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