Exhibit T_RHRP-DP_Services_Supplement 2025.docx

Exhibit T - Remote Health Readiness Program (RHRP) Dental Program (RHRP-DP) Covered Services, Limitations, and Exclusions January 2025

These covered services, exclusions and limitations currently conform to the ADA’s Current Dental Terminology (CDT) 2025 Dental Procedure Codes. RHRP Dental Program (RHRP-DP) provides services intended to treat deployment limiting Dental Readiness Classification (DRC 3) conditions and restore a Service Member (SM) to a deployable DRC 2 status (deployable, unlikely to have a dental emergency in the next 12 months) in accordance with DoD Instruction 6025.19.

1. General Policies All covered services are subject to the following general policies:

1. Services must be necessary and meet accepted standards of dental practice. Services determined to be unnecessary or which do not meet accepted standards of practice are not billable to the patient by a network dentist unless the dentist notifies the Service Member (SM) of his or her liability prior to treatment and SM chooses to receive the treatment. RHRP network dentists shall document such notification in their records.

2. An appeal is not available when the services are determined to be unnecessary or do not meet accepted standards of dental practice unless the dentist notifies the SM of his or her liability prior to treatment and the SM chooses to receive the treatment. This is because such services are not billable to the SM, and there would be no amount in dispute to consider at appeal. The SM notification must be in writing, signed by both parties, specific to the dental treatment and cannot be a general financial agreement.

3. Medical procedures, as well as procedures covered as adjunctive dental care under TRICARE/Medical policy, are not covered under the RHRP-DP.

4. Procedures should be reported using the American Dental Association’s (ADA) current dental procedure codes and terminology. Note: For OCONUS services, if a procedure code is not given, a complete description of the service performed, including applicable tooth numbers, should be provided. OCONUS in this document does not include the States and Territories with U.S. National Guard home units, which must meet CONUS standards.

5. Services, including evaluations, which are routinely performed in conjunction with or as part of another service, are considered integral. Network dentists may not separately bill SMs for services if they are considered integral to another service.

6. Infection control procedures and fees associated with Occupational Safety and Health Administration (OSHA) and/or other Governmental agency compliance are considered part of the dental services provided and may not be billed separately by a network dentist.

7. Local anesthesia is considered integral to the procedure(s) for which it is provided.

8. Time periods for routine oral exams, and bitewing X-rays are based on the month of service and are measured backward from the date of the most recent service in each category.

9. Writing of prescriptions and authorizations for medications is integral to the procedure. Cost of medications picked up at a pharmacy will be self-pay by the Service Member. Oral medications provided as the time of service are considered integral to the procedure.

10. The 36-month time limitation for a panoramic or complete series of x-rays or a denture reline/rebase is calculated to the month in which the service was performed. A Panoramic x-ray is valid without time limitation if it represents the current condition (less than 4 restorations or 2 extractions have occurred) of the Service Members mouth. Additional Panoramic x-rays may be ordered by exception when needed for diagnostic purposes and approved by the government.

11. The five-year time limitation for removable prosthodontic services is based on the exact date of service (day and month) when the procedure was performed.

12. For reporting purposes, the completion date for, buildups, posts and cores is the cementation date; for removable prostheses is the insertion date; and for endodontic therapy is the date the tooth is sealed.

2. Documentation Required for Specific Services Some covered procedures require the submission of diagnostic materials, such as periodontal charting, x-rays and/or a brief narrative report of the specific service(s) performed and any factors that may have affected the care provided. Where applicable, these requirements are indicated on the list of covered procedures. If x-rays are required, contractor will request that dentists submit all x-rays used for diagnosis and treatment planning.

Contractor will request only those x-rays that are generally taken as part of diagnosis and treatment planning. If, for some reason, x-rays were not taken or are not available, a brief explanation should be included with the service report.

"Report required" means that these services will be paid only in well documented circumstances and documentation of the circumstances must be submitted with the treatment plan or service report.

“Periodontal charting required” means that complete periodontal charting must be submitted for review.

Note: The requirement for providers to submit radiographs and other clinical documentation for certain specified procedures, as indicated throughout this attachment, may be relaxed by the RHRP Contracting Office Representative (COR).

Note: For OCONUS services, the submission of x-rays and periodontal charting is not required unless specifically requested by the COR. All procedures received from the OCONUS service area will be processed without a “report” requirement.

3. Diagnostic Services R = report required

Coverage and Limitations for Diagnostic Services:

1. Three oral evaluations (D0150,) are covered in a consecutive 12-month period. Only two of these oral evaluations may be from the same office. A third oral evaluation is covered only if it is rendered by a different office.

2. Limited oral evaluation, problem-focused (D0140), is eligible once per patient per dentist in a consecutive 12- month period in conjunction with consultations (D9310) – only one of these services is eligible within a consecutive 12-month period. A limited oral evaluation will be considered integral when provided on the same date of service by the same dentist as any other oral evaluation.

3. Re-evaluations are considered integral procedures.

4. X-rays which are not of diagnostic quality are not covered and may not be charged to the patient, when provided by a network dentist.

5. One full mouth x-ray (complete series or panoramic x-ray) is covered in a 36-month period, see general policies.

6. One set of bitewing x-rays, consisting of up to four bitewing x-rays per visit, is covered during a consecutive 12-month period. A complete series of x-rays counts as an occurrence of bitewing x-rays. By exception the government may request additional bitewing x-rays to support deployment readiness.

7. Vertical bitewings (D0277) will be paid at the same allowance as four bitewings and are subject to the same service limitations as four bitewing x-rays. The patient is not responsible for the difference between the allowance and the dentist’s charge.

8. X-rays are not a covered service when taken by a radiograph laboratory unless billed by a licensed dentist. Any difference between the allowance for the x-rays and the fee charged by the x-ray laboratory cannot be charged to the patient.

9. If the total allowance for individually reported periapical, occlusal and/or bitewing x-rays equals or exceeds the allowance for a complete series, the individually listed x-rays are paid as a complete series and are subject to the same service limitations as a complete series. A network dentist may not charge any difference in fees to the patient.

10. Periapical and/or bitewing x-rays are considered integral when performed on the same date of service, by the same dentist, as a complete series of x-rays.

11. Bitewing x-rays are not considered integral when performed on the same date of service as a panoramic x-ray; they are paid as a separate service.

12. Payment for individually reported periapical x-rays and a panoramic x-ray will be limited to the payment allowance for a complete series of x-rays.

13. The x-ray taken to diagnose the need for a root canal is eligible for payment in addition to the root canal therapy. An additional x-ray is authorized for the treating doctor at the time of service. All other x-rays taken within 30 days of the root canal therapy and in conjunction with the root canal therapy, including post-treatment radiographic images, are considered integral and should not be billed separately.

14. X-rays are not covered when performed in conjunction with the diagnosis or treatment of Temporomandibular Joint Dysfunction (TMD).

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

4. Restorative Services

Coverage and Limitations for Restorative Services:

1. Diagnostic casts (study models) or 3D printing of a 3D dental surface scan (D00396) done in conjunction with restorative or prosthodontic procedures are considered integral.

2. Sedative restorations are not a covered service.

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

4. An amalgam or resin restoration reported with a crown buildup or post and core is considered an integral procedure.

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

6. Restorative services are covered only when necessary due to decay, tooth fracture, attrition, erosion, abrasion, congenital or developmental defects. Restorative services are not covered when performed for cosmetic purposes.

7. For purposes of determining billing, a restoration involving two or more surfaces will be processed using the appropriate multiple surface restoration code.

8. Multiple restorations performed on the same surface of a posterior tooth, without involvement of a second surface, on the same date and by the same dentist, will be processed as a single surface restoration.

9. If multiple posterior 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.

10. Multiple restorations involving contiguous (touching) surfaces provided on the same date of service by the same dentist will be processed as one restoration reflective of the number of different surfaces reported. For example, a one surface amalgam restoration of the lingual surface, and a one surface amalgam restoration of the mesial surface will be combined and processed as a two surface amalgam restoration. This policy applies regardless of restorations being reported as separate services.

11. Repair or replacement of restorations by the same dentist and involving the same tooth surfaces, performed within 12 months of the previous 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 placed following root canal therapy.

12. Resin (composite) restorations on greater than three surfaces are not covered when performed on posterior teeth. However, an allowance will be made for a comparable amalgam restoration. The member is responsible for the difference between the dentist's charge for the resin restoration and the amount paid by the contractor for the amalgam restoration.

13. 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.

5. Other Restorative Services X = X-ray required

Coverage and Limitations for Other Restorative Services:

1. For reporting and coverage purposes, the completion date for buildups is the bonding date.

2. Core buildups (D2950), refers to the building up of coronal structure when there is insufficient retention for a separate extracoronal restorative procedure. A core buildup is not a filler used to eliminate any undercut, box form or concave irregularity in a preparation.

3. Additional posts (D2953, D2957) are considered integral to the associated restorative procedure.

4. Posts and cores are payable only when necessary due to decay or tooth fracture. However, if the tooth can be adequately restored with amalgam or composite (resin) filling material, payment will be made for that service.

5. Recementation or re-bonding of single prosthetics (D2910, D2915, D2920) is eligible once per 12- month period. Recementation or re-bonding provided within 12 months of placement by the same dentist is considered integral.

6. When performed as an independent procedure, the placement of a post is not a covered service. Posts are only eligible when provided as part of a buildup for a crown and are considered integral to the buildup.

7. Payment for an anterior resin restoration will be made when a laboratory fabricated porcelain or resin veneer is used to restore anterior teeth due to tooth fracture or caries.

8. Porcelain ceramic, metallic, and composite resin inlays are not covered. However, payment will be made for a corresponding amalgam restoration for a posterior tooth reflective of the number of different surfaces restored.

9. Glass ionomer restorations will be paid based upon the fees for amalgam restorations for posterior teeth or resin restorations for anterior teeth.

6. Endodontic Services X = X-ray required R = report required

Procedure Code Description of Service

Coverage and Limitations for Endodontic Services:

1. Direct and indirect pulp caps are considered an integral service when provided on the same date as a restoration. When covered, service is limited to one indirect pulp cap per tooth per lifetime.

2. Pulpotomies are considered integral when performed by the same dentist within a 45-day period prior to the completion of root canal therapy.

3. A pulpotomy is covered when performed as a final endodontic procedure and is payable generally on primary teeth only. Pulpotomies performed on permanent teeth are considered integral to root canal therapy and are not reimbursable unless specific rationale is provided and root canal therapy is not and will not be provided on the same tooth.

4. Pulpal debridement is eligible when provided to relieve acute pain. It is considered integral to root canal therapy or palliative emergency treatment when provided on the same day by the same dentist.

5. Partial pulpotomy for apexogenesis is considered integral when performed on the same day or within 45 days prior to root canal therapy.

6. Treatment of a root canal obstruction is considered an integral procedure.

7. Incomplete endodontic therapy is not a covered service when due to the patient discontinuing treatment. All other circumstances require a pretreatment x-ray and a report describing the treatment provided and why it could not be completed.

8. Retreatment of previous root canal therapy (D3346, D3347, and D3348) is NOT covered within the first 12 months of initial treatment if performed by the same dentist. A network dentist cannot charge a fee to the member.

9. Internal root repair of a perforation defect is not a covered service when the dentist providing the treatment causes the perforation.

10. The placement of a post is not a covered service when provided as an independent procedure. Posts are eligible only when provided as part of a crown buildup and are considered integral to the buildup.

11. Canal preparation and fitting of a preformed dowel or post (D3950) is not a covered service.

12. For reporting purposes, the completion date for endodontic therapy is the date the tooth is sealed.

13. No allowance is made for the treatment of additional canals.

14. An “open and drain” performed on an abscessed tooth to relieve pain in an emergency is considered palliative emergency treatment (D9110).

15. Placement of a final restoration following endodontic therapy is eligible as a separate procedure.

16. Bone grafts (D3428) are covered once per tooth, per lifetime, and only in conjunction with endodontic services. Bone grafting after extraction is not a covered service when used to prepare a site for implant placement. Service Member may opt for bone grafting to prepare site for an implant as a self-pay procedure but only if agreed to by the SM in writing prior to the procedure.

7. Periodontal Services

Coverage and Limitations for Periodontal Services:

1. Gingivectomy or gingivoplasty performed in conjunction with the placement of posts and cores or basic restorations are considered integral to the restoration.

2. Gingival flap procedure is considered integral when provided on the same date of service by the same dentist in the same area of the mouth as endodontic procedures, and oral surgery procedures.

3. Full mouth debridement involves the preliminary removal of plaque and calculius that interferes with the ability of the dentist to perform a comprehensive periodontal evaluation. (Code D4355) is covered once within a consecutive 12-month period. Not to be completed on the same day as D0160.

8. Prosthodontic Services Prosthodontics, removable:

Mandibular

Prosthodontics, fixed

Coverage and Limitations for Prosthodontic Services:

1. The fee, for diagnostic casts (study models) or 3D printing of a 3D dental surface scan (D0396) performed in conjunction with prosthetic and restorative procedures, is included in the fee for these procedures. A separate fee is not chargeable to the member by a network dentist.

2. Flexible base partial dentures (D5225 and D5226) are a covered service.

3. Tissue conditioning is considered integral when performed on the same day as the delivery of a denture or a reline/rebase.

4. Recementation or re-bonding of fixed prosthetics (D6930) is eligible once per 12-month period. Recementation or rebonding provided within 12 months of placement by the same dentist is considered integral.

5. Adjustments provided within six months of the insertion of an initial or replacement denture are integral to the denture.

6. The relining or rebasing of a denture, including immediate dentures, is considered integral when performed within six months following the insertion of that denture when performed by the same dentist.

7. A reline/rebase is covered once in any 36-month period.

8. Payment for a denture or an overdenture made with precious metals is based on the allowance for a conventional denture. Any additional cost is the member’s responsibility.

9. Specialized procedures performed in conjunction with an overdenture are not covered.

10. Provisional prostheses are designed for use over a limited period of time, after which they are replaced by a more definitive prosthesis. Interim complete and partial dentures are only covered once during a 12-month period.

11. Cast unilateral removable partial dentures are not covered.

12. Indirectly fabricated post and cores are processed as an alternate service of a prefabricated post and core. The member is responsible for the difference between the dentist’s charge for the indirectly fabricated post and core and the allowance for the prefabricated post and core.

13. Precision attachments, personalization, precious metal bases, and other specialized techniques are not covered.

14. Temporary fixed partial dentures are not a covered service and, when done in conjunction with permanent fixed partial dentures, are considered integral to the allowance for the fixed partial dentures.

15. Replacement of removable prostheses (D5110 through D5226) and buildups, posts and cores is covered only if the existing removable and/or fixed prostheses, buildup or past and core was inserted at least five years prior to the replacement and satisfactory evidence is presented that the existing removable and/or fixed prostheses cannot be made serviceable. Satisfactory evidence must show that the existing removable prostheses and/or fixed prostheses cannot be made serviceable. The five-year service date is measured based on the actual date (i.e., day and month) of the initial service, rather than the first day of the month during which the initial service was received.

16. Repairs to removable and fixed dentures (D5511, D5512, D5520, D5611, D5612, D5621, D5622, D5630, ) are each covered once per mouth area, per 24-month period.

Implant Services

Coverage and Limitations for Implant Services:

1. Recementation or re-bonding of an implant/abutment supported crown (D6092) is eligible once per 12- month period. Recementation or re-bonding provided within 12 months of placement by same dentist is considered integral.

2. Recementation of an implant/abutment supported fixed partial denture (D6093) is eligible once per 12- month period. Recementation or rebonding provided within 12 months of placement by the same dentist is considered integral.

9. Oral Surgery Services X = X-ray required R = Report required

Coverage and Limitations for Oral Surgery Services:

1. Simple incision and drainage reported with root canal therapy is considered integral to the root canal therapy.

2. Extraction of erupted tooth (D7210) includes related cutting of gingival and bone, removal of tooth structure, minor smoothing of socket bone and closure.

3. Coronectomy (D7251) can be considered for coverage only when the patient is symptomatic and there is evidence that complete removal would put the inferior alveolar nerve at considerable risk of damage. Coronectomy submitted for predetermination requires pretreatment x-rays, description of the patient’s specific symptoms, and a report explaining why complete removal would put the inferior alveolar nerve at considerable risk of damage.

4. Intraoral soft tissue incision and drainage is only covered when it is provided as the definitive treatment of an abscess. Routine follow up care is considered integral to the procedure.

5. Biopsies are an eligible service when tissue is surgically removed for the specific purpose of histopathological examination and diagnosis. Histopathological examination processing is integral to the biopsy procedure bill.

6. Biopsies are considered integral when performed in conjunction with other surgical procedures on the same day in the same area of the mouth.

7. Charges for related services such as necessary wires and splints, adjustments, and follow up visits are considered integral to the fee for reimplantation and/or stabilization.

8. Routine postoperative care such as suture removal is considered integral to the fee for the surgery.

9. Alveoloplasties performed in conjunction with extraction, involving less than four teeth is not covered as a separate procedure. A fee cannot be charged to the patient by a network dentist.

10. Removal of lateral exostosis (D7471) is only approved for use in conjunction with prosthodontic services.

11. Bone grafting for ridge preservation (D7953) [socket grafts] are not a covered procedure when used to prepare a site for implant placement and are covered once per tooth, per lifetime. A report is required indicating the reason why the bone graft is being placed. Service Member may opt for bone grafting to prepare site for an implant as a self-pay procedure only if agreed to in writing by the SM prior to procedure.

12. Removal of residual roots (D7250) is integral when reported by the same dentist who removed the tooth.

13. Removal of a complete bony impaction with unusual surgical complications (D7241) is eligible for complicating factors such as nerve dissection, sinus closure, or aberrant tooth position. A pretreatment x-ray and report describing the complicating factor are required for review.

10. Orthodontic Services Note: National Guard/Reserve service members should check with their unit commanders to ensure compliance with Service policies prior to receiving orthodontic treatment. The presence of orthodontic appliances may affect dental readiness for recall and eligibility for certain assignments and may necessitate the inactivation or removal of the orthodontic appliances at the reservist’s expense.

1. Repair of damaged orthodontic appliances is not covered.

2. Recementation of an orthodontic appliance by the same dentist who placed the appliance and/or who is responsible for the ongoing care of the patient is not covered. However, recementation by a different dentist will be considered for payment as palliative emergency treatment.

3. The rebonding and/or repair of a fixed retainer (D8698 or D8699) is not a covered service.

4. The replacement of a lost or missing appliance is not a covered service.

5. Myofunctional therapy is integral to orthodontic treatment and is not payable as a separate service.

6. It is the dentist’s and the member’s responsibility to notify the contractor if orthodontic treatment is discontinued or completed sooner than anticipated.

11. General Services The RHRP-DP will provide coverage for the following services. To be eligible, these services must be directly related to the covered services already listed.

R = Report required Emergency Services

General Anesthesia Services

Intravenous Sedation Services

Consultation Services

Office Visit Services

Medications Services

Post-surgical Services

Miscellaneous Services

Nitrous Oxide

Coverage and Limitations for General Services:

1. Intravenous moderate (conscious) sedation/analgesia (D9239, D9243) are only authorized when provided for support of an Oral Surgery Service as outlined above.

2. Deep sedation/general anesthesia and intravenous conscious sedation are covered (by report) only when provided in connection with a covered procedure(s) and when rendered by a dentist or other professional provider licensed and approved to provide anesthesia in the state where the service is rendered.

3. Deep sedation/general anesthesia and intravenous conscious sedation are covered only by report when determined to be medically or dentally necessary for documented handicapped or uncontrollable patients or justifiable medical or dental conditions.

4. In order for deep sedation/general anesthesia and intravenous conscious sedation to be covered, the procedure for which it was provided must be submitted.

5. Deep sedation/general anesthesia and intravenous conscious sedation submitted without a report will be denied payment.

6. Palliative (emergency) treatment is a “per visit” code and is payable once per provider per date of service.

7. Palliative (emergency) treatment is covered only if no definitive treatment is provided.

8. In order for palliative (emergency) treatment to be covered, it must involve a problem or symptom that occurred suddenly and unexpectedly, that requires immediate attention, and for which the dentist must provide treatment to alleviate the member’s problem. If the only service provided is to evaluate the patient and refer to another dentist and/or prescribe medication, it would be considered a limited oral evaluation - problem focused.

9. Consultations (D9310) provided as a diagnostic service by a dentist or physician other than the requesting dentist or physician are a covered service. They are limited to one per patient per dentist per 12-month period in combination with problem-focused evaluations (D0140) – only one of these services is eligible in a 12-month period.

10. The consultation code (D9310) includes an oral evaluation. Any oral evaluation provided on the same date by the same office is considered integral to the consultation.

11. Consultations (D9310) reported for a non-covered condition, such as, Temporomandibular Joint Dysfunction (TMD), are not covered.

12. After hours visits are covered only when the dentist must return to the office after regularly scheduled hours to treat the patient in an emergency situation. After hours visit only applies for In-Clinic services and is not payable for any services provided at an RHRP Group Event.

13. Therapeutic drug administrations are only payable in unusual circumstances, which must be documented by report. They are not covered if performed routinely or in conjunction with, or for the purposes of, general anesthesia, analgesia, sedation or premedication.

14. Therapeutic drug administration codes D9610 and D9612 are not to be used to report sedatives, anesthetics, or reversal agents.

15. Therapeutic drug administration code D9612 is not to be reported in addition to D9610. It should be reported when two or more different drugs are administered.

16. Preparations that can be used at home, such as fluoride gels, special mouth rinses (including antimicrobials), etc., are not covered.

17. Occlusal guards are covered when the purpose of the occlusal guard is for the treatment of bruxism or diagnoses other than temporomandibular joint dysfunction (TMD). Occlusal guards are limited to one per consecutive 12-month period.

18. Consultation for diagnostic purposes (D9310) cannot exceed one per patient per dentist in a 12-month period.

19. Occlusal adjustments (D9951 and D9952) are considered integral to procedure.

12. Alternative/Optional Methods of Treatment In instances where the dentist and the patient select a more expensive service, procedure, or course of treatment, an allowance for an alternative treatment may be billed toward the cost of the actual treatment performed. To be eligible for payment under this provision, the treatment actually performed must be consistent with sound professional standards of dental practice, and the alternative procedure for which an allowance is being paid must be a generally accepted alternative to the procedure actually performed. (Note: This provision applies only when the service actually performed would be covered. If the service actually provided is not covered, then the payment will not be allowed for an alternative service.)

In cases where alternative methods of treatment exist, payment will be allowed for the least costly, professionally accepted treatment.

The determination that an alternate treatment is an acceptable treatment is not a recommendation of which treatment should be provided. The dentist and patient should decide which treatment to select. Should the dentist and patient decide to proceed with the more expensive treatment; the Service Member will be financially responsible for the difference between the dentist’s fee for the more expensive treatment and the payment for the alternative service. Dentist and patient must enter into a signed agreement for additional payment prior to services being provided.

13. Non-Covered Services Except as specifically provided, the following services, supplies, or charges are not covered:

1. Any dental service or treatment not specifically listed as a covered service.

2. Those 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, the contractor will pay for eligible covered services provided by an authorized dental hygienist performing within the scope of his or her license and applicable state law.

3. Those submitted by a dentist, which are for the same services performed on the same date for the same member by another dentist.

4. Those which are experimental or investigative (deemed unproven).

5. Those 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.

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

7. Those provided free of charge by any Governmental unit, except where this exclusion is prohibited by law.

8. Those for which the patient would have no obligation to pay in the absence of this or any similar coverage. Treatment rendered by a dentist or physician who is a close relative, including spouse, children, adopted and step relatives, sisters and brothers, parents and grandparents of the beneficiary will be declined as not a covered service under the RHRP-DP.

9. Those 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.

10. Those which are not medically or dentally necessary, or which are not recommended or approved by the treating dentist. (Note: Services determined to be unnecessary or which do not meet accepted standards of dental practice are not billable to the patient by a network dentist unless the dentist notifies the patient of his/her liability prior to treatment and the patient chooses to receive the treatment. Network dentists should document such notification in their records.)

11. Those not meeting accepted standards of dental practice.

12. Those which are for unusual procedures and techniques.

13. Those performed by a dentist who is compensated by a facility for similar covered services performed for members.

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

15. Telephone consultations.

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

17. Duplicate and temporary devices, appliances, and services.

18. Services related to the diagnosis and treatment of Temporomandibular Joint Dysfunction (TMD).

19. Plaque control programs, oral hygiene instruction, and dietary instructions.

20. 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 misalignment of teeth.

21. Restorations which are placed for cosmetic purposes only.

22. Gold foil restorations.

23. 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.

24. Hospital costs or any additional fees that the dentist or hospital charges for treatment at the hospital (inpatient or outpatient).

25. Adjunctive dental services as defined by applicable federal regulations.

26. Charges for copies of members’ records, charts or x-rays, or any costs associated with forwarding/mailing copies of members’ records, charts or x-rays.

27. Oral sedation.

28. State or territorial taxes on dental services performed.

14. Adjunctive Services

1. Adjunctive dental care is dental care that is:

a. Medically necessary in the treatment of an otherwise covered medical (not dental) condition.

b. An integral part of the treatment of such medical condition.

c. Essential to the control of the primary medical condition.

d. Required in preparation for or as the result of dental trauma, which may be or is caused by medically necessary treatment of an injury or disease (iatrogenic).

2. The RHRP-DP does not cover services that are adjunctive dental care. These are medical services that may be covered under a medical benefit even when provided by a general dentist or oral surgeon, such as the following diagnoses or conditions:

a. Treatment for relief of Myofacial Pain Dysfunction Syndrome or Temporomandibular Joint Dysfunction (TMD).

b. Orthodontic treatment for cleft lip or cleft palate, or when required in preparation for, or as a result of, trauma to teeth and supporting structures caused by medically necessary treatment of an injury or disease.

c. Procedures associated with preventive and restorative dental care when associated with radiation therapy to the head or neck, unless otherwise covered as a routine preventive procedure under this plan.

d. Total or complete ankyloglossia.

e. Intraoral abscesses which extend beyond the dental alveolus.

f. Extraoral abscesses.

g. Cellulitis and osteitis which is clearly exacerbating and directly affecting a medical condition currently under treatment.

h. Removal of teeth and tooth fragments in order to treat and repair facial trauma resulting from an accidental injury.

i. Prosthetic replacement of either the maxilla or mandible due to reduction of body tissues associated with traumatic injury (such as a gunshot wound) in addition to services related to treating neoplasms or iatrogenic dental trauma.