Performance_Work_Statement.pdf

Performance Work Statement (PWS) for

Dental Services

1.0 General.

1.1 Scope. The contractor shall provide all personnel, facilities, equipment, tools, materials, supervision, and quality control necessary, except as specified in Paragraph 3.0 as Government

Furnished, to perform Dental treatment Services, as defined in this PWS.

1.2 Background. The Global War on Terrorism (GWOT) has significantly increased the operations and deployments within the Puerto Rico Army National Guard (PRARNG) and has placed additional strain and requirements on our Soldiers and their families. Increased deployments and missions locally and around the globe have required Soldiers to be deployed more frequently, for longer periods in high physical and mental stress operations. Additional resources and programs are required to increase the PR-ARNG medical readiness. PRARNG leadership requires support to identify and quantify the magnitude and status of medical readiness across all Army National Guard units in the State of Puerto Rico.

1.3 Period of Performance (PoP). The Period of Performance shall be one Base Year of

10 months and 4 / 12-month option years.

The period of performance for the base year is: 28 September 2016 to 1 August 2017.

The period of performance for Option Year 1: 2 August 2017 to 1 August 2018.

The period of performance for Option Year 2: 2 August 2018 to 1 August 2019.

The period of performance for Option Year 3: 2 August 2019 to 1 August 2020.

The period of performance for Option Year 4: 2 August 2020 to 1 August 2021.

1.4 General Information.

1.4.1 Quality Control (QC). The contractor shall develop and maintain an effective QC Plan (QCP) to ensure services are performed in accordance with this PWS. The contractor shall develop and implement procedures to identify, prevent, and ensure non- recurrence of defective services. The contractor’s QCP is the means by which it assures itself that its work complies with the requirements of the contract. As a minimum, the contractor shall develop QC procedures that address the areas identified in Technical Exhibit 1, Performance Requirements Summary. Provide a Quality Control

Plan within 10 calendar days after contract award. After acceptance of the QCP, the contractor shall obtain the Contracting Officer’s (KO) acceptance in writing of any proposed changes to its QCP.

1.4.2 Quality Assurance (QA). The Government shall evaluate the contractor’s performance under this contract in accordance with the Quality Assurance Surveillance Plan (QASP). This plan is primarily focused on what the Government must do to ensure that the contractor has performed in accordance with the performance standards. It defines how the performance standards will be applied, the frequency of surveillance, and acceptable quality level(s) (defect rate(s)).

1.4.3 Recognized Holidays: The following are recognized US holidays. The contractor shall perform services on these days:

1.4.3.1 New Year’s Day

1.4.3.2 Martin Luther King, Jr.’s Birthday

1.4.3.3 President’s Day

1.4.3.4 Memorial Day

1.4.3.5 Independence Day

1.4.3.6 Labor Day

1.4.3.7 Columbus Day

1.4.3.8 Veteran’s Day

1.4.3.9 Thanksgiving Day

1.4.3.10 Christmas Day

1.4.4 Place and Performance of Services. Hours of Operation: The contractor shall have the capability of providing dental treatment services seven days a week at their professional office. Monday through

Sunday, normal business hours, except on recognized US holidays. Services shall be completed at one of the following geographical areas: Barceloneta, Mayagüez, Guayama, Guaynabo and Villalba.

1.4.5 In the event the contractor need to visit MEDCOM Office located at Salinas, PR consider that unscheduled gate closures by the Security Police may occur at any time causing all personnel entering or exiting a closed installation to experience a delay. This cannot be predicted or prevented. Vehicles operated by contractor personnel are subject to search pursuant to applicable regulations. Any moving violation of any applicable motor vehicle regulation may result in the termination of the contractor employee’s installation driving privileges.

1.4.6 The contractor’s employees shall become familiar with and obey the regulations of the installation; including fire, traffic, safety and security regulations while on the installation. Contractor employees should only enter restricted areas when required to do so and only upon prior approval. All contractor employees shall carry proper identification with them at all times. The contractor shall ensure compliance with all regulations and orders of the installation which may affect performance.

1.4.7 Security Requirements. The contractor shall comply with all applicable installation/facility access and local security policies and procedures, which may be obtained from the Contracting Officer’s Representative (COR). The contractor shall also provide all information required for background checks to meet installation access requirements to be accomplished by installation Provost Marshal Office, Director of

Emergency Services or Security Office. The contractor shall ensure compliance with all personal identity verification requirements as directed by DOD, HQDA and/or local policy. Should the Force Protection Condition (FPCON) change, the Government may require changes in contractor security matters or processes.

1.4.8 COMSEC/IT Security. All communications with DOD organizations are subject to communications security (COMSEC) review. All telephone communications networks are continually subject to intercept by unfriendly intelligence organizations. DOD has authorized the military departments to conduct COMSEC monitoring and recording of telephone calls originating from, or terminating at, DOD organizations. Therefore, the contractor is advised that any time contractor place or receive a call they are subject to COMSEC procedures. The contractor shall ensure wide and frequent dissemination of the above information to all employees dealing with DOD information. The contractor shall abide by all Government regulations concerning the authorized use of the

Government's computer network, including the restriction against using the network to recruit

Government personnel or advertise job openings.

1.4.9 Use of Government Information Systems (IS) and access to Government networks is a revocable privilege, not a right. This contract does not require use of Government Information systems.

1.4.10 Protection of Personally Identifiable Information (PII). The contractor shall protect all

Personally Identifiable Information (PII) encountered in the performance of services in accordance with

DFARS 224.103 and DoDD 5400.11, Department of Defense Privacy Program, and DoD 5400.11-R. If a PII breach results from the contractor’s violation of the aforementioned policies, the contractor shall bear all notification costs, call-center support costs, and credit monitoring service costs for all individuals who’s PII has been compromised.

1.5 Special Qualifications. Contractors must ensure that all personnel performing under this contract are fully trained, licensed, certified and qualified to provide services. The Government does not provide training to contractors. Contractor shall Contractor shall comply with: HIPAA, Privacy Act and OSHA certifications.

1.6 Post Award Conference/Periodic Progress Meetings. The contractor agrees to attend any post award conference convened by the KO in accordance with Federal Acquisition Regulations Subpart

42.5. The KO, Contracting Officer’s Representative (COR), and other Government personnel, as appropriate, may meet periodically with the contractor to review the contactor’s performance. At these meetings, the Contacting Officer will apprise the contractor of how the Government views the contractor’s performance and the contractor shall apprise the Government of problems, if any, being experienced The contractor shall resolve outstanding issues raised by the Government. Contractor attendance at these meetings shall be at no additional cost to the Government.

1.7 Contract Manager (CM). The contactor shall designate a CM who shall ensure performance under this contract. The name of this person, and an alternate who shall act for the contractor when the

CM is absent, shall be designated in writing to the KO within 3 calendar days after contract award. The

CM or alternate shall have full authority to act for the contractor on all contract matters relating to daily operation of this contract. The CM shall work through the COR, (or the KO if a COR is not assigned), to resolve issues, receive technical instructions, and ensure adequate performance of services. The CM shall ensure that contractor employees do not perform any services outside the scope of the contract without an official modification issued by the KO. The CM shall ensure contractor employees understand that services performed outside the scope of the contract are performed wholly at the expense of the contractor.

1.8 Combating Trafficking in Persons. The United States Government has adopted a zero tolerance policy regarding trafficking in persons. Contractors and contractor employees shall not engage in any forms of trafficking in persons during the period of performance of the contract; procure commercial sex acts during the period of performance of the contract; or use forced labor in the performance of the contract. The Contractor shall notify its employees of the United States Government’s zero tolerance policy, the actions that will be taken against employees for violations of this policy. Such actions may include, but are not limited to, removal from the contract, reduction in benefits, or termination of employment. The Contractor shall take appropriate action, up to and including termination, against employees or subcontractors that violate the US Government policy as described at FAR 22.17.Contractor shall complete the following online training within 10 calendar days after contract award available at: http://static.dma.mil/ctip/contractingacquisition/M/wrap_menupage.htm.

1.9 Contractor Travel: Not authorized on this PWS.

1.10 Data Rights: The Government has unlimited rights to all documents/material produced under this contract. All documents and materials, to include the source codes of any software, produced under this contract shall be Government owned and are the property of the Government with all rights and privileges of ownership /copyright belonging exclusively to the Government. These documents and materials may not be used or sold by the contractor without written permission from the KO. All materials supplied to the Government shall be the sole property of the Government and may not be used for any other purpose. Provide a copy 10 calendar days after contract completion.

This right does not abrogate any other Government rights.

1.11 Organizational Conflicts of Interest (OCI): The contractor and subcontractor personnel performing services under this contract may receive, have access to or participate in the development of proprietary or source selection information (e.g., cost or pricing information, budget information or analyses, specifications or work statements, etc.) or perform evaluation services which may create a current or subsequent OCIs, as defined in FAR Subpart 9.5. The contractor shall notify the KO immediately whenever it becomes aware that such access or participation may result in any actual or potential OCI and shall promptly submit a plan to the

KO to avoid or mitigate any such OCI. The contractor’s mitigation plan will be determined to be acceptable solely at the discretion of the KO and in the event the KO unilaterally determines that any such OCI cannot be satisfactorily avoided or mitigated, the KO may affect other remedies as he or she deems necessary, including prohibiting the contractor from participation in subsequent contracted requirements which may be affected by the OCI.

2.0 Definitions and Acronyms.

2.1 Definitions.

2.1.1 CONTRACTOR. A supplier or vendor awarded a contract to provide specific supplies or services to the government. The term used in this contract refers to the prime.

2.1.2 CONTRACTING OFFICER (KO). A person with authority to enter into, administer, and or terminate contracts, and make related determinations and findings on behalf of the government. Note:

The only individual who can legally bind the government.

2.1.3 CONTRACTING OFFICER'S REPRESENTATIVE (COR). An employee of the

U.S. Government designated by the KO to monitor contractor performance. Such appointment shall be in writing and shall state the scope of authority and limitations. This individual has authority to provide technical direction to the Contractor as long as that direction is within the scope of the contract, does not constitute a change, and has no funding implications. This individual does NOT have authority to change the terms and conditions of the contract.

2.1.4 DEFECTIVE SERVICE. A service output that does not meet the standard of performance associated with the Performance Work Statement.

2.1.5 DELIVERABLE. Anything that can be physically delivered and includes non-manufactured things such as meeting minutes or reports.

2.1.6 KEY PERSONNEL. Contractor personnel that are evaluated in a source selection process and that may be required to be used in the performance of a contract by the Key Personnel listed in the

PWS. When key personnel are used as an evaluation factor in best value procurement, an offer can be rejected if it does not have a firm commitment from the persons that are listed in the proposal.

2.1.7 PHYSICAL SECURITY. Actions that prevent the loss or damage of Government property.

2.1.8 QUALITY ASSURANCE. The government procedures to verify that services being performed by the Contractor are performed according to acceptable standards.

2.1.9 QUALITY ASSURANCE SURVEILLANCE PLAN (QASP). An organized written document specifying the surveillance methodology to be used for surveillance of contractor performance.

2.1.10 QUALITY CONTROL. All necessary measures taken by the Contractor to assure that the quality of an end product or service shall meet contract requirements.

2.1.11 SUBCONTRACTOR. One that enters into a contract with a prime contractor. The

Government does not have privity of contract with the subcontractor.

2.1.12 WORK DAY. The number of hours per day the Contractor provides services in accordance with the contract.

2.1.13 WORK WEEK. Monday through Friday, unless specified otherwise.

2.2 Acronyms

AAR After Action Report

AEI Army Enterprise Info Structure

AFARS Army Federal Acquisition Regulation Supplement

ANG Army National Guard

AR Army Regulation

AUP Acceptable Use Policy

BBP Better Business Practice

CDM Concept Development Meeting

CFR Code of Federal Regulations

CM Contract Manager

CNGB Chief National Guard Bureau

COMSEC Communications Security

CONUS Continental United States (excludes Alaska and Hawaii)

COR Contracting Officer Representative

COTR Contracting Officer's Technical Representative

COTS Commercial-Off-the-Shelf

DA Department of the Army

DNECOM Dental Command

DFARS Defense Federal Acquisition Regulation Supplement

DMDC Defense Manpower Data Center

DOD Department of Defense

DRC Dental Record Classification

FAR Federal Acquisition Regulation

DFA Federal Drug Administration

FEMA Federal Emergency Management Agency

FPCON Force Protection Condition

FPM Final Planning Meeting

HIPAA Health Insurance Portability and Accountability Act of 1996

HQDA Headquarter Department of Army

IA Information Assurance

IPM Initial Planning Meeting

IT Information Technology

JFHQ Joint Forces Headquarters

JOC Joint Operations Center

JTR Joint Travel Regulation

KO Contracting Officer

LNO Liaison Officer

MEDCOM Medical Command

MPM Mid-Planning Meeting

MSR Monthly Status Report

NACI National Agency Check Inquires

NGB National Guard Bureau

NGRF National Guard Reaction Force

NLT Not Later Than

OCI Organizational Conflict of Interest

OCONUS Outside Continental United States

OCT Observer Controller Trainer

ODC Other Direct Costs

OPSEC Operations Security

PCO Procuring Contracting Officer

PII Protection of Personally Identifiable Information

POC Point of Contact

PRS Performance Requirements Summary

PWS Performance Work Statement

QA Quality Assurance

QAP Quality Assurance Program

QASP Quality Assurance Surveillance Plan

QC Quality Control

QCP Quality Control Program

SME Subject Matter Experts

TAR Travel Authorization Request

TE Technical Exhibit

TTX Table Top Exercise

WWAF-RA Wide Area Workflow-Receipt and Acceptance

3.0 Government Furnished Property, Material, Equipment and Services (GFP/M/E/S). The

Government will provide the property, material, equipment, and/or services listed below solely for the purpose of performance under this contract.

3.1 Property: None

3.2 Materials: None.

3.3 Equipment: None.

3.4 Services: None.

3.5 Utilities: None

4.0 Contractor Furnished Property, Materials, and Equipment (CFP/M/E).

4.1 General: Except for those items specifically stated to be Government-Furnished in Paragraph

3.0, the contractor shall furnish everything required to perform these services as indicated in

Paragraph 1.1.

5.0 Requirements.

5.1 The contractor shall provide all management, labor, material, equipment, certifications and supplies necessary to provide dental care services at their Personal Office, for the Puerto Rico Army

National Guard Soldiers. Services will be notified to contractor by memorandum with proper authorization from the State Surgeon’s Office, PRARNG. The contractor shall provide an appointment within 30 days of notification. Once service has been requested, the contractor will provide dental treatment, proper documentation for each Soldier’s, as necessary to meet Department of the Army standards and ensure mission capability of the Puerto Rico Army National Guard. The service will comply with medical/dental readiness and deployability, on converting the Soldier from Dental Class 3 to Dental Class 1 or 2. The contractor will insure that their agents are appropriately trained with dental classification system. This contract will provide services at the following five geographical areas :

Barceloneta, Mayagüez, Guayama, Gaynabo and Villalba. The contractor shall provide customized comprehensive dental readiness services to include:

5.2 Class 3 dental treatments for alerted Soldiers (as identified by PRANG). Dental treatment authorized is outlined in Appendix 5.10.4. These services will be completed at contractor professional office unless otherwise specified in a separate written agreement.

5.3 Specified Dental Specialty Services to include:

5.3.1 Oral and Maxillofacial Surgery (to include pathology reports if indicated)

5.3.2 Endodontics

5.3.3 Periodontics

5.3.4 Prosthodontics

5.3.5 Other

5.3.6 Prescriptions for pharmaceuticals and controlled substances necessary for the care and treatment of Soldiers throughout the event, to include but not limited to analgesics and antibiotics. Prescriptions for maintenance pharmaceuticals for Soldiers with high caries risk or periodontal disease, as indicated.

5.4 Radiographs shall be taken only for clinical reasons according to FDA and DENCOM guidelines as determined by the patient’s dentist. Radiographs should be of diagnostic quality, properly identified and dated. A panoramic radiograph of adequate quality for diagnostic/identification purposes is required to be part of the dental record. There is no time requirement on updating panoramic radiographs. However, the panoramic radiograph will adequately represent the current oral condition of the Soldier. Bitewing (or “bitewing slice” at the discretion of the State Dental Officer) radiographs are also required to be part of the dental record. All radiographs provided under this contract will be digital

(unless specified in a separate written agreement) and transferred to the Dental Classification module within 24 hours of exposure.

5.5 A listing of all DRC 3 conditions

5.6 Any condition of significance that is not readily apparent on the radiographs.

5.7 The Contractor shall furnish the following documentation :

5.7.1 Upon completion of services, medical information will be documented in accordance with

Department of the Army Policy and be updated in the approved Army National Guard automated system. The contractor shall also ensure the requirements of Occupational Safety and Health

Administration (OSHA) and applicable Federal regulations are met. The contractor shall develop and maintain records that fully document serviced performed, examination results, and names of soldiers referred to dental specialists. These records will be made available to the Puerto Rico State

Surgeon/PR-Medical Command or Medical representative, NLT 5 days after initial request. Contractor will return memorandum to the State Dental Office once treatment are finished with detail procedure and signature.

5.7.2 All Soldiers must have a complete military dental record. No dental record is considered complete unless the documentation is complete and in the proper order as outlined in 5.8.3.

5.7.3 A complete record includes the following:

5.8.3.1 Military dental record jacket, DA Form 8005 through 8005-9

5.8.3.2 The automated Health History Form or DA Form 5570 (with notations to “yes” answers and signed by both the Soldier and reviewing Doctor), Health Questionnaire envelope

5.8.3.3 DD Form 2005 (signed), Privacy Act Statement

5.8.3.4 SF 603/603A, Record of Dental Exam

5.8.3.5 Supporting radiographs (panoramic and diagnostic bitewing radiographs documenting existing conditions). All radiographs will be uploaded into the ARNG automated system by the Dental NCOIC. A diagnostic quality copy of all radiographs will be placed in the Dental Record by the Dental NCOIC.

5.8 The Contractor will conduct additional dental treatments as required. The Government may request additional treatment not listed, but may be required. These requests will be discussed with KO and Contractor prior to any changes.

5.9 APPENDICES:

5.9.1 Estimated Workload Data

5.9.2 Oral Health And Readiness Classification System

5.9.3 DA Form 5570E and SF 603-A (Dental Classification Module Version)

5.9.4 Authorized Dental Treatment

5.10 Contractor Manpower Reporting Application (CMRA).

5.10.1 The contractor shall report all contractor labor hours (including subcontractor labor hours) required for performance of services provided under this contract for the Puerto Rico National Guard, via a secure data collection site.

5.10.2 The contractor shall completely fill in all required data fields using the following web address:

http://www.ecmra.mil/. Reporting inputs shall be for the labor executed during the period of performance during each Government fiscal year (FY), which runs October 1 through September 30.

While inputs may be reported any time during the FY, all data shall be reported no later than October 31 of each calendar year, beginning with 2013. Contractors may direct questions to the help desk at http://www.ecmra.mil.

6.0 References

Publications Date of Publication Mandatory or

Advisory

Website

DOD Instruction

6025.19 Individual

Medical Readiness

(IMR)

9 June 20147 Mandatory http://adp.army.mil

Army Regulation 40-

501 Standards of

Medical Fitness

Chapter 8, 10

14 December 2007 Mandatory http://adp.army.mil http://www.ecmra.mil/

Technical Exhibit 1 Performance Requirements Summary

This Performance Requirements Summary includes performance standards applicable to this PWS. The

Government will use these standards to determine contractor performance and will compare contractor performance to the Acceptable Quality Level (AQL).

PWS Paragraph Performance

Standard Task

Acceptable

Quality

Levels (AQL)

Surveillance

Method / By

Whom

5.1

Soldiers must receive an appointment in a timely manner.

(within 30 days)

Access for Dental

Services 98%

Periodic Inspection -

COR will review monthly work order logs.

5.1

Treatment provided to

Soldiers will be only the one authorized in

Memo’s generated by State

Dental Office.

Dental Treatment

Authorization.

100%

Periodic

Inspection - COR will review monthly work order logs.

5.8.1

Contractor will assure that procedures are done as per

Federal

Regulations

Dental Treatment

Procedure 100%

Periodic

Inspection - COR will review monthly work order logs.

5.8.1

The contractor shall develop and maintain records that fully document serviced performed, examination results, and names of

Soldiers referred to dental specialists.

(NLT 5 days after initial request)

List of Names and Services 100%

Periodic

Inspection - COR will review

5.8.1

Contractor will return memorandum to the State Dental

Office once treatment is finished with detail procedure and signature.

Memorandum of treatment authorization

100%

Periodic

Inspection - COR will review

Technical Exhibit 2 Deliverables Schedule

PWS Reference /

Deliverable Title Frequency

Number of

Copies Medium/Format Submit To

1.4.1 Quality Control

Plan

Provide within 10 calendar days after

Contract Award

Electronic Submission

KO

1.7 Contract Manager

Provide within 3 calendar days after

Contract Award

Electronic Submission

COR

1.8 Combating of

Trafficking in Persons

Provide within 10 calendar days after Contract

Award

Electronic

Submission

COR

1.10 Data Rights

Provide 10 days after contract completion

Hard and Digital

Copies

COR

APPENDIX 5.10.1

ESTIMATED WORKLOAD DATA

Deputy State Surgeon: CPT Edalia E Cedeño

Senior Dental NCO: SFC William Bautista

Name Last four

SSN

Date of

Procedures

ADA

Codes

Procedures

Description Price

Provider Signature: ____________________

State Surgeon Representative Signature: __________________________________

Date: _________________________ Date: ________________

APPENDIX 5.10.2

Department of Defense

Oral Health and Readiness Classification System

The oral health status of uniformed personnel shall be classified as follows:

a. Class 1 (Oral Health): Patients with a current dental examination, who do not require dental treatment or reevaluation. Class 1 patients are worldwide deployable.

b. Class 2: Patients with a current dental examination, which require non-urgent dental treatment or reevaluation for oral conditions, which are unlikely to result in dental emergencies within 12 months. Class 2 patients are worldwide deployable. Patients in dental class 2 may exhibit the following:

(1) Treatment or follow-up indicated for dental caries or minor defective restorations that can be maintained by the patient.

(2) Interim restorations or prosthesis that can be maintained for a 12 month period. This includes teeth that have been restored with permanent restorative materials for which protective cuspal coverage is indicated.

(3) Edentulous areas requiring prostheses but not on an immediate basis.

(4) Periodotium that:

(a) requires oral prophylaxis

(b) requires maintenance therapy

(c) requires treatment for slight to moderate periodontitis and stable cases of more advanced periodontitis

(5) Unerupted partially erupted or malposed teeth that are without historical, clinical or radiographic signs or symptoms of pathosis, but which are recommended for prophylactic removal.

(6) Active orthodontic treatment. The provider should consider placing the patient in passive appliances for deployment up to six months. For longer periods of deployment, the provider should consider removing active appliances and placing the patient in passive retention.

(7) Temporomandibular disorder patients in remission. The provider anticipates the patient can perform duties while deployed without ongoing care and any medications or appliances required for maintenance will not interfere with duties.

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

(1) Treatment or follow-up indicated for dental caries, symptomatic tooth fracture or defective restorations that cannot be maintained by the patient.

(2) Interim restorations or prostheses that cannot be maintained for a 12 month period.

(3) Patients requiring treatment for the following periodontal conditions that may result in dental emergencies within the next 12 months.

(a) Edentulous areas or teeth requiring immediate prosthodontic treatment for adequate mastication or communication or acceptable esthetics.

(b) Active progressive moderate or advanced periodontitis.

(c) Periodontontal abscess

(d) Progressive mucogingival condition

(e) Periodontal manifestations of systemic disease or hormonal disturbances

(f) Heavy subgingival calculus

(4) Edentulous areas or teeth requiring immediate prosthodontic treatment for adequate mastication or communication or acceptable esthetics.

(5) Unerupted, partially erupted or malposed teeth with historical, clinical or radiographic signs or symptoms of pathosis that are recommended for removal.

(6) Chronic oral infections or other pathologic lesions including:

(a) Pulpal, periapical or resorptive pathology requiring treatment.

(b) Lesions requiring biopsy or awaiting biopsy report.

(7) Emergency situations requiring therapy to relieve pain, treat trauma, treat acute oral infections or provide timely follow-up care (e.g., drain or suture removal0 until resolved.

(8) Acute Temporomandibular disorders requiring active treatment that may interfere with duties.

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

APPENDIX 5.10.3

APPENDIX 5.10.3

APPENDIX 5.10.4

AUTHORIZED DENTAL TREATMENT

1. The following dental procedures are authorized:

(a) Diagnostic Services which are funded through the NG6H 2065 Medical Readiness or

VFRE 2065 Medical & Readiness Funding:

D0120-Periodic Oral Evaluation

D0150-Comprehensive Oral Evaluation

D0330-Digital Panoramic Film

D0272-Bitewings-Two Films

D0274-Bitewings-Four Films

D0220- Periapical (First films) limited

D0230- Periapical (limited)

(b) Restorative Services which are funded through the NG6H 2065 Medical Readiness

(provided only to soldiers non-alerted or VFRE 2020 Dental Treatment Funding (provided only to soldiers alerted to an OCONUS Mission):

D2140-Amalgam-One Surface

D2150-Amalgam-Two Surfaces

D2160-Amalgam-Three Surfaces

D2161-Amalgam-Four or More Surfaces

D2330-Composite-One Surface

D2331-Composite-Two Surfaces

D2332-Composite-Three Surfaces

Posterior composites will be authorized only when a posterior composite is necessary to provide a quality restoration and no other alternative is available.

D2335-Composite-Four or More Surfaces

D2391-Composite-One Surface

D2392-Composite-Two Surfaces

D2393-Composite-Three Surfaces

D2394-Composite-Four or More Surfaces

D2799-Provisional Crown

D2931-Prefabricated Stainless Steel Crown

D2950-Core Buildup, including any pins

D2954-Prefabricated Post and Core

(c) Endodontic Services which are funded through the NG6H 2065 Medical Readiness or

VFRE 2020 Dental Treatment Funding (provided only to Soldiers alerted to an OCONUS

Mission):

D3310-Anterior Root Canal Therapy

D3320-Bicuspid Root Canal Therapy

D3330-Molar Root Canal Therapy

D3346-Anterior Root Canal Retreatment

D3347-Bicuspid Root Canal Retreatment

D3348-Molar Root Canal Retreatment

(d) Periodontal Services which are funded through the NG6H 2065 Medical Readiness or

D4355-Full Mouth Debridement

D4342-Periodontal Scaling and Root Planning, 1 to 3 teeth per quadrant

Periodontal scaling and root planning is authorized only when a periodontal abscess is present)

(e) Prosthodontic Services which are funded through the NG6H 2065 Medical Readiness or

D5110-Complete Denture-Maxillary

D5120-Complete Denture-Mandibular

D5211-Maxillary Partial Denture-Resin Base

D5212-Mandibular Partial Denture-Resin Base

(f) Oral Surgery Services which are funded through the NG6H 2065 Medical Readiness or

D7140-Extraction, Erupted Tooth or Exposed Root

D7210-Surgical Removal of Erupted Tooth

D7220-Romoval of Impacted Tooth, Soft Tissue

D7230-Removal of Impacted Tooth, Partial Bony

D7240-Removal of Impacted Tooth, Completely Bony

(g) Orthodontic Services which are funded through the NG6H 2065 Medical Readiness or

D8680-Orthodontic Retention

2. The following dental procedures are not authorized:

Crown (PFM) or (Gold)

Bridges and/or implants

Removal of Asymptomatic third molars

Routine Prophylaxes (cleanings)

Restorations for aesthetics only

Restorations for small (non-class 3) caries

Extensive Root plane/scaling

Osseous Surgery

Other diagnostic services

The above listings are guides to assist the State Dental Officer or his/her designee in determining treatment to be authorized. The treatment provided by the PRARNG is to get the Soldier from a dental class 3 to a dental class 2 only. Comprehensive Treatment (to dental class I) is not authorized.

3. If a Soldier needs all of his/her remaining teeth in an arch extracted and a denture placed, the

Soldier will not be available for deployment for at least 6 months and shall be disqualified from immediate deployment. However, if the Soldier is otherwise deployable (passes all medical, personnel and training requirements) and, after extraction and placement of prosthesis, would be deployable, the dental treatment could be provided and the Soldier could be considered as a replacement at a later date.

4. If a Soldier will have a number of teeth extracted to the extent mastication and speech are adversely affected, then an acrylic removable partial denture will be authorized if there is sufficient time for healing and construction of the partial denture prior to departure to Mobilization Station.

5. Soldiers requiring extensive periodontal treatment will be disqualified from deployment and educated on the TRICARE Dental Program. If he/she obtains the required therapy (from his/her private dental provider) and reaches a maintenance level, then he/she would become deployable.

6. The State Dental Officer (or designated representative) will review any dental treatment plan for dental care which exceeds $2000 to insure that the above clinical guidelines are met.

Exceptions can be made, but they must be coordinated with the State Surgeon Office.