2016 Buy Up Dental Care Plan Procedure List

Size: px
Start display at page:

Download "2016 Buy Up Dental Care Plan Procedure List"

Transcription

1 * This is in addition to the embedded Preventive Plan (see procedure list at deltadentalco.com/kp_preventive. BASIC SERVICES Minor Restorative Services D2140 Amalgam 1 surface, primary or permanent D2150 Amalgam 2 surfaces, primary or permanent D2160 Amalgam 3 surfaces, primary or permanent D2161 Amalgam 4 or more surfaces, primary or permanent D2330 Resin-based composite 1 surface, anterior D2331 Resin-based composite 2 surfaces, anterior D2332 Resin-based composite 3 surfaces, anterior D2335 Resin-based composite 4 or more surfaces or involving incisal angle D2391 Resin-based composite 1 surface, posterior D2392 Resin-based composite 2 surfaces, posterior D2393 Resin-based composite 3 surfaces, posterior D2394 Resin-based composite 4 or more surfaces, posterior Oral Surgery D7140 Extraction erupted tooth or exposed root D7210 Surgical removal of erupted tooth D7220 Removal of impacted tooth soft tissue D7230 Removal of impacted tooth partially bony D7240 Removal of impacted tooth completely bony D7241 Removal of impacted tooth completely bony with unusual surgical complications D7250 Surgical removal of residual tooth roots (cutting procedure) Endodontics D3220 Therapeutic pulpotomy primary tooth, excluding final restoration D3310 Root canal therapy anterior (excluding final restoration) D3320 Root canal therapy bicuspid (excluding final restoration) D3330 Root canal therapy molar (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 D3410 Apicoectomy anterior

2 BASIC SERVICES (CONTINUED) Endodontics (continued) D3421 Apicoectomy bicuspid D3425 Apicoectomy molar (first root) Periodontics D4210 Gingivectomy or gingivoplasty per quadrant D4211 Gingivectomy or gingivoplasty 1 3 teeth per quadrant D4240 Gingival flap procedure, including root planing per quadrant D4241 D4260 D4261 Gingival flap procedure, including root planing 1 3 teeth per quadrant Osseous surgery per quadrant (including flap entry and closures) Osseous surgery 1 3 teeth per quadrant (including flap entry and closures) D4263 Bone replacement graft first site in quadrant D4264 Bone replacement graft each additional site in quadrant D4341 Periodontal scaling and root planing per quadrant D4342 Periodontal scaling and root planing 1 3 teeth per quadrant D4910 Periodontal maintenance procedures following active therapy (periodontal prophylaxis) MAJOR SERVICES D2740 Crown porcelain/ceramic substrate D2750 Crown porcelain fused to high noble metal D2751 Crown porcelain fused to predominantly base metal D2752 Crown porcelain fused to noble metal D2780 Crown 3/4 cast high noble metal D2781 Crown 3/4 cast predominantly base metal D2782 Crown 3/4 cast noble metal D2790 Crown full cast high noble metal D2791 Crown full cast predominantly base metal D2792 Crown full cast noble metal D2920 Recement crown

3 MAJOR SERVICES (CONTINUED) D2930 Prefabricated stainless steel crown primary tooth D2940 Protective restoration D2950 Core buildup, including any pins when required D2951 Pin retention per tooth, in addition to restoration D2952 Post and core in addition to crown, indirectly fabricated D2953 Each additional indirectly fabricated post same tooth D2954 Prefabricated post and core in addition to crown D2957 Each additional prefabricated post same tooth Implant Surgical Services D3460 Endodontic endosseous implant D6010 Surgical placement of implant body: endosteal implant D6011 Second stage implant surgery D6013 Surgical placement of mini implant D6040 Surgical placement: eposteal implant D6050 Surgical placement: transosteal implant D6051 Interim abutment D6052 Semi-precision attachment abutment D6055 Connecting bar implant supported or abutment supported D6056 Prefabricated abutment includes modification and placement D6057 Custom fabricated abutment includes placement D6100 Implant removal, by report D6190 Radiographic/surgical implant index, by report Implant Restorative Services D6058 Abutment supported porcelain/ceramic crown D6059 D6060 D6061 Abutment supported porcelain fused to metal crown (high noble metal) Abutment supported porcelain fused to metal crown (predominantly base metal) Abutment supported porcelain fused to metal crown (noble metal) D6062 Abutment supported cast metal crown (high noble metal)

4 MAJOR RESTORATIVE SERVICES (CONTINUED) Implant Restorative Services (continued) D6063 Abutment supported cast metal crown (predominantly base metal) D6064 Abutment supported cast metal crown (noble metal) D6065 Implant supported porcelain/ceramic crown D6066 D6067 Implant supported porcelain fused to metal crown (titanium, titanium allow, high noble metal) Implant supported metal crown (titanium, titanium allow, high noble metal) D6068 Abutment supported retainer for porcelain/ceramic FPD D6069 D6070 D6071 D6072 D6073 Abutment supported retainer for porcelain fused to metal FPD (high noble metal) Abutment supported retainer for porcelain fused to metal FPD (predominantly base metal) Abutment supported retainer for porcelain fused to metal FPD (noble metal) Abutment supported retainer for cast metal FPD (high noble metal) Abutment supported retainer for cast metal FPD (predominantly base metal) D6074 Abutment supported retainer for cast metal FPD (noble metal) D6075 Implant supported retainer for ceramic FPD D6076 D6077 Implant supported retainer for porcelain fused to metal FPD (titanium, titanium alloy, or high noble metal) Implant supported retainer for cast metal FPD (titanium, titanium allow, or high noble metal) D6092 Abutment supported crown (titanium) D6093 Abutment supported retainer crown for FPD (titanium) D6094 Abutment supported crown (titanium) D6110 D6111 D6112 D6113 D6114 D6115 D6116 Implant /abutment supported removable denture for edentulous arch maxillary Implant /abutment supported removable denture for edentulous arch mandibular Implant /abutment supported removable denture for partially edentulous arch maxillary Implant /abutment supported removable denture for partially edentulous arch mandibular Implant /abutment supported fixed denture for edentulous arch maxillary Implant /abutment supported fixed denture for edentulous arch mandibular Implant /abutment supported fixed denture for partially edentulous arch maxillary

5 MAJOR RESTORATIVE SERVICES (CONTINUED) Implant Restorative Services (continued) D6117 Implant /abutment supported fixed denture for partially edentulous arch - mandibular D6194 Abutment supported retainer crown for FPD (titanium) Other Implant-related Services D5875 Modification of removable prosthesis following implant surgery D6090 Repair implant supported prosthesis, by report D6092 Recement implant/abutment supported crown D6093 Recement implant/abutment supported fixed partial denture D6095 Repair implant abutment, by report D6190 Radiographic/surgical implant index, by report Fixed Prosthetics D6210 Pontic cast high noble metal D6211 Pontic cast predominantly base metal D6212 Pontic cast noble metal D6240 Pontic porcelain fused to high noble metal D6241 Pontic porcelain fused to predominantly base metal D6242 Pontic porcelain fused to noble metal D6750 Crown porcelain fused to high noble metal D6751 Crown porcelain fused to predominantly base metal D6752 Crown porcelain fused to noble metal D6790 Crown full cast high noble metal D6791 Crown full cast predominantly base metal D6792 Crown full cast noble metal Removable Prosthetics D5110 Complete denture upper D5120 Complete denture lower D5130 Immediate denture upper D5140 Immediate denture lower D5213 D5214 Upper partial denture-metal base with resin saddles (including Lower partial denture metal base with resin saddles (including

6 MAJOR SERVICES (CONTINUED) Fixed Prosthetics D6210 Pontic cast high noble metal D6211 Pontic cast predominantly base metal D6212 Pontic cast noble metal D6240 Pontic porcelain fused to high noble metal D6241 Pontic porcelain fused to predominantly base metal D6242 Pontic porcelain fused to noble metal D6750 Crown porcelain fused to high noble metal D6751 Crown porcelain fused to predominantly base metal D6752 Crown porcelain fused to noble metal D6790 Crown full cast high noble metal D6791 Crown full cast predominantly base metal D6792 Crown full cast noble metal Removable Prosthetics D5110 Complete denture upper D5120 Complete denture lower D5130 Immediate denture upper D5140 Immediate denture lower D5213 D5214 Upper partial denture-metal base with resin saddles (including Lower partial denture metal base with resin saddles (including D5510 Repair broken complete denture base D5520 Replace missing/broken teeth-complete denture (each tooth) D5630 Repair/replace broken clasp partial denture D5640 Replace tooth on partial denture per tooth D5650 Add tooth to existing partial denture D5660 Add clasp to existing partial denture D5750 Reline complete upper denture (laboratory) D5751 Reline complete lower denture (laboratory)

deltadentalins.com/usc

deltadentalins.com/usc Plan Benefit Highlights for: UNIVERSITY OF SOUTHERN CALIFORNIA STUDENT PLAN Group No: 05008 The Delta Dental PPO table plan provides you great dental benefits at a reasonable cost. With a table of allowance

More information

Procedure Description. Prophylaxis - adult. Periodic oral evaluation - established patient. Resin-based composite - three surfaces, posterior

Procedure Description. Prophylaxis - adult. Periodic oral evaluation - established patient. Resin-based composite - three surfaces, posterior Top ADA Dental Procedure Codes - Pediatric Patients Ranked by Contribution to Total Pediatric Dental Claim Costs based on 15 Milliman Health Cost Guidelines-Dental 12 08 13 51 74 91 71 93 03 12 06 Procedure

More information

General Dentist Fees

General Dentist Fees General Dentist Fees January 1, 2015 Not all codes are covered benefits. Please check the member s plan for verification and limitations. There are no fee increases for 2015, but new CDT codes have been

More information

Schedule B Indemnity plan People First Plan Code #4084

Schedule B Indemnity plan People First Plan Code #4084 : Calendar year deductible Waived for Type I preventive dental services Calendar year maximum Type I, II, III Waiting period Type I, II, III $50 individual $150 family (3 per family) $1,000 per covered

More information

Humana Health Plans of Florida. Important:

Humana Health Plans of Florida. Important: Humana Health Plans of Florida Important: Dental discount membership in Florida is determined by viewing the member s ID card and verifying that the Humana Logo and Medicare name is listed with an effective

More information

Cigna Dental Care (*DHMO) Patient Charge Schedule

Cigna Dental Care (*DHMO) Patient Charge Schedule A3O08 Cigna Dental Care (*DHMO) Schedule This Schedule lists the benefits of the Dental Plan including covered procedures and patient charges. Important Highlights This Schedule applies only when covered

More information

Dental Benefits Summary

Dental Benefits Summary CODE Office Visit Copay PATIENT PAYS CODE DIAGNOSTIC PATIENT PAYS D0120-D0180 Oral Evaluations D0277 Vertical Bitewings - 7 to 8 Films D0210 Full mouth series X-rays D0330 Panoramic X-Ray D0220-D0230 Periapicals

More information

A Dental Benefit Summary for Rice University

A Dental Benefit Summary for Rice University Aetna Dental presents A Dental Benefit Summary for Rice University CODE CODE Office Visit Copay $5 DIAGNOSTIC CROWNS/BRIDGES D0120 Exam-Periodic No Charge D2510 Inlay, Metallic, One surface $225 D0150

More information

FLORIDA COMBINED LIFE INSURANCE COMPANY, INC.

FLORIDA COMBINED LIFE INSURANCE COMPANY, INC. FLORIDA COMBINED LIFE INSURANCE COMPANY, INC. PEDIATRIC POLICY SCHEDULE This Pediatric Policy Schedule applies only to Covered Persons who are age 19 and under. Pediatric Dental Benefits end on the last

More information

Dental Benefits Summary

Dental Benefits Summary PATIENT PAYS PATIENT PAYS CODE PROCEDURE CODE PROCEDURE Office Visit Copay $0 DIAGNOSTIC D0120-D0180 Oral Evaluations D0277 Vertical Bitewings - 7 to 8 Films D0210 Full mouth series X-rays D0330 Panoramic

More information

Cigna Dental Care (*DHMO) Patient Charge Schedule

Cigna Dental Care (*DHMO) Patient Charge Schedule L1-08 Cigna Dental Care (*DHMO) Schedule This Schedule lists the benefits of the Dental Plan including covered procedures and patient charges. Important Highlights This Schedule applies only when covered

More information

PROVIDER CHOICE Plan PC - 5

PROVIDER CHOICE Plan PC - 5 The Dental Network Suite 200, 7400 York Road Towson, Maryland 21204 Telephone: (410) 847-9060 Fax: (410) 847-9062 Toll Free: (888) 833-8464 Website: www.thedentalnet.org Email: service@thedentalnet.org

More information

Dental Benefits Summary

Dental Benefits Summary CODE PROCEDURE Office Visit Copay PATIENT PAYS CODE $0 DIAGNOSTIC PROCEDURE PATIENT PAYS D0120-D0180 Oral Evaluations D0277 Vertical Bitewings - 7 to 8 Films D0210 Full mouth series Images D0330 Panoramic

More information

ADA Insurance Codes for Laboratory Procedures:

ADA Insurance Codes for Laboratory Procedures: ADA Insurance Codes for Laboratory Procedures: Inlay/Onlay Restorations D2510 Inlay - metallic - one surface D2520 Inlay - metallic - two surfaces D2530 Inlay - metallic - three or more surfaces D2542

More information

DISCOUNT DENTAL PLAN COMPLETE LISTING OF MEMBER COPAYMENTS

DISCOUNT DENTAL PLAN COMPLETE LISTING OF MEMBER COPAYMENTS DISCOUNT DENTAL PLAN COMPLETE LISTING OF MEMBER COPAYMENTS 0120 PERIODIC ORAL EXAMINATION - ESTABLISHED PATIENT 20 0140 LIMITED ORAL EVALUATION - PROBLEM FOCUSED 33 0150 COMPREHENSIVE ORAL EVALUATION -

More information

LIST OF DENTAL PROCEDURES (LOW PLAN) PREVENTIVE PROCEDURES

LIST OF DENTAL PROCEDURES (LOW PLAN) PREVENTIVE PROCEDURES LIST OF DENTAL PROCEDURES (LOW PLAN) The following is a complete list of the dental procedures for which benefits are payable under this section. No benefits are payable for a procedure that is not listed.

More information

Network Plus Prepaid plan People First Plan Code #4004

Network Plus Prepaid plan People First Plan Code #4004 Selecting a dentist For participating dentist information you may visit our website at www.humanadental.com/custom/fl/ or call our dedicated Customer Care number at 1-800-943-6880. Once you become enrolled

More information

Alberta Blue Cross Usual and Customary dental fees

Alberta Blue Cross Usual and Customary dental fees Alberta Blue Cross Usual and Customary dental fees Why Usual and Customary dental fees? In Alberta, individual dental providers set their own prices. As a result, dental offices across the province charge

More information

FLORIDA COMBINED LIFE INSURANCE COMPANY, INC.

FLORIDA COMBINED LIFE INSURANCE COMPANY, INC. FLORIDA COMBINED LIFE INSURANCE COMPANY, INC. PEDIATRIC POLICY SCHEDULE This Pediatric Policy Schedule applies only to Covered Persons who are age 19 and under. Pediatric Dental Benefits end on the last

More information

4-1-2005. Dental Clinical Criteria and Documentation Requirements

4-1-2005. Dental Clinical Criteria and Documentation Requirements 4-1-2005 Dental Clinical Criteria and Documentation Requirements Table of Contents Dental Clinical Criteria Cast Restorations and Veneer Procedures... Pages 1-3 Crown Repair... Page 3 Endodontic Procedures...

More information

PATIENT CHARGE SCHEDULE

PATIENT CHARGE SCHEDULE B1-05 Important Highlights PATIENT CHARGE SCHEDULE This Schedule lists the benefits of the Dental Plan including covered procedures and patient charges. This Schedule applies only when covered dental services

More information

CCPOA PRIMARY DENTAL. CCPOA s Fee-for-Service. Procedure Code List

CCPOA PRIMARY DENTAL. CCPOA s Fee-for-Service. Procedure Code List CCPOA PRIMARY DENTAL CCPOA s Fee-for-Service Procedure Code List Effective May 2016 We have provided these payment allowances for informational purposes only and not as a guarantee of payment. All claims

More information

DIRECT REFERRAL DENTAL PLAN HN VALUE DHMO 150 SCHEDULE OF BENEFITS

DIRECT REFERRAL DENTAL PLAN HN VALUE DHMO 150 SCHEDULE OF BENEFITS DIRECT REFERRAL DENTAL PLAN HN VALUE DHMO 150 SCHEDULE OF BENEFITS Benefits provided by Dental Benefit Providers of California, Inc. This document describes the Covered Services of this Health Net of California

More information

Cigna Dental Care (*DHMO) Patient Charge Schedule

Cigna Dental Care (*DHMO) Patient Charge Schedule Cigna Dental Care (*DHMO) Patient Charge Schedule This Patient Charge Schedule lists the benefits of the Dental Plan including covered procedures and patient charges. Important Highlights This Patient

More information

2015 Dental Plan 5000S Benefit Information BALTIMORE CITY PUBLIC SCHOOLS. Baltimore City Public Schools 2015 Dental Options C1

2015 Dental Plan 5000S Benefit Information BALTIMORE CITY PUBLIC SCHOOLS. Baltimore City Public Schools 2015 Dental Options C1 2015 Dental Plan 5000S Benefit Information BALTIMORE CITY PUBLIC SCHOOLS Baltimore City Public Schools 2015 Dental Options C1 Important Information for 2015 The State of Maryland legalized same sex marriage

More information

Delta Dental s Federal Employees Dental Program deltadentalfeds.org

Delta Dental s Federal Employees Dental Program deltadentalfeds.org Delta Dental s Federal Employees Dental Program deltadentalfeds.org A Nationwide Dental PPO Plan 2014 Who may enroll in this Plan: All Federal employees and annuitants in the United States and overseas

More information

SMALL GROUP PLANS FOR FAMILIES AND ADULTS WITH COMPREHENSIVE COVERAGE Page 1 of 9 Features & Benefit Details

SMALL GROUP PLANS FOR FAMILIES AND ADULTS WITH COMPREHENSIVE COVERAGE Page 1 of 9 Features & Benefit Details SMALL GROUP PLANS FOR FAMILIES AND ADULTS WITH COMPREHENSIVE COVERAGE Page 1 of 9 PLAN NETWORK Premium range child under age 19* Sample premium range typical family of 4* Is this a smaller network? Is

More information

Delta Dental Patient Direct Schedule 19

Delta Dental Patient Direct Schedule 19 Delta Dental Patient Direct Schedule 19 ADA CODE DENTAL PROCEDURE /ADA CODE DESCRIPTION NORMAL FEE* MEMBER FEE YOU SAVE Diagnostic and Preventive Services (x-rays and cleanings) D0999 Routine office visit

More information

Aetna Life Insurance Company Hartford, Connecticut 06156

Aetna Life Insurance Company Hartford, Connecticut 06156 Aetna Life Insurance Company Hartford, Connecticut 06156 Extraterritorial Certificate Rider (GR-9N-CR1) Policyholder: Choctaw Enterprises Group Policy No.: GP-819977 Rider: Florida ET Dental (PPO) Issue

More information

RETIREE DENTAL PLANS MEMBER HANDBOOK THE DENTAL PLAN ORGANIZATIONS AND THE DENTAL EXPENSE PLAN

RETIREE DENTAL PLANS MEMBER HANDBOOK THE DENTAL PLAN ORGANIZATIONS AND THE DENTAL EXPENSE PLAN STATE OF NEW JERSEY DEPARTMENT OF THE TREASURY DIVISION OF PENSIONS AND BENEFITS RETIREE DENTAL PLANS MEMBER HANDBOOK THE DENTAL PLAN ORGANIZATIONS AND THE DENTAL EXPENSE PLAN For Retired Group Members

More information

TABLE OF DENTAL PROCEDURES PLEASE READ THE FOLLOWING INFORMATION CAREFULLY FOR YOUR PROCEDURE FREQUENCIES AND PROVISIONS.

TABLE OF DENTAL PROCEDURES PLEASE READ THE FOLLOWING INFORMATION CAREFULLY FOR YOUR PROCEDURE FREQUENCIES AND PROVISIONS. TABLE OF DENTAL PROCEDURES PLEASE READ THE FOLLOWING INFORMATION CAREFULLY FOR YOUR PROCEDURE FREQUENCIES AND PROVISIONS. The attached is a list of dental procedures for which benefits are payable under

More information

Comprehensive Plan Benefits Booklet

Comprehensive Plan Benefits Booklet Comprehensive Plan Benefits Booklet For eligible Veterans and CHAMPVA beneficiaries Veterans Affairs Dental Insurance Program deltadentalvadip.org Comprehensive Plan Contact Information and Resources About

More information

DentalBlue Gold SM INDIVIDUAL DENTAL POLICY OTHER INSURANCE REDUCES BENEFITS READ CAREFULLY

DentalBlue Gold SM INDIVIDUAL DENTAL POLICY OTHER INSURANCE REDUCES BENEFITS READ CAREFULLY DentalBlue Gold SM INDIVIDUAL DENTAL POLICY OTHER INSURANCE REDUCES BENEFITS READ CAREFULLY Attached is the Schedule of Benefits, showing name of Policyholder, Policy number, type of Policy (individual

More information

Enroll in DeltaCare USA and you ll enjoy these features:

Enroll in DeltaCare USA and you ll enjoy these features: DeltaCare USA provided by Delta Dental of California We ll do whatever it takes and then some. Find a DeltaCare USA dentist Select from among the many conveniently located DeltaCare USA contracted general

More information

Humana Dental feds.humana.com

Humana Dental feds.humana.com Humana Dental feds.humana.com 2015 A Regional Copay Based Network Dental Plan Serving: Alabama, Arizona, Arkansas, California, Colorado, District of Columbia, Florida, Georgia, Illinois, Indiana, Kansas,

More information

TABLE OF DENTAL PROCEDURES PLEASE READ THE FOLLOWING INFORMATION CAREFULLY FOR YOUR PROCEDURE FREQUENCIES AND PROVISIONS.

TABLE OF DENTAL PROCEDURES PLEASE READ THE FOLLOWING INFORMATION CAREFULLY FOR YOUR PROCEDURE FREQUENCIES AND PROVISIONS. TABLE OF DENTAL PROCEDURES PLEASE READ THE FOLLOWING INFORMATION CAREFULLY FOR YOUR PROCEDURE FREQUENCIES AND PROVISIONS. The attached is a list of dental procedures for which benefits are payable under

More information

AMS Premier Group Dental Insurance Plan

AMS Premier Group Dental Insurance Plan AMS Premier Group Dental Insurance Plan American Military Society Acceptance Guaranteed Comprehensive Coverage Economical Insurance Protection Choice of your own dentist You deserve more! AMS Premier Group

More information

DeltaCare USA. Pediatric Basic Plan for Small Businesses. Dental plan administered and underwritten by Delta Dental Insurance Company

DeltaCare USA. Pediatric Basic Plan for Small Businesses. Dental plan administered and underwritten by Delta Dental Insurance Company DeltaCare USA Pediatric Basic Plan for Small Businesses Dental plan administered and underwritten by Delta Dental Insurance Company Available together with select medical plans offered through Florida

More information

2015 Dental Procedures Chart for Basic Dental Benefits

2015 Dental Procedures Chart for Basic Dental Benefits The dental procedures chart provides you with a list of the covered procedures and copayments for the Basic Dental benefits you receive as part of your CareMore Health Plan. Note: None of the procedures

More information

group dental & eye care For Cornell Employees and Their Families Ameritas Life Insurance Corp. of New York Coverage provided and underwritten by:

group dental & eye care For Cornell Employees and Their Families Ameritas Life Insurance Corp. of New York Coverage provided and underwritten by: group dental & eye care For Cornell Employees and Their Families 2015 Coverage provided and underwritten by: Ameritas Life Insurance Corp. of New York GR 6685 NY Rev. 9-14 Plan A+ $3,000 calendar year

More information

Dental Services Rider Harbor Choice Plus, a product of Harbor Health Plan, Inc.

Dental Services Rider Harbor Choice Plus, a product of Harbor Health Plan, Inc. Your Agreement gives You important information about Your health care benefits. This Dental Services Rider ( Rider ) is issued to You with Your Agreement because the plan you selected includes Other Dental

More information

Massachusetts State Health Care. Professionals Dental Fund. Summary Plan Description

Massachusetts State Health Care. Professionals Dental Fund. Summary Plan Description Massachusetts State Health Care Professionals Dental Fund Summary Plan Description Effective February 1, 2008 MASSACHUSETTS STATE HEALTH CARE PROFESSIONALS DENTAL FUND P.O. Box 9631, Boston, MA 02114-9631

More information

Aetna Dental Plan Organization (DPO) Plan. 2015 New Jersey SHBP Active Employees Covered Services

Aetna Dental Plan Organization (DPO) Plan. 2015 New Jersey SHBP Active Employees Covered Services Aetna Dental Plan Organization (DPO) Plan 2015 New Jersey SHBP Active Employees Covered Services The following is a list of covered services and, if applicable, required copayments. Copayments are your

More information

Contributory dental (2-9) Alaska 2016

Contributory dental (2-9) Alaska 2016 Contributory dental (2-9) Option 1 Indemnity 1500 Indemnity 100/80/50 Option 2 PPO 1000 Option 3 PPO 1500 Option 4 PPO 2000 PPO 100/80/50 PPO 100/80/50 PPO 100/80/50 $50; 3X Family Maximum $50; 3X Family

More information

TABLE OF DENTAL PROCEDURES PLEASE READ THE FOLLOWING INFORMATION CAREFULLY FOR YOUR PROCEDURE FREQUENCIES AND PROVISIONS.

TABLE OF DENTAL PROCEDURES PLEASE READ THE FOLLOWING INFORMATION CAREFULLY FOR YOUR PROCEDURE FREQUENCIES AND PROVISIONS. TABLE OF DENTAL PROCEDURES PLEASE READ THE FOLLOWING INFORMATION CAREFULLY FOR YOUR PROCEDURE FREQUENCIES AND PROVISIONS. The attached is a list of dental procedures for which benefits are payable under

More information

2014 Dental Benefits Summary

2014 Dental Benefits Summary 2014 Dental Benefits Summary ICUBA Dental Benefit Options from HumanaDental The dental coverage is offered, so you and your family can receive the important dental care you need for good health. You can

More information

PWU REPRESENTED EMPLOYEES - ODA CODES COVERED UNDER THE KINECTRICS DENTAL PLAN (DRAFT) PROCEDURE

PWU REPRESENTED EMPLOYEES - ODA CODES COVERED UNDER THE KINECTRICS DENTAL PLAN (DRAFT) PROCEDURE PWU REPRESENTED EMPLOYEES - COVERED UNDER THE KINECTRICS DENTAL PLAN 01101 100% Class A Initial examination of a new patient 01102 100% Class A Initial examination of a new patient 01103 100% Class A Initial

More information

LIBERTY Dental Plan of California, Inc.

LIBERTY Dental Plan of California, Inc. LIBERTY Dental Plan of California, Inc. CA80 PLAN SCHEDULE OF BENEFITS Covered Benefits, Member Co-payments, Limitations & Exclusions No Annual Deductible No Annual Dollar Amount Maximum Provider office

More information

Dominion Dental Services FederalDentalPlans.com

Dominion Dental Services FederalDentalPlans.com Dominion Dental Services FederalDentalPlans.com 2014 A Regional Based Dental HMO Plan Serving: Mid-Atlantic States of District of Columbia, Delaware, Maryland, Pennsylvania and parts of Virginia and parts

More information

CDT These changes take effect January 1, If you have questions, please feel free to contact:

CDT These changes take effect January 1, If you have questions, please feel free to contact: CDT 2016 Current Dental Terminology American Dental Association procedure codes (CDT codes) are the recognized dental codes set by the Federal Government. CDT codes are used for dental claim transactions

More information

DeltaCare Plan SCHEDULE OF DENTAL BENEFITS PATIENT

DeltaCare Plan SCHEDULE OF DENTAL BENEFITS PATIENT DeltaCare Plan SCHEDULE OF DENTAL BENEFITS CODE (D0100-D0999) DIAGNOSTIC Office visit, per visit (in addition to other services) No Cost D0120 Periodic oral evaluation No Cost D0140 Limited oral evaluation

More information

Union Security Insurance Company 2323 Grand Boulevard Kansas City, MO 64108-2670 800.443.2995 EVIDENCE OF COVERAGE

Union Security Insurance Company 2323 Grand Boulevard Kansas City, MO 64108-2670 800.443.2995 EVIDENCE OF COVERAGE Union Security Insurance Company 2323 Grand Boulevard Kansas City, MO 64108-2670 800.443.2995 EVIDENCE OF COVERAGE ARTICLE I DEFINITIONS 1.1 Agreement: The Group Dental Service Agreement between Group

More information

healthy teeth healthy body arkansas medicaid s dental care for adults

healthy teeth healthy body arkansas medicaid s dental care for adults healthy teeth healthy body arkansas medicaid s dental care for adults eeping your teeth healthy can help your whole body stay well. If your mouth and teeth are clean, you might not get sick as much. That

More information

REQUIRED OUTLINE OF COVERAGE FOR BLUEEXTRA INDIVIDUAL SUPPLEMENTAL INSURANCE COVERAGE DENTAL, VISION AND HEARING AID BENEFITS

REQUIRED OUTLINE OF COVERAGE FOR BLUEEXTRA INDIVIDUAL SUPPLEMENTAL INSURANCE COVERAGE DENTAL, VISION AND HEARING AID BENEFITS REQUIRED OUTLINE OF COVERAGE FOR BLUEEXTRA INDIVIDUAL SUPPLEMENTAL INSURANCE COVERAGE DENTAL, VISION AND HEARING AID BENEFITS BASIC POLICY Issued by QCC Insurance Company* (Called the Company) *a subsidiary

More information

EMPLOYEE DENTAL PLANS

EMPLOYEE DENTAL PLANS STATE OF NEW JERSEY DEPARTMENT OF THE TREASURY DIVISION OF PENSIONS AND BENEFITS EMPLOYEE DENTAL PLANS MEMBER HANDBOOK THE DENTAL PLAN ORGANIZATIONS AND THE DENTAL EXPENSE PLAN For Members of the State

More information

Dental Coverage Limitations By Program

Dental Coverage Limitations By Program Dental Coverage Limitations By Program Procedure or Service Common ADA Codes Program Coverage Periodic Oral Exam D0120 If you are less than 21 you may have an exam every 6 months. If you are 21 or older,

More information

Aetna Student Health Aetna PPO Dental Plan Design and Benefits Summary Policy Year: 2015 2016 Policy Number 867853

Aetna Student Health Aetna PPO Dental Plan Design and Benefits Summary Policy Year: 2015 2016 Policy Number 867853 Aetna Student Health Aetna PPO Dental Plan Design and Benefits Summary Policy Year: 2015 2016 Policy Number 867853 www.aetnastudenthealth.com (888) 238 4825 This Aetna Dental Preferred Provider Organization

More information

Aetna Dental http://www.aetnafeds.com

Aetna Dental http://www.aetnafeds.com Aetna Dental http://www.aetnafeds.com 2014 A Nationwide Dental PPO Plan Who may enroll in this plan: All Federal employees and annuitants in the United States and overseas who are eligible to enroll in

More information

SCHEDULE OF BENEFITS DIRECT REFERRAL DENTAL PLAN*

SCHEDULE OF BENEFITS DIRECT REFERRAL DENTAL PLAN* SCHEDULE OF BENEFITS DIRECT REFERRAL DENTAL PLAN* Nexus 150 This document describes the Covered Services of this dental plan, as well as Copayment requirements, Limitations of Benefits and Exclusions.

More information

Employers Dental Services. Enrollment and Coverage Booklet

Employers Dental Services. Enrollment and Coverage Booklet Employers Dental Services Enrollment and Coverage Booklet EDS 700R W E U N D E R S T A N D W H A T Y O U R E W O R K I N G F O R SM Know? Did You About 80% of the population believes that a smile is very

More information

USA provided by Delta Dental of California

USA provided by Delta Dental of California DeltaCare USA provided by Delta Dental of California Weʼll do whatever it takes and then some. Find a DeltaCare USA dentist Select from among the many conveniently located DeltaCare USA contracted general

More information

Dentists. Schedule of Dental Services and Fees for Ontario Works Adults

Dentists. Schedule of Dental Services and Fees for Ontario Works Adults Dentists Schedule of Dental Services and Fees for Ontario Works Adults 2015 2015 Ontario Works Adults - Schedule of Dental Services and Fees PURPOSE OF THE PROGRAM Halton Region does not intend to provide

More information

2014 Preventive/Comprehensive. Dental HMO Plan. Health Net Medicare Advantage Plans. California. Josefina Bravo Health Net

2014 Preventive/Comprehensive. Dental HMO Plan. Health Net Medicare Advantage Plans. California. Josefina Bravo Health Net 2014 Preventive/Comprehensive Dental HMO Plan Health Net Medicare Advantage Plans California Josefina Bravo Health Net Material ID # H0562_2014_0289 CMS Accepted 09222013 1 2014 Preventive/Comprehensive

More information

Attachment S: Benefits Covered - ADULTS - AGE 21 AND OVER

Attachment S: Benefits Covered - ADULTS - AGE 21 AND OVER Diagnostic services include the oral examinations and selected radiographs needed to assess the oral health, diagnose oral pathology and develop an adequate treatment plan for the Participant s oral health.

More information

Summary of Benefits. Mount Holyoke College

Summary of Benefits. Mount Holyoke College Dental Blue Program 2 Summary of Benefits Mount Holyoke College Blue Cross Blue Shield of Massachusetts is an Independent Licensee of the Blue Cross and Blue Shield Association Dental Blue Program 2 Preventive

More information

TEAMSTERSCARE DENTAL FEE SCHEDULE Effective: 01/01/ Delta Dental PPO Plus Premier National

TEAMSTERSCARE DENTAL FEE SCHEDULE Effective: 01/01/ Delta Dental PPO Plus Premier National Effective: 01/01/ - Delta Dental PPO Plus Premier National D0120 PERIODIC ORAL EXAMINATION $20.00 D0140 LIMITED EVAL PROBLEM FOCUS $37.00 D0145 ORAL EVALUATION FOR PATIENTS UNDER THREE YEARS OF AGE $20.00

More information

Cone Beam CT Capture and Interpretation with Field of View and One Full Dental Arch-Mandible D0366

Cone Beam CT Capture and Interpretation with Field of View and One Full Dental Arch-Mandible D0366 CDT Procedure Code HCBS-DD and SLS WAIVER PARTICIPANT Procedure Code Description New DIDD Rate D0120 Periodic Oral Evaluation 45.57 D0140 Limited Oral Evaluation Problem Focused 66.06 D0150 Comprehensive

More information

Dental Benefits (866) 212-2743 A. Choice of Physician and Provider B. Scheduling Appointments C. Referrals to Specialists D. Changing Your Dentist

Dental Benefits (866) 212-2743 A. Choice of Physician and Provider B. Scheduling Appointments C. Referrals to Specialists D. Changing Your Dentist Dental Benefits Dental Benefits are provided through Delta Dental of California. Upon enrollment you will receive a dental provider directory that lists Delta Dental dentists participating in the Healthy

More information

SCHEDULE OF BENEFITS Benefits provided by SafeGuard Health Plans, Inc., a MetLife company Self-Referral Dental Plan

SCHEDULE OF BENEFITS Benefits provided by SafeGuard Health Plans, Inc., a MetLife company Self-Referral Dental Plan SCHEDULE OF BENEFITS Benefits provided by SafeGuard Health Plans, Inc., a MetLife company Self-Referral Dental Plan Univ II This Schedule of Benefits lists the services available to you under your SafeGuard

More information

SECURITY LIFE INSURANCE COMPANY OF AMERICA Minnetonka, Minnesota

SECURITY LIFE INSURANCE COMPANY OF AMERICA Minnetonka, Minnesota SECURITY LIFE INSURANCE COMPANY OF AMERICA Minnetonka, Minnesota COVERAGE SCHEDULE PREFERRED (In-Network) PROVIDER: WE WILL PAY BASED ON THE CONTRACTED FEE FOR SERVICE WITH THE PREFERRED PROVIDER ORGANIZATION

More information

HumanaDental State of Florida Employees

HumanaDental State of Florida Employees HumanaDental State of Florida Employees FLHHB32HH 0914 2 - HumanaDental Four plans to choose from Humana is pleased to offer you four dental plans to choose from this year. While some of the benefits are

More information

LifeWise Health Plan of Washington LifeWise Adult Health Plan ($75 Deductible) For Individuals and Families Residing in Washington

LifeWise Health Plan of Washington LifeWise Adult Health Plan ($75 Deductible) For Individuals and Families Residing in Washington LifeWise Health Plan of Washington LifeWise Adult Health Plan ($75 Deductible) For Individuals and Families Residing in Washington PLEASE READ THIS CONTRACT CAREFULLY This is a contract between the subscriber

More information

Learn. dental plans: > Basic Plan. > My. Always. to enroll for. included withh. son is away. plan cover this?? radiation. please visit. dentist?

Learn. dental plans: > Basic Plan. > My. Always. to enroll for. included withh. son is away. plan cover this?? radiation. please visit. dentist? Cigna Dental Open Enrollment Brochure You and your family have the opportunity to receive dental care through one of the following State of Connecticut dental plans: > Basic Plan > Enhanced Plan > Dental

More information

Anthem Blue Dental PPO Plan

Anthem Blue Dental PPO Plan Anthem Blue Dental PPO Plan For Individuals and Families Anthem Blue Cross and Blue Shield 700 Broadway Denver, Colorado 80273 anthem.com An independent licensee of the Blue Cross and Blue Shield Association.

More information

Choosing your plan. We ll do whatever it takes and then some. Your Two Delta Dental Plan Options

Choosing your plan. We ll do whatever it takes and then some. Your Two Delta Dental Plan Options City of Sacramento Choosing your plan Your Two Delta Dental Plan Options The choice is yours. When it comes to dental health, you want benefits that provide you with the best balance of value and coverage.

More information

Dental HMO Plan. Evidence of Coverage and Health Service Agreement. Individual and Family Plan

Dental HMO Plan. Evidence of Coverage and Health Service Agreement. Individual and Family Plan Dental HMO Plan Evidence of Coverage and Health Service Agreement Individual and Family Plan An independent member of the Blue Shield Association (Intentionally left blank) Blue Shield of California Individual

More information

MEDICAL ASSISTANCE PROGRAM DENTAL FEE SCHEDULE

MEDICAL ASSISTANCE PROGRAM DENTAL FEE SCHEDULE Dental General Payment Policies Children under 21 years of age are eligible for all medically necessary dental services. For children under 21 years of age who require medically necessary dental services

More information

Triple-S Salud http://www.ssspr.com

Triple-S Salud http://www.ssspr.com Triple-S Salud http://www.ssspr.com 2015 A Regional Dental PPO Plan Serving: Puerto Rico Enrollment Options for this Plan: High Option Self Only High Option Self Plus One High Option Self and Family Enrollment

More information

GROUP DENTAL PLAN WINSTON-SALEM/FORSYTH COUNTY SCHOOLS. Plan Number: 10-301002. Administered by:

GROUP DENTAL PLAN WINSTON-SALEM/FORSYTH COUNTY SCHOOLS. Plan Number: 10-301002. Administered by: GROUP DENTAL PLAN WINSTON-SALEM/FORSYTH COUNTY SCHOOLS Plan Number: 10-301002 Administered by: TABLE OF CONTENTS Name of Provision Page Number Schedule of Benefits Begins on 9040 Benefit Information,

More information

CDT 2015 Code Change Summary New codes effective 1/1/2015

CDT 2015 Code Change Summary New codes effective 1/1/2015 CDT 2015 Code Change Summary New codes effective 1/1/2015 Code Nomenclature Delta Dental Policy D0171 Re-Evaluation Post Operative Office Visit Not a Covered Benefit D0351 3D Photographic Image Not a Covered

More information

Dental Coverage. Hawai i. Coordinated Care Plans. H2491_H1015506_WCM_BRO_ENG CMS Approved 08022011 WellCare 2011 HI_07_11_WC

Dental Coverage. Hawai i. Coordinated Care Plans. H2491_H1015506_WCM_BRO_ENG CMS Approved 08022011 WellCare 2011 HI_07_11_WC Dental Coverage Coordinated Care Plans Hawai i Ohana is pleased to offer you dental coverage that focuses on the importance of preventive care. Taking care of your teeth and gums begins with regular checkups

More information

NEW YORK STATE MEDICAID PROGRAM DENTAL PROCEDURE CODES

NEW YORK STATE MEDICAID PROGRAM DENTAL PROCEDURE CODES NEW YORK STATE MEDICAID PROGRAM DENTAL PROCEDURE S Table of Contents GENERAL INFORMATION AND INSTRUCTIONS... 2 I. DIAGNOSTIC D0100 - D0999... 5 II. PREVENTIVE D1000 - D1999... 7 III. RESTORATIVE D2000

More information

Humana Dental feds.humana.com

Humana Dental feds.humana.com Humana Dental feds.humana.com 2016 A Regional Copay Based Network Dental Plan Serving: Alabama, Arizona, Arkansas, California, Colorado, District of Columbia, Florida, Georgia, Illinois, Indiana, Kansas,

More information

Do Not Pay High Premiums for Dental Benefits Pay for Your Services When and If Used. It Just Makes Good Financial Sense!

Do Not Pay High Premiums for Dental Benefits Pay for Your Services When and If Used. It Just Makes Good Financial Sense! CYPRESS FAIRBANKS I.S.D. The QCD of America Dental & Vision Benefit Program (QCD) is a managed cost program offering a large selection of highly qualified private practice dental and optical professionals.

More information

Henrico County General Government and Public Schools 2016 Dental Plans

Henrico County General Government and Public Schools 2016 Dental Plans Henrico County General Government and Public Schools 2016 Dental Plans DeltaCare (DHMO) program Under this program, you select a DeltaCare (DHMO) panel dentist for your dental care. Delta Dental of Virginia

More information

EmblemHealth Preferred Dental

EmblemHealth Preferred Dental EmblemHealth Preferred Dental Unique coverage levels at affordable group rates. Here s how EmblemHealth Preferred Dental will deliver for you: Complete your benefits package with paid-infull* in-network

More information

Access PPO 1 Adults Maximum access, convenience and flexibility.

Access PPO 1 Adults Maximum access, convenience and flexibility. Access PPO 1 Adults Maximum access, convenience and flexibility. Benefit Features Deductibles: $50 ($150) per family Annual Maximum: $1,000 Waiting Periods: None Receive Care From: Any Dentist or Access

More information

Welcome to DeltaCare. Using Your Dental Plan. Emergency Dental Care. Choosing Your Primary Care Dentist

Welcome to DeltaCare. Using Your Dental Plan. Emergency Dental Care. Choosing Your Primary Care Dentist Welcome to DeltaCare DeltaCare is an innovative dental plan that provides you with comprehensive care at a significantly lower cost than most other dental plans which means great value for you. The plan

More information

Complete Dentist Handbook for Treating Patients Enrolled in Delta Dental s Veterans Affairs Dental Insurance Program

Complete Dentist Handbook for Treating Patients Enrolled in Delta Dental s Veterans Affairs Dental Insurance Program Veterans Affairs Dental Insurance Program Complete Dentist Handbook for Treating Patients Enrolled in Delta Dental s Veterans Affairs Dental Insurance Program deltadentalvadip.org Delta Dental s Veterans

More information

Diagnostic. 6-20 No One of (D0210, D0330) per 60 Month(s) Per patient. 0-20 No

Diagnostic. 6-20 No One of (D0210, D0330) per 60 Month(s) Per patient. 0-20 No Exhibit A Benefits Covered for OH Paramount Advantage Medicaid Children Diagnostic services include the oral examinations, and selected radiographs, needed to assess the oral health, diagnose oral pathology,

More information

HEALTH SERVICES POLICY & PROCEDURE MANUAL. SUBJECT: Types of Dental Treatments Provided EFFECTIVE DATE: July 2014 SUPERCEDES DATE: January 2014

HEALTH SERVICES POLICY & PROCEDURE MANUAL. SUBJECT: Types of Dental Treatments Provided EFFECTIVE DATE: July 2014 SUPERCEDES DATE: January 2014 PAGE 1 of 5 References Related ACA Standards 4 th Edition Standards for Adult Correctional Institutions 4-4369, 4-4375 PURPOSE To provide guidelines for determining appropriate levels of care and types

More information

Attachment J-2 Benefits, Limitations and Exclusions

Attachment J-2 Benefits, Limitations and Exclusions INTRODUCTION Covered dental services must meet accepted standards of dental practice. All dental procedures in this document conform to the 2016 version of the American Dental Association (ADA) Code on

More information

Schedule of Covered Services and Copayments Family Dental HMO SHOP Plan (CA-FD)

Schedule of Covered Services and Copayments Family Dental HMO SHOP Plan (CA-FD) Schedule of Covered Services and Copayments Family Dental HMO SHOP Plan (CA-FD) D9543 Diagnostic D0120 D0140 D0150 D0160 D0170 D0180 D0190 D0191 D0210 D0220 D0230 D0240 D0250 D0270 D0272 D0273 D0274 D0277

More information

A Nationwide Dental PPO Plan 2016

A Nationwide Dental PPO Plan 2016 http://www.uccife A Nationwide Dental PPO Plan 2016 Who may enroll in this plan: All Federal employees and annuitants in the United States and overseas who are eligible to enroll in the Federal Employees

More information

TWO GREAT DENTAL PROGRAMS

TWO GREAT DENTAL PROGRAMS A REGISTERED MARK OF DELTA DENTAL PLANS ASSOCIATION TWO GREAT DENTAL PROGRAMS FOR 2015 KAISER PERMANENTE FEDERAL MEMBERS You must be enrolled in one of Kaiser Permanente s medical plans to elect fee-for-service

More information

Welcome to the growing number of people who receive fully insured dental benefits from Delta Dental of New Mexico.

Welcome to the growing number of people who receive fully insured dental benefits from Delta Dental of New Mexico. Delta Dental of New Mexico Frm 119 01/09 New Mexico Retiree Health Care Authority Dental Benefits Handbook Welcome to the growing number of people who receive fully insured dental benefits from Delta

More information

Texas. Use your HumanaOne Dental benefits. Choose HumanaOne dental benefits. HumanaOne Dental Prepaid HI215 Plan. Be healthy

Texas. Use your HumanaOne Dental benefits. Choose HumanaOne dental benefits. HumanaOne Dental Prepaid HI215 Plan. Be healthy HumanaOne Dental Prepaid HI215 Plan Texas Use your HumanaOne Dental benefits The HumanaOne Dental Prepaid HI215 plan has you covered for any circumstance. Whether you simply need quality routine dental

More information

P REMIER A CCESS TABLE OF CONTENTS

P REMIER A CCESS TABLE OF CONTENTS Important Contacts Questions Can Be Answered By: Premier Provider Relations Department (916) 920-2500 1-800-640-4466 Submit Claims To: Premier Access Insurance Company Claims Department P. O. Box 659010

More information

CDT- Current Dental Terminology- a reference manual used by the dental profession to outline the dental code. Developed by the ADA

CDT- Current Dental Terminology- a reference manual used by the dental profession to outline the dental code. Developed by the ADA A Letter Numbering system used to identify dental procedures and their descriptions for a standardized coding system to document and communicate accurate information regarding dental treatment and procedures

More information

EMBLEMHEALTH Dental (Formerly GHIDental) http://www.emblemhealth.com

EMBLEMHEALTH Dental (Formerly GHIDental) http://www.emblemhealth.com EMBLEMHEALTH Dental (Formerly GHIDental) http://www.emblemhealth.com 2016 Dental PPO Plan High Option Plan Serving: All of New York and New Jersey counties of Bergen, Essex, Hudson, Middlesex, Monmouth,

More information