Attachments_J1-J7.pdf

Attachment J-1 Definitions

TDRAW HT9402-17-R-0001 Attachment J-1

Additional definitions are located in the 32 CFR 199.13(b) and the TRICARE Operations Manual (TOM), Appendix A.

Active Duty Service Member (ADSM) – A person on active duty in a Uniformed Service who is under a call or order that does not specify a period of 30 days or less.

This contract only applies to the following Uniformed Services: The Army, Navy, Air Force, Marine Corps, Coast Guard, and uniformed members of the Commissioned Corps of the National Oceanographic and Atmospheric Administration (NOAA), and the Commissioned Corps of the Public Health Service (PHS).

Allowed Charge – Relative to network providers, the allowed charge for any procedure is the lower of: (1) the amount billed or (2) the amount under the network agreement that the network provider has agreed to accept as payment in full, inclusive of the beneficiary’s share of the cost. The beneficiary’s share of the cost includes both the cost share percentage and amounts above the benefit maximums (annual/orthodontic).

Anesthesia Services – The administration of an anesthetic agent by injection or inhalation, the purpose and effect of which is to produce surgical anesthesia characterized by muscular relaxation, loss of sensation, or loss of consciousness when administered by or under the direction of a physician or dentist in connection with otherwise covered surgery. Anesthesia services do not include hypnosis or acupuncture.

Assignment of Benefits - Acceptance by a non-network provider of payment directly from the insurer while reserving the right to charge the beneficiary, active duty, Selected Reserve or Individual Ready Reserve member for any remaining amount of the fees for services which exceeds the prevailing fee allowance of the insurer.

Authorized Provider – A dentist, dental hygienist, or certified and licensed anesthetist specifically authorized to provide benefits under the TRICARE Dental and Wellness

(TDRAW).

Average Allowed Charge – The average allowed charge is the mean across all procedures for a given code performed in a given three-digit zip code.

Balance Billing – When a provider seeks any payment, other than any payment relating to applicable deductible and cost sharing amounts, from a beneficiary for TDRAW covered services for any amount in excess of the applicable allowable charge.

Beneficiary Counseling and Assistance Coordinators (BCAC) – Individuals in the customer service community who address TRICARE and Military Health System issues and concerns. A directory of BCAC locations may be found on the TRICARE website at: http://www.tricare.mil/bcacdcao.

Billed Charge – The billed charge is equal to the undiscounted amount charged by a provider.

http://www.tricare.mil/bcacdcao

By Report – "By report" or "Report required" means dental procedures, which are authorized as benefits only in unusual circumstances requiring justification of exceptional conditions related to otherwise authorized procedures.

Child – An unmarried child of a member or former member who meets the criteria (including age requirements) stated in 32 CFR 199.3.

Contracting Officer – A Government employee having authority vested by a Contracting Officer’s Warrant to execute, administer, and terminate contracts and orders, and modifications thereto, which obligate Government funds and commit the Government to contractual terms and conditions.

Coordination of Benefits – A system to determine who the primary payer is and who the secondary payer is when more than one health and/or dental insurance coverage applies to a dental procedure.

Cost-Share – The amount of money for which the beneficiary is responsible in connection with otherwise covered dental services (other than disallowed amounts). A cost-share may also be referred to as a “co-payment.”

Covered Benefit - Dental procedure included in a dental benefit plan subject to plan limitations.

Covered Services – Dental procedure codes specified as a benefit in a dental benefits plan.

Denied Benefit – Dental procedure denied based on an enrollee’s dental plan limitations (e.g., a procedure that is allowed twice within a 12-month period would be denied if a claim was filed for a third time because of the dental plan limitations).

Denied Service – A dental procedure that is not a covered benefit under the dental benefit plan (e.g., teeth whitening is a service, but it is not a benefit covered by the TDRAW dental benefits plan).

Dental Care - Services relating to the teeth and their supporting structures.

Dental Encounter Data – Records that provide detailed dental information for each treatment encounter and are required to be produced by the TDRAW contractor for dental care data and financial reporting.

Dental Explanation of Benefits (DEOB) – The document prepared by insurance carriers, health care organizations, and TRICARE provided to enrollees and dentists explaining benefits determinations to include such information as: type of service received, the amount billed, the allowable charge, the cost share amount, services denied (with denial reasons), and application of annual and lifetime maximums.

Dental Hygienist – Practitioner in rendering complete oral prophylaxis services, applying medication, performing dental radiography, and providing dental education services with a certificate, associate degree, or bachelor’s degree in the field, and licensed by an appropriate authority.

Dental Readiness Classifications – The oral health status of uniformed personnel is classified into four categories.

• Class 1: Patients with current dental examination who do not require dental treatment or reevaluation. Class 1 patients are worldwide deployable.

• Class 2: Patients with current dental examination whose oral conditions are unlikely to result in dental emergencies within 12 months. Class 2 patients are worldwide deployable.

• Class 3: Patients who require urgent or emergent dental treatment. Class 3 patients normally are not considered to be worldwide deployable.

• Class 4: Patients who require periodic dental examinations or patients with unknown dental classification. Class 4 patients normally are not considered to be worldwide deployable.

Dental Service Point of Contact – A dentist assigned as the point of contact for all dental issues arising from care rendered to ADSMs in the civilian community and who review dental care for appropriateness. The Dental Service Point of Contact (DSPOC) positions are established within the DHA Dental Care Section to provide a means to identify, manage, and provide dental oversight of civilian dental care provided to ADSMs.

Dental Treatment Facility (DTF) – A facility operated by the military that provides dental care to ADSMs. DTFs have responsibility for management of all service members within their service areas even if that service member is not in the same branch of service as the DTF base or post. DTFs also manage the care of non-active duty service members (e.g., Reservists) who have a dental Line Of Duty (LOD) determination while in a drill or on active duty for less than 30 days.

Dentist – Doctor of Dental Medicine (D.M.D.) or Doctor of Dental Surgery (D.D.S.) or doctor with an equivalent dental degree, who is licensed to practice dentistry by an appropriate authority.

Diagnostic Services – Category of dental services including clinical oral examinations, radiographic examinations, and diagnostic laboratory tests and examinations provided in connection with other dental procedures authorized as TDRAW benefits.

Emergency Care – Care which includes any treatment necessary to relieve pain, treat infection, control hemorrhaging, or repair broken fillings by placement of temporary or permanent fillings (not crowns). Root canal treatment and extractions may be needed to relieve the pain and infection. Crowns, implants, bridges and dentures work are not considered emergency care.

Endodontics – The etiology, prevention, diagnosis, and treatment of diseases and injuries affecting the dental pulp, tooth root, and periapical tissue.

Enrolled Member – A TRICARE beneficiary who is enrolled in the TDRAW program, also referred to as an enrollee.

Enrollee Liability – The legal obligation of an enrollee, his or her estate, or responsible family member to pay for the costs of dental care or treatment received. Specifically, for the purposes of services and supplies covered by TDRAW, enrollee liability includes cost-sharing amounts or any amount above the prevailing fee determination by the contractor where the provider selected by the enrollee is not a network provider or a provider within an approved alternative delivery system. In cases where a non-network provider does not accept assignment of benefits, enrollees may have to pay the non-network provider in full at the time of treatment and seek reimbursement directly from the insurer for all or a portion of the non-network provider’s fee. Enrollee liability also includes any expenses for services and supplies not covered by TDRAW, less any available discount provided as a part of the insurer’s agreement with an approved alternative delivery system.

Excludable Services – Excludable services are services that are not specifically excluded but are not covered because they are not medically necessary based on the circumstance.

Former Spouse – A former husband or wife of a Uniformed Service member or former member who meets the criteria as set forth in 32 CFR 199.3(b)(2)(ii).

Fraud – For purposes of the TDRAW, fraud is defined as (1) a deception or misrepresentation by a provider, beneficiary, sponsor, or any person acting on behalf of a provider, sponsor, or beneficiary with the knowledge (or who had reason to know or should have known) that the deception or misrepresentation could result in some unauthorized TDRAW benefit to self or some other person, or some unauthorized TDRAW payment, or (2) a claim that is false or fictitious, or includes or is supported by any written statement which asserts a material fact which is false or fictitious, or includes or is supported by any written statement that (a) omits a material fact and (b) is false or fictitious as a result of such omission and (c) is a statement in which the person making, presenting, or submitting such statement has a duty to include such material fact. It is presumed that, if a deception or misrepresentation is established and a TDRAW claim is filed, the person responsible for the claim had the requisite knowledge. This presumption is refutable only by substantial evidence. It is further presumed that the provider of the services is responsible for the actions of all individuals who file a claim on behalf of the provider (for example, billing clerks); this presumption may only be rebutted by clear and convincing evidence.

Geographical Area Of Coverage:

• CONUS Service Area - The "CONUS" or "Continental United States" service area includes the fifty (50) United States, District of Columbia, U.S. Virgin Islands, Guam, Puerto Rico, American Samoa, and the Northern Mariana Islands..

• OCONUS Service Area - The "OCONUS" or "Outside the Continental United States" service area includes all other countries, island masses and territorial waters. Covered services provided on a civilian ship or vessel that is outside the territorial waters of the CONUS service area are considered covered under the OCONUS service area, regardless of the provider’s home address.

Inactive National Guard (ING) – The ING are personnel in an inactive status in the Ready Reserve, but not in the Selected Reserve. They are attached to a specific National Guard unit, who are required to muster once a year with their assigned unit, but do not participate in training activities.

Individual Ready Reserve (IRR) – The IRR consists of those members of the Ready Reserve who are not in the Selected Reserve or the Inactive National Guard. Within the IRR of each reserve component there two types of mobilization categories:

• Mobilization Only Personnel – The IRR member volunteers for a specific service category or the member is selected for a specific category by the Secretary concerned, based upon the needs of the service and the grade and military skills of that member. An IRR mobilization member is eligible for benefits (other than pay and training) as are normally available to members of the Selected Reserve.

• Non-Mobilization Only Personnel - The IRR member is subject to being ordered to active duty involuntarily. An IRR non-mobilization member has limited benefits and is not entitled to the same benefits as a Selected Reserve member.

Initial Determination – A formal written decision on dental reimbursement or a request for a benefit pre-determination. Rejection of dental reimbursement or pre-determination, or of a request for benefit or provider authorization for failure to comply with administrative requirements, including failure to submit reasonably requested information, is not an initial determination. Responses to general or specific inquiries regarding dental benefits are not initial determinations.

Line of Duty (LOD) – Reserve Component members, to include the National Guard members, serving on duty 30 days or less are not eligible for DTF dental care except for emergencies. If a Reserve Component Member in an active duty status becomes injured or ill during training or duty related incident and requires dental treatment, they are only entitled to treatment for that injury or illness. The responsibility for determining eligibility for treatment rests with military medical authorities in accordance with published service regulations. The care may be received after a member is inactivated provided that the appropriate LOD documentation is on file; Defense Enrollment Eligibility Reporting System (DEERS) will not indicate eligibility.

Member Liability – The ADSM is liable for any expenses for services and supplies not covered, but for which the member has agreed in writing to pay. The ADSM, his/her estate, or responsible family member, has no legal obligation to pay for the costs of dental care or treatment received for covered services, and where required, services that were authorized.

Network Provider – A dentist or dental hygienist who has agreed to accept the contractor's reasonable fee allowances or other fee arrangements as the total charge (even though less than the actual billed amount).

Non-Network Provider – A dentist or dental hygienist that furnished dental services to a TDRAW beneficiary, but who has not agreed to accept the insurer's fee allowances and applicable cost-share as the total charge for the services. A non-network provider looks to the beneficiary or active duty, Selected Reserve or Individual Ready Reserve member for final responsibility for payment of his or her charge, but may accept payment (assignment of benefits) directly from the insurer or assist the beneficiary in filing the claim for reimbursement by the dental plan contractor. Where the non-network provider does not accept payment directly from the insurer, the insurer pays the beneficiary, not the provider.

Oral and Maxillofacial Surgery – Surgical procedures performed in the oral cavity or maxillofacial region.

Oral Surgeon – A person who has received a degree in dentistry and has completed residential training in oral and maxillofacial surgery, that is, that branch of the healing arts that deals with the diagnosis and the surgical correction and adjunctive treatment of diseases, injuries, and defects of the mouth, the jaws, and associated structures.

Orthodontics – The supervision, guidance, and correction of the growing or mature dentofacial structures, including those conditions that require movement of teeth or correction of malrelationships and malformations of their related structures and adjustment of relationships between and among teeth and facial bones by the application of forces and/or the stimulation and redirection of functional forces within the craniofacial complex.

Party to the Initial Determination – A TDRAW beneficiary, a TDRAW network provider, and/or a provider seeking to become or remain an authorized TDRAW provider whose interest have been adjudicated by the initial determination.

Periodontics – The examination, diagnosis, and treatment of diseases affecting the surrounding and supporting structures of the teeth.

Prevailing Charge – The charges submitted by certain dental providers which fall within the range of charges that are most frequently used in a state for a particular procedure or service. The top of the range establishes the maximum amount TDRAW will authorize for payments of a given procedure or service, except where unusual circumstances or dental complications warrant an additional charge.

Preventive Services – Dental care services to prevent dental disease, including traditional prophylaxis, scaling deposits from teeth, polishing teeth, and topical application of fluoride to teeth, sealants, etc.

Prosthodontics - The diagnosis, planning, making, insertion, adjustment, refinement, and repair of artificial devices intended for the replacement of missing teeth, deficient teeth that cannot be corrected with direct restorations, and associated tissues.

Provider – A dentist, dental hygienist, or certified and licensed anesthetist, or other individual professional provider, or other provider of services or supplies in accordance with 32 CFR 199.2. This term, when used in relation to OCONUS service area providers, may include other recognized professions authorized to furnish care under laws of that particular territory, possession or country.

Readiness Care – Readiness care is when the Selected Reserve members and Individual Ready Reserve members [mobilization asset only as identified in Title 10 U.S.C. Chapter 55 Section 10144(b)] are classified at the Dental Readiness Classification (DRC) 3 level.

Ready Reserve – The Ready Reserve consists of units or Reserves, or both, liable for active duty. The Ready Reserve comprises military members of the Reserve and National Guard that consists of three reserve component subcategories: (1) Selected Reserve, (2) Individual Ready Reserve, and (3) Inactive National Guard.

Remote Active Duty Service Member – An active duty service member who works and lives more than 50 miles from a military Dental Treatment Facility. This also includes eligible members enrolled in TRICARE Prime Remote, uniformed members of NOAA, Early Activation reserve component members, Foreign Forces members in CONUS geographic regions, Line of Duty members, Wounded Warriors and certain Reserve component members under TAMP.

Residual Claim – A claim for dental care services rendered during the dental care delivery period of the contract, but processed during the Phase-Out period of that contract when that contractor is no longer providing dental care delivery (i.e. the contract has been transitioned to another contractor).

Restorative Services – Restoration of teeth including those procedures commonly described as amalgam restorations, resin restorations, pin retention, and stainless steel crowns for primary teeth.

Retained Claims – Claims retained by the contractor for processing to completion or development.

Routine Care – Covered benefits for remote ADSMs that do not require authorization which includes diagnostic (exams and X-rays), preventive (cleanings), routine restorations (amalgam or composite fillings), and single tooth extractions that does not exceed $750 per appointment. It does not include crowns.

Routine Care Appointment - A routine appointment is for care such as a 6-month, annual exam and preventive services (i.e. prophylaxis and application of fluoride).

Sealants – A material designed for application on specified teeth to seal the surface irregularities to prevent ingress of oral fluids, food, and debris in order to prevent tooth decay.

Selected Reserve – The Selected Reserve consist of those units and individuals within the Ready Reserve designated by their respective Services and approved by the Chairman of the Joint Chiefs of Staff as so essential to initial wartime missions that they have priority over all other Reserves.

Service Point of Contact (SPOC) – Serves as a centralized service point of contact and is the primary POC for respective service headquarters and commands.

Specialty Care – Other dental care (prosthodontics, periodontics, oral surgery) or diagnostic procedure not considered emergency or routine care.

State – For purposes of the TDRAW, any of the fifty States of the United States, the District of Columbia, the Commonwealth of Puerto Rico, Guam, and the U.S. Virgin Islands.

Wellness Care – Wellness care is when the Individual Ready Reserve members [mobilization asset only as identified in Title 10 U.S.C. Chapter 55 Section 10144(b)] are classified at the Dental Readiness Classification (DRC) 1 or 2 level.

Attachment J-2a Benefits, Limitations and Exclusions for Active Duty Service Members (ADSMs)

TDRAW HT9402-17-R-0001 Attachment J-2a

These ADSM benefits, exclusions and limitations currently conform to the American Dental Association’s (ADA) Current Dental Terminology (CDT) 2018 Dental Procedure Codes.

1.0. GENERAL POLICIES

1.1. Purchased care dental benefits are intended to be an adjunct, not a replacement for, Dental Treatment Facility (DTF) dental care provided to Active Duty Service Members (ADSMs).

Treatment and services not immediately required to establish or maintain dental health to meet dental readiness or world-wide deployability standards may be delayed by the DTF or Dental Service Point of Contact (DSPOC) until this treatment can be provided at a DTF.

All treatment and procedures should be reported following the guidelines and definitions of the most current version of the ADA’s CDT.

1.2. The following services, supplies, or charges are not covered for purchased care dental benefits unless specifically authorized by the Services' Dental Corps Chief(s) or designated representative(s) (e.g., DSPOCs if remote care and DTF if referred care):

1.2.1. Any dental service or treatment not specifically listed as a Covered Service.

1.2.2. Any dental service or treatment determined Services' Dental Corps specialty consultants or DSPOCto be unnecessary or which does not meet accepted standards of dental practice.

1.2.3. Those services not prescribed by or under the direct supervision of a dentist, except in those states where dental hygienists are permitted to practice without supervision by a dentist. In these states, only those covered services provided by an authorized dental hygienist performing within the scope of his or her license and applicable state law will be eligible for payment or reimbursement.

1.2.4. Those services submitted by a dental provider that are for the same service(s) performed on the same date for the same member by another dental provider.

1.2.5. Those services which are experimental or investigative in nature.

1.2.6. Those services which are for any illness or bodily injury which occurs in the course of employment if benefits or compensation is available, in whole or in part, under the provision of any legislation of any governmental unit. This exclusion applies whether or not the member claims the benefits or compensation.

1.2.7. Those services which are later recovered in a lawsuit or in a compromise or settlement of any claim, except where prohibited by law.

1.2.8. Those services provided free of charge by any governmental unit, except where this exclusion is prohibited by law.

1.2.9. Those services for which the member would have no obligation to pay in the absence of this or any similar coverage.

1.2.10. Those services received from a dental or medical department maintained by or on behalf of an employer, mutual benefit association, labor union, trust, or similar person or group.

1.2.11. Those services performed prior to the member’s effective coverage date. This includes any treatment for crowns, inlays, onlays, cast post and cores, or dentures/bridges initiated prior to the effective date of the member’s eligibility.

1.2.12. Those services provided after the termination date of the member’s eligibility for coverage unless otherwise indicated. This includes those prosthesis delivered after the termination date of active duty eligibility and any further treatment for crowns, inlays, onlays, cast post and cores, or dentures/bridges that were delivered or inserted prior to the termination date of active duty eligibility. The date of service for prosthodontic services (crowns, inlays, onlays, east post and core, dentures/bridges) is the date of preparation. That date of service should be used when billing for all claims.

1.2.13. Those services which are for unusual procedures and techniques.

1.2.14. Those services performed by a dental provider who is compensated by a facility for similar covered services performed for members.

1.2.15. Those services resulting from the patient’s failure to comply with professionally prescribed treatment.

1.2.16. Telephone consultations.

1.2.17. Any charges for failure to keep a scheduled appointment.

1.2.18. Network providers may not bill patients for the completion of claim forms.

1.2.19. Any services or restorations that are strictly cosmetic in nature including, but not limited to, charges for personalization or characterization of prosthetic appliances.

1.2.20. Duplicate and temporary devices, appliances and services.

1.2.21. Plaque control programs, oral hygiene instruction, home care items and dietary instructions.

1.2.22. Services including evaluations, which are routinely performed in conjunction with, or as part of, another service are considered integral and will not be paid or reimbursed as a separate charge.

1.2.23. Services applicable to a “per site” payment as defined in the effective ADA CDT Dental Procedure Codes will not be paid as separate charges even if referred multiple times.

1.2.24. Services to alter vertical dimension and/or restore or maintain the occlusion. Such procedures include, but are not limited to, equilibration, periodontal splinting, full mouth rehabilitation and restoration for mal-alignment of teeth.

1.2.25. Gold foil restorations.

1.2.26. Treatment or services for injuries resulting from the maintenance or use of a motor vehicle if such treatment or service is paid or payable under a plan or policy of motor vehicle insurance, including a certified self-insurance plan.

1.2.27. Hospital costs or any additional fees that the dental provider or hospital charges for treatment at the hospital (inpatient or outpatient).

1.2.28. Medical procedures as well as procedures covered as adjunctive dental care under TRICARE/Medical or other medical benefit coverage.

1.2.29. Infection control procedures and fees associated with Occupational Safety and Health Administration (OSHA) and/or governmental agency compliance are considered integral to the dental service(s) provide and will not be paid or reimbursed as a separate charge.

1.2.30. Adjunctive dental benefits as defined by applicable federal regulations.

1.2.31. Any request for payment of a Continental United States (CONUS) claim more than 12 months after the month the service was provided is not eligible for payment. Any request for payment of an Outside the Continental United States (OCONUS) claim more than 3 years after the month the service was provided is not eligible for payment. A network dentist may not bill the member for services that are denied for this reason.

1.2.32. For remote ADSMs seeking services that include time and frequency limitations, if a service is provided within 30 days of the expiration of the time period, the service shall be considered authorized.

2.0. EMERGENCY CARE

Emergency care is care that is required to treat or control hemorrhage, infection, swelling and pain. This includes treatment necessary to relieve pain, treat infection, or control hemorrhage to include: temporary or permanent fillings, root canal treatment, single tooth extractions, incision and drainage or other immediate required treatment. Crowns, bridges and dentures are not considered emergency care and require authorization (see below). For example, root canal therapy required to relieve acute pain or treat an acute exacerbation of a periradicular infection can be completed without authorization even if this treatment requires more than one appointment. If a crown is indicated following the root canal therapy, the crown must have authorization before initiating the crown preparation.

3.0. COVERED SERVICES

3.1. To be considered a covered service, a procedure or treatment must be appropriate and necessary to establish and maintain dental health to meet military worldwide readiness/deployment status.

3.2. In addition, non-emergency covered services that exceed $750 per procedure or appointment or $1500 for any episode of treatment requires authorization to be considered for payment or reimbursement. (See definition of emergency care.) This includes appointments where routine care under $750 may be combined with specialty care provided on the same date of service. In these cases, authorization for all care is required even if a portion of it was previously approved. Certain procedures will always need an authorization regardless of the cost as indicated in this attachment. Authorization requirements may vary for each specific procedure but generally require the submission of a current diagnostic-quality periapical x-ray. A brief narrative report of the specific service(s) to be performed is recommended if there are any factors that may affect the care provided. Initiating dental care requiring authorization without written authorization may result in the service member being responsible for part or all cost of treatment. If the dental provider initiates this care without receiving written authorization, the provider has the responsibility to obtain written consent from the service member clearly explaining this financial responsibility and risk. Substitution of a non-covered service for a covered service is not allowed even if the fee for the non-covered service is less than or equal to the covered service. Therefore, obtaining a written authorization of benefit is highly recommended prior to initiating care.

Note: There are procedures listed under “Other Dental Services” in which the ADSM may be eligible for if their dental condition meets accepted clinical diagnostic criteria.

3.3. For each CDT Code listed, there is a letter code defined in the table below. All four codes are only applicable to remote ADSM utilization. The code “N” only applies for DTF referred care; that is the DSPOCs may authorize care that is not typically covered care.

Code Description E Emergency care – No authorization required R Routine care - No authorization required (unless over $750) S Specialty care – Authorization is required

N or Not Listed Non-covered procedure

4.0. DIAGNOSTIC

D0120 R periodic oral evaluation – established patient D0140 R limited oral evaluation - problem focused

D0150 R comprehensive oral evaluation –new or established patient D0160 R detailed and extensive oral evaluation - problem focused, by report D0170 R re-evaluation-limited, problem focused (established patient, not post-operative visit) D0171 N re‐evaluation ‐ post-operative office visit D0180 R comprehensive periodontal evaluation – new or established patient D0190 N screening of a patient D0191 N assessment of a patient D0210 R intraoral - complete series of radiographic images D0220 R intraoral - periapical first radiographic image D0230 R intraoral - periapical each additional radiographic image D0240 R intraoral - occlusal radiographic image D0250 R extraoral - 2D projection radiographic image created using a stationary radiation source, and detector D0251 R extraoral posterior dental radiographic image D0270 R bitewing - single radiographic image D0272 R bitewings - two radiographic images D0273 R bitewings – three radiographic images D0274 R bitewings - four radiographic images D0277 R vertical bitewings - 7 to 8 radiographic images D0310 R sialography D0320 S temporomandibular joint arthrogram, including injection D0321 S other temporomandibular joint radiographic images, by report D0322 S tomographic survey D0330 R panoramic radiographic image D0340 S 2D cephalometric radiographic image – acquisition, measurement and analysis D0364 S cone beam CT capture and interpretation with limited field of view – less than one whole jaw D0365 S cone beam CT capture and interpretation with field of view of one full dental arch

– mandible D0366 S cone beam CT capture and interpretation with field of view of one full dental arch

– maxilla, with or without cranium D0367 S cone beam CT capture and interpretation with field of view of both jaws, with or without cranium D0368 S cone beam CT capture and interpretation for TMJ series including two or more exposures D0369 S maxillofacial MRI capture and interpretation D0370 S maxillofacial ultrasound capture and interpretation D0371 S sialoendoscopy capture and interpretation D0380 S cone beam CT image capture with limited field of view – less than one whole jaw D0381 S cone beam CT image capture with field of view of one full dental arch – mandible D0382 S cone beam CT image capture with field of view of one full dental arch – maxilla, with or without cranium D0383 S cone beam CT image capture with field of view of both jaws, with or without cranium

D0384 S cone beam CT image capture for TMJ series including two or more exposures D0385 S maxillofacial MRI image capture D0386 S maxillofacial ultrasound image capture D0391 S interpretation of diagnostic image by a practitioner not associated with capture of the image, including report D0393 S treatment simulation using 3D image volume D0394 S digital subtraction of two or more images or image volumes of the same modality D0395 S fusion of two or more 3D image volumes of one or more modalities D0411 S HbA1c in office point of service testing D0414 S laboratory processing of microbial specimen to include culture and sensitivity studies, preparation and transmission of written report D0415 S collection of microorganisms for culture and sensitivity D0416 S viral culture D0417 S collection and preparation of saliva sample for laboratory diagnostic testing D0418 S analysis of saliva sample D0422 N collection and preparation of genetic sample material for laboratory analysis and report D0423 N genetic test for susceptibility to diseases – specimen analysis D0425 S caries susceptibility test D0431 N adjunctive pre-diagnostic test that aids in the detection of mucosal abnormalities including premalignant and malignant lesions, not to include cytology or biopsy procedures

D0460 S pulp vitality tests D0472 S accession of tissue, gross examination, preparation and transmission of written report D0473 S accession of tissue, gross and microscopic examination, preparation and transmission of written report D0474 S accession of tissue, gross and microscopic examination, including assessment of surgical margins for presence of disease, preparation and transmission of written report

D0475 S decalicification procedure D0476 S special stains for microorganisms D0477 S special stains, not for microorganisms D0478 S immunohistochemical stains D0479 S tissue in-situ hybridization, including interpretation D0480 S accession of exfoliative cytologic smears, microscopic examination, preparation and transmission of written report D0481 S electron microscopy D0482 S direct immunofluorescence D0483 S indirect immunofluorescence D0484 S consultation on slides prepared elsewhere D0485 S consultation, including preparation of slides from biopsy material supplied by referring source D0486 S laboratory accession of transepithelial cytologic sample, microscopic examination, preparation and transmission of written report

D0502 S other oral pathology procedures, by report D0600 N non-ionizing diagnostic procedure capable of quantifying, monitoring, and recording changes in structure of enamel, dentin and cementum D0601 N caries risk assessment and documentation, with a finding of low risk D0602 N caries risk assessment and documentation, with a finding of moderate risk D0603 N caries risk assessment and documentation, with a finding of high risk D0999 N unspecified diagnostic procedure, by report

4.1. Benefits and Limitations for Diagnostic Services:

4.1.1. For Remote ADSMs, two routine examinations per consecutive 12-month period are covered without obtaining authorization. Oral evaluations are considered integral when provided on the same date of service as palliative or surgical procedure(s) by the same dental provider. If a Remote ADSM desires a second opinion, he/she may obtain a third exam from a different performing provider without obtaining authorization. Radiographic images completed during the third exam on the same day, by the same provider, in support of a second opinion are covered for payment.

4.1.2. Only one limited oral evaluation, problem-focused (D0140) will be allowed per patient per dentist in a consecutive 12-month period.

4.1.3. For a limited oral evaluation - problem focused or palliative (emergency) treatment to be covered, it must involve a problem or symptom that occurred suddenly and unexpectedly and require immediate attention.

4.1.4. Re-evaluations are considered integral procedures.

4.1.5. Radiographic images which are not of diagnostic quality are not covered and may not be charged to the patient when provided by a network dentist.

4.1.6. Unless approved by DSPOC, one complete series of radiographic images or one panoramic radiographic image is covered in a 36-month period for Remote ADSMs.

4.1.7. Unless approved by DSPOC, one set of bitewing radiographic images, consisting of up to four bitewing radiographic images per visit, is covered during a consecutive 12-month period for Remote ADSMs.

4.1.8. Vertical bitewings (D0277) will be paid at the same allowance as four bitewings and are subject to the same benefit limitations as four bitewing radiographic images.

4.1.9. Periapical radiographic images are covered, when necessary.

4.1.10. Radiographic images are not a covered benefit when taken by an x-ray laboratory, unless billed by a licensed dental provider.

4.1.11. If the total allowance for individually reported periapical and/or bitewing radiographic images equals or exceeds the allowance for a complete series, the individually reported radiographic images are paid as a complete series and are subject to the same benefit limitations as a complete series. Any difference in fees may not be charged to the member by a network dentist.

4.1.12. Periapical and/or bitewing radiographic images are considered integral when performed on the same date of service, by the same dental provider, as a complete series of radiographic images.

4.1.13. Bitewing radiographic images are not considered integral when performed on the same date of service as a panoramic radiographic image; they may be paid as a separate service.

4.1.14. Pulp vitality tests are considered integral to all services.

4.1.15. Caries susceptibility tests are not payable unless specifically authorized in writing prior to initiating this service. This service will be considered only in conjunction with an intensive regimen of home preventive therapy (including prescription mouth rinses) to determine if the therapy should be continued. The test is payable once per regimen. The regimen must be initiated immediately following completion of restorative care for a recent episode of rampant caries.

4.1.16. Caries susceptibility tests are not payable on a routine basis, for patients with un-restored carious lesions, or when performed for patient education.

4.1.17. Diagnostic casts (study models) taken in conjunction with restorative procedures are considered integral to the restorative procedure. Diagnostic casts are not covered as independent procedures.

4.1.18. A panoramic radiograph (D0330) is covered when performed by an oral surgeon.

4.1.19. The contractor may reimburse dental care not indicated on the DTF referral/authorization if the service provided is a panoramic radiograph (D0330) performed by an oral surgeon. For all provider specialties, the contractor may issue reimbursement for up to two bitewing radiographs (D0270/D0272) or two periapical radiographs (D0220/D0230). Additionally, the contractor may reimburse for a limited oral evaluation-problem focused (D0140).

4.1.20. Lab fees for biopsies are a covered benefit at 100% of charge. The contractor does not pay the lab directly but will reimburse the provider if a lab invoice is submitted with the claim. If the member has paid for the lab fee, the contractor will reimburse the member at 100% of charge.

4.1.21. HbA1c point of service testing (D0411) to be submitted in conjunction with or before surgical procedure for a known diabetic patient.

5.0. PREVENTIVE

D1110 R prophylaxis – adult D1206 R topical application of fluoride varnish D1208 R topical application of fluoride – excluding varnish D1351 S sealant – per tooth D1352 S preventive resin restoration in a moderate to high caries risk patient – permanent tooth D1353 S sealant repair – per tooth D1354 N interim caries arresting medicament application D1575 N distal shoe space maintainer-fixed-unilateral

5.1. Note

5.1.1. If a remote member requests or obtains care that exceeds the allowed quantity in a consecutive 12-month period, the care will be considered authorized if it occurs no more than one month prior to the expiration of the consecutive 12-month period.

5.2. Benefits and Limitations for Preventive Services

5.2.1. For remote ADSM, two routine prophylaxes are covered in a consecutive 12-month period. Additional prophylaxes in a 12-month period must be approved by the DSPOC.

5.2.2. Routine prophylaxes are considered integral when performed by the same dental provider/facility within 45 days as scaling and root planing, periodontal surgery and periodontal maintenance procedures.

5.2.3. A routine prophylaxis is considered integral when performed in conjunction with, or as a finishing procedure to, periodontal scaling and root planing, periodontal maintenance, gingivectomies, gingival flap procedures, mucogingival surgery, osseous surgery or curettage.

5.2.4. A routine prophylaxis includes associated scaling and polishing procedures. There are no provisions for any additional allowance based on degree of difficulty.

5.2.5. Two topical fluoride applications are covered in a consecutive 12-month period when performed as independent procedures. Additional fluoride applications must be preauthorized.

The use of a prophylaxis paste containing fluoride qualifies for payment only as a prophylaxis.

5.2.6. Topical fluoride applications (D1204) are covered when provided as part of an intensive regimen of home preventive therapy to treat rampant caries. This service is only covered if authorized in writing prior to initiating the service.

5.2.7. Sealants for teeth other than permanent bicuspids and permanent molars are not covered.

5.2.8. Sealants provided on the same date of service and on the same tooth as a restoration involving the occlusal surface are considered integral procedures.

6.0. RESTORATIVE

D2140 R amalgam - one surface, permanent or primary D2150 R amalgam - two surfaces, permanent or primary D2160 R amalgam - three surfaces, permanent or primary D2161 R amalgam - four or more surfaces, permanent or primary D2330 R resin-based composite - one surface, anterior D2331 R resin-based composite - two surfaces, anterior D2332 R resin-based composite - three surfaces, anterior D2335 R resin-based composite - four or more surfaces or involving incisal angle (anterior) D2390 S resin-based composite crown, anterior D2391 R resin-based composite - one surface, posterior D2392 R resin-based composite - two surfaces, posterior D2393 R resin-based composite - three surfaces, posterior D2394 R resin-based composite – four or more surfaces, posterior D2410 N gold foil – one surface D2420 N gold foil – two surfaces D2430 N gold foil – three surfaces D2510 N inlay – metallic – one surface D2520 N inlay – metallic – two surfaces D2530 N inlay – metallic – three or more surfaces D2542 S onlay - metallic-two surfaces D2543 S onlay - metallic-three surfaces D2544 S onlay - metallic-four or more surfaces D2710 N crown – resin-based composite (indirect) D2712 N crown – ¾ resin-based composite (indirect) D2750 S crown - porcelain fused to high noble metal D2751 N crown - porcelain fused to predominantly base metal D2752 S crown - porcelain fused to noble metal D2780 S crown - ¾ cast high noble metal D2781 N crown - ¾ cast predominantly base metal D2782 S crown - ¾ cast noble metal D2790 S crown - full cast high noble metal D2791 N crown - full cast predominantly base metal D2792 S crown - full cast noble metal D2794 S crown - titanium

6.1. Benefits and Limitations for Restorative Services

6.1.1. Diagnostic casts (study models) taken in conjunction with restorative procedures are considered integral.

6.1.2. The payment for restorations includes all related services including, but not limited to, etching, bases, liners, dentinal adhesives, local anesthesia, polishing, caries removal, preparation of gingival tissue, occlusal/contact adjustments and detection agents.

6.1.3. Pin retention is covered only when reported in conjunction with an eligible restoration.

6.1.4. An amalgam or resin restoration reported with a pin (D2951), in addition to a crown, is considered to be a pin-retained core buildup (D2950).

6.1.5. Preventive resin restorations or other restorations that do not extend into the dentin are considered sealants for purposes of determining benefits.

6.1.6. Restorative services are covered only when necessary due to decay or fracture.

Restorative services are not benefits when performed for cosmetic purposes.

6.1.7. Restorative services that are needed due to attrition, erosion, abrasion, or congenital or developmental defects require authorization.

6.1.8. Multiple restorations performed on the same surface of a tooth, without involvement of a second surface, on the same date of service and by the same dental provider/facility, will be processed as a single surface restoration.

6.1.9. A restoration involving two or more surfaces should be reported using the appropriate multiple surface restoration code.

6.1.10. If multiple restorations involving multiple surfaces with at least one common surface are reported, an allowance will be made for a single restoration reflecting the number of different surfaces involved.

6.1.11. Repair or replacement of restorations by the same dentist and involving the same tooth surfaces, performed within 12 months of the original restoration are considered integral procedures and a separate fee is not chargeable to the member by a network dentist. However, payment may be allowed if the repair or replacement is due to fracture of the tooth or the restoration involves the occlusal surface of a posterior tooth or the lingual surface of an anterior tooth and is required to restore the tooth following root canal therapy.

6.1.12. Restorations performed on the same tooth and by the same dentist/facility within twelve months following the placement of any type of crown or onlay are considered integral.

6.1.13. For reporting and benefit purposes, the completion date for crowns, onlays and buildups is the preparation date for all claims.

6.1.14. The charge for a crown or onlay should include all charges for work related to its placement and any follow-up care including, but not limited to, preparation of gingival tissue, tooth preparation, temporary crown, diagnostic casts (study models), impressions, try-in visits, limited occlusal adjustments and cementations of both temporary and permanent crowns.

6.1.15. Prefabricated stainless steel crowns (with or without resin windows for anterior and premolar teeth) are covered only when authorized in writing prior to initiating the procedure.

6.1.16 Restorative and removable and fixed prostheses initiated prior to the effective date of coverage or inserted/cemented after the cancellation date of coverage are not eligible for payment or reimbursement.

7.0. OTHER RESTORATIVE SERVICES

D2910 R recement or rebond inlay, onlay, veneer or partial coverage restoration D2915 S recement or rebond indirectly fabricated or prefabricated post and core D2920 R recement or rebond crown D2921 E reattachment of tooth fragment, incisal edge or cusp D2929 N prefabricated porcelain/ceramic crown – primary tooth D2930 N prefabricated stainless steel crown – primary tooth D2931 S prefabricated stainless steel crown - permanent tooth D2932 N prefabricated resin crown D2933 N prefabricated stainless steel crown with resin window D2940 E protective restoration D2941 N interim therapeutic restoration-primary dentition D2949 S restorative foundation for an indirect restoration D2950 S core buildup, including any pins when required D2951 R pin retention - per tooth, in addition to restoration D2952 S post and core in addition to crown, indirectly fabricated D2953 N each additional indirectly fabricated post - same tooth D2954 S prefabricated post and core in addition to crown D2955 S post removal D2957 N each additional prefabricated post - same tooth D2960 N labial veneer (resin laminate) – chairside D2971 S additional procedures to construct new crown under existing partial denture framework D2975 S coping D2980 R crown repair, necessitated by restorative material failure D2981 N inlay repair necessitated by restorative material failure D2982 N onlay repair necessitated by restorative material failure D2983 N veneer repair necessitated by restorative material failure D2990 S resin infiltration of incipient smooth surface lesions D2999 N unspecified restorative procedure, by report

7.1. Benefits and Limitations for Other Restorative Services

7.1.1. For Remote ADSMs, replacement of crowns, onlays, buildups and posts and cores is covered only…