin-

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site

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ree

surf

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, ant

erio

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resi

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com

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inci

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erio

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o

D233

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sin-

base

d co

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site

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e su

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nter

ior

No

D233

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base

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site

- tw

o su

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es, a

nter

ior

No

unlim

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D216

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m -

thre

e su

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es, p

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per

man

ent

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m -

four

or m

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, prim

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or p

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D251

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D239

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No

D239

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site

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es, p

oste

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No

D253

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lay

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ree

or m

ore

surf

aces

No

D254

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lay

met

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, tw

o su

rfac

esN

o

3838

unlim

ited

unlim

ited

unlim

ited

unlim

ited

D279

1

D271

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own

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resi

n-ba

sed

com

posi

te (i

ndire

ct)

No

D272

0D2

721

D272

2

D254

4on

lay-

met

allic

-four

or m

ore

surf

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No

crow

n - r

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with

hig

h no

ble

met

alcr

own

- res

in w

ith p

redo

min

antly

bas

e m

etal

crow

n - r

esin

with

nob

le m

etal

No

No

No

D279

2D2

794

D274

0D2

750

D275

1D2

752

D278

0D2

781

D278

2D2

783

D279

0

D271

0cr

own,

resi

n-ba

sed

com

posi

te (i

ndire

ct)

No

D254

3on

lay-

met

allic

-thr

ee su

rfac

esN

o

D291

5D2

920

D293

1D2

932

D294

0D2

941

D295

0D2

951

D295

2D2

953

D295

4D2

957

D297

1D3

110

D312

0D3

220

D331

0D3

320

D333

0D3

332

D334

6D3

347

D334

8D3

410

D342

1D3

425

D342

6D3

427

D343

0D3

950

D421

0

D421

1

D424

0

crow

n - p

orce

lain

/cer

amic

subs

trat

ecr

own

- por

cela

in fu

sed

to h

igh

nobl

e m

etal

crow

n - p

orce

lain

fuse

d to

pre

dom

inan

tly b

ase

met

alcr

own

- por

cela

in fu

sed

to n

oble

met

alcr

own,

3/4

cas

t hig

h no

ble

met

alcr

own,

3/4

cas

t pre

dom

inat

ely

base

met

al

pin

rete

ntio

n - p

er to

oth,

in a

dditi

on to

rest

orat

ion

cast

pos

t and

cor

e in

add

ition

to c

row

nea

ch a

dditi

onal

indi

rect

ly fa

bric

ated

pos

t, sa

me

toot

h

crow

n, 3

/4 c

ast n

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3/4

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cela

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- ful

l cas

t hig

h no

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- ful

l cas

t pre

dom

inan

tly b

ase

met

alcr

own

- ful

l cas

t nob

le m

etal

crow

n - t

itani

umre

cem

ent o

r re-

bond

cas

t ind

irect

ly fa

bric

ated

or p

refa

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ated

pos

t and

cor

ere

cem

ent o

r re-

bond

cro

wn

pref

abric

ated

stai

nles

s ste

el c

row

n - p

erm

anen

t too

thpr

efab

ricat

ed re

sin

crow

npr

otec

tive

rest

orat

ion

inte

rim th

erap

eutic

rest

orat

ion-

prim

ary

dent

ition

Core

bui

ldup

, inc

ludi

ng a

ny p

ins w

hen

requ

ired

pref

abric

ated

pos

t and

cor

e in

add

ition

to c

row

nea

ch a

dditi

onal

pre

fabr

icat

ed p

ost,

sam

e to

oth

addi

tiona

l pro

cedu

res t

o co

nstr

uct n

ew c

row

n un

der e

xist

ing

part

ial d

entu

re fr

amew

ork

(to

be

repo

rted

in a

dditi

on to

cro

wn

pulp

cap

- di

rect

(exc

ludi

ng fi

nal r

esto

ratio

n)pu

lp c

ap -

indi

rect

(exc

ludi

ng fi

nal r

esto

ratio

n)th

erap

eutic

pul

poto

my

(exc

ludi

ng fi

nal r

esto

ratio

n)en

dodo

ntic

ther

apy,

ant

erio

r too

th (e

xclu

ding

fina

l res

tora

tion)

endo

dont

ic th

erap

y, b

icus

pid

toot

h (e

xclu

ding

fina

l res

tora

tion)

endo

dont

ic th

erap

y, m

olar

(exc

ludi

ng fi

nal r

esto

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n)in

com

plet

e en

dodo

ntic

ther

apy;

inop

erab

le, u

nres

tora

ble

or fr

actu

red

toot

hre

trea

tmen

t of p

revi

ous r

oot c

anal

ther

apy

- ant

erio

rre

trea

tmen

t of p

revi

ous r

oot c

anal

ther

apy

- bic

uspi

dre

trea

tmen

t of p

revi

ous r

oot c

anal

ther

apy

- mol

arAp

icoe

ctom

y - a

nter

ior

Apic

oect

omy

- bic

uspi

d (fi

rst r

oot)

Apic

oect

omy

- mol

ar (f

irst r

oot)

Apic

oect

omy

(eac

h ad

ditio

nal r

oot)

perir

adic

ular

surg

ery

with

out a

pico

ecto

my

retr

ogra

de fi

lling

- pe

r roo

tca

nal p

repa

ratio

n an

d fit

ting

of p

refo

rmed

dow

el o

r pos

t

ging

ivec

tom

y or

gin

givo

plas

ty -

four

or m

ore

cont

iguo

us te

eth

or to

oth

boun

ded

spac

es p

er q

uadr

ant

ging

ivec

tom

y or

gin

givo

plas

ty -

one

to th

ree

cont

iguo

us te

eth

or to

oth

boun

ded

spac

es p

er q

uadr

ant

ging

ival

flap

pro

cedu

re, i

nclu

ding

root

pla

nnin

g - f

our o

r mor

e co

ntig

uous

teet

h or

toot

h bo

unde

d sp

aces

per

qua

dran

t

Yes

Yes

Yes

Yes

No

Yes

Yes

Yes

Yes

Yes

Yes

Yes

Yes

Yes

No

No

No

No

No

No

No

Yes

Yes

Yes

No

No

No

No

Yes

Yes

Yes

No

Yes

Yes

Yes

No

No

No

No

No

No

No

No

No

No

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ited

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ited

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39

D424

1

D426

0

D426

1D4

341

D434

2D4

355

D491

0D4

921

D511

0D5

120

D513

0D5

140

D521

1

D521

2

D521

3

D521

4D5

225

D522

6

D528

1D5

410

D541

1D5

421

D542

2

D551

0D5

520

D561

0D5

620

D563

0D5

640

D565

0D5

660

D567

0D5

671

D573

0D5

731

D574

0D5

741

D575

0D5

751

D576

0D5

761

D585

0D5

851

D586

3D5

864

D586

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ging

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pro

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incl

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to th

ree

cont

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eth

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ded

spac

es p

er q

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ant

osse

ous s

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ry (i

nclu

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flap

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ry a

nd c

losu

re) -

four

or m

ore

cont

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us te

eth

or to

oth

boun

ded

spac

es p

er q

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ant

osse

ous s

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ry (i

nclu

ding

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ry a

nd c

losu

re) -

one

to th

ree

cont

iguo

us te

eth

or to

oth

boun

ded

spac

es p

er q

uadr

ant

perio

dont

al sc

alin

g an

d ro

ot p

lann

ing

- fou

r or m

ore

teet

h pe

r qua

dran

tpe

riodo

ntal

scal

ing

and

root

pla

nnin

g - o

ne -

thre

e te

eth,

per

qua

dran

tfu

ll m

outh

deb

ridem

ent t

o en

able

com

preh

ensi

ve e

valu

atio

n an

d di

agno

sis

perio

dont

al m

aint

enan

cegi

ngiv

al ir

rigat

ion

- per

qua

dran

tco

mpl

ete

dent

ure

- max

illar

yco

mpl

ete

dent

ure

- man

dibu

lar

imm

edia

te d

entu

re -

max

illar

yim

med

iate

den

ture

- m

andi

bula

r

max

illar

y pa

rtia

l den

ture

- re

sin b

ase

(incl

udin

g an

y co

nven

tiona

l cla

sps,

rest

s and

teet

h)

man

dibu

lar p

artia

l den

ture

- re

sin

base

(inc

ludi

ng a

ny c

onve

ntio

nal c

lasp

s, re

sts a

nd te

eth)

max

illar

y pa

rtia

l den

ture

- ca

st m

etal

fram

ewor

k w

ith re

sin d

entu

re b

ases

(inc

ludi

ng a

ny c

onve

ntio

nal

clas

ps, r

ests

and

man

dibu

lar p

artia

l den

ture

- ca

st m

etal

fram

ewor

k w

ith re

sin

dent

ure

base

s (in

clud

ing

any

conv

entio

nal c

lasp

s, re

sts a

ndm

axill

ary

part

ial d

entu

re -

flexi

ble

base

(inc

ludi

ng a

ny c

lasp

s, re

sts a

nd te

eth)

man

dibu

lar p

artia

l den

ture

- fle

xibl

e ba

se (i

nclu

ding

any

cla

sps,

rest

s and

teet

h)

rem

ovab

le u

nila

tera

l par

tial d

entu

re -

one

piec

e ca

st m

etal

(inc

ludi

ng c

lasp

s and

teet

h)ad

just

com

plet

e de

ntur

e - m

axill

ary

adju

st c

ompl

ete

dent

ure

- man

dibu

lar

adju

st p

artia

l den

ture

- m

axill

ary

adju

st p

artia

l den

ture

- m

andi

bula

r

repa

ir br

oken

com

plet

e de

ntur

e ba

sere

plac

e m

issi

ng o

r bro

ken

teet

h - c

ompl

ete

dent

ure

(eac

h to

oth)

repa

ir re

sin

dent

ure

base

repa

ir ca

st fr

amew

ork

repa

ir or

repl

ace

brok

en c

lasp

- pe

r too

thre

plac

e br

oken

teet

h - p

er to

oth

add

toot

h to

exi

stin

g pa

rtia

l den

ture

add

clas

p to

exi

stin

g pa

rtia

l den

ture

- pe

r too

thre

plac

e al

l tee

th a

nd a

cryl

ic o

n ca

st m

etal

fram

ewor

k (m

axill

ary)

repl

ace

all t

eeth

and

acr

ylic

on

cast

met

al fr

amew

ork

(man

dibu

lar)

relin

e co

mpl

ete

max

illar

y de

ntur

e (c

hairs

ide)

relin

e co

mpl

ete

man

dibu

lar d

entu

re (c

hairs

ide)

relin

e m

axill

ary

part

ial d

entu

re (c

hairs

ide)

relin

e m

andi

bula

r par

tial d

entu

re (c

hairs

ide)

relin

e co

mpl

ete

max

illar

y de

ntur

e (la

bora

tory

)re

line

com

plet

e m

andi

bula

r den

ture

(lab

orat

ory)

relin

e m

axill

ary

part

ial d

entu

re (l

abor

ator

y)re

line

man

dibu

lar p

artia

l den

ture

(lab

orat

ory)

tissu

e co

nditi

onin

g, m

axill

ary

tissu

e co

nditi

onin

g, m

andi

bula

rO

verd

entu

re-c

ompl

ete

max

illar

yO

verd

entu

re-p

artia

l max

illar

yO

verd

entu

re -

com

plet

e m

andi

bula

rO

verd

entu

re-p

artia

l man

dibu

lar

No

Yes

No

No

No

No

No

No

No

No

No

No

No

No

No

No

No

No

No

No

No

No

No

No

No

No

No

No

No

No

No

No

No

No

No

No

No

No

No

No

No

No

No

No

No

No

No

unlim

ited

unlim

ited

unlim

ited

4 ev

ery

year

unlim

ited

unlim

ited

unlim

ited

unlim

ited

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ited

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ited

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ited

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ited

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ited

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ited

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ited

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ited

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ited

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ited

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ited

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ited

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ited

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ited

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ited

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ited

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ited

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ited

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ited

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ited

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ited

unlim

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unlim

ited

unlim

ited

4040

D621

0D6

211

D621

2D6

214

D624

0D6

241

D624

2D6

245

D625

0D6

251

D625

2D6

602

D660

3D6

604

D660

5D6

606

D660

7D6

624

D672

0D6

721

D672

2

D674

0D6

750

D675

1D6

752

D678

0D6

781

D678

2D6

783

D679

0D6

791

D679

2D6

794

D693

0

D711

1D7

140

D721

0D7

220

D723

0D7

240

D725

0D7

285

D728

6

D731

0

D731

1

D732

0

D747

2D7

473

D748

5

pont

ic -

cast

hig

h no

ble

met

alpo

ntic

- ca

st p

redo

min

antly

bas

e m

etal

pont

ic -

cast

nob

le m

etal

pont

ic -

titan

ium

pont

ic -

porc

elai

n fu

sed

to h

igh

nobl

e m

etal

pont

ic -

porc

elai

n fu

sed

to p

redo

min

antly

bas

e m

etal

pont

ic -

porc

elai

n fu

sed

to n

oble

met

alpo

ntic

-por

cela

in/c

eram

icpo

ntic

- re

sin

with

hig

h no

ble

met

alpo

ntic

- re

sin

with

pre

dom

inan

tly b

ase

met

alpo

ntic

- re

sin

with

nob

le m

etal

reta

iner

inla

y - c

ast h

igh

nobl

e m

etal

, tw

o su

rfac

esre

tain

er in

lay

- cas

t hig

h no

ble

met

al, t

hree

or m

ore

surf

aces

reta

iner

inla

y - c

ast p

redo

min

antly

bas

e m

etal

, tw

o su

rfac

esre

tain

er in

lay

- cas

t pre

dom

inan

tly b

ase

met

al, t

hree

or m

ore

surf

aces

reta

iner

inla

y - c

ast n

oble

met

al, t

wo

surf

aces

reta

iner

inla

y - c

ast n

oble

met

al, t

hree

or m

ore

surf

aces

reta

iner

inla

y - t

itani

umre

tain

er c

row

n - r

esin

with

hig

h no

ble

met

alre

tain

er c

row

n - r

esin

with

pre

dom

inan

tly b

ase

met

alre

tain

er c

row

n - r

esin

with

nob

le m

etal

reta

iner

cro

wn-

porc

elai

n/ce

ram

icre

tain

er c

row

n - p

orce

lain

fuse

d to

hig

h no

ble

met

alre

tain

er c

row

n - p

orce

lain

fuse

d to

pre

dom

inan

tly b

ase

met

alre

tain

er c

row

n - p

orce

lain

fuse

d to

nob

le m

etal

reta

iner

cro

wn

- 3/4

cas

t hig

h no

ble

met

alre

tain

er c

row

n-3/

4 ca

st p

redo

min

atel

y ba

sed

met

alre

tain

er c

row

n-3/

4 ca

st n

oble

met

alre

tain

er c

row

n-3/

4 po

rcel

ain/

cera

mic

reta

iner

cro

wn

- ful

l cas

t hig

h no

ble

met

alre

tain

er c

row

n - f

ull c

ast p

redo

min

antly

bas

e m

etal

reta

iner

cro

wn

- ful

l cas

t nob

le m

etal

reta

iner

cro

wn

- tita

nium

rece

men

t or r

e-bo

nd fi

xed

part

ial d

entu

re

extr

actio

n, c

oron

al re

mna

nts -

dec

iduo

us to

oth

extr

actio

n, e

rupt

ed to

oth

or e

xpos

ed ro

ot (e

leva

tion

and/

or fo

rcep

s rem

oval

)su

rgic

al re

mov

al o

f eru

pted

toot

h re

q re

mov

al o

f bon

e, se

ctio

ning

of t

ooth

and

incl

udin

g el

evat

ion

of

muc

oper

iost

eal f

lap

rem

oval

of i

mpa

cted

toot

h - s

oft t

issue

rem

oval

of i

mpa

cted

toot

h - p

artia

lly b

ony

rem

oval

of i

mpa

cted

toot

h - c

ompl

etel

y bo

ny

surg

ical

rem

oval

of r

esid

ual t

ooth

root

s (cu

ttin

g pr

oced

ure)

inci

sion

al b

iops

y of

ora

l tis

sue

- har

d (b

one,

toot

h)in

cisi

onal

bio

psy

of o

ral t

issu

e - s

oft (

all o

ther

s)

Yes

Yes

Yes

No

Yes

Yes

Yes

No

Yes

Yes

No

No

No

No

No

No

No

No

Yes

Yes

Yes

Yes

Yes

Yes

Yes

Yes

Yes

Yes

Yes

Yes

Yes

Yes

No

No

No

No

No

Yes

Yes

Yes

Yes

Yes

No

No

No

No

No

No

No

No

No

unlim

ited

unlim

ited

unlim

ited

unlim

ited

unlim

ited

unlim

ited

unlim

ited

unlim

ited

unlim

ited

unlim

ited

unlim

ited

unlim

ited

unlim

ited

unlim

ited

unlim

ited

unlim

ited

unlim

ited

unlim

ited

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ited

unlim

ited

unlim

ited

unlim

ited

unlim

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unlim

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unlim

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unlim

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unlim

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unlim

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unlim

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unlim

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unlim

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unlim

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unlim

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unlim

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1 pe

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1 pe

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1 pe

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alve

olop

last

y in

con

junc

tion

with

ext

ract

ions

- fo

ur o

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or to

oth

spac

es, p

er q

uadr

ant

alve

opla

sty

in c

onju

nctio

n w

ith e

xtra

ctio

n - o

ne to

thre

e te

eth

or to

oth

spac

es, p

er q

uadr

ant

alve

olop

last

y no

t in

conj

unct

ion

with

ext

ract

ions

- fo

ur o

r mor

e te

eth

or to

oth

spac

es, p

er q

uadr

ant

alve

opla

sty

not i

n co

njun

ctio

n w

ith e

xtra

ctio

n - o

ne to

thre

e te

eth

or to

oth

spac

es, p

er q

uadr

ant

rem

oval

of l

ater

al e

xost

osis

(max

illa

or m

andi

ble)

rem

oval

of t

orus

pal

atin

usre

mov

al o

f tor

us m

andi

bula

rissu

rgic

al re

duct

ion

of o

sseo

us tu

bero

sity

D732

1D7

471

unlim

ited

41

The

Calif

orni

a Hi

gh O

ptio

n Ri

der D

HMO

supp

lem

enta

l ben

efit

plan

cov

ers t

he d

enta

l cod

es li

sted

abo

ve. T

his s

uppl

emen

tal b

enef

it is

offe

red

to m

embe

rs th

at a

re e

nrol

led

in A

ARP

Med

icar

eCom

plet

e Se

cure

Horiz

ons p

lans

. Pr

ovid

er p

aym

ent i

s mad

e on

a F

ee-fo

r-Se

rvic

e ba

sis.

Mem

bers

hav

e In

-net

wor

k on

ly b

enef

its. S

ome

serv

ices

requ

ire p

rior a

utho

rizat

ion.

The

$10

00 a

nnua

l max

imum

app

lies t

o co

vere

d pr

even

tive

and

com

preh

ensi

ve

bene

fits.

Mem

ber c

an b

e bi

lled

for s

ervi

ces o

ver t

he $

1000

ann

ual m

axim

um b

enef

it. T

he m

embe

r cop

ays v

ary

for c

over

ed se

rvic

es fr

om $

0 - $

500.

The

re is

no

coin

sura

nce

or d

educ

tible

.

D751

0

D751

1

D995

1

D752

1D7

881

D911

0D9

215

D921

9D9

310

D943

0D9

440

D945

0

inci

sion

and

dra

inag

e of

abs

cess

- in

trao

ral s

oft t

issu

e

No

No

No

No

No

No

No

No

No

No

No

No

In a

n ef

fort

to c

ompl

y w

ith th

e Ce

nter

s for

Med

icar

e an

d M

edic

aid

(CM

S) st

ate

man

date

d re

quire

men

ts, p

leas

e be

adv

ised

that

DHM

O E

ncou

nter

Dat

a Su

bmis

sion

s are

now

requ

ired.

CM

S no

w re

quire

s tha

t we

repo

rt 1

00%

of

util

izat

ion

data

for o

ur C

alifo

rnia

Hig

h O

ptio

n Ri

der D

HMO

mem

bers

. To

ens

ure

that

we

mee

t CM

S re

quire

men

t of r

epor

ting

100%

util

izatio

n, w

e ar

e ha

ppy

to re

-intr

oduc

e ou

r Den

tal I

ncen

tive

Prog

ram

effe

ctiv

e im

med

iate

ly.

Dent

al B

enef

it Pr

ovid

ers w

ill re

imbu

rse

our p

rovi

ders

$2.

00 fo

r eac

h en

coun

ter c

laim

subm

itted

for C

alifo

rnia

Hig

h O

ptio

n Ri

der D

HM

O m

embe

rs o

nly

for a

ll pr

oced

ures

(cov

ered

und

er th

e m

embe

r's p

lan)

pe

rfor

med

on

thos

e m

embe

rs, f

or e

ach

date

of s

ervi

ce.

All p

roce

dure

s per

form

ed M

UST

be

repo

rted

incl

udin

g pr

oced

ures

whe

ther

or n

ot th

e m

embe

r has

a c

opay

men

t. T

his i

s a re

quire

men

t for

all

cont

ract

ed p

rovi

ders

to

subm

it ut

iliza

tion

for e

ach

patie

nt tr

eate

d.

Her

e ar

e a

few

way

s the

Enc

ount

er In

form

atio

n ca

n be

subm

itted

:

1) Electronically

- As

you

wou

ld a

PPO

or I

ndem

nity

Cla

im

2) W

eb S

ite -

Clai

ms c

an b

e su

bmitt

ed in

divi

dual

ly o

n ou

r web

site

at w

ww

.uhc

prov

ider

s.co

m

3)

By

Mai

l - A

s you

wou

ld a

PPO

or I

ndem

nity

Cla

im

4) U

tiliz

atio

n Re

port

s - M

ust c

onta

in A

LL re

quire

d in

form

atio

n:

•

Subs

crib

er ID

• Su

bscr

iber

Dat

e of

Birt

h •

Gro

up N

ame

or N

umbe

r•

Patie

nt’s

Ful

l Nam

e•

Patie

nt’s

Dat

e of

Birt

h•

Rela

tions

hip

to S

ubsc

riber

• Ph

ysic

al A

ddre

ss•

ADA

Code

Per

form

ed•

Toot

h# /

Qua

dran

t•

Surf

ace

• Tr

eatin

g De

ntis

t Nam

e•

Dent

ist T

ax I.

D. fo

r Bill

ingloca

l ane

sthe

sia

in c

onju

nctio

n w

ith o

pera

tive

or su

rgic

al p

roce

dure

sev

alua

tion

for d

eep

seda

tion

or g

ener

al a

nest

hesi

aco

nsul

tatio

n (d

iagn

ostic

serv

ice

prov

ided

by

dent

ist o

r phy

sici

an o

ther

than

pra

ctiti

oner

pro

vidi

ng

offic

e vi

sit f

or o

bser

vatio

n (d

urin

g re

gula

rly sc

hedu

led

hour

s) -

no o

ther

serv

ices

per

form

edof

fice

visi

t - a

fter

regu

larly

sche

dule

d ho

urs

Enco

unte

r/U

tiliza

tion

Repo

rtin

g - W

hen

subm

ittin

g En

coun

ter/

Util

izat

ion

clai

ms,

you

mus

t inc

lude

Cod

e D0

999

alon

g w

ith a

ll co

vere

d se

rvic

e pr

oced

ure

code

s you

per

form

on

each

AAR

P M

edic

are

Com

plet

e DH

MO

mem

ber.

Pl

ease

not

e th

e fo

llow

ing:

1)

If y

ou su

bmit

D099

9 al

one

no a

dditi

onal

$2.

00 re

imbu

rsem

ent w

ill n

ot b

e pa

id.

Addi

tiona

lly, c

laim

subm

issio

n w

ould

be

cons

ider

ed n

on-c

ompl

iant

.

2)

If y

ou su

bmit

all s

ervi

ce p

roce

dure

serv

ice

code

s but

don

't in

clud

e D0

999

as w

ell a

s you

won

't be

reim

burs

ed th

e ad

ditio

nal $

2.00

. In

add

ition

, the

cla

im w

ill b

e co

nsid

ered

non

-com

plia

nt,

unlim

ited

unlim

ited

unlim

ited

4 ev

ery

24 m

onth

s

unlim

ited

unlim

ited

unlim

ited

unlim

ited

unlim

ited

unlim

ited

unlim

ited

unlim

ited

case

pre

sent

atio

n, d

etai

led

and

exte

nsiv

e tr

eatm

ent p

lann

ing

occl

usal

adj

ustm

ent -

lim

ited

inci

sion

and

dra

inag

e of

abs

cess

- in

trao

ral s

oft t

issu

e - c

ompl

icat

ed (i

nclu

des d

rain

age

of m

ultip

le

fasc

ial s

pace

s)in

cisi

on a

nd d

rain

age

of a

bsce

ss -

extr

aora

l sof

t tis

sue

- com

plic

ated

(inc

lude

s dra

inag

e of

mul

tiple

fa

scia

l spa

ces)

occl

usal

ort

hotic

dev

ice

adju

stm

ent

palli

ativ

e (e

mer

genc

y) tr

eatm

ent o

f den

tal p

ain

- min

or p

roce

dure

4242

Prov

ider

Cla

im D

ispu

tes

Mem

ber A

ppea

ls &

Grie

vanc

es

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r Aut

horiz

atio

n Re

ques

ts

CA_F

ACET

S D0

0120

25_P

kg D

N04

8, 6

0_Hi

gh O

ptio

n De

ntal

-DM

O77

09/2

016

“Prio

r Aut

horiz

atio

n re

quire

d” m

eans

the

prac

titio

ner m

ust s

ubm

it th

ose

proc

edur

es fo

r app

rova

l with

clin

ical

doc

umen

tatio

n su

ppor

ting

nece

ssity

bef

ore

perf

orm

ing

thos

e pr

oced

ures

. To

do th

is c

ompl

ete

a st

anda

rd A

DA

clai

m fo

rm a

nd c

heck

the

box

mar

ked

“Pre

-Tre

atm

ent E

STIM

ATE.

” Pr

ior a

utho

rizat

ion

requ

est c

an b

e su

bmitt

ed v

ia th

e pr

ovid

er w

eb p

orta

l (at

ww

w.m

yuhc

prov

ider

s.co

m),

subm

itted

ele

ctro

nica

lly v

ia y

our c

lear

ingh

ouse

, or

simpl

y m

ail t

he fo

rm, t

o th

e be

low

add

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, alo

ng w

ith a

ny re

quire

d su

pple

men

tal i

nfor

mat

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(film

s, n

arra

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per

io-c

hart

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etc

.). Y

our o

ffice

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then

rece

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xpla

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efits

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utlin

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the

deni

al o

r app

rova

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requ

este

d tr

eatm

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nd p

lan

paym

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mou

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hen

appl

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Dent

al P

rovi

ders

with

com

plai

nts a

re to

con

tact

Uni

tedH

ealth

care

Den

tal’s

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vide

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vice

dep

artm

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t (87

7) 8

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wor

k Pr

ovid

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ontr

actu

al d

ispu

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-of-N

etw

ork

prov

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dis

pute

s, a

nd re

proc

essi

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ques

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will

be

logg

ed in

to th

e ap

peal

s dat

abas

e. P

leas

e m

ail t

o th

e Ap

peal

s & G

rieva

nces

PO

Box

list

ed a

bove

. Res

earc

h an

d re

solu

tion

will

be

com

plet

ed w

ithin

30

cale

ndar

day

s.

Mem

ber a

ppea

ls a

re re

view

ed b

y th

e he

alth

pla

n, a

nd a

re n

ot d

eleg

ated

to U

HC D

enta

l. Al

l Mem

ber a

ppea

ls (i

nclu

des P

re-S

ervi

ce a

ppea

ls, I

n N

etw

ork

Prov

ider

app

eals

, and

Out

of N

etw

ork

prov

ider

app

eals

) rec

eive

d by

UHC

De

ntal

will

be

forw

arde

d to

the

heal

th p

lan

via

over

nigh

t mai

l, w

ithin

7 d

ays o

f rec

eipt

of t

he a

ppea

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Mai

l mem

ber a

ppea

ls to

: Uni

tedH

ealth

care

, Att

n: A

ppea

l Dep

artm

ent,

MS

CA12

4-01

57, P

O B

ox 6

106,

Cyp

ress

, CA

9063

0

43

Iden

tific

atio

n Ca

rds

Sam

ple

Mem

ber I

D C

ard*

Fron

t of c

ard

Back

of c

ard

Fron

t of c

ard

Back

of c

ard

Impo

rtan

t Tel

epho

ne N

umbe

rs &

Web

site

s

Prov

ider

Qui

ck R

efer

ence

Gui

de -

Effe

ctiv

e 1/

1/20

17Ca

lifor

nia

Opt

iona

l Rid

er -

DH

MO

AARP

Med

icar

eCom

plet

e Se

cure

Hor

izon

s Pla

ns

*Ple

ase

note

that

the

Med

ical

ID C

ard

is un

iver

sal a

nd in

clud

es a

ll lin

es o

f cov

erag

e. T

he M

edic

al p

lan

can

be H

MO

or P

PO a

nd th

is d

oes n

ot re

flect

the

Dent

al P

lan

Bene

fits.

Ple

ase

flip

the

ID C

ard

over

to se

e th

e De

ntal

Pro

vide

r in

form

atio

n on

the

back

(i.e

. car

rier w

ebsi

te a

nd to

ll-fr

ee n

umbe

r). T

his i

nfor

mat

ion

can

be u

sed

to c

onfir

m p

rovi

der p

artic

ipat

ion,

mem

ber e

ligib

ility

and

ben

efits

. Thi

s is a

SAM

PLE

ID C

ard

and

may

diff

er fr

om th

e m

embe

r's ID

Ca

rd.

Elig

ibili

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Bene

fits,

Cla

im(s

) and

Aut

horiz

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7-81

6-35

96Li

ve A

gent

: Mon

day

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ay, 8

:00A

M -

6:00

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STIV

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day

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to In

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pdat

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53Li

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day

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0PM

, EST

4444

Impo

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t Add

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Impo

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ctro

nic

Clai

ms &

Prio

r Aut

horiz

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n Su

bmis

sion

Info

rmat

ion

unlim

ited

1 ev

ery

6 m

onth

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m la

st d

ate

of se

rvic

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limite

dun

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unlim

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unlim

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unlim

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unlim

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unlim

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unlim

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unlim

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unlim

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unlim

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unlim

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unlim

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unlim

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unlim

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unlim

ited

unlim

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unlim

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No

D023

0in

trao

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per

iapi

cal e

ach

addi

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l rad

iogr

aphi

c im

age

No

D024

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trao

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occ

lusa

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aphi

c im

age

No

D021

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220

Asse

ssm

ent o

f a p

atie

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trao

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aphi

c im

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intr

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eria

pica

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t rad

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aphi

c im

age

No

D012

0D0

140

D014

5D0

150

perio

dic

oral

eva

luat

ion

limite

d or

al e

valu

atio

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robl

em fo

cuse

d

oral

eva

luat

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for a

pat

ient

und

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ree

year

s of a

ge a

nd c

ouns

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ith p

rimar

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regi

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com

preh

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valu

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ew o

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patie

nt

D019

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reen

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of a

pat

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Cove

red

Den

tal S

ervi

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Prio

r Aut

horiz

atio

n Re

quire

d?Pr

oced

ure

Code

Freq

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mita

tions

24 h

ours

a d

ay

Proc

edur

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escr

iptio

n

24 h

ours

a d

ay

Clai

ms

D017

0D0

171

5213

3

Prio

r Aut

horiz

atio

nAp

peal

s & G

rieva

nces

Uni

tedH

ealth

care

Den

tal,

PO B

ox 3

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, Sal

t Lak

e Ci

ty, U

T 84

130-

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tedH

ealth

care

Den

tal,

PO B

ox 3

0552

, Sal

t Lak

e Ci

ty, U

T 8

4130

-055

2U

nite

dHea

lthca

re D

enta

l, Ap

peal

s Disp

utes

, PO

Box

305

69, S

alt L

ake

City

, UT

8413

0-05

69

D018

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deta

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and

exte

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al e

valu

atio

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robl

em-fo

cuse

d, b

y re

port

unlim

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2 ev

ery

year

No

No

D019

0

No

No

No

No

re-e

valu

atio

n, li

mite

d, p

robl

em fo

cuse

dre

-eva

luat

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- pos

t-op

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offic

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com

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ensi

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erio

dont

al e

valu

atio

n - n

ew o

r est

ablis

hed

patie

nt

D016

0

No

No

No

No

Med

icar

ew

ww

.med

icar

e.go

v24

hou

rs a

day

Elig

ibili

ty,

Bene

fits,

Cla

im(s

) and

Aut

horiz

atio

nsw

ww

.dbp

.com

Cent

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or M

edic

aid

and

Med

icar

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rvic

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ww

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s.hh

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v

Prov

ider

Rea

son

for M

ailin

g

EDI P

ayer

Num

ber f

or C

laim

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o

D046

0pu

lp v

italit

y te

sts

No

D111

0pr

ophy

laxi

s - a

dult

No

No

D214

0am

alga

m -

one

surf

ace,

prim

ary

or p

erm

anen

tN

oD2

150

amal

gam

- tw

o su

rfac

es, p

rimar

y or

per

man

ent

No

D120

8To

pica

l app

licat

ion

of fl

uorid

e - e

xclu

ding

var

nish

No

D133

0or

al h

ygie

ne in

stru

ctio

nsN

o

D216

0am

alga

m -

thre

e su

rfac

es, p

rimar

y or

per

man

ent

No

D216

1am

alga

m -

four

or m

ore

surf

aces

, prim

ary

or p

erm

anen

t

No

D271

2cr

own

- 3/4

resi

n-ba

sed

com

posi

te (i

ndire

ct)

No

D239

3re

sin-

base

d co

mpo

site

- th

ree

surf

aces

, pos

terio

rN

oD2

394

resi

n-ba

sed

com

posi

te -

four

or m

ore

surf

aces

, pos

terio

rN

o

unlim

ited

D233

2re

sin-

base

d co

mpo

site

- th

ree

surf

aces

, ant

erio

rN

oD2

335

resi

n-ba

sed

com

posi

te -

four

or m

ore

surf

aces

or i

nvol

ving

inci

sal a

ngle

(ant

erio

r)N

o

D233

0re

sin-

base

d co

mpo

site

- on

e su

rfac

e, a

nter

ior

No

D233

1re

sin-

base

d co

mpo

site

- tw

o su

rfac

es, a

nter

ior

No

D271

0cr

own,

resi

n-ba

sed

com

posi

te (i

ndire

ct)

D239

1re

sin-

base

d co

mpo

site

- on

e su

rfac

e, p

oste

rior

No

D239

2re

sin-

base

d co

mpo

site

- tw

o su

rfac

es, p

oste

rior

No

D272

0cr

own

- res

in w

ith h

igh

nobl

e m

etal

No

45

unlim

ited

unlim

ited

unlim

ited

unlim

ited

unlim

ited

D293

2D2

940

D294

1

D278

2D2

783

D279

0D2

791

D279

2D2

794

D291

5D2

920

D293

1

D275

0cr

own

- por

cela

in fu

sed

to h

igh

nobl

e m

etal

Yes

D275

1cr

own

- por

cela

in fu

sed

to p

redo

min

antly

bas

e m

etal

Yes

D275

2D2

780

D278

1

D274

0cr

own

- por

cela

in/c

eram

ic su

bstr

ate

Yes

crow

n - p

orce

lain

fuse

d to

nob

le m

etal

crow

n, 3

/4 c

ast h

igh

nobl

e m

etal

crow

n, 3

/4 c

ast p

redo

min

atel

y ba

se m

etal

Yes

No

Yes

D272

2cr

own

- res

in w

ith n

oble

met

alN

oD2

721

crow

n - r

esin

with

pre

dom

inan

tly b

ase

met

alN

o

D295

1D2

952

D295

3D2

954

D295

7D2

971

D299

0D3

110

D312

0D3

220

D331

0D3

320

D333

0D3

332

D395

0D4

341

D434

2D4

355

D491

0D4

921

D511

0D5

120

D513

0D5

140

D521

1

D521

2

D521

3

D521

4D5

225

D522

6

D528

1D5

410

crow

n, 3

/4 c

ast n

oble

met

alcr

own,

3/4

por

cela

in/c

eram

iccr

own

- ful

l cas

t hig

h no

ble

met

alcr

own

- ful

l cas

t pre

dom

inan

tly b

ase

met

alcr

own

- ful

l cas

t nob

le m

etal

crow

n - t

itani

um

pulp

cap

- in

dire

ct (e

xclu

ding

fina

l res

tora

tion)

ther

apeu

tic p

ulpo

tom

y (e

xclu

ding

fina

l res

tora

tion)

endo

dont

ic th

erap

y, a

nter

ior t

ooth

(exc

ludi

ng fi

nal r

esto

ratio

n)

rece

men

t or r

e-bo

nd c

ast i

ndire

ctly

fabr

icat

ed o

r pre

fabr

icat

ed p

ost a

nd c

ore

rece

men

t or r

e-bo

nd c

row

npr

efab

ricat

ed st

ainl

ess s

teel

cro

wn

- per

man

ent t

ooth

pref

abric

ated

resi

n cr

own

prot

ectiv

e re

stor

atio

nin

terim

ther

apeu

tic re

stor

atio

n-pr

imar

y de

ntiti

onpi

n re

tent

ion

- per

toot

h, in

add

ition

to re

stor

atio

nca

st p

ost a

nd c

ore

in a

dditi

on to

cro

wn

each

add

ition

al in

dire

ctly

fabr

icat

ed p

ost,

sam

e to

oth

pref

abric

ated

pos

t and

cor

e in

add

ition

to c

row

nea

ch a

dditi

onal

pre

fabr

icat

ed p

ost,

sam

e to

oth

addi

tiona

l pro

cedu

res t

o co

nstr

uct n

ew c

row

n un

der e

xist

ing

part

ial d

entu

re fr

amew

ork

(to

be

resi

n in

filtr

atio

n of

inci

pien

t sm

ooth

surf

ace

lesi

ons

pulp

cap

- di

rect

(exc

ludi

ng fi

nal r

esto

ratio

n)

endo

dont

ic th

erap

y, b

icus

pid

toot

h (e

xclu

ding

fina

l res

tora

tion)

endo

dont

ic th

erap

y, m

olar

(exc

ludi

ng fi

nal r

esto

ratio

n)in

com

plet

e en

dodo

ntic

ther

apy;

inop

erab

le, u

nres

tora

ble

or fr

actu

red

toot

hca

nal p

repa

ratio

n an

d fit

ting

of p

refo

rmed

dow

el o

r pos

tpe

riodo

ntal

scal

ing

and

root

pla

nnin

g - f

our o

r mor

e te

eth

per q

uadr

ant

perio

dont

al sc

alin

g an

d ro

ot p

lann

ing

- one

- th

ree

teet

h, p

er q

uadr

ant

full

mou

th d

ebrid

emen

t to

enab

le c

ompr

ehen

sive

eva

luat

ion

and

diag

nosi

spe

riodo

ntal

mai

nten

ance

ging

ival

irrig

atio

n - p

er q

uadr

ant

com

plet

e de

ntur

e - m

axill

ary

com

plet

e de

ntur

e - m

andi

bula

rim

med

iate

den

ture

- m

axill

ary

imm

edia

te d

entu

re -

man

dibu

lar

max

illar

y pa

rtia

l den

ture

- re

sin b

ase

(incl

udin

g an

y co

nven

tiona

l cla

sps,

rest

s and

teet

h)

man

dibu

lar p

artia

l den

ture

- re

sin

base

(inc

ludi

ng a

ny c

onve

ntio

nal c

lasp

s, re

sts a

nd te

eth)

max

illar

y pa

rtia

l den

ture

- ca

st m

etal

fram

ewor

k w

ith re

sin d

entu

re b

ases

(inc

ludi

ng a

ny c

onve

ntio

nal

clas

ps, r

ests

and

man

dibu

lar p

artia

l den

ture

- ca

st m

etal

fram

ewor

k w

ith re

sin

dent

ure

base

s (in

clud

ing

any

conv

entio

nal c

lasp

s, re

sts a

ndm

axill

ary

part

ial d

entu

re -

flexi

ble

base

(inc

ludi

ng a

ny c

lasp

s, re

sts a

nd te

eth)

man

dibu

lar p

artia

l den

ture

- fle

xibl

e ba

se (i

nclu

ding

any

cla

sps,

rest

s and

teet

h)

rem

ovab

le u

nila

tera

l par

tial d

entu

re -

one

piec

e ca

st m

etal

(inc

ludi

ng c

lasp

s and

teet

h)ad

just

com

plet

e de

ntur

e - m

axill

ary

Yes

Yes

Yes

Yes

Yes

No

No

No

No

No

No

No

No

No

No

Yes

Yes

Yes

Yes

Yes

No

No

Yes

Yes

Yes

No

No

No

No

No

No

No

No

No

No

No

No

No

No

No

No

No

No

No

unlim

ited

unlim

ited

unlim

ited

unlim

ited

unlim

ited

unlim

ited

unlim

ited

unlim

ited

unlim

ited

unlim

ited

unlim

ited

unlim

ited

unlim

ited

unlim

ited

unlim

ited

unlim

ited

unlim

ited

unlim

ited

unlim

ited

unlim

ited

unlim

ited

unlim

ited

unlim

ited

unlim

ited

unlim

ited

unlim

ited

unlim

ited

unlim

ited

unlim

ited

unlim

ited

4 ev

ery

year

unlim

ited

unlim

ited

unlim

ited

unlim

ited

unlim

ited

unlim

ited

unlim

ited

unlim

ited

unlim

ited

unlim

ited

unlim

ited

unlim

ited

unlim

ited

unlim

ited

unlim

ited

unlim

ited

4646

D541

1D5

421

D542

2D5

510

D552

0D5

610

D562

0D5

630

D564

0D5

650

D566

0D5

670

D567

1D5

730

D573

1D5

740

D574

1D5

750

D575

1D5

760

D576

1D5

863

D586

4D5

865

D586

6D6

210

D621

1D6

212

D621

4D6

240

D624

1D6

242

D624

5D6

250

D625

1D6

252

D672

0

D679

2D6

794

D693

0D7

111

D714

0D7

510

D751

1

D672

1D6

722

D674

0D6

750

D675

1D6

752

D678

0D6

781

D678

2D6

783

D679

0D6

791

adju

st c

ompl

ete

dent

ure

- man

dibu

lar

adju

st p

artia

l den

ture

- m

axill

ary

adju

st p

artia

l den

ture

- m

andi

bula

rre

pair

brok

en c

ompl

ete

dent

ure

base

repl

ace

mis

sing

or b

roke

n te

eth

- com

plet

e de

ntur

e (e

ach

toot

h)re

pair

resi

n de

ntur

e ba

sere

pair

cast

fram

ewor

kre

pair

or re

plac

e br

oken

cla

sp -

per t

ooth

repl

ace

brok

en te

eth

- per

toot

had

d to

oth

to e

xist

ing

part

ial d

entu

read

d cl

asp

to e

xist

ing

part

ial d

entu

re -

per t

ooth

repl

ace

all t

eeth

and

acr

ylic

on

cast

met

al fr

amew

ork

(max

illar

y)re

plac

e al

l tee

th a

nd a

cryl

ic o

n ca

st m

etal

fram

ewor

k (m

andi

bula

r)re

line

com

plet

e m

axill

ary

dent

ure

(cha

irsid

e)re

line

com

plet

e m

andi

bula

r den

ture

(cha

irsid

e)re

line

max

illar

y pa

rtia

l den

ture

(cha

irsid

e)re

line

man

dibu

lar p

artia

l den

ture

(cha

irsid

e)re

line

com

plet

e m

axill

ary

dent

ure

(labo

rato

ry)

relin

e co

mpl

ete

man

dibu

lar d

entu

re (l

abor

ator

y)re

line

max

illar

y pa

rtia

l den

ture

(lab

orat

ory)

relin

e m

andi

bula

r par

tial d

entu

re (l

abor

ator

y)

reta

iner

cro

wn

- res

in w

ith h

igh

nobl

e m

etal

reta

iner

cro

wn

- res

in w

ith p

redo

min

antly

bas

e m

etal

reta

iner

cro

wn

- res

in w

ith n

oble

met

al

Ove

rden

ture

-com

plet

e m

axill

ary

Ove

rden

ture

-par

tial m

axill

ary

Ove

rden

ture

- co

mpl

ete

man

dibu

lar

Ove

rden

ture

-par

tial m

andi

bula

rpo

ntic

- ca

st h

igh

nobl

e m

etal

pont

ic -

cast

pre

dom

inan

tly b

ase

met

alpo

ntic

- ca

st n

oble

met

alpo

ntic

- tit

aniu

mpo

ntic

- po

rcel

ain

fuse

d to

hig

h no

ble

met

alpo

ntic

- po

rcel

ain

fuse

d to

pre

dom

inan

tly b

ase

met

alpo

ntic

- po

rcel

ain

fuse

d to

nob

le m

etal

pont

ic-p

orce

lain

/cer

amic

pont

ic -

resi

n w

ith h

igh

nobl

e m

etal

pont

ic -

resi

n w

ith p

redo

min

antly

bas

e m

etal

pont

ic -

resi

n w

ith n

oble

met

al

reta

iner

cro

wn

- ful

l cas

t pre

dom

inan

tly b

ase

met

alre

tain

er c

row

n - f

ull c

ast n

oble

met

alre

tain

er c

row

n - t

itani

umre

cem

ent o

r re-

bond

fixe

d pa

rtia

l den

ture

extr

actio

n, c

oron

al re

mna

nts -

dec

iduo

us to

oth

extr

actio

n, e

rupt

ed to

oth

or e

xpos

ed ro

ot (e

leva

tion

and/

or fo

rcep

s rem

oval

)in

cisi

on a

nd d

rain

age

of a

bsce

ss -

intr

aora

l sof

t tis

sue

inci

sion

and

dra

inag

e of

abs

cess

- in

trao

ral s

oft t

issu

e - c

ompl

icat

ed (i

nclu

des d

rain

age

of m

ultip

le

fasc

ial s

pace

s)

reta

iner

cro

wn-

porc

elai

n/ce

ram

icre

tain

er c

row

n - p

orce

lain

fuse

d to

hig

h no

ble

met

alre

tain

er c

row

n - p

orce

lain

fuse

d to

pre

dom

inan

tly b

ase

met

alre

tain

er c

row

n - p

orce

lain

fuse

d to

nob

le m

etal

reta

iner

cro

wn

- 3/4

cas

t hig

h no

ble

met

alre

tain

er c

row

n-3/

4 ca

st p

redo

min

atel

y ba

sed

met

alre

tain

er c

row

n-3/

4 ca

st n

oble

met

alre

tain

er c

row

n-3/

4 po

rcel

ain/

cera

mic

reta

iner

cro

wn

- ful

l cas

t hig

h no

ble

met

al

No

No

No

No

No

No

No

No

No

No

No

No

No

No

No

No

No

No

No

No

No

Yes

Yes

No

No

No

No

No

Yes

Yes

Yes

No

Yes

Yes

Yes

No

No

No

No

No

No

Yes

Yes

Yes

Yes

Yes

Yes

Yes

Yes

Yes

Yes

Yes

Yes

No

Yes

Yes

unlim

ited

unlim

ited

unlim

ited

unlim

ited

unlim

ited

unlim

ited

unlim

ited

unlim

ited

unlim

ited

unlim

ited

unlim

ited

unlim

ited

unlim

ited

unlim

ited

unlim

ited

unlim

ited

unlim

ited

unlim

ited

unlim

ited

unlim

ited

unlim

ited

unlim

ited

unlim

ited

unlim

ited

unlim

ited

unlim

ited

unlim

ited

unlim

ited

unlim

ited

unlim

ited

unlim

ited

unlim

ited

unlim

ited

unlim

ited

unlim

ited

unlim

ited

unlim

ited

unlim

ited

unlim

ited

unlim

ited

unlim

ited

unlim

ited

unlim

ited

unlim

ited

unlim

ited

unlim

ited

unlim

ited

unlim

ited

unlim

ited

unlim

ited

unlim

ited

unlim

ited

1 pe

r too

th1

per t

ooth

unlim

ited

unlim

ited

47

Prov

ider

Cla

im D

ispu

tes

The

Calif

orni

a O

ptio

nal R

ider

DHM

O D

enta

l sup

plem

enta

l ben

efit

plan

cov

ers t

he d

enta

l cod

es li

sted

abo

ve. T

his s

uppl

emen

tal b

enef

it is

offe

red

to m

embe

rs th

at a

re e

nrol

led

in A

ARP

Med

icar

eCom

plet

e Se

cure

Horiz

ons a

nd

Shar

p Se

cure

Horiz

ons P

lans

. Pro

vide

r pay

men

t is m

ade

on a

Fee

-for-

Serv

ice

basi

s. M

embe

rs h

ave

In-n

etw

ork

only

ben

efits

. Som

e se

rvic

es re

quire

prio

r aut

horiz

atio

n. T

he m

embe

r cop

ays v

ary

for c

over

ed se

rvic

es fr

om $

3 -

$650

. The

re is

no

annu

al m

axim

um, c

oins

uran

ce o

r ded

uctib

le.

Dent

al P

rovi

ders

with

com

plai

nts a

re to

con

tact

Uni

tedH

ealth

care

Den

tal’s

Pro

vide

r Ser

vice

dep

artm

ent a

t (87

7) 8

16-3

596.

Net

wor

k Pr

ovid

er c

ontr

actu

al d

ispu

tes,

Out

-of-N

etw

ork

prov

ider

dis

pute

s, a

nd re

proc

essi

ng re

ques

ts

will

be

logg

ed in

to th

e ap

peal

s dat

abas

e. P

leas

e m

ail t

o th

e Ap

peal

s & G

rieva

nces

PO

Box

list

ed a

bove

. Res

earc

h an

d re

solu

tion

will

be

com

plet

ed w

ithin

30

cale

ndar

day

s.

D995

1

D788

1D9

110

occl

usal

ort

hotic

dev

ice

adju

stm

ent

No

No

No

No

No

No

In a

n ef

fort

to c

ompl

y w

ith th

e Ce

nter

s for

Med

icar

e an

d M

edic

aid

(CM

S) st

ate

man

date

d re

quire

men

ts, p

leas

e be

adv

ised

that

DHM

O E

ncou

nter

Dat

a Su

bmis

sion

s are

now

requ

ired.

CM

S no

w re

quire

s tha

t we

repo

rt 1

00%

of

util

izat

ion

data

for o

ur C

alifo

rnia

Opt

iona

l Rid

er D

HMO

mem

bers

. To

ens

ure

that

we

mee

t CM

S re

quire

men

t of r

epor

ting

100%

util

izatio

n, w

e ar

e ha

ppy

to re

-intr

oduc

e ou

r Den

tal I

ncen

tive

Prog

ram

effe

ctiv

e im

med

iate

ly.

Dent

al B

enef

it Pr

ovid

ers w

ill re

imbu

rse

our p

rovi

ders

$2.

00 fo

r eac

h en

coun

ter c

laim

subm

itted

for C

alifo

rnia

Opt

iona

l Rid

er D

HM

O m

embe

rs o

nly

for a

ll pr

oced

ures

(cov

ered

und

er th

e m

embe

r's p

lan)

per

form

ed o

n th

ose

mem

bers

, for

eac

h da

te o

f ser

vice

. Al

l pro

cedu

res p

erfo

rmed

MU

ST b

e re

port

ed in

clud

ing

proc

edur

es w

heth

er o

r not

the

mem

ber h

as a

cop

aym

ent.

Thi

s is a

requ

irem

ent f

or a

ll co

ntra

cted

pro

vide

rs to

subm

it ut

iliza

tion

for

each

pat

ient

trea

ted.

Her

e ar

e a

few

way

s the

Enc

ount

er In

form

atio

n ca

n be

subm

itted

:

1)

Electronically

- As

you

wou

ld a

PPO

or I

ndem

nity

Cla

im

2) W

eb S

ite -

Clai

ms c

an b

e su

bmitt

ed in

divi

dual

ly o

n ou

r web

site

at w

ww

.uhc

prov

ider

s.co

m

3) B

y M

ail -

As y

ou w

ould

a P

PO o

r Ind

emni

ty C

laim

4)

Util

izat

ion

Repo

rts -

Mus

t con

tain

ALL

requ

ired

info

rmat

ion:

• Su

bscr

iber

ID•

Subs

crib

er D

ate

of B

irth

• G

roup

Nam

e or

Num

ber

• Pa

tient

’s F

ull N

ame

• Pa

tient

’s D

ate

of B

irth

• Re

latio

nshi

p to

Sub

scrib

er•

Phys

ical

Add

ress

• AD

A Co

de P

erfo

rmed

• To

oth#

/ Q

uadr

ant

• Su

rfac

e•

Trea

ting

Dent

ist N

ame

• De

ntist

Tax

I.D.

for B

illin

g

Enco

unte

r/U

tiliza

tion

Repo

rtin

g - W

hen

subm

ittin

g En

coun

ter/

Util

izat

ion

clai

ms,

you

mus

t inc

lude

Cod

e D0

999

alon

g w

ith a

ll co

vere

d se

rvic

e pr

oced

ure

code

s you

per

form

on

each

Opt

iona

l Cal

iforn

ia D

HMO

mem

ber.

Pl

ease

not

e th

e fo

llow

ing:

1)

If y

ou su

bmit

D099

9 al

one

no a

dditi

onal

$2.

00 re

imbu

rsem

ent w

ill n

ot b

e pa

id.

Addi

tiona

lly, c

laim

subm

issio

n w

ould

be

cons

ider

ed n

on-c

ompl

iant

.

2) If

yo

u su

bmit

all s

ervi

ce p

roce

dure

serv

ice

code

s but

don

't in

clud

e D0

999

as w

ell a

s you

won

't be

reim

burs

ed th

e ad

ditio

nal $

2.00

. In

add

ition

, the

cla

im w

ill b

e co

nsid

ered

non

-com

plia

nt.

unlim

ited

unlim

ited

unlim

ited

unlim

ited

unlim

ited

unlim

ited

4 ev

ery

24 m

onth

s fro

m la

st d

ate

of se

rvic

eN

o

palli

ativ

e (e

mer

genc

y) tr

eatm

ent o

f den

tal p

ain

- min

or p

roce

dure

loca

l ane

sthe

sia

in c

onju

nctio

n w

ith o

pera

tive

or su

rgic

al p

roce

dure

s

offic

e vi

sit f

or o

bser

vatio

n (d

urin

g re

gula

rly sc

hedu

led

hour

s) -

no o

ther

serv

ices

per

form

edof

fice

visi

t - a

fter

regu

larly

sche

dule

d ho

urs

case

pre

sent

atio

n, d

etai

led

and

exte

nsiv

e tr

eatm

ent p

lann

ing

D921

5

D943

0D9

440

D945

0oc

clus

al a

djus

tmen

t - li

mite

d

4848

Mem

ber A

ppea

ls &

Grie

vanc

es

Prio

r Aut

horiz

atio

n Re

ques

ts

CA_F

ACET

S D0

0120

24_P

kg D

N05

4_O

ptio

nal D

enta

l-DM

O75

09/2

016

“Prio

r Aut

horiz

atio

n re

quire

d” m

eans

the

prac

titio

ner m

ust s

ubm

it th

ose

proc

edur

es fo

r app

rova

l with

clin

ical

doc

umen

tatio

n su

ppor

ting

nece

ssity

bef

ore

perf

orm

ing

thos

e pr

oced

ures

. To

do th

is c

ompl

ete

a st

anda

rd A

DA

clai

m fo

rm a

nd c

heck

the

box

mar

ked

“Pre

-Tre

atm

ent E

STIM

ATE.

” Pr

ior a

utho

rizat

ion

requ

est c

an b

e su

bmitt

ed v

ia th

e pr

ovid

er w

eb p

orta

l (at

ww

w.m

yuhc

prov

ider

s.co

m),

subm

itted

ele

ctro

nica

lly v

ia y

our c

lear

ingh

ouse

, or

simpl

y m

ail t

he fo

rm, t

o th

e be

low

add

ress

, alo

ng w

ith a

ny re

quire

d su

pple

men

tal i

nfor

mat

ion

(film

s, n

arra

tive,

per

io-c

hart

ing,

etc

.). Y

our o

ffice

will

then

rece

ive

an E

xpla

natio

n of

Ben

efits

(EO

B) o

utlin

ing

the

deni

al o

r app

rova

l of

requ

este

d tr

eatm

ent a

nd p

lan

paym

ent a

mou

nts w

hen

appl

icab

le.

Mem

ber a

ppea

ls a

re re

view

ed b

y th

e he

alth

pla

n, a

nd a

re n

ot d

eleg

ated

to U

HC D

enta

l. Al

l Mem

ber a

ppea

ls (i

nclu

des P

re-S

ervi

ce a

ppea

ls, I

n N

etw

ork

Prov

ider

app

eals

, and

Out

of N

etw

ork

prov

ider

app

eals

) rec

eive

d by

UHC

De

ntal

will

be

forw

arde

d to

the

heal

th p

lan

via

over

nigh

t mai

l, w

ithin

7 d

ays o

f rec

eipt

of t

he a

ppea

l.

Mai

l mem

ber a

ppea

ls to

: Uni

tedH

ealth

care

, Att

n: A

ppea

l Dep

artm

ent,

MS

CA12

4-01

57, P

O B

ox 6

106,

Cyp

ress

, CA

9063

0

49

Iden

tific

atio

n Ca

rds

Sam

ple

Mem

ber I

D C

ard*

Fron

t of c

ard

Back

of c

ard

Fron

t of c

ard

Back

of c

ard

Impo

rtan

t Tel

epho

ne N

umbe

rs &

Web

site

s

Call

to In

quire

Abo

utTe

leph

one

Num

ber

Hou

rs o

f Ope

ratio

n

Emai

l to

Inqu

ire A

bout

Web

site

Hou

rs o

f Ope

ratio

nTo

dis

cuss

you

r par

ticip

atio

n, c

ontr

actu

al is

sues

, den

tist c

hang

es o

r offi

ce u

pdat

es80

0-82

2-53

53Li

ve A

gent

: Mon

day

- Frid

ay, 8

:00A

M -

11:0

0PM

, EST

Prov

ider

Qui

ck R

efer

ence

Gui

de -

Effe

ctiv

e 1/

1/20

17Co

lora

do H

igh

Opt

ion

Ride

r 260

DH

MO

- $1

000

Annu

al M

axim

umAA

RP M

edic

areC

ompl

ete

Secu

reH

oriz

ons P

lans

1, 2

, and

Ess

entia

l Pla

ns

*Ple

ase

note

that

the

Med

ical

ID C

ard

is un

iver

sal a

nd in

clud

es a

ll lin

es o

f cov

erag

e. T

he M

edic

al p

lan

can

be H

MO

or P

PO a

nd th

is d

oes n

ot re

flect

the

Dent

al P

lan

Bene

fits.

Ple

ase

flip

the

ID C

ard

over

to se

e th

e De

ntal

Pro

vide

r in

form

atio

n on

the

back

(i.e

. car

rier w

ebsi

te a

nd to

ll-fr

ee n

umbe

r). T

his i

nfor

mat

ion

can

be u

sed

to c

onfir

m p

rovi

der p

artic

ipat

ion,

mem

ber e

ligib

ility

and

ben

efits

. Thi

s is a

SAM

PLE

ID C

ard

and

may

diff

er fr

om th

e m

embe

r's ID

Ca

rd.

Elig

ibili

ty,

Bene

fits,

Cla

im(s

) and

Aut

horiz

atio

ns87

7-81

6-35

96Li

ve A

gent

: Mon

day

- Frid

ay, 8

:00A

M -

6:00

PM, E

STIV

R: 2

4 ho

urs a

day

51

Impo

rtan

t Add

ress

es

Impo

rtan

t Ele

ctro

nic

Clai

ms &

Prio

r Aut

horiz

atio

n Su

bmis

sion

Info

rmat

ion

D233

0re

sin-

base

d co

mpo

site

- on

e su

rfac

e, a

nter

ior

No

D216

0am

alga

m -

thre

e su

rfac

es, p

rimar

y or

per

man

ent

No

D216

1am

alga

m -

four

or m

ore

surf

aces

, prim

ary

or p

erm

anen

tN

o

D214

0am

alga

m -

one

surf

ace,

prim

ary

or p

erm

anen

tN

oD2

150

amal

gam

- tw

o su

rfac

es, p

rimar

y or

per

man

ent

No

D155

0re

cem

ent o

r re-

bond

of s

pace

mai

ntai

ner

No

D155

5re

mov

al o

f fix

ed sp

ace

mai

ntai

ner

No

D152

5sp

ace

mai

ntai

ner -

rem

ovab

le -

bila

tera

lN

o

D151

0sp

ace

mai

ntai

ner -

fixe

d - u

nila

tera

lN

oD1

515

spac

e m

aint

aine

r - fi

xed

- bila

tera

lN

o

pano

ram

ic ra

diog

raph

ic im

age

No

D047

0di

agno

stic

cas

tsN

o

D112

0pr

ophy

laxi

s - c

hild

No

D120

6to

pica

l app

licat

ion

of fl

uorid

e va

rnis

hN

o

D060

3ca

ries r

isk

asse

ssm

ent a

nd d

ocum

enta

tion,

with

a fi

ndin

g of

hig

h ris

kN

oD1

110

prop

hyla

xis -

adu

ltN

o

Med

icar

ew

ww

.med

icar

e.go

v24

hou

rs a

day

Elig

ibili

ty,

Bene

fits,

Cla

im(s

) and

Aut

horiz

atio

nsw

ww

.dbp

.com

Cent

ers f

or M

edic

aid

and

Med

icar

e Se

rvic

esw

ww

.cm

s.hh

s.go

v

Prov

ider

Rea

son

for M

ailin

g

Uni

tedH

ealth

care

Den

tal,

PO B

ox 3

0552

, Sal

t Lak

e Ci

ty, U

T 8

4130

-055

2U

nite

dHea

lthca

re D

enta

l, Ap

peal

s Disp

utes

, PO

Box

305

69, S

alt L

ake

City

, UT

8413

0-05

69

D021

0

deta

iled

and

exte

nsiv

e or

al e

valu

atio

n - p

robl

em-fo

cuse

d, b

y re

port

unlim

ited

unlim

ited

No

No

D022

0

No

No

No

No

re-e

valu

atio

n, li

mite

d, p

robl

em fo

cuse

dco

mpr

ehen

sive

per

iodo

ntal

eva

luat

ion

- new

or e

stab

lishe

d pa

tient

intr

aora

l - c

ompl

ete

serie

s of r

adio

grap

hic

imag

es

D016

0

No

No

No

No

EDI P

ayer

Num

ber f

or C

laim

s Sub

mitt

ed

D060

1ca

ries r

isk

asse

ssm

ent a

nd d

ocum

enta

tion,

with

a fi

ndin

g of

low

risk

No

D060

2ca

ries r

isk

asse

ssm

ent a

nd d

ocum

enta

tion,

with

a fi

ndin

g of

mod

erat

e ris

kN

o

D033

0

com

preh

ensi

ve o

ral e

valu

atio

n - n

ew o

r est

ablis

hed

patie

nt

D023

0in

trao

ral -

per

iapi

cal f

irst r

adio

grap

hic

imag

e

Cove

red

Den

tal S

ervi

ces:

Prio

r Aut

horiz

atio

n Re

quire

d?Pr

oced

ure

Code

Freq

uenc

y/Li

mita

tions

24 h

ours

a d

ay

Proc

edur

e D

escr

iptio

n

24 h

ours

a d

ay

Clai

ms

D017

0D0

180

5213

3

Prio

r Aut

horiz

atio

nAp

peal

s & G

rieva

nces

Uni

tedH

ealth

care

Den

tal,

PO B

ox 3

0567

, Sal

t Lak

e Ci

ty, U

T 84

130-

0567

unlim

ited

unlim

ited

unlim

ited

unlim

ited

unlim

ited

unlim

ited

unlim

ited

unlim

ited

unlim

ited

unlim

ited

2 ev

ery

year

unlim

ited

No

D027

2bi

tew

ings

- tw

o ra

diog

raph

ic im

ages

No

D027

4bi

tew

ings

- fo

ur ra

diog

raph

ic im

ages

No

D024

0D0

270

intr

aora

l - p

eria

pica

l eac

h ad

ditio

nal r

adio

grap

hic

imag

ein

trao

ral -

occ

lusa

l rad

iogr

aphi

c im

age

bite

win

g - s

ingl

e ra

diog

raph

ic im

age

No

D012

0D0

140

D014

5D0

150

perio

dic

oral

eva

luat

ion

limite

d or

al e

valu

atio

n - p

robl

em fo

cuse

d

oral

eva

luat

ion

for a

pat

ient

und

er th

ree

year

s of a

ge a

nd c

ouns

elin

g w

ith p

rimar

y ca

regi

ver

unlim

ited

unlim

ited

unlim

ited

unlim

ited

unlim

ited

unlim

ited

unlim

ited

unlim

ited

unlim

ited

unlim

ited

unlim

ited

unlim

ited

unlim

ited

1 ev

ery

6 m

onth

s1

ever

y 6

mon

ths

unlim

ited

unlim

ited

unlim

ited

unlim

ited

unlim

ited

unlim

ited

unlim

ited

unlim

ited

D135

2pr

even

tive

resi

n re

stor

atio

n - p

erm

anen

t too

thN

oD1

353

seal

ant r

epai

r - p

er to

oth

No

D120

8To

pica

l app

licat

ion

of fl

uorid

e - e

xclu

ding

var

nish

No

D135

1se

alan

t - p

er to

oth

No

No

D152

0sp

ace

mai

ntai

ner -

rem

ovab

le -

unila

tera

l

5252

unlim

ited

unlim

ited

unlim

ited

unlim

ited

unlim

ited

unlim

ited

unlim

ited

unlim

ited

unlim

ited

unlim

ited

unlim

ited

unlim

ited

unlim

ited

unlim

ited

unlim

ited

unlim

ited

unlim

ited

unlim

ited

unlim

ited

unlim

ited

unlim

ited

unlim

ited

unlim

ited

unlim

ited

unlim

ited

unlim

ited

unlim

ited

unlim

ited

unlim

ited

unlim

ited

unlim

ited

unlim

ited

unlim

ited

unlim

ited

unlim

ited

unlim

ited

unlim

ited

unlim

ited

unlim

ited

unlim

ited

unlim

ited

unlim

ited

unlim

ited

unlim

ited

unlim

ited

unlim

ited

No

Yes

Yes

Yes

Yes

Yes

Yes

Yes

Yes

Yes

Yes

Yes

Yes

Yes

No

No

No

No

No

No

No

No

No

No

No

No

No

No

No

Yes

Yes

No

No

No

No

No

No

No

No

No

No

No

No

inte

rim th

erap

eutic

rest

orat

ion-

prim

ary

dent

ition

Core

bui

ldup

, inc

ludi

ng a

ny p

ins w

hen

requ

ired

pin

rete

ntio

n - p

er to

oth,

in a

dditi

on to

rest

orat

ion

cast

pos

t and

cor

e in

add

ition

to c

row

nea

ch a

dditi

onal

indi

rect

ly fa

bric

ated

pos

t, sa

me

toot

hpr

efab

ricat

ed p

ost a

nd c

ore

in a

dditi

on to

cro

wn

crow

n - p

orce

lain

/cer

amic

subs

trat

ecr

own

- por

cela

in fu

sed

to h

igh

nobl

e m

etal

crow

n - p

orce

lain

fuse

d to

pre

dom

inan

tly b

ase

met

al

crow

n, 3

/4 c

ast n

oble

met

alcr

own,

3/4

por

cela

in/c

eram

iccr

own

- ful

l cas

t hig

h no

ble

met

alcr

own

- ful

l cas

t pre

dom

inan

tly b

ase

met

alcr

own

- ful

l cas

t nob

le m

etal

crow

n - t

itani

umre

cem

ent o

r re-

bond

inla

y, o

nlay

, ven

eer o

r par

tial c

over

age

rest

orat

ion

rece

men

t or r

e-bo

nd c

ast i

ndire

ctly

fabr

icat

ed o

r pre

fabr

icat

ed p

ost a

nd c

ore

rece

men

t or r

e-bo

nd c

row

npr

efab

ricat

ed st

ainl

ess s

teel

cro

wn

- prim

ary

toot

hpr

efab

ricat

ed st

ainl

ess s

teel

cro

wn

- per

man

ent t

ooth

pref

abric

ated

resi

n cr

own

pref

abric

ated

stai

nles

s ste

el c

row

n w

ith re

sin

win

dow

prot

ectiv

e re

stor

atio

n

inla

y - p

orce

lain

/cer

amic

- on

e su

rfac

ein

lay

- por

cela

in/c

eram

ic -

two

surf

aces

inla

y - p

orce

lain

/cer

amic

- th

ree

or m

ore

surf

aces

onla

y - p

orce

lain

/cer

amic

- tw

o su

rfac

eson

lay

- por

cela

in/c

eram

ic -

thre

e su

rfac

eson

lay

- por

cela

in/c

eram

ic -

four

or m

ore

surf

aces

crow

n - p

orce

lain

fuse

d to

nob

le m

etal

crow

n, 3

/4 c

ast h

igh

nobl

e m

etal

crow

n, 3

/4 c

ast p

redo

min

atel

y ba

se m

etal

inla

y - c

ompo

site

/res

in -

one

surf

ace

inla

y - c

ompo

site

/res

in -

two

surf

aces

inla

y - c

ompo

site/

resi

n - t

hree

or m

ore

surf

aces

onla

y - c

ompo

site

/res

in -

two

surf

aces

onla

y - c

ompo

site

/res

in -

thre

e su

rfac

eson

lay

- com

posi

te/r

esin

- fo

ur o

r mor

e su

rfac

escr

own,

resi

n-ba

sed

com

posi

te (i

ndire

ct)

crow

n - 3

/4 re

sin-

base

d co

mpo

site

(ind

irect

)cr

own

- res

in w

ith h

igh

nobl

e m

etal

crow

n - r

esin

with

pre

dom

inan

tly b

ase

met

alcr

own

- res

in w

ith n

oble

met

al

D291

0D2

915

D292

0D2

930

D293

1D2

932

D293

3D2

940

D294

1D2

950

D295

1D2

952

D295

3D2

954

D271

0D2

712

D272

0D2

721

D272

2D2

740

D275

0D2

751

D275

2D2

780

D278

1D2

782

D278

3D2

790

D279

1D2

792

D279

4

D239

4re

sin-

base

d co

mpo

site

- fo

ur o

r mor

e su

rfac

es, p

oste

rior

No

D239

0re

sin-

base

d co

mpo

site

cro

wn,

ant

erio

r

D233

1re

sin-

base

d co

mpo

site

- tw

o su

rfac

es, a

nter

ior

No

D239

2re

sin-

base

d co

mpo

site

- tw

o su

rfac

es, p

oste

rior

No

D239

3re

sin-

base

d co

mpo

site

- th

ree

surf

aces

, pos

terio

rN

o

D252

0in

lay

- met

allic

- tw

o su

rfac

esN

oD2

530

inla

y - m

etal

lic -

thre

e or

mor

e su

rfac

esN

oD2

542

D254

3D2

544

D251

0in

lay

- met

allic

- on

e su

rfac

eN

o

onla

y m

etal

lic, t

wo

surf

aces

onla

y-m

etal

lic-t

hree

surf

aces

onla

y-m

etal

lic-fo

ur o

r mor

e su

rfac

es

No

No

No

D266

2D2

663

D266

4

No

D239

1re

sin-

base

d co

mpo

site

- on

e su

rfac

e, p

oste

rior

No

D233

2re

sin-

base

d co

mpo

site

- th

ree

surf

aces

, ant

erio

rN

oD2

335

resi

n-ba

sed

com

posi

te -

four

or m

ore

surf

aces

or i

nvol

ving

inci

sal a

ngle

(ant

erio

r)N

o

D261

0D2

620

D263

0D2

642

D264

3D2

644

D265

0D2

651

D265

2

unlim

ited

unlim

ited

unlim

ited

unlim

ited

unlim

ited

unlim

ited

unlim

ited

unlim

ited

unlim

ited

unlim

ited

unlim

ited

53

unlim

ited

unlim

ited

unlim

ited

unlim

ited

unlim

ited

unlim

ited

unlim

ited

unlim

ited

unlim

ited

unlim

ited

unlim

ited

unlim

ited

unlim

ited

unlim

ited

unlim

ited

unlim

ited

unlim

ited

unlim

ited

unlim

ited

unlim

ited

unlim

ited

unlim

ited

unlim

ited

unlim

ited

unlim

ited

unlim

ited

unlim

ited

unlim

ited

unlim

ited

unlim

ited

unlim

ited

unlim

ited

unlim

ited

unlim

ited

unlim

ited

unlim

ited

unlim

ited

unlim

ited

unlim

ited

unlim

ited

unlim

ited

unlim

ited

unlim

ited

unlim

ited

unlim

ited

unlim

ited

No

No

No

No

No

No

No

No

No

No

No

No

Yes

Yes

No

Yes

No

No

Yes

Yes

Yes

No

No

No

Yes

Yes

Yes

No

No

No

No

No

No

No

No

Yes

No

No

No

No

No

No

No

No

No

No

dist

al o

r pro

xim

al w

edge

pro

cedu

re (w

hen

not p

erfo

rmed

in c

onju

nctio

n w

ith su

rgic

al p

roce

dure

s in

the

sam

e an

atom

ical

are

a

Apic

oect

omy

- mol

ar (f

irst r

oot)

Apic

oect

omy

(eac

h ad

ditio

nal r

oot)

perir

adic

ular

surg

ery

with

out a

pico

ecto

my

retr

ogra

de fi

lling

- pe

r roo

tro

ot a

mpu

tatio

n - p

er ro

othe

mis

ectio

n (in

clud

ing

any

root

rem

oval

), no

t inc

ludi

ng ro

ot c

anal

ther

apy

ging

ivec

tom

y or

gin

givo

plas

ty -

four

or m

ore

cont

iguo

us te

eth

or to

oth

boun

ded

spac

es p

er q

uadr

ant

ging

ivec

tom

y or

gin

givo

plas

ty -

one

to th

ree

cont

iguo

us te

eth

or to

oth

boun

ded

spac

es p

er q

uadr

ant

ging

ival

flap

pro

cedu

re, i

nclu

ding

root

pla

nnin

g - f

our o

r mor

e co

ntig

uous

teet

h or

toot

h bo

unde

d sp

aces

per

qua

dran

t

ging

ival

flap

pro

cedu

re -

incl

udin

g ro

ot p

lann

ing

-one

to th

ree

cont

iguo

us te

eth

or to

oth

boun

ded

spac

es p

er q

uadr

ant

apic

ally

pos

ition

ed fl

ap

clin

ical

cro

wn

leng

then

ing

- har

d tis

sue

osse

ous s

urge

ry (i

nclu

ding

flap

ent

ry a

nd c

losu

re) -

four

or m

ore

cont

iguo

us te

eth

or to

oth

boun

ded

spac

es p

er q

uadr

ant

osse

ous s

urge

ry (i

nclu

ding

flap

ent

ry a

nd c

losu

re) -

one

to th

ree

cont

iguo

us te

eth

or to

oth

boun

ded

Bone

repl

acem

ent g

raft

- fir

st si

te in

qua

dran

tBo

ne re

plac

emen

t gra

ft -

each

add

ition

al si

te in

qua

dran

tpe

dicl

e so

ft tis

sue

graf

t pro

cedu

re

endo

dont

ic th

erap

y, a

nter

ior t

ooth

(exc

ludi

ng fi

nal r

esto

ratio

n)en

dodo

ntic

ther

apy,

bic

uspi

d to

oth

(exc

ludi

ng fi

nal r

esto

ratio

n)en

dodo

ntic

ther

apy,

mol

ar (e

xclu

ding

fina

l res

tora

tion)

trea

tmen

t of r

oot c

anal

obs

truc

tion,

non

-sur

gica

l acc

ess

inco

mpl

ete

endo

dont

ic th

erap

y; in

oper

able

, unr

esto

rabl

e or

frac

ture

d to

oth

inte

rnal

toot

h re

pair

of p

erfo

ratio

n de

fect

sre

trea

tmen

t of p

revi

ous r

oot c

anal

ther

apy

- ant

erio

rre

trea

tmen

t of p

revi

ous r

oot c

anal

ther

apy

- bic

uspi

dre

trea

tmen

t of p

revi

ous r

oot c

anal

ther

apy

- mol

arAp

exifi

catio

n/re

calc

ifica

tion-

initi

al v

isit (

apic

al c

losu

re/c

alci

fic re

pair

of p

erfo

ratio

ns, r

oot r

esor

ptio

n,

etc.

Apex

ifica

tion/

reca

lcifi

catio

n/pu

lpal

rege

nera

tion

- int

erim

med

icat

ion

repl

acem

ent

apex

ifica

tion/

reca

lcifi

catio

n - f

inal

visi

t (in

clud

es c

ompl

eted

root

Pupa

l reg

ener

atio

n-in

itial

vis

itPu

lpal

rege

nera

tion-

inte

rim m

edic

amen

t rep

lace

men

tPu

lpal

rege

nera

tion-

com

plet

ion

of tr

eatm

ent

Apic

oect

omy

- ant

erio

rAp

icoe

ctom

y - b

icus

pid

(firs

t roo

t)

each

add

ition

al p

refa

bric

ated

pos

t, sa

me

toot

hla

bial

ven

eer (

lam

inat

e) -

chai

rsid

ela

bial

ven

eer (

resi

n la

min

ate)

- la

bora

tory

labi

al v

enee

r (po

rcel

ain

lam

inat

e) -

labo

rato

ryve

neer

repa

ir ne

cess

itate

d by

rest

orat

ive

mat

eria

l fai

lure

pulp

cap

- di

rect

(exc

ludi

ng fi

nal r

esto

ratio

n)pu

lp c

ap -

indi

rect

(exc

ludi

ng fi

nal r

esto

ratio

n)th

erap

eutic

pul

poto

my

(exc

ludi

ng fi

nal r

esto

ratio

n)pu

lpal

deb

ridem

ent,

prim

ary

and

perm

anen

t tee

th

pulp

al th

erap

y (r

esto

rabl

e fil

ling)

- an

terio

r, pr

imar

y to

oth

(exc

ludi

ng fi

nal r

esto

ratio

n)

pulp

al th

erap

y (r

esto

rabl

e fil

ling)

- po

ster

ior,

prim

ary

toot

h (e

xclu

ding

fina

l res

tora

tion)

D424

1D4

245

D424

9

D426

0D4

261

D426

3D4

264

D427

0

D427

4

D335

1D3

352

D335

3D3

355

D335

6D3

357

D341

0D3

421

D342

5D3

426

D342

7D3

430

D345

0D3

920

D421

0

D421

1

D424

0

D296

2D2

983

D311

0D3

120

D322

0D3

221

D323

0

D324

0D3

310

D332

0D3

330

D333

1D3

332

D333

3D3

346

D334

7D3

348

D295

7D2

960

D296

1

5454

unlim

ited

unlim

ited

unlim

ited

unlim

ited

unlim

ited

unlim

ited

unlim

ited

unlim

ited

unlim

ited

unlim

ited

unlim

ited

unlim

ited

unlim

ited

unlim

ited

unlim

ited

unlim

ited

unlim

ited

unlim

ited

unlim

ited

unlim

ited

unlim

ited

unlim

ited

unlim

ited

unlim

ited

unlim

ited

unlim

ited

unlim

ited

unlim

ited

unlim

ited

unlim

ited

unlim

ited

unlim

ited

unlim

ited

unlim

ited

unlim

ited

unlim

ited

unlim

ited

4 ev

ery

year

unlim

ited

unlim

ited

unlim

ited

unlim

ited

unlim

ited

unlim

ited

unlim

ited

unlim

ited

unlim

ited

No

No

No

No

No

No

No

No

No

No

No

No

No

No

No

No

No

No

No

No

No

No

No

No

No

No

No

No

No

No

No

Yes

No

No

No

Yes

No

No

No

No

No

No

No

No

No

No

No

add

clas

p to

exi

stin

g pa

rtia

l den

ture

- pe

r too

thre

plac

e al

l tee

th a

nd a

cryl

ic o

n ca

st m

etal

fram

ewor

k (m

axill

ary)

repl

ace

all t

eeth

and

acr

ylic

on

cast

met

al fr

amew

ork

(man

dibu

lar)

reba

se c

ompl

ete

max

illar

y de

ntur

ere

base

com

plet

e m

andi

bula

r den

ture

reba

se m

axill

ary

part

ial d

entu

rere

base

man

dibu

lar p

artia

l den

ture

relin

e co

mpl

ete

max

illar

y de

ntur

e (c

hairs

ide)

relin

e co

mpl

ete

man

dibu

lar d

entu

re (c

hairs

ide)

relin

e m

axill

ary

part

ial d

entu

re (c

hairs

ide)

relin

e m

andi

bula

r par

tial d

entu

re (c

hairs

ide)

relin

e co

mpl

ete

max

illar

y de

ntur

e (la

bora

tory

)re

line

com

plet

e m

andi

bula

r den

ture

(lab

orat

ory)

relin

e m

axill

ary

part

ial d

entu

re (l

abor

ator

y)

imm

edia

te m

andi

bula

r par

tial d

entu

re -

resi

n ba

se

imm

edia

te m

axill

ary

part

ial d

entu

re -

cast

met

al fr

amew

ork

with

resin

den

ture

bas

es

imm

edia

te m

andi

bula

r par

tial d

entu

re-c

ast m

etal

fram

ewor

k w

ith re

sin

dent

ure

base

sm

axill

ary

part

ial d

entu

re -

flexi

ble

base

(inc

ludi

ng a

ny c

lasp

s, re

sts a

nd te

eth)

man

dibu

lar p

artia

l den

ture

- fle

xibl

e ba

se (i

nclu

ding

any

cla

sps,

rest

s and

teet

h)

rem

ovab

le u

nila

tera

l par

tial d

entu

re -

one

piec

e ca

st m

etal

(inc

ludi

ng c

lasp

s and

teet

h)ad

just

com

plet

e de

ntur

e - m

axill

ary

adju

st c

ompl

ete

dent

ure

- man

dibu

lar

adju

st p

artia

l den

ture

- m

axill

ary

adju

st p

artia

l den

ture

- m

andi

bula

rre

pair

brok

en c

ompl

ete

dent

ure

base

repl

ace

mis

sing

or b

roke

n te

eth

- com

plet

e de

ntur

e (e

ach

toot

h)re

pair

resi

n de

ntur

e ba

sere

pair

cast

fram

ewor

kre

pair

or re

plac

e br

oken

cla

sp -

per t

ooth

repl

ace

brok

en te

eth

- per

toot

had

d to

oth

to e

xist

ing

part

ial d

entu

re

free

soft

tiss

ue g

raft

pro

cedu

re e

ach

addi

tiona

l con

tiguo

us to

oth,

impl

ant o

r ede

ntul

ous t

ooth

perio

dont

al sc

alin

g an

d ro

ot p

lann

ing

- fou

r or m

ore

teet

h pe

r qua

dran

tpe

riodo

ntal

scal

ing

and

root

pla

nnin

g - o

ne -

thre

e te

eth,

per

qua

dran

tfu

ll m

outh

deb

ridem

ent t

o en

able

com

preh

ensi

ve e

valu

atio

n an

d di

agno

sis

loca

lized

del

iver

y of

ant

imic

robi

al a

gent

s via

a c

ontr

olle

d re

leas

e ve

hicl

e in

to d

isea

sed

crev

icul

ar

tissu

e, p

er to

oth

perio

dont

al m

aint

enan

ce

unsc

hedu

led

dres

sing

cha

nge

(by

som

eone

oth

er th

an tr

eatin

g de

ntis

t or t

heir

staf

f)co

mpl

ete

dent

ure

- max

illar

y

com

plet

e de

ntur

e - m

andi

bula

r

imm

edia

te d

entu

re -

max

illar

yim

med

iate

den

ture

- m

andi

bula

r

max

illar

y pa

rtia

l den

ture

- re

sin b

ase

(incl

udin

g an

y co

nven

tiona

l cla

sps,

rest

s and

teet

h)

man

dibu

lar p

artia

l den

ture

- re

sin

base

(inc

ludi

ng a

ny c

onve

ntio

nal c

lasp

s, re

sts a

nd te

eth)

max

illar

y pa

rtia

l den

ture

- ca

st m

etal

fram

ewor

k w

ith re

sin d

entu

re b

ases

(inc

ludi

ng a

ny c

onve

ntio

nal

clas

ps, r

ests

and

man

dibu

lar p

artia

l den

ture

- ca

st m

etal

fram

ewor

k w

ith re

sin

dent

ure

base

s (in

clud

ing

any

imm

edia

te m

axill

ary

part

ial d

entu

re -

resin

bas

e

D574

0D5

741

D575

0D5

751

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D564

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pont

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ith n

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pont

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relin

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abor

ator

y)

pont

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porc

elai

n fu

sed

to p

redo

min

antly

bas

e m

etal

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604

D660

5D6

606

D660

7D6

608

D660

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610

D661

1D6

612

D576

1D5

820

D582

1D5

850

D585

1D5

863

D586

4D5

865

D586

6D6

210

D621

1

D660

0

D621

2D6

214

D624

0D6

241

D624

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245

D625

0D6

251

D625

2

D661

3D6

614

D661

5D6

624

D663

4D6

720

D672

1D6

722

D674

0

D679

2D6

794

D693

0D7

111

D714

0

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780

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782

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wn

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in w

ith h

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in w

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cro

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- res

in w

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cro

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cela

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to h

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pre

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base

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, thr

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lay

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ast h

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lay

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t nob

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st h

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, tw

o su

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- ca

st h

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- ca

st p

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bas

e m

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, tw

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bas

e m

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- ca

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onl

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cast

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lay

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cro

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bond

fixe

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extr

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oron

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mna

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dec

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us to

oth

extr

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rupt

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oth

or e

xpos

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ot (e

leva

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and/

or fo

rcep

s rem

oval

)

Yes

Yes

Yes

Yes

Yes

No

No

No

No

No

No

No

No

No

No

No

No

No

No

No

No

No

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5656

The

Colo

rado

Hig

h O

ptio

n Ri

der 2

60 D

HMO

supp

lem

enta

l ben

efit

plan

cov

ers t

he d

enta

l cod

es li

sted

abo

ve. T

his s

uppl

emen

tal b

enef

it is

offe

red

to m

embe

rs th

at a

re e

nrol

led

in A

ARP

Med

icar

eCom

plet

e pl

ans.

Pro

vide

r pay

men

t is

mad

e on

a F

ee-fo

r-Se

rvic

e ba

sis.

Mem

bers

hav

e In

-net

wor

k on

ly b

enef

its. S

ome

serv

ices

requ

ire p

rior a

utho

rizat

ion.

The

$10

00 a

nnua

l max

imum

app

lies t

o co

vere

d pr

even

tive

and

com

preh

ensi

ve b

enef

its. M

embe

r can

be

bille

d fo

r ser

vice

s ove

r the

$10

00 a

nnua

l max

imum

ben

efit.

The

mem

ber c

opay

s var

y fo

r cov

ered

serv

ices

from

$0

- $63

3. T

here

is n

o co

insu

ranc

e or

ded

uctib

le.

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D723

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0

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963

D797

0

D724

1D7

250

D727

0D7

280

D728

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285

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6

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0

D731

1

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243

D931

0D9

440

D994

0D9

943

D995

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952

D797

1D7

972

D807

0D8

080

D809

0

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0D9

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rem

oval

of l

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inci

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dra

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abs

cess

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trao

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oft t

issu

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of a

bsce

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intr

aora

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t tis

sue

- com

plic

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(inc

lude

s dra

inag

e of

mul

tiple

fa

scia

l spa

ces)

surg

ical

rem

oval

of e

rupt

ed to

oth

req

rem

oval

of b

one,

sect

ioni

ng o

f too

th a

nd in

clud

ing

elev

atio

n of

m

ucop

erio

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l fla

pre

mov

al o

f im

pact

ed to

oth

- sof

t tiss

uere

mov

al o

f im

pact

ed to

oth

- par

tially

bon

yre

mov

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f im

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ed to

oth

- com

plet

ely

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rem

oval

of i

mpa

cted

toot

h - c

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y bo

ny, w

ith u

nusu

al su

rgic

alsu

rgic

al re

mov

al o

f res

idua

l too

th ro

ots (

cutt

ing

proc

edur

e)

toot

h re

impl

anta

tion

and/

or st

abili

zatio

n of

acc

iden

tally

avu

lsed

or d

ispl

aced

toot

hsu

rgic

al a

cces

s of a

n un

erup

ted

toot

hm

obili

zatio

n of

eru

pted

or m

alpo

sitio

ned

toot

h to

aid

eru

ptio

n

occl

usal

adj

ustm

ent

occl

usal

adj

ustm

ent -

lim

ited

occl

usal

adj

ustm

ent -

com

plet

e

orth

odon

tic re

tent

ion

(rem

oval

of a

pplia

nces

, con

stru

ctio

n an

d pl

acem

ent o

f ret

aine

r(s)

)pa

lliat

ive

(em

erge

ncy)

trea

tmen

t of d

enta

l pai

n - m

inor

pro

cedu

relo

cal a

nest

hesi

a in

con

junc

tion

with

ope

rativ

e or

surg

ical

pro

cedu

res

eval

uatio

n fo

r dee

p se

datio

n or

gen

eral

ane

sthe

sia

deep

seda

tion/

gene

ral a

nest

hesi

a-ea

ch 1

5 m

inut

e in

crem

ent

intr

aven

ous m

oder

ate

(con

scio

us) s

edat

ion/

anal

gesi

a-ea

ch 1

5 m

inut

e in

crem

ent

cons

ulta

tion

(dia

gnos

tic se

rvic

e pr

ovid

ed b

y de

ntis

t or p

hysi

cian

oth

er th

an p

ract

ition

er p

rovi

ding

of

fice

visi

t - a

fter

regu

larly

sche

dule

d ho

urs

occl

usal

gua

rd, b

y re

port

occl

usal

ort

hotic

dev

ice

adju

stm

ent

fren

ulec

tom

y (fr

enec

tom

y or

fren

otom

y) -

sepa

rate

pro

cedu

re n

ot in

cide

ntal

to a

noth

er p

roce

dure

fren

ulop

last

yex

cisi

on o

f hyp

erpl

astic

tiss

ue -

per a

rch

exci

sion

of p

eric

oron

al g

ingi

vasu

rgic

al re

duct

ion

of fi

brou

s tub

eros

ityco

mpr

ehen

sive

ort

hodo

ntic

trea

tmen

t of t

he tr

ansi

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l den

titio

nco

mpr

ehen

sive

ort

hodo

ntic

trea

tmen

t of t

he a

dole

scen

t den

titio

nco

mpr

ehen

sive

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hodo

ntic

trea

tmen

t of t

he a

dult

dent

ition

inci

sion

al b

iops

y of

ora

l tis

sue

- har

d (b

one,

toot

h)in

cisi

onal

bio

psy

of o

ral t

issu

e - s

oft (

all o

ther

s)

alve

olop

last

y in

con

junc

tion

with

ext

ract

ions

- fo

ur o

r mor

e te

eth

or to

oth

spac

es, p

er q

uadr

ant

alve

opla

sty

in c

onju

nctio

n w

ith e

xtra

ctio

n - o

ne to

thre

e te

eth

or to

oth

spac

es, p

er q

uadr

ant

alve

olop

last

y no

t in

conj

unct

ion

with

ext

ract

ions

- fo

ur o

r mor

e te

eth

or to

oth

spac

es, p

er q

uadr

ant

alve

opla

sty

not i

n co

njun

ctio

n w

ith e

xtra

ctio

n - o

ne to

thre

e te

eth

or to

oth

spac

es, p

er q

uadr

ant

No

No

No

Yes

Yes

Yes

Yes

Yes

Yes

No

No

No

No

No

No

No

No

No

No

No

No

No

No

Yes

No

No

No

No

No

No

No

No

No

Yes

No

Yes

No

No

No

1 pe

r too

th

unlim

ited

unlim

ited

unlim

ited

unlim

ited

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ited

unlim

ited

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ited

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r too

th1

per t

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1 pe

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4 ev

ery

24 m

onth

s fro

m la

st d

ate

of se

rvic

e4

ever

y 24

mon

ths f

rom

last

dat

e of

serv

ice

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57

Prov

ider

Cla

im D

ispu

tes

Mem

ber A

ppea

ls &

Grie

vanc

es

Prio

r Aut

horiz

atio

n Re

ques

ts

CO_F

ACET

S D0

0120

26_P

kg D

N04

8, D

enta

l 260

-DM

O80

09/2

016

In a

n ef

fort

to c

ompl

y w

ith th

e Ce

nter

s for

Med

icar

e an

d M

edic

aid

(CM

S) st

ate

man

date

d re

quire

men

ts, p

leas

e be

adv

ised

that

DHM

O E

ncou

nter

Dat

a Su

bmis

sion

s are

now

requ

ired.

CM

S no

w re

quire

s tha

t we

repo

rt 1

00%

of

utili

zatio

n da

ta fo

r our

Col

orad

o Hi

gh O

ptio

n Ri

der 2

60 D

HMO

mem

bers

. To

ens

ure

that

we

mee

t CM

S re

quire

men

t of r

epor

ting

100%

util

izatio

n, w

e ar

e ha

ppy

to re

-intr

oduc

e ou

r Den

tal I

ncen

tive

Prog

ram

effe

ctiv

e im

med

iate

ly.

Dent

al B

enef

it Pr

ovid

ers w

ill re

imbu

rse

our p

rovi

ders

$2.

00 fo

r eac

h en

coun

ter c

laim

subm

itted

for C

olor

ado

Hig

h O

ptio

n Ri

der 2

60 D

HM

O m

embe

rs o

nly

for a

ll pr

oced

ures

(cov

ered

und

er th

e m

embe

r's p

lan)

per

form

ed o

n th

ose

mem

bers

, for

eac

h da

te o

f ser

vice

. Al

l pro

cedu

res p

erfo

rmed

MU

ST b

e re

port

ed in

clud

ing

proc

edur

es w

heth

er o

r not

the

mem

ber h

as a

cop

aym

ent.

Thi

s is a

requ

irem

ent f

or a

ll co

ntra

cted

pro

vide

rs to

subm

it ut

iliza

tion

for e

ach

patie

nt tr

eate

d.

Her

e ar

e a

few

way

s the

Enc

ount

er In

form

atio

n ca

n be

subm

itted

:

1) Electronically

- As

you

wou

ld a

PPO

or I

ndem

nity

Cla

im

2)

Web

Site

- Cl

aim

s can

be

subm

itted

indi

vidu

ally

on

our w

ebsi

te a

t ww

w.u

hcpr

ovid

ers.

com

3)

By

Mai

l - A

s you

wou

ld a

PPO

or I

ndem

nity

Cla

im

4)

Util

izat

ion

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rts -

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t con

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requ

ired

info

rmat

ion:

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bscr

iber

ID•

Subs

crib

er D

ate

of B

irth

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roup

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e or

Num

ber

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tient

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ull N

ame

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tient

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ate

of B

irth

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latio

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er•

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ress

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e•

Trea

ting

Dent

ist N

ame

• De

ntist

Tax

I.D.

for B

illin

g

Enco

unte

r/U

tiliza

tion

Repo

rtin

g - W

hen

subm

ittin

g En

coun

ter/

Util

izat

ion

clai

ms,

you

mus

t inc

lude

Cod

e D0

999

alon

g w

ith a

ll co

vere

d se

rvic

e pr

oced

ure

code

s you

per

form

on

each

AAR

P M

edic

are

Com

plet

e DH

MO

mem

ber.

Plea

se n

ote

the

follo

win

g:

1)

If y

ou su

bmit

D099

9 al

one

no a

dditi

onal

$2.

00 re

imbu

rsem

ent w

ill n

ot b

e pa

id.

Addi

tiona

lly, c

laim

subm

issio

n w

ould

be

cons

ider

ed n

on-c

ompl

iant

.

2)

If y

ou su

bmit

all s

ervi

ce p

roce

dure

serv

ice

code

s but

don

't in

clud

e D0

999

as w

ell a

s you

won

't be

reim

burs

ed th

e ad

ditio

nal $

2.00

. In

add

ition

, the

cla

im w

ill b

e co

nsid

ered

non

-com

plia

nt.

Mai

l mem

ber a

ppea

ls to

: Uni

tedH

ealth

care

, Att

n: A

ppea

l Dep

artm

ent,

MS

CA12

4-01

57, P

O B

ox 6

106,

Cyp

ress

, CA

9063

0

“Prio

r Aut

horiz

atio

n re

quire

d” m

eans

the

prac

titio

ner m

ust s

ubm

it th

ose

proc

edur

es fo

r app

rova

l with

clin

ical

doc

umen

tatio

n su

ppor

ting

nece

ssity

bef

ore

perf

orm

ing

thos

e pr

oced

ures

. To

do th

is c

ompl

ete

a st

anda

rd A

DA c

laim

fo

rm a

nd c

heck

the

box

mar

ked

“Pre

-Tre

atm

ent E

STIM

ATE.

” Pr

ior a

utho

rizat

ion

requ

est c

an b

e su

bmitt

ed v

ia th

e pr

ovid

er w

eb p

orta

l (at

ww

w.m

yuhc

prov

ider

s.co

m),

subm

itted

ele

ctro

nica

lly v

ia y

our c

lear

ingh

ouse

, or s

impl

y m

ail t

he fo

rm, t

o th

e be

low

add

ress

, alo

ng w

ith a

ny re

quire

d su

pple

men

tal i

nfor

mat

ion

(film

s, n

arra

tive,

per

io-c

hart

ing,

etc

.). Y

our o

ffice

will

then

rece

ive

an E

xpla

natio

n of

Ben

efits

(EO

B) o

utlin

ing

the

deni

al o

r app

rova

l of

requ

este

d tr

eatm

ent a

nd p

lan

paym

ent a

mou

nts w

hen

appl

icab

le.

Dent

al P

rovi

ders

with

com

plai

nts a

re to

con

tact

Uni

tedH

ealth

care

Den

tal’s

Pro

vide

r Ser

vice

dep

artm

ent a

t (87

7) 8

16-3

596.

Net

wor

k Pr

ovid

er c

ontr

actu

al d

ispu

tes,

Out

-of-N

etw

ork

prov

ider

dis

pute

s, a

nd re

proc

essi

ng re

ques

ts

will

be

logg

ed in

to th

e ap

peal

s dat

abas

e. P

leas

e m

ail t

o th

e Ap

peal

s & G

rieva

nces

PO

Box

list

ed a

bove

. Res

earc

h an

d re

solu

tion

will

be

com

plet

ed w

ithin

30

cale

ndar

day

s.

Mem

ber a

ppea

ls a

re re

view

ed b

y th

e he

alth

pla

n, a

nd a

re n

ot d

eleg

ated

to U

HC D

enta

l. Al

l Mem

ber a

ppea

ls (i

nclu

des P

re-S

ervi

ce a

ppea

ls, I

n N

etw

ork

Prov

ider

app

eals

, and

Out

of N

etw

ork

prov

ider

app

eals

) rec

eive

d by

UHC

De

ntal

will

be

forw

arde

d to

the

heal

th p

lan

via

over

nigh

t mai

l, w

ithin

7 d

ays o

f rec

eipt

of t

he a

ppea

l.

5858

“Prio

r Aut

horiz

atio

n re

quire

d” m

eans

the

prac

titio

ner m

ust s

ubm

it th

ose

proc

edur

es fo

r app

rova

l with

clin

ical

doc

umen

tatio

n su

ppor

ting

nece

ssity

bef

ore

perf

orm

ing

thos

e pr

oced

ures

. To

do th

is c

ompl

ete

a st

anda

rd

ADA

clai

m fo

rm a

nd c

heck

the

box

mar

ked

“Pre

-Tre

atm

ent E

STIM

ATE.

” Pr

ior a

utho

rizat

ion

requ

est c

an b

e su

bmitt

ed v

ia th

e pr

ovid

er w

eb p

orta

l (at

ww

w.m

yuhc

prov

ider

s.co

m),

subm

itted

ele

ctro

nica

lly v

ia y

our

Dent

al P

rovi

ders

with

com

plai

nts a

re to

con

tact

Uni

tedH

ealth

care

Den

tal’s

Pro

vide

r Ser

vice

dep

artm

ent a

t

61

Iden

tific

atio

n Ca

rds

Sam

ple

Mem

ber I

D C

ard*

Fron

t of c

ard

Back

of c

ard

Impo

rtan

t Tel

epho

ne N

umbe

rs &

Web

site

s

Impo

rtan

t Add

ress

es

Impo

rtan

t Ele

ctro

nic

Clai

ms &

Prio

r Aut

horiz

atio

n Su

bmis

sion

Info

rmat

ion

Prov

ider

Qui

ck R

efer

ence

Gui

de -

Effe

ctiv

e 1/

1/20

17U

nite

dHea

lthca

re A

ARP

Com

plet

e Pl

ans (

form

ally

Oxf

ord

DH

MO

)

CT, N

J, an

d N

Y

24 h

ours

a d

ay24

hou

rs a

day

*Ple

ase

note

that

the

Med

ical

ID C

ard

is un

iver

sal a

nd in

clud

es a

ll lin

es o

f cov

erag

e. T

he M

edic

al p

lan

can

be H

MO

or P

PO a

nd th

is d

oes n

ot re

flect

the

Dent

al P

lan

Bene

fits.

Ple

ase

flip

the

ID C

ard

over

to se

e th

e De

ntal

Pr

ovid

er in

form

atio

n on

the

back

(i.e

. car

rier w

ebsi

te a

nd to

ll-fr

ee n

umbe

r). T

his i

nfor

mat

ion

can

be u

sed

to c

onfir

m p

rovi

der p

artic

ipat

ion,

mem

ber e

ligib

ility

and

ben

efits

. Thi

s is a

SAM

PLE

ID C

ard

and

may

diff

er fr

om

the

mem

ber's

ID C

ard.

Elig

ibili

ty,

Bene

fits,

Cla

im(s

) and

Aut

horiz

atio

ns84

4-27

5-87

50Li

ve A

gent

: Mon

day

- Frid

ay, 8

:00A

M -

6:00

PM, E

STIV

R: 2

4 ho

urs a

day

Clai

ms

GP1

33

Prio

r Aut

horiz

atio

nAp

peal

s & G

rieva

nces

Uni

tedH

ealth

care

Den

tal,

PO B

ox 2

176,

Milw

auke

e, W

I 532

01U

nite

dHea

lthca

re D

enta

l, PO

Box

205

3, M

ilwau

kee,

WI 5

3201

Uni

tedH

ealth

care

Den

tal,

Appe

als D

isput

es, P

O B

ox 3

61, M

ilwau

kee,

WI 5

3201

Cove

red

Den

tal S

ervi

ces:

Prov

ider

Rea

son

for M

ailin

g

EDI P

ayer

Num

ber f

or C

laim

s Sub

mitt

ed

No

Annu

al M

axim

um

Call

to In

quire

Abo

utTe

leph

one

Num

ber

Hou

rs o

f Ope

ratio

n

Emai

l to

Inqu

ire A

bout

Web

site

Hou

rs o

f Ope

ratio

n

Med

icar

ew

ww

.med

icar

e.go

v24

hou

rs a

day

To d

iscu

ss y

our p

artic

ipat

ion,

con

trac

tual

issu

es, d

entis

t cha

nges

or o

ffice

upd

ates

800-

822-

5353

Live

Age

nt: M

onda

y - F

riday

, 8:0

0AM

- 11

:00P

M, E

ST

Elig

ibili

ty,

Bene

fits,

Cla

im(s

) and

Aut

horiz

atio

nsw

ww

.uhc

prov

ider

s.co

mCe

nter

s for

Med

icai

d an

d M

edic

are

Serv

ices

ww

w.c

ms.

hhs.

gov

63

No

No

1 ev

ery

6 M

onth

(s)

1 ev

ery

6 M

onth

(s)

1 ev

ery

6 M

onth

(s)

1 ev

ery

6 M

onth

(s)

1 ev

ery

6 M

onth

(s)

1 ev

ery

6 M

onth

(s)

1 ev

ery

6 M

onth

(s)

1 ev

ery

6 M

onth

(s)

1 ev

ery

3 Ye

ar(s

)1

ever

y Ye

ar1

ever

y Ye

ar1

ever

y Ye

ar1

ever

y Ye

ar1

ever

y Ye

ar1

ever

y Ye

ar1

ever

y Ye

ar1

ever

y 3

Year

(s)

1 ev

ery

Year

1 ev

ery

6 M

onth

(s)

Her

e ar

e a

few

way

s the

Enc

ount

er In

form

atio

n ca

n be

subm

itted

:

1)

Electronically

- As

you

wou

ld a

PPO

or I

ndem

nity

Cla

im

2) W

eb S

ite -

Clai

ms c

an b

e su

bmitt

ed in

divi

dual

ly o

n ou

r web

site

at w

ww

.uhc

prov

ider

s.co

m

3)

By

Mai

l - A

s you

wou

ld a

PPO

or I

ndem

nity

Cla

im

4) U

tiliz

atio

n Re

port

s - M

ust c

onta

in A

LL re

quire

d in

form

atio

n:

•

Subs

crib

er ID

• Su

bscr

iber

Dat

e of

Birt

h •

Gro

up N

ame

or N

umbe

r•

Patie

nt’s

Ful

l Nam

e•

Patie

nt’s

Dat

e of

Birt

h•

Rela

tions

hip

to S

ubsc

riber

• Ph

ysic

al A

ddre

ss•

ADA

Code

Per

form

ed•

Toot

h# /

Qua

dran

t•

Surf

ace

• Tr

eatin

g De

ntis

t Nam

e•

Dent

ist T

ax I.

D. fo

r Bill

ing

Enco

unte

r/U

tiliza

tion

Repo

rtin

g - W

hen

subm

ittin

g En

coun

ter/

Util

izat

ion

clai

ms,

you

mus

t inc

lude

Cod

e D0

999

alon

g w

ith a

ll co

vere

d se

rvic

e pr

oced

ure

code

s you

per

form

on

each

AAR

P M

edic

are

Com

plet

e DH

MO

m

embe

r.

Plea

se n

ote

the

follo

win

g:

1) If

you

subm

it D0

999

alon

e no

add

ition

al $

2.00

reim

burs

emen

t will

not

be

paid

. Ad

ditio

nally

, cla

im su

bmiss

ion

wou

ld b

e co

nsid

ered

non

-com

plia

nt.

2)

If y

ou su

bmit

all s

ervi

ce p

roce

dure

serv

ice

code

s but

don

't in

clud

e D0

999

as w

ell a

s you

won

't be

reim

burs

ed th

e ad

ditio

nal $

2.00

. In

add

ition

, the

cla

im w

ill b

e co

nsid

ered

non

-com

plia

nt.

D022

0

D012

0D0

140

D015

0D0

210

perio

dic

oral

eva

luat

ion

limite

d or

al e

valu

atio

n - p

robl

em fo

cuse

dco

mpr

ehen

sive

ora

l eva

luat

ion

- new

or e

stab

lishe

d pa

tient

intr

aora

l - c

ompl

ete

serie

s (in

clud

ing

bite

win

gs)

D027

2D0

273

bite

win

g - t

wo

film

sN

o

D111

0pr

ophy

laxi

s - a

dult

No

D131

0nu

triti

onal

cou

nsel

ing

for c

ontr

ol o

f den

tal d

isea

seN

o

D027

4D0

330

bite

win

g - t

hree

film

s

D132

0to

bacc

o co

unse

ling

for t

he c

ontr

ol a

nd p

reve

ntio

n of

ora

l dis

ease

No

D099

9un

spec

ified

dia

gnos

tic p

roce

dure

No

bite

win

g - f

our f

ilms

pano

ram

ic fi

lmN

oD0

470

diag

nost

ic c

asts

No

D112

0D1

206

D120

8

prop

hyla

xis -

chi

ldto

pica

l app

licat

ion

of fl

uorid

e va

rnis

hto

pica

l app

licat

ion

of fl

uorid

e

No

No

No

D133

0or

al h

ygie

ne in

stru

ctio

nsN

o

Prio

r Aut

horiz

atio

n Re

quire

d?Pr

oced

ure

Code

Freq

uenc

y/Li

mita

tions

Proc

edur

e D

escr

iptio

n

In a

n ef

fort

to c

ompl

y w

ith th

e Ce

nter

s for

Med

icar

e an

d M

edic

aid

(CM

S) st

ate

man

date

d re

quire

men

ts, p

leas

e be

adv

ised

that

DHM

O E

ncou

nter

Dat

a Su

bmis

sion

s are

now

requ

ired.

CM

S no

w re

quire

s tha

t we

repo

rt

100%

of u

tiliza

tion

data

for o

ur A

ARP

Med

icar

e Co

mpl

ete

DHM

O m

embe

rs.

To e

nsur

e th

at w

e m

eet C

MS

requ

irem

ent o

f rep

ortin

g 10

0% u

tiliza

tion,

we

are

happ

y to

re-in

trod

uce

our D

enta

l Inc

entiv

e Pr

ogra

m e

ffect

ive

imm

edia

tely

. De

ntal

Ben

efit

Prov

ider

s will

reim

burs

e ou

r pro

vide

rs $

2.00

for e

ach

enco

unte

r cla

im su

bmitt

ed fo

r AAR

P M

edic

are

Com

plet

e D

HM

O m

embe

rs o

nly

for a

ll pr

oced

ures

(cov

ered

und

er th

e m

embe

r's p

lan)

pe

rfor

med

on

thos

e m

embe

rs, f

or e

ach

date

of s

ervi

ce.

All p

roce

dure

s per

form

ed M

UST

be

repo

rted

incl

udin

g pr

oced

ures

whe

ther

or n

ot th

e m

embe

r has

a c

opay

men

t. T

his i

s a re

quire

men

t for

all

cont

ract

ed

prov

ider

s to

subm

it ut

iliza

tion

for e

ach

patie

nt tr

eate

d.

No

D023

0D0

250

D027

0

intr

aora

l - p

eria

pica

l - fi

rst f

ilm

1 ev

ery

6 M

onth

(s)

1 ev

ery

6 M

onth

(s)

No

No

No

No

No

No

No

intr

aora

l - p

eria

pica

l - e

ach

addi

tiona

l film

extr

aora

l firs

t rad

iogr

aphi

c im

age

bite

win

g - s

ingl

e fil

m

6464

Prov

ider

Cla

im D

ispu

tes

Mem

ber A

ppea

ls &

Grie

vanc

es

Prio

r Aut

horiz

atio

n Re

ques

ts

CT, N

J, N

Y_SC

ION

143

_Pkg

DT0

36_D

T036

-H00

00a-

Oxf

rd

09/2

016

“Prio

r Aut

horiz

atio

n re

quire

d” m

eans

the

prac

titio

ner m

ust s

ubm

it th

ose

proc

edur

es fo

r app

rova

l with

clin

ical

doc

umen

tatio

n su

ppor

ting

nece

ssity

bef

ore

perf

orm

ing

thos

e pr

oced

ures

. To

do th

is c

ompl

ete

a st

anda

rd

ADA

clai

m fo

rm a

nd c

heck

the

box

mar

ked

“Pre

-Tre

atm

ent E

STIM

ATE.

” Pr

ior a

utho

rizat

ion

requ

est c

an b

e su

bmitt

ed v

ia th

e pr

ovid

er w

eb p

orta

l (at

ww

w.m

yuhc

prov

ider

s.co

m),

subm

itted

ele

ctro

nica

lly v

ia y

our

clea

ringh

ouse

, or s

impl

y m

ail t

he fo

rm, t

o th

e be

low

add

ress

, alo

ng w

ith a

ny re

quire

d su

pple

men

tal i

nfor

mat

ion

(film

s, n

arra

tive,

per

io-c

hart

ing,

etc

.). Y

our o

ffice

will

then

rece

ive

an E

xpla

natio

n of

Ben

efits

(EO

B)

outli

ning

the

deni

al o

r app

rova

l of r

eque

sted

trea

tmen

t and

pla

n pa

ymen

t am

ount

s whe

n ap

plic

able

.

Dent

al P

rovi

ders

with

com

plai

nts a

re to

con

tact

Uni

tedH

ealth

care

Den

tal’s

Pro

vide

r Ser

vice

dep

artm

ent a

t (84

4) 2

75-8

750.

Net

wor

k Pr

ovid

er c

ontr

actu

al d

ispu

tes,

Out

-of-N

etw

ork

prov

ider

dis

pute

s, a

nd re

proc

essi

ng

requ

ests

will

be

logg

ed in

to th

e ap

peal

s dat

abas

e. P

leas

e m

ail t

o th

e Ap

peal

s & G

rieva

nces

PO

Box

list

ed a

bove

. Res

earc

h an

d re

solu

tion

will

be

com

plet

ed w

ithin

30

cale

ndar

day

s.

Mem

ber a

ppea

ls a

re re

view

ed b

y th

e he

alth

pla

n, a

nd a

re n

ot d

eleg

ated

to U

HC D

enta

l. Al

l Mem

ber a

ppea

ls (i

nclu

des P

re-S

ervi

ce a

ppea

ls, I

n N

etw

ork

Prov

ider

app

eals

, and

Out

of N

etw

ork

prov

ider

app

eals

) rec

eive

d by

U

HC D

enta

l will

be

forw

arde

d to

the

heal

th p

lan

via

over

nigh

t mai

l, w

ithin

7 d

ays o

f rec

eipt

of t

he a

ppea

l.

Mai

l mem

ber a

ppea

ls to

: Uni

tedH

ealth

care

, Att

n: A

ppea

l Dep

artm

ent,

MS

CA12

4-01

57, P

O B

ox 6

106,

Cyp

ress

, CA

9063

0

65

Dent

al P

rovi

ders

with

com

plai

nts a

re to

con

tact

Uni

tedH

ealth

care

Den

tal’s

Pro

vide

r Ser

vice

dep

artm

ent a

t

69

“Prio

r Aut

horiz

atio

n re

quire

d” m

eans

the

prac

titio

ner m

ust s

ubm

it th

ose

proc

edur

es fo

r app

rova

l with

clin

ical

doc

umen

tatio

n su

ppor

ting

nece

ssity

bef

ore

perf

orm

ing

thos

e pr

oced

ures

. To

do th

is

com

plet

e a

stan

dard

ADA

cla

im fo

rm a

nd c

heck

the

box

mar

ked

“Pre

-Tre

atm

ent E

STIM

ATE.

” Pr

ior a

utho

rizat

ion

requ

est c

an b

e su

bmitt

ed v

ia th

e pr

ovid

er w

eb p

orta

l (at

ww

w.m

yuhc

prov

ider

s.co

m),

7070

“Prio

r Aut

horiz

atio

n re

quire

d” m

eans

the

prac

titio

ner m

ust s

ubm

it th

ose

proc

edur

es fo

r app

rova

l with

clin

ical

doc

umen

tatio

n su

ppor

ting

nece

ssity

bef

ore

perf

orm

ing

thos

e pr

oced

ures

. To

do th

is

com

plet

e a

stan

dard

ADA

cla

im fo

rm a

nd c

heck

the

box

mar

ked

“Pre

-Tre

atm

ent E

STIM

ATE.

” Pr

ior a

utho

rizat

ion

requ

est c

an b

e su

bmitt

ed v

ia th

e pr

ovid

er w

eb p

orta

l (at

ww

w.m

yuhc

prov

ider

s.co

m),

Dent

al P

rovi

ders

with

com

plai

nts a

re to

con

tact

Uni

tedH

ealth

care

Den

tal’s

Pro

vide

r Ser

vice

dep

artm

ent a

t

73

1 ev

ery

year

1 ev

ery

36 m

onth

s fro

m la

st d

ate

of s

ervi

ce

2 ev

ery

day

2 ev

ery

year

7676

“Prio

r Aut

horiz

atio

n re

quire

d” m

eans

the

prac

titio

ner m

ust s

ubm

it th

ose

proc

edur

es fo

r app

rova

l with

clin

ical

doc

umen

tatio

n su

ppor

ting

nece

ssity

bef

ore

perf

orm

ing

thos

e pr

oced

ures

. To

do th

is c

ompl

ete

a st

anda

rd A

DA c

laim

form

and

che

ck th

e bo

x m

arke

d “P

re-T

reat

men

t EST

IMAT

E.”

Prio

r aut

horiz

atio

n re

ques

t can

be

subm

itted

via

the

prov

ider

web

por

tal (

at w

ww

.myu

hcpr

ovid

ers.

com

), su

bmitt

ed

Dent

al P

rovi

ders

with

com

plai

nts a

re to

con

tact

Uni

tedH

ealth

care

Den

tal’s

Pro

vide

r Ser

vice

dep

artm

ent a

t

77

Iden

tific

atio

n Ca

rds

Sam

ple

Mem

ber I

D C

ard*

Fron

t of c

ard

Back

of c

ard

Impo

rtan

t Tel

epho

ne N

umbe

rs &

Web

site

s

Prov

ider

Qui

ck R

efer

ence

Gui

de -

Effe

ctiv

e 1/

1/20

17U

nite

dHea

lthca

re C

omm

unity

Pla

n/U

nite

dHea

lthca

re o

f Flo

rida

Dua

l Com

plet

e LP

$1,5

00 A

nnua

l Max

Call

to In

quire

Abo

utTe

leph

one

Num

ber

Hou

rs o

f Ope

ratio

n

Emai

l to

Inqu

ire A

bout

Web

site

Hou

rs o

f Ope

ratio

n

Med

icar

ew

ww

.med

icar

e.go

v24

hou

rs a

day

Cent

ers f

or M

edic

aid

and

Med

icar

e Se

rvic

esw

ww

.cm

s.hh

s.go

v

*Ple

ase

note

that

the

Med

ical

ID C

ard

is un

iver

sal a

nd in

clud

es a

ll lin

es o

f cov

erag

e. T

he M

edic

al p

lan

can

be H

MO

or P

PO a

nd th

is d

oes n

ot re

flect

the

Dent

al P

lan

Bene

fits.

Ple

ase

flip

the

ID C

ard

over

to se

e th

e De

ntal

Pro

vide

r inf

orm

atio

n on

the

back

(i.e

. car

rier w

ebsi

te a

nd to

ll-fr

ee n

umbe

r). T

his i

nfor

mat

ion

can

be u

sed

to c

onfir

m p

rovi

der p

artic

ipat

ion,

mem

ber e

ligib

ility

and

ben

efits

. Th

is is

a S

AMPL

E ID

Car

d an

d m

ay d

iffer

from

the

mem

ber's

ID C

ard.

Elig

ibili

ty,

Bene

fits,

Cla

im(s

) and

Aut

horiz

atio

ns87

7-37

8-52

93Li

ve A

gent

: Mon

day

- Frid

ay, 8

:00A

M -

6:00

PM, E

STIV

R: 2

4 ho

urs a

day

24 h

ours

a d

ay

To d

iscu

ss y

our p

artic

ipat

ion,

con

trac

tual

issu

es, d

entis

t cha

nges

or o

ffice

up

date

s80

0-82

2-53

53Li

ve A

gent

: Mon

day

- Frid

ay, 8

:00A

M -

11:0

0PM

, EST

Elig

ibili

ty,

Bene

fits,

Cla

im(s

) and

Aut

horiz

atio

nsw

ww

.uhc

prov

ider

s.co

m24

hou

rs a

day

FL D

SNP

H104

5-03

9 an

d H1

045-

040

7878

Impo

rtan

t Add

ress

es

Impo

rtan

t Ele

ctro

nic

Clai

ms &

Prio

r Aut

horiz

atio

n Su

bmis

sion

Info

rmat

ion

D027

41

ever

y 6

Mon

th(s

)

1 ev

ery

6 M

onth

(s)

intr

aora

l - o

cclu

sal f

ilm

D216

0U

nlim

ited

Unl

imite

d

1 ev

ery

3 Ye

ar(s

)

EDI P

ayer

Num

ber f

or C

laim

s Sub

mitt

ed

Prov

ider

Rea

son

for M

ailin

g

No

No

GP1

33

Clai

ms

Prio

r Aut

horiz

atio

nAp

peal

s & G

rieva

nces

UHC

Med

icar

e Cl

aim

s, P

O B

ox 2

176,

Milw

auke

e, W

I 532

01U

HC M

edic

are

Auth

oriza

tions

, PO

Box

205

3, M

ilwau

kee,

WI 5

3201

UHC

Med

icar

e Co

mpl

aint

s, G

rieva

nces

& A

ppea

ls, P

O B

ox 3

61, M

ilwau

kee,

WI 5

3201

Yes

Yes

Yes

Yes

No

No

Unl

imite

d

Unl

imite

dU

nlim

ited

Unl

imite

dU

nlim

ited

Unl

imite

dU

nlim

ited

1 ev

ery

24 M

onth

(s)

1 ev

ery

24 M

onth

(s)

1 ev

ery

24 M

onth

(s)

No

No

No

No

Unl

imite

dU

nlim

ited

Unl

imite

d

Unl

imite

dN

oN

oN

oN

oN

o

D233

2D2

335

D239

0D2

391

D239

2

Unl

imite

d

Yes

Yes

Yes

Yes

resi

n-ba

sed

com

posi

te -

thre

e su

rfac

es, p

oste

rior

resi

n-ba

sed

com

posi

te -

four

or m

ore

surf

aces

, pos

terio

rcr

own

- res

in-b

ased

com

posi

te (i

ndire

ct)

crow

n - p

orce

lain

/cer

amic

subs

trat

ecr

own

- por

cela

in fu

sed

to h

igh

nobl

e m

etal

crow

n - p

orce

lain

fuse

d to

pre

dom

inan

tly b

ase

met

alcr

own

- por

cela

in fu

sed

to n

oble

met

alcr

own

- ful

l cas

t pre

dom

inan

tly b

ase

met

alcr

own

- ful

l cas

t nob

le m

etal

perio

dont

al m

aint

enan

cefu

ll m

outh

deb

ridem

ent t

o en

able

com

preh

ensi

ve e

valu

atio

n an

d di

agno

sis

core

bui

ldup

, inc

ludi

ng a

ny p

ins

pref

abric

ated

pos

t and

cor

e in

add

ition

to c

row

npe

riodo

ntal

scal

ing

and

root

pla

nnin

g - f

our o

r mor

e pe

r qua

dran

tpe

riodo

ntal

scal

ing

and

root

pla

nnin

g - o

ne to

thre

e te

eth

per q

uadr

ant

resi

n-ba

sed

com

posi

te -

thre

e su

rfac

es, a

nter

ior

resi

n-ba

sed

com

posi

te -

four

or m

ore

surf

aces

or i

nvol

ving

inci

sal a

ngle

(ant

erio

r)re

sin-

base

d co

mpo

site

cro

wn,

ant

erio

rre

sin-

base

d co

mpo

site

- on

e su

rfac

e, p

oste

rior

resi

n-ba

sed

com

posi

te -

two

surf

aces

, pos

terio

r

rece

men

t cro

wn

pref

abric

ated

stai

nles

s ste

el c

row

n - p

rimar

y to

oth

pref

abric

ated

stai

nles

s ste

el c

row

n - p

erm

anen

t too

thpr

otec

tive

rest

orat

ion

D293

0D2

931

D294

0D2

950

D295

4D4

341

D434

2D4

355

D491

0

1 ev

ery

6 M

onth

(s)

1 ev

ery

6 M

onth

(s)

1 ev

ery

6 M

onth

(s)

1 ev

ery

6 M

onth

(s)

1 ev

ery

6 M

onth

(s)

1 ev

ery

6 M

onth

(s)

1 ev

ery

6 M

onth

(s)

Unl

imite

dU

nlim

ited

1 ev

ery

6 M

onth

(s)

1 ev

ery

6 M

onth

(s)

Unl

imite

d1

ever

y 36

Mon

th(s

)1

ever

y 36

Mon

th(s

)1

ever

y 36

Mon

th(s

)1

ever

y 36

Mon

th(s

)1

ever

y 36

Mon

th(s

)1

ever

y 36

Mon

th(s

)1

ever

y 36

Mon

th(s

)

Unl

imite

dU

nlim

ited

D292

0

D233

1re

sin-

base

d co

mpo

site

- tw

o su

rfac

es, a

nter

ior

No

D216

1am

alga

m -

four

or m

ore

surf

aces

, prim

ary

or p

erm

anen

tN

oD2

330

resi

n-ba

sed

com

posi

te -

one

surf

ace,

ant

erio

rN

o

D239

3D2

394

D271

0D2

740

D275

0D2

751

D275

2D2

791

D279

2

No

No

Yes

Yes

Yes

D214

0am

alga

m -

one

surf

ace,

prim

ary

or p

erm

anen

tN

oD2

150

amal

gam

- tw

o su

rfac

es, p

rimar

y or

per

man

ent

No

D012

0D0

140

D015

0D0

210

No

No

D022

0in

trao

ral -

per

iapi

cal -

firs

t film

No

D027

0bi

tew

ing

- sin

gle

film

No

D033

0pa

nora

mic

film

No

D111

0

No

bite

win

g - f

our f

ilms

bite

win

g - t

hree

film

sN

o

Freq

uenc

y/Li

mita

tions

Proc

edur

e D

escr

iptio

npe

riodi

c or

al e

valu

atio

nlim

ited

oral

eva

luat

ion

- pro

blem

focu

sed

com

preh

ensi

ve o

ral e

valu

atio

n - n

ew o

r est

ablis

hed

patie

ntin

trao

ral -

com

plet

e se

ries (

incl

udin

g bi

tew

ings

)

amal

gam

- th

ree

surf

aces

, prim

ary

or p

erm

anen

tN

oU

nlim

ited

1 ev

ery

6 M

onth

(s)

Cove

red

Den

tal S

ervi

ces:

Prio

r Aut

horiz

atio

n Re

quire

d?Pr

oced

ure

Code

No

No

D027

2bi

tew

ing

- tw

o fil

ms

No

D023

0D0

240

intr

aora

l - p

eria

pica

l - e

ach

addi

tiona

l film

prop

hyla

xis -

adu

ltN

o

D027

3

FL D

SNP

H104

5-03

9 an

d H1

045-

040

79

Prov

ider

Cla

im D

ispu

tes

Mem

ber A

ppea

ls &

Grie

vanc

es

Prio

r Aut

horiz

atio

n Re

ques

ts

Foot

note

: FL_

SCIO

N 3

64_D

T100

_DT0

15-H

1500

B-FF

S73

09/2

016

Unl

imite

d

Unl

imite

d

Unl

imite

d

D731

1al

veol

opla

sty

in c

onju

nctio

n w

ith e

xtra

ctio

ns -

one

to th

ree

teet

h or

toot

h sp

aces

, per

qu

adra

ntN

oD9

110

palli

ativ

e (e

mer

genc

y) tr

eatm

ent o

f den

tal p

ain

- min

or p

roce

dure

No

D725

0su

rgic

al re

mov

al o

f res

idua

l too

th ro

ots (

cutt

ing

proc

edur

e)Ye

s

D731

0al

veol

opla

sty

in c

onju

nctio

n w

ith e

xtra

ctio

ns -

four

or m

ore

teet

h or

toot

h sp

aces

, per

qu

adra

ntN

o

D714

0ex

trac

tion,

eru

pted

toot

h or

exp

osed

root

(ele

vatio

n an

d/or

forc

eps)

No

D721

0su

rgic

al re

mov

al o

f eru

pted

toot

h re

q re

mov

al o

f bon

e, se

ctio

ning

of t

ooth

and

incl

udin

g el

evat

ion

of m

ucop

erio

stea

l fla

pN

o

D711

1ex

trac

tion,

cor

onal

rem

nant

s - d

ecid

uous

toot

hN

o

“Prio

r Aut

horiz

atio

n re

quire

d” m

eans

the

prac

titio

ner m

ust s

ubm

it th

ose

proc

edur

es fo

r app

rova

l with

clin

ical

doc

umen

tatio

n su

ppor

ting

nece

ssity

bef

ore

perf

orm

ing

thos

e pr

oced

ures

. To

do th

is

com

plet

e a

stan

dard

ADA

cla

im fo

rm a

nd c

heck

the

box

mar

ked

“Pre

-Tre

atm

ent E

STIM

ATE.

” Pr

ior a

utho

rizat

ion

requ

est c

an b

e su

bmitt

ed v

ia th

e pr

ovid

er w

eb p

orta

l (at

w

ww

.myu

hcpr

ovid

ers.

com

), su

bmitt

ed e

lect

roni

cally

via

you

r cle

arin

ghou

se, o

r sim

ply

mai

l the

form

, to

the

belo

w a

ddre

ss, a

long

with

any

requ

ired

supp

lem

enta

l inf

orm

atio

n (fi

lms,

nar

rativ

e,

perio

-cha

rtin

g, e

tc.).

You

r offi

ce w

ill th

en re

ceiv

e an

Exp

lana

tion

of B

enef

its (E

OB)

out

linin

g th

e de

nial

or a

ppro

val o

f req

uest

ed tr

eatm

ent a

nd p

lan

paym

ent a

mou

nts w

hen

appl

icab

le.

The

Uni

tedH

ealth

care

(UHC

) Com

mun

ity P

lan

for D

ual C

ompl

ete

mem

bers

cov

ers t

he d

enta

l cod

es li

sted

abo

ve. P

rovi

der p

aym

ent i

s mad

e on

a F

ee-fo

r-Se

rvic

e ba

sis.

Som

e se

rvic

es re

quire

prio

r au

thor

izatio

n. T

he d

enta

l pla

n ha

s a $

1,50

0 an

nual

max

that

app

lies t

o co

vere

d pr

even

tive

and

com

preh

ensi

ve b

enef

its. T

his p

lan

is o

ffere

d to

Uni

tedH

ealth

care

Dua

l Com

plet

e m

embe

rs in

Fl

orid

a. T

here

is n

o m

embe

r cop

ay, c

oins

uran

ce o

r ded

uctib

le fo

r IN

Net

wor

k Pr

ovid

ers.

Mem

ber c

an b

e bi

lled

for s

ervi

ces o

ver t

he $

1,50

0 an

nual

max

imum

ben

efit.

Dent

al P

rovi

ders

with

com

plai

nts a

re to

con

tact

Uni

tedH

ealth

care

Den

tal’s

Pro

vide

r Ser

vice

dep

artm

ent a

t (84

4) 2

75-8

750.

Net

wor

k Pr

ovid

er c

ontr

actu

al d

ispu

tes,

Out

-of-N

etw

ork

prov

ider

di

sput

es, a

nd re

proc

essin

g re

ques

ts w

ill b

e lo

gged

into

the

appe

als d

atab

ase.

Ple

ase

mai

l to

the

Appe

als &

Grie

vanc

es P

O B

ox li

sted

abo

ve. R

esea

rch

and

reso

lutio

n w

ill b

e co

mpl

eted

with

in 3

0 ca

lend

ar d

ays.

Mem

ber a

ppea

ls a

re re

view

ed b

y th

e he

alth

pla

n, a

nd a

re n

ot d

eleg

ated

to U

HC D

enta

l. Al

l Mem

ber a

ppea

ls (i

nclu

des P

re-S

ervi

ce a

ppea

ls, I

n N

etw

ork

Prov

ider

app

eals

, and

Out

of N

etw

ork

prov

ider

app

eals)

rece

ived

by

UHC

Den

tal w

ill b

e fo

rwar

ded

to th

e he

alth

pla

n vi

a ov

erni

ght m

ail,

with

in 7

day

s of r

ecei

pt o

f the

app

eal.

Unl

imite

d

Unl

imite

dU

nlim

ited

Unl

imite

d

Mai

l mem

ber a

ppea

ls to

: Uni

tedH

ealth

care

, Att

n: A

ppea

l Dep

artm

ent,

MS

CA12

4-01

57, P

O B

ox 6

106,

Cyp

ress

, CA

9063

0

FL D

SNP

H104

5-03

9 an

d H1

045-

040

8080

Iden

tific

atio

n Ca

rds

Sam

ple

Mem

ber I

D C

ard*

Prov

ider

Qui

ck R

efer

ence

Gui

de -

Effe

ctiv

e 1/

1/20

17U

nite

dHea

lthca

re C

omm

unity

Pla

n/U

nite

dHea

lthca

re o

f Flo

rida

Dua

l Com

plet

e M

edic

aid

Wra

p

FL W

rap

R744

4 PB

P 01

2 G

roup

#82

080,

R74

44 P

BP 0

13 G

roup

#82

981,

H10

45 P

BP 0

39 G

roup

#82

060,

H10

45 P

BP 0

40 G

roup

#82

941

81

Fron

t of C

ard

Back

of C

ard

Impo

rtan

t Tel

epho

ne N

umbe

rs &

Web

site

s

Impo

rtan

t Add

ress

es

Impo

rtan

t Ele

ctro

nic

Clai

ms &

Prio

r Aut

horiz

atio

n Su

bmis

sion

Info

rmat

ion

EDI P

ayer

Num

ber f

or C

laim

s Sub

mitt

ed

Prov

ider

Rea

son

for M

ailin

g

Call

to In

quire

Abo

utTe

leph

one

Num

ber

Hou

rs o

f Ope

ratio

n

Emai

l to

Inqu

ire A

bout

Web

site

Hou

rs o

f Ope

ratio

n

Med

icar

ew

ww

.med

icar

e.go

v24

hou

rs a

day

Cent

ers f

or M

edic

aid

and

Med

icar

e Se

rvic

esw

ww

.cm

s.hh

s.go

v24

hou

rs a

day

*Ple

ase

note

that

the

Med

ical

ID C

ard

is u

nive

rsal

and

incl

udes

all

lines

of c

over

age.

The

Med

ical

pla

n ca

n be

HM

O o

r PPO

and

this

doe

s not

refle

ct th

e De

ntal

Pla

n Be

nefit

s. P

leas

e fli

p th

e ID

Car

d ov

er to

see

the

Dent

al P

rovi

der i

nfor

mat

ion

on th

e ba

ck (i

.e. c

arrie

r web

site

and

toll-

free

num

ber)

. Thi

s inf

orm

atio

n ca

n be

use

d to

con

firm

pro

vide

r par

ticip

atio

n, m

embe

r elig

ibili

ty a

nd b

enef

its.

This

is a

SAM

PLE

ID C

ard

and

may

diff

er fr

om th

e m

embe

r's ID

Car

d. P

leas

e lo

ok in

the

bott

om le

ft h

and

corn

er fo

r the

Pla

n an

d PB

P# a

nd th

e up

per r

ight

han

d co

rner

for t

he c

orre

ct g

roup

num

ber.

Elig

ibili

ty,

Bene

fits,

Cla

im(s

) and

Aut

horiz

atio

ns87

7-37

8-52

93

GP1

33

Clai

ms

Prio

r Aut

horiz

atio

nAp

peal

s & G

rieva

nces

Uni

tedH

ealth

care

Den

tal F

L M

edic

aid

PO B

ox 1

167,

Milw

auke

e, W

I 532

01U

nite

dHea

lthca

re D

enta

l FL

Med

icai

d PO

Box

753

Uni

tedH

ealth

care

Den

tal F

L M

edic

aid

Attn

: App

eals

, PO

Box

667

D014

0D0

150

D021

0D0

220

Live

Age

nt: M

onda

y - F

riday

, 8:0

0AM

- 6:

00PM

, EST

IVR:

24

hour

s a d

ay

24 h

ours

a d

ay

To d

iscu

ss y

our p

artic

ipat

ion,

con

trac

tual

issu

es, d

entis

t cha

nges

or o

ffice

up

date

s80

0-82

2-53

53Li

ve A

gent

: Mon

day

- Frid

ay, 8

:00A

M -

11:0

0PM

, EST

Elig

ibili

ty,

Bene

fits,

Cla

im(s

) and

Aut

horiz

atio

nsw

ww

.uhc

prov

ider

s.co

m

2 ev

ery

12 M

onth

s2

ever

y 12

Mon

ths

2 ev

ery

12 M

onth

sun

limite

dun

limite

d1

ever

y 36

Mon

ths

Freq

uenc

y/Li

mita

tions

Proc

edur

e D

escr

iptio

nLi

mite

d O

ral E

valu

atio

n - P

robl

em F

ocus

edCo

mpr

ehen

sive

Ora

l Eva

luat

ion

- New

Or E

stab

lishe

d Pa

tient

Intr

aora

l - C

ompl

ete

Serie

s of R

adio

grap

hic

Imag

esIn

trao

ral -

Per

iapi

cal F

irst R

adio

grap

hic

Imag

e

Cove

red

Den

tal S

ervi

ces:

Prio

r Aut

horiz

atio

n Re

quire

d?Pr

oced

ure

Code

D024

0In

trao

ral -

Per

iapi

cal E

ach

Addi

tiona

l Im

age

No

No

No

No

No

No

Intr

aora

l - O

cclu

sal R

adio

grap

hic

Imag

eD0

230

FL W

rap

R744

4 PB

P 01

2 G

roup

#82

080,

R74

44 P

BP 0

13 G

roup

#82

981,

H10

45 P

BP 0

39 G

roup

#82

060,

H10

45 P

BP 0

40 G

roup

#82

941

8282

Prov

ider

Cla

im D

ispu

tes

Mem

ber A

ppea

ls &

Grie

vanc

es

3 ev

ery

12 M

ON

THS

2 ev

ery

12 M

ON

THS

2 ev

ery

12 M

ON

THS

unlim

ited

unlim

ited

1 ev

ery

LIFE

TIM

E

1 ev

ery

LIFE

TIM

E

Yes

Yes

Yes

D511

0D5

120

3 ev

ery

60 M

ON

THS

3 ev

ery

60 M

ON

THS

3 ev

ery

60 M

ON

THS

1 ev

ery

12 M

ON

THS

1 ev

ery

12 M

ON

THS

1 ev

ery

12 M

ON

THS

1 ev

ery

12 M

ON

THS

1 ev

ery

12 M

ON

THS

1 ev

ery

12 M

ON

THS

1 ev

ery

12 M

ON

THS

1 ev

ery

12 M

ON

THS

D589

9

unlim

ited

1 ev

ery

36 M

onth

s1

ever

y LI

FETI

ME

1 ev

ery

LIFE

TIM

E1

ever

y LI

FETI

ME

3 ev

ery

60 M

ON

THS

3 ev

ery

60 M

ON

THS

1 ev

ery

12 M

ON

THS

1 ev

ery

12 M

ON

THS

D714

0U

nspe

cifie

d Re

mov

able

Pro

stho

dont

ic P

roce

dure

, By

Repo

rtEx

trac

tion,

Eru

pted

Too

th O

r Exp

osed

Roo

t1

ever

y LI

FETI

ME

1 ev

ery

LIFE

TIM

EYe

sYe

s

Yes

1 ev

ery

LIFE

TIM

ERe

mov

al O

f Im

pact

ed T

ooth

- Co

mpl

etel

y Bo

nyD7

240

D723

0Re

mov

al O

f Im

pact

ed T

ooth

- Pa

rtia

lly B

ony

Yes

1 ev

ery

LIFE

TIM

E

1 ev

ery

LIFE

TIM

E1

ever

y LI

FETI

ME

D721

0Su

rgic

al R

emov

al O

f Eru

pted

Too

thYe

sD7

220

Rem

oval

Of I

mpa

cted

Too

th -

Soft

Tis

sue

Yes

D576

0Re

line

Max

illar

y Pa

rtia

l Den

ture

(Lab

orat

ory)

No

D576

1Re

line

Man

dibu

lar P

artia

l Den

ture

(Lab

orat

ory)

No

D575

0Re

line

Com

plet

e M

axill

ary

Dent

ure

(Lab

orat

ory)

No

D575

1Re

line

Com

plet

e M

andi

bula

r Den

ture

(Lab

orat

ory)

No

D574

0Re

line

Max

illar

y Pa

rtia

l Den

ture

(Cha

irsid

e)N

oD5

741

Relin

e M

axill

ary

Part

ial D

entu

re (C

hairs

ide)

No

D573

0Re

line

Com

plet

e M

axill

ary

Dent

ure

(Cha

irsid

e)N

oD5

731

Relin

e Co

mpl

ete

Man

dibu

lar D

entu

re (C

hairs

ide)

No

D565

0Ad

d To

oth

To E

xist

ing

Part

ial D

entu

reN

oD5

660

Add

Clas

p To

Exi

stin

g Pa

rtia

l Den

ture

No

D563

0Re

pair

Or R

epla

ce B

roke

n Cl

asp

No

D564

0Re

plac

e Br

oken

Tee

th -

Per T

ooth

No

Repa

ir Re

sin

Dent

ure

Base

No

D562

0Re

pair

Cast

Fra

mew

ork

No

D551

0Re

pair

Brok

en C

ompl

ete

Dent

ure

Base

No

D552

0Re

plac

e M

issi

ng O

r Bro

ken

Teet

h - C

ompl

ete

Dent

ure

(Eac

h To

oth)

No

Yes

D542

1Ad

just

Par

tial D

entu

re -

Max

illar

yN

oD5

422

Adju

st P

artia

l Den

ture

- M

andi

bula

rN

o

D541

0Ad

just

Com

plet

e De

ntur

e - M

axill

ary

No

Mai

l mem

ber a

ppea

ls to

: Uni

tedH

ealth

care

, Att

n: A

ppea

l Dep

artm

ent,

P.O

. Box

313

64, S

alt L

ake

City

, UT

8413

1

D029

0D0

330

D521

4M

andi

bula

r Par

tial D

entu

re -

Cast

Met

al F

ram

ewor

k W

ith R

esin

Den

ture

Bas

esYe

s

D521

1D5

212

Com

plet

e De

ntur

e - M

andi

bula

rM

axill

ary

Part

ial D

entu

re -

Resin

Bas

e

The

Uni

tedH

ealth

care

(UHC

) Com

mun

ity P

lan

cove

rs th

e de

ntal

cod

es li

sted

abo

ve. P

rovi

der p

aym

ent i

s mad

e on

a F

ee-fo

r-Se

rvic

e ba

sis.

Mem

bers

hav

e co

vera

ge w

ith p

artic

ipat

ing

prov

ider

s.

Som

e se

rvic

es re

quire

prio

r aut

horiz

atio

n. T

here

is n

o m

embe

r cop

ay, c

oins

uran

ce o

r ded

uctib

le.

Dent

al P

rovi

ders

with

com

plai

nts a

re to

con

tact

Uni

tedH

ealth

care

Den

tal’s

Pro

vide

r Ser

vice

dep

artm

ent a

t (87

7) 3

78-5

293.

Net

wor

k Pr

ovid

er c

ontr

actu

al d

ispu

tes,

Out

-of-N

etw

ork

prov

ider

di

sput

es, a

nd re

proc

essin

g re

ques

ts w

ill b

e lo

gged

into

the

appe

als d

atab

ase.

Ple

ase

mai

l to

the

Appe

als &

Grie

vanc

es P

O B

ox li

sted

abo

ve. R

esea

rch

and

reso

lutio

n w

ill b

e co

mpl

eted

with

in 3

0 ca

lend

ar d

ays.

Mem

ber a

ppea

ls a

re re

view

ed b

y th

e he

alth

pla

n, a

nd a

re n

ot d

eleg

ated

to U

HC D

enta

l. Al

l Mem

ber a

ppea

ls (i

nclu

des P

re-S

ervi

ce a

ppea

ls, I

n N

etw

ork

Prov

ider

app

eals

, and

Out

of N

etw

ork

prov

ider

app

eals)

rece

ived

by

UHC

Den

tal w

ill b

e fo

rwar

ded

to th

e he

alth

pla

n vi

a ov

erni

ght m

ail,

with

in 7

day

s of r

ecei

pt o

f the

app

eal.

No

No

Intr

aora

l - O

cclu

sal R

adio

grap

hic

Imag

ePa

nora

mic

Rad

iogr

aphi

c Im

age

1 ev

ery

LIFE

TIM

EM

andi

bula

r Par

tial D

entu

re -

Resi

n Ba

se

D541

1Ad

just

Com

plet

e De

ntur

e - M

andi

bula

rN

o

D561

0

Com

plet

e De

ntur

e - M

axill

ary

Yes

D521

3M

axill

ary

Part

ial D

entu

re -

Cast

Met

al F

ram

ewor

k W

ith R

esin

Den

ture

Bas

es

FL W

rap

R744

4 PB

P 01

2 G

roup

#82

080,

R74

44 P

BP 0

13 G

roup

#82

981,

H10

45 P

BP 0

39 G

roup

#82

060,

H10

45 P

BP 0

40 G

roup

#82

941

83

Prio

r Aut

horiz

atio

n Re

ques

ts

Foot

note

: FL_

SCIO

N 2

89_D

SNP

Med

icai

d W

rap

01/2

017

“Prio

r Aut

horiz

atio

n re

quire

d” m

eans

the

prac

titio

ner m

ust s

ubm

it th

ose

proc

edur

es fo

r app

rova

l with

clin

ical

doc

umen

tatio

n su

ppor

ting

nece

ssity

bef

ore

perf

orm

ing

thos

e pr

oced

ures

. To

do th

is

com

plet

e a

stan

dard

ADA

cla

im fo

rm a

nd c

heck

the

box

mar

ked

“Pre

-Tre

atm

ent E

STIM

ATE.

” Pr

ior a

utho

rizat

ion

requ

est c

an b

e su

bmitt

ed v

ia th

e pr

ovid

er w

eb p

orta

l (at

w

ww

.myu

hcpr

ovid

ers.

com

), su

bmitt

ed e

lect

roni

cally

via

you

r cle

arin

ghou

se, o

r sim

ply

mai

l the

form

, to

the

belo

w a

ddre

ss, a

long

with

any

requ

ired

supp

lem

enta

l inf

orm

atio

n (fi

lms,

nar

rativ

e,

perio

-cha

rtin

g, e

tc.).

You

r offi

ce w

ill th

en re

ceiv

e an

Exp

lana

tion

of B

enef

its (E

OB)

out

linin

g th

e de

nial

or a

ppro

val o

f req

uest

ed tr

eatm

ent a

nd p

lan

paym

ent a

mou

nts w

hen

appl

icab

le.

FL W

rap

R744

4 PB

P 01

2 G

roup

#82

080,

R74

44 P

BP 0

13 G

roup

#82

981,

H10

45 P

BP 0

39 G

roup

#82

060,

H10

45 P

BP 0

40 G

roup

#82

941

8484

Iden

tific

atio

n Ca

rds

Sam

ple

Mem

ber I

D C

ard*

Fron

t of c

ard

Back

of c

ard

Prov

ider

Qui

ck R

efer

ence

Gui

de -

Effe

ctiv

e 1/

1/20

17U

nite

dHea

lthca

re C

omm

unity

Pla

n/U

nite

dHea

lthca

re o

f Flo

rida

Dua

l Com

plet

e RP

$1,5

00 A

nnua

l Max

*Ple

ase

note

that

the

Med

ical

ID C

ard

is un

iver

sal a

nd in

clud

es a

ll lin

es o

f cov

erag

e. T

he M

edic

al p

lan

can

be H

MO

or P

PO a

nd th

is d

oes n

ot re

flect

the

Dent

al P

lan

Bene

fits.

Ple

ase

flip

the

ID C

ard

over

to se

e th

e De

ntal

Pro

vide

r inf

orm

atio

n on

the

back

(i.e

. car

rier w

ebsi

te a

nd to

ll-fr

ee n

umbe

r). T

his i

nfor

mat

ion

can

be u

sed

to c

onfir

m p

rovi

der p

artic

ipat

ion,

mem

ber e

ligib

ility

and

ben

efits

. Th

is is

a S

AMPL

E ID

Car

d an

d m

ay d

iffer

from

the

mem

ber's

ID C

ard.

FL D

NSP

R74

44-0

12 a

nd R

7444

-013

85

Impo

rtan

t Tel

epho

ne N

umbe

rs &

Web

site

s

Impo

rtan

t Add

ress

es

Impo

rtan

t Ele

ctro

nic

Clai

ms &

Prio

r Aut

horiz

atio

n Su

bmis

sion

Info

rmat

ion

EDI P

ayer

Num

ber f

or C

laim

s Sub

mitt

ed

Prov

ider

Rea

son

for M

ailin

g

Call

to In

quire

Abo

utTe

leph

one

Num

ber

Hou

rs o

f Ope

ratio

n

Emai

l to

Inqu

ire A

bout

Web

site

Hou

rs o

f Ope

ratio

n

Med

icar

ew

ww

.med

icar

e.go

v24

hou

rs a

day

Cent

ers f

or M

edic

aid

and

Med

icar

e Se

rvic

esw

ww

.cm

s.hh

s.go

v24

hou

rs a

day

Elig

ibili

ty,

Bene

fits,

Cla

im(s

) and

Aut

horiz

atio

ns84

4-27

5-87

50

Unl

imite

dU

nlim

ited

Unl

imite

dU

nlim

ited

GP1

33

Clai

ms

Prio

r Aut

horiz

atio

nAp

peal

s & G

rieva

nces

UHC

Med

icar

e Cl

aim

s, P

O B

ox 2

176,

Milw

auke

e, W

I 532

01U

HC M

edic

are

Auth

oriza

tions

, PO

Box

205

3, M

ilwau

kee,

WI 5

3201

UHC

Med

icar

e Co

mpl

aint

s, G

rieva

nces

& A

ppea

ls, P

O B

ox 3

61, M

ilwau

kee,

WI 5

3201

Unl

imite

d

No

No

D027

2D0

273

bite

win

g - t

wo

film

sN

o

D111

0pr

ophy

laxi

s - a

dult

No

Freq

uenc

y/Li

mita

tions

Proc

edur

e D

escr

iptio

npe

riodi

c or

al e

valu

atio

nlim

ited

oral

eva

luat

ion

- pro

blem

focu

sed

com

preh

ensi

ve o

ral e

valu

atio

n - n

ew o

r est

ablis

hed

patie

ntin

trao

ral -

com

plet

e se

ries (

incl

udin

g bi

tew

ings

)

Unl

imite

dU

nlim

ited

Live

Age

nt: M

onda

y - F

riday

, 8:0

0AM

- 6:

00PM

, EST

IVR:

24

hour

s a d

ay

24 h

ours

a d

ay

To d

iscu

ss y

our p

artic

ipat

ion,

con

trac

tual

issu

es, d

entis

t cha

nges

or o

ffice

up

date

s80

0-82

2-53

53Li

ve A

gent

: Mon

day

- Frid

ay, 8

:00A

M -

11:0

0PM

, EST

Elig

ibili

ty,

Bene

fits,

Cla

im(s

) and

Aut

horiz

atio

nsw

ww

.uhc

prov

ider

s.co

m

1 ev

ery

6 M

onth

(s)

1 ev

ery

6 M

onth

(s)

1 ev

ery

6 M

onth

(s)

1 ev

ery

6 M

onth

(s)

1 ev

ery

6 M

onth

(s)

1 ev

ery

6 M

onth

(s)

1 ev

ery

6 M

onth

(s)

1 ev

ery

6 M

onth

(s)

1 ev

ery

6 M

onth

(s)

D012

0D0

140

D015

0D0

210

No

1 ev

ery

6 M

onth

(s)

1 ev

ery

6 M

onth

(s)

Unl

imite

dU

nlim

ited

Unl

imite

dU

nlim

ited

1 ev

ery

36 M

onth

(s)

Unl

imite

d

1 ev

ery

6 M

onth

(s)

Unl

imite

d

D271

0cr

own

- res

in-b

ased

com

posi

te (i

ndire

ct)

Yes

D239

3re

sin-

base

d co

mpo

site

- th

ree

surf

aces

, pos

terio

rN

oD2

394

resi

n-ba

sed

com

posi

te -

four

or m

ore

surf

aces

, pos

terio

rN

o

D239

1re

sin-

base

d co

mpo

site

- on

e su

rfac

e, p

oste

rior

No

D239

2re

sin-

base

d co

mpo

site

- tw

o su

rfac

es, p

oste

rior

No

D215

0am

alga

m -

two

surf

aces

, prim

ary

or p

erm

anen

tN

o

No

D233

1re

sin-

base

d co

mpo

site

- tw

o su

rfac

es, a

nter

ior

No

D233

2re

sin-

base

d co

mpo

site

- th

ree

surf

aces

, ant

erio

rN

o

Cove

red

Den

tal S

ervi

ces:

Prio

r Aut

horiz

atio

n Re

quire

d?Pr

oced

ure

Code

D023

0D0

240

D027

0

intr

aora

l - p

eria

pica

l - fi

rst f

ilm

No

No

D214

0am

alga

m -

one

surf

ace,

prim

ary

or p

erm

anen

tN

o

D027

4D0

330

bite

win

g - t

hree

film

sbi

tew

ing

- fou

r film

s

D216

1am

alga

m -

four

or m

ore

surf

aces

, prim

ary

or p

erm

anen

tN

oD2

330

resi

n-ba

sed

com

posi

te -

one

surf

ace,

ant

erio

rN

o

No

No

No

No

No

No

intr

aora

l - p

eria

pica

l - e

ach

addi

tiona

l film

intr

aora

l - o

cclu

sal f

ilmbi

tew

ing

- sin

gle

film

1 ev

ery

3 Ye

ar(s

)

D022

0

pano

ram

ic fi

lm

D216

0am

alga

m -

thre

e su

rfac

es, p

rimar

y or

per

man

ent

No

D233

5re

sin-

base

d co

mpo

site

- fo

ur o

r mor

e su

rfac

es o

r inv

olvi

ng in

cisa

l ang

le (a

nter

ior)

No

D239

0re

sin-

base

d co

mpo

site

cro

wn,

ant

erio

r

FL D

NSP

R74

44-0

12 a

nd R

7444

-013

8686

Prov

ider

Cla

im D

ispu

tes

Mem

ber A

ppea

ls &

Grie

vanc

es

Prio

r Aut

horiz

atio

n Re

ques

ts

Foot

note

: SCI

ON

288

_DT0

99_D

T015

-P15

00A-

FFS7

3

09/2

016

Unl

imite

d

Unl

imite

d

1 ev

ery

24 M

onth

(s)

1 ev

ery

24 M

onth

(s)

1 ev

ery

36 M

onth

(s)

1 ev

ery

36 M

onth

(s)

1 ev

ery

36 M

onth

(s)

1 ev

ery

36 M

onth

(s)

1 ev

ery

36 M

onth

(s)

Unl

imite

d

Unl

imite

d

D293

0pr

efab

ricat

ed st

ainl

ess s

teel

cro

wn

- prim

ary

toot

hU

nlim

ited

No

Unl

imite

d

D279

2cr

own

- ful

l cas

t nob

le m

etal

Yes

D292

0re

cem

ent c

row

nN

o

D275

2cr

own

- por

cela

in fu

sed

to n

oble

met

alYe

sD2

791

crow

n - f

ull c

ast p

redo

min

antly

bas

e m

etal

Yes

surg

ical

rem

oval

of r

esid

ual t

ooth

root

s (cu

ttin

g pr

oced

ure)

Yes

pref

abric

ated

stai

nles

s ste

el c

row

n - p

erm

anen

t too

thU

nlim

ited

No

Yes

1 ev

ery

24 M

onth

(s)

perio

dont

al sc

alin

g an

d ro

ot p

lann

ing

- fou

r or m

ore

per q

uadr

ant

pref

abric

ated

pos

t and

cor

e in

add

ition

to c

row

nYe

s

Unl

imite

d

surg

ical

rem

oval

of e

rupt

ed to

oth

req

rem

oval

of b

one,

sect

ioni

ng o

f too

th a

nd in

clud

ing

elev

atio

n of

muc

oper

iost

eal f

lap

No

No

Unl

imite

dD7

250

D731

0

D731

1D9

110

1 ev

ery

36 M

onth

(s)

D721

0

Unl

imite

dU

nlim

ited

Unl

imite

d

Unl

imite

d

Unl

imite

d

alve

olop

last

y in

con

junc

tion

with

ext

ract

ions

- fo

ur o

r mor

e te

eth

or to

oth

spac

es, p

er

quad

rant

alve

olop

last

y in

con

junc

tion

with

ext

ract

ions

- on

e to

thre

e te

eth

or to

oth

spac

es, p

er

quad

rant

palli

ativ

e (e

mer

genc

y) tr

eatm

ent o

f den

tal p

ain

- min

or p

roce

dure

No

No

No

D293

1

D434

1

D711

1ex

trac

tion,

cor

onal

rem

nant

s - d

ecid

uous

toot

hD7

140

extr

actio

n, e

rupt

ed to

oth

or e

xpos

ed ro

ot (e

leva

tion

and/

or fo

rcep

s)N

o

D435

5fu

ll m

outh

deb

ridem

ent t

o en

able

com

preh

ensi

ve e

valu

atio

n an

d di

agno

sis

No

D491

0pe

riodo

ntal

mai

nten

ance

No

D434

2pe

riodo

ntal

scal

ing

and

root

pla

nnin

g - o

ne to

thre

e te

eth

per q

uadr

ant

Yes

D294

0pr

otec

tive

rest

orat

ion

No

D295

0co

re b

uild

up, i

nclu

ding

any

pin

sYe

sD2

954

D275

0cr

own

- por

cela

in fu

sed

to h

igh

nobl

e m

etal

Yes

D275

1cr

own

- por

cela

in fu

sed

to p

redo

min

antly

bas

e m

etal

Yes

D274

0cr

own

- por

cela

in/c

eram

ic su

bstr

ate

Yes

Mai

l mem

ber a

ppea

ls to

: Uni

tedH

ealth

care

, Att

n: A

ppea

l Dep

artm

ent,

MS

CA12

4-01

57, P

O B

ox 6

106,

Cyp

ress

, CA

9063

0

“Prio

r Aut

horiz

atio

n re

quire

d” m

eans

the

prac

titio

ner m

ust s

ubm

it th

ose

proc

edur

es fo

r app

rova

l with

clin

ical

doc

umen

tatio

n su

ppor

ting

nece

ssity

bef

ore

perf

orm

ing

thos

e pr

oced

ures

. To

do th

is

com

plet

e a

stan

dard

ADA

cla

im fo

rm a

nd c

heck

the

box

mar

ked

“Pre

-Tre

atm

ent E

STIM

ATE.

” Pr

ior a

utho

rizat

ion

requ

est c

an b

e su

bmitt

ed v

ia th

e pr

ovid

er w

eb p

orta

l (at

ww

w.m

yuhc

prov

ider

s.co

m),

subm

itted

ele

ctro

nica

lly v

ia y

our c

lear

ingh

ouse

, or s

impl

y m

ail t

he fo

rm, t

o th

e be

low

add

ress

, alo

ng w

ith a

ny re

quire

d su

pple

men

tal i

nfor

mat

ion

(film

s, n

arra

tive,

per

io-c

hart

ing,

etc

.). Y

our o

ffice

w

ill th

en re

ceiv

e an

Exp

lana

tion

of B

enef

its (E

OB)

out

linin

g th

e de

nial

or a

ppro

val o

f req

uest

ed tr

eatm

ent a

nd p

lan

paym

ent a

mou

nts w

hen

appl

icab

le.

The

Uni

tedH

ealth

care

(UHC

) Com

mun

ity P

lan

for D

ual C

ompl

ete

mem

bers

cov

ers t

he d

enta

l cod

es li

sted

abo

ve. P

rovi

der p

aym

ent i

s mad

e on

a F

ee-fo

r-Se

rvic

e ba

sis.

Som

e se

rvic

es re

quire

prio

r au

thor

izatio

n. T

he d

enta

l pla

n ha

s a $

1,50

0 an

nual

max

that

app

lies t

o co

vere

d pr

even

tive

and

com

preh

ensi

ve b

enef

its. T

his p

lan

is of

fere

d to

Uni

tedH

ealth

care

Dua

l Com

plet

e m

embe

rs in

Fl

orid

a. T

here

is n

o m

embe

r cop

ay, c

oins

uran

ce o

r ded

uctib

le fo

r In-

Net

wor

k Pr

ovid

ers.

Dent

al P

rovi

ders

with

com

plai

nts a

re to

con

tact

Uni

tedH

ealth

care

Den

tal’s

Pro

vide

r Ser

vice

dep

artm

ent a

t (84

4) 2

75-8

750.

Net

wor

k Pr

ovid

er c

ontr

actu

al d

ispu

tes,

Out

-of-N

etw

ork

prov

ider

dis

pute

s,

and

repr

oces

sing

requ

ests

will

be

logg

ed in

to th

e ap

peal

s dat

abas

e. P

leas

e m

ail t

o th

e Ap

peal

s & G

rieva

nces

PO

Box

list

ed a

bove

. Res

earc

h an

d re

solu

tion

will

be

com

plet

ed w

ithin

30

cale

ndar

day

s.

Mem

ber a

ppea

ls a

re re

view

ed b

y th

e he

alth

pla

n, a

nd a

re n

ot d

eleg

ated

to U

HC D

enta

l. Al

l Mem

ber a

ppea

ls (i

nclu

des P

re-S

ervi

ce a

ppea

ls, I

n N

etw

ork

Prov

ider

app

eals

, and

Out

of N

etw

ork

prov

ider

FL D

NSP

R74

44-0

12 a

nd R

7444

-013

87

1 ev

ery

year

1 ev

ery

36 m

onth

s fro

m la

st d

ate

of s

ervi

ce

2 ev

ery

year

89

2 ev

ery

day

“Prio

r Aut

horiz

atio

n re

quire

d” m

eans

the

prac

titio

ner m

ust s

ubm

it th

ose

proc

edur

es fo

r app

rova

l with

clin

ical

doc

umen

tatio

n su

ppor

ting

nece

ssity

bef

ore

perf

orm

ing

thos

e pr

oced

ures

. To

do th

is c

ompl

ete

a st

anda

rd

ADA

clai

m fo

rm a

nd c

heck

the

box

mar

ked

“Pre

-Tre

atm

ent E

STIM

ATE.

” Pr

ior a

utho

rizat

ion

requ

est c

an b

e su

bmitt

ed v

ia th

e pr

ovid

er w

eb p

orta

l (at

ww

w.m

yuhc

prov

ider

s.co

m),

subm

itted

ele

ctro

nica

lly v

ia y

our

Dent

al P

rovi

ders

with

com

plai

nts a

re to

con

tact

Uni

tedH

ealth

care

Den

tal’s

Pro

vide

r Ser

vice

dep

artm

ent a

t

9090

“Prio

r Aut

horiz

atio

n re

quire

d” m

eans

the

prac

titio

ner m

ust s

ubm

it th

ose

proc

edur

es fo

r app

rova

l with

clin

ical

doc

umen

tatio

n su

ppor

ting

nece

ssity

bef

ore

perf

orm

ing

thos

e pr

oced

ures

. To

do th

is c

ompl

ete

a st

anda

rd A

DA

clai

m fo

rm a

nd c

heck

the

box

mar

ked

“Pre

-Tre

atm

ent E

STIM

ATE.

” Pr

ior a

utho

rizat

ion

requ

est c

an b

e su

bmitt

ed v

ia th

e pr

ovid

er w

eb p

orta

l (at

ww

w.m

yuhc

prov

ider

s.co

m),

subm

itted

ele

ctro

nica

lly v

ia y

our c

lear

ingh

ouse

, or

Dent

al P

rovi

ders

with

com

plai

nts a

re to

con

tact

Uni

tedH

ealth

care

Den

tal’s

Pro

vide

r Ser

vice

dep

artm

ent a

t

93

Iden

tific

atio

n Ca

rds

Sam

ple

Mem

ber I

D C

ard*

Fron

t of c

ard

Back

of c

ard

Impo

rtan

t Tel

epho

ne N

umbe

rs &

Web

site

s

Impo

rtan

t Add

ress

es

Impo

rtan

t Ele

ctro

nic

Clai

ms &

Prio

r Aut

horiz

atio

n Su

bmis

sion

Info

rmat

ion

Clai

ms

Prio

r Aut

horiz

atio

n

Appe

als &

Grie

vanc

es

UHC

Med

icar

e Cl

aim

s, P

O B

ox 2

176,

Milw

auke

e, W

I 53

201

UHC

Med

icar

e Au

thor

izatio

ns, P

O B

ox 2

053,

Milw

auke

e, W

I 53

201

UHC

Med

icar

e Co

mpl

aint

s, G

rieva

nces

& A

ppea

ls, P

O B

ox 3

61, M

ilwau

kee,

WI

5320

1

Prov

ider

Rea

son

for M

ailin

g

Call

to In

quire

Abo

utTe

leph

one

Num

ber

Hou

rs o

f Ope

ratio

n

Emai

l to

Inqu

ire A

bout

Web

site

Hou

rs o

f Ope

ratio

n

Med

icar

ew

ww

.med

icar

e.go

v24

hou

rs a

day

To d

iscu

ss y

our p

artic

ipat

ion,

con

trac

tual

issu

es, d

entis

t cha

nges

or o

ffice

upd

ates

(800

) 822

-535

3Li

ve A

gent

: Mon

day

- Frid

ay, 8

:00A

M -

11:0

0PM

, EST

Elig

ibili

ty,

Bene

fits,

Cla

im(s

) and

Aut

horiz

atio

nsw

ww

.uhc

prov

ider

s.co

m

Prov

ider

Qui

ck R

efer

ence

Gui

de -

Effe

ctiv

e 1/

1/20

17U

nite

dHea

lthca

re C

are

Impr

ovem

ent P

lus M

edic

are

Adva

ntag

e

Geo

rgia

24 h

ours

a d

ayCe

nter

s for

Med

icai

d an

d M

edic

are

Serv

ices

ww

w.c

ms.

hhs.

gov

24 h

ours

a d

ay

*Ple

ase

note

that

the

Med

ical

ID C

ard

is u

nive

rsal

and

incl

udes

all

lines

of c

over

age .

The

Med

ical

pla

n ca

n be

HM

O o

r PPO

and

this

doe

s not

refle

ct th

e De

ntal

Pla

n Be

nefit

s. P

leas

e fli

p th

e ID

Car

d ov

er to

see

the

Dent

al

Prov

ider

info

rmat

ion

on th

e ba

ck (i

.e. c

arrie

r web

site

and

toll-

free

num

ber)

. Thi

s inf

orm

atio

n ca

n be

use

d to

con

firm

pro

vide

r par

ticip

atio

n, m

embe

r elig

ibili

ty a

nd b

enef

its. T

his i

s a S

AMPL

E ID

Car

d an

d m

ay d

iffer

from

th

e m

embe

r's ID

Car

d.

Elig

ibili

ty,

Bene

fits,

Cla

im(s

) and

Aut

horiz

atio

ns(8

44) 2

75-8

750

Live

Age

nt: M

onda

y - F

riday

, 8:0

0AM

- 6:

00PM

, EST

IVR:

24

hour

s a d

ay

$500

Ann

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axim

um

EDI P

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ber f

or C

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1 ev

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2 ye

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1 ev

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No

No

Yes

No

No

No

No

No

No

Yes

Yes

Yes

No

Yes

No

No

No

Yes

Yes

Yes

Yes

No

No

No

No

No

No

No

No

No

No

Yes

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No

Resi

n-Ba

sed

Com

posi

te -

Thre

e Su

rfac

es, A

nter

ior

No

No

No

No

No

No

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Perio

dic

Ora

l Eva

luat

ion

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D731

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D275

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D279

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D293

0

D233

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D027

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330

D111

0D2

140

D215

0

D911

0

D434

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D491

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D714

0

D293

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D295

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tal S

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unlim

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unlim

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No

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Com

posi

te -

Two

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, Ant

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r

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win

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our R

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age

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Prov

ider

Cla

im D

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tes

Mem

ber A

ppea

ls &

Grie

vanc

es

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r Aut

horiz

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n Re

ques

ts

CIP_

SCIO

N 4

02_P

kg D

T457

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55-P

0500

B-FF

S28

09/2

016

Mai

l mem

ber a

ppea

ls to

: Uni

tedH

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care

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n: A

ppea

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PO B

ox 6

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CA12

4-01

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ypre

ss, C

A 90

630

“Prio

r Aut

horiz

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quire

d” m

eans

the

prac

titio

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ust s

ubm

it th

ose

proc

edur

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r app

rova

l with

clin

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doc

umen

tatio

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ting

nece

ssity

bef

ore

perf

orm

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thos

e pr

oced

ures

. To

do th

is c

ompl

ete

a st

anda

rd

ADA

clai

m fo

rm a

nd c

heck

the

box

mar

ked

“Pre

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atm

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STIM

ATE.

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ior a

utho

rizat

ion

requ

est c

an b

e su

bmitt

ed v

ia th

e pr

ovid

er w

eb p

orta

l (at

ww

w.m

yuhc

prov

ider

s.co

m),

subm

itted

ele

ctro

nica

lly v

ia y

our

clea

ringh

ouse

, or s

impl

y m

ail t

he fo

rm, t

o th

e be

low

add

ress

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ng w

ith a

ny re

quire

d su

pple

men

tal i

nfor

mat

ion

(film

s, n

arra

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per

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etc

.). Y

our o

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will

then

rece

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an E

xpla

natio

n of

Ben

efits

(EO

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outli

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the

deni

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rova

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eque

sted

trea

tmen

t and

pla

n pa

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t am

ount

s whe

n ap

plic

able

.

The

Uni

tedH

ealth

care

Pla

n fo

r Car

e Im

prov

emen

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s Med

icar

e Ad

vant

age

mem

bers

cov

ers t

he d

enta

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es li

sted

abo

ve. P

rovi

der p

aym

ent i

s mad

e on

a F

ee-fo

r-Se

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e ba

sis.

Mem

bers

hav

e bo

th In

-Net

wor

k an

d O

ut-

of-N

etw

ork

cove

rage

. Som

e se

rvic

es m

ay re

quire

prio

r aut

horiz

atio

n. T

he d

enta

l pla

n ha

s a $

500

annu

al m

axim

um th

at a

pplie

s to

cove

red

prev

entiv

e an

d co

mpr

ehen

sive

ben

efits

. The

re is

no

mem

ber c

opay

, co

insu

ranc

e or

ded

uctib

le. M

embe

r can

be

bille

d fo

r ser

vice

s ove

r the

$50

0 an

nual

max

imum

ben

efit.

Thi

s pla

n is

offe

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to C

are

Impr

ovem

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lus M

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are

Adva

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Geo

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Dent

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plai

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re to

con

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Den

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ontr

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Out

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prov

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dis

pute

s, a

nd re

proc

essi

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requ

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will

be

logg

ed in

to th

e ap

peal

s dat

abas

e. P

leas

e m

ail t

o th

e Ap

peal

s & G

rieva

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PO

Box

list

ed a

bove

. Res

earc

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d re

solu

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will

be

com

plet

ed w

ithin

30

cale

ndar

day

s.

Mem

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ppea

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re re

view

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e he

alth

pla

n, a

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re n

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l Mem

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ppea

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be

forw

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via

over

nigh

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7 d

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f rec

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of t

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ppea

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9696

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Mem

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D C

ard*

Fron

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Back

of c

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Impo

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Web

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and

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24 h

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a d

ayCe

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icai

d an

d M

edic

are

Serv

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ww

w.c

ms.

hhs.

gov

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ours

a d

ay

*Ple

ase

note

that

the

Med

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ID C

ard

is u

nive

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and

incl

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all

lines

of c

over

age .

The

Med

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pla

n ca

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HM

O o

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this

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refle

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leas

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e ID

Car

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see

the

Dent

al

Prov

ider

info

rmat

ion

on th

e ba

ck (i

.e. c

arrie

r web

site

and

toll-

free

num

ber)

. Thi

s inf

orm

atio

n ca

n be

use

d to

con

firm

pro

vide

r par

ticip

atio

n, m

embe

r elig

ibili

ty a

nd b

enef

its. T

his i

s a S

AMPL

E ID

Car

d an

d m

ay d

iffer

from

th

e m

embe

r's ID

Car

d.

Elig

ibili

ty,

Bene

fits,

Cla

im(s

) and

Aut

horiz

atio

ns(8

44) 2

75-8

750

Live

Age

nt: M

onda

y - F

riday

, 8:0

0AM

- 6:

00PM

, EST

IVR:

24

hour

s a d

ay

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0 An

nual

Max

imum

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con

trac

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or o

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upd

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(800

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day

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0PM

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Elig

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fits,

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horiz

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ww

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O B

ox 3

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5320

1

97

1 ev

ery

6 m

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sun

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limite

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dun

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Intr

aora

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ompl

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Per

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unlim

ited

unlim

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1 ev

ery

6 m

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ever

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mon

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6 m

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mon

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6 m

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mon

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ever

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mon

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Cove

red

Den

tal S

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Proc

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dePr

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Des

crip

tion

Prio

r Aut

horiz

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quire

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240

D027

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D022

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D216

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161

D233

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331

D233

2

D027

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D111

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0

No

No

No

No

No

No

No

No

No

Perio

dic

Ora

l Eva

luat

ion

- Est

ablis

hed

Patie

ntLi

mite

d O

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valu

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n - P

robl

em F

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edCo

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l Eva

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ion

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stab

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390

D239

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0

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355

D491

0D7

111

D714

0

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own

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in-B

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stra

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own

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cela

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used

To

High

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le M

etal

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9898

Prov

ider

Cla

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ispu

tes

Mem

ber A

ppea

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ques

ts

CIP_

SCIO

N 3

67_P

kg D

T455

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55-P

1000

a_FF

S28

09/2

016

Mai

l mem

ber a

ppea

ls to

: Uni

tedH

ealth

care

, Att

n: A

ppea

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nd G

rieva

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PO B

ox 6

106,

MS

CA12

4-01

57, C

ypre

ss, C

A 90

630

“Prio

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quire

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eans

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prac

titio

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ust s

ubm

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proc

edur

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r app

rova

l with

clin

ical

doc

umen

tatio

n su

ppor

ting

nece

ssity

bef

ore

perf

orm

ing

thos

e pr

oced

ures

. To

do th

is c

ompl

ete

a st

anda

rd

ADA

clai

m fo

rm a

nd c

heck

the

box

mar

ked

“Pre

-Tre

atm

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STIM

ATE.

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ior a

utho

rizat

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requ

est c

an b

e su

bmitt

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ia th

e pr

ovid

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eb p

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ww

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prov

ider

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subm

itted

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our

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add

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s, n

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per

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etc

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our o

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will

then

rece

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an E

xpla

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(EO

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outli

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the

deni

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rova

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trea

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pla

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care

Pla

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prov

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s Silv

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x m

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den

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list

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bove

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vide

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men

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mad

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a F

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sis.

Mem

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hav

e bo

th In

-Net

wor

k an

d O

ut-o

f-Net

wor

k co

vera

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ome

serv

ices

may

requ

ire p

rior a

utho

rizat

ion.

The

den

tal p

lan

has a

$10

00 a

nnua

l max

imum

that

app

lies t

o co

vere

d pr

even

tive

and

com

preh

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is n

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ay, c

oins

uran

ce o

r de

duct

ible

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ber c

an b

e bi

lled

for s

ervi

ces o

ver t

he $

1000

ann

ual m

axim

um b

enef

it. T

his p

lan

is o

ffere

d to

Car

e Im

prov

emen

t Plu

s Silv

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x m

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Geo

rgia

and

Sou

th C

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Dent

al P

rovi

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plai

nts a

re to

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tact

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care

Den

tal’s

Pro

vide

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dep

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ovid

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ontr

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prov

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dis

pute

s, a

nd re

proc

essi

ng

requ

ests

will

be

logg

ed in

to th

e ap

peal

s dat

abas

e. P

leas

e m

ail t

o th

e Ap

peal

s & G

rieva

nces

PO

Box

list

ed a

bove

. Res

earc

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d re

solu

tion

will

be

com

plet

ed w

ithin

30

cale

ndar

day

s.

Mem

ber a

ppea

ls a

re re

view

ed b

y th

e he

alth

pla

n, a

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re n

ot d

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to U

HC D

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l Mem

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ppea

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ppea

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app

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prov

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app

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HC D

enta

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be

forw

arde

d to

the

heal

th p

lan

via

over

nigh

t mai

l, w

ithin

7 d

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f rec

eipt

of t

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ppea

l.

99

100100

“Prio

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horiz

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quire

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eans

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prac

titio

ner m

ust s

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proc

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clin

ical

doc

umen

tatio

n su

ppor

ting

nece

ssity

bef

ore

perf

orm

ing

thos

e pr

oced

ures

. To

do th

is

com

plet

e a

stan

dard

ADA

cla

im fo

rm a

nd c

heck

the

box

mar

ked

“Pre

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atm

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STIM

ATE.

” Pr

ior a

utho

rizat

ion

requ

est c

an b

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bmitt

ed v

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ovid

er w

eb p

orta

l (at

ww

w.m

yuhc

prov

ider

s.co

m),

Dent

al P

rovi

ders

with

com

plai

nts a

re to

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tact

Uni

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ealth

care

Den

tal’s

Pro

vide

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vice

dep

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102102

104104

“Prio

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horiz

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quire

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the

prac

titio

ner m

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ubm

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proc

edur

es fo

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rova

l with

clin

ical

doc

umen

tatio

n su

ppor

ting

nece

ssity

bef

ore

perf

orm

ing

thos

e pr

oced

ures

. To

do th

is

com

plet

e a

stan

dard

ADA

cla

im fo

rm a

nd c

heck

the

box

mar

ked

“Pre

-Tre

atm

ent E

STIM

ATE.

” Pr

ior a

utho

rizat

ion

requ

est c

an b

e su

bmitt

ed v

ia th

e pr

ovid

er w

eb p

orta

l (at

ww

w.m

yuhc

prov

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s.co

m),

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al P

rovi

ders

with

com

plai

nts a

re to

con

tact

Uni

tedH

ealth

care

Den

tal’s

Pro

vide

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vice

dep

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ent a

t

105

106106

108108

“Prio

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horiz

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quire

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prac

titio

ner m

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proc

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clin

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doc

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tatio

n su

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ting

nece

ssity

bef

ore

perf

orm

ing

thos

e pr

oced

ures

. To

do th

is

com

plet

e a

stan

dard

ADA

cla

im fo

rm a

nd c

heck

the

box

mar

ked

“Pre

-Tre

atm

ent E

STIM

ATE.

” Pr

ior a

utho

rizat

ion

requ

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an b

e su

bmitt

ed v

ia th

e pr

ovid

er w

eb p

orta

l (at

Dent

al P

rovi

ders

with

com

plai

nts a

re to

con

tact

Uni

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care

Den

tal’s

Pro

vide

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dep

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ent a

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109

110110

112112

“Prio

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horiz

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quire

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the

prac

titio

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proc

edur

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clin

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doc

umen

tatio

n su

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ting

nece

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bef

ore

perf

orm

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thos

e pr

oced

ures

. To

do th

is

com

plet

e a

stan

dard

ADA

cla

im fo

rm a

nd c

heck

the

box

mar

ked

“Pre

-Tre

atm

ent E

STIM

ATE.

” Pr

ior a

utho

rizat

ion

requ

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an b

e su

bmitt

ed v

ia th

e pr

ovid

er w

eb p

orta

l (at

ww

w.m

yuhc

prov

ider

s.co

m),

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al P

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with

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nts a

re to

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Den

tal’s

Pro

vide

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vice

dep

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ent a

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113

114114

“Prio

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horiz

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quire

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eans

the

prac

titio

ner m

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proc

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tatio

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e pr

oced

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. To

do th

is c

ompl

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a st

anda

rd A

DA c

laim

form

and

che

ck th

e bo

x m

arke

d “P

re-T

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men

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Prio

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ques

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be

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via

the

prov

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por

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at w

ww

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com

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116116

118118

“Prio

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tatio

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is c

ompl

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anda

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DA c

laim

fo

rm a

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box

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ked

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atm

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ATE.

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rizat

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bmitt

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e pr

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eb p

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yuhc

prov

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impl

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vide

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dep

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119

120120

122122

“Prio

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quire

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prac

titio

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tatio

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. To

do th

is c

ompl

ete

a st

anda

rd

ADA

clai

m fo

rm a

nd c

heck

the

box

mar

ked

“Pre

-Tre

atm

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STIM

ATE.

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utho

rizat

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e su

bmitt

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m),

subm

itted

ele

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nica

lly v

ia y

our

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com

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nts a

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tal’s

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vide

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dep

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123

124124

126126

“Prio

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prac

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com

plet

e a

stan

dard

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cla

im fo

rm a

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box

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127

128128

“Prio

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artm

ent a

t

130130

132132

“Prio

r Aut

horiz

atio

n re

quire

d” m

eans

the

prac

titio

ner m

ust s

ubm

it th

ose

proc

edur

es fo

r app

rova

l with

clin

ical

doc

umen

tatio

n su

ppor

ting

nece

ssity

bef

ore

perf

orm

ing

thos

e pr

oced

ures

. To

do th

is c

ompl

ete

a st

anda

rd A

DA c

laim

form

and

che

ck th

e bo

x m

arke

d “P

re-T

reat

men

t EST

IMAT

E.”

Prio

r aut

horiz

atio

n re

ques

t can

be

subm

itted

via

the

prov

ider

web

por

tal (

at w

ww

.myu

hcpr

ovid

ers.

com

), su

bmitt

ed

Dent

al P

rovi

ders

with

com

plai

nts a

re to

con

tact

Uni

tedH

ealth

care

Den

tal’s

Pro

vide

r Ser

vice

dep

artm

ent a

t

133

134134

136136

“Prio

r Aut

horiz

atio

n re

quire

d” m

eans

the

prac

titio

ner m

ust s

ubm

it th

ose

proc

edur

es fo

r app

rova

l with

clin

ical

doc

umen

tatio

n su

ppor

ting

nece

ssity

bef

ore

perf

orm

ing

thos

e pr

oced

ures

. To

do th

is c

ompl

ete

a st

anda

rd A

DA c

laim

form

and

che

ck th

e bo

x m

arke

d “P

re-T

reat

men

t EST

IMAT

E.”

Prio

r aut

horiz

atio

n re

ques

t can

be

subm

itted

via

the

prov

ider

web

por

tal (

at w

ww

.myu

hcpr

ovid

ers.

com

), su

bmitt

ed

Dent

al P

rovi

ders

with

com

plai

nts a

re to

con

tact

Uni

tedH

ealth

care

Den

tal’s

Pro

vide

r Ser

vice

dep

artm

ent a

t

137

138138

Iden

tific

atio

n Ca

rds

Sam

ple

Mem

ber I

D C

ard*

Fron

t of c

ard

Back

of c

ard

Impo

rtan

t Tel

epho

ne N

umbe

rs &

Web

site

s

Impo

rtan

t Add

ress

es

Impo

rtan

t Ele

ctro

nic

Clai

ms &

Prio

r Aut

horiz

atio

n Su

bmis

sion

Info

rmat

ion

Prov

ider

Rea

son

for M

ailin

g

EDI P

ayer

Num

ber f

or C

laim

s Sub

mitt

ed

No

Annu

al M

axim

um

Call

to In

quire

Abo

utTe

leph

one

Num

ber

Hou

rs o

f Ope

ratio

n

Emai

l to

Inqu

ire A

bout

Web

site

Hou

rs o

f Ope

ratio

n

Med

icar

ew

ww

.med

icar

e.go

v24

hou

rs a

day

To d

iscu

ss y

our p

artic

ipat

ion,

con

trac

tual

issu

es, d

entis

t cha

nges

or o

ffice

upd

ates

800-

822-

5353

Live

Age

nt: M

onda

y - F

riday

, 8:0

0AM

- 11

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M, E

ST

Elig

ibili

ty,

Bene

fits,

Cla

im(s

) and

Aut

horiz

atio

nsw

ww

.uhc

prov

ider

s.co

mCe

nter

s for

Med

icai

d an

d M

edic

are

Serv

ices

ww

w.c

ms.

hhs.

gov

Cove

red

Den

tal S

ervi

ces:

Prov

ider

Qui

ck R

efer

ence

Gui

de -

Effe

ctiv

e 1/

1/20

17U

nite

dHea

lthca

re A

ARP

Com

plet

e Pl

ans (

form

ally

Oxf

ord

DH

MO

)

CT, N

J, an

d N

Y

24 h

ours

a d

ay24

hou

rs a

day

*Ple

ase

note

that

the

Med

ical

ID C

ard

is un

iver

sal a

nd in

clud

es a

ll lin

es o

f cov

erag

e. T

he M

edic

al p

lan

can

be H

MO

or P

PO a

nd th

is d

oes n

ot re

flect

the

Dent

al P

lan

Bene

fits.

Ple

ase

flip

the

ID C

ard

over

to se

e th

e De

ntal

Pr

ovid

er in

form

atio

n on

the

back

(i.e

. car

rier w

ebsi

te a

nd to

ll-fr

ee n

umbe

r). T

his i

nfor

mat

ion

can

be u

sed

to c

onfir

m p

rovi

der p

artic

ipat

ion,

mem

ber e

ligib

ility

and

ben

efits

. Thi

s is a

SAM

PLE

ID C

ard

and

may

diff

er fr

om

the

mem

ber's

ID C

ard.

Elig

ibili

ty,

Bene

fits,

Cla

im(s

) and

Aut

horiz

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ns84

4-27

5-87

50Li

ve A

gent

: Mon

day

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ay, 8

:00A

M -

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PM, E

STIV

R: 2

4 ho

urs a

day

Clai

ms

GP1

33

Prio

r Aut

horiz

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peal

s & G

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tedH

ealth

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tal,

PO B

ox 2

176,

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e, W

I 532

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nite

dHea

lthca

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enta

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Box

205

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WI 5

3201

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tedH

ealth

care

Den

tal,

Appe

als D

isput

es, P

O B

ox 3

61, M

ilwau

kee,

WI 5

3201

139

In a

n ef

fort

to c

ompl

y w

ith th

e Ce

nter

s for

Med

icar

e an

d M

edic

aid

(CM

S) st

ate

man

date

d re

quire

men

ts, p

leas

e be

adv

ised

that

DHM

O E

ncou

nter

Dat

a Su

bmis

sion

s are

now

requ

ired.

CM

S no

w re

quire

s tha

t we

repo

rt

100%

of u

tiliza

tion

data

for o

ur A

ARP

Med

icar

e Co

mpl

ete

DHM

O m

embe

rs.

To e

nsur

e th

at w

e m

eet C

MS

requ

irem

ent o

f rep

ortin

g 10

0% u

tiliza

tion,

we

are

happ

y to

re-in

trod

uce

our D

enta

l Inc

entiv

e Pr

ogra

m e

ffect

ive

imm

edia

tely

. De

ntal

Ben

efit

Prov

ider

s will

reim

burs

e ou

r pro

vide

rs $

2.00

for e

ach

enco

unte

r cla

im su

bmitt

ed fo

r AAR

P M

edic

are

Com

plet

e D

HM

O m

embe

rs o

nly

for a

ll pr

oced

ures

(cov

ered

und

er th

e m

embe

r's p

lan)

pe

rfor

med

on

thos

e m

embe

rs, f

or e

ach

date

of s

ervi

ce.

All p

roce

dure

s per

form

ed M

UST

be

repo

rted

incl

udin

g pr

oced

ures

whe

ther

or n

ot th

e m

embe

r has

a c

opay

men

t. T

his i

s a re

quire

men

t for

all

cont

ract

ed

prov

ider

s to

subm

it ut

iliza

tion

for e

ach

patie

nt tr

eate

d.

No

D023

0D0

250

D027

0

intr

aora

l - p

eria

pica

l - fi

rst f

ilm

1 ev

ery

6 M

onth

(s)

1 ev

ery

6 M

onth

(s)

No

No

No

No

No

No

No

intr

aora

l - p

eria

pica

l - e

ach

addi

tiona

l film

extr

aora

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t rad

iogr

aphi

c im

age

bite

win

g - s

ingl

e fil

m

Prio

r Aut

horiz

atio

n Re

quire

d?Pr

oced

ure

Code

Freq

uenc

y/Li

mita

tions

Proc

edur

e D

escr

iptio

n

D132

0to

bacc

o co

unse

ling

for t

he c

ontr

ol a

nd p

reve

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n of

ora

l dis

ease

No

D099

9un

spec

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dia

gnos

tic p

roce

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bite

win

g - f

our f

ilms

pano

ram

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lmN

oD0

470

diag

nost

ic c

asts

No

D112

0D1

206

D120

8

prop

hyla

xis -

chi

ldto

pica

l app

licat

ion

of fl

uorid

e va

rnis

hto

pica

l app

licat

ion

of fl

uorid

e

No

No

No

D133

0or

al h

ygie

ne in

stru

ctio

nsN

o

Her

e ar

e a

few

way

s the

Enc

ount

er In

form

atio

n ca

n be

subm

itted

:

1)

Electronically

- As

you

wou

ld a

PPO

or I

ndem

nity

Cla

im

2) W

eb S

ite -

Clai

ms c

an b

e su

bmitt

ed in

divi

dual

ly o

n ou

r web

site

at w

ww

.uhc

prov

ider

s.co

m

3)

By

Mai

l - A

s you

wou

ld a

PPO

or I

ndem

nity

Cla

im

4) U

tiliz

atio

n Re

port

s - M

ust c

onta

in A

LL re

quire

d in

form

atio

n:

•

Subs

crib

er ID

• Su

bscr

iber

Dat

e of

Birt

h •

Gro

up N

ame

or N

umbe

r•

Patie

nt’s

Ful

l Nam

e•

Patie

nt’s

Dat

e of

Birt

h•

Rela

tions

hip

to S

ubsc

riber

• Ph

ysic

al A

ddre

ss•

ADA

Code

Per

form

ed•

Toot

h# /

Qua

dran

t•

Surf

ace

• Tr

eatin

g De

ntis

t Nam

e•

Dent

ist T

ax I.

D. fo

r Bill

ing

Enco

unte

r/U

tiliza

tion

Repo

rtin

g - W

hen

subm

ittin

g En

coun

ter/

Util

izat

ion

clai

ms,

you

mus

t inc

lude

Cod

e D0

999

alon

g w

ith a

ll co

vere

d se

rvic

e pr

oced

ure

code

s you

per

form

on

each

AAR

P M

edic

are

Com

plet

e DH

MO

m

embe

r.

Plea

se n

ote

the

follo

win

g:

1) If

you

subm

it D0

999

alon

e no

add

ition

al $

2.00

reim

burs

emen

t will

not

be

paid

. Ad

ditio

nally

, cla

im su

bmiss

ion

wou

ld b

e co

nsid

ered

non

-com

plia

nt.

2)

If y

ou su

bmit

all s

ervi

ce p

roce

dure

serv

ice

code

s but

don

't in

clud

e D0

999

as w

ell a

s you

won

't be

reim

burs

ed th

e ad

ditio

nal $

2.00

. In

add

ition

, the

cla

im w

ill b

e co

nsid

ered

non

-com

plia

nt.

D022

0

D012

0D0

140

D015

0D0

210

perio

dic

oral

eva

luat

ion

limite

d or

al e

valu

atio

n - p

robl

em fo

cuse

dco

mpr

ehen

sive

ora

l eva

luat

ion

- new

or e

stab

lishe

d pa

tient

intr

aora

l - c

ompl

ete

serie

s (in

clud

ing

bite

win

gs)

D027

2D0

273

bite

win

g - t

wo

film

sN

o

D111

0pr

ophy

laxi

s - a

dult

No

D131

0nu

triti

onal

cou

nsel

ing

for c

ontr

ol o

f den

tal d

isea

seN

o

D027

4D0

330

bite

win

g - t

hree

film

s

No

No

1 ev

ery

6 M

onth

(s)

1 ev

ery

6 M

onth

(s)

1 ev

ery

6 M

onth

(s)

1 ev

ery

6 M

onth

(s)

1 ev

ery

6 M

onth

(s)

1 ev

ery

6 M

onth

(s)

1 ev

ery

6 M

onth

(s)

1 ev

ery

6 M

onth

(s)

1 ev

ery

3 Ye

ar(s

)1

ever

y Ye

ar1

ever

y Ye

ar1

ever

y Ye

ar1

ever

y Ye

ar1

ever

y Ye

ar1

ever

y Ye

ar1

ever

y Ye

ar1

ever

y 3

Year

(s)

1 ev

ery

Year

1 ev

ery

6 M

onth

(s)

140140

Prov

ider

Cla

im D

ispu

tes

Mem

ber A

ppea

ls &

Grie

vanc

es

Prio

r Aut

horiz

atio

n Re

ques

ts

CT, N

J, N

Y_SC

ION

143

_Pkg

DT0

36_D

T036

-H00

00a-

Oxf

rd

09/2

016

“Prio

r Aut

horiz

atio

n re

quire

d” m

eans

the

prac

titio

ner m

ust s

ubm

it th

ose

proc

edur

es fo

r app

rova

l with

clin

ical

doc

umen

tatio

n su

ppor

ting

nece

ssity

bef

ore

perf

orm

ing

thos

e pr

oced

ures

. To

do th

is c

ompl

ete

a st

anda

rd

ADA

clai

m fo

rm a

nd c

heck

the

box

mar

ked

“Pre

-Tre

atm

ent E

STIM

ATE.

” Pr

ior a

utho

rizat

ion

requ

est c

an b

e su

bmitt

ed v

ia th

e pr

ovid

er w

eb p

orta

l (at

ww

w.m

yuhc

prov

ider

s.co

m),

subm

itted

ele

ctro

nica

lly v

ia y

our

clea

ringh

ouse

, or s

impl

y m

ail t

he fo

rm, t

o th

e be

low

add

ress

, alo

ng w

ith a

ny re

quire

d su

pple

men

tal i

nfor

mat

ion

(film

s, n

arra

tive,

per

io-c

hart

ing,

etc

.). Y

our o

ffice

will

then

rece

ive

an E

xpla

natio

n of

Ben

efits

(EO

B)

outli

ning

the

deni

al o

r app

rova

l of r

eque

sted

trea

tmen

t and

pla

n pa

ymen

t am

ount

s whe

n ap

plic

able

.

Dent

al P

rovi

ders

with

com

plai

nts a

re to

con

tact

Uni

tedH

ealth

care

Den

tal’s

Pro

vide

r Ser

vice

dep

artm

ent a

t (84

4) 2

75-8

750.

Net

wor

k Pr

ovid

er c

ontr

actu

al d

ispu

tes,

Out

-of-N

etw

ork

prov

ider

dis

pute

s, a

nd re

proc

essi

ng

requ

ests

will

be

logg

ed in

to th

e ap

peal

s dat

abas

e. P

leas

e m

ail t

o th

e Ap

peal

s & G

rieva

nces

PO

Box

list

ed a

bove

. Res

earc

h an

d re

solu

tion

will

be

com

plet

ed w

ithin

30

cale

ndar

day

s.

Mem

ber a

ppea

ls a

re re

view

ed b

y th

e he

alth

pla

n, a

nd a

re n

ot d

eleg

ated

to U

HC D

enta

l. Al

l Mem

ber a

ppea

ls (i

nclu

des P

re-S

ervi

ce a

ppea

ls, I

n N

etw

ork

Prov

ider

app

eals

, and

Out

of N

etw

ork

prov

ider

app

eals

) rec

eive

d by

U

HC D

enta

l will

be

forw

arde

d to

the

heal

th p

lan

via

over

nigh

t mai

l, w

ithin

7 d

ays o

f rec

eipt

of t

he a

ppea

l.

Mai

l mem

ber a

ppea

ls to

: Uni

tedH

ealth

care

, Att

n: A

ppea

l Dep

artm

ent,

MS

CA12

4-01

57, P

O B

ox 6

106,

Cyp

ress

, CA

9063

0

141

142142

144144

“Prio

r Aut

horiz

atio

n re

quire

d” m

eans

the

prac

titio

ner m

ust s

ubm

it th

ose

proc

edur

es fo

r app

rova

l with

clin

ical

doc

umen

tatio

n su

ppor

ting

nece

ssity

bef

ore

perf

orm

ing

thos

e pr

oced

ures

. To

do th

is c

ompl

ete

a st

anda

rd A

DA

clai

m fo

rm a

nd c

heck

the

box

mar

ked

“Pre

-Tre

atm

ent E

STIM

ATE.

” Pr

ior a

utho

rizat

ion

requ

est c

an b

e su

bmitt

ed v

ia th

e pr

ovid

er w

eb p

orta

l (at

ww

w.m

yuhc

prov

ider

s.co

m),

subm

itted

ele

ctro

nica

lly v

ia y

our c

lear

ingh

ouse

,

Dent

al P

rovi

ders

with

com

plai

nts a

re to

con

tact

Uni

tedH

ealth

care

Den

tal’s

Pro

vide

r Ser

vice

dep

artm

ent a

t

145

146146

148148

Dent

al P

rovi

ders

with

com

plai

nts a

re to

con

tact

Uni

tedH

ealth

care

Den

tal’s

Pro

vide

r Ser

vice

dep

artm

ent a

t (84

4) 2

75-8

750.

Net

wor

k Pr

ovid

er c

ontr

actu

al d

ispu

tes,

and

repr

oces

sing

requ

ests

will

be

logg

ed in

to

149

“Prio

r Aut

horiz

atio

n re

quire

d” m

eans

the

prac

titio

ner m

ust s

ubm

it th

ose

proc

edur

es fo

r app

rova

l with

clin

ical

doc

umen

tatio

n su

ppor

ting

nece

ssity

bef

ore

perf

orm

ing

thos

e pr

oced

ures

. To

do th

is c

ompl

ete

a st

anda

rd A

DA c

laim

form

and

che

ck th

e bo

x m

arke

d “P

re-T

reat

men

t EST

IMAT

E.”

Prio

r aut

horiz

atio

n re

ques

t can

be

subm

itted

via

the

prov

ider

web

por

tal (

at w

ww

.myu

hcpr

ovid

ers.

com

), su

bmitt

ed e

lect

roni

cally

150150

Iden

tific

atio

n Ca

rds

Sam

ple

Mem

ber I

D C

ard*

Fron

t of c

ard

Back

of c

ard

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rtan

t Tel

epho

ne N

umbe

rs &

Web

site

s

Impo

rtan

t Add

ress

es

Impo

rtan

t Ele

ctro

nic

Clai

ms &

Prio

r Aut

horiz

atio

n Su

bmis

sion

Info

rmat

ion

Prov

ider

Rea

son

for M

ailin

g

EDI P

ayer

Num

ber f

or C

laim

s Sub

mitt

ed

No

Annu

al M

axim

um

Call

to In

quire

Abo

utTe

leph

one

Num

ber

Hou

rs o

f Ope

ratio

n

Emai

l to

Inqu

ire A

bout

Web

site

Hou

rs o

f Ope

ratio

n

Med

icar

ew

ww

.med

icar

e.go

v24

hou

rs a

day

To d

iscu

ss y

our p

artic

ipat

ion,

con

trac

tual

issu

es, d

entis

t cha

nges

or o

ffice

upd

ates

800-

822-

5353

Live

Age

nt: M

onda

y - F

riday

, 8:0

0AM

- 11

:00P

M, E

ST

Elig

ibili

ty,

Bene

fits,

Cla

im(s

) and

Aut

horiz

atio

nsw

ww

.uhc

prov

ider

s.co

mCe

nter

s for

Med

icai

d an

d M

edic

are

Serv

ices

ww

w.c

ms.

hhs.

gov

Cove

red

Den

tal S

ervi

ces:

Prov

ider

Qui

ck R

efer

ence

Gui

de -

Effe

ctiv

e 1/

1/20

17U

nite

dHea

lthca

re A

ARP

Com

plet

e Pl

ans (

form

ally

Oxf

ord

DH

MO

)

CT, N

J, an

d N

Y

24 h

ours

a d

ay24

hou

rs a

day

*Ple

ase

note

that

the

Med

ical

ID C

ard

is un

iver

sal a

nd in

clud

es a

ll lin

es o

f cov

erag

e. T

he M

edic

al p

lan

can

be H

MO

or P

PO a

nd th

is d

oes n

ot re

flect

the

Dent

al P

lan

Bene

fits.

Ple

ase

flip

the

ID C

ard

over

to se

e th

e De

ntal

Pr

ovid

er in

form

atio

n on

the

back

(i.e

. car

rier w

ebsi

te a

nd to

ll-fr

ee n

umbe

r). T

his i

nfor

mat

ion

can

be u

sed

to c

onfir

m p

rovi

der p

artic

ipat

ion,

mem

ber e

ligib

ility

and

ben

efits

. Thi

s is a

SAM

PLE

ID C

ard

and

may

diff

er fr

om

the

mem

ber's

ID C

ard.

Elig

ibili

ty,

Bene

fits,

Cla

im(s

) and

Aut

horiz

atio

ns84

4-27

5-87

50Li

ve A

gent

: Mon

day

- Frid

ay, 8

:00A

M -

6:00

PM, E

STIV

R: 2

4 ho

urs a

day

Clai

ms

GP1

33

Prio

r Aut

horiz

atio

nAp

peal

s & G

rieva

nces

Uni

tedH

ealth

care

Den

tal,

PO B

ox 2

176,

Milw

auke

e, W

I 532

01U

nite

dHea

lthca

re D

enta

l, PO

Box

205

3, M

ilwau

kee,

WI 5

3201

Uni

tedH

ealth

care

Den

tal,

Appe

als D

isput

es, P

O B

ox 3

61, M

ilwau

kee,

WI 5

3201

151

In a

n ef

fort

to c

ompl

y w

ith th

e Ce

nter

s for

Med

icar

e an

d M

edic

aid

(CM

S) st

ate

man

date

d re

quire

men

ts, p

leas

e be

adv

ised

that

DHM

O E

ncou

nter

Dat

a Su

bmis

sion

s are

now

requ

ired.

CM

S no

w re

quire

s tha

t we

repo

rt

100%

of u

tiliza

tion

data

for o

ur A

ARP

Med

icar

e Co

mpl

ete

DHM

O m

embe

rs.

To e

nsur

e th

at w

e m

eet C

MS

requ

irem

ent o

f rep

ortin

g 10

0% u

tiliza

tion,

we

are

happ

y to

re-in

trod

uce

our D

enta

l Inc

entiv

e Pr

ogra

m e

ffect

ive

imm

edia

tely

. De

ntal

Ben

efit

Prov

ider

s will

reim

burs

e ou

r pro

vide

rs $

2.00

for e

ach

enco

unte

r cla

im su

bmitt

ed fo

r AAR

P M

edic

are

Com

plet

e D

HM

O m

embe

rs o

nly

for a

ll pr

oced

ures

(cov

ered

und

er th

e m

embe

r's p

lan)

pe

rfor

med

on

thos

e m

embe

rs, f

or e

ach

date

of s

ervi

ce.

All p

roce

dure

s per

form

ed M

UST

be

repo

rted

incl

udin

g pr

oced

ures

whe

ther

or n

ot th

e m

embe

r has

a c

opay

men

t. T

his i

s a re

quire

men

t for

all

cont

ract

ed

prov

ider

s to

subm

it ut

iliza

tion

for e

ach

patie

nt tr

eate

d.

No

D023

0D0

250

D027

0

intr

aora

l - p

eria

pica

l - fi

rst f

ilm

1 ev

ery

6 M

onth

(s)

1 ev

ery

6 M

onth

(s)

No

No

No

No

No

No

No

intr

aora

l - p

eria

pica

l - e

ach

addi

tiona

l film

extr

aora

l firs

t rad

iogr

aphi

c im

age

bite

win

g - s

ingl

e fil

m

Prio

r Aut

horiz

atio

n Re

quire

d?Pr

oced

ure

Code

Freq

uenc

y/Li

mita

tions

Proc

edur

e D

escr

iptio

n

D132

0to

bacc

o co

unse

ling

for t

he c

ontr

ol a

nd p

reve

ntio

n of

ora

l dis

ease

No

D099

9un

spec

ified

dia

gnos

tic p

roce

dure

No

bite

win

g - f

our f

ilms

pano

ram

ic fi

lmN

oD0

470

diag

nost

ic c

asts

No

D112

0D1

206

D120

8

prop

hyla

xis -

chi

ldto

pica

l app

licat

ion

of fl

uorid

e va

rnis

hto

pica

l app

licat

ion

of fl

uorid

e

No

No

No

D133

0or

al h

ygie

ne in

stru

ctio

nsN

o

Her

e ar

e a

few

way

s the

Enc

ount

er In

form

atio

n ca

n be

subm

itted

:

1)

Electronically

- As

you

wou

ld a

PPO

or I

ndem

nity

Cla

im

2) W

eb S

ite -

Clai

ms c

an b

e su

bmitt

ed in

divi

dual

ly o

n ou

r web

site

at w

ww

.uhc

prov

ider

s.co

m

3)

By

Mai

l - A

s you

wou

ld a

PPO

or I

ndem

nity

Cla

im

4) U

tiliz

atio

n Re

port

s - M

ust c

onta

in A

LL re

quire

d in

form

atio

n:

•

Subs

crib

er ID

• Su

bscr

iber

Dat

e of

Birt

h •

Gro

up N

ame

or N

umbe

r•

Patie

nt’s

Ful

l Nam

e•

Patie

nt’s

Dat

e of

Birt

h•

Rela

tions

hip

to S

ubsc

riber

• Ph

ysic

al A

ddre

ss•

ADA

Code

Per

form

ed•

Toot

h# /

Qua

dran

t•

Surf

ace

• Tr

eatin

g De

ntis

t Nam

e•

Dent

ist T

ax I.

D. fo

r Bill

ing

Enco

unte

r/U

tiliza

tion

Repo

rtin

g - W

hen

subm

ittin

g En

coun

ter/

Util

izat

ion

clai

ms,

you

mus

t inc

lude

Cod

e D0

999

alon

g w

ith a

ll co

vere

d se

rvic

e pr

oced

ure

code

s you

per

form

on

each

AAR

P M

edic

are

Com

plet

e DH

MO

m

embe

r.

Plea

se n

ote

the

follo

win

g:

1) If

you

subm

it D0

999

alon

e no

add

ition

al $

2.00

reim

burs

emen

t will

not

be

paid

. Ad

ditio

nally

, cla

im su

bmiss

ion

wou

ld b

e co

nsid

ered

non

-com

plia

nt.

2)

If y

ou su

bmit

all s

ervi

ce p

roce

dure

serv

ice

code

s but

don

't in

clud

e D0

999

as w

ell a

s you

won

't be

reim

burs

ed th

e ad

ditio

nal $

2.00

. In

add

ition

, the

cla

im w

ill b

e co

nsid

ered

non

-com

plia

nt.

D022

0

D012

0D0

140

D015

0D0

210

perio

dic

oral

eva

luat

ion

limite

d or

al e

valu

atio

n - p

robl

em fo

cuse

dco

mpr

ehen

sive

ora

l eva

luat

ion

- new

or e

stab

lishe

d pa

tient

intr

aora

l - c

ompl

ete

serie

s (in

clud

ing

bite

win

gs)

D027

2D0

273

bite

win

g - t

wo

film

sN

o

D111

0pr

ophy

laxi

s - a

dult

No

D131

0nu

triti

onal

cou

nsel

ing

for c

ontr

ol o

f den

tal d

isea

seN

o

D027

4D0

330

bite

win

g - t

hree

film

s

No

No

1 ev

ery

6 M

onth

(s)

1 ev

ery

6 M

onth

(s)

1 ev

ery

6 M

onth

(s)

1 ev

ery

6 M

onth

(s)

1 ev

ery

6 M

onth

(s)

1 ev

ery

6 M

onth

(s)

1 ev

ery

6 M

onth

(s)

1 ev

ery

6 M

onth

(s)

1 ev

ery

3 Ye

ar(s

)1

ever

y Ye

ar1

ever

y Ye

ar1

ever

y Ye

ar1

ever

y Ye

ar1

ever

y Ye

ar1

ever

y Ye

ar1

ever

y Ye

ar1

ever

y 3

Year

(s)

1 ev

ery

Year

1 ev

ery

6 M

onth

(s)

152152

Prov

ider

Cla

im D

ispu

tes

Mem

ber A

ppea

ls &

Grie

vanc

es

Prio

r Aut

horiz

atio

n Re

ques

ts

CT, N

J, N

Y_SC

ION

143

_Pkg

DT0

36_D

T036

-H00

00a-

Oxf

rd

09/2

016

“Prio

r Aut

horiz

atio

n re

quire

d” m

eans

the

prac

titio

ner m

ust s

ubm

it th

ose

proc

edur

es fo

r app

rova

l with

clin

ical

doc

umen

tatio

n su

ppor

ting

nece

ssity

bef

ore

perf

orm

ing

thos

e pr

oced

ures

. To

do th

is c

ompl

ete

a st

anda

rd

ADA

clai

m fo

rm a

nd c

heck

the

box

mar

ked

“Pre

-Tre

atm

ent E

STIM

ATE.

” Pr

ior a

utho

rizat

ion

requ

est c

an b

e su

bmitt

ed v

ia th

e pr

ovid

er w

eb p

orta

l (at

ww

w.m

yuhc

prov

ider

s.co

m),

subm

itted

ele

ctro

nica

lly v

ia y

our

clea

ringh

ouse

, or s

impl

y m

ail t

he fo

rm, t

o th

e be

low

add

ress

, alo

ng w

ith a

ny re

quire

d su

pple

men

tal i

nfor

mat

ion

(film

s, n

arra

tive,

per

io-c

hart

ing,

etc

.). Y

our o

ffice

will

then

rece

ive

an E

xpla

natio

n of

Ben

efits

(EO

B)

outli

ning

the

deni

al o

r app

rova

l of r

eque

sted

trea

tmen

t and

pla

n pa

ymen

t am

ount

s whe

n ap

plic

able

.

Dent

al P

rovi

ders

with

com

plai

nts a

re to

con

tact

Uni

tedH

ealth

care

Den

tal’s

Pro

vide

r Ser

vice

dep

artm

ent a

t (84

4) 2

75-8

750.

Net

wor

k Pr

ovid

er c

ontr

actu

al d

ispu

tes,

Out

-of-N

etw

ork

prov

ider

dis

pute

s, a

nd re

proc

essi

ng

requ

ests

will

be

logg

ed in

to th

e ap

peal

s dat

abas

e. P

leas

e m

ail t

o th

e Ap

peal

s & G

rieva

nces

PO

Box

list

ed a

bove

. Res

earc

h an

d re

solu

tion

will

be

com

plet

ed w

ithin

30

cale

ndar

day

s.

Mem

ber a

ppea

ls a

re re

view

ed b

y th

e he

alth

pla

n, a

nd a

re n

ot d

eleg

ated

to U

HC D

enta

l. Al

l Mem

ber a

ppea

ls (i

nclu

des P

re-S

ervi

ce a

ppea

ls, I

n N

etw

ork

Prov

ider

app

eals

, and

Out

of N

etw

ork

prov

ider

app

eals

) rec

eive

d by

U

HC D

enta

l will

be

forw

arde

d to

the

heal

th p

lan

via

over

nigh

t mai

l, w

ithin

7 d

ays o

f rec

eipt

of t

he a

ppea

l.

Mai

l mem

ber a

ppea

ls to

: Uni

tedH

ealth

care

, Att

n: A

ppea

l Dep

artm

ent,

MS

CA12

4-01

57, P

O B

ox 6

106,

Cyp

ress

, CA

9063

0

153

154154

Dent

al P

rovi

ders

with

com

plai

nts a

re to

con

tact

Uni

tedH

ealth

care

Den

tal’s

Pro

vide

r Ser

vice

dep

artm

ent a

t

156156

“Prio

r Aut

horiz

atio

n re

quire

d” m

eans

the

prac

titio

ner m

ust s

ubm

it th

ose

proc

edur

es fo

r app

rova

l with

clin

ical

doc

umen

tatio

n su

ppor

ting

nece

ssity

bef

ore

perf

orm

ing

thos

e pr

oced

ures

. To

do th

is

com

plet

e a

stan

dard

ADA

cla

im fo

rm a

nd c

heck

the

box

mar

ked

“Pre

-Tre

atm

ent E

STIM

ATE.

” Pr

ior a

utho

rizat

ion

requ

est c

an b

e su

bmitt

ed v

ia th

e pr

ovid

er w

eb p

orta

l (at

ww

w.m

yuhc

prov

ider

s.co

m),

157

158158

“Prio

r Aut

horiz

atio

n re

quire

d” m

eans

the

prac

titio

ner m

ust s

ubm

it th

ose

proc

edur

es fo

r app

rova

l with

clin

ical

doc

umen

tatio

n su

ppor

ting

nece

ssity

bef

ore

perf

orm

ing

thos

e pr

oced

ures

. To

do th

is c

ompl

ete

a st

anda

rd A

DA c

laim

form

and

che

ck th

e bo

x m

arke

d “P

re-T

reat

men

t EST

IMAT

E.”

Prio

r aut

horiz

atio

n re

ques

t can

be

subm

itted

via

the

prov

ider

web

por

tal (

at w

ww

.myu

hcpr

ovid

ers.

com

), su

bmitt

ed

Dent

al P

rovi

ders

with

com

plai

nts a

re to

con

tact

Uni

tedH

ealth

care

Den

tal’s

Pro

vide

r Ser

vice

dep

artm

ent a

t

160160

“Prio

r Aut

horiz

atio

n re

quire

d” m

eans

the

prac

titio

ner m

ust s

ubm

it th

ose

proc

edur

es fo

r app

rova

l with

clin

ical

doc

umen

tatio

n su

ppor

ting

nece

ssity

bef

ore

perf

orm

ing

thos

e pr

oced

ures

. To

do th

is c

ompl

ete

a st

anda

rd A

DA c

laim

form

and

che

ck th

e bo

x m

arke

d “P

re-T

reat

men

t EST

IMAT

E.”

Prio

r aut

horiz

atio

n re

ques

t can

be

subm

itted

via

the

prov

ider

web

por

tal (

at w

ww

.myu

hcpr

ovid

ers.

com

), su

bmitt

ed

Dent

al P

rovi

ders

with

com

plai

nts a

re to

con

tact

Uni

tedH

ealth

care

Den

tal’s

Pro

vide

r Ser

vice

dep

artm

ent a

t

162162

164164

Dent

al P

rovi

ders

with

com

plai

nts a

re to

con

tact

Uni

tedH

ealth

care

Den

tal’s

Pro

vide

r Ser

vice

dep

artm

ent a

t

166166

“Prio

r Aut

horiz

atio

n re

quire

d” m

eans

the

prac

titio

ner m

ust s

ubm

it th

ose

proc

edur

es fo

r app

rova

l with

clin

ical

doc

umen

tatio

n su

ppor

ting

nece

ssity

bef

ore

perf

orm

ing

thos

e pr

oced

ures

. To

do th

is c

ompl

ete

a st

anda

rd

ADA

clai

m fo

rm a

nd c

heck

the

box

mar

ked

“Pre

-Tre

atm

ent E

STIM

ATE.

” Pr

ior a

utho

rizat

ion

requ

est c

an b

e su

bmitt

ed v

ia th

e pr

ovid

er w

eb p

orta

l (at

ww

w.m

yuhc

prov

ider

s.co

m),

subm

itted

ele

ctro

nica

lly v

ia y

our

167

168168

Iden

tific

atio

n Ca

rds

Sam

ple

Mem

ber I

D C

ard*

Fron

t of c

ard

Back

of c

ard

Impo

rtan

t Tel

epho

ne N

umbe

rs &

Web

site

s

Impo

rtan

t Add

ress

es

Impo

rtan

t Ele

ctro

nic

Clai

ms &

Prio

r Aut

horiz

atio

n Su

bmis

sion

Info

rmat

ion

Live

Age

nt: M

onda

y - F

riday

, 8:0

0AM

- 6:

00PM

, EST

IVR:

24

hour

s a d

ay

24 h

ours

a d

ay

To d

iscu

ss y

our p

artic

ipat

ion,

con

trac

tual

issu

es, d

entis

t cha

nges

or o

ffice

up

date

s80

0-82

2-53

53Li

ve A

gent

: Mon

day

- Frid

ay, 8

:00A

M -

11:0

0PM

, EST

Elig

ibili

ty,

Bene

fits,

Cla

im(s

) and

Aut

horiz

atio

nsw

ww

.uhc

prov

ider

s.co

m

Clai

ms

Prio

r Aut

horiz

atio

nAp

peal

s & G

rieva

nces

UHC

Med

icar

e Cl

aim

s, P

O B

ox 2

176,

Milw

auke

e, W

I 532

01U

HC M

edic

are

Auth

oriza

tions

, PO

Box

205

3, M

ilwau

kee,

WI 5

3201

UHC

Med

icar

e Co

mpl

aint

s, G

rieva

nces

& A

ppea

ls, P

O B

ox 3

61, M

ilwau

kee,

WI 5

3201

Prov

ider

Qui

ck R

efer

ence

Gui

de -

Effe

ctiv

e 1/

1/20

17U

nite

dHea

lthca

re C

omm

unity

Pla

nO

hio

Dua

l Com

plet

e - $

2,00

0 m

ax

EDI P

ayer

Num

ber f

or C

laim

s Sub

mitt

ed

Prov

ider

Rea

son

for M

ailin

g

Call

to In

quire

Abo

utTe

leph

one

Num

ber

Hou

rs o

f Ope

ratio

n

Emai

l to

Inqu

ire A

bout

Web

site

Hou

rs o

f Ope

ratio

n

Med

icar

ew

ww

.med

icar

e.go

v24

hou

rs a

day

Cent

ers f

or M

edic

aid

and

Med

icar

e Se

rvic

esw

ww

.cm

s.hh

s.go

v24

hou

rs a

day

*Ple

ase

note

that

the

Med

ical

ID C

ard

is un

iver

sal a

nd in

clud

es a

ll lin

es o

f cov

erag

e. T

he M

edic

al p

lan

can

be H

MO

or P

PO a

nd th

is d

oes n

ot re

flect

the

Dent

al P

lan

Bene

fits.

Ple

ase

flip

the

ID C

ard

over

to

see

the

Dent

al P

rovi

der i

nfor

mat

ion

on th

e ba

ck (i

.e. c

arrie

r web

site

and

toll-

free

num

ber)

. Thi

s inf

orm

atio

n ca

n be

use

d to

con

firm

pro

vide

r par

ticip

atio

n, m

embe

r elig

ibili

ty a

nd b

enef

its. T

his i

s a

SAM

PLE

ID C

ard

and

may

diff

er fr

om th

e m

embe

r's ID

Car

d.

Elig

ibili

ty,

Bene

fits,

Cla

im(s

) and

Aut

horiz

atio

ns84

4-27

5-87

50

169

No

No

No

No

No

No

intr

aora

l - p

eria

pica

l - e

ach

addi

tiona

l film

intr

aora

l - o

cclu

sal f

ilmbi

tew

ing

- sin

gle

film

1 ev

ery

3 Ye

ar(s

)

D022

0

pano

ram

ic fi

lm

D216

0am

alga

m -

thre

e su

rfac

es, p

rimar

y or

per

man

ent

No

D233

5

Unl

imite

d

No

No

No

Cove

red

Den

tal S

ervi

ces:

Prio

r Aut

horiz

atio

n Re

quire

d?Pr

oced

ure

Code

D023

0D0

240

D027

0

intr

aora

l - p

eria

pica

l - fi

rst f

ilm

No

No

D214

0am

alga

m -

one

surf

ace,

prim

ary

or p

erm

anen

tN

o

D027

4D0

330

bite

win

g - t

hree

film

sbi

tew

ing

- fou

r film

s

prop

hyla

xis -

adu

ltN

o

D216

1am

alga

m -

four

or m

ore

surf

aces

, prim

ary

or p

erm

anen

tN

o

Freq

uenc

y/Li

mita

tions

Proc

edur

e D

escr

iptio

npe

riodi

c or

al e

valu

atio

nlim

ited

oral

eva

luat

ion

- pro

blem

focu

sed

com

preh

ensi

ve o

ral e

valu

atio

n - n

ew o

r est

ablis

hed

patie

ntin

trao

ral -

com

plet

e se

ries (

incl

udin

g bi

tew

ings

)

D233

2re

sin-

base

d co

mpo

site

- th

ree

surf

aces

, ant

erio

rN

o

D012

0D0

140

D015

0D0

210

D027

2D0

273

bite

win

g - t

wo

film

sN

o

D111

0

D233

0re

sin-

base

d co

mpo

site

- on

e su

rfac

e, a

nter

ior

No

D215

0am

alga

m -

two

surf

aces

, prim

ary

or p

erm

anen

tN

o

D233

1re

sin-

base

d co

mpo

site

- tw

o su

rfac

es, a

nter

ior

No

D239

2re

sin-

base

d co

mpo

site

- tw

o su

rfac

es, p

oste

rior

No

resin

-bas

ed c

ompo

site

- fo

ur o

r mor

e su

rfac

es o

r inv

olvi

ng in

cisa

l ang

le (a

nter

ior)

No

D239

0re

sin-

base

d co

mpo

site

cro

wn,

ant

erio

rN

o

D271

0cr

own

- res

in-b

ased

com

posi

te (i

ndire

ct)

Yes

D239

1re

sin-

base

d co

mpo

site

- on

e su

rfac

e, p

oste

rior

No

D274

0cr

own

- por

cela

in/c

eram

ic su

bstr

ate

Yes

D239

3re

sin-

base

d co

mpo

site

- th

ree

surf

aces

, pos

terio

rN

oD2

394

resi

n-ba

sed

com

posi

te -

four

or m

ore

surf

aces

, pos

terio

rN

o

D275

2cr

own

- por

cela

in fu

sed

to n

oble

met

alYe

sD2

791

crow

n - f

ull c

ast p

redo

min

antly

bas

e m

etal

Yes

D275

0cr

own

- por

cela

in fu

sed

to h

igh

nobl

e m

etal

Yes

D275

1cr

own

- por

cela

in fu

sed

to p

redo

min

antly

bas

e m

etal

Yes

D294

0pr

otec

tive

rest

orat

ion

No

D295

0co

re b

uild

up, i

nclu

ding

any

pin

sYe

s

D279

2cr

own

- ful

l cas

t nob

le m

etal

Yes

D292

0re

cem

ent c

row

nN

o

1 ev

ery

6 M

onth

(s)

Unl

imite

d

D721

0su

rgic

al re

mov

al o

f eru

pted

toot

h re

q re

mov

al o

f bon

e, se

ctio

ning

of t

ooth

and

incl

udin

g el

evat

ion

of m

ucop

erio

stea

l fla

pN

oD7

250

D731

0

D731

1D9

110

D711

1ex

trac

tion,

cor

onal

rem

nant

s - d

ecid

uous

toot

hN

oD7

140

extr

actio

n, e

rupt

ed to

oth

or e

xpos

ed ro

ot (e

leva

tion

and/

or fo

rcep

sN

o

D435

5fu

ll m

outh

deb

ridem

ent t

o en

able

com

preh

ensi

ve e

valu

atio

n an

d di

agno

sis

Yes

D491

0pe

riodo

ntal

mai

nten

ance

No

D434

2pe

riodo

ntal

scal

ing

and

root

pla

nnin

g - o

ne to

thre

e te

eth

per q

uadr

ant

Yes

Unl

imite

dU

nlim

ited

Unl

imite

d

Unl

imite

d

Unl

imite

d

1 ev

ery

6 M

onth

(s)

1 ev

ery

6 M

onth

(s)

1 ev

ery

6 M

onth

(s)

1 ev

ery

6 M

onth

(s)

1 ev

ery

6 M

onth

(s)

1 ev

ery

6 M

onth

(s)

1 ev

ery

6 M

onth

(s)

1 ev

ery

6 M

onth

(s)

1 ev

ery

6 M

onth

(s)

1 ev

ery

6 M

onth

(s)

1 ev

ery

6 M

onth

(s)

Unl

imite

d

Unl

imite

dU

nlim

ited

Unl

imite

dU

nlim

ited

1 ev

ery

36 M

onth

(s)

1 ev

ery

36 M

onth

(s)

Unl

imite

d

pref

abric

ated

pos

t and

cor

e in

add

ition

to c

row

nYe

s

No

No

No

No

surg

ical

rem

oval

of r

esid

ual t

ooth

root

s (cu

ttin

g pr

oced

ure)

alve

olop

last

y in

con

junc

tion

with

ext

ract

ions

- fo

ur o

r mor

e te

eth

or to

oth

spac

es, p

er

quad

rant

alve

olop

last

y in

con

junc

tion

with

ext

ract

ions

- on

e to

thre

e te

eth

or to

oth

spac

es, p

er

quad

rant

palli

ativ

e (e

mer

genc

y) tr

eatm

ent o

f den

tal p

ain

- min

or p

roce

dure

Unl

imite

d

Unl

imite

d

Unl

imite

d

D293

0D2

931

pref

abric

ated

stai

nles

s ste

el c

row

n - p

rimar

y to

oth

pref

abric

ated

stai

nles

s ste

el c

row

n - p

erm

anen

t too

thU

nlim

ited

Unl

imite

dN

oN

o

Yes

1 ev

ery

24 M

onth

(s)

perio

dont

al sc

alin

g an

d ro

ot p

lann

ing

- fou

r or m

ore

per q

uadr

ant

D434

1D2

954

GP1

33

Unl

imite

d

Unl

imite

dU

nlim

ited

Unl

imite

dU

nlim

ited

Unl

imite

d

1 ev

ery

24 M

onth

(s)

1 ev

ery

24 M

onth

(s)

1 ev

ery

36 M

onth

(s)

1 ev

ery

36 M

onth

(s)

1 ev

ery

36 M

onth

(s)

1 ev

ery

36 M

onth

(s)

1 ev

ery

36 M

onth

(s)

Unl

imite

dU

nlim

ited

Unl

imite

d

170170

Cove

red

in th

e fo

llow

ing

Ohi

o Co

untie

s: B

utle

r, Cl

ark,

Cuy

ahog

a, F

rank

lin, G

reen

e, H

amilt

on, M

adis

on, M

ahon

ing,

Mon

tgom

ery,

Sta

rk, S

umm

itt, T

rum

bull

and

War

ren

Prov

ider

Cla

im D

ispu

tes

Mem

ber A

ppea

ls &

Grie

vanc

es

Prio

r Aut

horiz

atio

n Re

ques

ts

OH_

SCIO

N 3

69_P

kg D

T057

_DT0

15-H

2000

b-FF

S28

09/2

016

“Prio

r Aut

horiz

atio

n re

quire

d” m

eans

the

prac

titio

ner m

ust s

ubm

it th

ose

proc

edur

es fo

r app

rova

l with

clin

ical

doc

umen

tatio

n su

ppor

ting

nece

ssity

bef

ore

perf

orm

ing

thos

e pr

oced

ures

. To

do th

is

com

plet

e a

stan

dard

ADA

cla

im fo

rm a

nd c

heck

the

box

mar

ked

“Pre

-Tre

atm

ent E

STIM

ATE.

” Pr

ior a

utho

rizat

ion

requ

est c

an b

e su

bmitt

ed v

ia th

e pr

ovid

er w

eb p

orta

l (at

ww

w.m

yuhc

prov

ider

s.co

m),

subm

itted

ele

ctro

nica

lly v

ia y

our c

lear

ingh

ouse

, or s

impl

y m

ail t

he fo

rm, t

o th

e be

low

add

ress

, alo

ng w

ith a

ny re

quire

d su

pple

men

tal i

nfor

mat

ion

(film

s, n

arra

tive,

per

io-c

hart

ing,

etc

.). Y

our o

ffice

will

th

en re

ceiv

e an

Exp

lana

tion

of B

enef

its (E

OB)

out

linin

g th

e de

nial

or a

ppro

val o

f req

uest

ed tr

eatm

ent a

nd p

lan

paym

ent a

mou

nts w

hen

appl

icab

le.

The

Uni

tedH

ealth

care

(UHC

) Com

mun

ity P

lan

for D

ual C

ompl

ete

mem

bers

cov

ers t

he d

enta

l cod

es li

sted

abo

ve. P

rovi

der p

aym

ent i

s mad

e on

a F

ee-fo

r-Se

rvic

e ba

sis.

Som

e se

rvic

es re

quire

prio

r au

thor

izatio

n. T

he d

enta

l pla

n ha

s a $

2,00

0 an

nual

max

that

app

lies t

o co

vere

d pr

even

tive

and

com

preh

ensi

ve b

enef

its. T

his p

lan

is o

ffere

d to

Uni

tedH

ealth

care

Dua

l Com

plet

e m

embe

rs in

Ohi

o.

Ther

e is

no

mem

ber c

opay

, coi

nsur

ance

or d

educ

tible

. Mem

ber c

an b

e bi

lled

for s

ervi

ces o

ver t

he $

2,00

0 an

nual

max

imum

ben

efit.

Dent

al P

rovi

ders

with

com

plai

nts a

re to

con

tact

Uni

tedH

ealth

care

Den

tal’s

Pro

vide

r Ser

vice

dep

artm

ent a

t (84

4) 2

75-8

750.

Net

wor

k Pr

ovid

er c

ontr

actu

al d

ispu

tes,

Out

-of-N

etw

ork

prov

ider

dis

pute

s,

and

repr

oces

sing

requ

ests

will

be

logg

ed in

to th

e ap

peal

s dat

abas

e. P

leas

e m

ail t

o th

e Ap

peal

s & G

rieva

nces

PO

Box

list

ed a

bove

. Res

earc

h an

d re

solu

tion

will

be

com

plet

ed w

ithin

30

cale

ndar

day

s.

Mem

ber a

ppea

ls a

re re

view

ed b

y th

e he

alth

pla

n, a

nd a

re n

ot d

eleg

ated

to U

HC D

enta

l. Al

l Mem

ber a

ppea

ls (i

nclu

des P

re-S

ervi

ce a

ppea

ls, I

n N

etw

ork

Prov

ider

app

eals

, and

Out

of N

etw

ork

prov

ider

ap

peal

s) re

ceiv

ed b

y U

HC D

enta

l will

be

forw

arde

d to

the

heal

th p

lan

via

over

nigh

t mai

l, w

ithin

7 d

ays o

f rec

eipt

of t

he a

ppea

l.

Mai

l mem

ber a

ppea

ls to

: Uni

tedH

ealth

care

, Att

n: A

ppea

l Dep

artm

ent,

MS

CA12

4-01

57, P

O B

ox 6

106,

Cyp

ress

, CA

9063

0

171

172172

“Prio

r Aut

horiz

atio

n re

quire

d” m

eans

the

prac

titio

ner m

ust s

ubm

it th

ose

proc

edur

es fo

r app

rova

l with

clin

ical

doc

umen

tatio

n su

ppor

ting

nece

ssity

bef

ore

perf

orm

ing

thos

e pr

oced

ures

. To

do th

is c

ompl

ete

a st

anda

rd A

DA c

laim

form

and

che

ck th

e bo

x m

arke

d “P

re-T

reat

men

t EST

IMAT

E.”

Prio

r aut

horiz

atio

n re

ques

t can

be

subm

itted

via

the

prov

ider

web

por

tal (

at w

ww

.myu

hcpr

ovid

ers.

com

), su

bmitt

ed

Dent

al P

rovi

ders

with

com

plai

nts a

re to

con

tact

Uni

tedH

ealth

care

Den

tal’s

Pro

vide

r Ser

vice

dep

artm

ent a

t

174174

“Prio

r Aut

horiz

atio

n re

quire

d” m

eans

the

prac

titio

ner m

ust s

ubm

it th

ose

proc

edur

es fo

r app

rova

l with

clin

ical

doc

umen

tatio

n su

ppor

ting

nece

ssity

bef

ore

perf

orm

ing

thos

e pr

oced

ures

. To

do th

is c

ompl

ete

a st

anda

rd

ADA

clai

m fo

rm a

nd c

heck

the

box

mar

ked

“Pre

-Tre

atm

ent E

STIM

ATE.

” Pr

ior a

utho

rizat

ion

requ

est c

an b

e su

bmitt

ed v

ia th

e pr

ovid

er w

eb p

orta

l (at

ww

w.m

yuhc

prov

ider

s.co

m),

subm

itted

ele

ctro

nica

lly v

ia y

our

Dent

al P

rovi

ders

with

com

plai

nts a

re to

con

tact

Uni

tedH

ealth

care

Den

tal’s

Pro

vide

r Ser

vice

dep

artm

ent a

t

176176

178178

Dent

al P

rovi

ders

with

com

plai

nts a

re to

con

tact

Uni

tedH

ealth

care

Den

tal’s

Pro

vide

r Ser

vice

dep

artm

ent a

t

“Prio

r Aut

horiz

atio

n re

quire

d” m

eans

the

prac

titio

ner m

ust s

ubm

it th

ose

proc

edur

es fo

r app

rova

l with

clin

ical

doc

umen

tatio

n su

ppor

ting

nece

ssity

bef

ore

perf

orm

ing

thos

e pr

oced

ures

. To

do th

is c

ompl

ete

a st

anda

rd A

DA c

laim

form

and

che

ck th

e bo

x m

arke

d “P

re-T

reat

men

t EST

IMAT

E.”

Prio

r aut

horiz

atio

n re

ques

t can

be

subm

itted

via

the

prov

ider

web

por

tal (

at w

ww

.myu

hcpr

ovid

ers.

com

), su

bmitt

ed e

lect

roni

cally

179

180180

182182

“Prio

r Aut

horiz

atio

n re

quire

d” m

eans

the

prac

titio

ner m

ust s

ubm

it th

ose

proc

edur

es fo

r app

rova

l with

clin

ical

doc

umen

tatio

n su

ppor

ting

nece

ssity

bef

ore

perf

orm

ing

thos

e pr

oced

ures

. To

do th

is c

ompl

ete

a st

anda

rd

ADA

clai

m fo

rm a

nd c

heck

the

box

mar

ked

“Pre

-Tre

atm

ent E

STIM

ATE.

” Pr

ior a

utho

rizat

ion

requ

est c

an b

e su

bmitt

ed v

ia th

e pr

ovid

er w

eb p

orta

l (at

ww

w.m

yuhc

prov

ider

s.co

m),

subm

itted

ele

ctro

nica

lly v

ia y

our

Dent

al P

rovi

ders

with

com

plai

nts a

re to

con

tact

Uni

tedH

ealth

care

Den

tal’s

Pro

vide

r Ser

vice

dep

artm

ent a

t

183

184184

Iden

tific

atio

n Ca

rds

Sam

ple

Mem

ber I

D C

ard*

Fron

t of c

ard

Back

of c

ard

Impo

rtan

t Tel

epho

ne N

umbe

rs &

Web

site

s

Impo

rtan

t Add

ress

es

Impo

rtan

t Ele

ctro

nic

Clai

ms &

Prio

r Aut

horiz

atio

n Su

bmis

sion

Info

rmat

ion

EDI P

ayer

Num

ber f

or C

laim

s Sub

mitt

edG

P133

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ider

Qui

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efer

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nite

dHea

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are

Impr

ovem

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ilver

Rx

Geo

rgia

and

Sou

th C

arol

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24 h

ours

a d

ayCe

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s for

Med

icai

d an

d M

edic

are

Serv

ices

ww

w.c

ms.

hhs.

gov

24 h

ours

a d

ay

*Ple

ase

note

that

the

Med

ical

ID C

ard

is u

nive

rsal

and

incl

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all

lines

of c

over

age .

The

Med

ical

pla

n ca

n be

HM

O o

r PPO

and

this

doe

s not

refle

ct th

e De

ntal

Pla

n Be

nefit

s. P

leas

e fli

p th

e ID

Car

d ov

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see

the

Dent

al

Prov

ider

info

rmat

ion

on th

e ba

ck (i

.e. c

arrie

r web

site

and

toll-

free

num

ber)

. Thi

s inf

orm

atio

n ca

n be

use

d to

con

firm

pro

vide

r par

ticip

atio

n, m

embe

r elig

ibili

ty a

nd b

enef

its. T

his i

s a S

AMPL

E ID

Car

d an

d m

ay d

iffer

from

th

e m

embe

r's ID

Car

d.

Elig

ibili

ty,

Bene

fits,

Cla

im(s

) and

Aut

horiz

atio

ns(8

44) 2

75-8

750

Live

Age

nt: M

onda

y - F

riday

, 8:0

0AM

- 6:

00PM

, EST

IVR:

24

hour

s a d

ay

$100

0 An

nual

Max

imum

Prov

ider

Rea

son

for M

ailin

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to In

quire

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utTe

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ber

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bout

Web

site

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ew

ww

.med

icar

e.go

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hou

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day

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our p

artic

ipat

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con

trac

tual

issu

es, d

entis

t cha

nges

or o

ffice

upd

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(800

) 822

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3Li

ve A

gent

: Mon

day

- Frid

ay, 8

:00A

M -

11:0

0PM

, EST

Elig

ibili

ty,

Bene

fits,

Cla

im(s

) and

Aut

horiz

atio

nsw

ww

.uhc

prov

ider

s.co

m

Clai

ms

Prio

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horiz

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Appe

als &

Grie

vanc

es

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Med

icar

e Cl

aim

s, P

O B

ox 2

176,

Milw

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I 53

201

UHC

Med

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thor

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O B

ox 2

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I 53

201

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Med

icar

e Co

mpl

aint

s, G

rieva

nces

& A

ppea

ls, P

O B

ox 3

61, M

ilwau

kee,

WI

5320

1

185

1 ev

ery

6 m

onth

sun

limite

dun

limite

dun

limite

dun

limite

dun

limite

dun

limite

d

Intr

aora

l - C

ompl

ete

Serie

s of R

adio

grap

hic

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esIn

trao

ral -

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iapi

cal F

irst R

adio

grap

hic

Imag

eIn

trao

ral -

Per

iapi

cal E

ach

Addi

tiona

l Im

age

No

No

No

No

unlim

ited

unlim

ited

1 ev

ery

6 m

onth

s1

ever

y 6

mon

ths

1 ev

ery

6 m

onth

s1

ever

y 6

mon

ths

1 ev

ery

6 m

onth

s1

ever

y 6

mon

ths

1 ev

ery

6 m

onth

s1

ever

y 6

mon

ths

1 ev

ery

3 ye

ars

Cove

red

Den

tal S

ervi

ces:

Proc

edur

e Co

dePr

oced

ure

Des

crip

tion

Prio

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horiz

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n Re

quire

d?

D023

0D0

240

D027

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272

D027

3

D012

0D0

140

D015

0D0

210

D022

0

D216

0D2

161

D233

0D2

331

D233

2

D027

4D0

330

D111

0D2

140

D215

0

No

No

No

No

No

No

No

No

No

Perio

dic

Ora

l Eva

luat

ion

- Est

ablis

hed

Patie

ntLi

mite

d O

ral E

valu

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n - P

robl

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ocus

edCo

mpr

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sive

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l Eva

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stab

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tient

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390

D239

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392

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3

D911

0

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355

D491

0D7

111

D714

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D293

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940

D295

0D2

954

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1

D721

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250

D731

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311

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n-Ba

sed

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posi

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terio

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own

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in-B

ased

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posi

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ndire

ct)

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n - P

orce

lain

/Cer

amic

Sub

stra

teCr

own

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cela

in F

used

To

High

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etal

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edom

inan

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ase

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al

D239

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710

D274

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abric

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inle

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teel

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wn

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man

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ooth

Prot

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stor

atio

nCo

re B

uild

up, I

nclu

ding

Any

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s Whe

n Re

quire

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efab

ricat

ed P

ost A

nd C

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dditi

on T

o Cr

own

D275

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D279

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last

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Con

junc

tion

With

Ext

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ne T

o Th

ree

Teet

hPa

lliat

ive

(Em

erge

ncy)

Tre

atm

ent O

f Den

tal P

ain

- Min

or P

roce

dure

Perio

dont

al S

calin

g An

d Ro

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lann

ing

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e Te

eth

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uadr

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Mou

th D

ebrid

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riodo

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Mai

nten

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Extr

actio

n, C

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emna

nts -

Dec

iduo

us T

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Extr

actio

n, E

rupt

ed T

ooth

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xpos

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Intr

aora

l - O

cclu

sal R

adio

grap

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eBi

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gle

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phic

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eBi

tew

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o Ra

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ages

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dont

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calin

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t Pre

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inan

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ase

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own

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l Cas

t Nob

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etal

Re-C

emen

t or R

e-Bo

nd C

row

nPr

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tain

less

Ste

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row

n - P

rimar

y To

oth

Surg

ical

Rem

oval

Of E

rupt

ed T

ooth

Surg

ical

Rem

oval

Of R

esid

ual T

ooth

(Cut

ting

Proc

edur

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veol

opla

sty

In C

onju

nctio

n W

ith E

xtra

ctio

ns -

Four

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ore

Teet

h

Resi

n-Ba

sed

Com

posi

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ore

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aces

Or I

nvol

ving

Inci

se A

ngle

Resi

n-Ba

sed

Com

posi

te C

row

n, A

nter

ior

Resi

n-Ba

sed

Com

posi

te -

One

Sur

face

, Pos

terio

rRe

sin-

Base

d Co

mpo

site

- Tw

o Su

rfac

es, P

oste

rior

Resi

n-Ba

sed

Com

posi

te -

Thre

e Su

rfac

es, P

oste

rior

No

No

Yes

Yes

Yes

Yes

No

Bite

win

gs- T

hree

Rad

iogr

aphi

c Im

ages

Bite

win

gs- F

our R

adio

grap

hic

Imag

esPa

nora

mic

Rad

iogr

aphi

c Im

age

Prop

hyla

xis -

Adu

ltAm

alga

m -

One

Sur

face

, Prim

ary

Or P

erm

anen

tAm

alga

m -

Two

Surf

aces

, Prim

ary

Or P

erm

anen

tAm

alga

m -

Thre

e Su

rfac

es, P

rimar

y O

r Per

man

ent

Amal

gam

- Fo

ur O

r Mor

e Su

rfac

es, P

rimar

y O

r Per

man

ent

Resi

n-Ba

sed

Com

posi

te -

One

Sur

face

, Ant

erio

rRe

sin-

Base

d Co

mpo

site

- Tw

o Su

rfac

es, A

nter

ior

Resi

n-Ba

sed

Com

posi

te -

Thre

e Su

rfac

es, A

nter

ior

No

No

No

No

No

No

No

No

No

No

No

No

No

Yes

No

No

No

No

No

No

Yes

Yes

Yes

No

Yes

No

Yes

Yes

Yes

No

unlim

ited

unlim

ited

unlim

ited

unlim

ited

unlim

ited

1 ev

ery

3 ye

ars

1 ev

ery

3 ye

ars

1 ev

ery

3 ye

ars

1 ev

ery

3 ye

ars

unlim

ited

unlim

ited

Freq

uenc

y/Li

mita

tions

1 ev

ery

6 m

onth

s1

ever

y 6

mon

ths

1 ev

ery

6 m

onth

s

1 ev

ery

2 ye

ars

1 ev

ery

2 ye

ars

1 ev

ery

2 ye

ars

unlim

ited

unlim

ited

unlim

ited

unlim

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unlim

ited

unlim

ited

1 ev

ery

3 ye

ars

1 ev

ery

3 ye

ars

1 ev

ery

3 ye

ars

unlim

ited

unlim

ited

unlim

ited

unlim

ited

unlim

ited

unlim

ited

186186

Prov

ider

Cla

im D

ispu

tes

Mem

ber A

ppea

ls &

Grie

vanc

es

Prio

r Aut

horiz

atio

n Re

ques

ts

CIP_

SCIO

N 3

67_P

kg D

T455

_DT4

55-P

1000

a_FF

S28

09/2

016

Mai

l mem

ber a

ppea

ls to

: Uni

tedH

ealth

care

, Att

n: A

ppea

ls a

nd G

rieva

nce

Depa

rtm

ent,

PO B

ox 6

106,

MS

CA12

4-01

57, C

ypre

ss, C

A 90

630

“Prio

r Aut

horiz

atio

n re

quire

d” m

eans

the

prac

titio

ner m

ust s

ubm

it th

ose

proc

edur

es fo

r app

rova

l with

clin

ical

doc

umen

tatio

n su

ppor

ting

nece

ssity

bef

ore

perf

orm

ing

thos

e pr

oced

ures

. To

do th

is c

ompl

ete

a st

anda

rd

ADA

clai

m fo

rm a

nd c

heck

the

box

mar

ked

“Pre

-Tre

atm

ent E

STIM

ATE.

” Pr

ior a

utho

rizat

ion

requ

est c

an b

e su

bmitt

ed v

ia th

e pr

ovid

er w

eb p

orta

l (at

ww

w.m

yuhc

prov

ider

s.co

m),

subm

itted

ele

ctro

nica

lly v

ia y

our

clea

ringh

ouse

, or s

impl

y m

ail t

he fo

rm, t

o th

e be

low

add

ress

, alo

ng w

ith a

ny re

quire

d su

pple

men

tal i

nfor

mat

ion

(film

s, n

arra

tive,

per

io-c

hart

ing,

etc

.). Y

our o

ffice

will

then

rece

ive

an E

xpla

natio

n of

Ben

efits

(EO

B)

outli

ning

the

deni

al o

r app

rova

l of r

eque

sted

trea

tmen

t and

pla

n pa

ymen

t am

ount

s whe

n ap

plic

able

.

The

Uni

tedH

ealth

care

Pla

n fo

r Car

e Im

prov

emen

t Plu

s Silv

er R

x m

embe

rs c

over

s the

den

tal c

odes

list

ed a

bove

. Pro

vide

r pay

men

t is

mad

e on

a F

ee-fo

r-Se

rvic

e ba

sis.

Mem

bers

hav

e bo

th In

-Net

wor

k an

d O

ut-o

f-Net

wor

k co

vera

ge. S

ome

serv

ices

may

requ

ire p

rior a

utho

rizat

ion.

The

den

tal p

lan

has a

$10

00 a

nnua

l max

imum

that

app

lies t

o co

vere

d pr

even

tive

and

com

preh

ensi

ve b

enef

its. T

here

is n

o m

embe

r cop

ay, c

oins

uran

ce o

r de

duct

ible

. Mem

ber c

an b

e bi

lled

for s

ervi

ces o

ver t

he $

1000

ann

ual m

axim

um b

enef

it. T

his p

lan

is o

ffere

d to

Car

e Im

prov

emen

t Plu

s Silv

er R

x m

embe

rs in

Geo

rgia

and

Sou

th C

arol

ina.

Dent

al P

rovi

ders

with

com

plai

nts a

re to

con

tact

Uni

tedH

ealth

care

Den

tal’s

Pro

vide

r Ser

vice

dep

artm

ent a

t (84

4) 2

75-8

750.

Net

wor

k Pr

ovid

er c

ontr

actu

al d

ispu

tes,

Out

-of-N

etw

ork

prov

ider

dis

pute

s, a

nd re

proc

essi

ng

requ

ests

will

be

logg

ed in

to th

e ap

peal

s dat

abas

e. P

leas

e m

ail t

o th

e Ap

peal

s & G

rieva

nces

PO

Box

list

ed a

bove

. Res

earc

h an

d re

solu

tion

will

be

com

plet

ed w

ithin

30

cale

ndar

day

s.

Mem

ber a

ppea

ls a

re re

view

ed b

y th

e he

alth

pla

n, a

nd a

re n

ot d

eleg

ated

to U

HC D

enta

l. Al

l Mem

ber a

ppea

ls (i

nclu

des P

re-S

ervi

ce a

ppea

ls, I

n N

etw

ork

Prov

ider

app

eals

, and

Out

of N

etw

ork

prov

ider

app

eals

) rec

eive

d by

U

HC D

enta

l will

be

forw

arde

d to

the

heal

th p

lan

via

over

nigh

t mai

l, w

ithin

7 d

ays o

f rec

eipt

of t

he a

ppea

l.

187

188188

190190

“Prio

r Aut

horiz

atio

n re

quire

d” m

eans

the

prac

titio

ner m

ust s

ubm

it th

ose

proc

edur

es fo

r app

rova

l with

clin

ical

doc

umen

tatio

n su

ppor

ting

nece

ssity

bef

ore

perf

orm

ing

thos

e pr

oced

ures

. To

do th

is

com

plet

e a

stan

dard

ADA

cla

im fo

rm a

nd c

heck

the

box

mar

ked

“Pre

-Tre

atm

ent E

STIM

ATE.

” Pr

ior a

utho

rizat

ion

requ

est c

an b

e su

bmitt

ed v

ia th

e pr

ovid

er w

eb p

orta

l (at

ww

w.m

yuhc

prov

ider

s.co

m),

Dent

al P

rovi

ders

with

com

plai

nts a

re to

con

tact

Uni

tedH

ealth

care

Den

tal’s

Pro

vide

r Ser

vice

dep

artm

ent a

t

191

192192

194194

“Prio

r Aut

horiz

atio

n re

quire

d” m

eans

the

prac

titio

ner m

ust s

ubm

it th

ose

proc

edur

es fo

r app

rova

l with

clin

ical

doc

umen

tatio

n su

ppor

ting

nece

ssity

bef

ore

perf

orm

ing

thos

e pr

oced

ures

. To

do th

is c

ompl

ete

a st

anda

rd A

DA c

laim

form

and

che

ck th

e bo

x m

arke

d “P

re-T

reat

men

t EST

IMAT

E.”

Prio

r aut

horiz

atio

n re

ques

t can

be

subm

itted

via

the

prov

ider

web

por

tal (

at w

ww

.myu

hcpr

ovid

ers.

com

), su

bmitt

ed

Dent

al P

rovi

ders

with

com

plai

nts a

re to

con

tact

Uni

tedH

ealth

care

Den

tal’s

Pro

vide

r Ser

vice

dep

artm

ent a

t

195

196196

“Prio

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ical

ID C

ard

is un

iver

sal a

nd in

clud

es a

ll lin

es o

f cov

erag

e. T

he M

edic

al p

lan

can

be H

MO

or P

PO a

nd th

is d

oes n

ot re

flect

the

Dent

al P

lan

Bene

fits.

Ple

ase

flip

the

ID C

ard

over

to se

e th

e De

ntal

Pro

vide

r in

form

atio

n on

the

back

(i.e

. car

rier w

ebsi

te a

nd to

ll-fr

ee n

umbe

r). T

his i

nfor

mat

ion

can

be u

sed

to c

onfir

m p

rovi

der p

artic

ipat

ion,

mem

ber e

ligib

ility

and

ben

efits

. Thi

s is a

SAM

PLE

ID C

ard

and

may

diff

er fr

om th

e m

embe

r's ID

Ca

rd.

Elig

ibili

ty,

Bene

fits,

Cla

im(s

) and

Aut

horiz

atio

ns87

7-81

6-35

96Li

ve A

gent

: Mon

day

- Frid

ay, 8

:00A

M -

6:00

PM, E

STIV

R: 2

4 ho

urs a

day

Clai

ms

243

Unl

imite

dU

nlim

ited

Unl

imite

dU

nlim

ited

1 ev

ery

24 M

onth

(s)

1 ev

ery

24 M

onth

(s)

1 ev

ery

24 M

onth

(s)

D731

1al

veol

opla

sty

in c

onju

nctio

n w

ith e

xtra

ctio

ns -

one

to th

ree

teet

h or

toot

h sp

aces

, per

qua

dran

tN

o

D714

0ex

trac

tion,

eru

pted

toot

h or

exp

osed

root

(ele

vatio

n an

d/or

forc

eps

No

D721

0su

rgic

al re

mov

al o

f eru

pted

toot

h re

q re

mov

al o

f bon

e, se

ctio

ning

of t

ooth

and

incl

udin

g el

evat

ion

of

muc

oper

iost

eal f

lap

No

D491

0pe

riodo

ntal

mai

nten

ance

No

D711

1ex

trac

tion,

cor

onal

rem

nant

s - d

ecid

uous

toot

hN

o

D434

2pe

riodo

ntal

scal

ing

and

root

pla

nnin

g - o

ne to

thre

e te

eth

per q

uadr

ant

D911

0pa

lliat

ive

(em

erge

ncy)

trea

tmen

t of d

enta

l pai

n - m

inor

pro

cedu

reN

o

D725

0su

rgic

al re

mov

al o

f res

idua

l too

th ro

ots (

cutt

ing

proc

edur

e)N

o

D731

0al

veol

opla

sty

in c

onju

nctio

n w

ith e

xtra

ctio

ns -

four

or m

ore

teet

h or

toot

h sp

aces

, per

qua

dran

tN

o

Yes

D435

5fu

ll m

outh

deb

ridem

ent t

o en

able

com

preh

ensi

ve e

valu

atio

n an

d di

agno

sis

Yes

D295

4pr

efab

ricat

ed p

ost a

nd c

ore

in a

dditi

on to

cro

wn

Yes

D434

1pe

riodo

ntal

scal

ing

and

root

pla

nnin

g - f

our o

r mor

e pe

r qua

dran

tYe

s

D294

0pr

otec

tive

rest

orat

ion

No

D295

0co

re b

uild

up, i

nclu

ding

any

pin

sYe

s

D293

0pr

efab

ricat

ed st

ainl

ess s

teel

cro

wn

- prim

ary

toot

hN

oD2

931

pref

abric

ated

stai

nles

s ste

el c

row

n - p

erm

anen

t too

thN

o

D279

2cr

own

- ful

l cas

t nob

le m

etal

Yes

D292

0re

cem

ent c

row

nN

o

D275

2cr

own

- por

cela

in fu

sed

to n

oble

met

alYe

sD2

791

crow

n - f

ull c

ast p

redo

min

antly

bas

e m

etal

Yes

D275

0cr

own

- por

cela

in fu

sed

to h

igh

nobl

e m

etal

Yes

D275

1cr

own

- por

cela

in fu

sed

to p

redo

min

antly

bas

e m

etal

Yes

D271

0cr

own

- res

in-b

ased

com

posi

te (i

ndire

ct)

Yes

D274

0cr

own

- por

cela

in/c

eram

ic su

bstr

ate

Yes

D239

3re

sin-

base

d co

mpo

site

- th

ree

surf

aces

, pos

terio

rN

oD2

394

resi

n-ba

sed

com

posi

te -

four

or m

ore

surf

aces

, pos

terio

rN

o

D239

1re

sin-

base

d co

mpo

site

- on

e su

rfac

e, p

oste

rior

No

D239

2re

sin-

base

d co

mpo

site

- tw

o su

rfac

es, p

oste

rior

No

D233

5re

sin-

base

d co

mpo

site

- fo

ur o

r mor

e su

rfac

es o

r inv

olvi

ng in

cisa

l ang

le (a

nter

ior)

No

D239

0re

sin-

base

d co

mpo

site

cro

wn,

ant

erio

rN

o

D233

1re

sin-

base

d co

mpo

site

- tw

o su

rfac

es, a

nter

ior

No

D233

2re

sin-

base

d co

mpo

site

- th

ree

surf

aces

, ant

erio

rN

o

D216

1am

alga

m -

four

or m

ore

surf

aces

, prim

ary

or p

erm

anen

tN

oD2

330

resi

n-ba

sed

com

posi

te -

one

surf

ace,

ant

erio

rN

o

D215

0am

alga

m -

two

surf

aces

, prim

ary

or p

erm

anen

tN

oD2

160

amal

gam

- th

ree

surf

aces

, prim

ary

or p

erm

anen

tN

o

No

No

No

No

intr

aora

l - p

eria

pica

l - e

ach

addi

tiona

l film

intr

aora

l - o

cclu

sal f

ilmbi

tew

ing

- sin

gle

film

No

No

No

No

Cove

red

Den

tal S

ervi

ces:

Prio

r Aut

horiz

atio

n Re

quire

d?Pr

oced

ure

Code

Freq

uenc

y/Li

mita

tions

Proc

edur

e D

escr

iptio

n

Unl

imite

dU

nlim

ited

Unl

imite

d

Unl

imite

dU

nlim

ited

Unl

imite

d

1 ev

ery

3 Ye

ar(s

)

D022

0

D012

0D0

140

D015

0D0

210

perio

dic

oral

eva

luat

ion

limite

d or

al e

valu

atio

n - p

robl

em fo

cuse

dco

mpr

ehen

sive

ora

l eva

luat

ion

- new

or e

stab

lishe

d pa

tient

intr

aora

l - c

ompl

ete

serie

s (in

clud

ing

bite

win

gs)

D023

0D0

240

D027

0

intr

aora

l - p

eria

pica

l - fi

rst f

ilm

1 ev

ery

6 M

onth

(s)

Unl

imite

d

No

No

D027

2D0

273

bite

win

g - t

wo

film

sN

o

D111

0pr

ophy

laxi

s - a

dult

No

D214

0am

alga

m -

one

surf

ace,

prim

ary

or p

erm

anen

tN

o

D027

4D0

330

bite

win

g - t

hree

film

sbi

tew

ing

- fou

r film

spa

nora

mic

film

No

Unl

imite

dU

nlim

ited

Unl

imite

d

Unl

imite

d

1 ev

ery

6 M

onth

(s)

1 ev

ery

6 M

onth

(s)

1 ev

ery

6 M

onth

(s)

1 ev

ery

6 M

onth

(s)

1 ev

ery

6 M

onth

(s)

1 ev

ery

6 M

onth

(s)

1 ev

ery

6 M

onth

(s)

1 ev

ery

6 M

onth

(s)

1 ev

ery

6 M

onth

(s)

1 ev

ery

6 M

onth

(s)

1 ev

ery

6 M

onth

(s)

Unl

imite

d

Unl

imite

d

Unl

imite

dU

nlim

ited

Unl

imite

dU

nlim

ited

1 ev

ery

36 M

onth

(s)

1 ev

ery

36 M

onth

(s)

Unl

imite

d

Unl

imite

dU

nlim

ited

Unl

imite

dU

nlim

ited

Unl

imite

d

1 ev

ery

36 M

onth

(s)

1 ev

ery

36 M

onth

(s)

1 ev

ery

36 M

onth

(s)

1 ev

ery

36 M

onth

(s)

1 ev

ery

36 M

onth

(s)

244244

Prov

ider

Cla

im D

ispu

tes

Mem

ber A

ppea

ls &

Grie

vanc

es

Prio

r Aut

horiz

atio

n Re

ques

ts

AR, A

Z, K

Y, O

H_FA

CETS

D00

1589

4_Pk

g DT

069_

DT01

5-H1

000c

-FFS

28

10/2

016

Mai

l mem

ber a

ppea

ls to

: Uni

tedH

ealth

care

, Att

n: A

ppea

l Dep

artm

ent,

MS

CA12

4-01

57, P

O B

ox 6

106,

Cyp

ress

, CA

9063

0

“Prio

r Aut

horiz

atio

n re

quire

d” m

eans

the

prac

titio

ner m

ust s

ubm

it th

ose

proc

edur

es fo

r app

rova

l with

clin

ical

doc

umen

tatio

n su

ppor

ting

nece

ssity

bef

ore

perf

orm

ing

thos

e pr

oced

ures

. To

do th

is c

ompl

ete

a st

anda

rd A

DA

clai

m fo

rm a

nd c

heck

the

box

mar

ked

“Pre

-Tre

atm

ent E

STIM

ATE.

” Pr

ior a

utho

rizat

ion

requ

est c

an b

e su

bmitt

ed v

ia th

e pr

ovid

er w

eb p

orta

l (at

ww

w.m

yuhc

prov

ider

s.co

m),

subm

itted

ele

ctro

nica

lly v

ia y

our c

lear

ingh

ouse

, or

simpl

y m

ail t

he fo

rm, t

o th

e be

low

add

ress

, alo

ng w

ith a

ny re

quire

d su

pple

men

tal i

nfor

mat

ion

(film

s, n

arra

tive,

per

io-c

hart

ing,

etc

.). Y

our o

ffice

will

then

rece

ive

an E

xpla

natio

n of

Ben

efits

(EO

B) o

utlin

ing

the

deni

al o

r app

rova

l of

requ

este

d tr

eatm

ent a

nd p

lan

paym

ent a

mou

nts w

hen

appl

icab

le.

The

Uni

tedH

ealth

care

Med

icar

eCom

plet

e Pl

ans c

over

the

dent

al c

odes

list

ed a

bove

. Pro

vide

r pay

men

t is m

ade

on a

Fee

-for-

Serv

ice

basi

s. M

embe

rs h

ave

In-N

etw

ork

Onl

y Be

nefit

s. S

ome

serv

ices

requ

ire p

rior a

utho

rizat

ion.

Th

e de

ntal

pla

n ha

s a $

1000

ann

ual m

axim

um th

at a

pplie

s to

cove

red

prev

entiv

e an

d co

mpr

ehen

sive

ben

efits

. The

re is

no

mem

ber c

opay

, coi

nsur

ance

or d

educ

tible

. Mem

ber c

an b

e bi

lled

for s

ervi

ces o

ver t

he $

1000

ann

ual

max

imum

ben

efit.

Dent

al P

rovi

ders

with

com

plai

nts a

re to

con

tact

Uni

tedH

ealth

care

Den

tal’s

Pro

vide

r Ser

vice

dep

artm

ent a

t (87

7) 8

16-3

596.

Net

wor

k Pr

ovid

er c

ontr

actu

al d

ispu

tes,

Out

-of-N

etw

ork

prov

ider

dis

pute

s, a

nd re

proc

essi

ng re

ques

ts

will

be

logg

ed in

to th

e ap

peal

s dat

abas

e. P

leas

e m

ail t

o th

e Ap

peal

s & G

rieva

nces

PO

Box

list

ed a

bove

. Res

earc

h an

d re

solu

tion

will

be

com

plet

ed w

ithin

30

cale

ndar

day

s.

Mem

ber a

ppea

ls a

re re

view

ed b

y th

e he

alth

pla

n, a

nd a

re n

ot d

eleg

ated

to U

HC D

enta

l. Al

l Mem

ber a

ppea

ls (i

nclu

des P

re-S

ervi

ce a

ppea

ls, I

n N

etw

ork

Prov

ider

app

eals

, and

Out

of N

etw

ork

prov

ider

app

eals

) rec

eive

d by

UHC

De

ntal

will

be

forw

arde

d to

the

heal

th p

lan

via

over

nigh

t mai

l, w

ithin

7 d

ays o

f rec

eipt

of t

he a

ppea

l.

245

246246

“Prio

r Aut

horiz

atio

n re

quire

d” m

eans

the

prac

titio

ner m

ust s

ubm

it th

ose

proc

edur

es fo

r app

rova

l with

clin

ical

doc

umen

tatio

n su

ppor

ting

nece

ssity

bef

ore

perf

orm

ing

thos

e pr

oced

ures

. To

do th

is

com

plet

e a

stan

dard

ADA

cla

im fo

rm a

nd c

heck

the

box

mar

ked

“Pre

-Tre

atm

ent E

STIM

ATE.

” Pr

ior a

utho

rizat

ion

requ

est c

an b

e su

bmitt

ed v

ia th

e pr

ovid

er w

eb p

orta

l (at

ww

w.m

yuhc

prov

ider

s.co

m),

Dent

al P

rovi

ders

with

com

plai

nts a

re to

con

tact

Uni

tedH

ealth

care

Den

tal’s

Pro

vide

r Ser

vice

dep

artm

ent a

t

248248

“Prio

r Aut

horiz

atio

n re

quire

d” m

eans

the

prac

titio

ner m

ust s

ubm

it th

ose

proc

edur

es fo

r app

rova

l with

clin

ical

doc

umen

tatio

n su

ppor

ting

nece

ssity

bef

ore

perf

orm

ing

thos

e pr

oced

ures

. To

do th

is c

ompl

ete

a st

anda

rd

ADA

clai

m fo

rm a

nd c

heck

the

box

mar

ked

“Pre

-Tre

atm

ent E

STIM

ATE.

” Pr

ior a

utho

rizat

ion

requ

est c

an b

e su

bmitt

ed v

ia th

e pr

ovid

er w

eb p

orta

l (at

ww

w.m

yuhc

prov

ider

s.co

m),

subm

itted

ele

ctro

nica

lly v

ia y

our

Dent

al P

rovi

ders

with

com

plai

nts a

re to

con

tact

Uni

tedH

ealth

care

Den

tal’s

Pro

vide

r Ser

vice

dep

artm

ent a

t

250250

“Prio

r Aut

horiz

atio

n re

quire

d” m

eans

the

prac

titio

ner m

ust s

ubm

it th

ose

proc

edur

es fo

r app

rova

l with

clin

ical

doc

umen

tatio

n su

ppor

ting

nece

ssity

bef

ore

perf

orm

ing

thos

e pr

oced

ures

. To

do th

is c

ompl

ete

a st

anda

rd

ADA

clai

m fo

rm a

nd c

heck

the

box

mar

ked

“Pre

-Tre

atm

ent E

STIM

ATE.

” Pr

ior a

utho

rizat

ion

requ

est c

an b

e su

bmitt

ed v

ia th

e pr

ovid

er w

eb p

orta

l (at

ww

w.m

yuhc

prov

ider

s.co

m),

subm

itted

ele

ctro

nica

lly v

ia y

our

Dent

al P

rovi

ders

with

com

plai

nts a

re to

con

tact

Uni

tedH

ealth

care

Den

tal’s

Pro

vide

r Ser

vice

dep

artm

ent a

t

252252

Iden

tific

atio

n Ca

rds

Sam

ple

Mem

ber I

D C

ard*

Fron

t of c

ard

Back

of c

ard

Impo

rtan

t Tel

epho

ne N

umbe

rs &

Web

site

s

Impo

rtan

t Add

ress

es

Impo

rtan

t Ele

ctro

nic

Clai

ms &

Prio

r Aut

horiz

atio

n Su

bmis

sion

Info

rmat

ion

$500

Ann

ual M

axim

um

Prov

ider

Rea

son

for M

ailin

g

Med

icar

ew

ww

.med

icar

e.go

v24

hou

rs a

day

Hou

rs o

f Ope

ratio

nTo

dis

cuss

you

r par

ticip

atio

n, c

ontr

actu

al is

sues

, den

tist c

hang

es o

r offi

ce u

pdat

es(8

00) 8

22-5

353

Live

Age

nt: M

onda

y - F

riday

, 8:0

0AM

- 11

:00P

M, E

ST

Elig

ibili

ty,

Bene

fits,

Cla

im(s

) and

Aut

horiz

atio

ns

Prov

ider

Qui

ck R

efer

ence

Gui

de -

Effe

ctiv

e 1/

1/20

17U

nite

dHea

lthca

re C

are

Impr

ovem

ent P

lus (

Silv

er R

x, D

ual A

dvan

tage

)

Arka

nsas

and

Mis

sour

i

24 h

ours

a d

ayCe

nter

s for

Med

icai

d an

d M

edic

are

Serv

ices

ww

w.c

ms.

hhs.

gov

24 h

ours

a d

ay

*Ple

ase

note

that

the

Med

ical

ID C

ard

is u

nive

rsal

and

incl

udes

all

lines

of c

over

age.

The

Med

ical

pla

n ca

n be

HM

O o

r PPO

and

this

doe

s not

refle

ct th

e De

ntal

Pla

n Be

nefit

s. P

leas

e fli

p th

e ID

Car

d ov

er to

see

the

Dent

al

Prov

ider

info

rmat

ion

on th

e ba

ck (i

.e. c

arrie

r web

site

and

toll-

free

num

ber)

. Thi

s inf

orm

atio

n ca

n be

use

d to

con

firm

pro

vide

r par

ticip

atio

n, m

embe

r elig

ibili

ty a

nd b

enef

its. T

his i

s a S

AMPL

E ID

Car

d an

d m

ay d

iffer

from

th

e m

embe

r's ID

Car

d.

Elig

ibili

ty,

Bene

fits,

Cla

im(s

) and

Aut

horiz

atio

ns(8

44) 2

75-8

750

Live

Age

nt: M

onda

y - F

riday

, 8:0

0AM

- 6:

00PM

, EST

IVR:

24

hour

s a d

ay

Call

to In

quire

Abo

utTe

leph

one

Num

ber

Hou

rs o

f Ope

ratio

n

Emai

l to

Inqu

ire A

bout

Web

site

ww

w.u

hcpr

ovid

ers.

com

Clai

ms

Prio

r Aut

horiz

atio

n

Appe

als &

Grie

vanc

es

UHC

Med

icar

e Cl

aim

s, P

O B

ox 2

176,

Milw

auke

e, W

I 53

201

UHC

Med

icar

e Au

thor

izatio

ns, P

O B

ox 2

053,

Milw

auke

e, W

I 53

201

UHC

Med

icar

e Co

mpl

aint

s, G

rieva

nces

& A

ppea

ls, P

O B

ox 3

61, M

ilwau

kee,

WI

5320

1

EDI P

ayer

Num

ber f

or C

laim

s Sub

mitt

edG

P133

253

unlim

ited

unlim

ited

unlim

ited

unlim

ited

unlim

ited

1 ev

ery

6 m

onth

s1

ever

y 6

mon

ths

1 ev

ery

6 m

onth

s1

ever

y 6

mon

ths

1 ev

ery

6 m

onth

s1

ever

y 6

mon

ths

1 ev

ery

3 ye

ars f

rom

last

dat

e of

serv

ice

1 ev

ery

6 m

onth

sun

limite

d

Cove

red

Den

tal S

ervi

ces:

Proc

edur

e Co

dePr

oced

ure

Des

crip

tion

Prio

r Aut

horiz

atio

n Re

quire

d?

D023

0D0

240

D027

0D0

272

D027

3

D012

0D0

140

D015

0D0

210

No

No

No

Perio

dic

Ora

l Eva

luat

ion

- Est

ablis

hed

Patie

nt

1 ev

ery

6 m

onth

s

Lim

ited

Ora

l Eva

luat

ion

- Pro

blem

Foc

used

Com

preh

ensi

ve O

ral E

valu

atio

n - N

ew O

r Est

ablis

hed

Patie

nt

D721

0D7

250

D731

0D7

311

Resi

n-Ba

sed

Com

posi

te -

Four

Or M

ore

Surf

aces

, Pos

terio

rCr

own

- Res

in-B

ased

Com

posi

te (I

ndire

ct)

Crow

n - P

orce

lain

/Cer

amic

Sub

stra

te

D233

2

D027

4D0

330

D111

0D2

140

D215

0

No

No

No

No

D239

4D2

710

D274

0D2

750

D275

1

Pref

abric

ated

Sta

inle

ss S

teel

Cro

wn

- Per

man

ent T

ooth

Prot

ectiv

e Re

stor

atio

n

1 ev

ery

6 m

onth

s

D233

5D2

390

D239

1D2

392

D239

3

D293

1D2

940

No

No

D022

0

D216

0D2

161

D233

0D2

331

unlim

ited

unlim

ited

D275

2D2

791

D279

2D2

920

D293

0

Alve

olop

last

y In

Con

junc

tion

With

Ext

ract

ions

- O

ne T

o Th

ree

Teet

hPa

lliat

ive

(Em

erge

ncy)

Tre

atm

ent O

f Den

tal P

ain

- Min

or P

roce

dure

Perio

dont

al S

calin

g An

d Ro

ot P

lann

ing

- One

To

Thre

e Te

eth

Per Q

uadr

ant

Full

Mou

th D

ebrid

emen

tPe

riodo

ntal

Mai

nten

ance

Extr

actio

n, C

oron

al R

emna

nts -

Dec

iduo

us T

ooth

Extr

actio

n, E

rupt

ed T

ooth

Or E

xpos

ed R

oot

Surg

ical

Rem

oval

Of E

rupt

ed T

ooth

Surg

ical

Rem

oval

Of R

esid

ual T

ooth

(Cut

ting

Proc

edur

e)Al

veol

opla

sty

In C

onju

nctio

n W

ith E

xtra

ctio

ns -

Four

Or M

ore

Teet

h

D911

0

D434

2D4

355

D491

0D7

111

D714

0

D295

0D2

954

D434

1Pe

riodo

ntal

Sca

ling

And

Root

Pla

nnin

g - F

our O

r Mor

e Te

eth

Per Q

uadr

ant

Crow

n - P

orce

lain

Fus

ed T

o N

oble

Met

alCr

own

- Ful

l Cas

t Pre

dom

inan

tly B

ase

Met

alCr

own

- Ful

l Cas

t Nob

le M

etal

Re-C

emen

t or R

e-Bo

nd C

row

nPr

efab

ricat

ed S

tain

less

Ste

el C

row

n - P

rimar

y To

oth

Resi

n-Ba

sed

Com

posi

te -

Four

Or M

ore

Surf

aces

Or I

nvol

ving

Inci

sal A

ngle

Resi

n-Ba

sed

Com

posi

te C

row

n, A

nter

ior

Resi

n-Ba

sed

Com

posi

te -

One

Sur

face

, Pos

terio

rRe

sin-

Base

d Co

mpo

site

- Tw

o Su

rfac

es, P

oste

rior

Resi

n-Ba

sed

Com

posi

te -

Thre

e Su

rfac

es, P

oste

rior

Core

Bui

ldup

, Inc

ludi

ng A

ny P

ins W

hen

Requ

ired

Pref

abric

ated

Pos

t And

Cor

e In

Add

ition

To

Crow

n

Crow

n - P

orce

lain

Fus

ed T

o Hi

gh N

oble

Met

alCr

own

- Por

cela

in F

used

To

Pred

omin

antly

Bas

e M

etal

Intr

aora

l - C

ompl

ete

Serie

s of R

adio

grap

hic

Imag

esIn

trao

ral -

Per

iapi

cal F

irst R

adio

grap

hic

Imag

eIn

trao

ral -

Per

iapi

cal E

ach

Addi

tiona

l Im

age

No

No

No

No

Intr

aora

l - O

cclu

sal R

adio

grap

hic

Imag

eBi

tew

ing

- Sin

gle

Radi

ogra

phic

Imag

eBi

tew

ings

- Tw

o Ra

diog

raph

ic Im

ages

No

No

Yes

Yes

Yes

Yes

No

Bite

win

gs- T

hree

Rad

iogr

aphi

c Im

ages

Bite

win

gs- F

our R

adio

grap

hic

Imag

esPa

nora

mic

Rad

iogr

aphi

c Im

age

Prop

hyla

xis -

Adu

ltAm

alga

m -

One

Sur

face

, Prim

ary

Or P

erm

anen

tAm

alga

m -

Two

Surf

aces

, Prim

ary

Or P

erm

anen

tAm

alga

m -

Thre

e Su

rfac

es, P

rimar

y O

r Per

man

ent

Amal

gam

- Fo

ur O

r Mor

e Su

rfac

es, P

rimar

y O

r Per

man

ent

Resi

n-Ba

sed

Com

posi

te -

One

Sur

face

, Ant

erio

rRe

sin-

Base

d Co

mpo

site

- Tw

o Su

rfac

es, A

nter

ior

Resi

n-Ba

sed

Com

posi

te -

Thre

e Su

rfac

es, A

nter

ior

No

No

No

No

No

No

No

No

No

No

No

No

No

Yes

No

No

No

No

No

No

Yes

Yes

Yes

No

Yes

No

Yes

Yes

Yes

No

unlim

ited

unlim

ited

unlim

ited

unlim

ited

unlim

ited

unlim

ited

unlim

ited

1 ev

ery

3 ye

ars f

rom

last

dat

e of

serv

ice

1 ev

ery

3 ye

ars f

rom

last

dat

e of

serv

ice

1 ev

ery

3 ye

ars f

rom

last

dat

e of

serv

ice

1 ev

ery

3 ye

ars f

rom

last

dat

e of

serv

ice

unlim

ited

unlim

ited

Freq

uenc

y/Li

mita

tions

1 ev

ery

6 m

onth

s1

ever

y 6

mon

ths

1 ev

ery

6 m

onth

s

1 ev

ery

2 ye

ars f

rom

last

dat

e of

serv

ice

1 ev

ery

2 ye

ars f

rom

last

dat

e of

serv

ice

1 ev

ery

2 ye

ars f

rom

last

dat

e of

serv

ice

unlim

ited

unlim

ited

unlim

ited

unlim

ited

unlim

ited

unlim

ited

1 ev

ery

3 ye

ars f

rom

last

dat

e of

serv

ice

1 ev

ery

3 ye

ars f

rom

last

dat

e of

serv

ice

1 ev

ery

3 ye

ars f

rom

last

dat

e of

serv

ice

unlim

ited

unlim

ited

unlim

ited

unlim

ited

254254

Prov

ider

Cla

im D

ispu

tes

Mem

ber A

ppea

ls &

Grie

vanc

es

Prio

r Aut

horiz

atio

n Re

ques

ts

CIP_

SCIO

N 3

66_P

kg D

T456

_DT4

55-P

0500

a-FF

S28

09/2

016

Mai

l mem

ber a

ppea

ls to

: Uni

tedH

ealth

care

, Att

n: A

ppea

ls a

nd G

rieva

nce

Depa

rtm

ent,

PO B

ox 6

106,

MS

CA12

4-01

57, C

ypre

ss, C

A 90

630

“Prio

r Aut

horiz

atio

n re

quire

d” m

eans

the

prac

titio

ner m

ust s

ubm

it th

ose

proc

edur

es fo

r app

rova

l with

clin

ical

doc

umen

tatio

n su

ppor

ting

nece

ssity

bef

ore

perf

orm

ing

thos

e pr

oced

ures

. To

do th

is c

ompl

ete

a st

anda

rd

ADA

clai

m fo

rm a

nd c

heck

the

box

mar

ked

“Pre

-Tre

atm

ent E

STIM

ATE.

” Pr

ior a

utho

rizat

ion

requ

est c

an b

e su

bmitt

ed v

ia th

e pr

ovid

er w

eb p

orta

l (at

ww

w.m

yuhc

prov

ider

s.co

m),

subm

itted

ele

ctro

nica

lly v

ia y

our

clea

ringh

ouse

, or s

impl

y m

ail t

he fo

rm, t

o th

e be

low

add

ress

, alo

ng w

ith a

ny re

quire

d su

pple

men

tal i

nfor

mat

ion

(film

s, n

arra

tive,

per

io-c

hart

ing,

etc

.). Y

our o

ffice

will

then

rece

ive

an E

xpla

natio

n of

Ben

efits

(EO

B)

outli

ning

the

deni

al o

r app

rova

l of r

eque

sted

trea

tmen

t and

pla

n pa

ymen

t am

ount

s whe

n ap

plic

able

.

The

Uni

tedH

ealth

care

Pla

n fo

r Car

e Im

prov

emen

t (Pl

us S

ilver

Rx,

Dua

l Adv

anta

ge) m

embe

rs c

over

s the

den

tal c

odes

list

ed a

bove

. Pro

vide

r pay

men

t is m

ade

on a

Fee

-for-

Serv

ice

basi

s. M

embe

rs h

ave

both

In-N

etw

ork

and

Out

-of-N

etw

ork

cove

rage

. Som

e se

rvic

es m

ay re

quire

prio

r aut

horiz

atio

n. T

he d

enta

l pla

n ha

s a $

500

annu

al m

axim

um th

at a

pplie

s to

cove

red

prev

entiv

e an

d co

mpr

ehen

sive

ben

efits

. The

re is

no

mem

ber c

opay

, co

insu

ranc

e or

ded

uctib

le. M

embe

r can

be

bille

d fo

r ser

vice

s ove

r the

$50

0 an

nual

max

imum

ben

efit.

Thi

s pla

n is

offe

red

to C

are

Impr

ovem

ent (

Plus

Silv

er R

x, D

ual A

dvan

tage

) mem

bers

in A

rkan

sas a

nd M

isso

uri.

Dent

al P

rovi

ders

with

com

plai

nts a

re to

con

tact

Uni

tedH

ealth

care

Den

tal’s

Pro

vide

r Ser

vice

dep

artm

ent a

t (84

4) 2

75-8

750.

Net

wor

k Pr

ovid

er c

ontr

actu

al d

ispu

tes,

Out

-of-N

etw

ork

prov

ider

dis

pute

s, a

nd re

proc

essi

ng

requ

ests

will

be

logg

ed in

to th

e ap

peal

s dat

abas

e. P

leas

e m

ail t

o th

e Ap

peal

s & G

rieva

nces

PO

Box

list

ed a

bove

. Res

earc

h an

d re

solu

tion

will

be

com

plet

ed w

ithin

30

cale

ndar

day

s.

Mem

ber a

ppea

ls a

re re

view

ed b

y th

e he

alth

pla

n, a

nd a

re n

ot d

eleg

ated

to U

HC D

enta

l. Al

l Mem

ber a

ppea

ls (i

nclu

des P

re-S

ervi

ce a

ppea

ls, I

n N

etw

ork

Prov

ider

app

eals

, and

Out

of N

etw

ork

prov

ider

app

eals

) rec

eive

d by

U

HC D

enta

l will

be

forw

arde

d to

the

heal

th p

lan

via

over

nigh

t mai

l, w

ithin

7 d

ays o

f rec

eipt

of t

he a

ppea

l.

255

256256

Iden

tific

atio

n Ca

rds

Sam

ple

Mem

ber I

D C

ard*

Fron

t of c

ard

Back

of c

ard

Fron

t of c

ard

Back

of c

ard

Fron

t of c

ard

Back

of c

ard

Prov

ider

Qui

ck R

efer

ence

Gui

de -

Effe

ctiv

e 1/

1/20

17U

nite

dHea

lthca

re D

enta

l Pla

tinum

Rid

er$1

000

Annu

al M

axim

um

257

Impo

rtan

t Tel

epho

ne N

umbe

rs &

Web

site

s

Impo

rtan

t Add

ress

es

Impo

rtan

t Ele

ctro

nic

Clai

ms &

Prio

r Aut

horiz

atio

n Su

bmis

sion

Info

rmat

ion

1 ev

ery

36 m

onth

s fro

m la

st d

ate

of se

rvic

e1

ever

y 36

mon

ths f

rom

last

dat

e of

serv

ice

1 ev

ery

36 m

onth

s fro

m la

st d

ate

of se

rvic

eun

limite

dD0

416

vira

l cul

ture

No

D035

13D

pho

togr

aphi

c im

age

No

D041

5co

llect

ion

of m

icro

orga

nism

s for

cul

ture

and

sens

itivi

tyN

o

D033

0pa

nora

mic

radi

ogra

phic

imag

eN

oD0

350

2D O

ral/f

acia

l pho

togr

aphi

c im

ages

obt

aine

d in

trao

rally

or e

xtra

oral

lyN

o

No

Call

to In

quire

Abo

utTe

leph

one

Num

ber

Hou

rs o

f Ope

ratio

n

Emai

l to

Inqu

ire A

bout

Web

site

Hou

rs o

f Ope

ratio

n

Med

icar

ew

ww

.med

icar

e.go

v24

hou

rs a

day

To d

iscu

ss y

our p

artic

ipat

ion,

con

trac

tual

issu

es, d

entis

t cha

nges

or o

ffice

upd

ates

800-

822-

5353

Live

Age

nt: M

onda

y - F

riday

, 8:0

0AM

- 11

:00P

M, E

ST

Elig

ibili

ty,

Bene

fits,

Cla

im(s

) and

Aut

horiz

atio

nsw

ww

.dbp

.com

Cent

ers f

or M

edic

aid

and

Med

icar

e Se

rvic

esw

ww

.cm

s.hh

s.go

v

No

No

No

No

re-e

valu

atio

n, li

mite

d, p

robl

em fo

cuse

dco

mpr

ehen

sive

per

iodo

ntal

eva

luat

ion

- new

or e

stab

lishe

d pa

tient

intr

aora

l - c

ompl

ete

serie

s of r

adio

grap

hic

imag

es

Prov

ider

Rea

son

for M

ailin

g

EDI P

ayer

Num

ber f

or C

laim

s Sub

mitt

ed52

133

Prio

r Aut

horiz

atio

nAp

peal

s & G

rieva

nces

Uni

tedH

ealth

care

Den

tal,

PO B

ox 3

0567

, Sal

t Lak

e Ci

ty, U

T 84

130-

0567

Uni

tedH

ealth

care

Den

tal,

PO B

ox 3

0552

, Sal

t Lak

e Ci

ty, U

T 8

4130

-055

2U

nite

dHea

lthca

re D

enta

l, Ap

peal

s Disp

utes

, PO

Box

305

69, S

alt L

ake

City

, UT

8413

0-05

69

No

No

No

No

D014

0D0

145

D015

0

perio

dic

oral

eva

luat

ion

limite

d or

al e

valu

atio

n - p

robl

em fo

cuse

dor

al e

valu

atio

n fo

r a p

atie

nt u

nder

thre

e ye

ars o

f age

and

cou

nsel

ing

with

prim

ary

care

give

rco

mpr

ehen

sive

ora

l eva

luat

ion

- new

or e

stab

lishe

d pa

tient

D017

0D0

180

D021

0

deta

iled

and

exte

nsiv

e or

al e

valu

atio

n - p

robl

em-fo

cuse

d, b

y re

port

Cove

red

Den

tal S

ervi

ces:

Prio

r Aut

horiz

atio

n Re

quire

d?Pr

oced

ure

Code

Freq

uenc

y/Li

mita

tions

24 h

ours

a d

ay

Proc

edur

e D

escr

iptio

n

24 h

ours

a d

ay

*Ple

ase

note

that

the

Med

ical

ID C

ard

is un

iver

sal a

nd in

clud

es a

ll lin

es o

f cov

erag

e. T

he M

edic

al p

lan

can

be H

MO

or P

PO a

nd th

is d

oes n

ot re

flect

the

Dent

al P

lan

Bene

fits.

Ple

ase

flip

the

ID C

ard

over

to se

e th

e De

ntal

Pro

vide

r in

form

atio

n on

the

back

(i.e

. car

rier w

ebsi

te a

nd to

ll-fr

ee n

umbe

r). T

his i

nfor

mat

ion

can

be u

sed

to c

onfir

m p

rovi

der p

artic

ipat

ion,

mem

ber e

ligib

ility

and

ben

efits

. Thi

s is a

SAM

PLE

ID C

ard

and

may

diff

er fr

om th

e m

embe

r's ID

Car

d.

Elig

ibili

ty,

Bene

fits,

Cla

im(s

) and

Aut

horiz

atio

ns87

7-81

6-35

96Li

ve A

gent

: Mon

day

- Frid

ay, 8

:00A

M -

6:00

PM, E

STIV

R: 2

4 ho

urs a

day

Clai

ms

1 ev

ery

year

D016

0

D012

0

1 ev

ery

year

4 ev

ery

year

No

No

D022

0D0

230

intr

aora

l - p

eria

pica

l firs

t rad

iogr

aphi

c im

age

No

D025

1ex

tra-

oral

pos

terio

r den

tal r

adio

grap

hic

imag

eN

oD0

270

bite

win

g - s

ingl

e ra

diog

raph

ic im

age

No

D024

0

D025

0

intr

aora

l - p

eria

pica

l eac

h ad

ditio

nal r

adio

grap

hic

imag

ein

trao

ral -

occ

lusa

l rad

iogr

aphi

c im

age

extr

aora

l - 2

D pr

ojec

tion

radi

ogra

phic

imag

e cr

eate

d us

ing

a st

atio

nary

radi

atio

n so

urce

and

det

ecto

rN

o

D027

4bi

tew

ings

- fo

ur ra

diog

raph

ic im

ages

No

D027

7ve

rtic

al b

itew

ings

- 7

to 8

radi

ogra

phic

imag

esN

o

D027

2bi

tew

ings

- tw

o ra

diog

raph

ic im

ages

No

D027

3bi

tew

ings

- th

ree

radi

ogra

phic

imag

es1

ever

y ye

ar1

ever

y ye

ar1

ever

y ye

ar

2 ev

ery

year

2 ev

ery

year

2 ev

ery

year

2 ev

ery

year

2 ev

ery

year

1 ev

ery

12 m

onth

s fro

m la

st d

ate

of se

rvic

e2

ever

y ye

ar1

ever

y 36

mon

ths f

rom

last

dat

e of

serv

ice

unlim

ited

unlim

ited

unlim

ited

unlim

ited

1 ev

ery

36 m

onth

s fro

m la

st d

ate

of se

rvic

e

258258

1 ev

ery

60 m

onth

s fro

m la

st d

ate

of se

rvic

e1

ever

y 60

mon

ths f

rom

last

dat

e of

serv

ice

1 ev

ery

60 m

onth

s fro

m la

st d

ate

of se

rvic

e1

ever

y 60

mon

ths f

rom

last

dat

e of

serv

ice

1 ev

ery

60 m

onth

s fro

m la

st d

ate

of se

rvic

e1

ever

y 60

mon

ths f

rom

last

dat

e of

serv

ice

unlim

ited

unlim

ited

unlim

ited

unlim

ited

1 ev

ery

60 m

onth

s fro

m la

st d

ate

of se

rvic

eun

limite

dun

limite

dun

limite

dun

limite

dun

limite

dun

limite

dun

limite

d1

ever

y 60

mon

ths f

rom

last

dat

e of

serv

ice

1 ev

ery

60 m

onth

s fro

m la

st d

ate

of se

rvic

e1

ever

y 60

mon

ths f

rom

last

dat

e of

serv

ice

1 ev

ery

60 m

onth

s fro

m la

st d

ate

of se

rvic

e1

ever

y 60

mon

ths f

rom

last

dat

e of

serv

ice

1 ev

ery

60 m

onth

s fro

m la

st d

ate

of se

rvic

e1

ever

y 60

mon

ths f

rom

last

dat

e of

serv

ice

1 ev

ery

60 m

onth

s fro

m la

st d

ate

of se

rvic

e1

ever

y 60

mon

ths f

rom

last

dat

e of

serv

ice

Yes

Yes

No

No

No

No

No

No

No

No

No

No

No

No

No

No

No

No

No

No

Yes

Yes

Yes

No

No

No

Yes

onla

y - p

orce

lain

/cer

amic

- fo

ur o

r mor

e su

rfac

esin

lay

- com

posi

te/r

esin

- on

e su

rfac

ein

lay

- com

posi

te/r

esin

- tw

o su

rfac

esin

lay

- com

posit

e/re

sin

- thr

ee o

r mor

e su

rfac

es

resi

n-ba

sed

com

posi

te -

one

surf

ace,

pos

terio

rre

sin-

base

d co

mpo

site

- tw

o su

rfac

es, p

oste

rior

resi

n-ba

sed

com

posi

te -

thre

e su

rfac

es, p

oste

rior

resi

n-ba

sed

com

posi

te -

four

or m

ore

surf

aces

, pos

terio

rgo

ld fo

il - o

ne su

rfac

ego

ld fo

il - t

wo

surf

aces

gold

foil

- thr

ee su

rfac

esin

lay

- met

allic

- on

e su

rfac

ein

lay

- met

allic

- tw

o su

rfac

esin

lay

- met

allic

- th

ree

or m

ore

surf

aces

onla

y m

etal

lic, t

wo

surf

aces

onla

y-m

etal

lic-t

hree

surf

aces

spac

e m

aint

aine

r - re

mov

able

- un

ilate

ral

D216

0am

alga

m -

thre

e su

rfac

es, p

rimar

y or

per

man

ent

D265

0D2

651

D265

2

onla

y-m

etal

lic-fo

ur o

r mor

e su

rfac

esin

lay

- por

cela

in/c

eram

ic -

one

surf

ace

inla

y - p

orce

lain

/cer

amic

- tw

o su

rfac

esin

lay

- por

cela

in/c

eram

ic -

thre

e or

mor

e su

rfac

eson

lay

- por

cela

in/c

eram

ic -

two

surf

aces

onla

y - p

orce

lain

/cer

amic

- th

ree

surf

aces

resi

n-ba

sed

com

posi

te -

one

surf

ace,

ant

erio

rre

sin-

base

d co

mpo

site

- tw

o su

rfac

es, a

nter

ior

resi

n-ba

sed

com

posi

te -

thre

e su

rfac

es, a

nter

ior

resi

n-ba

sed

com

posi

te -

four

or m

ore

surf

aces

or i

nvol

ving

inci

sal a

ngle

(ant

erio

r)re

sin-

base

d co

mpo

site

cro

wn,

ant

erio

r

D242

0D2

430

D251

0

D254

2D2

543

D254

4D2

610

D262

0D2

630

D264

2D2

643

D264

4

1 ev

ery

60 m

onth

s fro

m la

st d

ate

of se

rvic

e1

ever

y 60

mon

ths f

rom

last

dat

e of

serv

ice

1 ev

ery

60 m

onth

s fro

m la

st d

ate

of se

rvic

e

D214

0am

alga

m -

one

surf

ace,

prim

ary

or p

erm

anen

tN

o

D215

0am

alga

m -

two

surf

aces

, prim

ary

or p

erm

anen

tN

o

D155

0re

cem

ent o

r re-

bond

of s

pace

mai

ntai

ner

No

D155

5re

mov

al o

f fix

ed sp

ace

mai

ntai

ner

No

D152

0

D252

0D2

530

No

D152

5sp

ace

mai

ntai

ner -

rem

ovab

le -

bila

tera

lN

o

D151

0sp

ace

mai

ntai

ner -

fixe

d - u

nila

tera

lN

oD1

515

spac

e m

aint

aine

r - fi

xed

- bila

tera

lN

o

D135

3se

alan

t rep

air -

per

toot

hN

oD1

354

inte

rim c

arie

s arr

estin

g m

edic

amen

t app

licat

ion

No

No

D216

1am

alga

m -

four

or m

ore

surf

aces

, prim

ary

or p

erm

anen

tN

oD2

330

D233

1D2

332

D233

5D2

390

D239

1D2

392

D239

3D2

394

D241

0

D135

1se

alan

t - p

er to

oth

No

D135

2pr

even

tive

resi

n re

stor

atio

n - p

erm

anen

t too

thN

o

D120

6to

pica

l app

licat

ion

of fl

uorid

e va

rnis

hN

oD1

208

Topi

cal a

pplic

atio

n of

fluo

ride

- exc

ludi

ng v

arni

shN

o

D111

0pr

ophy

laxi

s - a

dult

No

D112

0pr

ophy

laxi

s - c

hild

No

D046

0pu

lp v

italit

y te

sts

No

D047

0di

agno

stic

cas

tsN

o

D042

3ge

netic

test

for s

usce

ptib

ility

to d

isea

ses-

spec

imen

ana

lysi

sN

o

D043

1ad

junc

tive

pre-

diag

nost

ic te

st th

at a

ids i

n de

tect

ion

of m

ucos

al a

bnor

mal

ities

incl

udin

g pr

emal

igna

nt

and

mal

igna

nt le

isN

o

D041

8an

alys

is o

f sal

iva

sam

ple

No

D042

2co

llect

ion

and

prep

arat

ion

of g

enet

ic sa

mpl

e m

ater

ial f

or la

bora

tory

ana

lysi

s and

repo

rtN

o

D041

7co

llect

ion

and

prep

arat

ion

of sa

liva

sam

ple

for l

abor

ator

y di

agno

stic

test

ing

No

1 ev

ery

6 m

onth

s fro

m la

st d

ate

of se

rvic

eun

limite

dun

limite

d

unlim

ited

unlim

ited

2 ev

ery

year

2 ev

ery

year

unlim

ited

1 ev

ery

36 m

onth

s fro

m la

st d

ate

of se

rvic

e

unlim

ited

unlim

ited

unlim

ited

unlim

ited

1 ev

ery

12 m

onth

s fro

m la

st d

ate

of se

rvic

e

2 ev

ery

year

1 ev

ery

36 m

onth

s fro

m la

st d

ate

of se

rvic

e

1 ev

ery

36 m

onth

s fro

m la

st d

ate

of se

rvic

eun

limite

d1

ever

y 60

mon

ths f

rom

last

dat

e of

serv

ice

1 pe

r too

th1

ever

y 24

mon

ths f

rom

last

dat

e of

serv

ice

2 ev

ery

year

259

1 pe

r life

time

1 pe

r life

time

1 pe

r life

time

1 pe

r life

time

1 pe

r life

time

1 ev

ery

6 m

onth

s fro

m la

st d

ate

of se

rvic

e1

ever

y 6

mon

ths f

rom

last

dat

e of

serv

ice

1 ev

ery

6 m

onth

s fro

m la

st d

ate

of se

rvic

eun

limite

dun

limite

d1

per l

ifetim

e1

per l

ifetim

e

1 pe

r life

time

1 pe

r life

time

unlim

ited

unlim

ited

unlim

ited

2 pe

r too

thun

limite

dun

limite

dun

limite

dun

limite

d1

ever

y 60

mon

ths f

rom

last

dat

e of

serv

ice

unlim

ited

unlim

ited

unlim

ited

1 ev

ery

6 m

onth

s fro

m la

st d

ate

of se

rvic

e1

ever

y 60

mon

ths f

rom

last

dat

e of

serv

ice

1 ev

ery

60 m

onth

s fro

m la

st d

ate

of se

rvic

e1

ever

y 60

mon

ths f

rom

last

dat

e of

serv

ice

1 ev

ery

60 m

onth

s fro

m la

st d

ate

of se

rvic

e1

ever

y 60

mon

ths f

rom

last

dat

e of

serv

ice

1 ev

ery

60 m

onth

s fro

m la

st d

ate

of se

rvic

e1

ever

y 60

mon

ths f

rom

last

dat

e of

serv

ice

1 ev

ery

60 m

onth

s fro

m la

st d

ate

of se

rvic

e1

ever

y 60

mon

ths f

rom

last

dat

e of

serv

ice

1 ev

ery

60 m

onth

s fro

m la

st d

ate

of se

rvic

e1

ever

y 60

mon

ths f

rom

last

dat

e of

serv

ice

1 ev

ery

60 m

onth

s fro

m la

st d

ate

of se

rvic

e1

ever

y 60

mon

ths f

rom

last

dat

e of

serv

ice

1 ev

ery

60 m

onth

s fro

m la

st d

ate

of se

rvic

e

1 ev

ery

60 m

onth

s fro

m la

st d

ate

of se

rvic

e1

ever

y 60

mon

ths f

rom

last

dat

e of

serv

ice

1 ev

ery

60 m

onth

s fro

m la

st d

ate

of se

rvic

e1

ever

y 60

mon

ths f

rom

last

dat

e of

serv

ice

1 ev

ery

60 m

onth

s fro

m la

st d

ate

of se

rvic

e1

ever

y 60

mon

ths f

rom

last

dat

e of

serv

ice

1 ev

ery

60 m

onth

s fro

m la

st d

ate

of se

rvic

e1

ever

y 60

mon

ths f

rom

last

dat

e of

serv

ice

1 ev

ery

60 m

onth

s fro

m la

st d

ate

of se

rvic

e

1 ev

ery

60 m

onth

s fro

m la

st d

ate

of se

rvic

e1

ever

y 60

mon

ths f

rom

last

dat

e of

serv

ice

1 ev

ery

60 m

onth

s fro

m la

st d

ate

of se

rvic

e

No

No

No

No

No

No

No

No

No

No

No

No

No

No

Yes

No

Yes

Yes

Yes

Yes

Yes

No

No

No

No

No

No

No

No

No

No

Yes

Yes

Yes

Yes

Yes

Yes

Yes

Yes

No

Yes

No

No

No

Yes

Yes

Yes

Yes

Yes

Yes

Yes

Yes

Yes

endo

dont

ic th

erap

y, b

icus

pid

toot

h (e

xclu

ding

fina

l res

tora

tion)

endo

dont

ic th

erap

y, m

olar

(exc

ludi

ng fi

nal r

esto

ratio

n)tr

eatm

ent o

f roo

t can

al o

bstr

uctio

n, n

on-s

urgi

cal a

cces

s

ther

apeu

tic p

ulpo

tom

y (e

xclu

ding

fina

l res

tora

tion)

pulp

al d

ebrid

emen

t, pr

imar

y an

d pe

rman

ent t

eeth

part

ial p

ulpo

tom

y fo

r ape

xoge

nesi

s - p

erm

anen

t too

th w

ith in

com

plet

e ro

ot d

evel

opm

ent

pulp

al th

erap

y (r

esto

rabl

e fil

ling)

- an

terio

r, pr

imar

y to

oth

(exc

ludi

ng fi

nal r

esto

ratio

n)

pulp

al th

erap

y (r

esto

rabl

e fil

ling)

- po

ster

ior,

prim

ary

toot

h (e

xclu

ding

fina

l res

tora

tion)

endo

dont

ic th

erap

y, a

nter

ior t

ooth

(exc

ludi

ng fi

nal r

esto

ratio

n)

Core

bui

ldup

, inc

ludi

ng a

ny p

ins w

hen

requ

ired

pin

rete

ntio

n - p

er to

oth,

in a

dditi

on to

rest

orat

ion

cast

pos

t and

cor

e in

add

ition

to c

row

nea

ch a

dditi

onal

indi

rect

ly fa

bric

ated

pos

t, sa

me

toot

hpr

efab

ricat

ed p

ost a

nd c

ore

in a

dditi

on to

cro

wn

each

add

ition

al p

refa

bric

ated

pos

t, sa

me

toot

hco

ping

crow

n re

pair

nece

ssita

ted

by re

stor

ativ

e m

ater

ial f

ailu

rein

lay

repa

ir ne

cess

itate

d by

rest

orat

ive

mat

eria

l fai

lure

pref

abric

ated

resi

n cr

own

pref

abric

ated

stai

nles

s ste

el c

row

n w

ith re

sin

win

dow

pref

abric

ated

est

hetic

coa

ted

stai

nles

s ste

el c

row

n - p

rimar

y to

oth

prot

ectiv

e re

stor

atio

nin

terim

ther

apeu

tic re

stor

atio

n-pr

imar

y de

ntiti

on

crow

n, 3

/4 c

ast n

oble

met

alcr

own,

3/4

por

cela

in/c

eram

iccr

own

- ful

l cas

t hig

h no

ble

met

alcr

own

- ful

l cas

t pre

dom

inan

tly b

ase

met

alcr

own

- ful

l cas

t nob

le m

etal

crow

n - t

itani

um

prov

isio

nal c

row

n - f

urth

er tr

eatm

ent o

r com

plet

ion

of d

iagn

osis

nec

essa

ry p

rior t

o fin

al im

pres

sion

rece

men

t or r

e-bo

nd in

lay,

onl

ay, v

enee

r or p

artia

l cov

erag

e re

stor

atio

nre

cem

ent o

r re-

bond

cas

t ind

irect

ly fa

bric

ated

or p

refa

bric

ated

pos

t and

cor

e

onla

y re

pair

nece

ssita

ted

by re

stor

ativ

e m

ater

ial f

ailu

repu

lp c

ap -

dire

ct (e

xclu

ding

fina

l res

tora

tion)

pulp

cap

- in

dire

ct (e

xclu

ding

fina

l res

tora

tion)

crow

n - p

orce

lain

fuse

d to

pre

dom

inan

tly b

ase

met

alcr

own

- por

cela

in fu

sed

to n

oble

met

alcr

own,

3/4

cas

t hig

h no

ble

met

alcr

own,

3/4

cas

t pre

dom

inat

ely

base

met

al

onla

y - c

ompo

site

/res

in -

two

surf

aces

onla

y - c

ompo

site

/res

in -

thre

e su

rfac

eson

lay

- com

posi

te/r

esin

- fo

ur o

r mor

e su

rfac

escr

own,

resi

n-ba

sed

com

posi

te (i

ndire

ct)

crow

n - 3

/4 re

sin-

base

d co

mpo

site

(ind

irect

)

rece

men

t or r

e-bo

nd c

row

nre

atta

chm

ent o

f too

th fr

agm

ent,

inci

sal e

dge

or c

usp

pref

abric

ated

stai

nles

s ste

el c

row

n - p

rimar

y to

oth

pref

abric

ated

stai

nles

s ste

el c

row

n - p

erm

anen

t too

th

crow

n - r

esin

with

hig

h no

ble

met

alcr

own

- res

in w

ith p

redo

min

antly

bas

e m

etal

crow

n - r

esin

with

nob

le m

etal

crow

n - p

orce

lain

/cer

amic

subs

trat

ecr

own

- por

cela

in fu

sed

to h

igh

nobl

e m

etal

D333

0D3

331

D311

0D3

120

D322

0D3

221

D322

2D3

230

D324

0D3

310

D332

0

D295

1D2

952

D295

3D2

954

D295

7D2

975

D298

0D2

981

D298

2

D292

1D2

930

D293

1D2

932

D293

3D2

934

D294

0D2

941

D295

0

D278

3D2

790

D279

1D2

792

D279

4

D279

9D2

910

D291

5D2

920

D272

1D2

722

D274

0D2

750

D275

1D2

752

D278

0D2

781

D278

2

D266

2D2

663

D266

4D2

710

D271

2D2

720

260260

1 ev

ery

36 m

onth

s fro

m la

st d

ate

of se

rvic

e

1 ev

ery

36 m

onth

s fro

m la

st d

ate

of se

rvic

e

1 ev

ery

36 m

onth

s fro

m la

st d

ate

of se

rvic

e

1 ev

ery

36 m

onth

s fro

m la

st d

ate

of se

rvic

e1

ever

y 36

mon

ths f

rom

last

dat

e of

serv

ice

1 ev

ery

36 m

onth

s fro

m la

st d

ate

of se

rvic

e

1 ev

ery

36 m

onth

s fro

m la

st d

ate

of se

rvic

e1

ever

y 36

mon

ths f

rom

last

dat

e of

serv

ice

1 ev

ery

36 m

onth

s fro

m la

st d

ate

of se

rvic

e

1 ev

ery

36 m

onth

s fro

m la

st d

ate

of se

rvic

e

1 ev

ery

36 m

onth

s fro

m la

st d

ate

of se

rvic

e

1 ev

ery

36 m

onth

s fro

m la

st d

ate

of se

rvic

e

1 ev

ery

36 m

onth

s fro

m la

st d

ate

of se

rvic

e1

ever

y 36

mon

ths f

rom

last

dat

e of

serv

ice

1 ev

ery

36 m

onth

s fro

m la

st d

ate

of se

rvic

e

1 ev

ery

36 m

onth

s fro

m la

st d

ate

of se

rvic

e1

ever

y 36

mon

ths f

rom

last

dat

e of

serv

ice

1 ev

ery

36 m

onth

s fro

m la

st d

ate

of se

rvic

e

1 ev

ery

36 m

onth

s fro

m la

st d

ate

of se

rvic

e

1 ev

ery

36 m

onth

s fro

m la

st d

ate

of se

rvic

e1

ever

y 36

mon

ths f

rom

last

dat

e of

serv

ice

1 pe

r life

time

2 pe

r life

time

2 pe

r life

time

1 pe

r life

time

1 pe

r life

time

1 pe

r life

time

per t

ooth

1 pe

r life

time

1 ev

ery

36 m

onth

s fro

m la

st d

ate

of se

rvic

e

1 ev

ery

36 m

onth

s fro

m la

st d

ate

of se

rvic

e

1 pe

r life

time

1 pe

r life

time

1 pe

r life

time

1 pe

r life

time

1 pe

r life

time

1 pe

r life

time

1 pe

r life

time

1 pe

r life

time

1 pe

r life

time

1 pe

r life

time

1 pe

r life

time

1 pe

r life

time

1 pe

r life

time

Yes

Yes

Yes

No

No

No

No

Yes

No

Yes

Yes

Yes

No

No

No

Yes

Yes

Yes

Yes

No

No

No

No

No

No

No

No

No

Yes

No

No

No

No

No

No

No

No

No

No

No

Yes

Yes

Yes

auto

geno

us c

onne

ctiv

e tis

sue

graf

t pro

cedu

re -

each

add

ition

al c

ontig

uous

toot

h, im

plan

t or

eden

tulo

us to

oth

guid

ed ti

ssue

rege

nera

tion

- res

tora

ble

barr

ier,

per s

ite

guid

ed ti

ssue

rege

nera

tion

- non

rest

orab

le b

arrie

r, pe

r site

(Inc

lude

s mem

bran

e re

mov

al)

surg

ical

revi

sion

pro

cedu

re, p

er to

oth

pedi

cle

soft

tissu

e gr

aft p

roce

dure

auto

geno

us c

onne

ctiv

e tis

sue

graf

t pro

cedu

re, p

er fi

rst t

ooth

, im

plan

t or e

dent

ulou

s too

th p

ositi

on in

gr

aft

dist

al o

r pro

xim

al w

edge

pro

cedu

re (w

hen

not p

erfo

rmed

in c

onju

nctio

n w

ith su

rgic

al p

roce

dure

s in

the

sam

e an

atom

ical

are

a)no

n-au

toge

nous

con

nect

ive

tissu

e gr

aft (

incl

udin

g re

cipi

ent s

ite a

nd d

onor

mat

eria

l) fir

st to

oth

impl

ant

com

bine

d co

nnec

tive

tissu

e an

d do

uble

ped

icle

gra

ft, p

er to

oth

free

soft

tiss

ue g

raft

pro

cedu

re e

ach

addi

tiona

l con

tiguo

us to

oth,

impl

ant o

r ede

ntul

ous t

ooth

ging

ival

flap

pro

cedu

re -

incl

udin

g ro

ot p

lann

ing

-one

to th

ree

cont

iguo

us te

eth

or to

oth

boun

ded

spac

es p

er q

uadr

ant

apic

ally

pos

ition

ed fl

apcl

inic

al c

row

n le

ngth

enin

g - h

ard

tissu

eos

seou

s sur

gery

(inc

ludi

ng fl

ap e

ntry

and

clo

sure

) - fo

ur o

r mor

e co

ntig

uous

teet

h or

toot

h bo

unde

d sp

aces

per

qua

dran

tos

seou

s sur

gery

(inc

ludi

ng fl

ap e

ntry

and

clo

sure

) - o

ne to

thre

e co

ntig

uous

teet

h or

toot

h bo

unde

d sp

aces

per

qua

dran

tBo

ne re

plac

emen

t gra

ft -

first

site

in q

uadr

ant

Bone

repl

acem

ent g

raft

- ea

ch a

dditi

onal

site

in q

uadr

ant

biol

ogic

mat

eria

ls to

aid

in so

ft an

d os

seou

s tis

sue

rege

nera

tion

perir

adic

ular

surg

ery

with

out a

pico

ecto

my

retr

ogra

de fi

lling

- pe

r roo

tro

ot a

mpu

tatio

n - p

er ro

otin

tent

iona

l rei

mpl

anta

tion

(incl

udin

g ne

cess

ary

splin

ting)

hem

isec

tion

(incl

udin

g an

y ro

ot re

mov

al),

not i

nclu

ding

root

can

al th

erap

y

ging

ivec

tom

y or

gin

givo

plas

ty -

four

or m

ore

cont

iguo

us te

eth

or to

oth

boun

ded

spac

es p

er q

uadr

ant

ging

ivec

tom

y or

gin

givo

plas

ty -

one

to th

ree

cont

iguo

us te

eth

or to

oth

boun

ded

spac

es p

er q

uadr

ant

anat

omic

al c

row

n ex

posu

re -

four

or m

ore

cont

iguo

us te

eth

per q

uadr

ant

anat

omic

al c

row

n ex

posu

re -

one

to th

ree

teet

h pe

r qua

dran

t

Pupa

l reg

ener

atio

n-in

itial

vis

itPu

lpal

rege

nera

tion-

inte

rim m

edic

amen

t rep

lace

men

tPu

lpal

rege

nera

tion-

com

plet

ion

of tr

eatm

ent

Apic

oect

omy

- ant

erio

rAp

icoe

ctom

y - b

icus

pid

(firs

t roo

t)Ap

icoe

ctom

y - m

olar

(firs

t roo

t)Ap

icoe

ctom

y (e

ach

addi

tiona

l roo

t)

inco

mpl

ete

endo

dont

ic th

erap

y; in

oper

able

, unr

esto

rabl

e or

frac

ture

d to

oth

inte

rnal

toot

h re

pair

of p

erfo

ratio

n de

fect

sre

trea

tmen

t of p

revi

ous r

oot c

anal

ther

apy

- ant

erio

rre

trea

tmen

t of p

revi

ous r

oot c

anal

ther

apy

- bic

uspi

dre

trea

tmen

t of p

revi

ous r

oot c

anal

ther

apy

- mol

arAp

exifi

catio

n/re

calc

ifica

tion-

initi

al v

isit (

apic

al c

losu

re/c

alci

fic re

pair

of p

erfo

ratio

ns, r

oot r

esor

ptio

n,

etc.

ging

ival

flap

pro

cedu

re, i

nclu

ding

root

pla

nnin

g - f

our o

r mor

e co

ntig

uous

teet

h or

toot

h bo

unde

d sp

aces

per

qua

dran

t

Apex

ifica

tion/

reca

lcifi

catio

n/pu

lpal

rege

nera

tion

- int

erim

med

icat

ion

repl

acem

ent

apex

ifica

tion/

reca

lcifi

catio

n - f

inal

visi

t (in

clud

es c

ompl

eted

root

D426

7D4

268

D427

0

D427

3

D427

4

D427

5D4

276

D427

7

D428

3

D424

1D4

245

D424

9

D426

0

D426

1D4

263

D426

4D4

265

D426

6

D343

0D3

450

D347

0D3

920

D421

0

D421

1D4

230

D423

1

D424

0

D335

3D3

355

D335

6D3

357

D341

0D3

421

D342

5D3

426

D342

7

D333

2D3

333

D334

6D3

347

D334

8

D335

1

D335

2

261

1 ev

ery

12 m

onth

s fro

m la

st d

ate

of se

rvic

e1

ever

y 12

mon

ths f

rom

last

dat

e of

serv

ice

1 ev

ery

12 m

onth

s fro

m la

st d

ate

of se

rvic

e1

ever

y 12

mon

ths f

rom

last

dat

e of

serv

ice

1 ev

ery

12 m

onth

s fro

m la

st d

ate

of se

rvic

e

1 ev

ery

6 m

onth

s fro

m la

st d

ate

of se

rvic

e1

ever

y 6

mon

ths f

rom

last

dat

e of

serv

ice

1 ev

ery

6 m

onth

s fro

m la

st d

ate

of se

rvic

e1

ever

y 6

mon

ths f

rom

last

dat

e of

serv

ice

1 ev

ery

6 m

onth

s fro

m la

st d

ate

of se

rvic

e1

ever

y 12

mon

ths f

rom

last

dat

e of

serv

ice

1 ev

ery

12 m

onth

s fro

m la

st d

ate

of se

rvic

e1

ever

y 12

mon

ths f

rom

last

dat

e of

serv

ice

1 ev

ery

12 m

onth

s fro

m la

st d

ate

of se

rvic

e

1 ev

ery

6 m

onth

s fro

m la

st d

ate

of se

rvic

e1

ever

y 6

mon

ths f

rom

last

dat

e of

serv

ice

1 ev

ery

6 m

onth

s fro

m la

st d

ate

of se

rvic

e1

ever

y 6

mon

ths f

rom

last

dat

e of

serv

ice

1 ev

ery

6 m

onth

s fro

m la

st d

ate

of se

rvic

e1

ever

y 6

mon

ths f

rom

last

dat

e of

serv

ice

1 ev

ery

6 m

onth

s fro

m la

st d

ate

of se

rvic

e1

ever

y 6

mon

ths f

rom

last

dat

e of

serv

ice

1 ev

ery

6 m

onth

s fro

m la

st d

ate

of se

rvic

e

1 ev

ery

60 m

onth

s fro

m la

st d

ate

of se

rvic

e

1 ev

ery

60 m

onth

s fro

m la

st d

ate

of se

rvic

e1

ever

y 60

mon

ths f

rom

last

dat

e of

serv

ice

1 ev

ery

60 m

onth

s fro

m la

st d

ate

of se

rvic

e

1 ev

ery

60 m

onth

s fro

m la

st d

ate

of se

rvic

e

1 ev

ery

60 m

onth

s fro

m la

st d

ate

of se

rvic

e1

ever

y 60

mon

ths f

rom

last

dat

e of

serv

ice

1 ev

ery

60 m

onth

s fro

m la

st d

ate

of se

rvic

e

1 ev

ery

60 m

onth

s fro

m la

st d

ate

of se

rvic

e

12 p

er li

fetim

e2

ever

y 12

mon

ths f

rom

last

dat

e of

serv

ice

unlim

ited

1 ev

ery

60 m

onth

s fro

m la

st d

ate

of se

rvic

e1

ever

y 60

mon

ths f

rom

last

dat

e of

serv

ice

1 ev

ery

60 m

onth

s fro

m la

st d

ate

of se

rvic

e1

ever

y 60

mon

ths f

rom

last

dat

e of

serv

ice

1 ev

ery

60 m

onth

s fro

m la

st d

ate

of se

rvic

e

1 ev

ery

60 m

onth

s fro

m la

st d

ate

of se

rvic

e

1 ev

ery

36 m

onth

s fro

m la

st d

ate

of se

rvic

e1

ever

y 36

mon

ths f

rom

last

dat

e of

serv

ice

1 ev

ery

36 m

onth

s fro

m la

st d

ate

of se

rvic

e1

ever

y 24

mon

ths f

rom

last

dat

e of

serv

ice

1 ev

ery

24 m

onth

s fro

m la

st d

ate

of se

rvic

e1

ever

y 36

mon

ths f

rom

last

dat

e of

serv

ice

No

No

No

No

No

No

No

No

No

No

No

No

No

No

No

No

No

No

No

No

No

No

No

No

No

No

No

No

No

No

No

No

No

No

No

No

No

No

No

No

Yes

No

No

No

No

No

Yes

relin

e m

axill

ary

part

ial d

entu

re (c

hairs

ide)

relin

e m

andi

bula

r par

tial d

entu

re (c

hairs

ide)

relin

e co

mpl

ete

max

illar

y de

ntur

e (la

bora

tory

)

add

clas

p to

exi

stin

g pa

rtia

l den

ture

- pe

r too

thre

plac

e al

l tee

th a

nd a

cryl

ic o

n ca

st m

etal

fram

ewor

k (m

axill

ary)

repl

ace

all t

eeth

and

acr

ylic

on

cast

met

al fr

amew

ork

(man

dibu

lar)

reba

se c

ompl

ete

max

illar

y de

ntur

ere

base

com

plet

e m

andi

bula

r den

ture

reba

se m

axill

ary

part

ial d

entu

rere

base

man

dibu

lar p

artia

l den

ture

relin

e co

mpl

ete

max

illar

y de

ntur

e (c

hairs

ide)

relin

e co

mpl

ete

man

dibu

lar d

entu

re (c

hairs

ide)

adju

st p

artia

l den

ture

- m

axill

ary

adju

st p

artia

l den

ture

- m

andi

bula

rre

pair

brok

en c

ompl

ete

dent

ure

base

repl

ace

mis

sing

or b

roke

n te

eth

- com

plet

e de

ntur

e (e

ach

toot

h)re

pair

resi

n de

ntur

e ba

sere

pair

cast

fram

ewor

kre

pair

or re

plac

e br

oken

cla

sp -

per t

ooth

repl

ace

brok

en te

eth

- per

toot

had

d to

oth

to e

xist

ing

part

ial d

entu

re

imm

edia

te m

axill

ary

part

ial d

entu

re -

resin

bas

eim

med

iate

man

dibu

lar p

artia

l den

ture

- re

sin

base

imm

edia

te m

axill

ary

part

ial d

entu

re -

cast

met

al fr

amew

ork

with

resin

den

ture

bas

es

imm

edia

te m

andi

bula

r par

tial d

entu

re-c

ast m

etal

fram

ewor

k w

ith re

sin

dent

ure

base

sm

axill

ary

part

ial d

entu

re -

flexi

ble

base

(inc

ludi

ng a

ny c

lasp

s, re

sts a

nd te

eth)

man

dibu

lar p

artia

l den

ture

- fle

xibl

e ba

se (i

nclu

ding

any

cla

sps,

rest

s and

teet

h)

rem

ovab

le u

nila

tera

l par

tial d

entu

re -

one

piec

e ca

st m

etal

(inc

ludi

ng c

lasp

s and

teet

h)ad

just

com

plet

e de

ntur

e - m

axill

ary

adju

st c

ompl

ete

dent

ure

- man

dibu

lar

unsc

hedu

led

dres

sing

cha

nge

(by

som

eone

oth

er th

an tr

eatin

g de

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t or t

heir

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mpl

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illar

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imm

edia

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max

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iate

den

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r

max

illar

y pa

rtia

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ture

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ase

(incl

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y co

nven

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rest

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teet

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ture

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sin

base

(inc

ludi

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ny c

onve

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s, re

sts a

nd te

eth)

max

illar

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rtia

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ture

- ca

st m

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ith re

sin d

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ases

(inc

ludi

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clas

ps, r

ests

and

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artia

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ture

- ca

st m

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k w

ith re

sin

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base

s (in

clud

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conv

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s, re

sts a

nd

non-

auto

geno

us c

onne

ctiv

e tis

sue

graf

t pro

cedu

re -

each

add

ition

al c

ontig

uous

toot

h, im

plan

t or

eden

tulo

us to

oth

prov

isio

nal s

plin

ting

- int

raco

rona

lpr

ovis

iona

l spl

intin

g - e

xtra

coro

nal

perio

dont

al sc

alin

g an

d ro

ot p

lann

ing

- fou

r or m

ore

teet

h pe

r qua

dran

tpe

riodo

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scal

ing

and

root

pla

nnin

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ne -

thre

e te

eth,

per

qua

dran

tfu

ll m

outh

deb

ridem

ent t

o en

able

com

preh

ensi

ve e

valu

atio

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d di

agno

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loca

lized

del

iver

y of

ant

imic

robi

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gent

s via

a c

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d re

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e ve

hicl

e in

to d

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ar

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er to

oth

perio

dont

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aint

enan

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711

D572

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D573

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0

D542

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D552

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610

D562

0D5

630

D564

0D5

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D566

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D522

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D522

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D522

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225

D522

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D528

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D541

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D511

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D513

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D521

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D521

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D521

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D521

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D428

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D432

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D434

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D438

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D492

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262262

1 ev

ery

60 m

onth

s fro

m la

st d

ate

of se

rvic

e1

ever

y 60

mon

ths f

rom

last

dat

e of

serv

ice

1 ev

ery

60 m

onth

s fro

m la

st d

ate

of se

rvic

e1

ever

y 60

mon

ths f

rom

last

dat

e of

serv

ice

1 ev

ery

60 m

onth

s fro

m la

st d

ate

of se

rvic

e1

ever

y 60

mon

ths f

rom

last

dat

e of

serv

ice

1 ev

ery

60 m

onth

s fro

m la

st d

ate

of se

rvic

e1

ever

y 60

mon

ths f

rom

last

dat

e of

serv

ice

1 ev

ery

60 m

onth

s fro

m la

st d

ate

of se

rvic

e1

ever

y 60

mon

ths f

rom

last

dat

e of

serv

ice

1 ev

ery

60 m

onth

s fro

m la

st d

ate

of se

rvic

e1

ever

y 60

mon

ths f

rom

last

dat

e of

serv

ice

1 ev

ery

60 m

onth

s fro

m la

st d

ate

of se

rvic

e

1 ev

ery

60 m

onth

s fro

m la

st d

ate

of se

rvic

e1

ever

y 60

mon

ths f

rom

last

dat

e of

serv

ice

1 ev

ery

60 m

onth

s fro

m la

st d

ate

of se

rvic

e1

ever

y 60

mon

ths f

rom

last

dat

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serv

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1 ev

ery

60 m

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s fro

m la

st d

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of se

rvic

e1

ever

y 60

mon

ths f

rom

last

dat

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serv

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1 ev

ery

60 m

onth

s fro

m la

st d

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of se

rvic

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ever

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mon

ths f

rom

last

dat

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serv

ice

1 ev

ery

60 m

onth

s fro

m la

st d

ate

of se

rvic

e1

ever

y 60

mon

ths f

rom

last

dat

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serv

ice

1 ev

ery

60 m

onth

s fro

m la

st d

ate

of se

rvic

e

1 ev

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60 m

onth

s fro

m la

st d

ate

of se

rvic

e1

ever

y 60

mon

ths f

rom

last

dat

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serv

ice

1 ev

ery

60 m

onth

s fro

m la

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ate

of se

rvic

e

1 ev

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60 m

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s fro

m la

st d

ate

of se

rvic

e1

ever

y 60

mon

ths f

rom

last

dat

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serv

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1 ev

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60 m

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m la

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of se

rvic

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mon

ths f

rom

last

dat

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1 ev

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60 m

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s fro

m la

st d

ate

of se

rvic

e1

ever

y 60

mon

ths f

rom

last

dat

e of

serv

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1 ev

ery

60 m

onth

s fro

m la

st d

ate

of se

rvic

e1

ever

y 60

mon

ths f

rom

last

dat

e of

serv

ice

1 ev

ery

60 m

onth

s fro

m la

st d

ate

of se

rvic

e1

ever

y 60

mon

ths f

rom

last

dat

e of

serv

ice

1 ev

ery

60 m

onth

s fro

m la

st d

ate

of se

rvic

e1

ever

y 60

mon

ths f

rom

last

dat

e of

serv

ice

1 ev

ery

60 m

onth

s fro

m la

st d

ate

of se

rvic

e1

ever

y 60

mon

ths f

rom

last

dat

e of

serv

ice

1 ev

ery

60 m

onth

s fro

m la

st d

ate

of se

rvic

e

1 ev

ery

60 m

onth

s fro

m la

st d

ate

of se

rvic

e1

ever

y 60

mon

ths f

rom

last

dat

e of

serv

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1 ev

ery

60 m

onth

s fro

m la

st d

ate

of se

rvic

e1

ever

y 12

mon

ths f

rom

last

dat

e of

serv

ice

1 ev

ery

12 m

onth

s fro

m la

st d

ate

of se

rvic

e1

ever

y 60

mon

ths f

rom

last

dat

e of

serv

ice

1 ev

ery

60 m

onth

s fro

m la

st d

ate

of se

rvic

e1

ever

y 60

mon

ths f

rom

last

dat

e of

serv

ice

1 ev

ery

60 m

onth

s fro

m la

st d

ate

of se

rvic

e

1 ev

ery

12 m

onth

s fro

m la

st d

ate

of se

rvic

e1

ever

y 12

mon

ths f

rom

last

dat

e of

serv

ice

1 ev

ery

12 m

onth

s fro

m la

st d

ate

of se

rvic

e1

ever

y 60

mon

ths f

rom

last

dat

e of

serv

ice

Yes

Yes

Yes

Yes

Yes

Yes

Yes

Yes

Yes

Yes

Yes

Yes

Yes

Yes

Yes

Yes

Yes

Yes

Yes

Yes

Yes

Yes

Yes

Yes

Yes

No

Yes

Yes

Yes

Yes

Yes

Yes

Yes

Yes

Yes

Yes

Yes

Yes

Yes

Yes

Yes

No

No

No

No

No

No

No

No

Yes

No

No

No

No

No

reta

iner

cro

wn-

porc

elai

n/ce

ram

icre

tain

er c

row

n - p

orce

lain

fuse

d to

hig

h no

ble

met

alre

tain

er c

row

n - p

orce

lain

fuse

d to

pre

dom

inan

tly b

ase

met

alre

tain

er c

row

n - p

orce

lain

fuse

d to

nob

le m

etal

reta

iner

onl

ay -

cast

pre

dom

inan

tly b

ase

met

al, t

hree

or m

ore

surf

aces

reta

iner

onl

ay -

cast

nob

le m

etal

, tw

o su

rfac

esre

tain

er o

nlay

- ca

st n

oble

met

al, t

hree

or m

ore

surf

aces

reta

iner

inla

y - t

itani

umre

tain

er o

nlay

- tit

aniu

m

reta

iner

cro

wn

- ind

irect

resi

n ba

sed

com

posi

te (n

ot to

be

used

as a

tem

pora

ry o

r pro

visi

onal

cro

wn)

reta

iner

cro

wn

- res

in w

ith h

igh

nobl

e m

etal

reta

iner

cro

wn

- res

in w

ith p

redo

min

antly

bas

e m

etal

reta

iner

cro

wn

- res

in w

ith n

oble

met

al

reta

iner

inla

y - c

ast p

redo

min

antly

bas

e m

etal

, tw

o su

rfac

esre

tain

er in

lay

- cas

t pre

dom

inan

tly b

ase

met

al, t

hree

or m

ore

surf

aces

reta

iner

inla

y - c

ast n

oble

met

al, t

wo

surf

aces

reta

iner

inla

y - c

ast n

oble

met

al, t

hree

or m

ore

surf

aces

reta

iner

onl

ay -

porc

elai

n/ce

ram

ic, t

wo

surf

aces

reta

iner

onl

ay -

porc

elai

n/ce

ram

ic, t

hree

or m

ore

surf

aces

reta

iner

onl

ay -

cast

hig

h no

ble

met

al, t

wo

surf

aces

reta

iner

onl

ay -

cast

hig

h no

ble

met

al, t

hree

or m

ore

surf

aces

reta

iner

onl

ay -

cast

pre

dom

inan

tly b

ase

met

al, t

wo

surf

aces

pont

ic -

resi

n w

ith n

oble

met

al

prov

isio

nal p

ontic

- fu

rthe

r tre

atm

ent o

r com

plet

ion

of d

iagn

osis

nec

essa

ry p

rior t

o fin

al im

pres

sion

reta

iner

- ca

st m

etal

for r

esin

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ded

fixed

pro

sthe

sis

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cela

in/c

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r res

in b

onde

d fix

ed p

rost

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sre

sin

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iner

- fo

r res

in b

onde

d fix

ed p

rost

hesi

sre

tain

er in

lay-

porc

elai

n/ce

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ic, t

wo

surf

aces

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iner

inla

y - p

orce

lain

/cer

amic

, thr

ee o

r mor

e su

rfac

esre

tain

er in

lay

- cas

t hig

h no

ble

met

al, t

wo

surf

aces

reta

iner

inla

y - c

ast h

igh

nobl

e m

etal

, thr

ee o

r mor

e su

rfac

es

pont

ic -

cast

pre

dom

inan

tly b

ase

met

alpo

ntic

- ca

st n

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met

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ntic

- tit

aniu

mpo

ntic

- po

rcel

ain

fuse

d to

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h no

ble

met

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- po

rcel

ain

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d to

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tly b

ase

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- po

rcel

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le m

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orce

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/cer

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pont

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resi

n w

ith h

igh

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e m

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pont

ic -

resi

n w

ith p

redo

min

antly

bas

e m

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inte

rim p

artia

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ture

(man

dibu

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tissu

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g, m

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indi

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n ba

sed

com

posi

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ntic

- ca

st h

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nobl

e m

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relin

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mpl

ete

man

dibu

lar d

entu

re (l

abor

ator

y)re

line

max

illar

y pa

rtia

l den

ture

(lab

orat

ory)

relin

e m

andi

bula

r par

tial d

entu

re (l

abor

ator

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terim

com

plet

e de

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e (m

axill

ary)

inte

rim c

ompl

ete

dent

ure

(man

dibu

lar)

inte

rim p

artia

l den

ture

(max

illar

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D662

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0D6

720

D672

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722

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D660

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D660

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D576

1D5

810

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263

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1 ev

ery

60 m

onth

s fro

m la

st d

ate

of se

rvic

e1

ever

y 60

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rom

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1 pe

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1 ev

ery

60 m

onth

s fro

m la

st d

ate

of se

rvic

e1

ever

y 60

mon

ths f

rom

last

dat

e of

serv

ice

1 ev

ery

60 m

onth

s fro

m la

st d

ate

of se

rvic

e1

ever

y 60

mon

ths f

rom

last

dat

e of

serv

ice

1 ev

ery

60 m

onth

s fro

m la

st d

ate

of se

rvic

e1

ever

y 60

mon

ths f

rom

last

dat

e of

serv

ice

unlim

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1 ev

ery

6 m

onth

s fro

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st d

ate

of se

rvic

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per l

ifetim

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1 ev

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onth

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st d

ate

of se

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ever

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mon

ths f

rom

last

dat

e of

serv

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1 ev

ery

60 m

onth

s fro

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st d

ate

of se

rvic

e

No

No

No

No

No

No

No

No

No

No

No

No

No

No

Yes

Yes

No

No

Yes

No

No

No

No

No

No

No

No

No

No

No

No

No

Yes

No

Yes

Yes

Yes

Yes

Yes

No

No

No

No

Yes

Yes

Yes

Yes

rem

oval

of b

enig

n od

onto

geni

c cy

st o

r tum

or -

lesi

on d

iam

eter

gre

ater

than

1.2

5 cm

rem

oval

of b

enig

n no

nodo

ntog

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cys

t or t

umor

- le

sion

dia

met

er u

p to

1.2

5 cm

rem

oval

of b

enig

n no

nodo

ntog

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cys

t or t

umor

- le

sion

dia

met

er g

reat

er th

an 1

.25

cmre

mov

al o

f tor

us p

alat

inus

rem

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of t

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man

dibu

laris

inci

sion

and

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abs

cess

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ral s

oft t

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e

alve

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in c

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ith e

xtra

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ne to

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e te

eth

or to

oth

spac

es, p

er q

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ant

alve

olop

last

y no

t in

conj

unct

ion

with

ext

ract

ions

- fo

ur o

r mor

e te

eth

or to

oth

spac

es, p

er q

uadr

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alve

opla

sty

not i

n co

njun

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n w

ith e

xtra

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ne to

thre

e te

eth

or to

oth

spac

es, p

er q

uadr

ant

vest

ibul

opla

sty

- rid

ge e

xten

sion

(sec

onda

ry e

pith

elia

lizat

ion)

vest

ibul

opla

sty

- rid

ge e

xten

sion

(inc

ludi

ng so

ft ti

ssue

gra

fts,

mus

cle

reat

tach

men

t, re

visi

on o

f sof

t ex

cisi

on o

f ben

ign

lesi

on u

p to

1.2

5 cm

exci

sion

of b

enig

n le

sion

gre

ater

than

1.2

5 cm

exci

sion

of b

enig

n le

sion

, com

plic

ated

rem

oval

of b

enig

n od

onto

geni

c cy

st o

r tum

or -

lesi

on d

iam

eter

up

to 1

.25

cm

surg

ical

acc

ess o

f an

uner

upte

d to

oth

mob

iliza

tion

of e

rupt

ed o

r mal

posi

tione

d to

oth

to a

id e

rupt

ion

plac

emen

t of d

evic

e to

faci

litat

e er

uptio

n of

impa

cted

toot

hin

cisi

onal

bio

psy

of o

ral t

issu

e - h

ard

(bon

e, to

oth)

inci

sion

al b

iops

y of

ora

l tis

sue

- sof

t (al

l oth

ers)

exfo

lliat

ive

cyto

logi

cal s

ampl

e co

llect

ion

brus

h bi

opsy

- tr

ans e

pith

elia

l sam

ple

colle

ctio

ntr

ans s

epta

l fib

erot

omy/

supr

a cr

usta

l fib

erot

omy,

by

repo

rt

alve

olop

last

y in

con

junc

tion

with

ext

ract

ions

- fo

ur o

r mor

e te

eth

or to

oth

spac

es, p

er q

uadr

ant

rem

oval

of i

mpa

cted

toot

h - s

oft t

issue

rem

oval

of i

mpa

cted

toot

h - p

artia

lly b

ony

rem

oval

of i

mpa

cted

toot

h - c

ompl

etel

y bo

nyre

mov

al o

f im

pact

ed to

oth

- com

plet

ely

bony

, with

unu

sual

surg

ical

surg

ical

rem

oval

of r

esid

ual t

ooth

root

s (cu

ttin

g pr

oced

ure)

oroa

ntra

l fis

tula

clo

sure

prim

ary

clos

ure

of a

sinu

s per

fora

tion

toot

h re

impl

anta

tion

and/

or st

abili

zatio

n of

acc

iden

tally

avu

lsed

or d

ispl

aced

toot

h

toot

h tr

ansp

lant

atio

n (in

clud

es re

impl

anta

tion

from

one

site

to a

noth

er a

nd sp

lintin

g an

d/or

st

abili

zatio

n)

reta

iner

cro

wn

- ful

l cas

t pre

dom

inan

tly b

ase

met

alre

tain

er c

row

n - f

ull c

ast n

oble

met

alpr

ovis

iona

l ret

aine

r cro

wn-

furt

her t

reat

men

t or c

ompl

etio

n of

dia

gnos

is n

eces

sary

prio

r to

final

im

pres

sion

reta

iner

cro

wn

- tita

nium

rece

men

t or r

e-bo

nd fi

xed

part

ial d

entu

refix

ed p

artia

l den

ture

repa

ir, n

eces

sita

ted

by re

stor

ativ

e m

ater

ial f

ailu

reex

trac

tion,

cor

onal

rem

nant

s - d

ecid

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toot

hex

trac

tion,

eru

pted

toot

h or

exp

osed

root

(ele

vatio

n an

d/or

forc

eps r

emov

al)

surg

ical

rem

oval

of e

rupt

ed to

oth

req

rem

oval

of b

one,

sect

ioni

ng o

f too

th a

nd in

clud

ing

elev

atio

n of

m

ucop

erio

stea

l fla

p

reta

iner

cro

wn

- 3/4

cas

t hig

h no

ble

met

alre

tain

er c

row

n-3/

4 ca

st p

redo

min

atel

y ba

sed

met

alre

tain

er c

row

n-3/

4 ca

st n

oble

met

alre

tain

er c

row

n-3/

4 po

rcel

ain/

cera

mic

reta

iner

cro

wn

- ful

l cas

t hig

h no

ble

met

al

D746

0

D746

1D7

472

D747

3D7

510

D732

0

D732

1D7

340

D735

0D7

410

D741

1D7

412

D745

0D7

451

D728

2D7

283

D728

5D7

286

D728

7D7

288

D729

1

D731

0

D731

1

D723

0D7

240

D724

1D7

250

D726

0D7

261

D727

0

D727

2D7

280

D679

2

D679

3D6

794

D693

0D6

980

D711

1D7

140

D721

0D7

220

D678

0D6

781

D678

2D6

783

D679

0D6

791

264264

Prov

ider

Cla

im D

ispu

tes

unlim

ited

unlim

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1 ev

ery

36 m

onth

s fro

m la

st d

ate

of se

rvic

e1

ever

y 12

mon

ths f

rom

last

dat

e of

serv

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1 ev

ery

6 m

onth

s fro

m la

st d

ate

of se

rvic

e1

ever

y 60

mon

ths f

rom

last

dat

e of

serv

ice

unlim

ited

unlim

ited

unlim

ited

unlim

ited

unlim

ited

unlim

ited

unlim

ited

unlim

ited

1 pe

r too

th1

per t

ooth

unlim

ited

unlim

ited

1 ev

ery

36 m

onth

s fro

m la

st d

ate

of se

rvic

e1

ever

y 36

mon

ths f

rom

last

dat

e of

serv

ice

unlim

ited

1 pe

r life

time

per t

ooth

unlim

ited

1 ev

ery

60 m

onth

s fro

m la

st d

ate

of se

rvic

eun

limite

dun

limite

d

1 pe

r too

th

1 pe

r too

th1

per t

ooth

1 pe

r too

th1

per t

ooth

1 pe

r too

th1

ever

y 6

mon

ths f

rom

last

dat

e of

serv

ice

1 pe

r life

time

per t

ooth

unlim

ited

1 pe

r too

th

No

No

No

No

No

No

No

Yes

Yes

Yes

Yes

No

No

No

No

No

No

No

Yes

No

No

No

No

No

No

No

No

No

No

No

No

No

Yes

Yes

No

No

occl

usal

gua

rd, b

y re

port

repa

ir an

d/or

relin

e of

occ

lusa

l gua

rds

occl

usal

adj

ustm

ent

occl

usio

n an

alys

is -

mou

nted

cas

eoc

clus

al a

djus

tmen

t - li

mite

doc

clus

al a

djus

tmen

t - c

ompl

ete

inha

latio

n of

nitr

ous o

xide

/anx

ioly

sis a

nalg

esia

intr

aven

ous m

oder

ate

(con

scio

us) s

edat

ion/

anal

gesi

a-ea

ch 1

5 m

inut

e in

crem

ent

non-

intr

aven

ous c

onsc

ious

seda

tion.

Thi

s inc

lude

s non

-iv m

inim

al a

nd m

oder

ate

seda

tion.

cons

ulta

tion

(dia

gnos

tic se

rvic

e pr

ovid

ed b

y de

ntis

t or p

hysi

cian

oth

er th

an p

ract

ition

er p

rovi

ding

tr

eatm

ent)

ther

apeu

tic p

aren

tera

l dru

g, si

ngle

adm

inis

trat

ion

ther

apeu

tic p

aren

tera

l dru

gs, t

wo

or m

ore

adm

inis

trat

ions

, diff

eren

t med

icat

ions

othe

r dru

gs a

nd/o

r med

icam

ents

, by

repo

rtap

plic

atio

n of

des

ensi

tizin

g m

edic

amen

tap

plic

atio

n of

des

ensi

tizin

g re

sin

for c

ervi

cal a

nd/o

r roo

t sur

face

, per

toot

h

exci

sion

of p

eric

oron

al g

ingi

vasu

rgic

al re

duct

ion

of fi

brou

s tub

eros

ity

appl

ianc

e re

mov

al (n

ot b

y de

ntis

t who

pla

ced

appl

ianc

e), i

nclu

des r

emov

al o

f arc

hbar

palli

ativ

e (e

mer

genc

y) tr

eatm

ent o

f den

tal p

ain

- min

or p

roce

dure

fixed

par

tial d

entu

re se

ctio

ning

loca

l ane

sthe

sia

not i

n co

njun

ctio

n w

ith o

pera

tive

or su

rgic

al p

roce

dure

slo

cal a

nest

hesi

a in

con

junc

tion

with

ope

rativ

e or

surg

ical

pro

cedu

res

eval

uatio

n fo

r dee

p se

datio

n or

gen

eral

ane

sthe

sia

deep

seda

tion/

gene

ral a

nest

hesi

a-ea

ch 1

5 m

inut

e in

crem

ent

rem

oval

of f

orei

gn b

ody

from

muc

osa,

skin

, or s

ubcu

tane

ous a

lveo

lar t

issu

ere

mov

al o

f rea

ctio

n-pr

oduc

ing

fore

ign

bodi

es -

mus

culo

skel

etal

syst

empa

rtia

l ost

ecto

my/

sequ

estr

ecto

my

for r

emov

al o

f non

-vita

l bon

em

axill

ary

sinus

otom

y fo

r rem

oval

of t

ooth

frag

men

t or f

orei

gn b

ody

occl

usal

ort

hotic

dev

ice

adju

stm

ent

Bone

repl

acem

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raft

for r

idge

pre

serv

atio

n - p

er si

te

fren

ulec

tom

y (fr

enec

tom

y or

fren

otom

y) -

sepa

rate

pro

cedu

re n

ot in

cide

ntal

to a

noth

er p

roce

dure

fren

ulop

last

yex

cisi

on o

f hyp

erpl

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tiss

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per a

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inci

sion

and

dra

inag

e of

abs

cess

- in

trao

ral s

oft t

issu

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ompl

icat

ed (i

nclu

des d

rain

age

of m

ultip

le

fasc

ial s

pace

s)in

cisi

on a

nd d

rain

age

of a

bsce

ss -

extr

aora

l sof

t tis

sue

inci

sion

and

dra

inag

e of

abs

cess

- ex

trao

ral s

oft t

issu

e - c

ompl

icat

ed (i

nclu

des d

rain

age

of m

ultip

le

fasc

ial s

pace

s)

D994

2D9

943

D995

0D9

951

D995

2

D924

3

D924

8

D931

0D9

610

D961

2D9

630

D991

0D9

911

D994

0

D797

2

D799

7D9

110

D912

0D9

210

D921

5D9

219

D922

3D9

230

D788

1D7

953

D796

0D7

963

D797

0D7

971

D751

1D7

520

D752

1D7

530

D754

0D7

550

D756

0

The

Plat

inum

Rid

er D

enta

l sup

plem

enta

l ben

efit

cove

rs th

e de

ntal

cod

es li

sted

abo

ve. T

his s

uppl

emen

tal b

enef

it is

offe

red

to m

embe

rs th

at a

re e

nrol

led

in C

are

Impr

ovem

ent P

lus,

AAR

P M

edic

areC

ompl

ete,

Uni

tedH

ealth

care

M

edic

areC

ompl

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and

Uni

tedH

ealth

care

Ass

iste

d Li

ving

Pla

ns. P

rovi

der p

aym

ent i

s mad

e on

a F

ee-fo

r-Se

rvic

e ba

sis.

Mem

bers

hav

e In

-net

wor

k an

d O

ut-o

f-net

wor

k be

nefit

s. S

ome

serv

ices

requ

ire p

rior a

utho

rizat

ion.

The

$10

00

annu

al m

axim

um a

pplie

s to

cove

red

prev

entiv

e an

d co

mpr

ehen

sive

ben

efits

. Mem

ber c

an b

e bi

lled

for s

ervi

ces o

ver t

he $

1000

ann

ual m

axim

um b

enef

it. T

here

is n

o m

embe

r cop

ay. T

here

is n

o co

insu

ranc

e or

ded

uctib

le fo

r pr

even

tive

and

diag

nost

ic se

rvic

es. T

here

is a

$10

0 in

divi

dual

ded

uctib

le th

at a

pplie

s to

com

preh

ensiv

e be

nefit

s. T

here

is a

20%

coi

nsur

ance

for m

inor

rest

orat

ive/

adju

nctiv

e se

rvic

es a

nd 5

0% c

oins

uran

ce fo

r maj

or d

enta

l ser

vice

s (E

ndod

ontic

s, P

erio

dont

ics a

nd O

ral S

urge

ry).

Dent

al P

rovi

ders

with

com

plai

nts a

re to

con

tact

Uni

tedH

ealth

care

Den

tal’s

Pro

vide

r Ser

vice

dep

artm

ent a

t (87

7) 8

16-3

596.

Net

wor

k Pr

ovid

er c

ontr

actu

al d

ispu

tes,

Out

-of-N

etw

ork

prov

ider

dis

pute

s, a

nd re

proc

essi

ng re

ques

ts w

ill b

e lo

gged

into

the

appe

als d

atab

ase.

Ple

ase

mai

l to

the

Appe

als &

Grie

vanc

es P

O B

ox li

sted

abo

ve. R

esea

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and

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ill b

e co

mpl

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with

in 3

0 ca

lend

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265

Mem

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ppea

ls &

Grie

vanc

es

Prio

r Aut

horiz

atio

n Re

ques

ts

Nat

iona

l_FA

CETS

D00

1337

, D00

1506

7_Pk

g DN

055,

56,

57,

62_

Plat

inum

Den

tal-F

FS28

09/2

016

Mai

l mem

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ppea

ls to

: Uni

tedH

ealth

care

, Att

n: A

ppea

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MS

CA12

4-01

57, P

O B

ox 6

106,

Cyp

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, CA

9063

0

“Prio

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horiz

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quire

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eans

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prac

titio

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ust s

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proc

edur

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l with

clin

ical

doc

umen

tatio

n su

ppor

ting

nece

ssity

bef

ore

perf

orm

ing

thos

e pr

oced

ures

. To

do th

is c

ompl

ete

a st

anda

rd A

DA c

laim

fo

rm a

nd c

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the

box

mar

ked

“Pre

-Tre

atm

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STIM

ATE.

” Pr

ior a

utho

rizat

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requ

est c

an b

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bmitt

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e pr

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eb p

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w.m

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prov

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subm

itted

ele

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ia y

our c

lear

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, or s

impl

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ail t

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form

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belo

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with

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requ

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supp

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enta

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orm

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lms,

nar

rativ

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-cha

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g, e

tc.).

You

r offi

ce w

ill th

en re

ceiv

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Exp

lana

tion

of B

enef

its (E

OB)

out

linin

g th

e de

nial

or a

ppro

val o

f req

uest

ed

trea

tmen

t and

pla

n pa

ymen

t am

ount

s whe

n ap

plic

able

.

Mem

ber a

ppea

ls a

re re

view

ed b

y th

e he

alth

pla

n, a

nd a

re n

ot d

eleg

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to U

HC D

enta

l. Al

l Mem

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ppea

ls (i

nclu

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re-S

ervi

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ppea

ls, I

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Prov

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app

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will

be

forw

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266266

“Prio

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prac

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clin

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doc

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tatio

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ssity

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ore

perf

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thos

e pr

oced

ures

. To

do th

is c

ompl

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a st

anda

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ADA

clai

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rm a

nd c

heck

the

box

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“Pre

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atm

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STIM

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utho

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requ

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an b

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Dent

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doc

umen

tatio

n su

ppor

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nece

ssity

bef

ore

perf

orm

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thos

e pr

oced

ures

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do th

is c

ompl

ete

a st

anda

rd

ADA

clai

m fo

rm a

nd c

heck

the

box

mar

ked

“Pre

-Tre

atm

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STIM

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ior a

utho

rizat

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requ

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an b

e su

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ia th

e pr

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eb p

orta

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ww

w.m

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prov

ider

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m),

subm

itted

ele

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nica

lly v

ia y

our

Dent

al P

rovi

ders

with

com

plai

nts a

re to

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Uni

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Den

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Pro

vide

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dep

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271

272272

274274

“Prio

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is c

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mar

ked

“Pre

-Tre

atm

ent E

STIM

ATE.

” Pr

ior a

utho

rizat

ion

requ

est c

an b

e su

bmitt

ed v

ia th

e pr

ovid

er w

eb p

orta

l (at

ww

w.m

yuhc

prov

ider

s.co

m),

subm

itted

ele

ctro

nica

lly v

ia y

our

Dent

al P

rovi

ders

with

com

plai

nts a

re to

con

tact

Uni

tedH

ealth

care

Den

tal’s

Pro

vide

r Ser

vice

dep

artm

ent a

t

275

276276

$180

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can

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ww

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277

Proc

edur

e Co

dePr

oced

ure

Des

crip

tion

Prio

r Aut

horiz

atio

n Re

quire

d?

D027

3D0

274

D033

0D1

110

D214

0

D012

0D0

140

D015

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270

D027

2

D233

2D2

335

D911

0

D239

2

D215

0D2

160

D216

1D2

330

D233

1

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391

resi

n-ba

sed

com

posi

te -

thre

e su

rfac

es, a

nter

ior

resi

n-ba

sed

com

posi

te -

four

or m

ore

surf

aces

or i

nvol

ving

inci

sal a

ngle

(ant

erio

r)re

sin-

base

d co

mpo

site

cro

wn,

ant

erio

rre

sin-

base

d co

mpo

site

- on

e su

rfac

e, p

oste

rior

resi

n-ba

sed

com

posi

te -

two

surf

aces

, pos

terio

r

bite

win

gs -

four

radi

ogra

phic

imag

espa

nora

mic

radi

ogra

phic

imag

epr

ophy

laxi

s - a

dult

D731

1

D434

1D4

342

D435

5D4

910

D711

1

D275

1D2

752

D279

1D2

792

D292

0D2

930

D293

1D2

940

D295

0D2

954

D714

0

D721

0D7

250

D731

0

D239

3D2

394

D271

0D2

740

D275

0

No

No

No

palli

ativ

e (e

mer

genc

y) tr

eatm

ent o

f den

tal p

ain

- min

or p

roce

dure

extr

actio

n, e

rupt

ed to

oth

or e

xpos

ed ro

ot (e

leva

tion

and/

or fo

rcep

s rem

oval

)su

rgic

al re

mov

al o

f eru

pted

toot

h re

q re

mov

al o

f bon

e, se

ctio

ning

of t

ooth

and

incl

udin

g el

evat

ion

of

muc

oper

iost

eal f

lap

surg

ical

rem

oval

of r

esid

ual t

ooth

root

s (cu

ttin

g pr

oced

ure)

alve

olop

last

y in

con

junc

tion

with

ext

ract

ions

- fo

ur o

r mor

e te

eth

or to

oth

spac

es, p

er q

uadr

ant

alve

opla

sty

in c

onju

nctio

n w

ith e

xtra

ctio

n - o

ne to

thre

e te

eth

or to

oth

spac

es, p

er q

uadr

ant

perio

dont

al sc

alin

g an

d ro

ot p

lann

ing

- fou

r or m

ore

teet

h pe

r qua

dran

tpe

riodo

ntal

scal

ing

and

root

pla

nnin

g - o

ne -

thre

e te

eth,

per

qua

dran

tfu

ll m

outh

deb

ridem

ent t

o en

able

com

preh

ensi

ve e

valu

atio

n an

d di

agno

sis

perio

dont

al m

aint

enan

ceex

trac

tion,

cor

onal

rem

nant

s - d

ecid

uous

toot

h

pref

abric

ated

stai

nles

s ste

el c

row

n - p

rimar

y to

oth

pref

abric

ated

stai

nles

s ste

el c

row

n - p

erm

anen

t too

thpr

otec

tive

rest

orat

ion

Core

bui

ldup

, inc

ludi

ng a

ny p

ins w

hen

requ

ired

pref

abric

ated

pos

t and

cor

e in

add

ition

to c

row

n

crow

n - p

orce

lain

fuse

d to

pre

dom

inan

tly b

ase

met

alcr

own

- por

cela

in fu

sed

to n

oble

met

alcr

own

- ful

l cas

t pre

dom

inan

tly b

ase

met

alcr

own

- ful

l cas

t nob

le m

etal

rece

men

t or r

e-bo

nd c

row

n

No

No

No

amal

gam

- on

e su

rfac

e, p

rimar

y or

per

man

ent

crow

n - p

orce

lain

fuse

d to

hig

h no

ble

met

al

No

No

No

No

No

No

resi

n-ba

sed

com

posi

te -

four

or m

ore

surf

aces

, pos

terio

rcr

own,

resi

n-ba

sed

com

posi

te (i

ndire

ct)

crow

n - p

orce

lain

/cer

amic

subs

trat

e

No

No

No

No

perio

dic

oral

eva

luat

ion

limite

d or

al e

valu

atio

n - p

robl

em fo

cuse

dco

mpr

ehen

sive

ora

l eva

luat

ion

- new

or e

stab

lishe

d pa

tient

bite

win

g - s

ingl

e ra

diog

raph

ic im

age

bite

win

gs -

two

radi

ogra

phic

imag

esbi

tew

ings

- th

ree

radi

ogra

phic

imag

es

No

No

No

No

No

No

No

No

No

No

No

No

No

No

unlim

ited

unlim

ited

No

No

unlim

ited

unlim

ited

unlim

ited

unlim

ited

unlim

ited

unlim

ited

unlim

ited

unlim

ited

unlim

ited

unlim

ited

No

No

No

No

No

No

No

No

No

No

2 ev

ery

year

unlim

ited

2 ev

ery

year

unlim

ited

unlim

ited

unlim

ited

unlim

ited

unlim

ited

unlim

ited

unlim

ited

unlim

ited

unlim

ited

unlim

ited

unlim

ited

unlim

ited

unlim

ited

2 ev

ery

year

2 ev

ery

year

2 ev

ery

year

2 ev

ery

year

1 ev

ery

36 m

onth

s fro

m la

st d

ate

of se

rvic

e2

ever

y ye

ar

Cove

red

Den

tal S

ervi

ces:

Mos

t den

tal s

ervi

ces i

nclu

ding

Pre

vent

ive,

Dia

gnos

tic, R

esto

rativ

e, E

ndod

ontic

s, P

erio

dont

ics,

Ext

ract

ions

, Ora

l Sur

gery

, and

Pro

stho

dont

ics a

re c

over

ed. O

rtho

dont

ics a

nd c

osm

etic

se

rvic

es a

re n

ot c

over

ed. T

he b

elow

is a

list

of s

ome

of th

e co

vere

d co

des.

amal

gam

- tw

o su

rfac

es, p

rimar

y or

per

man

ent

amal

gam

- th

ree

surf

aces

, prim

ary

or p

erm

anen

tam

alga

m -

four

or m

ore

surf

aces

, prim

ary

or p

erm

anen

t

unlim

ited

unlim

ited

unlim

ited

unlim

ited

unlim

ited

unlim

ited

unlim

ited

unlim

ited

unlim

ited

unlim

ited

unlim

ited

unlim

ited

resi

n-ba

sed

com

posi

te -

one

surf

ace,

ant

erio

rre

sin-

base

d co

mpo

site

- tw

o su

rfac

es, a

nter

ior

No

No

No

No

resi

n-ba

sed

com

posi

te -

thre

e su

rfac

es, p

oste

rior

Freq

uenc

y/Li

mita

tions

278278

Prov

ider

Cla

im D

ispu

tes

Mem

ber A

ppea

ls &

Grie

vanc

es

Prio

r Aut

horiz

atio

n Re

ques

ts

AZ, C

O, F

L_FA

CETS

D00

1477

7_Pk

g DT

052_

DT00

1-P1

800a

-FFS

28

09/2

016

Mai

l mem

ber a

ppea

ls to

: Uni

tedH

ealth

care

, Att

n: A

ppea

ls a

nd G

rieva

nce

Depa

rtm

ent,

PO B

ox 6

106,

MS

CA12

4-01

57, C

ypre

ss, C

A 90

630

“Prio

r Aut

horiz

atio

n re

quire

d” m

eans

the

prac

titio

ner m

ust s

ubm

it th

ose

proc

edur

es fo

r app

rova

l with

clin

ical

doc

umen

tatio

n su

ppor

ting

nece

ssity

bef

ore

perf

orm

ing

thos

e pr

oced

ures

. To

do th

is c

ompl

ete

a st

anda

rd

ADA

clai

m fo

rm a

nd c

heck

the

box

mar

ked

“Pre

-Tre

atm

ent E

STIM

ATE.

” Pr

ior a

utho

rizat

ion

requ

est c

an b

e su

bmitt

ed v

ia th

e pr

ovid

er w

eb p

orta

l (at

ww

w.m

yuhc

prov

ider

s.co

m),

subm

itted

ele

ctro

nica

lly v

ia y

our

clea

ringh

ouse

, or s

impl

y m

ail t

he fo

rm, t

o th

e be

low

add

ress

, alo

ng w

ith a

ny re

quire

d su

pple

men

tal i

nfor

mat

ion

(film

s, n

arra

tive,

per

io-c

hart

ing,

etc

.). Y

our o

ffice

will

then

rece

ive

an E

xpla

natio

n of

Ben

efits

(EO

B)

outli

ning

the

deni

al o

r app

rova

l of r

eque

sted

trea

tmen

t and

pla

n pa

ymen

t am

ount

s whe

n ap

plic

able

.

The

Uni

tedH

ealth

care

Nur

sing

Hom

e Pl

an a

nd A

ssis

ted

Livi

ng P

lan

cove

rs th

e de

ntal

cod

es li

sted

abo

ve. P

rovi

der p

aym

ent i

s mad

e on

a F

ee-fo

r-Se

rvic

e ba

sis.

Mem

bers

hav

e bo

th In

-Net

wor

k an

d O

ut-o

f-Net

wor

k co

vera

ge. S

ervi

ces d

o no

t req

uire

prio

r aut

horiz

atio

n. T

he d

enta

l pla

n ha

s a $

1800

ann

ual m

axim

um th

at a

pplie

s to

cove

red

prev

entiv

e an

d co

mpr

ehen

sive

ben

efits

. The

re is

no

mem

ber c

opay

, coi

nsur

ance

or

dedu

ctib

le. M

embe

r can

be

bille

d fo

r ser

vice

s ove

r the

$18

00 a

nnua

l max

imum

ben

efit.

Dent

al P

rovi

ders

with

com

plai

nts a

re to

con

tact

Uni

tedH

ealth

care

Den

tal’s

Pro

vide

r Ser

vice

dep

artm

ent a

t 877

-816

-359

6. N

etw

ork

Prov

ider

con

trac

tual

dis

pute

s, O

ut-o

f-Net

wor

k pr

ovid

er d

ispu

tes,

and

repr

oces

sing

re

ques

ts w

ill b

e lo

gged

into

the

appe

als d

atab

ase.

Ple

ase

mai

l to

the

Appe

als &

Grie

vanc

es P

O B

ox li

sted

abo

ve. R

esea

rch

and

reso

lutio

n w

ill b

e co

mpl

eted

with

in 3

0 ca

lend

ar d

ays.

Mem

ber a

ppea

ls a

re re

view

ed b

y th

e he

alth

pla

n, a

nd a

re n

ot d

eleg

ated

to U

HC D

enta

l. Al

l Mem

ber a

ppea

ls (i

nclu

des P

re-S

ervi

ce a

ppea

ls, I

n N

etw

ork

Prov

ider

app

eals

, and

Out

of N

etw

ork

prov

ider

app

eals

) rec

eive

d by

U

HC D

enta

l will

be

forw

arde

d to

the

heal

th p

lan

via

over

nigh

t mai

l, w

ithin

7 d

ays o

f rec

eipt

of t

he a

ppea

l.

279

280280

282282

“Prio

r Aut

horiz

atio

n re

quire

d” m

eans

the

prac

titio

ner m

ust s

ubm

it th

ose

proc

edur

es fo

r app

rova

l with

clin

ical

doc

umen

tatio

n su

ppor

ting

nece

ssity

bef

ore

perf

orm

ing

thos

e pr

oced

ures

. To

do th

is c

ompl

ete

a st

anda

rd

ADA

clai

m fo

rm a

nd c

heck

the

box

mar

ked

“Pre

-Tre

atm

ent E

STIM

ATE.

” Pr

ior a

utho

rizat

ion

requ

est c

an b

e su

bmitt

ed v

ia th

e pr

ovid

er w

eb p

orta

l (at

ww

w.m

yuhc

prov

ider

s.co

m),

subm

itted

ele

ctro

nica

lly v

ia y

our

Dent

al P

rovi

ders

with

com

plai

nts a

re to

con

tact

Uni

tedH

ealth

care

Den

tal’s

Pro

vide

r Ser

vice

dep

artm

ent a

t

283

284284

2017 Provider Quick Reference Guide for Medicare Advantage Plans

UnitedHealthcareAttn: Provider Quick Reference Guidec/o PCA15 W. Aylesbury Road, Suite 200Timonium, MD 21093

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