INDIANA DENTAL HEALTH PARTNER MANUAL - CareSource

CareSource | Health Partner Dental Manual
INDIANA DENTAL HEALTH PARTNER MANUAL HOOSIER HEALTHWISE | HEALTHY INDIANA PLAN
CARESOURCE HOOSIER HEALTHWISE (HHW) DENTAL QUICK REFERENCE GUIDE At CareSource®, our goal is to help you improve and maintain the dental health of our members. This guide shares information about covered services, authorization requirements and claim and authorization submissions for Indiana Hoosier Healthwise (HHW) members.
Both adults and children who are enrolled in Hoosier Healthwise are covered for dental services.
DENTAL SERVICES THAT REQUIRE PRIOR AUTHORIZATION • Gingivectomy or gingivoplasty
• Periodontal scaling and root planing
• Complete dentures
• Partial dentures
• Orthodontia services
PROVIDER PORTAL CareSource offers a Dental Provider Web Portal. Just log in to the CareSource Provider Portal and click the “Dental Provider Login” link on the left. The portal can also be accessed directly by visiting https://pwp.sciondental.com/PWP/Landing. The time-saving functions of the Dental Provider Web Portal allow you to:
• Verify member eligibility
• View member service history, covered benefits and fee schedules.
• Create a member eligibility calendar and view real-time eligibility for multiple members.
• View authorization guidelines and required documentation prior to submitting authorizations.
• Submit authorizations with attachments for faster determinations.
For questions about the Dental Provider Web Portal, contact the web portal team at [email protected] or call 1-855-434-9239.
COVERED DENTAL SERVICES
ELECTRONIC FUNDS TRANSFER We encourage our dental health partners to enroll in Scion Dental’s Electronic Funds Transfer (EFT) to enjoy efficient and reliable claim payments. Visit https://pwp.sciondental.com/PWP/Landing to enroll.
PRIOR AUTHORIZATION Online: Dental health partners may submit authorization requests online at https://pwp.sciondental.com/PWP/Landing. Paper: CareSource GA: Authorization P.O. Box 474 Milwaukee, WI 53201
Contact the web portal team at [email protected] or call 1-855-434-9239 for questions regarding online submissions.
Contact CareSource Health Partner Services at 1-844-607-2831 for any questions regarding paper submissions.
HEALTH PARTNER COMPLAINTS Health partners may submit a complaint to CareSource. A health partner complaint is a written expression, which indicates dissatisfaction or dispute with CareSource’s policies, procedures or any aspect of CareSource’s administrative functions. Health partners have 30 calendar days from the date of the incident to file a health partner complaint: CareSource Attn: Health Partner Complaints – Indiana P.O. Box 2008 Dayton OH 45401-2008
Phone: 1-855-202-1058
CLAIM DISPUTES AND APPEALS Health partners may submit claim disputes and appeals through the CareSource Provider Portal or in writing. You must submit a dispute before requesting an appeal. Health partners have 60 calendar days after receipt of claim determination to submit a dispute, and 60 days from resolution of dispute to submit an appeal.
Provider Portal: https://providerportal.CareSource.com/IN Click the “Claim Disputes” or “Claim Appeals” link on the left.
Writing: Complete the appropriate form and follow the instructions to submit it to CareSource:
• Disputes*
• Appeals*
*You can find these forms online at https://www.caresource.com/providers/ indiana/medicaid/plan-resources/forms/ and in the Dental Forms section of this manual.
MEMBER GRIEVANCES AND APPEALS Health partners may also submit grievances and appeals on a member’s behalf, if the member’s written consent is obtained. All grievances should be clearly documented. Individuals who make decisions on grievances and appeals that involve clinical issues are health care professionals, under the supervision of CareSource’s Medical Director, who have the appropriate clinical expertise in treating the member’s condition or disease and who were not involved in any previous level of review or decision-making. CareSource responds to all grievances within 30 days of receipt. CareSource responds to all appeals in writing as fast as the member’s health condition requires, but no later than 20 business days after receipt of a standard appeal request. CareSource responds to all expedited appeal requests within 48 hours of receipt.
CARESOURCE HEALTHY INDIANA PLAN (HIP) DENTAL QUICK REFERENCE GUIDE At CareSource®, our goal is to help you improve and maintain the dental health of our members. This guide shares information about covered services, authorization requirements and claim and authorization submissions for Healthy Indiana Play (HIP) members.
Individuals age 19-64 who are enrolled in HIP Plus are covered for dental services:
HIP Basic members age 21-64 do NOT have dental coverage as part of their plan. DENTAL SERVICES THAT REQUIRE PRIOR AUTHORIZATION
• Gingivectomy or gingivoplasty
• Complete dentures
• Partial dentures
• Orthodontia services
PROVIDER PORTAL CareSource offers a Dental Provider Web Portal. Just log in to the CareSource Provider Portal and click the “Dental Provider Login” link on the left. The portal can also be accessed directly by visiting https://pwp.sciondental.com/PWP/Landing. The time-saving functions of the Dental Provider Web Portal allow you to:
• Verify member eligibility
• View member service history, covered benefits and fee schedules.
• Create a member eligibility calendar and view real-time eligibility for multiple members.
• View authorization guidelines and required documentation prior to submitting authorizations.
• Submit authorizations with attachments for faster determinations.
For questions about the Dental Provider Web Portal, contact the web portal team at [email protected] or call 1-855-434-9239.
COVERED DENTAL SERVICES
ELECTRONIC FUNDS TRANSFER We encourage our dental health partners to enroll in Scion Dental’s Electronic Funds Transfer (EFT) to enjoy efficient and reliable claim payments. Visit https://pwp.sciondental.com/PWP/Landing to enroll.
PRIOR AUTHORIZATION Online: Dental health partners may submit authorization requests online at https://pwp.sciondental.com/PWP/Landing. Paper: CareSource GA: Authorization P.O. Box 474 Milwaukee, WI 53201
Contact the web portal team at [email protected] or call 1-855-434-9239 for questions regarding online submissions.
Contact CareSource Health Partner Services at 1-844-607-2831 for any questions regarding paper submissions.
HEALTH PARTNER COMPLAINTS Health partners may submit a complaint to CareSource. A health partner complaint is a written expression which indicates dissatisfaction or dispute with CareSource’s policies, procedures or any aspect of CareSource’s administrative functions. Health partners have 30 calendar days from the date of the incident to file a health partner complaint: CareSource Attn: Health Partner Complaints – Indiana P.O. Box 2008 Dayton OH 45401-2008
Phone: 1-855-202-1058
CLAIM DISPUTES AND APPEALS Health partners may submit claim disputes and appeals through the CareSource Provider Portal or in writing. You must submit a dispute before requesting an appeal. Health partners have 60 calendar days after receipt of claim determination to submit a dispute, and 60 days from resolution of dispute to submit an appeal.
Provider Portal: https://providerportal.CareSource.com/IN Click the “Claim Disputes” or “Claim Appeals” link on the left.
Writing: Complete the appropriate form and follow the instructions to submit it to CareSource:
• Disputes*
• Appeals*
*You can find these forms online at https://www.caresource.com/providers/ indiana/medicaid/plan-resources/forms/ and in the Dental Forms section of this manual.
MEMBER GRIEVANCES AND APPEALS Health partners may also submit grievances and appeals on a member’s behalf, if the member’s written consent is obtained. All grievances should be clearly documented. Individuals who make decisions on grievances and appeals that involve clinical issues are health care professionals, under the supervision of CareSource’s Medical Director, who have the appropriate clinical expertise in treating the member’s condition or disease and who were not involved in any previous level of review or decision-making. CareSource responds to all grievances within 30 days of receipt. CareSource responds to all appeals in writing as fast as the member’s health condition requires, but no later than 20 business days after receipt of a standard appeal request. CareSource responds to all expedited appeal requests within 48 hours of receipt.
This content has been reviewed; however, changes and/or revisions occur frequently. Health partners should check our website at CareSource.com for the most current version of this manual.
DEAR CARESOURCE® DENTAL HEALTH PARTNER, CareSource welcomes your participation with our Indiana community and is pleased you have joined our network. CareSource is nationally recognized for leading the industry in providing member-centric health care coverage.
At CareSource, our goal is to help you improve and maintain the dental health of our members. We are committed to providing accessible, quality, comprehensive dental health care for our members, in the most cost-effective and efficient manner possible. We realize that to do so, strong partnerships with our providers are critical. We value this relationship as an important mission, and we work continuously to strengthen that partnership.
The CareSource Dental Health Partner Manual is designed as part of an initiative to improve efficiency and consistency in our care management services. It is intended to be a comprehensive resource for you and a helpful link between your office and CareSource.
Here you will find the tools and information needed to successfully administer dental services to our members. It provides important information on topics such as covered services, prior authorization and claims. Our intention is to lessen administrative burden and make it easier for you to do business with us.
As always, we are interested in your feedback. We will continue to update information periodically, and as changes and new information arise we will send updates to you or invite you to check what’s new on our health partner plan resources page.
CareSource has partnered with Scion Dental to further enhance the efficiency and consistency of our dental management services. Through our partnership with Scion, we offer enhanced functionality to our health partners. For your convenience, we offer free access and availability to secure online portals 24 hours a day.
You can access the Scion portal from the CareSource Provider Portal at https://providerportal.caresource.com/IN/ or directly at https://pwp.sciondental.com. You will find a variety of tools available for web-based transactions. The Scion web portal features an online provider inquiry tool for real-time eligibility, claims and authorization management. Scion Dental will handle all claim payments on our behalf. We encourage you to enroll for electronic funds transfer (EFT) to ensure faster payment.
If you have inquiries about claim issues, covered services, patient eligibility or other member-related concerns, please check our website or contact CareSource Health Partner Services at 1-844-607-2831, 8 a.m. to 8 p.m., Monday through Friday, Eastern Standard Time.
Oral health is an integral part of overall health and is important for our members. You play an important role as we serve our communities. Thank you for being a CareSource health partner.
We know you have a choice, and we are pleased that you are part of our network.
TABLE OF CONTENTS ABOUT US ......................................................................... 10
Who We Are .................................................................... 10
Vision and Mission ............................................................ 10
COMMUNICATING WITH US .................................................... 12
Website ......................................................................... 12
Complaints/Grievances ....................................................... 13
Credentialing ................................................................... 14
Access and Registration ..................................................... 16
Verify Member Eligibility ..................................................17
CLAIMS ............................................................................ 22
Online ........................................................................... 22
Paper ............................................................................ 22
COVERED DENTAL SERVICE CATEGORIES: CLINICAL INDICATIONS ASSOCIATED LIMITATIONS AND REQUIREMENTS .......................... 26
D0100 – D0999 DIAGNOSTIC SERVICES ................................... 27
D1110 – D1999 PREVENTIVE SERVICES ................................... 33
D2140 – D2999 RESTORATIVE SERVICES ................................. 37
D3110 – D3999 ENDODONTIC SERVICES .................................. 43
D4210 – D4999 PERIODONTIAL SERVICES ............................... 47
D5000 – D5899 REMOVABLE PROSTHODONTIC SERVICES ............ 51
D5900 – D5999 MAXILLOFACIAL PROSTHETICS ........................ 56
D6205 – D6999 PROSTHODONTICS (FIXED) .............................. 58
D7000 – D7999 ORAL AND MAXILLOFACIAL SURGERY ................ 59
D8000 – D8999 ORTHODONTICS ........................................... 73
DENTAL FORMS .................................................................. 82
ABOUT US Welcome, and thank you for becoming a participating health partner with CareSource.
• At CareSource, we call health care providers our health partners. A “health partner” is any health care provider who participates in CareSource’s provider network. You may find “health partner” and health care provider used interchangeably in our manual, agreements and website.
• CareSource is a leading nonprofit managed care company headquartered in Dayton, Ohio. CareSource has been meeting the needs of health care consumers for more than 25 years. Now expanding and serving five states, we have built a legacy of providing quality health care coverage for Medicaid consumers. Every year, CareSource is growing to meet the health care needs of Americans, and we are excited to support our “heartbeat” mission in Indiana.
Who We Are
CareSource was founded on the principles of quality and service delivered with compassion and a thorough understanding of caring for underserved consumers. As a nonprofit organization, we are mission-driven to provide quality care to our members. We offer process efficiencies and value-added benefits for our members and participating health partners.
Vision and Mission
• Our vision is transforming lives through innovative health and life services.
• Our mission is to make a lasting difference in our members’ lives by improving their health and well-being.
• At CareSource, our mission is one we take to heart. In fact, we call our mission our “heartbeat.” It is the essence of our company, and our unwavering dedication is the hallmark of our success.
Our goal is to create an integrated health care home for our members.
Our Commitment to Oral Health
CareSource recognizes and understands the vital role oral health plays in the overall health and well-being of our members. We are committed to decreasing oral health disparities through primary prevention; dental/oral health education; improving access to comprehensive quality oral health care; engaging and collaborating with stakeholders and professional associations; policy development, community engagement and ensuring that our care management services streamline into positive experiences for our dental health provider network and their teams.
CareSource is working innovatively to ensure real-time communication with our providers and members, implementing efficient procedures and case reviews, updated policies, enhanced coverage (for adults), patient education, provider resources, provider incentives to promote quality wellness for our members and much more.
COMMUNICATING WITH US Phone Numbers and Hours of Operation
To help us direct your call to the appropriate professional for assistance, you will be instructed to select the menu option(s) that best fits your need. Please note that our menu options are subject to change. We provide telephone-based, self-service applications that allow you to verify member eligibility.
Katie, our automated phone system, will help you and our members reach the best person to assist in the quickest, most efficient way possible.
Health Partner Services • Benefit Questions • Provider Issues/
Concerns • CareSource Policies
1-844-607-2831 Monday to Friday, 8 a.m. to 8 p.m. (EST)
Scion Dental Provider Portal Issues 1-855-434-9239 Monday to Friday, 9 a.m. to 6 p.m. (EST)
Member Services 1-844-607-2829 Monday to Friday, 8 a.m. to 8 p.m. (EST)
CareSource24® (Nurse Advice Line) 1-800-206-5947 24/7/365
Website
Network Notifications
Correspondence Address
Fraud, Waste and Abuse
You have a responsibility to report suspected fraud, waste or abuse. You can do so by contacting us using the following mechanisms:
CareSource Attn: Special Investigations Department P.O. Box 1940 Dayton, OH 45401-1940
Call 1-888-880-4889 and follow the prompts for reporting fraud.
Email: [email protected]
The fraud reporting form may be found at CareSource.com.
Information reported to us can be reported anonymously and is kept confidential to the extent permitted by law.
Complaints/Grievances
Health partners are permitted to submit complaints to CareSource regarding CareSource’s policies, procedures or any aspect of CareSource’s administrative functions. All health partner complaints should be clearly documented.
Health partners have 30 calendar days from the date of the incident to file a provider complaint:
CareSource Health Partner Complaints – Indiana P.O. Box 2008 Dayton OH 45401-2008
Phone: 1-855-202-1058
CareSource responds to all grievances within 30 days of receipt.
CareSource responds to all appeals in writing as fast as the member’s health condition requires, but no later than 20 business days after receipt of a standard appeal request.
CareSource responds to all expedited appeal requests within 48 hours of receipt.
We ensure that CareSource executives with the authority to require corrective action are involved in the health partner complaint process.
Credentialing
CareSource credentials and recredentials all licensed independent practitioners including physicians, facilities and non-physicians with whom it contracts and who fall within its scope of authority and action. Through credentialing, CareSource checks the qualifications and performance of physicians and other health care practitioners. Our Senior Medical Director is responsible for the credentialing and recredentialing program. Please refer to the CareSource Indiana Health Partner Manual for detailed information about contracting and credentialing.
SCION PROVIDER PORTAL Access and Registration
Dental health partners can access the Scion portal directly at https://pwp.sciondental.com/PWP/Landing or via the “Dental Provider Login” link on the CareSource Provider Portal.
New health partners should register prior to accessing the portals. To register for the Scion Provider Web Portal, click the “Register Now” link.
Online access requires only an internet browser, a valid user ID and a password. From an internet browser, health partners and authorized office staff can log in for secured access to the system anytime from anywhere to handle a variety of day-to-day tasks, including:
• Checking patient treatment history for specific services
• Submitting claims for services rendered by simply entering procedure codes, tooth numbers, etc.
• Submitting authorization requests using interactive clinical algorithms when appropriate
• Sending electronic attachments, such as digital x-rays, Explanations of Benefits (EOBs) and treatment plans
• Checking the status of submitted claims and authorizations
• Accessing and reviewing remittance information
• Downloading and printing provider manuals, clinical criteria, provider newsletters and fee schedules
• Verifying eligibility and prepopulating claim forms for online submission
• Uploading and downloading documents using a secure encryption protocol
• Participating in provider surveys to rate satisfaction with Scion Dental
Member Eligibility, Claim Processing and More
Once registered, health partners can begin verifying eligibility, processing claims, submitting and checking the status of authorizations and much more. We have streamlined the process for you, using Scion’s technology tools for efficiency.
Verify Member Eligibility
• Verify up to 250 members at one time.
• View member eligibility and service history reports.
• Manage patient rosters and schedule appointments on the patient calendar.
Manage Claims
The Scion provider portal can be used to submit and view claims in real time.
• Submit claims for services performed.
• Review and print or save a list of claims submitted today for your records, before they are sent on for processing.
• Check the status of previously submitted claims.
• View pre-claim estimate reports.
• Search for historical claims and authorizations.
• View a claims dashboard for an overview of recently submitted claims.
• Create a provider-billed amounts list for service codes.
Obtain Authorizations
• Submit authorizations before performing services to obtain approval.
• Attach electronic files, including x-rays, and review submitted authorizations before they are sent on for processing.
• Check the status of previously submitted authorizations.
Other Tasks
• View primary care assignment reports for associated providers.
• Upload files and review files shared by associated insurers and/or networks.
• View and edit official contact information for providers, locations and payees.
• Create and manage portal subaccounts for staff.
• Manage personal portal account information. The Scion Portal team is available to train providers by hosting webinars and/or on-site training/seminars quarterly. Contact the web portal team at [email protected] or call 1-855-434-9239.
DENTAL ELIGIBILITY The following CareSource members have dental coverage as part of their plan:
• Hoosier Healthwise members
• HIP Plus members
• HIP State Plan members
HIP Basic members age 21-64 do NOT have dental coverage as part of their plan.
Dental providers are responsible for verifying that members are eligible at the time services are rendered and determining if members have other health insurance.
Use the Scion Provider Web Portal to view real-time member eligibility. The portal is located at https://sdsfpwp.wonderboxsystem.com/PWP/Landing.
You can also verify a member’s eligibility by calling our automated phone system at 1-844-607-2831.
Please note due to possible eligibility status changes, the information provided does not guarantee payment. If you are having difficulty verifying eligibility, please contact Health Partner Services at 1-844-607-2831.
PRIOR AUTHORIZATION Online
Dental health partners may submit online prior authorizations requests at https://pwp.sciondental.com/PWP/Landing.
Contact the web portal team at [email protected] or call 1-855-434-9239 for questions regarding the web portal.
Paper
Send paper prior authorization requests to: CareSource IN: Authorization P.O. Box 745 Milwaukee, WI, 53201
Contact CareSource Health Partner Services at 1-844-607-2831 for questions regarding prior authorization requests.
CLAIMS Online
Contact the web portal team at [email protected] or call 1-855-434-9239 for any questions regarding the web portal.
We encourage our health partners to enroll directly with Scion Dental to receive electronic funds transfer (EFT) payments.
Paper
CareSource Attn: Claims Department P.O. Box 3607 Dayton, OH 45401
Contact CareSource Health Partner Services at 1-844-607-2831 for questions regarding claim submissions.
Filing Limits
The timely filing requirement for the CareSource Medicaid programs is 90 calendar days from the date of service and receipt of claim. CareSource determines whether a claim has been filed timely by comparing the date of service to the receipt date applied to the claim when the claim is received. If the span between these two dates exceeds the time limitation, the claim is considered to have not been filed timely.
Coordination of Benefits
All claims must be filed with commercial insurance companies or third party administrators prior to filing claims with CareSource via Scion for reimbursement for services rendered to CareSource members.
If CareSource is not the primary payer you must bill the primary payer first. If the claim is initially filed with CareSource via Scion, the claim will be denied. If the primary payor pays less than the agreed upon fee, you may bill CareSource for the balance if a covered benefit of CareSource. Remaining charges will be reimbursed up to the maximum allowed amount had CareSource paid as the primary payer. You must enclose the Remittance Advice from the primary payor. CareSource must receive the claim within 90 calendar days of the date of the primary payer’s Remittance Advice.
Claim Disputes and Appeals
If you are dissatisfied with a determination made by our Medical Management department regarding a member’s dental services or benefits, you may dispute and appeal the decision.
If you believe the claim was processed incorrectly due to incomplete, incorrect or unclear information on the claim, you should submit a corrected claim. You do not need to file a dispute or appeal.
Claim Disputes • The health partner must complete a claim dispute prior to requesting an appeal.
• The dispute must be submitted within 60 days after the health partner’s receipt of the written determination of the claim.
• If CareSource fails to decision a claim within 30 days after receipt, the 90 day submission period for the dispute begins as of the claim submission date per 405 IAC 1-1.6-1.
• Claim disputes may be submitted using the CareSource Provider Portal or in writing.
- CareSource Provider Portal: https://providerportal.caresource.com/IN – Click the “Claim Disputes” link on the left.
- Writing: Use the Claim Dispute form*.
Claim Appeals • Health partners may only submit appeals after completing the claim dispute process
as outlined above.
• Appeals must be submitted within 60 days of the resolution of the informal dispute process.
• CareSource must issue a written decision within 45 days of receipt of the written request for appeal.
• If the appeal is not resolved within the 45 day time frame, the appeal will be determined as an approval.
• Appeal requests must be submitted using one of the methods below. The portal is the preferred method of submission to ensure timely receipt and resolution of the appeal.
- CareSource Provider Portal: https://providerportal.caresource.com/IN – Click the “Claim Appeals” link on the left.
- Paper: Use the Claim Appeal form* and include:
· Member’s name and CareSource member ID number
· Health partner’s name and ID number
· Codes and reasons the determination should be reconsidered
· Any additional available medical information that supports your request to reverse the determination or that supports medical necessity
· If submitting a timely filing appeal, proof of original receipt of the appeal by fax or Electronic Data Information (EDI)
· If the appeal is regarding a clinical edit denial, all supporting documentation as to the justification of reversing the determination
· If a health partner is submitting an appeal on behalf of a member, a signed member consent authorizing the health partner to act on the member’s behalf CareSource Attn: Health Partner Appeals P.O. Box 2008 Dayton, OH 45401-2008 Fax: 937-531-2398
All appeals are reviewed by an independent panel that is knowledgeable about the clinical, legal and policy issues involved in the subject matter of the appeal. This panel of individuals, who have not been involved in any previous consideration of the matter, will consider all information and material submitted by the health partner. Additional information concerning appeal reviews can be found at 405 IAC 1-1.6.
For additional information, contact Health Partner Services at 1-844-607-2831.
* You can find these forms online at https://www.caresource.com/providers/indiana/ medicaid/plan-resources/forms/ and in the Dental Forms section of this manual.
COVERED DENTAL SERVICE CATEGORIES: CLINICAL INDICATIONS, ASSOCIATED LIMITATIONS AND REQUIREMENTS Covered benefits are to be performed by licensed dental professionals in the state of Indiana as defined by their scope of practice by the Indiana Board of Dentistry.
All claims must provide proper codes based upon the current edition of the ADA CDT Code. Claims must be submitted within 90 calendar days from the date of service.
This section provides clinical guidelines with dental criteria based on standardized utilization criteria and coverage guidelines. It was designed to provide guidance for the adjudication of claims or prior authorization requests. It further details service indications, the dental service coverage categories and service CDT codes of each of these groups (Hoosier Healthwise, Presumptive Eligibility for Pregnant Women, HIP State Plans and HIP Plus), and associated limitations, frequencies and required documentation to be submitted where applicable for each covered benefit.
CareSource reserves the right to review documentation retrospectively, if disputes occur, and to make adjustments. Please follow this guide and contact CareSource Health Partner Services at 1-844-607-2831 if you have any questions.
Exclusions and Limitations
• Please refer to the next section and the benefits grid for clinical criteria, applicable limitations, required documents and additional information for each service code.
• Any service not listed as a covered service is excluded.
• Please call Health Partner Services if you have any questions.
Additional Exclusions
• Any dental procedure performed solely for cosmetic/aesthetic reasons
• Any procedure not performed in a dental setting that has not been prior authorized
• Service for injuries or conditions covered by workmen’s compensation or employer liability laws and services that are provided without cost to the covered persons by any municipality, county or other political subdivision - This exclusion does not apply to any services covered by Medicaid or Medicare.
• Expenses for dental procedures begun prior to the covered person’s eligibility with the plan (excluding 45-day transition of care cases)
• Dental services otherwise covered under the policy but rendered after the date that an individual’s coverage under the policy terminates, including dental services for dental conditions arising prior to the date that an individual’s coverage under the policy terminates
D0100 - D0999 DIAGNOSTIC SERVICES
A. Clinical Examinations D0120 - D0180
The following dental examination codes may be billed for any place of service in accordance with the coverage and limitations set forth below.
D0120 Periodic oral examination This includes an evaluation performed on an established patient to determine whether the patient’s dental and medical health has changed since a previous comprehensive or periodic evaluation. The periodic oral examination includes periodontal screening and may require interpretation of information gathered through additional diagnostic procedures. Additional diagnostic procedures should be reported separately.
D0140 Limited oral evaluation – problem focused This is an evaluation limited to a specific oral health problem or complaint. It may require interpretation of information gathered through additional diagnostic procedures. Additional diagnostic procedures should be reported separately. This evaluation will include any necessary palliative treatment. Evaluations solely for the purpose of adjusting dentures or in conjunction with multi-visit procedures are not covered (for example endodontics and orthodontia).
Providers should not use D0140 for periodic oral evaluations or other types of evaluations. Dental evaluations are closely monitored by CareSource and are subject to recoupment. Documentation in the dental and medical records must support that the provider rendered the oral evaluation in compliance with the procedure definition for the dental code being used.
Providers can bill procedure code D0140 for the emergency exam. If the procedure for the palliative care has a corresponding ADA code, providers should bill that code for the procedure. For example, if a provider performs an emergency incision and drainage of an abscess or intraoral soft tissue procedure, the provider should bill code D7510 with code D0140.
D0145 Oral evaluation, for a patient under 3 yrs of age and counseling with primary caregiver (Covered for ages 0 – 2) This is an evaluation that focuses on diagnostic services performed for a child under the age of three, preferably within the first six months of the eruption of the first primary tooth, including recording the oral and physical health history, evaluation of caries susceptibility, development of an appropriate preventive oral health regimen and communication with and counseling of the child’s parent, legal guardian and/or primary caregiver.
D0150 Comprehensive oral evaluation – new or established patient This code is typically used by a general dentist and/or specialist when evaluating a patient comprehensively. It is a thorough evaluation and recording of the extraoral and intraoral hard and soft tissues. It may require interpretation of information gathered through additional diagnostic procedures. Additional diagnostic procedures should be reported separately
This code includes evaluation and recording of the patient’s dental and medical history and a general health assessment. It also typically includes evaluation and recording of dental caries, missing or unerupted teeth, restorations, occlusal relationships, TMJ limited screening, periodontal conditions (including periodontal charting), hard and soft tissue anomalies and an oral cancer screening.
D0160 Detailed and extensive oral evaluation – problem focused A detailed and extensive problem focused evaluation entails extensive diagnostic and cognitive modalities based on the findings of a comprehensive oral evaluation. Integration of more extensive diagnostic modalities to develop a treatment plan for a specific problem is required. The condition requiring this type of evaluation should be described and documented. Examples of conditions requiring this type of evaluation may include dentofacial anomalies, complicated perio-prosthetic conditions, complex temporomandibular dysfunction, facial pain of unknown origin, conditions requiring multi-disciplinary consultation, etc.
D0170 Re-evaluation – limited, problem focused (established patient; not post-operative visit) Assessing the status of a previously existing condition. For example: - a traumatic injury where no treatment was rendered but patient needs follow-up monitoring; - evaluation for undiagnosed continuing pain; - soft tissue lesion requiring follow-up evaluation.
B. Radiographs/Diagnostic Imaging (including interpretation) D0120 - D0350
All radiographs submitted with prior authorization requests must be current and labeled with the member name, date of birth, date taken and indicate left or right side. All radiographs and diagnostic photographs must be of diagnostic quality, properly mounted, properly exposed, clearly focused, clearly readable, and free from defect for the area of the mouth on which these studies were performed.
D0210 Intraoral – complete series (including bitewings) A complete series of radiographs will consist of a minimum of 12 films, including all periapical, bitewings and occlusal film necessary for the diagnosis. Periapical films must show complete visibility of the periodontal ligament, crown and entire root structure.
D0220 Intraoral periapical – first film
D0230 Each additional intraoral periapical film
D0240 Intraoral occlusal radiographic Image
D0250 Extra-oral 2D projection radiographic image
D0251 Extra-oral posterior dental radiographic image
D0270 Bitewing – single film
D0272 Bitewing – two films
D0273 Bitewing – three films
D0274 Bitewing – complete series – minimum of four films
D0277 Vertical bitewings – 7 to 8 images Bitewing films must show complete visibility of clinical crowns with no overlapping. They cannot be substituted for periapical films in cases where endodontic treatment is requested.
D0310 Sialography A radiographic contrast study is performed to visualize the salivary glands and ducts, typically to demonstrate possible lesions or tumors, salivary fistulae, or to localize calcium deposits within the gland. The radiologist injects the main salivary duct with radiopaque dye (contrast), after which it flows into the duct system and is examined with x-ray fluoroscopy. The projected image is amplified and displayed on a monitor.
D0330 Panoramic film The panoramic film is an extraoral radiograph on which the maxilla and mandible are depicted on a single film. All bitewing and periapical films needed to render the necessary radiographic diagnosis are included in the fee for panoramic radiographs.
D0340 Cephalometric radiographic image 2D cephalometric radiographic image - acquisition, measurement and analysis; Image of the head made using a cephalostat to standardize anatomic positioning, and with reproducible x-ray beam geometry
Service Category
Package C
HIP Plus
HIP State Plan Plus
DIAGNOSTICS
D0120 D0140 D0145 D0150 D0160 D0170 D0210 D0220 D0230 D0240 D0250 D0251 D0270 D0272 D0273 D0274 D0277 D0330 D0340
D0120 D0140 D0150 D0160 D0170 D0210 D0220 D0230 D0240 D0250 D0251 D0270 D0272 D0273 D0274 D0277 D0330 D0340
Code Service Description
Benefit Limitations/ Frequency
Prior Auth. Required
Required Documents Additional Information
The comprehensive D0150 or the periodic exam D0120 may not occur in conjunction with a limited oral evaluation (examination during office hours — D0140 or examination after office hours — D9440). Multiple oral evaluations by the same dentist/dental office on the same day will be disallowed.
D0120 Periodic oral evaluation
No NONE
The periodic oral evaluation may not occur in combination with the comprehensive oral evaluation and not until 180 days after the comprehensive oral evaluation.
D0140 Limited oral evaluation - problem focused
This is a benefit once per patient per dentist/dental office, per 12 month period. If this limit is exceeded, a narrative of explanation will be needed and reviewed.
No NONE
Note: This procedure code is to be used for emergency examinations during regularly scheduled office hours. Evaluations solely for the purpose of adjusting dentures or in conjunction with multi-visit procedures are not covered (e.g., endodontics and orthodontia).
D0145 Oral evaluation, for a patient under three years of age
One per year, per member, any provider Age range 0-2
No NONE
D0150 Comprehensive oral evaluation
One per lifetime, per member, per provider The two-unit limitation applies to any combination of these two codes billed per year, per member with a lifetime limit of one per lifetime, per member, per provider.
No NONE
This code is typically used when evaluating a patient comprehensively. As noted, it may not occur in combination with the periodic evaluation.
D0160
No NONE
D0170 Re-evaluation – limited problem focused
No NONE This code is for established patient visits and not related to post-operative visits.
Diagnostic services such as radiographic images must be necessary for clinical reasons. Radiographic images are adjunctive to diagnostic services and should be prescribed in accordance with the guidelines of the American Dental Association. A panoramic radiographic image D0330 or a panoramic radiographic image with associated periapicals (D0220/D0230) or bitewings D0272/D0274) should not be submitted for payment as procedure code D0210 intra-oral complete series. Charges for duplication (copying) of radiographic images for insurance purposes are disallowed. Radiographic images used intraoperatively or considered a component of the primary procedure, for example periapical images taken during an endodontic procedure, are disallowed for reimbursement.
D0210
Intraoral – complete set of radiographic images including bitewings
Intraoral and extraoral radiographs are limited to one first film and seven additional films per member every 12 months.
No NONE
The two types of full-mouth radiographs reimbursable under this program are Full Mouth Series (D0210) and Panoramic Option (D0330).
D0220
No NONE
Intraoral – occlusal radiographic image
One per lifetime, per member, per provider The two-unit limitation applies to any combination of these two codes billed per year, per member with a lifetime limit of one per lifetime, per member, per provider.
No NONE
This code is typically used when evaluating a patient comprehensively. As noted, it may not occur in combination with the periodic evaluation.
D0160
No NONE
D0240 – two units per member per day
No NONE
Any additional films (D0220 - D0330) performed on the same date of service are considered content of service of the complete series or its equivalent and will not be reimbursed.
D0250
Extra-oral - 2D projection radiographic image created using a stationary radiation source, and detector
No NONE
No NONE
D0270 Bitewing - single image
Bitewing radiographs are limited to one set per member every 12 months. One set of bitewings is defined as either four horizontal films or seven to eight vertical films.
No NONE
D0310 Sialography No NONE
D0330 Panoramic radiographic image
Neither panoramic D0330 nor FMX/FMS D0210 radiographs are reimbursable more than once every three calendar years for the same member and not in conjunction with each other.
No NONE
The two types of full-mouth radiographs reimbursable under this program are Full Mouth Series (D0210) and Panoramic Option (D0330).
These two types of full mouth radiographs are mutually exclusive within a three calendar year time frame.
D0340 Cephalometric radiographic image
Only for orthodontic services and limits it to provider specialty of Orthodontists
No NONE
D1110 - D1999 PREVENTIVE SERVICES
A. Prophylaxis D1110 - D1120
Prophylaxis includes the necessary scaling and/or polishing of the teeth to remove plaque, calculus, and stains of primary transitional or permanent dentition.
D1110 Dental prophylaxis – adult Dental prophylaxis typically for permanent dentition
D1120 Dental prophylaxis – child Dental prophylaxis typically for primary dentition
B. Fluoride Treatment D1206 - D1208
D1206 Topical Application of Fluoride Varnish Fluoride varnish is indicated for the following:
• As the preferred caries prevention agent for children under age 6
• For head and neck radiation therapy patients
• For sensitivity that does not resolve with an over the counter desensitizing dentifrice
• For moderate to high caries risk patients with a medical or cognitive impairment that limits cooperation with a tray or rinse delivery method
• For xerostomia due to systemic disease or medication
• For patients in active orthodontic treatment
• For the remineralization of incipient or white spot enamel carious lesions
D1208 Topical application of fluoride (including sodium, stannous and acid phosphate fluoride, foam, gel, varnish and in-office rinse) Topical fluoride treatments in the form of gel, foam and rinses applied as a caries preventive agent in the dental office
C. Sealants D1351 – D1352 & D1354
The following are several clinical indications for sealants:
• Caries prevention in pit and fissures on permanent molars of children and adolescents
• Non-cavitated carious lesions on permanent teeth in children and adolescents
• Poor oral hygiene
• Patients with special health care needs
• Low socioeconomic status
• Other factors identified by professional literature
• Patients with special needs
D1351 Sealant (permanent, per tooth)
D1352 Preventative resin restorations in a moderate to high caries risk patient – permanent tooth
D1354 Interim caries medicament application
D. Space Maintainers D1510 - D1555
The preservation of arch length should be the main consideration in the evaluation of a patient for a space maintainer. Space maintainers are to be considered after the premature loss of a deciduous tooth when there is an indeterminate time before the eruption of the permanent tooth or teeth.
D1510 Space maintainer – fixed – unilateral
D1515 Space maintainer – fixed – bilateral
D1525 Space maintainer - removable – bilateral
D1550 Re-cementation or rebond space maintainer
D1555 Removal of fixed space maintainer
D1575 Distal shoe space maintainer - fixed - unilateral
Service Category
Package C
HIP Plus
HIP State Plan Plus
PREVENTIVE
D1110 D1120 D1206 D1208 D1351 D1352 D1354 D1510 D1515 D1520 D1550 D1555 D1575
D1110 D1206 D1208 D1351 D1352 D1354 D1510 D1515 D1525 D1550 D1555 D1575
D1110 D1120 D1206 D1208 D1351 D1352 D1354 D1510 D1515 D1525 D1550 D1555 D1575
D1110 D1120 D1206 D1208 D1351 D1352 D1354 D1510 D1515 D1525 D1550 D1555 D1575
D1110 Prophylaxis – Adult
One unit every six months for noninstitutionalized members 12 months of age up to their 21st birthday
One unit every 12 months for noninstitutionalized members 21 years of age or older
One unit every six months for institutionalized members, regardless of age
Members under 12 months of age are not eligible for prophylaxis service unless medical necessity can be established.
No NONE This service code should primarily be used for permanent dentition.
D1120 Prophylaxis – Child No NONE This service code should primarily be
used for primary dentition.
D1206 Topical Fluoride – Varnish
Procedure code D1208, topical application of fluoride, is billed for members age 1-20. Topical applications are not covered for members 21 years of age or older. Use procedure code D1206, Topical application of fluoride varnish, for members 1-20 years of age who have a moderate to high risk of dental caries.
No NONE
Treatment that incorporates fluoride with the polishing compound is considered part of the prophylaxis procedure and not a separate topical fluoride treatment.
The following treatments are not covered:
• Topical application of fluoride to the prepared portion of a tooth prior to restoration
• The use of self or home fluoride application procedures
• The application of sodium fluoride as a desensitizing agent
D1208
No NONE
Sealant - per tooth - unrestored permanent molars
Topical application of sealants is covered once per tooth in a four calendar-year period.
Sealants coverage is restricted to members under 21 years of age.
No NONE
The use of pit sealants on permanent molars and premolars only is a covered service for members under 21 years of age. There is a limit of one treatment per tooth, per lifetime.
1) Sealed teeth must be free of proximal caries. Sealants are allowed on occlusal surfaces.
2) Sealant material must be ADA approved.
D1352
Preventative resin restorations in a moderate to high caries risk patient - permanent tooth
No NONE
No NONE
D1510 Space maintainer – fixed – unilateral
Space management therapy is reimbursable for members under 21 years of age only.
D1510 - One per 12 months per quadrant
D1515 and D1525 - One per 12 months per arch
No NONE
Appropriate code must be put in the tooth number field on the claim form:
UR – upper right
LR – lower right
UL – upper left
LL – lower left.
No NONE
Re-cementation or rebond space maintainer
No NONE
No NONE
No NONE
D2140 – D2999 RESTORATIVE SERVICES
Amalgam and composite direct restorations are indicated for the following:
• To replace a tooth structure lost to caries or trauma
• To replace restorative material lost in the course of accessing pulp chamber for endodontic therapy
• To replace existing restorations that exhibit recurrent decay, fracture or marginal defects
A. Amalgam Restorations (Including polishing) D2140 – D2161
D2140 Amalgam – one surface – primary or permanent tooth
D2150 Amalgam – two surfaces – primary or permanent tooth
D2160 Amalgam – three surfaces – primary or permanent tooth
D2161 Amalgam – four or more surfaces – primary or permanent tooth
B. Resin Based Composite Resin D2330 – D2394
D2330 Resin-based composite restoration – one surface – anterior
D2331 Resin-based composite restoration – two surfaces – anterior
D2332 Resin-based composite restoration – three surfaces – anterior
D2335 Resin-based composite restoration – four or more surfaces or involving incisal (anterior)
D2390 Resin-based composite, crown, anterior
D2391 Resin-based composite restoration – one surface – posterior
D2392 Resin-based composite restoration – two surfaces – posterior
D2393 Resin-based composite restoration – three surfaces – posterior
D2394 Resin-based composite restoration – four or more surfaces – posterior
Single crown and prefabricated crown indirect restorations indications follow. Limited coverage on a case-by-case prior approval basis is provided for single crowns D2750 on permanent anterior teeth only. Stainless steel and prefabricated resin crowns do not require prior authorization but must follow the indication below:
C. Restorations
D2910 Re-cement inlay or rebond inlay, onlay veneer or partial coverage restoration
D2920 Re-cement or re-bone crown
D2930 Prefabricated stainless steel crown – primary tooth
D2931 Prefabricated stainless steel crown - permanent tooth
D2932 Prefabricated resin crown
• Permanent anterior or bicuspid teeth must have pathologic destruction to the tooth by caries or trauma and must involve four or more surfaces and at least 50% of the incisal edge or cusp fracture
• Endodontically treated teeth, unless minimal access opening on anterior tooth
i. Crown/root ratio must be favorable
ii. 50% bone support with no ligament or root pathology unless patient has undergone periodontal therapy/surgery, periodontium must be healthy or have documentation the member has periodontal disease under control for a period of at least 6 months, and no evidence of endodontic pathology or potential endodontic issues on the radiographic image.
iii. Documentation that a direct restoration is not possible and poor prognosis
D2933 Prefabricated stainless steel crown with resin window
• Stainless steel crowns are allowed only for teeth where multi-surface restorations are needed with a poor prognosis for restoration with amalgam or other materials.
• For one and two surface carious lesions in documented high caries risk children. Risk factors must be thoroughly documented by the provider in the dental records.
• Cervical decalcification and/or developmental defects
• Following pulpotomy or pulpectomy
• For restoring a primary tooth that is to be used as an abutment for a space maintainer
• For the intermediate restoration of fractured teeth
• For the restoration and protection of teeth exhibiting extensive attrition, abrasion or erosion
• In patients with impaired oral hygiene in which the breakdown of intra-coronal restorations is likely
Crowns for the following reasons will not be reimbursed/authorized:
• A lesser more conservative restoration is possible
• A primary tooth
• Tooth/teeth having advanced periodontal disease
D. Other Restorative
D2940 Protective restoration Temporary restoration intended to relieve pain. Not to be used as a base or liner under a restoration, or as sealant for deciduous teeth.
D2941 Interim therapeutic restoration – primary dentition
D2949 Restorative foundation for an indirect restoration
D2951 Pin retention - per tooth, in addition to restoration Pin retention is indicated for teeth with significant loss of coronal tooth structure due to caries or trauma, to allow retention of a direct restoration when preparation design alone is insufficient.
D2980 Crown repair
Service Category
Package C
HIP Plus
HIP State Plan Plus
Any amalgam or resin-based composite restoration that is billed with more than one unit for a one service area code will be reconfigured to the defined multiple service surface code (e.g., two units of D2140 would be one unit of D2150 or two units of D2330 would be one unit of D2331). Bases and copalite or calcium hydroxide liners placed under a restoration will be considered part of the restoration and are not reimbursable as separate procedures. Local anesthesia is included in the fee for all restorative services. Preventive resin-based restorations are not covered services.
D2140 Amalgam - one surface, primary or permanent
Reimburses for only one restoration code per tooth for restorations using the same material, performed on the same date by the same dentist for the same member.
Teeth covered: 1-32, 51-82 (SN), A-T, AS-TS (SN)
No NONE Composite and amalgam restorations are reimbursable based upon total number of restored surfaces, not to exceed four surfaces per tooth. For example, non-contiguous restorations, such as a separate Distal Occlusal (DO) and Mesial Occlusal (MO) on the same tooth, are billable as a three surface restoration. Each claim line for restorative services must relate to only one tooth number.
D2150 Amalgam - two surfaces, primary or permanent
No NONE
No NONE
No NONE
D2330 Resin–based composite - one surface, anterior Reimburses for
only one restoration code per tooth for restorations using the same material, performed on the same date by the same dentist for the same member.
Teeth covered: 6-11, 22-27, 56-61 (SN), 72-77 (SN), C-H, M–R, CS-HS (SN), MS-RS (SN)
No NONE The fee for resin-based composite restorations will include any necessary acid etching and bonding agents.
Non-contiguous restorations, such as a separate Distal Facial (DF) and Mesial Facial (MF) on the same tooth, are billable as a three surface restoration. Each claim line for restorative services must relate to only one tooth number.
Providers must bill D2335 with four surfaces or with an I.
D2331
No NONE
No NONE
Resin-based composite - four or more surfaces or involving incisal angle (anterior)
No NONE
D2390 Resin-based composite crown, anterior
Reimburses for only one restoration code per tooth for restorations using the same material, performed on the same date by the same dentist for the same member.
Teeth covered: 1-5, 12-21, 28-32, 51-55 (SN), 62-71 (SN), 78-82 (SN), A, B, I-L, S, T, AS (SN), BS (SN), IS-LS (SN), SS (SN),TS (SN)
No NONE
No NONE
Composite and amalgam restorations are reimbursable based upon total number of restored surfaces, not to exceed four surfaces per tooth. For example, non-contiguous restorations, such as a separate Distal Occlusal (DO) and Mesial Occlusal (MO) on the same tooth, are billable as a three surface restoration. Each claim line for restorative services must relate to only one tooth number.
D2392
No NONE
No NONE
No NONE
D2910
Re-cement inlay or re-bond inlay, onlay veneer or partial coverage restoration
No NONE
Tooth must be indicated on claim. No NONE
Re-cement or re-bond done on the same tooth by the same dentist within a 12 month period, reimbursement will be subject to post review.
D2921
No NONE
Prefabricated stainless steel crown - primary tooth Only one unit of
D2930- D2933 per member, per tooth
More than six teeth per member per calendar year per provider may be subject to post review.
No NONE
D2931
No ≤ Age 20
Yes ≥ Age 21
resin crown
No NONE
See the clinical guidelines preceding this grid.
D2941
No NONE
No NONE
A maximum of three pins per tooth will be reimbursed.
No NONE
D2990 Resin infiltration/ smooth surface No NONE
D3110 – D3999 ENDODONTIC SERVICES
A. Therapeutic Pulpotomy and Pulpal Therapy
D3220 Therapeutic pulpotomy/pulpal therapy Therapeutic pulpotomy (excluding final restoration) - removal of pulp coronal to the dentinocemental junction and application of medicament with the aim of maintaining the vitality of the remaining portion by means of an adequate dressing. This is not to be considered as the first stage of root canal therapy. Indications include:
• Exposed vital pulps or irreversible pulpitis of primary teeth
• As an emergency procedure in permanent teeth until root canal treatment can be accomplished
• As an interim procedure for permanent teeth with immature root formation to allow continued root development
When completed in primary teeth, there should be a reasonable period of retention of the tooth expected (approximately one year)
D3230 Pulpal therapy (resorbable filling) - anterior, primary tooth (excluding final restoration) Pulpal therapy is performed on the anterior primary teeth, which include the primary incisors and cuspids. The procedure includes only the resorbable filling placement. Final restoration services are reported separately.
D3240 Pulpal therapy (resorbable filling) - posterior, primary tooth excluding final restoration) Pulpal therapy is performed on the posterior primary teeth, which include the primary first and second molars. The procedure includes only the resorbable filling placement. Final restoration services are reported separately.
B. Complete Root Canal Therapy D3310-D3300
Root canal therapy is covered only for permanent teeth. Root canal therapy on primary teeth is not a covered service. The tooth must demonstrate at least 50% bone support.
D3310 Root canal therapy – anterior (excluding final restoration)
D3320 Root canal therapy – bicuspids (excluding final restoration)
D3330 Molar root canal (excluding final restoration)
D3346 Retreatment of previous root canal therapy – anterior
D3347 Retreatment of previous root canal therapy – bicuspid
D3348 Retreatment of previous root canal therapy - molar
Radiographs, including periapicals, panoramic film or full mouth series of radiographs submitted must show periapical radiolucency, or widening of periodontal ligament. Or, symptoms should include chronic pain (as evidenced by sensitivity to hot or cold, percussion or palpation), fistula associated with the tooth or chronic infection. If pathology is not visible on the radiograph, root canal treatment should be clinically documented.
C. Other Covered Endodontic Services
D3351 Apexification/recalcification – initial visit Includes opening tooth, preparation of canal spaces, and first placement of medication and necessary radiographs. (This procedure may include first phase of complete root canal therapy.)
D3352 Apexification/recalcification – interim medication replacement For visits in which the intra-canal medication is replaced with new medication. Includes any necessary radiographs.
D3353 Apexification/recalcification – final visit Includes removal of intra-canal medication and procedures necessary to place final root canal filling material including necessary radiographs. (This procedure includes last phase of complete root canal therapy.)
D3410 Apicoectomy/periradicular surgery - anterior For surgery on root of anterior tooth; does not include placement of retrograde filling material.
D3421 Apicoectomy/periradicular surgery – bicuspid (first root) For surgery on one root of a bicuspid. Does not include placement of retrograde filling material. If more than one root is treated, see D3426.
D3425 Apicoectomy/periradicular surgery – molar (first root) For surgery on one root of a molar tooth. Does not include placement of retrograde filling material. If more than one root is treated, see D3426.
D3426 Apicoectomy/periradicular surgery (each additional root) Typically used for bicuspids and molar surgeries when more than one root is treated during the same procedure. This does not include retrograde filling material placement.
D3427 Periradicular surgery without apicoectomy
D3430 Retrograde filling – per root For placement of retrograde filling material during periradicular surgery procedures. If more than one filling is placed in one root - report as D3999 and describe.
Service Category
Package C
HIP State Plan Plus
ENDODONTICS
NOTE: Endodontic services do not apply to HIP Basic members.
Therapeutic pulpotomy (excluding final restoration
To be performed on primary or permanent teeth up until the age of 20 years.
Teeth: A–T or 1-32
Greater than six units per member per calendar year may be subject to post review.
No NONE See the clinical guidelines preceding this grid.
D3230
No NONE
No NONE
D3310 Anterior root canal (excluding final restoration)
Once per tooth per lifetime except for exception cases of appropriate medical necessity.
The date the RCT is completed should be the date of service.
Yes
plan for each case
basis.
Reimbursement for a root canal includes opening and drainage, treatment planning, clinical procedures, follow-up care, X-rays during treatment, and postoperative X-rays.
No NONE
No NONE
No NONE
No NONE
No NONE
No NONE
No NONE
D3410 Apicoectomy/ peri-radicular surgery - anterior
Once per tooth per lifetime except for exception cases of appropriate medical necessity
No Diagnostic quality pre-op
plan/ narrative for each case
This does not include retrograde filling material placement.
D3421 Apicoectomy - bicuspid (first root)
No Ages 1–20 years
D3425 Apicoectomy - molar (first root) No Ages 1–20 years
D3426
No Used typically for bicuspids
D3427 Periradicular surgery without apicoectomy
No NONE
D4210 – D4999 PERIODONTIAL SERVICES
A. Gingivectomy or Gingivoplasty D4210 – D4212
D4210 Gingivectomy or gingivoplasty – four or more contiguous teeth or tooth bounded spaces per quadrant Involves the excision of the soft tissue wall of the periodontal pocket by either an external or an internal level. It is performed to eliminate suprabony pockets after adequate initial preparation, to allow access for restorative dentistry in the presence of suprabony pockets, and to restore normal architecture when gingival enlargements or asymmetrical or unaesthetic topography is evident with normal bony configuration.
D4211 Gingivectomy or gingivoplasty – one to three teeth
D4212 Gingivectomy or gingivoplasty - with restorative procedures, per tooth
B. Gingival Flap Procedure D4240 – D4241
D4240 Gingival flap procedure – four or more contiguous teeth or tooth bounded spaces per quadrant. This procedure includes root planing, and is indicated:
• For moderate to deep probing depths; not accessible by non-flap scaling and root planing and increased access to root is needed
• For access to assist in diagnosis of a cracked tooth, fractured root or root decay when this cannot be accomplished by non-invasive methods
D4241 Gingival flap procedure, including root planning - one to three contiguous teeth or tooth bounded spaces per quadrant
C. Periodontal Scaling and Root Planing D4341- D4345
D4341 Periodontal scaling and root planing, four or more teeth per quadrant This procedure involves instrumentation of the crown and root surfaces of the teeth to remove plaque and calculus from these surfaces. Clinical indications for coverage of this service include diagnosed localized or generalized mild, moderate or severe chronic periodontal disease; characterized by moderate to deep probing depths and or heavy calculus and plaque; and/or bleeding points; radiographic active bone loss and radiographic calculus.
D4342 Periodontal scaling and root planing-one to three teeth, per quadrant
D4355 Full mouth debridement to enable comprehensive evaluation and diagnosis
D. Periodontal Maintenance D4910
This procedure is instituted following periodontal therapy and continues at varying intervals for the life of the dentition. It includes removal of the bacterial plaque and calculus from supragingival and subgingival regions, site specific scaling and root planing where indicated, and polishing the teeth.
Service Category
Package C
HIP State Plan Plus
D4210 D4211 D4212 D4240 D4241 D4341 D4342 D4355 D4910
D4210 D4211 D4212 D4240 D4241 D4341 D4342 D4355 D4910
D4341 D4342 D4355 D4910 D4210 D4211 D4212 D4240 D4241 D4341 D4342 D4355 D4910
NOTE: Periodontic services do not apply to HIP Basic members.
D4210 D4211 D4212 D4240 D4241 D4341 D4342 D4355 D4910
D4210 Gingivectomy or gingivoplasty – four or more teeth
These services (full mouth- four quadrants) are limited to one per member per calendar year.
Yes
Radiographs of the area and perio charting, letter of medical
necessity and
review.
Services performed in additional or multiple years are subject to approval based on medical necessity for additional treatments.
D4211 Gingivectomy or gingivoplasty – one to three teeth
Yes NONE
Yes NONE
Pre-op radiograph of involved tooth and treatment plan for
each case
basis.
D4241
Gingival flap procedure, including root planning - one to three contiguous teeth or tooth bounded spaces per quadrant
Yes
radiographs of quadrants to treat, and a narrative
documenting medical
D4341
Periodontal scaling and root planing-four or more teeth per quadrant
Limits periodontal root planing and scaling for members over three years old and under 21 years old (or for institutionalized members) to four units every two years.
For noninstitutionalized members 21 years old and older, the IHCP limits periodontal root planing and scaling to four units per lifetime.
Yes NONE
D4342
Periodontal scaling and root planning-one to three teeth, per quadrant
Yes NONE
D4355
Limited to once per three years per member
Limited to one unit per date of service
No
D4910 Periodontal maintenance
Coverage is limited to once every 12 months for members 21 years of age and older.
Coverage is limited to once every six months for members three through 20 years of age or for institution-alized members.
This procedure is instituted following periodontal therapy and continues at varying intervals for the life of the dentition.
D5000 – D5899 REMOVABLE PROSTHODONTIC SERVICES
A. Complete Dentures (including routine post-delivery care) D5110 - D5120
The diagnosis for dentures should be based on the total condition of the mouth, the age of the patient, the ability to adjust to dentures and the desire to wear dentures. Natural teeth, which are sound and have healthy bone and a positive prognosis, should not be removed. Eight posterior teeth in occlusion – four maxillary and four mandibular teeth in functional contact with each other are considered to be adequate for functional purposes. Authorization for dentures must be received before the teeth are extracted for eligible CareSource members. For members who are edentulous prior to being eligible for CareSource, please note this on the request. Complete dentures are indicated for the following: 1) To replace teeth that are non-restorable due to gross caries and/or advanced periodontal disease, 2) To replace teeth lost due to orofacial trauma, and 3) To replace teeth lost due to oral cancer surgery and subsequent reconstruction.
D5110 Complete denture – maxillary
D5120 Complete denture – mandibular
D5130 Immediate denture - maxillary - ages 21 and older
D5140 Immediate denture - mandibular - ages 21 and older
C. Partial Dentures
Partial dentures are considered medically necessary when several teeth are missing in the arch and masticatory function is severely impaired. The health partner is responsible for constructing a completely functional partial denture.
Requests for partial dentures that replace anterior teeth only are not approved. Anterior tooth replacement is considered purely an aesthetic or cosmetic concern and not medically necessary.
D5211 Maxillary upper partial denture (resin-base) including conventional clasps, rests and teeth
D5212 Mandibular lower partial denture (resin-base) including conventional clasps, rests and teeth
D5213 Maxillary partial denture - cast metal framework with resin denture base
D5214 Mandibular partial denture - cast metal framework with resin denture base
D5225 Maxillary partial denture - flexible base (including any clasps, rests and teeth)
D5226 Mandibular partial denture - flexible base (including any clasps, rests and teeth)
D5281 Removable unilateral partial denture-one piece cast metal
D. Repairs to Dentures
Repairs to complete dentures: D5510 Repair broken complete denture base
D5520 Replace missing or broken teeth – complete denture (each tooth)
D5620 Replace missing or broken teeth - complete denture (each tooth)
Repairs to partial dentures: D5610 Repair resin denture baseD5630 Repair or replace broken clasp
D5640 Replace broken teeth – per tooth
D5650 Add tooth to existing partial denture
D5660 Add clasp to existing partial denture
E. Denture Reline and Tissue Conditioning Procedures
The reline must consist of the re-adaptation of the denture to the present oral tissues using accepted dental practice standards and procedures. The denture must be processed and finished with materials corresponding to the existing denture. Chair side self-curing materials are not covered.
D5730 Reline complete maxillary denture (chairside)
D5731 Reline complete mandibular denture (chairside)
D5740 Reline maxillary partial denture (chairside)
D5741 Reline mandibular partial denture (chairside)
D5750 Reline complete maxillary denture (laboratory)
D5751 Reline complete mandibular denture (laboratory)
D5760 Reline partial maxillary denture (laboratory)
D5761 Reline partial mandibular denture (laboratory)
Service Category
Package C
HIP State Plan Plus
PROSTHODONTICS
D5110 D5120 D5130* D5140* D5211 D5212 D5213 D5214 D5225 D5226 D5281 D5510 D5520 D5610 D5620 D5630 D5640 D5650 D5660 D5730 D5731 D5740 D5741 D5750 D5751 D5760 D5761
*Not covered for Pkg C
D5110 D5120 D5130 D5140 D5211 D5212 D5213 D5214 D5225 D5226 D5281 D5510 D5520 D5610 D5620 D5630 D5640 D5650 D5660 D5730 D5731 D5740 D5741 D5750 D5751 D5760 D5761
NOTE: Prosthodontic services do not apply to HIP Basic members.
Prosthetic devices shall be seated in the mouth before a claim is submitted for payment. The fee for complete and partial dentures includes all necessary corrections and adjustments for six months after the denture has been seated.
D5110 Complete denture – maxillary
The health partner is responsible for constructing a completely functional denture.
No reimbursement will be made for dentures/partial dentures replaced or remade within a six calendar-year period unless prior approval is obtained for exceptional circumstances.
D5120 Complete denture – mandibular
Yes
Includes limited follow-up care only; does not include required future rebasing/relining procedures or a complete new denture.
D5140
Yes
Yes – adults over age 21
D5212
Mandibular partial denture – resin base (including any conventional clasps, rests and teeth)
Maxillary partial denture - cast metal framework with resin denture base
Covered only for members with facial deformity due to congenital, developmental or acquired defects.
D5214
Mandibular partial denture - cast metal framework with resin denture base
D5225
Maxillary partial denture - flexible base (including any clasps, rests and teeth)
Covered only for members with documented allergic reaction to other denture materials or for members with a facial deformity due to congenital, developmental or acquired defects (such as cleft palate conditions) that require the use of a flexible base partial instead of an acrylic or cast-metal partial
Yes
D5226
Mandibular partial denture - flexible base (including any clasps, rests and teeth)
Yes
D5281 Removable unilateral partial denture-one piece cast metal
D5510 Repair broken complete denture base
Maximum of two repairs per calendar year is reimbursable.
Exception: Approval is required for additional repairs. Must submit narrative.
No NONE
D5520 Replace missing or broken teeth - complete denture (each tooth)
No NONE
D5630 Repair or replace broken clasp No NONE
D5650 Add tooth to existing partial denture
No NONE
No NONE
D5731 Reline complete mandibular denture
Chairside work No NONE
D5741 Reline mandibular partial denture
Chairside work No NONE
D5751 Reline complete mandibular denture
Laboratory work No NONE
D5761 Reline mandibular partial denture
Laboratory work No NONE
D5900 – D5999 MAXILLOFACIAL PROSTHETICS
Maxillofacial Prosthetics is a subspecialty of Prosthodontics that involves rehabilitation of patients with defects or disabilities that were present when born or developed due to disease or trauma.
Prostheses are often needed to replace missing areas of bone or tissue and restore oral functions such as swallowing, speech, and chewing. In other cases, prosthetic devices may be devised to position or shield facial structures during radiation therapy.
D5951 Feeding aid A prosthesis, which maintains the right and left maxillary segments of an infant cleft palate patient in their proper orientation until surgery is performed to repair the cleft. It closes the oral-nasal cavity defect, thus enhancing sucking and swallowing. Used on an interim basis, this prosthesis achieves separation of the oral and nasal cavities in infants born with wide clefts necessitating delayed closure.
D5952 Pediatric speech aid A temporary or interim prosthesis used to close a defect in the hard and/or soft palate. It may replace tissue lost due to developmental or surgical alterations. It is necessary for the production of intelligible speech. Normal lateral growth of the palatal bones necessitates occasional replacement of this prosthesis.
D5993 Maintenance and cleaning of a maxillofacial prosthesis (extra- or intra-oral) other than required adjustments A definitive prosthesis, which can improve speech in adult cleft palate patients either by obturating (sealing off) a palatal cleft or fistula, or occasionally by assisting an incompetent soft palate. Both mechanisms are necessary to achieve velopharyngeal competency.
Service Category
Package C
HIP State Plan Plus
NOTE: Maxillofacial prosthetics do not apply to HIP Basic members.
D5951 D5952 D5993
D5952 Pediatric s peech aid No NONE
D5993
Maintenance and cleaning of a maxillofacial prosthesis (extra- or intraoral) other than required adjustments
No NONE
D6205 – D6999 PROSTHODONTICS (FIXED)
Such dental restorations, also referred to as indirect restorations, include crowns, bridges (fixed dentures), inlays, onlays and veneers. Prosthodontists are specialist dentists who have undertaken training recognized by academic institutions in this field. Fixed prosthodontics can be used to restore single or multiple teeth, spanning areas where teeth have been lost. In general, the main advantages of fixed prosthodontics when compared to direct restorations is the superior strength when used in large restorations, and the ability to create an aesthetic looking tooth.
D6930 Recement fixed partial denture D6980 Fixed partial denture repair
Service Category
Package C
HIP State Plan Plus
NOTE: Maxillofacial prosthetics do not apply to HIP Basic members.
D6930 D6980
D7000 – D7999 ORAL AND MAXILLOFACIAL SURGERY • A tooth may be removed only if it cannot be saved because it is broken down, poorly
supported by the alveolar bone, and/or affected by a pathological condition.
• Extractions that render a patient edentulous must be deferred until authorization to construct a denture has been given, except in an absolute emergency. Documentation must be provided to support the absolute emergency removal of teeth.
• The extraction of an impacted tooth will be authorized only when the impaction makes removal necessary.
• Prophylactic removal of asymptomatic teeth or teeth exhibiting no overt clinical pathology is covered only when at least one tooth is symptomatic.
• Local anesthesia and routine postoperative care are included in the fee for extractions.
A. Non-Surgical Extractions
D7111 Extraction, coronal remnants - deciduous tooth
D7140 Extraction – erupted tooth or exposed root (elevation and/or forceps removal Includes routine removal of tooth, structure, minor smoothing of socket bone, and closure, as necessary.
B. Surgical Extractions
Surgical extraction is indicated when clinical crown is insufficient to allow for a non-surgical extraction; additional indications include unusual root morphology, developmental abnormalities, adjacent teeth and structures i

INDIANA DENTAL HEALTH PARTNER MANUAL - CareSource

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