Provider Manual. Published Date: 6/18/2014

Transcription

1 2014 Provider Manual Published Date: 6/18/2014

2 Scion Dental, Inc. Copyright Scion Dental, Inc. CONFIDENTIAL & PROPRIETARY

3 Contents Quick Reference Guide... 1 Provider Web Portal... 1 Contacts... 2 Summary... 3 Welcome... 6 Member Rights & Responsibilities... 7 Provider Rights & Responsibilities... 8 Provider Bill of Rights... 8 Provider Exience... 9 Access to Flexible Participation Options... 9 Consistent, Transparent Determination Logic... 9 Concierge-Level Care for Members... 9 Outreach Programs... 9 Provider Web Portal Provider Web Portal Registration Payee Dashboard Eligibility Verification Entry & Submission Summary Status Manage Roster Claim Entry & Submission Claims Status Claim Management Electronic Funds Transfer Electronic Funds Transfer Agreement Health Insurance Portability and Accountability Act (HIPAA) National Provider Identifier (NPI) , Scion Dental, Inc. PROPRIETARY AND CONFIDENTIAL Dental Health & Wellness i

4 Utilization Management Introduction Community Practice Patterns Evaluation Results n-incentivization Policy Fraud and Abuse Deficit Reduction Act: The False Claims Act Eligibility & Member Services Member Identification Card Eligibility Verification Eligibility Verification via Provider Web Portal Eligibility Verification via IVR Transportation Benefits Appointment Availability Standards Retrospective, Prior & Documentation Requirements Retrospective Prior Orthodontic Models Submission Procedures Submission via Provider Web Portal Submission via Clearinghouse Submission via HIPAA-Compliant 837D File Pa Submission ADA Approved Claim Form Claim Submission Procedures Claim Submission via Provider Web Portal Claim Submission via Emdeon Clearinghouse Claim Submission via KMAP Fiscal nt KanCare Front End Billing HIPAA-Compliant 837D File Claim Submission via National Electronic Attachment FastAttach Pa Claim Submission Coordination of Benefits (COB) ii , Scion Dental, Inc. PROPRIETARY AND CONFIDENTIAL Dental Health & Wellness

5 Corrected Claim Process Receipt and Audit of Claims Claims Adjudication and Payment Appeals, Complaints & Grievances Provider Appeal Procedures Member Appeals Fair Hearing Procedures Provider Enrollment & Contracting Credentialing Health Guidelines s 0 18 Years Appendix Benefits Benefit Descriptions Title 21 CHIP Children s Title 19 Medicaid Children s Title 19 Medicaid Adults s 21 and over ICF/MR Adults s 21 and over Money Follows the Person (MFP) Adults s 21 and Over (IDD, TB(HI) and PD Waivers) Money Follows the Person (MFP) Frail and Elderly HCBS Adult s 65 and Over (not ICR/MR) Medically Needy (Spenddown) Crisis Process Additional Benefit Information Clinical Criteria Benefit Plan Details and Requirements Title 21 CHIP Children (s 0-18) Title 19 Medicaid Children (s 0-20) Title 19 Medicaid Adults (s 21 and Over) ICF/MR Adults (s 21 and Over) Money Follows Person (MFP) Adults s 21 and Over (IDD, TB(HI) and PD Waivers) Money Follows Person (MFP) Frail and Elderly HCBS Adults s 65 and Over (not ICF/MR) , Scion Dental, Inc. PROPRIETARY AND CONFIDENTIAL Dental Health & Wellness iii

6 iv , Scion Dental, Inc. PROPRIETARY AND CONFIDENTIAL Dental Health & Wellness

7 Quick Reference Guide Quick Reference Guide Provider Web Portal Everything You Need When You Need It 24/7/365 Our user friendly Provider Web Portal features a full complement of resources. Real-Time Eligibility s Submit & Status Claims Submit & Status Clinical Guidelines Referral Directories Electronic Remittance Advice Electronic Fund Transfer Up-to-Date Provider Manual Access the Provider Web Portal by clicking this link: , Scion Dental, Inc. PROPRIETARY AND CONFIDENTIAL Dental Health & Wellness 1

8 Quick Reference Guide Contacts For information about Contact Provider Web Portal Provider Services Sunflower Member Services TDD: Credentialing Fraud & Abuse Address Dental Health & Wellness - s PO Box 1183 Milwaukee, WI Pa Claim Address KanCare P.O. Box 3571 Topeka, KS , Scion Dental, Inc. PROPRIETARY AND CONFIDENTIAL Dental Health & Wellness

9 Quick Reference Guide Summary Quick Reference Guide Member Eligibility Retrospective Submission Providers may access eligibility through one of the following: Provider Web Portal Call Interactive Voice Response (IVR) eligibility hotline: Call Provider Services: Retrospective claim submission requires providers to submit documentation associated with certain dental services rendered as outlined in the benefit descriptions beginning on page 45. Submit Retrospective claims in one of the following formats: Provider Web Portal at Electronic submission via clearinghouse Payer ID Pa Retrospective claims must be submitted through the KanCare Front Billing process. Submit Pa Retrospective claims to: KanCare P.O. Box 3571 Topeka, KS All Retrospective requests submitted through KanCare Front End Billing must include the provider NPI number along with the member s Medicaid ID (sometimes known as a KMAP ID). Retrospective claims submitted via Front End Billing with the Sunflower Health Plan ID will be rejected. Submission submissions must be received in one of the following formats: Provider Web Portal at Electronic submission via Emdeon clearinghouse : Payer ID HIPAA-compliant 837D file (see page 31) Pa authorization via ADA 2012 Claim Form Mailed authorizations must be sent to: Dental Health & Wellness s PO Box 1183 Milwaukee, WI , Scion Dental, Inc. PROPRIETARY AND CONFIDENTIAL Dental Health & Wellness 3

10 Quick Reference Guide Quick Reference Guide Claims Submission Inquiries and Grievances The timely filing requirement for Sunflower Health Plan is 180 calendar days. Submit claims in one of the following formats: Provider Web Portal at Electronic claim submission via Emdeon clearinghouse : Payer ID Electronic claim submission via KMAP Fiscal nt KanCare Front End Billing Electronic claim submission via National Electronic Attachment (NEA) HIPAA-compliant 837D file (see page 35) Pa claims must be submitted through KanCare Front End Billing: KanCare P.O. Box 3571 Topeka, KS All claims submitted through KanCare Front End Billing must include the member s Medicaid ID (sometimes known as a KMAP ID). Claims submitted via Front End Billing with the Sunflower Health Plan ID will be rejected. All claims should also include the Provider NPI number. To make an inquiry or grievance: Call: Write: Dental Health & Wellness Grievances PO Box 1432 Milwaukee, WI Provider Appeals - s Appeals must be filed within thirty-three (33) days following the date the denial letter was mailed. To request reconsideration of a denied authorization, a provider may: Call: Write: Dental Health & Wellness Appeal PO Box 1432 Milwaukee, WI Providers must exhaust their appeal rights with Dental Health & Wellness prior to requesting a Fair Hearing. Fair Hearing requests must be submitted in writing to the following address within thirty-three (33) days of receipt of the letter with Dental Health & Wellness s final resolution: Office of Administrative Hearings 1020 S. Kansas Ave. Topeka, KS , Scion Dental, Inc. PROPRIETARY AND CONFIDENTIAL Dental Health & Wellness

11 Quick Reference Guide Quick Reference Guide Provider Appeals - Claims Claim Payment Appeals must be filed within ninety (90) days following the receipt of the determination mailed. To request a reconsideration of a claims denial, a provider may: Call: Write: Dental Health & Wellness Appeals PO Box 1432 Milwaukee, WI Member Appeals Submit written appeals to: Sunflower State Clinical Appeals Coordinator 8325 Lenexa Drive Lenexa, KS Fair Hearing requests must be submitted in writing: Office of Administrative Hearings 1020 S. Kansas Ave. Topeka, KS For more information about filing an appeal, please contact the clinical appeals coordinator at Members who file verbal appeals must follow with a written, signed appeal unless an expedited resolution is requested. Dental Services in a Hospital Setting Providers must use a participating Sunflower Health Plan hospital. To obtain the most recent listing of hospitals in your area: Visit Sunflower Health Plan s Website: Call Sunflower Health Plan Provider Services: Additional Provider Resources For information about additional provider resources: Call Provider Services: Access the Provider Web Portal at Send to: [email protected] , Scion Dental, Inc. PROPRIETARY AND CONFIDENTIAL Dental Health & Wellness 5

12 Welcome Welcome Welcome to the Dental Health & Wellness provider network! We are pleased you have joined our provider network, which is composed of the best providers in the state established to deliver quality dental healthcare. Dental Health & Wellness is a subsidiary of Centene Corporation, a Fortune 500 company with nearly thirty years of exience in Medicaid Managed Care Programs. We have partnered with Sunflower Health Plan, our sister company, to administer the dental benefit for their members in the KanCare Managed Care Program. Throughout your ongoing relationship with Dental Health & Wellness, this provider manual will give you useful information concerning the plan. When communicating with our providers, we make every effort to be clear and concise. Our expectation is to answer questions promptly and accurately when they arise. If you require assistance or information not included within this manual, please contact Provider Services at , Monday Friday, 8:00 AM to 5:00 PM (CST). Dental Health & Wellness retains the right to add to, delete from and otherwise modify this provider manual. Contracted providers must acknowledge this provider manual and any other written materials provided by Dental Health & Wellness as proprietary and confidential , Scion Dental, Inc. PROPRIETARY AND CONFIDENTIAL Dental Health & Wellness

13 Member Rights & Responsibilities Member Rights & Responsibilities Dental Health & Wellness is committed to the following core concepts to member care: Access to providers and services Wellness programs, which include member education and disease management initiatives Outreach programs to educate members and give them the tools they need to make informed decisions about their dental care Feedback measuring provider and member satisfaction. Members have the right to: Privacy, respectful treatment and recognition of their dignity when receiving dental care Fully participate with caregivers in decision-making process surrounding their health care Be fully informed about the appropriate or medically necessary treatment options for any condition, regardless of the coverage or cost for the care discussed Voice a grievance against Dental Health & Wellness, or any of its participating dental offices, or any of the care provided by these groups or people, when their formance has not met the member s expectations Appeal any decisions related to patient care and treatment Make recommendations regarding Dental Health & Wellness s member rights and responsibilities policies. Receive relevant written and up-to-date information about Dental Health & Wellness, the services we provide, the participating dentists and dental offices; as well as member rights and responsibilities Members are responsible for: Providing to his or her dental care provider, to the best of his or her knowledge, accurate and complete information about present complaints, past illnesses, hospitalizations, medications, and other matters related to his or her health Reporting unexpected changes in his or her condition to the dental care provider. Reporting to his or her dental care provider whether he or she comprehends a contemplated course of action and what is expected of him or her. Following the treatment plan recommended by his or her dental care provider. Keeping appointments and, when he or she is unable to do so for any reason, for notifying the dental care provider or dental care facility , Scion Dental, Inc. PROPRIETARY AND CONFIDENTIAL Dental Health & Wellness 7

14 Provider Rights & Responsibilities Provider Rights & Responsibilities Dental Health & Wellness has established the following core concepts in its approach to a positive provider exience: Access to flexible participation options in provider networks Outreach programs that lower provider participation costs Technology tools that increase efficiency and lower administrative costs Feedback that measures provider and member satisfaction Enrolled participating providers shall have the right to: Communicate with patients, including members, regarding dental treatment options Recommend a course of treatment to a member even if the course of treatment is not a covered benefit or approved by Dental Health & Wellness File an appeal or grievance pursuant to the procedures of Dental Health & Wellness Supply accurate, relevant and factual information to a member in conjunction with a grievance filed by the member Object to policies, procedures or decisions made by Dental Health & Wellness Participating providers have the following responsibilities: If a recommended treatment plan is not covered, the participating dentist, if intending to charge the member for the non-covered services, must notify the member A provider wishing to terminate participation with the Dental Health & Wellness Network due to retirement, relocation or voluntary termination must supply written notification to Dental Health & Wellness at least 60 days prior to expected final date of participation. A list of existing Sunflower Health Plan patients currently in treatment should accompany the termination notification. All other Sunflower Health Plan patients should be referred to Provider Services at to find another dentist in their area A provider may not bill both medical and dental codes for the same procedure Provider Bill of Rights To be treated with respect To be paid accurately To be paid on time , Scion Dental, Inc. PROPRIETARY AND CONFIDENTIAL Dental Health & Wellness

15 Provider Rights & Responsibilities Provider Exience Committed dentists are critical to the success of every government-sponsored dental program. At Dental Health & Wellness, we have structured our provider networks to give dentists the flexibility they need to participate in dental programs on their own terms. Dental Health & Wellness considers itself an ally of dental associations while maintaining flexibility within the changing political climate surrounding government-sponsored dental programs. We recognize the significant link between good dental care and overall patient health, and advocate increasing provider funding while improving member education and outreach. We partner with providers to deliver high-quality care to all members of government-sponsored dental programs. Access to Flexible Participation Options Dental Health & Wellness invites all licensed dentists, regardless of their past commitment to government-sponsored dental programs, to participate in its provider network. Providers can choose their own level of participation for each of their practice locations. Providers can choose to: Be listed in a directory, accept appointments for all new patients Be excluded from directory, accept appointments for only new patients directed to their office from Dental Health & Wellness Treat only emergencies or special needs cases on an individual basis Access web-based applications and credentialing To make it easy to apply and accepted into the program, we use our Provider Web Portal and electronic documents to streamline the provider/clinic contracting and credentialing process. Consistent, Transparent Determination Logic Dental Health & Wellness s trained paraprofessionals and dental consultants use clinical algorithms to ensure a consistent approach for determining authorizations. These algorithms are available at our Provider Services Web Portal so providers can follow the decision matrix and understand the logic behind authorization decisions. In addition, we foster a sense of partnership by encouraging providers to offer feedback about the algorithms. A consistent, well-understood approach to authorization determinations promotes clarity and transparency for providers, which in turn reduces provider administrative costs. Concierge-Level Care for Members To reduce further costs for providers while promoting member satisfaction, Dental Health & Wellness offers members sonalized concierge-level service to help with appointment scheduling and oral health education. This highly successful program reduces administrative costs for dentists and routinely sends satisfied, eligible members directly to provider practice locations. Outreach Programs Lowering costs and ensuring a positive exience are the focus points for Dental Health & Wellness s Provider Outreach Programs. Visit for Outreach Programs available in your area , Scion Dental, Inc. PROPRIETARY AND CONFIDENTIAL Dental Health & Wellness 9

16 Provider Web Portal Provider Web Portal Dental Health & Wellness s Web Portal allows providers to manage benefit administration via a host of web-based services. By utilizing the Provider Web Portal providers see the following benefits Lower administrative and participation costs Faster payment through streamlined claim and authorization submission processes Ability to review member information, claim and authorization history and payment records at any time; access is available 24 hours a day, 7 days a week A web browser, a valid user ID and password are required for online access. From the Provider Web Portal, providers and authorized office staff can log in for secure access anytime from anywhere and handle a variety of day-to-day tasks, including: Verify member eligibility and check patient treatment history Set up office appointment schedules automatically verifying eligibility and prepopulate claim forms for online submission Submit claims and authorizations by simply entering procedure codes, relevant tooth numbers, etc. Send electronic attachments, such as digital X-rays, EOBs and treatment plans Check the status of in-process claims and authorizations, or review historical payment records provider clinical profiling data relative to peers Download and print provider manuals Participate in provider surveys to rate satisfaction with Dental Health & Wellness , Scion Dental, Inc. PROPRIETARY AND CONFIDENTIAL Dental Health & Wellness

17 Provider Web Portal Provider Web Portal Registration The Dental Health & Wellness Provider Web Portal allow us to maintain our commitment of helping you keep your office costs low, access information efficiently, get paid faster and submit claims and authorizations electronically. To register for our Provider Web Portal, visit and click the provider login link. On the login page, click Register w. Register as a Payee so you will have the option to view remittances and be paid electronically. Call Provider Services at to obtain your Payee ID number , Scion Dental, Inc. PROPRIETARY AND CONFIDENTIAL Dental Health & Wellness 11

18 Provider Web Portal Payee Dashboard Once registered, use the Provider Web Portal to access the available resources and features to help streamline data entry. After logging-in you will arrive at the Payee Dashboard: Fee Schedules All fee schedules that are linked to your participation are listed on the Payee Dashboard. Track Open/Processed Records Status and final disposition of all authorizations can be reviewed via the Provider Web Portal. The number of open and processed authorizations is listed on the Payee Dashboard to allow providers to track authorization progress. Individual authorizations can be reviewed down the service level by clicking on the linked pictured above. The Provider Web Portal also has search functionality allowing a specific authorization to be retrieved; which will be explained in a later section. Track Open/Processed Claim Records Status and final disposition of all claims can be reviewed via the Provider Web Portal. The number of open and processed claims is listed on the Payee Dashboard to allow providers to track payment progress. Individual claims can be reviewed down the service level by clicking on the linked pictured above. The Provider Web Portal also has search functionality allowing a specific claim to be retrieved; which will be explained in a later section. Access Electronic Remittances PDF copies of all EOPs/remittances are archived on the Provider Web Portal and can be retrieved at any time , Scion Dental, Inc. PROPRIETARY AND CONFIDENTIAL Dental Health & Wellness

19 Provider Web Portal Eligibility Verification Use the Check Eligibility to confirm a patient s benefit coverage, and eligibility for service on a specific date. 1. Click the Eligibility tab. 2. Enter the member s Subscriber ID, Date of Birth, and projected Date of Service. 3. Click Check Eligibility and review the Eligibility Report detailing the member s coverage , Scion Dental, Inc. PROPRIETARY AND CONFIDENTIAL Dental Health & Wellness 13

20 Provider Web Portal Entry & Submission Submit authorization requests via the Provider Web Portal. Track review and determination of authorizations and access historical records for all authorizations processed. Enter authorization, provide applicable narratives and attach any required documentation using the Provider Web Portal s Entry functionality. 1. Click the Auths tab. 2. Enter member s Subscriber ID, and Date of Birth, chose Location and Provider. 3. Click Check Eligibility to confirm patient s coverage. 4. Use check boxes to notate service details, i.e. orthodontic treatment, accident-related. 5. Enter Procedures by line, including tooth/surface/area information as required, projected Date of Service, Quantity, and the billed Rate. 6. Click tes tab to add additional narratives, i.e. NEA numbers, tinent details. 7. Once submission data is entered, click Submit Auth. 8. This will open the Summary screen which allows review of submission and ability to attach any required documentation prior to confirming the request. 9. Printing s is available here as well , Scion Dental, Inc. PROPRIETARY AND CONFIDENTIAL Dental Health & Wellness

21 Provider Web Portal Summary Summary can be accessed at any time for an in-process authorization to make changes or add attachments. Run any applicable authorization guidelines a list of documentation required for each covered service Attach electronic files to the authorization record See, review and edit authorizations that have been submitted Print a copy of the authorization summary , Scion Dental, Inc. PROPRIETARY AND CONFIDENTIAL Dental Health & Wellness 15

22 Provider Web Portal Status The Status search functionality allows a search for a single authorization by Number or for batches of authorization using various criteria Searches can be for open, processed or all authorizations. This allows authorizations currently under review to be tracked, or for review of determined authorizations Batches of authorizations can be searched for using a variety of criteria; o o o Manage Roster Date Span search by tentative date of service span or date entered span Member search by using a member s name and Subscriber ID to review all authorizations submitted for a specific member Provider or Location search for all authorizations associated with a specific provider or location under a dental group 1. Click the Manage Rosters tab. 2. Enter the member s Subscriber ID, Date of Birth, and First and Last Name. 3. Rosters can be created by day in order to manage daily patient schedule , Scion Dental, Inc. PROPRIETARY AND CONFIDENTIAL Dental Health & Wellness

23 Provider Web Portal Claim Entry & Submission Enter claim via the Provider Web Portal. Provide applicable narratives and attach required documentation. 1. Click Claims tab on up navigation bar. Then click the Submit Dental Claim tab on the right-side navigation bar. 2. Enter member s Subscriber ID, and Date of Birth, chose Location and Provider. 3. Click Check Eligibility to double-check patient coverage. The field will turn Green if the patient is covered; and Red if not covered. 4. Click Service History to review member s treatment history and confirm the service is appropriate and within limitations/guidelines. 5. Use the check boxes to notate service details i.e. orthodontic treatment, accidentrelated, 6. Enter Procedures rendered by line using CDT Codes, include tooth/surface/area information as required, Date of Service, Quantity, Number if applicable and billed Rate. 7. Click tes tab to add any additional narratives, i.e. NEA numbers or other tinent details. 8. Click Attachments tab to attach x-rays or other documents that are required for payment. 9. If an EOB is present and primary payment information needs to be entered; check the EOB Present box and click Alt-O (screenshot below) , Scion Dental, Inc. PROPRIETARY AND CONFIDENTIAL Dental Health & Wellness 17

24 Provider Web Portal Claims Status Track the status of claims currently in-process and review payment records for past claims. The Claim Status functionality allows a provider to search for a single claim by claim Encounter ID or for batches of claims using various criteria Searches can be for open, processed or all claims. This allows a provider to track claims currently in the payment process, or to review records of paid claims Batches of claims can be searched for using a variety of criteria; o o o Date Span search by date of service span or date entered span Member search by using a member s name and Subscriber ID to review all claims submitted for a specific member Provider or Location search for all claims associated with a specific provider or location under a dental group Claim Management Submit claims for services formed and print or save a list of claims submitted today before they are processed Check the status of previously submitted claims Enter additional information such as an NEA number in your notes , Scion Dental, Inc. PROPRIETARY AND CONFIDENTIAL Dental Health & Wellness

25 Provider Web Portal Electronic Funds Transfer The Provider Web Portal allows for faster payments through Electronic Funds Transfer (EFTs). EFT s offers direct deposit into a bank account and allows faster remittance. To obtain online remittances, select My Documents under the Documents tab or from the link on the main page , Scion Dental, Inc. PROPRIETARY AND CONFIDENTIAL Dental Health & Wellness 19

26 Provider Web Portal Electronic Funds Transfer Agreement , Scion Dental, Inc. PROPRIETARY AND CONFIDENTIAL Dental Health & Wellness

27 Provider Web Portal , Scion Dental, Inc. PROPRIETARY AND CONFIDENTIAL Dental Health & Wellness 21

28 Health Insurance Portability and Accountability Act (HIPAA) Health Insurance Portability and Accountability Act (HIPAA) As a health care provider, if you transmit any health information electronically, your office is required to comply with all aspects of the Health Insurance Portability and Accountability Act (HIPAA) regulations that have gone/will go into effect as indicated in the final publications of the various rules covered by HIPAA. Dental Health & Wellness has implemented various oational policies and procedures to ensure it is compliant with the Privacy Standards as well. Dental Health & Wellness also intends to comply with all Administrative Simplification and Security Standards by their compliance dates. One aspect of our compliance plan will be working cooatively with providers to comply with the HIPAA regulations. The provider and Dental Health & Wellness agree to conduct their respective activities in accordance with the applicable provisions of HIPAA and such implementing regulations. When contacting Provider Services, providers will be asked to supply their Tax ID or NPI number. When calling regarding member inquiries, providers will be asked to supply specific member identification such as member ID/SSN, date of birth, name, and/or address. In regulation to the Administrative Simplification Standards, you will note the benefit tables included in this provider manual reflect the most current coding standards (CDT-2014) recognized by the ADA. Effective the date of this manual, Dental Health & Wellness will require providers to submit all claims with the pro CDT codes listed in this manual. In addition, all pa claims must be submitted on the currently approved ADA 2012 claim form. te: Copies of Dental Health & Wellness s HIPAA policies are available upon request by contacting Provider Services at or via at [email protected]. National Provider Identifier (NPI) The Health Insurance Portability and Accountability Act (HIPAA) of 1996 required the adoption of a standard unique provider identifier for health care providers. An NPI number is required for all claims submitted for payment. You must use your individual and billing NPI numbers. To apply for an NPI, do one of the following: Complete the application online at Download and complete a pa copy from Call to request an application , Scion Dental, Inc. PROPRIETARY AND CONFIDENTIAL Dental Health & Wellness

29 Utilization Management Utilization Management Introduction Reimbursement to dentists for dental treatment rendered can come from any number of sources such as individuals, employers, insurance companies and local, state or federal government. The source of dollars varies depending on the particular program. For example, in traditional insurance, the dentist reimbursement is composed of an insurance payment and a patient coinsurance payment. The Kansas State Legislature annually appropriates or budgets the amount of dollars available for reimbursement to dentists for treating Sunflower Health Plan members. Since there is usually no patient copayment, these dollars represent all the reimbursement available to the dentist. The fair and appropriate distribution of these limited funds is critical. Community Practice Patterns To ensure fair and appropriate reimbursement, Dental Health & Wellness has developed a philosophy of Utilization Management which recognizes the fact there exists, as in all health care services, a relationship between the dentist s treatment planning, treatment costs and outcomes. The dynamics of these relationships, in any region, are reflected by community practice patterns of local dentists and their peers. With this in mind, Dental Health & Wellness s Utilization Management is designed to ensure the fair and appropriate distribution of health care dollars as defined by the regionally based community practice patterns of local dentists and their peers. All Utilization Management analysis, evaluations and outcomes are related to these patterns. Dental Health & Wellness s Utilization Management recognize individual dentist variance within these patterns among a community of dentists and accounts for such variance. Also, specialty dentists are evaluated as a separate group and not with general dentists since the types and nature of treatment may differ. Evaluation Dental Health & Wellness s Utilization Management evaluates claims submissions in such areas as: Diagnostic and preventive treatment Patient treatment planning and sequencing Types of treatment Treatment outcomes Treatment cost effectiveness , Scion Dental, Inc. PROPRIETARY AND CONFIDENTIAL Dental Health & Wellness 23

30 Utilization Management Results With the objective of ensuring the fair and appropriate distribution of these budgeted dollars to providers, Dental Health & Wellness s Utilization Management helps identify providers whose patterns show significant deviation from the normal practice patterns of the community of their peers (typically less than 5 cent of all dentists). Dental Health & Wellness is contractually obligated to report suspected fraud, abuse or misuse by members and participating dental providers to the Sunflower Health Plan. n-incentivization Policy It is Dental Health & Wellness s practice to ensure our contracted providers are making treatment decisions based upon individual members medical necessity. Providers are never offered, nor will they ever accept any kind of financial incentives or any other encouragement to influence their treatment decisions. Dental Health & Wellness s Utilization Management Department bases their decision-making only on appropriateness of care, service and existence of coverage. Dental Health & Wellness does not specifically reward practitioners or other individuals for issuing denials of coverage or care. If financial incentives exist for Utilization Management decision makers, they do not include or encourage decisions which result in underutilization. Fraud and Abuse Dental Health & Wellness is committed to detecting, reporting and preventing potential fraud and abuse. Fraud and abuse are defined as: Fraud. Fraud is intentional deception or misrepresentation made by a son with knowledge the deception could result in some unauthorized benefit to himself or some other son. It includes any act which constitutes fraud under federal or state law. Abuse. Practice that are inconsistent with sound fiscal, business or medical practices, and that result in the unnecessary cost to the government healthcare program, or in reimbursement for services medically unnecessary or that fail to meet professionally recognized standards for health care. It also includes beneficiary practices that result in unnecessary costs to the healthcare program. Intentional infliction of physical harm, injury caused by negligent acts or omissions, unreasonable confinement, sexual abuse or sexual assault. Provider Fraud. Any deception or misrepresentation committed intentionally, through willful ignorance, or reckless disregard by a son or entity in order to receive benefits or funds to which they are not entitled. This may include deception by impro coding or other false statements by providers seeking reimbursement, or false representations or other violations of federal health care program requirements, its associates or contractors , Scion Dental, Inc. PROPRIETARY AND CONFIDENTIAL Dental Health & Wellness

31 Utilization Management Deficit Reduction Act: The False Claims Act Section 6034 of the Deficit Reduction Act of 2005 signed into law in 2006 established the Medicaid Integrity Program in section 1936 of the Social Security Act. The legislation directed the Secretary of the United States Department of Health and Human Services (HHS) to establish a comprehensive plan to combat provider fraud, waste and abuse in the Medicaid program, beginning in The Comprehensive Medicaid Integrity Plan is issued for a successive 5-year iods. Under the False Claims Act, those who knowingly submit, or cause another son to submit false claims for payment of government funds are liable for up to three times the government s damages plus civil penalties of $5,500 to $11,000 for each false claim. The False Claims Act allows private sons to bring a civil action against those who knowingly submit false claims. If there is a recovery in the case brought under the False Claims Act, the son bringing the suit may receive a centage of the recovered funds. For the party found responsible for the false claim, the government may exclude them from future participation in Federal health care programs or impose additional obligations against the individual. The False Claims Act is the most effective tool U.S. taxpayers have to recover the billions of dollars stolen through fraud every year. Billions of dollars in health care fraud have been exposed, largely through the efforts of whistleblowers acting under federal and state false claims acts. For more information about the False Claims Act go to: Dental Health & Wellness is contractually obligated to report suspected fraud, waste or abuse by members and participating dental providers of the Sunflower Health Plan Dental Program. To report suspected fraud, waste or abuse of the Dental Health & Wellness Program contact Dental Health & Wellness s confidential Fraud Hotline at Whistleblower Protection The False Claims Act (FCA) provides protection to qui tam relators who are discharged, demoted, suspended, threatened, harassed, or in any other manner discriminated against in the terms and conditions of their employment as a result of their furtherance of an action under the FCA. 31 U.S.C. 3730(h). Remedies include reinstatement with comparable seniority as the qui tam relator would have had but for the discrimination, two times the amount of any back pay, interest on any back pay, and compensation for any special damages sustained as a result of the discrimination, including litigation costs and reasonable attorneys fees. Fraud and Abuse Hotlines Dental Health and Wellness Hotline: ncy for Health Care Administration: Kansas Attorney General Medicaid Hotline: or , Scion Dental, Inc. PROPRIETARY AND CONFIDENTIAL Dental Health & Wellness 25

32 Eligibility & Member Services Eligibility & Member Services Member Identification Card Sunflower Health Plan members are issued identification cards on a regular basis. Providers are responsible for verifying member eligibility at the time services are rendered and to determine if members have other health insurance. Presenting a Member Identification Card does not guarantee eligibility. Dental Health & Wellness recommends each dental office make a photocopy of the member s identification card each time treatment is provided. It is important to note the identification card does not need to be returned should a member lose eligibility. For more information about member identification cards, contact Provider Services at , Scion Dental, Inc. PROPRIETARY AND CONFIDENTIAL Dental Health & Wellness

33 Eligibility & Member Services Eligibility Verification Member Eligibility can be accessed using one of the following: The Provider Web Portal at Interactive Voice Response (IVR) system eligibility line at Eligibility information received from these sources is the same information you would receive by calling Provider Services. By utilizing the Provider Web Portal or IVR information is available 24 hours a day, 7 days a week without having to wait for an available Provider Services representative. Eligibility Verification via Provider Web Portal Our Provider Web Portal allows verification of member s eligibility. Log in using your ID and password at First time users need to self-register by utilizing their Payee ID, office name and office address. Once logged in, verify the member s eligibility by entering the member s date of birth, the expected date of service and the member s Medicaid Identification Number (also known as the KMAP ID) or their last name and first initial. You are able to verify an unlimited number of patients and can print the summary of eligibility displayed by the system for your records. Eligibility Verification via IVR Our IVR system will verify eligibility for as many members as you want to check. Call When prompted, enter the appropriate NPI or Tax ID Number (TIN). Follow the prompts and enter the members Sunflower Health Plan ID Number or Social Security Number (SSN) along with the members Date of Birth (MMDDYYYY). After our system analyzes the information entered, the patient s eligibility will be verified. If the system is unable to verify the member information, you will be transferred to a Providers Service representative. te: Due to possible eligibility status changes, eligibility information provided does not guarantee payment. Transportation Benefits Members who need assistance with transportation should contact Sunflower Member Services at , Scion Dental, Inc. PROPRIETARY AND CONFIDENTIAL Dental Health & Wellness 27

34 Eligibility & Member Services Appointment Availability Standards Dental Health & Wellness has established appointment time requirements for all situations to ensure members receive dental services in a time iod appropriate to their health condition. Providers should ensure appointment standards are adhered to in an effort to ensure accessibility of needed services, maintain member satisfaction and reduce unnecessary use of alternative services such as an emergency room. Routine dental care must be scheduled within twenty-one (21) calendar days (or within the standards for your community) Urgent care must be scheduled within forty-eight (48) hours Emergent care must be scheduled immediately Dental Health & Wellness will educate providers about appointment standards, monitor the adequacy of the process and take corrective action if required , Scion Dental, Inc. PROPRIETARY AND CONFIDENTIAL Dental Health & Wellness

35 Retrospective, Prior & Documentation Requirements Retrospective, Prior & Documentation Requirements Retrospective Services requiring Retrospective are outlined in the Plan Benefit beginning on Page 50 of this manual. Claims requiring retrospective review need to be submitted with appropriate documentation. The types of documentation required, but not limited to, are: Radiographs (pre-op, post-op or opposing arch x-rays as indicated in the benefits section) Narrative of medically necessity Perio charting Any claims for retrospective review submitted without the required documentation will be denied and must be resubmitted for reimbursement. A Dental Health & Wellness consultant reviews the documentation to ensure the services rendered meet the clinical criteria requirements as outlined in this manual. Once the clinical review is completed, the claim is either paid or denied within twenty (20) calendar days for clean claims and notification will be sent to the provider via the provider remittance statement. Prior Prior is only required for orthodontic, crisis exception and non-participating provider requests. Dental Health & Wellness must make a decision on a request for prior authorization within fourteen (14) calendar days from the date request is received provided all information is complete. If you indicate or we determine following this time frame could seriously jeopardize the member s life or health, or the ability to attain, maintain or regain maximum function, we will make an expedited authorization decision and provide notice of our decision within three (3) business days. If Dental Health & Wellness denies the approval for some or all of the services requested, the member will receive written notice of the reasons for the denial(s) and will inform the member he or she may appeal the decision. The requesting provider will also receive notice of the decision. Dental Health & Wellness has specific utilization criteria as well as a prior authorization and retrospective review process to manage the utilization of services. Consequently, oational focus is on assuring compliance with its dental utilization criteria. One method used on a limited basis to assure compliance is to require providers to supply specified documentation prior to authorizing payment for certain procedures. Services requiring prior authorization should not be started prior to the determination of coverage (approval or denial of the prior authorization) for nonemergency services. nemergency treatment started prior to the , Scion Dental, Inc. PROPRIETARY AND CONFIDENTIAL Dental Health & Wellness 29

36 Retrospective, Prior & Documentation Requirements determination of coverage will be formed at the financial risk of the dental office. If coverage is denied, the treating dentist will be financially responsible and may not balance bill the member, the state of Kansas or any agents, and/or Dental Health & Wellness. Prior authorizations will be honored for one hundred eighty (180) days from the date they are issued. An authorization does not guarantee payment. The member must be eligible at the time the services are provided. The provider should verify eligibility at the time of service. Requests for prior authorization should be sent with the appropriate documentation on a standard ADA 2012 approved form. Any claims or prior authorizations submitted without the required documentation will be denied and must be resubmitted to obtain reimbursement. The basis for granting or denying approval shall be whether the item or service is medically necessary, whether a less expensive service would adequately meet the member s needs and whether the proposed item or service conforms to commonly accepted standards in the dental community. If you have questions regarding a prior authorization decision or wish to speak to the dental reviewer, call Orthodontic Models Dental Health & Wellness does not currently accept orthodontic models as documentation for authorization or claim submissions. If an orthodontic model is received, Dental Health & Wellness will create a copy of all accompanying pawork, process the authorization and return the orthodontic model to the dentist plan guidelines , Scion Dental, Inc. PROPRIETARY AND CONFIDENTIAL Dental Health & Wellness

37 Submission Procedures Submission Procedures submissions must be received in one of the following formats: Provider Web Portal at Electronic submission via Emdeon clearinghouse Payer ID: HIPAA-compliant 837D file Pa authorization via ADA 2012 Claim Form available through American Dental Association Submission via Provider Web Portal Providers may submit authorization directly to Dental Health & Wellness by utilizing the provider section of our Provider Web Portal. Submitting authorizations via the Web Portal is quick and easy and allows you to get authorizations faster. To submit authorizations via the Web Portal, log on to If you have questions on submitting authorization or accessing the Web Portal, contact Provider Services or via Submission via Clearinghouse Providers may submit their authorizations via Emdeon clearinghouse. Your software vendor will be able to provide you with information you may need to ensure submitted authorizations are forwarded to Dental Health & Wellness. Dental Health & Wellness s Payer ID is Emdeon will ensure that by utilizing this unique payer ID, authorizations will be submitted successfully to Dental Health & Wellness. For more information on Emdeon, visit their Website Submission via HIPAA-Compliant 837D File For providers who are unable to submit electronically via the Internet or clearinghouse, Dental Health & Wellness will work on a case-by-case basis with the provider to receive authorizations electronically via a HIPAA Compliant 837D. Call Provider Services at to inquire about this option , Scion Dental, Inc. PROPRIETARY AND CONFIDENTIAL Dental Health & Wellness 31

38 Submission Procedures Pa Submission To ensure timely processing of the submitted authorization, the following information must be included on the form: Member Name Member Medicaid ID Number Member Date of Birth Provider Name Provider Location Billing Location Provider Kansas Medicaid ID Number, NPI or Tax Identification Number (TIN) Approved ADA dental codes as published in the 2014 CDT book or as defined in this manual must be used to define all services. Provider must list all quadrants, tooth numbers and surfaces for dental codes which necessitate identification (extractions, root canals, amalgams and resin fillings). Dental Health & Wellness recognizes tooth letters A through T for primary teeth and tooth numbers 1 to 32 for manent teeth. Sunumerary teeth should be designated by using codes AS through TS or 51 through 82. Designation of the tooth can be determined by using the nearest erupted tooth. If the tooth closest to the sunumerary tooth is #1 then the sunumerary tooth should be charted as #51; likewise, if the nearest tooth is A the sunumerary tooth should be charted as AS. These procedure codes must be referenced in the patient s file for record retention and review. Missing or incorrect information could result in the authorization being returned to the submitting provider s office causing a delay in determination. Use the pro postage when mailing bulk documentation. Postage due mail will be returned. Mail pa authorizations to: Dental Health & Wellness s PO Box 1183 Milwaukee, WI , Scion Dental, Inc. PROPRIETARY AND CONFIDENTIAL Dental Health & Wellness

39 Submission Procedures ADA Approved Claim Form , Scion Dental, Inc. PROPRIETARY AND CONFIDENTIAL Dental Health & Wellness 33

40 Submission Procedures , Scion Dental, Inc. PROPRIETARY AND CONFIDENTIAL Dental Health & Wellness

41 Claim Submission Procedures Claim Submission Procedures Claims may be submitted in the following formats: Electronic claim submission via Provider Web Portal Electronic claim submission via Emdeon clearinghouse Payer ID: Electronic claim submission via KMAP Fiscal nt KanCare Front End Billing Electronic claim submission via National Electronic Attachment (NEA) HIPAA-compliant 837D File Pa claims must be submitted through KanCare Front End Billing: KanCare P.O. Box 3571 Topeka, KS All claims submitted through KanCare Front End Billing must include the member s Medicaid ID (sometimes known as a KMAP ID). Claims submitted via Front End Billing with the Sunflower Health Plan ID will be rejected. All claims must also include the Provider NPI number. Claim Submission via Provider Web Portal Providers may submit claims directly to Dental Health & Wellness by utilizing the provider section of our Provider Web Portal. Submitting claims via the Web Portal is quick and easy and allows you to get paid faster. To submit claims via the Web Portal, log on to If you have questions on submitting claims or accessing the Web Portal, contact Provider Services or via [email protected] Claim Submission via Emdeon Clearinghouse Providers may submit their claims via Emdeon clearinghouse. Your software vendor will be able to provide you with information you may need to ensure submitted claims are forwarded to Dental Health & Wellness. Dental Health & Wellness s Payer ID is Emdeon will ensure that by utilizing this unique payer ID, claims will be submitted successfully to Dental Health & Wellness. For more information on Emdeon, visit their Website Claim Submission via KMAP Fiscal nt KanCare Front End Billing Providers may submit their electronic claims through Kansas Medicaid Assistance Program (KMAP) for detailed instructions please visit HIPAA-Compliant 837D File For providers who are unable to submit electronically via the Internet or clearinghouse, Dental Health & Wellness will work on a case-by-case basis with the provider to receive claims electronically via a HIPAA Compliant 837D. Call Provider Services at to inquire about this option , Scion Dental, Inc. PROPRIETARY AND CONFIDENTIAL Dental Health & Wellness 35

42 Claim Submission Procedures Claim Submission via National Electronic Attachment FastAttach Dental Health & Wellness in conjunction with National Electronic Attachment, Inc. (NEA) allows enrolled providers the ability to submit claims electronically via FastAttach. This program allows secure transmissions via the Internet for radiographs, iodontic charts, intraoral pictures, narratives and EOBs. FastAttach is a simple way to eliminate lost or damaged attachments, improve your payment cycle, save postage and printing costs, reduce your follow-up with payers, avoid sending unnecessary attachments s. FastAttach is inexpensive, reduces administrative costs, eliminates lost or damaged attachments and accelerates claims and prior authorization processing. It is compatible with most claims clearinghouses or practice management systems. For more information visit or call NEA at Pa Claim Submission Pa claims must be submitted through KanCare Front End Billing. Pa claims not for Retrospective submitted to Dental Health & Wellness will not be processed and returned to the provider. Providers submitting pa claims via Front End Billing must ensure they are providing the following information; Member s Medicaid ID (KMAP ID) this is listed on the Sunflower Health Plan member ID cards as Medicaid or CHIP number. Providers should not use the Sunflower Health Plan ID when submitting claims via the Front End Billing as these claims will be rejected. The state forwards claims to Dental Health & Wellness based on the Medicaid ID and claims submitted with the Sunflower Health Plan ID will be rejected, Provider NPI (not the KMAP Provider ID). View KMAP General Bulletin 12115: %20KanCare%20FEB.pdf Mail Pa Claims to: KanCare P.O. Box 3571 Topeka, KS Coordination of Benefits (COB) When Dental Health & Wellness is the secondary insurance carrier, a copy of the primary carrier s EOB must be submitted with the claim. For electronic claim submissions, the payment made by the primary carrier must be indicated in the appropriate COB field. When a primary carrier s payment meets or exceeds a provider s contracted rate or fee schedule, Dental Health & Wellness will consider the claim paid in full and no further payment will be made on the claim. te: Dental Health & Wellness follows KMAP TPL policy. All KMAP TPL billing requirements still apply. Please refer to KMAP General TPL Payment provider manual , Scion Dental, Inc. PROPRIETARY AND CONFIDENTIAL Dental Health & Wellness

43 Claim Submission Procedures Corrected Claim Process Providers who receive a claim denial and need to submit a corrected claim should send a corrected claim and appropriate documentation, if necessary to: Dental Health & Wellness Appeals PO Box 1432 Milwaukee, WI You can request an additional claim review if a claim was denied due to missing information, missing tooth number/surface on original submission or you have additional information you feel may change the payment decision. The determination of a corrected claim request will be provided on a remittance statement within thirty (30) days of receipt. Receipt and Audit of Claims To ensure timely, accurate remittances to each dentist, Dental Health & Wellness forms an audit of all claims upon receipt. This audit validates member eligibility, procedure codes and provider identifying information. A Dental Reimbursement Analyst dedicated to Kansas dental offices reviews any claim conditions that would result in nonpayment. When potential problems are identified, your office may be contacted and asked to assist in resolving this problem. Please contact Provider Services at with questions you have regarding claim submission or your remittance. If a provider wishes to appeal any reimbursement decision, submit an appeal in writing along with any necessary documentation within thirty-three (33) days to: Dental Health & Wellness Appeals PO Box 1432 Milwaukee, WI Dental Health & Wellness will have thirty (30) days to respond in writing to the provider with the outcome of the appeal. To validate accuracy we will form a Monthly audit of a statistically significant sample of all claim forms entered and adjudicated in the prior Month. Claims Adjudication and Payment Our system adjudicates all claims weekly. It also has the ability to automatically update individual and family claim history, form claim payment calculations, calculate and update copayment and deductible accumulations and track benefit maximums and frequency limits where appropriate. The claims processing system imports the data, edits the data for completeness and correctness, analyzes the data for clinical and coding correctness/appropriateness and audits against product and benefit limits. The claims processing system also evaluates claims/services requiring preauthorizations and automatically matches the claim/service to the appropriate member record for efficient claims processing. Claims will be finalized weekly on Fridays and once all claim processing edits are complete and claims are priced, a remittance summary is printed and a check or EFT payment is generated. Providers are able to review the status of claims submissions once finalized on our Provider Web Portal or via electronic submission , Scion Dental, Inc. PROPRIETARY AND CONFIDENTIAL Dental Health & Wellness 37

44 Appeals, Complaints & Grievances Appeals, Complaints & Grievances Dental Health & Wellness is committed to providing high-quality dental services to all members. As part of this commitment, Dental Health & Wellness supports Sunflower Health Plan s member grievances and appeals protocol and leads Sunflower Health Plan s dental provider complaint protocol ensuring all members have every opportunity to exercise their rights to a fair and expeditious resolution to any and all inquiries, grievances and appeals. Toward that end, Dental Health & Wellness has developed a procedure to meet those goals: To ensure Dental Health & Wellness assists in members and providers receiving a fair, just, and speedy resolution to inquiries, grievances and appeals by working with providers and supplying any documentation related to the member grievance and/or appeal to Sunflower Health Plan, upon request. To allow providers and members to be treated with dignity and respect at all levels of the grievances and appeals resolution process. To inform providers of their full rights as they relate to grievance and appeal resolutions, including their rights of appeal at each step in the process. To have provider grievances and appeals resolved in a satisfactory and acceptable manner within the Dental Health & Wellness protocol. To comply with all regulatory guidelines and policies with respect to member inquiries, grievances, and appeals. To efficiently track the resolution of provider-related grievances, so as to be able to track continuing unacceptable patterns of care over time. Dental Health & Wellness provides provider service, the primary purpose of which is to ensure provider access to information, services and assistance on issues affecting their coverage. The designated complaint coordinator is dedicated to the expedient, satisfactory resolution of provider inquiries, grievances and appeals. The toll-free number to file a provider grievance is The address to file a provider grievance: Dental Health & Wellness Grievances PO Box 1432 Miwaukee, WI , Scion Dental, Inc. PROPRIETARY AND CONFIDENTIAL Dental Health & Wellness

45 Appeals, Complaints & Grievances Provider Appeal Procedures In the oation of the program, differences may develop between Dental Health & Wellness and the dentist concerning the decision regarding the Prior Option and payment for service. Since many of these problems result from misunderstanding of processing policy, service coverage or payment levels, an understanding of Dental Health & Wellness will help prevent such problems. Appeal request should be sent to: Dental Health & Wellness Appeals PO Box 1432 Milwaukee, WI Member Appeals A member may appeal any Dental Health & Wellness decision which denies or reduces services. Such appeals will be reviewed under our existing administrative appeal procedure. Appeals must be filed within thirty-three (33) days of the date the denial letter was mailed in writing to: Sunflower State Clinical Appeals Coordinator 8325 Lenexa Drive Lenexa, KS Members who file verbal appeals must follow with a written, signed appeal unless an expedited resolution is requested. For additional information contact the clinical appeals coordinator at Members can request a State Fair Hearing at any time during the appeals process. The request must be submitted to the Office of Administrative Hearings so it is received within thirty-three (33) days of receipt of the letter with our decision. The request should be mailed to: Office of Administrative Hearings 1020 S. Kansas Ave. Topeka, KS The matter will be heard before an Administrative Hearing Officer. Dental Health & Wellness will provide and pay for services which any jurisdiction orders rendered, provided the member is eligible. Dental Health & Wellness shall make ext testimony available. Fair Hearing Procedures If a provider disagrees with a decision Dental Health & Wellness has made on a claim, the provider has the right to request a fair hearing within thirty-three (33) days of Dental Health & Wellness s final decision. All provider appeal rights must be exhausted prior to requesting a fair hearing. There is not a required form but the request needs to be sent in writing to: Office of Administrative Hearings 1020 S. Kansas Ave. Topeka, KS , Scion Dental, Inc. PROPRIETARY AND CONFIDENTIAL Dental Health & Wellness 39

46 Provider Enrollment & Contracting Provider Enrollment & Contracting New providers and/or locations can be added by visiting: Enter code KS and click Enter , Scion Dental, Inc. PROPRIETARY AND CONFIDENTIAL Dental Health & Wellness

47 Credentialing Credentialing As required by law, any DDS or DMD who is interested in participating with Dental Health & Wellness is invited to apply and submit a credentialing application form for review by our Credentialing Committee. Dental Health & Wellness has contracted with Scion Dental to form our credentialing. Providers who seek participation in any Dental Health & Wellness Managed Care network must be credentialed prior to participation in the network. Dental Health & Wellness will not differentiate or discriminate in the treatment of providers seeking credentialing on the basis of race, ethnicity, sex, age, national origin or religion. All applications reviewed by Dental Health & Wellness must satisfy NCQA and/or URAC standards of credentialing as they apply to dental services. Dental Health & Wellness, in conjunction with the plan, has the sole right to determine which dentists it shall accept and continue as participating providers. The Credentialing Committee has the discretion and authority to accept an application without restrictions. If the Credentialing Committee determines an application should be accepted with restriction or declined, it shall recommend the appropriate action to the Executive Subcommittee for approval. In reviewing an application, the Credentialing Committee may request further information from the applicant. The Credentialing Committee may table an application pending the outcome of an investigation of the applicant by a hospital, licensing board, government agency, institution or any other organization or recommend any other action it deems appropriate. Adverse credentialing recommendations of the Credentialing Committee can be forwarded to the Executive Subcommittee for final approval, subject to any appeal following such approval offered to and accepted by the applicant. If the applicant accepts the opportunity for a reconsideration review, the Credentialing Committee will review all original documents, as well as any additional information submitted for the reconsideration review. If an applicant accepts the opportunity to appeal the Credentialing Committee s recommendation, the Peer Committee will complete the review. Any acceptance of an applicant is conditioned upon the applicant s execution of a participation agreement with Dental Health & Wellness. The plan retains the ultimate responsibility for the credentialing process and final credentialing decisions. The plan is notified of any terminations or disciplinary actions. To begin the credentialing process, visit: , Scion Dental, Inc. PROPRIETARY AND CONFIDENTIAL Dental Health & Wellness 41

48 Credentialing Once at the credentialing portal, click First Time Users. Complete the form and click Register. Once registered, you can: Begin a credential application Check an application status Add and manage your locations , Scion Dental, Inc. PROPRIETARY AND CONFIDENTIAL Dental Health & Wellness

49 Credentialing Complete the step-by-step application for each provider to be credentialed , Scion Dental, Inc. PROPRIETARY AND CONFIDENTIAL Dental Health & Wellness 43

50 Health Guidelines s 0 18 Years Health Guidelines s 0 18 Years Recommendations for Pediatric Oral Health Assessment, Preventive Services and Anticipatory Guidance/Counseling. Since each child is unique, these recommendations are designed for the care of children who have no contributing medical conditions and are developing normally. These recommendations will need to be modified for children with special health care needs or if disease or trauma manifests variations from normal. The American Academy of Pediatric Dentistry (AAPD) emphasizes the importance of early professional intervention and the continuity of care based on the individualized needs of the child , Scion Dental, Inc. PROPRIETARY AND CONFIDENTIAL Dental Health & Wellness

51 Appendix Benefits Appendix Benefits Benefit Descriptions Plan Eligibility Title 21 CHIP - Children s 0-18 Title 19 Medicaid - Children s 0-20 Title 19 Medicaid Adults s 21 and over Title 21 CHIP Children s 0-18 KanCare covers iodic teeth cleaning, fluoride treatment, sealants, tooth restorations, radiographs, extractions and other dental services as outlined in benefit table starting on page 55. Title 19 Medicaid Children s 0-20 KanCare covers iodic teeth cleaning, fluoride treatment, sealants, tooth restorations, radiographs, extractions and other dental services as outlined in benefit table starting on page 70. Title 19 Medicaid Adults s 21 and over Sunflower Health Plan offers adult Medicaid members (ages 21 and over), dental cleaning every 6 Months using code D1110 (prior approval not required). KanCare covers extractions only when considered medically necessary. Exam and x-rays are reimbursable only when formed in conjunction with covered services or to make a diagnosis for such a situation. Refer to benefit table beginning on page 70. ICF/MR Adults s 21 and over ICF/MR beneficiaries s 21 and over are eligible for selected dental services. Refer to the benefit table beginning on page 87. KanCare beneficiaries under age 21 residing in an ICF/MR are allowed the full scope of dental services allowable for Title 19 and Title 21 children. Money Follows the Person (MFP) Adults s 21 and Over MFP adult beneficiaries covered through the PD, TBI (or HI) and IDD waivers are eligible for dental coverage. Refer to the benefit table beginning on page 101 for details , Scion Dental, Inc. PROPRIETARY AND CONFIDENTIAL Dental Health & Wellness 45

52 Appendix Benefits Money Follows the Person (MFP) Frail and Elderly MFP adult beneficiaries covered through the FE waiver are eligible for dental coverage. Refer to the benefit tables beginning on page 112 for details. HCBS Adult s 65 and Over (not ICR/MR) Refer to the Crisis process table beginning on page 125 for details. Medically Needy (Spenddown) In some cases, the income of a family or individual exceeds the income standard to receive public assistance monies. However, their income is not sufficient to meet all medical expenses. The family group/individual is considered Medically Needy (MN) and must incur a specified amount of medical expenses before they are eligible for Medicaid benefits. This process is referred to as spenddown. Dental Health & Wellness does not make payment on the amount which is the beneficiary s responsibility. Providers can call Dental Health & Wellness, or check the KMAP Web Portal to identify those beneficiaries with a spenddown obligation. te: Do not reduce the claim charges or balance due by the spenddown amount. This reduction is made automatically during claim processing. A full listing of covered services by benefit plan is outlined in the Requirements and Benefit Plan Detail section at the end of the manual. The Requirements and Benefit Plan Details provide you with: Complete listing of all covered codes Description of Retro Claim or Prior Requirement code Listing of documentation required for Retro Claim and Prior submissions maximums each code. Certain services are only covered to a certain age and the maximum age is listed in the column of the grid. Additional information regarding coverage or limitations for a specific code , Scion Dental, Inc. PROPRIETARY AND CONFIDENTIAL Dental Health & Wellness

53 Appendix Benefits Crisis Process The Frail and Elderly Waiver population is comprised of two segments; Home and Community Based Services (HCBS) which includes adults ages 65 and over (not ICF/MR) and Money Follows the Person (MFP) which includes adults 65 and over. Frail Elderly Waiver members are eligible for select oral health services above and beyond those dental services covered for all adult Medicaid members. These oral health services include accepted dental procedures, diagnostic, prophylactic and restorative care, and allow for the purchase, adjustment and repair of dentures. This includes anesthesia services provided in the dentist s office and billed by the dentist. These services do not include outpatient or inpatient facility care, orthodontic and implant services, or provision of oral health services for cosmetic services. MFP Frail and Elderly members additional oral health services are limited to the participant s assessed level of service need, as defined in the product category. There are no additional benefits beyond those outlined in the benefit tables at the end of the manual. HCBS Frail and Elderly members additional oral health services are limited to the participant s assessed level of service need, provided to the Adult T-19 members. However, additional benefits can be provided subject to a crisis exception process. In addition to the documentation required for the requested service, include a narrative of medical necessity. The narrative should include at a minimum a documented assessment of the member s oral health plus: Did the member have a treatment plan in place? If yes, what treatment remains in progress? Does the member require emergency treatment to resolve an oral health issue that is life threatening? How will non-treatment of the oral health issue impact the member? 1. Active Infection soft tissue or bone that causes: Abscess Class 3 mobility (non-restorable tooth) 2. Inflammation Leading to infection (chronic) Hygienist treatment 3. Cavity Infection possible (restore) 4. Chipped tooth/broken tooth - In addition, does the member have: Diabetes? (especially apply to questions 1 & 2) Only 3 to 4 teeth, lack of ability to eat and no dentures? A lack of infection but would rank above cavity/chipped tooth? Only a few remaining teeth and will risk maintaining good nutrition? Six (6) teeth on top and six (6) teeth on bottom could function depending on which teeth. A rate of inflammation to infection differs depending on specific circumstances? Once the patient is determined to have a life-threatening condition, the dental consultant will review the clinical criteria for the requested services to determine if the requested service is in the best interest of the member , Scion Dental, Inc. PROPRIETARY AND CONFIDENTIAL Dental Health & Wellness 47

54 Appendix Benefits Additional Benefit Information Missed Appointments Enrolled participating providers are not allowed to charge members for missed appointments. If your office mails letters to members who miss appointments, the following language may be helpful to include. We missed you when you did not come for your dental appointment on Month/date. Regular checkups are needed to keep your teeth healthy. Please call to reschedule another appointment. Call us in advance if you cannot keep the appointment. Missed appointments are very costly to us. Thank you for your help. Dental Health & Wellness recommends contacting the member by phone or postcard prior to the appointment to remind the individual of the time and place of the appointment. The Centers for Medicare & Medicaid Services (CMS) interpret federal law to prohibit a provider from billing any Sunflower Health Plan member for a missed appointment. In addition, your missed appointment policy for Sunflower Health Plan enrolled patients cannot be stricter than your private or commercial patients. If a Sunflower Health Plan member exceeds your office policy for missed appointments and you choose to discontinue seeing the patient, have them contact Dental Health & Wellness for a referral to a new dentist. Providers with benefit questions should contact Dental Health & Wellness s Provider Service directly at Payment for ncovered Services Enrolled participating providers shall hold members, Dental Health & Wellness, and Sunflower Health Plan harmless for the payment of non-covered services except as provided in this paragraph. Provider may bill a member for noncovered services if the provider obtains an agreement from the member prior to rendering such service which indicates: The services to be provided Dental Health & Wellness and Sunflower Health Plan will not pay for or be liable for said services Member will be financially liable for such services Providers must inform members in advance and in writing when the member is responsible for noncovered services, K.A.R (e)(4). Facilities with Encounter Payments (FQHC/RHCs) All dental services formed by facilities which are reimbursed through encounter payments need to submit an encounter claim for each unique member visit. The encounter claim is processed to track utilization of HEDIS/EPSDT services. It is mandatory to submit encounter data state and federal guidelines. Claims should be submitted with each individual service rendered. The services will be entered into Dental Health & Wellness s claims payment system for utilization tracking. The actual encounter payment will be presented on the first valid service line. Dental Health & Wellness s system automatically forms this function , Scion Dental, Inc. PROPRIETARY AND CONFIDENTIAL Dental Health & Wellness

55 Appendix Benefits Extended Care Permit (ECP) Hygiene Services - Code D9999 In accordance with the Kansas Dental Practice Act (KDPA), a participating dental provider can be reimbursed for certain services formed by an Extended Care Permit (ECP) hygienist. The sponsoring dentist must provide oral or written instruction directing the ECP to form the service(s). This includes services rendered by hygienists with an ECP I, ECP II or ECP III mit. If the ECP is fully certified and the sponsoring provider is participating in the network the services will be eligible for reimbursement based on the state s standard benefit guidelines and any service limitations that may be present based on member history. Guidelines regarding mit levels, qualification, and eligible services are detailed in the Kansas Statue Section of the KDPA website; In addition to the services outlined in the KDPA, dental procedure code D9999: clinical and caries risk assessment, toothbrush prophylaxis of a child ages 0-3 years and counseling to parents/primary caregiver, will be covered for FQHCs and all dental provider specialties when rendered by a Registered Dental Hygienist with an Extended Care Permit. (ECP) Please indicate in the comments section of the ADA Claim Form, ECP Risk Assessment 0-3 years of age. The maximum allowable amount for this treatment is $ Orthodontic Services Orthodontic services are limited to recipients whose disability and impairment to their physical development due to: History or current condition of a severe orthodontic abnormality caused by a genetic deformity (such as cleft lip or cleft palate) Traumatic facial injury substantiated by a medical report (i.e. auto accident) resulting in serious health impairment (reconstructive surgery, etc.) Exclusions Dental Health & Wellness will not reimburse for: Treatment primarily for cosmetic purposes Expanders Crossbite Overcrowding of teeth Overbite/underbite (buck teeth) Displacement of jaw (TMJ) Missing teeth or too many teeth Teeth growing in the palate area Split phase treatment, with exception of cleft palate cases , Scion Dental, Inc. PROPRIETARY AND CONFIDENTIAL Dental Health & Wellness 49

56 Clinical Criteria Clinical Criteria Clinical Criteria for Retro and Prior of Treatment and Emergency Treatment Some procedures require retrospective review (after treatment is formed) or prior authorization (before initiating treatment). When requesting these procedures, note documentation requirements when sending the information to Dental Health & Wellness. The criteria Dental Health & Wellness reviewers will look for in order to approve the request are listed below. Dental Health & Wellness criteria utilized for this medical necessity determination was developed from information collected from American Dental Association's Code Manuals, clinical articles and guidelines, as well as dental schools, practicing dentists, insurance companies, other dental related organizations and local state or health plan requirements. When you are uncertain whether a procedure will be paid due to not meeting the criteria of a Retrospective, you have the option of first submitting a procedure for prior authorization to ensure your payment. Radiographs/Diagnostic Imaging Documentation describes medical necessity Other Temporomandibular Joint Films, by Report Documentation describes medical necessity Crowns/Onlays/Coping- Retrospective Minimum 50 cent bone support iodontal furcation subcrestal caries Clinically acceptable RCT Anterior 50 cent incisal edge/4+ surfaces involved Bicuspid 1 cusp/3+ surfaces involved Molar 2 cusps/4+ surfaces involved Cast Posts and Cores/Prefabricated Post and Cores- Retrospective Minimum 50 cent bone support iodontal furcation subcrestal caries Clinically acceptable RCT Pulpotomy/Debridement/Pulp Therapy/Regeneration- Retrospective Documentation supports procedure Root Canals- Retrospective Minimum 50 cent bone support iodontal furcation subcrestal caries Evidence of apical pathology/fistula Pain from cussion/temp Closed apex , Scion Dental, Inc. PROPRIETARY AND CONFIDENTIAL Dental Health & Wellness

57 Clinical Criteria Treatment of Root Canal Obstruction- Retrospective Documentation supports procedure Apexification- Retrospective Minimum 50 cent bone support Evidence of apical pathology/fistula Evidence of deep caries/restoration, fracture, near pulpal exposure with open apex Pain from cussion or temature with open apex Fill X-ray (final visit) Apicoectomy/Periradicular Services- Retrospective Minimum 50 cent bone support History of RCT Apical pathology caries below bone level Gingivectomy or Gingivoplasty- Retrospective Hyplasia or hytrophy from drug therapy, hormonal disturbances or congenital defects Generalized 5 mm or more pocketing indicated on the io charting Anatomical Crown Exposure- Retrospective Documentation supports procedure, need to remove tissue/bone to provide anatomically correct gingival relationship Surgical Revision - Retrospective Documentation supports need to refine results of previous surgical procedure Scaling and Root Planning- Retrospective D4341 Four or more teeth in the quadrant 5 mm or more pocketing on two or more teeth indicated on the io charting Presence of root surface calculus and/or noticeable loss of bone support on X-rays D4342 One to three teeth in the quadrant 5 mm or more pocketing on one or more teeth indicated on the io charting Presence of root surface calculus and/or noticeable loss of bone support on X-rays Full Dentures- Retrospective Existing denture greater than 5 years old Remaining teeth do not have adequate bone support or are restorable Partial Dentures- Retrospective Replacing one or more anterior teeth Replacing two or more posterior teeth unilaterally (excluding third molars) Replacing three or more posterior teeth bilaterally (excluding third molars) Existing partial denture greater than 5 years old Remaining teeth have greater than 50 cent bone support and are restorable , Scion Dental, Inc. PROPRIETARY AND CONFIDENTIAL Dental Health & Wellness 51

58 Clinical Criteria Unilateral Partial Denture- Retrospective Replacing one or more missing teeth in one quadrant Existing partial denture greater than 5 years old Remaining teeth have greater than 50 cent bone support and are restorable Tissue Conditioning- Retrospective Date of service Implant Removal, by Report- Retrospective Documentation describes medical necessity for surgical removal of an implant Surgical Removal of Erupted - Retrospective Greater than 50 cent bone support Periapical pathology or furcation involvement Gross carious lesion or large existing restoration Curved or dilacerated root Elevation of flap and/or removal of bone and/or sectioning of tooth Impacted Teeth (Asymptomatic Impactions will not be approved) - Retrospective Documentation describes pain, swelling, etc. around tooth (must be symptomatic) and documentation noted in the patient record impinges on the root of an adjacent tooth, is horizontal impacted, or shows a documented enlarged tooth follicle or potential cystic formation Documentation supports procedure for unusual surgical complications X-rays match type of impaction code described Surgical Removal of Residual Roots- Retrospective root is completely covered by tissue on X-ray Documentation describes pain, swelling, etc. around tooth (must be symptomatic) and documentation noted in the patient record Oroantral Fistula Closure/Sinus Perforation- Retrospective Due to extraction, oral or sinus infection Surgical Access of an Unerupted - Retrospective Documentation supports impacted/unerupted tooth is beyond one year of normal eruption pattern Biopsy- Retrospective Copy of pathology report Alveoloplasty without Extractions- Retrospective Necessary for fabrication of a prosthesis Vestibuloplasty- Retrospective Documentation supports lack of ridge for denture placement Excision of Bone Tissue- Retrospective Necessary for fabrication of a prosthesis , Scion Dental, Inc. PROPRIETARY AND CONFIDENTIAL Dental Health & Wellness

59 Clinical Criteria illary Sinusotomy- Retrospective Documentation describes presence or description of root fracture of foreign body in maxillary antrum Fractures Simple/Compound- Retrospective Documentation describes accident, oative report and medical necessity Reduction and Dislocation and Management of TMJ Dysfunctions- Retrospective Narrative, X-rays or photos support medical necessity for procedure Skin Graft- Retrospective Documentation describes location and type of graft Other Repair Procedures (Oral and illofacial Surgery) - Retrospective Narrative, X-rays or photos support medical necessity for procedure Frenulectomy- Retrospective Documentation describes tongue tied, diastema or tissue pull condition Frenuloplasty- Retrospective Documentation indicates frenum will be repositioned instead of being excised Excision of Pericoronal Gingiva- Retrospective Documentation shows tissue partially covers occlusal surface of crown Documented history of repeat infections Regional/Trigeminal Division Block Anesthesia- Retrospective Documentation describes medical necessity for procedure beyond local anesthesia General Anesthesia/IV Sedation (Dental Office Setting) One or more of the criteria below- Retrospective Extractions of impacted or unerupted cuspids, wisdom teeth or surgical exposure of unerupted cuspids Two or more extractions in two or more quadrants Four or more extractions in one quadrant Excision of lesions greater than 1.25 cm Surgical recovery from the maxillary antrum Documentation showing the patient is younger than 9 years old with extensive treatment (described) Documentation of failed local anesthesia and documentation noted in patient record Documentation of situational anxiety and documentation noted in patient record Documentation and narrative of medical necessity supported by submitted medical records (cardiac, cerebral palsy, epilepsy or condition that would render patient noncompliant) Inhalation of Nitrous Oxide/Analgesia- Retrospective Documentation describes medical necessity for procedure , Scion Dental, Inc. PROPRIETARY AND CONFIDENTIAL Dental Health & Wellness 53

60 Clinical Criteria Hospital Call- Retrospective Documentation of time spent and reason for hospital call Therapeutic Drug Injection- Retrospective Description of drugs (antibiotics, steroids, anti-inflammation or other therapeutic medication) and parental administration Behavior Management, by Report- Retrospective Documentation (treatment history) supports indication of non-cooative child under the age of 9 years Documentation supports indication of patient with a medical condition (cardiac, cerebral palsy, epilepsy, or other condition that would render the patient noncompliant Unspecified Procedures, by Report- Retrospective Procedure cannot be adequately described by an existing code Orthodontics-Prior- For all orthodontic treatment listed below: History or a current condition of a severe orthodontic abnormality caused by a genetic deformity (such as cleft lip or cleft palate) Traumatic facial injury substantiated by a medical report (i.e., auto accident) resulting in serious health impairment (reconstructive jaw surgery, etc.) Fixed or removable appliance therapy Limited interceptive treatment Comprehensive Pre-orthodontic Treatment Visit (Ortho Records) -Prior- - Reimbursed only for denied treatment requests , Scion Dental, Inc. PROPRIETARY AND CONFIDENTIAL Dental Health & Wellness

61 Benefit Plan Details and Requirements Title 21 CHIP Children s 0-18 Code Code Description D0120 ic Oral Evaluation - Established Patient D0140 Limited Oral Evaluation - Problem Focused D0145 D0150 D0170 D0210 D0220 D0230 Oral Evaluation, Patient Under Three Comprehensive Oral Evaluation - New Or Established Patient Re-Evaluation - Limited, Problem Focused Intraoral - Complete Series (Including Bitewings) Intraoral-Periapical First Film Intraoral - Periapical Each Additional Film AUTHORIZATION REQUIREMENTS Documents Title 21 - CHIP s 0 18 Min BENEFIT DETAILS Count Length Type ADDITIONAL NOTES N/A Month Only one exam every 6 Months provider or provider billing group. Only one exam (D0120, D0145, D0150, D0170) date of service, beneficiary, provider or provider billing group. (D0140 is not limited to 1x every 6 Months) N/A 0 18 Only one exam (D0120, D0140, D0145, D0150, D0170) date of service, beneficiary, provider or provider billing group. Limited oral evaluation is only covered when formed in conjunction with treatment to address an emergency situation. An emergency is defined as treatment medically necessary to treat pain, infection, swelling, uncontrolled bleeding, or traumatic injury. (D0140 is not limited to 1x every 6 Months) N/A Month Only one exam every 6 Months provider or provider billing group. Only one exam (D0120, D0140, D0145, D0150, D0170) date of service, beneficiary, provider or provider billing group. (D0140 is not limited to 1x every 6 Months) N/A Month One comprehensive exam beneficiary, provider or provider billing group lifetime. Only one exam (D0120, D0145, or D0150) every six Months beneficiary, provider or provider billing group. N/A N/A Month Month One 12 Months. Established beneficiary to access the status of a previously existing condition (not post-oative visit). t covered with any other procedure other than radiographs. One 36 Months. The following are also considered an Intraoral Complete Series (D0210), D0330 and D0272 D0330 and D0273, D0330 and D0274, D0330 and D0277 N/A Days One day. Any additional films (D D0340) formed on the same date of service as a complete intraoral series, or its equivalent, are considered content of service of the complete series and will not be reimbursed. N/A 0 18 Any additional films (D D0340) formed on the same date of service as a complete intraoral series, or its equivalent, are considered content of service of the complete series and are not reimbursed , Scion Dental, Inc. PROPRIETARY AND CONFIDENTIAL Dental Health & Wellness 55

62 Benefit Plan Details and Requirements Title 21 CHIP Children s 0-18 Code Code Description AUTHORIZATION REQUIREMENTS Documents Title 21 - CHIP s 0 18 Min BENEFIT DETAILS Count Length Type ADDITIONAL NOTES D0240 Intraoral - Occlusal Film N/A 0 18 Any additional films (D D0340) formed on the same date of service as a complete intraoral series, or its equivalent, are considered content of service of the complete series and are not reimbursed. D0250 Extraoral - First Film N/A 0 18 Any additional films (D D0340) formed on the same date of service as a complete intraoral series, or its equivalent, are considered content of service of the complete series and are not reimbursed. D0260 Extraoral - Each Additional Film N/A 0 18 Any additional films (D D0340) formed on the same date of service as a complete intraoral series, or its equivalent, are considered content of service of the complete series and are not reimbursed. D0270 Bitewing - Single Film N/A 0 18 Any additional films (D D0340) formed on the same date of service as a complete intraoral series, or its equivalent, are considered content of service of the complete series and are not reimbursed. Only one bitewing code (D0270, D0272, D0273, D0274, D0277) date of service, beneficiary, provider or provider billing group. D0272 Bitewings - Two Films N/A 0 18 Any additional films (D D0340) formed on the same date of service as a complete intraoral series, or its equivalent, are considered content of service of the complete series and are not reimbursed. Only one bitewing code (D0270, D0272, D0273, D0274, D0277) date of service, beneficiary, provider or provider billing group. D0273 Bitewings - Three Films N/A 0 18 Any additional films (D D0340) formed on the same date of service as a complete intraoral series, or its equivalent, are considered content of service of the complete series and are not reimbursed. Only one bitewing code (D0270, D0272, D0273, D0274, D0277) date of service, beneficiary, provider or provider billing group. D0274 Bitewings - Four Films N/A 0 18 Any additional films (D D0340) formed on the same date of service as a complete intraoral series, or its equivalent, are considered content of service of the complete series and are not reimbursed. Only one bitewing code (D0270, D0272, D0273, D0274, D0277) date of service, beneficiary, provider or provider billing group. D0277 Vertical Bitewings - 7 To 8 Films D0290 Posterior - Anterior Or Lateral Skull And Facial Bone Survey Film N/A 0 18 Any additional films (D D0340) formed on the same date of service as a complete intraoral series, or its equivalent, are considered content of service of the complete series and are not reimbursed. Only one bitewing code (D0270, D0272, D0273, D0274, D0277) date of service, beneficiary, provider or provider billing group. N/A 0 18 Any additional films (D D0340) formed on the same date of service as a complete intraoral series, or its equivalent, are considered content of service of the complete series and are not reimbursed , Scion Dental, Inc. PROPRIETARY AND CONFIDENTIAL Dental Health & Wellness

63 Benefit Plan Details and Requirements Title 21 CHIP Children s 0-18 Code D0321 Code Description Other Temporomandibular Joint Films, By Report AUTHORIZATION REQUIREMENTS Documents Title 21 - CHIP s 0 18 Min BENEFIT DETAILS Count Length Type ADDITIONAL NOTES N/A 0 18 Any additional films (D D0340) formed on the same date of service as a complete intraoral series, or its equivalent, are considered content of service of the complete series and are not reimbursed. D0322 Tomographic Survey N/A 0 18 Any additional films (D D0340) formed on the same date of service as a complete intraoral series, or its equivalent, are considered content of service of the complete series and are not reimbursed. D0330 Panoramic Film N/A Month One 36 Months. The following are also considered an Intraoral Complete Series (D0210), D0330 and D0272 D0330 and D0273, D0330 and D0274, D0330 and D0277 D0460 Pulp Vitality Tests N/A Days imum of three teeth visit. Covered teeth are:1-32, (SN), A - T, AS - TS (SN) D1110 Prophylaxis - Adult N/A Month One six Months. Includes scaling and polishing procedures to remove coronal plaque, calculus, and stains. D1120 Prophylaxis - Child N/A Month One six Months. Includes scaling and polishing procedures to remove coronal plaque, calculus, and stains. D1206 Topical Fluoride Varnish N/A Month D1208 Topical Application Fluoride N/A Month D1351 Sealant - Per N/A Month Sealants are reimbursable when placed on the occlusal or occlusal-buccal surfaces of lower 1st and 2nd manent molars or up 1st and 2nd manent molars as well as manent up and lower bicuspids. Teeth must be caries free. Sealant is not covered when placed over restorations. D1510 Space Maintainer - Fixed - Unilateral N/A Month 1 12 Months quadrant. 10 (UR), 20 (UL), 30 (LL), 40 (LR) D1515 Space Maintainer - Fixed - Bilateral D1525 Space Maintainer - Removable - Bilateral N/A Month 1 12 Months arch. 01 (UA) 02 (LA) N/A Month 1 12 Months arch. 01 (UA) 02 (LA) D1550 D2140 D2150 D2160 Re-Cementation Of Space Maintainer Amalgam - One Surface, Primary Or Permanent Amalgam - Two Surfaces, Primary Or Permanent Amalgam - Three Surfaces, Primary Or Permanent N/A (UR), 20 (UL), 30 (LL), 40 (LR), 01 (UA), 02 (LA) t covered within 6 Months of initial placement within quadrant or arch. N/A Month Teeth Covered:1-32,51-82 (SN),A - T,AS - TS (SN) N/A Month Teeth Covered:1-32,51-82 (SN),A - T,AS - TS (SN) N/A Month Teeth Covered: 1-32,51-82 (SN),A - T,AS - TS (SN) , Scion Dental, Inc. PROPRIETARY AND CONFIDENTIAL Dental Health & Wellness 57

64 Benefit Plan Details and Requirements Title 21 CHIP Children s 0-18 Code D2161 Code Description Amalgam - Four Or More Surfaces, Primary Or Permanent D2330 Resin-Based Composite - One Surface, Anterior D2331 Resin-Based Composite - Two Surfaces, Anterior D2332 Resin-Based Composite - Three Surfaces, Anterior D2335 Resin-Based Composite - Four Or More Surfaces Or Involving Incisal Angle D2390 Resin-Based Composite Crown, Anterior D2391 Resin-Based Composite - One Surface, Posterior D2392 Resin-Based Composite - Two Surfaces, Posterior D2393 Resin-Based Composite - Three Surfaces, Posterior D2394 Resin-Based Composite - Four Or More Surfaces, Posterior D2710 D2740 D2751 Crown - Resin-Based Composite (Indirect) Crown - Porcelain/Ceramic Substrate Crown - Porcelain Fused To Predominantly Base Metal AUTHORIZATION REQUIREMENTS Documents Title 21 - CHIP s 0 18 Min BENEFIT DETAILS Count Length Type ADDITIONAL NOTES N/A Month Teeth Covered: 1-32,51-82 (SN),A - T,AS - TS (SN) N/A Month Teeth Covered: 6-11, 22-27, (SN), (SN), C - H, M - R, CS - HS (SN), MS - RS (SN) N/A Month Teeth Covered: 6-11, 22-27, (SN), (SN), C - H, M - R, CS - HS (SN), MS - RS (SN) N/A Month Teeth Covered: 6-11, 22-27, (SN), (SN), C - H, M - R, CS - HS (SN), MS - RS (SN) N/A Month Teeth Covered: 6-11, 22-27, (SN), (SN), C - H, M - R, CS - HS (SN), MS - RS (SN) N/A Month Teeth Covered: 6-11, 22-27, (SN), (SN), C - H, M - R, CS - HS (SN), MS - RS (SN) N/A Month Teeth Covered: 1-5, 12-21, 28-32, (SN), (SN), (SN,) A, B, I - L, S, T, AS (SN), BS (SN), IS - LS (SN), SS (SN),TS (SN) N/A Month Teeth Covered: 1-5, 12-21, 28-32, (SN), (SN), (SN,) A, B, I - L, S, T, AS (SN), BS (SN), IS - LS (SN), SS (SN),TS (SN) N/A Month Teeth Covered: 1-5, 12-21, 28-32, (SN), (SN), (SN,) A, B, I - L, S, T, AS (SN), BS (SN), IS - LS (SN), SS (SN),TS (SN) N/A Month Teeth Covered: 1-5, 12-21, 28-32, (SN), (SN), (SN,) A, B, I - L, S, T, AS (SN), BS (SN), IS - LS (SN), SS (SN),TS (SN) Preoative radiographs of adjacent and opposing teeth. If a tooth has had RCT, a postendodontic radiograph is also required showing the entire tooth,. Preoative radiographs of adjacent and opposing teeth. If a tooth has had RCT, a postendodontic radiograph is also required showing the entire tooth, Preoative radiographs of adjacent and opposing teeth. If a tooth has had RCT, a postendodontic radiograph is also required showing the entire tooth, Month Teeth Covered: 6 11, 22-27, (SN), (SN) Month Teeth Covered: 1 32, 51 82(SN) Month Teeth Covered: 1 32, (SN) , Scion Dental, Inc. PROPRIETARY AND CONFIDENTIAL Dental Health & Wellness

65 Benefit Plan Details and Requirements Title 21 CHIP Children s 0-18 Code D2752 Code Description Crown - Porcelain Fused To ble Metal D2783 Crown - 3/4 Porcelain/Ceramic D2791 D2792 D2910 Crown - Full Cast Predominantly Base Metal Crown - Full Cast ble Metal Recement Inlay, Onlay, Or Partial Coverage Restoration AUTHORIZATION REQUIREMENTS Documents Preoative radiographs of adjacent and opposing teeth. If a tooth has had RCT, a postendodontic radiograph is also required showing the entire tooth, Preoative radiographs of adjacent and opposing teeth. If a tooth has had RCT, a postendodontic radiograph is also required showing the entire tooth, Preoative radiographs of adjacent and opposing teeth. If a tooth has had RCT, a postendodontic radiograph is also required showing the entire tooth, Preoative radiographs of adjacent and opposing teeth. If a tooth has had RCT, a postendodontic radiograph is also required showing the entire tooth, Title 21 - CHIP s 0 18 Min BENEFIT DETAILS Count Length Type ADDITIONAL NOTES Month Teeth Covered: 1 32, (SN) Month Teeth Covered: 1 32, (SN) Month Teeth Covered: 1 32, (SN) Month Teeth Covered: 1 32, (SN) N/A 0 18 Teeth Covered: 1 32, (SN) D2920 Recement Crown N/A 0 18 Teeth Covered: 1 32, (SN) D2921 D2930 D2931 D2934 Reattachment of tooth fragment, incisal edge or cusp Prefabricated Stainless Steel Crown - Primary Prefabricated Stainless Steel Crown-Permanent Prefabricated Esthetic Coated Stainless Steel Crown - Primary Pre- and post-oative radiographic images shall be maintained in beneficiary records 0 18 Teeth Covered: 1 32, (SN), t allowed same tooth, same surface(s), same DOS as D2140, D2150, D2160, D2161, D2330, D2331, D2332, D2335, D2391, D2392 D2393 D2394. N/A Month Teeth Covered: A T. AS - TS (SN), D2930 and D2934 cannot be placed on the same tooth during a 24-Month iod. N/A Month Teeth Covered: 1 32, (SN) N/A Month Teeth Covered: C - H, M R, CS - HS (SN), MS - RS (SN) D2930 and D2934 cannot be placed on the same tooth during the 24-Month iod. D2940 Protective Restoration N/A 0 18 Teeth Covered: 1 32, (SN) Temporary restoration intended to relieve pain. t to be used as a base or liner under a restoration. D2951 Pin Retention - Per, In Addition To Restoration N/A 0 18 Teeth Covered: 1 32, (SN) , Scion Dental, Inc. PROPRIETARY AND CONFIDENTIAL Dental Health & Wellness 59

66 Benefit Plan Details and Requirements Title 21 CHIP Children s 0-18 Code D2954 D2957 D3110 Code Description Prefabricated Post And Core In Addition To Crown Each Additional Prefabricated Post - Same Pulp Cap - Direct (Excluding Final Restoration) AUTHORIZATION REQUIREMENTS Documents Pre-op x-rays of adj and opposing teeth, fill x-ray and narrative of medical necessity submitted Pre-op x-rays of adj and opposing teeth, fill x-ray and narrative of medical necessity submitted Title 21 - CHIP s 0 18 Min BENEFIT DETAILS Count Length Type ADDITIONAL NOTES Month Teeth Covered: 1 32, (SN) Month Teeth Covered: 1 3, 14 19, 30 32, (SN), (SN), (SN) N/A 0 18 Teeth Covered: 1 32, (SN) D3220 Therapeutic Pulpotomy N/A Lifetime D3221 Pulpal Debridement - Primary And Permanent Teeth D3222 D3310 D3320 D3330 D3331 Partial Pulpotomy For Apexogenesis - Permanent Endodontic Therapy, Anterior (Excluding Final Restoration) Endodontic Therapy, Bicuspid (Excluding Final Restoration) Endodontic Therapy, Molar (Excluding Final Restoration) Treatment Of Root Canal Obstruction; n-surgical Access D3351 Apexification / Recalcification / Pulpal Regeneration - Initial Visit D3352 Apexification / Recalcification / Pulpal Regeneration - Interim D3353 Apexification / Recalcification / Pulpal Regeneration - Final Visit D3410 Apicoectomy / Periradicular Surgery - Anterior N/A Lifetime Pre-oative x-rays (excluding bitewings), submitted Lifetime N/A Lifetime N/A Lifetime N/A Lifetime Pre-oative x-rays (excluding bitewings) and narrative of medical necessity, submitted. Pre- and postoative radiographs shall be maintained in beneficiary records Pre- and postoative radiographs shall be maintained in beneficiary records Pre- and postoative radiographs shall be maintained in beneficiary records Pre- and postoative radiographs shall be maintained in beneficiary records Teeth Covered: 1 32, (SN), A T, AS - TS t covered within 30 days of D3310-D3331 on same tooth. Teeth Covered: 1 32, (SN), A T, AS - TS t covered within 30 days of D3310-D3331 on same tooth. Teeth Covered: 1 32, (SN) Should only be formed as preparation for endodontic treatment. Teeth Covered: 6 11, 22 27, (SN), (SN) Teeth Covered: 4, 5, 12, 13,20, 21, 28, 29, 54 (SN), 55 (SN), 62 (SN), 63 (SN), 70 (SN), 71 (SN), 78 (SN), 79 (SN) Teeth Covered: 1-3, 14 19, 30 32, (SN), (SN), (SN) 0 18 Teeth Covered: 1 32, (SN) 0 18 Teeth Covered: 1 32, (SN) 0 18 Teeth Covered: 1 32, (SN) 0 18 Teeth Covered: 1 32, (SN) 0 18 Teeth Covered: 6 11, 22 27, (SN), (SN) , Scion Dental, Inc. PROPRIETARY AND CONFIDENTIAL Dental Health & Wellness

67 Benefit Plan Details and Requirements Title 21 CHIP Children s 0-18 Code D3421 D3425 D3426 D3427 D3430 D4210 D4211 D4230 D4231 D4268 D4341 Code Description Apicoectomy / Periradicular Surgery - Bicuspid (First Root) Apicoectomy / Periradicular Surgery - Molar (First Root) Apicoectomy / Periradicular Surgery - Each Additional Root) Periradicular surgery without apicoectomy Retrograde Filling - Per Root Gingivectomy Or Gingivoplasty - Four Or More Contiguous Teeth Gingivectomy Or Gingivoplasty - One To Three Contiguous Teeth Anatomical Crown Exposure - Four Or More Contiguous Teeth Per Quadrant Anatomical Crown Exposure - One To Three Teeth Per Quadrant Surgical Revision Procedure, Per ontal Scaling And Root Planing - Four Or More Teeth Per Quadrant AUTHORIZATION REQUIREMENTS Documents Title 21 - CHIP s 0 18 Min BENEFIT DETAILS Count Length Type ADDITIONAL NOTES N/A 0 18 Teeth Covered: 4, 5, 12, 13, 20, 21, 28, 29, 54 (SN), 55 (SN),62 (SN), 63 (SN),70 (SN), 71 (SN),78 (SN), 79 (SN) N/A 0 18 Teeth Covered: 1-3, 14 19, 30 32, (SN), (SN), (SN) N/A 0 18 Teeth Covered: 1-5, 12 21, 28 32, (SN), (SN), (SN) Pre- and post-oative radiographs shall be maintained in beneficiary records. Pre- and postoative radiographs shall be maintained in beneficiary records Pre-op x-rays, io charting, treatment plan and narrative of medical necessity, submitted. Pre-op x-rays, io charting, treatment plan and narrative of medical necessity, submitted. Pre-op x-rays, io charting, and narrative of medical necessity, photo (optional), submitted. Pre-op x-rays, io charting, and narrative of medical necessity, photo (optional), submitted. Pre-oative x-rays and narrative of medical necessity submitted. ontal charting and pre-op x-rays, and treatment plan submitted. There must be radiographic evidence of root calculus or noticeable loss of bone support Teeth Covered: 1-32, (SN), t allowed same tooth, same DOS as D3410, D3421, D3425, D Teeth Covered: 1 32, (SN) 0 18 Per quadrant: 10 (UR), 20 (UL), 30 (LL), 40 (LR) A minimum of four affected teeth in the quadrant Per quadrant: 10 (UR), 20 (UL), 30 (LL), 40 (LR) One to three affected teeth in the quadrant Per quadrant:10 (UR), 20 (UL), 30 (LL), 40 (LR) Must be billed same date same tooth in conjunction with the restorative codes (D D2957) Per quadrant:10 (UR), 20 (UL), 30 (LL), 40 (LR) Same date and same tooth in conjunction with the restorative code Teeth Covered: 1 32, (SN) Only covered after D Month Per quadrant: 10 (UR), 20 (UL), 30 (LL),40 (LR) A minimum of four affected teeth in the quadrant , Scion Dental, Inc. PROPRIETARY AND CONFIDENTIAL Dental Health & Wellness 61

68 Benefit Plan Details and Requirements Title 21 CHIP Children s 0-18 Code D4342 Code Description ontal Scaling And Root Planing - One To Three Teeth Per Quadrant AUTHORIZATION REQUIREMENTS Documents ontal charting and pre-op x-rays, and treatment plan submitted. There must be radiographic evidence of root calculus or noticeable loss of bone support. D4355 Full Mouth Debridement Documentation of medical necessity shall be maintained in beneficiary records. D5110 Complete Denture - illary D5120 Complete Denture - Mandibular D5211 illary Partial Denture - Resin Base D5212 Mandibular Partial Denture - Resin Base D5213 illary Partial Denture - Cast Metal Framework With Resin Denture Bases D5214 Mandibular Partial Denture - Cast Metal Framework With Resin Denture Bases D5225 illary Partial Denture - Flexible Base D5226 D5281 Mandibular Partial Denture - Flexible Base Removable Unilateral Partial Denture - One Piece Cast Metal D5410 Adjust Complete Denture - illary D5411 Adjust Complete Denture - Mandibular D5421 Adjust Partial Denture - illary D5422 Adjust Partial Denture - Mandibular D5510 Repair Broken Complete Denture Base Pre op x-rays, treatment plan Pre op x-rays, treatment plan Pre-op x-rays of adj and opposing teeth, trmt plan with claim Pre-op x-rays of adj and opposing teeth, trmt plan with claim Pre-op x-rays of adj and opposing teeth, trmt plan with claim Pre-op x-rays of adj and opposing teeth, trmt plan with claim Pre-op x-rays of adj and opposing teeth, trmt plan with claim Pre-op x-rays of adj and opposing teeth, trmt plan with claim Pre-op x-rays of adj and opposing teeth, trmt plan with claim Title 21 - CHIP s 0 18 Min BENEFIT DETAILS Count Length Type ADDITIONAL NOTES Month Per quadrant:10 (UR), 20 (UL), 30 (LL), 40 (LR) One to three affected teeth in the quadrant Month Month Month Month Month Month Month Month Month Month Per quadrant: 10 (UR), 20 (UL), 30 (LL), 40 (LR) N/A 0 18 t covered within 6 Months of placement. N/A 0 18 t covered within 6 Months of placement. N/A 0 18 t covered within 6 Months of placement. N/A 0 18 t covered within 6 Months of placement. N/A 0 18 Area covered: 01 (UA), 02 (LA) , Scion Dental, Inc. PROPRIETARY AND CONFIDENTIAL Dental Health & Wellness

69 Benefit Plan Details and Requirements Title 21 CHIP Children s 0-18 Code D5520 Code Description Replace Missing Or Broken Teeth - Complete Denture (Each ) AUTHORIZATION REQUIREMENTS Documents Title 21 - CHIP s 0 18 Min BENEFIT DETAILS Count Length N/A 0 18 Teeth Covered: 1-32 Type ADDITIONAL NOTES D5610 Repair Resin Denture Base N/A 0 18 Area covered:01(ua), 02 (LA), 10 (UR), 20 (UL), 30(LL),40 (LR) D5620 Repair Cast Framework N/A 0 18 Area covered:01(ua), 02 (LA), 10 (UR), 0 (UL),30 (LL),40 (LR) D5630 D5640 D5650 D5660 D5670 D5671 D5750 D5751 D5760 D5761 D5850 D5851 D6100 D6930 D7140 D7210 Repair Or Replace Broken Clasp Replace Broken Teeth - Per Add To Existing Partial Denture Add Clasp To Existing Partial Denture Replace All Teeth And Acrylic On Cast Metal Framework (illary) Replace All Teeth And Acrylic On Cast Metal Framework (Mandibular) Reline Complete illary Denture (Laboratory) Reline Complete Mandibular Denture (Laboratory) Reline illary Partial Denture (Laboratory) Reline Mandibular Partial Denture (Laboratory) Tissue Conditioning, illary Tissue Conditioning, Mandibular Implant Removal, By Report Recement Fixed Partial Denture Extraction, Erupted Or Exposed Root Surgical Removal Or Erupted N/A 0 18 Area covered:01(ua),02 (LA), 10 (UR), 20 (UL), 30 (LL),40(LR) N/A 0 18 Teeth Covered: 1-32 N/A 0 18 Teeth Covered: 1-32 N/A 0 18 Area covered:01(ua),02 (LA),10 (UR), 20 (UL), 30 (LL), 40 (LR) N/A 0 18 N/A 0 18 N/A Month t covered within 24 Months of placement. N/A Month t covered within 24 Months of placement. N/A Month t covered within 24 Months of placement. N/A Month t covered within 24 Months of placement. N/A 0 18 N/A 0 18 Pre-op & post-op x-rays, narr of med nec 0 18 Teeth Covered: 1 32, (SN) N/A 0 18 Area covered:01 (UA), 02 (LA), 10 (UR), 20 (UL), 30 (LL), 40 (LR) N/A Lifetime N/A Lifetime Teeth Covered: 1 32, (SN), A T, AS - TS (SN) Removal of asymptomic tooth not covered. Teeth Covered: 1 32, (SN), A T, AS - TS (SN) Removal of asymptomic tooth not covered. Includes cutting of gingiva and bone, removal of tooth structure, and closure , Scion Dental, Inc. PROPRIETARY AND CONFIDENTIAL Dental Health & Wellness 63

70 Benefit Plan Details and Requirements Title 21 CHIP Children s 0-18 Code D7220 D7230 D7240 D7241 D7250 Code Description Removal Of Impacted - Soft Tissue Removal Of Impacted - Partially Bony Removal Of Impacted - Completely Bony Removal Of Impacted - Completely Bony, Unusual Surgical Complications Surgical Removal Of Residual (Cutting Procedure) D7260 Oroantral Fistula Closure D7270 D7280 Reimplantation And/Or Stabilization Of Accidentally Evulsed / Displaced Surgical Access Of An Unerupted D7285 Biopsy Of Oral Tissue - Hard (Bone, ) AUTHORIZATION REQUIREMENTS Documents Pre-op x-rays (excluding bitewings) and narr of med nec Pre-op x-rays (excluding bitewings) and narr of med nec Pre-op x-rays (excluding bitewings) and narr of med nec Pre-op x-rays (excluding bitewings) and narr of med nec Title 21 - CHIP s 0 18 Min BENEFIT DETAILS Count Length Type Lifetime Lifetime Lifetime Lifetime N/A Lifetime Pre- and postoative radiographs and narrative of medical necessity submitted with claim Lifetime N/A Lifetime Pre-op x-rays, narr of med neck Pathology report should be kept in beneficiary record. D7286 Biopsy Of Oral Tissue - Soft Pathology report should be kept in beneficiary record. D7320 D7350 D7410 D7411 Alveoloplasty t In Conjunction With Extractions - Four Or More Teeth Vesibuloplasty - Ridge Extension (Including Soft Tissue Grafts) Excision Of Benign Lesion Up To 1.25 Cm Excision Of Benign Lesion Greater Than 1.25 Cm Pre-op x-rays, narr of med nec Pre-op x-rays, narr of med nec Lifetime N/A 0 18 N/A 0 18 ADDITIONAL NOTES Teeth Covered: 1 32, (SN) Removal of asymptomic tooth not covered. Includes cutting of gingiva and bone, removal of tooth structure, and closure. Teeth Covered: 1 32, (SN) Removal of asymptomic tooth not covered. Includes cutting of gingiva and bone, removal of tooth structure, and closure. Teeth Covered: 1 32, (SN) Removal of asymptomic tooth not covered. Includes cutting of gingiva and bone, removal of tooth structure, and closure. Teeth Covered:1 32, (SN) Removal of asymptomic tooth not covered. Includes cutting of gingiva and bone, removal of tooth structure, and closure. Unusual complications such as nerve dissection, separate closure of the maxillary sinus, or aberrant tooth position. Teeth Covered: 1 32, (SN), A T, AS - TS (SN) Includes cutting of gingiva and bone, removal of tooth structure, and closure. Will not be paid to the providers or group that originally removed the tooth. Teeth Covered: 1 32, (SN), A T, AS - TS (SN) Includes splinting and/or stabilization. Teeth Covered: 1 32, (SN) Will not be payable unless the orthodontic treatment has been authorized as a covered benefit Per quadrant:10 (UR), 20 (UL), 30 (LL), 40 (LR) extractions formed in an edentulous area. t covered when formed on the same day as an extraction for the same tooth Per quadrant:10 (UR), 20 (UL), 30 (LL), 40 (LR) , Scion Dental, Inc. PROPRIETARY AND CONFIDENTIAL Dental Health & Wellness

71 Benefit Plan Details and Requirements Title 21 CHIP Children s 0-18 Code D7412 D7413 D7414 D7415 D7440 D7441 D7450 D7451 D7460 D7461 D7471 D7472 D7473 D7490 D7510 D7511 Code Description Excision Of Benign Lesion, Complicated Excision Of Malignant Lesion Up To 1.25 cm Excision Of Malignant Lesion greater than 1.25cm Excision Of Malignant Lesion, Complicated Excision Of Malignant Tumor - Lesion Diameter Up To 1.25 Cm Excision Of Malignant Tumor - Lesion Diameter Greater Than 1.25 Cm Removal Of Benign Odontogenic Cyst Or Tumor - Dia Up To 1.25 Cm Removal Of Benign Odontogenic Cyst Or Tumor - Dia Greater Than 1.25 Cm Removal Of Benign nodontogenic Cyst Or Tumor - Dia Up To 1.25 Cm Removal Of Benign nodontogenic Cyst Or Tumor - Dia Greater Than 1.25 Cm Removal Of Lateral Exostosis (illa Or Mandible) Removal Of Torus Palatinus Removal Of Torus Mandibularis Radical Resection Of illa Or Mandible Incision And Drainage Of Abscess - Intraoral Soft Tissue Incision And Drainage Of Abscess - Intraoral Soft Tissue - Complicated AUTHORIZATION REQUIREMENTS Documents Title 21 - CHIP s 0 18 Min N/A 0 18 N/A 0 18 N/A 0 18 N/A 0 18 N/A 0 18 N/A 0 18 N/A 0 18 N/A 0 18 N/A 0 18 N/A 0 18 Pre-op x-rays, narr of med nec Pre-op x-rays, narr of med nec Pre-op x-rays, narr of med nec Pre-op x-rays, narr of med nec BENEFIT DETAILS Count Length Type Once Lifetime Once Lifetime Once Lifetime Area Covered: 01 (UA), 02 (LA) 0 18 Area Covered: 01 (UA), 02 (LA) ADDITIONAL NOTES N/A 0 18 t covered same date of service as D7511 N/A , Scion Dental, Inc. PROPRIETARY AND CONFIDENTIAL Dental Health & Wellness 65

72 Benefit Plan Details and Requirements Title 21 CHIP Children s 0-18 Code D7520 D7521 D7530 D7540 D7550 D7560 D7610 D7620 D7630 D7640 D7650 D7660 D7670 D7680 Code Description Incision And Drainage Of Abscess - Extraoral Soft Tissue Incision And Drainage Of Abscess - Extraoral Soft Tissue - Complicated Removal Of Foreign Body From Mucosa Removal Of Reaction Producing Foreign Bodies Partial Ostectomy/ Sequestrectomy For Removal Of n-vital Bone illary Sinusotomy For Removal Of Fragment Or Foreign Body illa - Open Reduction (Teeth Immobilized, If Present) illa - Closed Reduction (Teeth Immobilized, If Present) Mandible - Open Reduction (Teeth Immobilized, If Present) Mandible - Closed Reduction (Teeth Immobilized, If Present) Malar And/Or Zygomatic Arch - Open Reduction Malar And/Or Zygomatic Arch - Closed Reduction Alveolus - Closed Reduction, May Include Stabilization Of Teeth Facial Bones - Complicated Reduction With Fixation And Multiple Surgical AUTHORIZATION REQUIREMENTS Documents Title 21 - CHIP s 0 18 Min BENEFIT DETAILS Count Length Type ADDITIONAL NOTES N/A 0 18 t covered same date of service as D7521. N/A 0 18 N/A 0 18 N/A 0 18 N/A 0 18 Pre- and postoative radiographs along with narrative of medical necessity must be submitted N/A 0 18 N/A 0 18 N/A 0 18 N/A 0 18 N/A 0 18 N/A 0 18 N/A 0 18 Teeth Covered: 1 32 May include stabilization. Pre- and postoative radiographs along with narrative of medical necessity must be submitted D7710 illa - Open Reduction N/A 0 18 D7720 illa - Closed Reduction N/A , Scion Dental, Inc. PROPRIETARY AND CONFIDENTIAL Dental Health & Wellness

73 Benefit Plan Details and Requirements Title 21 CHIP Children s 0-18 Code Code Description AUTHORIZATION REQUIREMENTS Documents D7730 Mandible - Open Reduction Postoative radiographs must be available in the beneficiary records. D7740 D7750 D7760 D7770 D7780 D7820 Mandible - Closed Reduction Malar And/Or Zygomatic Arch - Open Reduction Malar And/Or Zygomatic Arch - Closed Reduction Alveolus - Open Reduction Stabilization Of Teeth Facial Bones - Complicated Reduction With Fixation And Multiple Surgical Closed Reduction Of Dislocation D7860 Arthrotomy D7865 Arthroplasty D7910 D7911 Suture Of Recent Small Wounds Up To 5 Cm Complicated Suture - Up To 5 Cm D7912 Complicated Suture - Greater Than 5 Cm D7920 D7955 D7960 Skin Graft (Identify Defect Covered, Location And Type Of Graft) Repair Of illofacial Soft And/Or Hard Tissue Defect Frenulectomy - Also Known As Frenectomy Or Frenotomy - Separate Procedure Title 21 - CHIP s 0 18 Min 0 18 N/A 0 18 N/A 0 18 N/A 0 18 N/A 0 18 N/A 0 18 N/A 0 18 Pre-op & post-op x-rays, narr of med nec Pre- and postoative radiographs along with narrative of medical necessity must be submitted BENEFIT DETAILS Count Length Type ADDITIONAL NOTES N/A 0 18 t covered on dame day as D7140, D7210, D7220, D7230, D7240, D7241, or D7250. N/A 0 18 t covered on dame day as D7140, D7210, D7220, D7230, D7240, D7241, or D7250. N/A 0 18 t covered on dame day as D7140, D7210, D7220, D7230, D7240, D7241, or D7250. Pre-op & post-op x-rays, narr of med nec Pre- and postoative radiographs along with narrative of medical necessity must be submitted Area covered: 01 (UA), 02 (LA), 10 (UR), 20 (UL), 30 (LL), 40 (LR) 0 18 N/A Lifetime Area Covered: 01 (UA), 02 (LA) Once Lifetime. Per location. Lingual, Buccal or Labial. t covered same date of service as D7963. The frenum may be excised when the tongue has limited mobility; for large diastemas between teeth, or when the frenum interferes with a prosthetic appliance; or when it is the etiology of iodontal tissue disease. D7963 Frenuloplasty N/A 0 18 Excision of frenum with the excision or repositioning of abervant muscle and z-plasty or other local flap closure , Scion Dental, Inc. PROPRIETARY AND CONFIDENTIAL Dental Health & Wellness 67

74 Benefit Plan Details and Requirements Title 21 CHIP Children s 0-18 Code D7971 Code Description Excision Of Pericoronal Gingiva AUTHORIZATION REQUIREMENTS Documents Title 21 - CHIP s 0 18 Min BENEFIT DETAILS Count Length N/A 0 18 Teeth Covered: 1-32 D7980 Sialolithotomy N/A 0 18 Type ADDITIONAL NOTES D7981 Excision Of Salivary Gland, By Report N/A 0 18 D7982 Sialodochoplasty N/A 0 18 D7983 Closure Of Salivary Fistula Narrative of medical necessity, x-rays or photos optional, submitted D7990 Emergency Tracheotomy N/A 0 18 D8010 D8020 D8050 D8060 D8070 D8080 D8210 Limited Orthodontic Treatment Of The Primary Dentition Limited Orthodontic Treatment Of The Transitional Dentition Interceptive Orthodontic Treatment Of The Primary Dentition Interceptive Orthodontic Treatment Of The Transitional Dentition Comprehensive Orthodontic Treatment Of The Transitional Dentition Comprehensive Orthodontic Treatment Of The Adolescent Dentition Removable Appliance Therapy Yes-Prior Yes-Prior Yes-Prior Yes-Prior Yes-Prior Yes-Prior Yes-Prior D8220 Fixed Appliance Therapy Yes-Prior D8999 D9212 D9220 Unspecified Orthodontic Procedure, By Report Trigeminal Division Block Anesthesia Deep Sedation/General Anesthesia-First 30 Minutes Yes-Prior Pan and/or cephalometric x-ray, diag quality photos, narr of med nec / trm plan Pan and/or cephalometric x-ray, diag quality photos, narr of med nec / trm plan Pan and/or cephalometric x-ray, diag quality photos, narr of med nec / trm plan Pan and/or cephalometric x-ray, diag quality photos, narr of med nec / trm plan Pan and/or cephalometric x-ray, diag quality photos, narr of med nec / trm plan Pan and/or cephalometric x-ray, diag quality photos, narr of med nec / trm plan Pan and/or cephalometric x-ray, diag quality photos, narr of med nec / trm plan Pan and/or cephalometric x-ray, diag quality photos, narr of med nec / trm plan Description of procedure and narrative of medical necessity Narrative of medical necessity shall be maintained in beneficiary records. Narrative of medical necessity and treatment plan 0 18 Limited to one replacement. Limited orthodontic treatment requires prior authorization and is only covered for eligible children with documented medical necessity Limited to one replacement. Limited orthodontic treatment requires prior authorization and is only covered for eligible children with documented medical necessity Interceptive orthodontic treatment requires prior authorization and is only covered for eligible children with documented medical necessity Interceptive orthodontic treatment requires prior authorization and is only covered for eligible children with documented medical necessity Comprehensive orthodontic treatment requires prior authorization and is only covered for eligible children with documented medical necessity Comprehensive orthodontic treatment requires prior authorization and is only covered for eligible children with documented medical necessity Limited to one replacement. Removable appliance therapy requires prior authorization and is only covered for eligible children with documented medical necessity Limited to one replacement. Removable appliance therapy requires prior authorization and is only covered for eligible children with documented medical necessity All orthodontic treatment requires prior authorization and is only covered for eligible children with documented medical necessity D9220 and D9221 are only billable when dental services other then ONLY diagnostic are provided on the same date of service , Scion Dental, Inc. PROPRIETARY AND CONFIDENTIAL Dental Health & Wellness

75 Benefit Plan Details and Requirements Title 21 CHIP Children s 0-18 Code D9221 D9230 D9241 D9242 D9310 D9410 D9420 D9610 D9920 D9999 Code Description Deep Sedation/General Anesthesia - Each Additional 15 Minutes Inhalation Of Nitrous/Analgesia, Anxiolysis Intravenous Conscious Sedation/Analgesia - First 30 Minutes Intravenous Conscious Sedation/Analgesia - Each Additional 15 Minutes Consultation - Diagnostic Service Provided By Dentist Or Physician House/Extended Care Facility Call Hospital Or Ambulatory Surgical Center Call Therapeutic Parenteral Drug, Single Administration Behavior Management, By Report Unspecified Adjunctive Procedure, By Report AUTHORIZATION REQUIREMENTS Documents Narrative of medical necessity and treatment plan Narrative of medical necessity shall be maintained in beneficiary records. Narrative of medical necessity and treatment plan Narrative of medical necessity and treatment plan Narrative of the consultation for dental services shall be maintained in beneficiary records. Narrative of medical necessity shall be maintained in beneficiary records. Narrative of medical necessity shall be maintained in beneficiary records. Description and dosage of drug shall be maintained in beneficiary records. Narrative of medical necessity Description of procedure and narrative of medical necessity, submitted Title 21 - CHIP s 0 18 Min BENEFIT DETAILS Count Length Type ADDITIONAL NOTES 0 18 D9220 and D9221 are only billable when dental services other then ONLY diagnostic are provided on the same date of service t covered when billed with only diagnostic and/or preventative services (D0120 through D1208, D1515 through D1550, D9410, D9420) Month D9310 is billable when ONLY diagnostic services are provided on the same date of service. One 12 Months by same provider. One inpatient follow up beneficiary within a 10 day iod by same provider. t covered on the same date of service as D0120-D0170, D9410, D Extended Care Facilities only Hospital Facilities only Effective with dates of service on and after July 1, 2011, registered dental hygienists with an extended care mit can bill for D clinical and caries risk assessment, toothbrush prophylaxis of a child 0-3 years of age and counseling to parents/primary caregivers , Scion Dental, Inc. PROPRIETARY AND CONFIDENTIAL Dental Health & Wellness 69

76 Benefit Plan Details and Requirements Title 19 Medicaid Children s 0-20 Title 19 Medicaid Children s 0-20 Title 19 Medicaid Adults s 21 and Over Title 19 Medicaid Children (s 0-20) and Title 19 Medicaid Adults (s 21 and Over) - Please note age limitations ****Codes with an 999 are covered for both children and adults and codes with an of 20 are covered for children only.**** Title 19 Adult s 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 beneficiary's oral health. Exams and radiographs are payable only when done in conjunction with or to determine if extractions are medically necessary. Code Code Description D0120 ic Oral Evaluation - Established Patient D0140 Limited Oral Evaluation - Problem Focused D0145 D0150 D0170 D0210 D0220 D0230 Oral Evaluation, Patient Under Three Comprehensive Oral Evaluation - New Or Established Patient Re-Evaluation - Limited, Problem Focused Intraoral - Complete Series (Including Bitewings) Intraoral - Periapical First Film Intraoral - Periapical Each Additional Film AUTHORIZATION REQUIREMENTS BENEFIT DETAILS ADDITIONAL NOTES Documents Min Count Length N/A Month Only one exam every 6 Months provider or provider billing group. Only one exam (D0120, D0140, D0145, D0150, D0170) date of service, beneficiary, provider or provider billing group. (D0140 is not limited to 1x every 6 Months) N/A Only one exam (D0120, D0140, D0145, D0150, D0170) date of service, beneficiary, provider or provider billing group. Limited oral evaluation only covered when formed in conjunction with treatment to address an emergency situation. An emergency is defined as treatment medically necessary to treat pain, infection, swelling, uncontrolled bleeding or traumatic injury. (D0140 is not limited to 1x every 6 Months) N/A Month Only one exam every 6 Months provider or provider billing group. Only one exam (D0120, D0140, D0145, D0150, D0170) date of service, beneficiary, provider or provider billing group. (D0140 is not limited to 1x every 6 Months) N/A Month One comprehensive exam beneficiary, provider or provider billing group lifetime. Only one exam (D0120, D0145, or D0150) every six Months beneficiary, provider or provider billing group. N/A Month One 12 Months. Established beneficiary to access the status of a previously existing condition (not post-oative visit). t covered with any other procedure other than radiographs. N/A Month One 36 Months. The following are also considered an Intraoral Complete Series (D0210), D0330 and D0272 D0330 and D0273, D0330 and D0274, D0330 and D0277 N/A Days One day. Any additional films (D D0340) formed on the same date of service as a complete intraoral series, or its equivalent, are considered content of service of the complete series and will not be reimbursed. N/A Any additional films (D D0340) formed on the same date of service as a complete intraoral series, or its equivalent, are considered content of service of the complete series and are not reimbursed. Type , Scion Dental, Inc. PROPRIETARY AND CONFIDENTIAL Dental Health & Wellness

77 Benefit Plan Details and Requirements Title 19 Medicaid Adults s 21 and Over Title 19 Medicaid Children (s 0-20) and Title 19 Medicaid Adults (s 21 and Over) - Please note age limitations ****Codes with an 999 are covered for both children and adults and codes with an of 20 are covered for children only.**** Title 19 Adult s 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 beneficiary's oral health. Exams and radiographs are payable only when done in conjunction with or to determine if extractions are medically necessary. Code Code Description AUTHORIZATION REQUIREMENTS BENEFIT DETAILS ADDITIONAL NOTES Documents Min , Scion Dental, Inc. PROPRIETARY AND CONFIDENTIAL Dental Health & Wellness 71 D0240 Intraoral - Occlusal Film N/A Any additional films (D D0340) formed on the same date of service as a complete intraoral series, or its equivalent, are considered content of service of the complete series and are not reimbursed. D0250 Extraoral - First Film N/A Any additional films (D D0340) formed on the same date of service as a complete intraoral series, or its equivalent, are considered content of service of the complete series and are not reimbursed. D0260 Extraoral - Each Additional Film Count Length N/A Any additional films (D D0340) formed on the same date of service as a complete intraoral series, or its equivalent, are considered content of service of the complete series and are not reimbursed. D0270 Bitewing - Single Film N/A Any additional films (D D0340) formed on the same date of service as a complete intraoral series, or its equivalent, are considered content of service of the complete series and are not reimbursed. Only one bitewing code (D0270, D0272, D0273, D0274, D0277) date of service, beneficiary, provider or provider billing group. D0272 Bitewings - Two Films N/A Any additional films (D D0340) formed on the same date of service as a complete intraoral series, or its equivalent, are considered content of service of the complete series and are not reimbursed. Only one bitewing code (D0270, D0272, D0273, D0274, D0277) date of service, beneficiary, provider or provider billing group. D0273 Bitewings - Three Films N/A Any additional films (D D0340) formed on the same date of service as a complete intraoral series, or its equivalent, are considered content of service of the complete series and are not reimbursed. Only one bitewing code (D0270, D0272, D0273, D0274, D0277) date of service, beneficiary, provider or provider billing group. D0274 Bitewings - Four Films N/A Any additional films (D D0340) formed on the same date of service as a complete intraoral series, or its equivalent, are considered content of service of the complete series and are not reimbursed. Only one bitewing code (D0270, D0272, D0273, D0274, D0277) date of service, beneficiary, provider or provider billing group. D0277 Vertical Bitewings - 7 To 8 Films N/A 0 20 Any additional films (D D0340) formed on the same date of service as a complete intraoral series, or its equivalent, are considered content of service of the complete series and are not reimbursed. Only one bitewing code (D0270, D0272, D0273, D0274, D0277) date of service, beneficiary, provider or provider billing group. Type

78 Benefit Plan Details and Requirements Title 19 Medicaid Adults s 21 and Over Title 19 Medicaid Children (s 0-20) and Title 19 Medicaid Adults (s 21 and Over) - Please note age limitations ****Codes with an 999 are covered for both children and adults and codes with an of 20 are covered for children only.**** Title 19 Adult s 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 beneficiary's oral health. Exams and radiographs are payable only when done in conjunction with or to determine if extractions are medically necessary. Code D0290 D0321 Code Description Posterior - Anterior Or Lateral Skull And Facial Bone Survey Film Other Temporomandibular Joint Films, By Report AUTHORIZATION REQUIREMENTS BENEFIT DETAILS ADDITIONAL NOTES Documents Min Count Length N/A 0 20 Any additional films (D D0340) formed on the same date of service as a complete intraoral series, or its equivalent, are considered content of service of the complete series and are not reimbursed. N/A 0 20 Any additional films (D D0340) formed on the same date of service as a complete intraoral series, or its equivalent, are considered content of service of the complete series and are not reimbursed. D0322 Tomographic Survey N/A 0 20 Any additional films (D D0340) formed on the same date of service as a complete intraoral series, or its equivalent, are considered content of service of the complete series and are not reimbursed. D0330 Panoramic Film N/A Month One 36 Months. The following are also considered an Intraoral Complete Series (D0210), D0330 and D0272, D0330 and D0273, D0330 and D0274, D0330 and D0277 D0460 Pulp Vitality Tests N/A Days imum of three teeth visit. Covered teeth are: 1-32, (SN), A - T, AS - TS (SN) D1110 Prophylaxis - Adult N/A Month One six Months. Includes scaling and polishing procedures to remove coronal plaque, calculus, and stains. D1120 Prophylaxis - Child N/A Month One six Months. Includes scaling and polishing procedures to remove coronal plaque, calculus, and stains. D1206 Topical Fluoride Varnish N/A Month D1208 Topical Application Fluoride N/A Month D1351 Sealant - Per N/A Month Sealants are reimbursable when placed on the occlusal or occlusal-buccal surfaces of lower 1st and 2nd manent molars or up 1st and 2nd manent molars as well as manent up and lower bicuspids. Teeth must be caries free. Sealant is not covered when placed over restorations. D1510 Space Maintainer - Fixed - Unilateral D1515 Space Maintainer - Fixed - Bilateral D1525 Space Maintainer - Removable - Bilateral D1550 Re-Cementation Of Space Maintainer N/A Month 1 12 Months quadrant.10 (UR), 20 (UL), 30 (LL),40 (LR) N/A Month 1 12 Months arch. 01 (UA), 02 (LA) N/A Month 1 12 Months arch. 01 (UA), 02 (LA) N/A 0 20 t covered within 6 Months of initial placement within quadrant or arch. 10 (UR), 20 (UL),30 (LL),40 (LR), 01 (UA), 02 (LA) Type , Scion Dental, Inc. PROPRIETARY AND CONFIDENTIAL Dental Health & Wellness

79 Benefit Plan Details and Requirements Title 19 Medicaid Adults s 21 and Over Title 19 Medicaid Children (s 0-20) and Title 19 Medicaid Adults (s 21 and Over) - Please note age limitations ****Codes with an 999 are covered for both children and adults and codes with an of 20 are covered for children only.**** Title 19 Adult s 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 beneficiary's oral health. Exams and radiographs are payable only when done in conjunction with or to determine if extractions are medically necessary. Code D2140 D2150 D2160 D2161 Code Description Amalgam - One Surface, Primary Or Permanent Amalgam - Two Surfaces, Primary Or Permanent Amalgam - Three Surfaces, Primary Or Permanent Amalgam - Four Or More Surfaces, Primary Or Permanent D2330 Resin-Based Composite - One Surface, Anterior D2331 Resin-Based Composite - Two Surfaces, Anterior D2332 Resin-Based Composite - Three Surfaces, Anterior D2335 Resin-Based Composite - Four Or More Surfaces Or Involving Incisal Angle D2390 Resin-Based Composite Crown, Anterior D2391 Resin-Based Composite - One Surface, Posterior D2392 Resin-Based Composite - Two Surfaces, Posterior D2393 Resin-Based Composite - Three Surfaces, Posterior D2394 Resin-Based Composite - Four Or More Surfaces, Posterior D2710 Crown - Resin-Based Composite (Indirect) AUTHORIZATION REQUIREMENTS BENEFIT DETAILS ADDITIONAL NOTES Documents Min Count N/A Month Teeth Covered:1-32,51-82 (SN),A - T,AS - TS (SN) N/A Month Teeth Covered:1-32,51-82 (SN),A - T,AS - TS (SN) N/A Month Teeth Covered:1-32,51-82 (SN),A - T,AS - TS (SN) N/A Month Teeth Covered:1-32,51-82 (SN),A - T,AS - TS (SN) Length N/A Month Teeth Covered:6-11, 22-27, (SN), (SN), C - H, M - R, CS - HS (SN), MS - RS (SN) N/A Month Teeth Covered:6-11, 22-27, (SN), (SN), C - H, M - R, CS - HS (SN), MS - RS (SN) N/A Month Teeth Covered:6-11, 22-27, (SN), (SN), C - H, M - R, CS - HS (SN), MS - RS (SN) N/A Month Teeth Covered:6-11, 22-27, (SN), (SN), C - H, M - R, CS - HS (SN), MS - RS (SN) N/A Month Teeth Covered:6-11, 22-27, (SN), (SN), C - H, M - R, CS - HS (SN), MS - RS (SN) N/A Month Teeth Covered:1-5, 12-21, 28-32, (SN), (SN), (SN,) A, B, I - L, S, T, AS (SN), BS (SN), IS - LS (SN), SS (SN),TS (SN) N/A Month Teeth Covered:1-5, 12-21, 28-32, (SN), (SN), (SN,) A, B, I-L, S, T, AS (SN), BS (SN), IS-LS (SN), SS (SN),TS (SN) N/A Month Teeth Covered:1-5, 12-21, 28-32, (SN), (SN), (SN,) A, B, I - L, S, T, AS (SN), BS (SN), IS - LS (SN), SS (SN),TS (SN) N/A Month Teeth Covered:1-5, 12-21, 28-32, (SN), (SN), (SN,) A, B, I - L, S, T, AS (SN), BS (SN), IS - LS (SN), SS (SN),TS (SN) for beneficiaries aged 0-20 Preoative radiographs of adjacent and opposing teeth. If a tooth has had RCT, a postendodontic radiograph is also required showing the entire tooth, Type Month Teeth Covered: 6 11, 22 27, (SN), (SN) t a covered benefit for Beneficiaries aged 21 and older , Scion Dental, Inc. PROPRIETARY AND CONFIDENTIAL Dental Health & Wellness 73

80 Benefit Plan Details and Requirements Title 19 Medicaid Adults s 21 and Over Title 19 Medicaid Children (s 0-20) and Title 19 Medicaid Adults (s 21 and Over) - Please note age limitations ****Codes with an 999 are covered for both children and adults and codes with an of 20 are covered for children only.**** Title 19 Adult s 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 beneficiary's oral health. Exams and radiographs are payable only when done in conjunction with or to determine if extractions are medically necessary. Code D2740 D2751 D2752 Code Description Crown - Porcelain/Ceramic Substrate Crown - Porcelain Fused To Predominantly Base Metal Crown - Porcelain Fused To ble Metal D2783 Crown - 3/4 Porcelain/Ceramic D2791 D2792 D2910 Crown - Full Cast Predominantly Base Metal Crown - Full Cast ble Metal Recement Inlay, Onlay, Or Partial Coverage Restoration for beneficiaries aged 0-20 for beneficiaries aged 0-20 for beneficiaries aged 0-20 for beneficiaries aged 0-20 for beneficiaries aged 0-20 for beneficiaries aged 0-20 AUTHORIZATION REQUIREMENTS BENEFIT DETAILS ADDITIONAL NOTES Documents Preoative radiographs of adjacent and opposing teeth. If a tooth has had RCT, a postendodontic radiograph is also required showing the entire tooth, Preoative radiographs of adjacent and opposing teeth. If a tooth has had RCT, a postendodontic radiograph is also required showing the entire tooth, Preoative radiographs of adjacent and opposing teeth. If a tooth has had RCT, a postendodontic radiograph is also required showing the entire tooth, Preoative radiographs of adjacent and opposing teeth. If a tooth has had RCT, a postendodontic radiograph is also required showing the entire tooth, Preoative radiographs of adjacent and opposing teeth. If a tooth has had RCT, a postendodontic radiograph is also required showing the entire tooth, Preoative radiographs of adjacent and opposing teeth. If a tooth has had RCT, a postendodontic radiograph is also required showing the entire tooth, Min Count Length Type Month Teeth Covered: 1 32, 51 82(SN) Month Teeth Covered: 1 32, (SN) Month Teeth Covered: 1 32, (SN) Month Teeth Covered: 1 32, (SN) Month Teeth Covered: 1 32, (SN) Month Teeth Covered: 1 32, (SN) N/A 0 20 Teeth Covered: 1 32, (SN) D2920 Recement Crown N/A 0 20 Teeth Covered: 1 32, (SN) , Scion Dental, Inc. PROPRIETARY AND CONFIDENTIAL Dental Health & Wellness

81 Benefit Plan Details and Requirements Title 19 Medicaid Adults s 21 and Over Title 19 Medicaid Children (s 0-20) and Title 19 Medicaid Adults (s 21 and Over) - Please note age limitations ****Codes with an 999 are covered for both children and adults and codes with an of 20 are covered for children only.**** Title 19 Adult s 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 beneficiary's oral health. Exams and radiographs are payable only when done in conjunction with or to determine if extractions are medically necessary. Code D2921 D2930 D2931 D2934 Code Description Reattachment of tooth fragment, incisal edge or cusp Prefabricated Stainless Steel Crown - Primary Prefabricated Stainless Steel Crown - Permanent Prefabricated Esthetic Coated Stainless Steel Crown - Primary AUTHORIZATION REQUIREMENTS BENEFIT DETAILS ADDITIONAL NOTES Documents Pre- and post-oative radiographic images shall be maintained in beneficiary records. Min , Scion Dental, Inc. PROPRIETARY AND CONFIDENTIAL Dental Health & Wellness 75 Count Length Type 0 20 Teeth Covered: 1 32, (SN), t allowed same tooth, same surface(s), same DOS as D2140, D2150, D2160, D2161, D2330, D2331, D2332, D2335, D2391, D2392 D2393 D2394. N/A Month Teeth Covered: A T, AS - TS (SN) D2930 and D2934 cannot be placed on the same tooth during a 24-Month iod. N/A Month Teeth Covered: 1 32, (SN) N/A Month Teeth Covered: C - H, M -R, CS - HS (SN), MS - RS (SN) D2930 and D2934 cannot be placed on the same tooth during the 24-Month iod. D2940 Protective Restoration N/A 0 20 Teeth Covered: 1 32, (SN) Temporary restoration intended to relieve pain. t to be used as a base or liner under a restoration. D2951 D2954 D2957 D3110 Pin Retention - Per, In Addition To Restoration Prefabricated Post And Core In Addition To Crown Each Additional Prefabricated Post - Same Pulp Cap - Direct (Excluding Final Restor.) N/A 0 20 Teeth Covered: 1 32, (SN) for beneficiaries aged 0-20 Pre-op x-rays of adj and opposing teeth, fill x-ray and narrative of medical necessity submitted Pre-op x-rays of adj and opposing teeth, fill x-ray and narrative of medical necessity submitted Month Teeth Covered: 1 32, (SN) Month Teeth Covered: 1 3, 14 19, 30 32, (SN), (SN), (SN) N/A 0 20 Teeth Covered: 1 32, (SN) D3220 Therapeutic Pulpotomy N/A Lifetime D3221 Pulpal Debridement - Primary And Permanent Teeth D3222 D3310 Partial Pulpotomy For Apexogenesis - Permanent Endodontic Therapy, Anterior (Excluding Final Restoration) N/A Lifetime Pre-oative x-rays (excluding bitewings) Lifetime N/A Lifetime Teeth Covered: 1 32, (SN), A T, AS TS t covered within 30 days of D3310-D3331 on same tooth. Teeth Covered: 1 32, (SN), A T, AS TS t covered within 30 days of D3310-D3331 on same tooth. Teeth Covered: 1 32, (SN) Should only be formed as preparation for endodontic treatment. Teeth Covered: 6 11, 22 27, (SN), (SN)

82 Benefit Plan Details and Requirements Title 19 Medicaid Adults s 21 and Over Title 19 Medicaid Children (s 0-20) and Title 19 Medicaid Adults (s 21 and Over) - Please note age limitations ****Codes with an 999 are covered for both children and adults and codes with an of 20 are covered for children only.**** Title 19 Adult s 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 beneficiary's oral health. Exams and radiographs are payable only when done in conjunction with or to determine if extractions are medically necessary. Code D3320 D3330 D3331 Code Description Endodontic Therapy, Bicuspid (Excluding Final Restoration) Endodontic Therapy, Molar (Excluding Final Restoration) Treatment Of Root Canal Obstruction; n-surgical Access D3351 Apexification / Recalcification / Pulpal Regeneration - Initial Visit D3352 Apexification / Recalcification / Pulpal Regeneration - Interim D3353 Apexification / Recalcification / Pulpal Regeneration - Final Visit D3410 D3421 D3425 D3426 D3427 D3430 D4210 Apicoectomy / Periradicular Surgery - Anterior Apicoectomy / Periradicular Surgery - Bicuspid (First Root) Apicoectomy / Periradicular Surgery - Molar (First Root) Apicoectomy / Periradicular Surgery - Each Additional Root) Periradicular surgery without apicoectomy Retrograde Filling - Per Root Gingivectomy Or Gingivoplasty - Four Or More Contiguous Teeth AUTHORIZATION REQUIREMENTS BENEFIT DETAILS ADDITIONAL NOTES Documents Min , Scion Dental, Inc. PROPRIETARY AND CONFIDENTIAL Dental Health & Wellness Count Length Type N/A Lifetime N/A Lifetime for beneficiaries aged 0-20 Pre-oative x-rays (excluding bitewings) and narrative of medical necessity, submitted. Pre- and postoative radiographs shall be maintained in beneficiary records Pre- and postoative radiographs shall be maintained in beneficiary records Pre- and postoative radiographs shall be maintained in beneficiary records Pre- and postoative radiographs shall be maintained in beneficiary records Teeth Covered: 4, 5, 12, 13, 20, 21, 28, 29, 54 (SN), 55 (SN), 62 (SN), 63 (SN) 70 (SN), 71 (SN), 78 (SN), 79 (SN) Teeth Covered: 1-3, 14 19, 30 32, (SN), (SN), (SN) 0 20 Teeth Covered: 1 32, (SN) 0 20 Teeth Covered: 1 32, (SN) 0 20 Teeth Covered: 1 32, (SN) 0 20 Teeth Covered: 1 32, (SN) 0 20 Teeth Covered: 6 11, 22 27, (SN),72-77 (SN) N/A 0 20 Teeth Covered: 4, 5, 12, 13, 20, 21, 28, 29, 54 (SN), 55 (SN), 62 (SN), 63 (SN), 70 (SN), 71 (SN), 78 (SN), 79 (SN) N/A 0 20 Teeth Covered: 1-3, 14 19, 30 32, (SN), (SN), (SN) N/A 0 20 Teeth Covered: 1-5, 12 21, 28 32, (SN), (SN), (SN) Pre- and post-oative radiographs shall be maintained in beneficiary records Pre- and postoative radiographs shall be maintained in beneficiary records Pre-op x-rays, io charting, treatment plan and narrative of medical necessity, submitted Teeth Covered: 1-32, (SN), t allowed same tooth, same DOS as D3410, D3421, D3425, D Teeth Covered: 1 32, (SN) 0 20 Per quadrant:10 (UR), 20 (UL), 30 (LL), 40 (LR) A minimum of four affected teeth in the quadrant.

83 Benefit Plan Details and Requirements Title 19 Medicaid Adults s 21 and Over Title 19 Medicaid Children (s 0-20) and Title 19 Medicaid Adults (s 21 and Over) - Please note age limitations ****Codes with an 999 are covered for both children and adults and codes with an of 20 are covered for children only.**** Title 19 Adult s 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 beneficiary's oral health. Exams and radiographs are payable only when done in conjunction with or to determine if extractions are medically necessary. Code D4211 D4230 D4231 D4268 D4341 D4342 Code Description Gingivectomy Or Gingivoplasty - One To Three Contiguous Teeth Anatomical Crown Exposure - Four Or More Contiguous Teeth Per Quadrant Anatomical Crown Exposure - One To Three Teeth Per Quadrant Surgical Revision Procedure, Per ontal Scaling And Root Planing - Four Or More Teeth Per Quadrant ontal Scaling And Root Planing - One To Three Teeth Per Quadrant AUTHORIZATION REQUIREMENTS BENEFIT DETAILS ADDITIONAL NOTES Documents Pre-op x-rays, io charting, treatment plan and narrative of medical necessity, submitted. Pre-op x-rays, io charting, and narrative of medical necessity, photo (optional), submitted. Pre-op x-rays, io charting, and narrative of medical necessity, photo (optional), submitted. Pre-oative x-rays and narrative of medical necessity submitted. ontal charting and pre-op x-rays, and treatment plan submitted. There must be radiographic evidence of root calculus or noticeable loss of bone support. ontal charting and pre-op x-rays, and treatment plan submitted. There must be radiographic evidence of root calculus or noticeable loss of bone support. D4355 Full Mouth Debridement Documentation of medical necessity shall be maintained in beneficiary records. D5110 Complete Denture - illary D5120 Complete Denture - Mandibular D5211 illary Partial Denture - Resin Base D5212 Mandibular Partial Denture - Resin Base Pre op x-rays, treatment plan Pre op x-rays, treatment plan Pre-op x-rays of adj and opposing teeth, trmt plan with claim Pre-op x-rays of adj and opposing teeth, trmt plan with claim Min Count Length Type 0 20 Per quadrant:10 (UR), 20 (UL), 30 (LL), 40 (LR) One to three affected teeth in the quadrant Per quadrant:10 (UR), 20 (UL), 30 (LL), 40 (LR) Must be billed same date same tooth in conjunction with the restorative codes (D2140-D2957) Per quadrant:10 (UR), 20 (UL), 30 (LL), 40 (LR) Same date and same tooth in conjunction with the restorative code Teeth Covered: 1 32, (SN) Only covered after D Month Per quadrant:10 (UR), 20 (UL), 30 (LL), 40 (LR) A minimum of four affected teeth in the quadrant Month Per quadrant: 10 (UR), 20 (UL), 30 (LL),40 (LR) One to three affected teeth in the quadrant Month Month Month Month Month , Scion Dental, Inc. PROPRIETARY AND CONFIDENTIAL Dental Health & Wellness 77

84 Benefit Plan Details and Requirements Title 19 Medicaid Adults s 21 and Over Title 19 Medicaid Children (s 0-20) and Title 19 Medicaid Adults (s 21 and Over) - Please note age limitations ****Codes with an 999 are covered for both children and adults and codes with an of 20 are covered for children only.**** Title 19 Adult s 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 beneficiary's oral health. Exams and radiographs are payable only when done in conjunction with or to determine if extractions are medically necessary. Code Code Description D5213 illary Partial Denture - Cast Metal Framework With Resin Denture Bases D5214 Mandibular Partial Denture - Cast Metal Framework With Resin Denture Bases D5225 illary Partial Denture - Flexible Base D5226 Mandibular Partial Denture - Flexible Base D5281 Removable Unilateral Partial Denture - One Piece Cast Metal D5410 Adjust Complete Denture - illary D5411 Adjust Complete Denture - Mandibular D5421 Adjust Partial Denture - illary D5422 Adjust Partial Denture - Mandibular D5510 D5520 Repair Broken Complete Denture Base Replace Missing Or Broken Teeth - Complete Denture (Each ) AUTHORIZATION REQUIREMENTS BENEFIT DETAILS ADDITIONAL NOTES Documents Pre-op x-rays of adj and opposing teeth, trmt plan with claim Pre-op x-rays of adj and opposing teeth, trmt plan with claim Pre-op x-rays of adj and opposing teeth, trmt plan with claim Pre-op x-rays of adj and opposing teeth, trmt plan with claim Pre-op x-rays of adj and opposing teeth, trmt plan with claim Min , Scion Dental, Inc. PROPRIETARY AND CONFIDENTIAL Dental Health & Wellness Count Length Type Month Month Month Month Month Per quadrant:10 (UR), 20 (UL), 30 (LL), 40 (LR) N/A 0 20 t covered within 6 Months of placement. N/A 0 20 t covered within 6 Months of placement. N/A 0 20 t covered within 6 Months of placement. N/A 0 20 t covered within 6 Months of placement. N/A 0 20 Area covered:01 (UA), 02 (LA) N/A 0 20 Teeth Covered: 1-32 D5610 Repair Resin Denture Base N/A 0 20 Area covered:01 (UA),02 (LA),10 (UR),20 (UL), 0 (LL),40 (LR) D5620 Repair Cast Framework N/A 0 20 Area covered:01 (UA),02 (LA),10 (UR) 20 (UL),30 (LL), 40 (LR) D5630 D5640 D5650 D5660 Repair Or Replace Broken Clasp Replace Broken Teeth - Per Add To Existing Partial Denture Add Clasp To Existing Partial Denture N/A 0 20 Area covered:01 (UA),02 (LA),10 (UR),20 (UL),30 (LL), 40 (LR) N/A 0 20 Teeth Covered: 1-32 N/A 0 20 Teeth Covered: 1-32 N/A 0 20 Area covered: 01 (UA), 02 (LA), 10 (UR), 20 (UL), 30 (LL), 40 (LR)

85 Benefit Plan Details and Requirements Title 19 Medicaid Adults s 21 and Over Title 19 Medicaid Children (s 0-20) and Title 19 Medicaid Adults (s 21 and Over) - Please note age limitations ****Codes with an 999 are covered for both children and adults and codes with an of 20 are covered for children only.**** Title 19 Adult s 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 beneficiary's oral health. Exams and radiographs are payable only when done in conjunction with or to determine if extractions are medically necessary. Code D5670 D5671 D5750 D5751 D5760 D5761 D5850 D5851 Code Description Replace All Teeth And Acrylic On Cast Metal Framework (illary) Replace All Teeth And Acrylic On Cast Metal Framework (Mandibular) Reline Complete illary Denture (Laboratory) Reline Complete Mandibular Denture (Laboratory) Reline illary Partial Denture (Laboratory) Reline Mandibular Partial Denture (Laboratory) Tissue Conditioning, illary Tissue Conditioning, Mandibular D6100 Implant Removal, By Report D6930 D7140 D7210 D7220 D7230 D7240 Recement Fixed Partial Denture Extraction, Erupted Or Exposed Root Surgical Removal Or Erupted Removal Of Impacted - Soft Tissue Removal Of Impacted - Partially Bony Removal Of Impacted - Completely Bony AUTHORIZATION REQUIREMENTS BENEFIT DETAILS ADDITIONAL NOTES Documents Min N/A 0 20 N/A 0 20 Count N/A Month t covered within 24 Months of placement. N/A Month t covered within 24 Months of placement. N/A Month t covered within 24 Months of placement. N/A Month t covered within 24 Months of placement. N/A 0 20 N/A 0 20 Pre-op & post-op x-rays, narr of med nec Length Type 0 20 Teeth Covered: 1 32, (SN) N/A 0 20 Area covered:01 (UA), 02 (LA), 10 (UR), 20 (UL), 30 (LL), 40 (LR) N/A Lifetime N/A Lifetime Pre-op x-rays (excluding bitewings) and narr of med nec Pre-op x-rays (excluding bitewings) and narr of med nec Pre-op x-rays (excluding bitewings) and narr of med nec Lifetime Lifetime Lifetime Teeth Covered: 1 32, (SN), A T, AS - TS (SN) Removal of asymptomic tooth not covered. Teeth Covered: 1 32, (SN), A T, AS - TS (SN) Removal of asymptomic tooth not covered. Includes cutting of gingiva and bone, removal of tooth structure, and closure. Teeth Covered: 1 32, (SN) Removal of asymptomic tooth not covered. Includes cutting of gingiva and bone, removal of tooth structure, and closure. Teeth Covered: 1 32, (SN) Removal of asymptomic tooth not covered. Includes cutting of gingiva and bone, removal of tooth structure, and closure. Teeth Covered: 1 32, (SN) Removal of asymptomic tooth not covered. Includes cutting of gingiva and bone, removal of tooth structure, and closure , Scion Dental, Inc. PROPRIETARY AND CONFIDENTIAL Dental Health & Wellness 79

86 Benefit Plan Details and Requirements Title 19 Medicaid Adults s 21 and Over Title 19 Medicaid Children (s 0-20) and Title 19 Medicaid Adults (s 21 and Over) - Please note age limitations ****Codes with an 999 are covered for both children and adults and codes with an of 20 are covered for children only.**** Title 19 Adult s 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 beneficiary's oral health. Exams and radiographs are payable only when done in conjunction with or to determine if extractions are medically necessary. Code D7241 D7250 Code Description Removal Of Impacted - Completely Bony, Unusual Surgical Complications Surgical Removal Of Residual (Cutting Procedure) D7260 Oroantral Fistula Closure D7270 D7280 Reimplantation And/Or Stabilization Of Accidentally Evulsed / Displaced Surgical Access Of An Unerupted D7285 Biopsy Of Oral Tissue - Hard (Bone, ) AUTHORIZATION REQUIREMENTS BENEFIT DETAILS ADDITIONAL NOTES Documents Pre-op x-rays (excluding bitewings) and narr of med nec Preoative radiographs and narrative of medical necessity shall be maintained in beneficiary records. Pre- and post- oative radiographs and narrative of medical necessity submitted with claim. Min Count Length Type Lifetime Lifetime Lifetime N/A Lifetime Pre-op x-rays, narr of med nec Pathology report should be kept in beneficiary record. D7286 Biopsy Of Oral Tissue - Soft Pathology report should be kept in beneficiary record. D7320 D7350 D7410 D7411 D7412 D7413 Alveoloplasty t In Conjunction With Extractions - Four Or More Teeth Vesibuloplasty - Ridge Extension (Including Soft Tissue Grafts) Excision Of Benign Lesion Up To 1.25 Cm Excision Of Benign Lesion Greater Than 1.25 Cm Excision Of Benign Lesion, Complicated Excision Of Malignant Lesion Up To 1.25 Cm Pre-op x-rays, narr of med nec Pre-op x-rays, narr of med nec Lifetime N/A N/A Days N/A Days N/A Teeth Covered: 1 32, (SN) Removal of asymptomic tooth not covered. Includes cutting of gingiva and bone, removal of tooth structure, and closure. Unusual complications such as nerve dissection, separate closure of the maxillary sinus, or aberrant tooth position. Teeth Covered: 1 32, (SN), A - T. AS - TS (SN) Includes cutting of gingiva and bone, removal of tooth structure, and closure. Will not be paid to the providers or group that originally removed the tooth. Teeth Covered: 1 32, (SN), A T, AS - TS (SN) Includes splinting and/or stabilization. Teeth Covered: 1 32, (SN) Will not be payable unless the orthodontic treatment has been authorized as a covered benefit Per quadrant:10 (UR), 20 (UL), 30 (LL), 40 (LR) extractions formed in an edentulous area. t covered when formed on the same day as an extraction for the same tooth Per quadrant:10 (UR), 20 (UL), 30 (LL), 40 (LR) , Scion Dental, Inc. PROPRIETARY AND CONFIDENTIAL Dental Health & Wellness

87 Benefit Plan Details and Requirements Title 19 Medicaid Adults s 21 and Over Title 19 Medicaid Children (s 0-20) and Title 19 Medicaid Adults (s 21 and Over) - Please note age limitations ****Codes with an 999 are covered for both children and adults and codes with an of 20 are covered for children only.**** Title 19 Adult s 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 beneficiary's oral health. Exams and radiographs are payable only when done in conjunction with or to determine if extractions are medically necessary. Code D7414 D7415 D7440 D7441 D7450 D7451 D7460 D7461 D7471 Code Description Excision Of Malignant Lesion Greater Than 1.25 Cm Excision Of Malignant Lesion, Complicated Excision Of Malignant Tumor - Lesion Diameter Up To 1.25 Cm Excision Of Malignant Tumor - Lesion Diameter Greater Than 1.25 Cm Removal Of Benign Odontogenic Cyst Or Tumor - Dia Up To 1.25 Cm Removal Of Benign Odontogenic Cyst Or Tumor Dia Greater Than 1.25 Cm Removal Of Benign nodontogenic Cyst Or Tumor - Dia Up To 1.25 Cm Removal Of Benign nodontogenic Cyst Or Tumor - Dia Greater Than 1.25 Cm Removal Of Lateral Exostosis (illa Or Mandible) AUTHORIZATION REQUIREMENTS BENEFIT DETAILS ADDITIONAL NOTES Documents Min N/A N/A N/A N/A N/A N/A N/A N/A D7472 Removal Of Torus Palatinus D7473 D7490 D7510 D7511 Removal Of Torus Mandibularis Radical Resection Of illa Or Mandible Incision And Drainage Of Abscess - Intraoral Soft Tissue Incision And Drainage Of Abscess - Intraoral Soft Tissue - Complicated Pre-op x-rays, narr of med nec Pre-op x-rays, narr of med nec Pre-op x-rays, narr of med nec Pre-op x-rays, narr of med nec Count Length Type Once Lifetime Once Lifetime Once Lifetime Area Covered:01 (UA), 02 (LA) Area Covered:01 (UA), 02 (LA) N/A t covered same date of service as D7511 N/A , Scion Dental, Inc. PROPRIETARY AND CONFIDENTIAL Dental Health & Wellness 81

88 Benefit Plan Details and Requirements Title 19 Medicaid Adults s 21 and Over Title 19 Medicaid Children (s 0-20) and Title 19 Medicaid Adults (s 21 and Over) - Please note age limitations ****Codes with an 999 are covered for both children and adults and codes with an of 20 are covered for children only.**** Title 19 Adult s 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 beneficiary's oral health. Exams and radiographs are payable only when done in conjunction with or to determine if extractions are medically necessary. Code D7520 D7521 D7530 D7540 D7550 D7560 D7610 D7620 D7630 D7640 D7650 D7660 D7670 Code Description Incision And Drainage Of Abscess - Extraoral Soft Tissue Incision And Drainage Of Abscess - Extraoral Soft Tissue - Complicated Removal Of Foreign Body From Mucosa Removal Of Reaction Producing Foreign Bodies Partial Ostectomy/ Sequestrectomy For Removal Of n-vital Bone illary Sinusotomy For Removal Of Fragment Or Foreign Body illa - Open Reduction (Teeth Immobilized, If Present) illa - Closed Reduction (Teeth Immobilized, If Present) Mandible - Open Reduction (Teeth Immobilized, If Present) Mandible - Closed Reduction (Teeth Immobilized, If Present) Malar And/Or Zygomatic Arch - Open Reduction Malar And/Or Zygomatic Arch - Closed Reduction Alveolus - Closed Reduction, May Include Stabilization Of Teeth AUTHORIZATION REQUIREMENTS BENEFIT DETAILS ADDITIONAL NOTES Documents Min Count N/A t covered same date of service as D7521. N/A N/A N/A N/A Pre- and postoative radiographs along with narrative of medical necessity must be submitted N/A N/A N/A N/A N/A N/A N/A Teeth Covered: 1 32 May include stabilization. Length Type , Scion Dental, Inc. PROPRIETARY AND CONFIDENTIAL Dental Health & Wellness

89 Benefit Plan Details and Requirements Title 19 Medicaid Adults s 21 and Over Title 19 Medicaid Children (s 0-20) and Title 19 Medicaid Adults (s 21 and Over) - Please note age limitations ****Codes with an 999 are covered for both children and adults and codes with an of 20 are covered for children only.**** Title 19 Adult s 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 beneficiary's oral health. Exams and radiographs are payable only when done in conjunction with or to determine if extractions are medically necessary. AUTHORIZATION REQUIREMENTS BENEFIT DETAILS ADDITIONAL NOTES Code Code Description Documents Min Count Length Type D7680 Facial Bones - Complicated Reduction With Fixation And Multiple Surgical Pre- and postoative radiographs along with narrative of medical necessity must be submitted D7710 illa - Open Reduction N/A D7720 illa - Closed Reduction N/A D7730 Mandible - Open Reduction Postoative radiographs must be available in the beneficiary records D7740 Mandible-Closed Reduction N/A D7750 D7760 D7770 D7780 D7820 Malar And/Or Zygomatic Arch - Open Reduction Malar And/Or Zygomatic Arch - Closed Reduction Alveolus - Open Reduction Stabilization Of Teeth Facial Bones - Complicated Reduction With Fixation And Multiple Surgical Closed Reduction Of Dislocation D7860 Arthrotomy D7865 Arthroplasty D7910 D7911 Suture Of Recent Small Wounds Up To 5 Cm Complicated Suture - Up To 5 Cm D7912 Complicated Suture - Greater Than 5 Cm D7920 Skin Graft (Identify Defect Covered, Location And Type Of Graft) N/A N/A N/A N/A N/A Pre-op & post-op x-rays, narr of med nec Pre- and postoative radiographs along with narrative of medical necessity must be submitted N/A t covered on dame day as D7140, D7210, D7220, D7230, D7240, D7241, or D7250. N/A t covered on dame day as D7140, D7210, D7220, D7230, D7240, D7241, or D7250. N/A t covered on dame day as D7140, D7210, D7220, D7230, D7240, D7241, or D7250. Pre-op & post-op x-rays, narr of med nec Area covered:01 (UA), 02 (LA), 10 (UR), 20 (UL), 30 (LL), 40 (LR) , Scion Dental, Inc. PROPRIETARY AND CONFIDENTIAL Dental Health & Wellness 83

90 Benefit Plan Details and Requirements Title 19 Medicaid Adults s 21 and Over Title 19 Medicaid Children (s 0-20) and Title 19 Medicaid Adults (s 21 and Over) - Please note age limitations ****Codes with an 999 are covered for both children and adults and codes with an of 20 are covered for children only.**** Title 19 Adult s 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 beneficiary's oral health. Exams and radiographs are payable only when done in conjunction with or to determine if extractions are medically necessary. Code D7955 D7960 Code Description Repair Of illofacial Soft And/Or Hard Tissue Defect Frenulectomy - Also Known As Frenectomy Or Frenotomy - Separate Procedure AUTHORIZATION REQUIREMENTS BENEFIT DETAILS ADDITIONAL NOTES Documents Pre- and postoative radiographs along with narrative of medical necessity must be submitted. Min 0 20 Count Length N/A Lifetime Area Covered:01 (UA), 02 (LA) t covered same date of service as D7963. The frenum may be excised when the tongue has limited mobility; for large diastemas between teeth, or when the frenum interferes with a prosthetic appliance; or when it is the etiology of iodontal tissue disease. D7963 Frenuloplasty N/A Excision of frenum with the excision or repositioning of abervant muscle and z-plasty or other local flap closure. D7971 Excision Of Pericoronal Gingiva N/A Teeth Covered: 1-32 D7980 Sialolithotomy N/A D7981 Excision Of Salivary Gland, By Report N/A D7982 Sialodochoplasty N/A D7983 Closure Of Salivary Fistula Narrative of medical necessity, x-rays or photos optional, submitted D7990 Emergency Tracheotomy N/A Type D8010 D8020 D8050 D8060 D8070 Limited Orthodontic Treatment Of The Primary Dentition Limited Orthodontic Treatment Of The Transitional Dentition Interceptive Orthodontic Treatment Of The Primary Dentition Interceptive Orthodontic Treatment Of The Transitional Dentition Comprehensive Orthodontic Treatment Of The Transitional Dentition Yes-Prior Yes-Prior Yes-Prior Yes-Prior Yes-Prior Pan and/or cephalometric x-ray, diag quality photos, narr of med nec / trm plan Pan and/or cephalometric x-ray, diag quality photos, narr of med nec / trm plan Pan and/or cephalometric x-ray, diag quality photos, narr of med nec / trm plan Pan and/or cephalometric x-ray, diag quality photos, narr of med nec / trm plan Pan and/or cephalometric x-ray, diag quality photos, narr of med nec / trm plan 0 20 Limited to one replacement. Limited orthodontic treatment requires prior authorization and is only covered for eligible children with documented medical necessity Limited to one replacement. Limited orthodontic treatment requires prior authorization and is only covered for eligible children with documented medical necessity Interceptive orthodontic treatment requires prior authorization and is only covered for eligible children with documented medical necessity Interceptive orthodontic treatment requires prior authorization and is only covered for eligible children with documented medical necessity Comprehensive orthodontic treatment requires prior authorization and is only covered for eligible children with documented medical necessity , Scion Dental, Inc. PROPRIETARY AND CONFIDENTIAL Dental Health & Wellness

91 Benefit Plan Details and Requirements Title 19 Medicaid Adults s 21 and Over Title 19 Medicaid Children (s 0-20) and Title 19 Medicaid Adults (s 21 and Over) - Please note age limitations ****Codes with an 999 are covered for both children and adults and codes with an of 20 are covered for children only.**** Title 19 Adult s 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 beneficiary's oral health. Exams and radiographs are payable only when done in conjunction with or to determine if extractions are medically necessary. Code D8080 D8210 Code Description Comprehensive Orthodontic Treatment Of The Adolescent Dentition Removable Appliance Therapy Yes-Prior Yes-Prior D8220 Fixed Appliance Therapy Yes-Prior D8999 D9212 D9220 D9221 D9230 D9241 D9242 D9310 D9410 Unspecified Orthodontic Procedure, By Report Trigeminal Division Block Anesthesia Deep Sedation/General Anesthesia - First 30 Minutes Deep Sedation/General Anesthesia - Each Additional 15 Minutes Inhalation Of Nitrous /Analgesia, Anxiolysis Intravenous Conscious Sedation/Analgesia - First 30 Minutes Intravenous Conscious Sedation/Analgesia - Each Additional 15 Minutes Consultation - Diagnostic Service Provided By Dentist Or Physician House/Extended Care Facility Call Yes-Prior for beneficiaries aged AUTHORIZATION REQUIREMENTS BENEFIT DETAILS ADDITIONAL NOTES Documents Pan and/or cephalometric x-ray, diag quality photos, narr of med nec / trm plan Pan and/or cephalometric x-ray, diag quality photos, narr of med nec / trm plan Pan and/or cephalometric x-ray, diag quality photos, narr of med nec / trm plan Description of procedure and narrative of medical necessity Narrative of medical necessity Narrative of medical necessity and treatment plan Narrative of medical necessity and treatment plan Narrative of medical necessity shall be maintained in beneficiary records. Narrative of medical necessity and treatment plan Narrative of medical necessity and treatment plan Narrative of the consultation for dental services shall be maintained in beneficiary records. Narrative of medical necessity shall be maintained in beneficiary records. Min Count Length Type 0 20 Comprehensive orthodontic treatment requires prior authorization and is only covered for eligible children with documented medical necessity Limited to one replacement. Removable appliance therapy requires prior authorization and is only covered for eligible children with documented medical necessity Limited to one replacement. Removable appliance therapy requires prior authorization and is only covered for eligible children with documented medical necessity All orthodontic treatment requires prior authorization and is only covered for eligible children with documented medical necessity For Beneficiary under age 21 a description and dosage of drug shall be maintained in the beneficiaries records, no Retro required D9220 and D9221 are only billable when dental services other then ONLY diagnostic are provided on the same date of service D9220 and D9221 are only billable when dental services other then ONLY diagnostic are provided on the same date of service t covered when billed with only diagnostic and/or preventative services (D0120 through D1208, D1515 through D1550, D9410, D9420) Month D9310 is billable when ONLY diagnostic services are provided on the same date of service. One 12 Months by same provider. One inpatient follow up beneficiary within a 10 day iod by same provider. t covered on the same date of service as D0120-D0170, D9410, D Extended Care Facilities only , Scion Dental, Inc. PROPRIETARY AND CONFIDENTIAL Dental Health & Wellness 85

92 Benefit Plan Details and Requirements ICF/MR Adults s 21 and Over Title 19 Medicaid Children (s 0-20) and Title 19 Medicaid Adults (s 21 and Over) - Please note age limitations ****Codes with an 999 are covered for both children and adults and codes with an of 20 are covered for children only.**** Title 19 Adult s 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 beneficiary's oral health. Exams and radiographs are payable only when done in conjunction with or to determine if extractions are medically necessary. Code D9420 D9610 D9920 D9999 Code Description Hospital Or Ambulatory Surgical Center Call Therapeutic Parenteral Drug, Single Administration Behavior Management, By Report Unspecified Adjunctive Procedure, By Report for beneficiaries aged AUTHORIZATION REQUIREMENTS BENEFIT DETAILS ADDITIONAL NOTES Documents Narrative of medical necessity shall be maintained in beneficiary records. Narrative of medical necessity and description and dosage of drug submitted. Narrative of medical necessity Description of procedure and narrative of medical necessity, submitted Min Count Length Type Hospital Facilities only For Beneficiary under age 21, a narrative of medical necessity shall be maintained in beneficiary records, no Retro required Effective with dates of service on and after July 1, 2011, registered dental hygienists with an extended care mit can bill for D clinical and caries risk assessment, toothbrush prophylaxis of a child 0-3 years of age and counseling to parents/primary caregivers , Scion Dental, Inc. PROPRIETARY AND CONFIDENTIAL Dental Health & Wellness

93 Benefit Plan Details and Requirements ICF/MR Adults s 21 and Over ICF/MR Adults s 21 and Over Code Code Description D0120 ic Oral Evaluation - Established patient D0140 Limited Oral Evaluation - Problem Focused D0150 D0170 D0210 D0220 D0230 Comprehensive Oral Evaluation - New Or Established Patient Re-Evaluation - Limited, Problem Focused Intraoral - Complete Series (Including Bitewings) Intraoral - Periapical First Film Intraoral - Periapical Each Additional Film ICF/MR Adults s 21 and Over AUTHORIZATION REQUIREMENT BENEFIT DETAILS ADDITIONAL NOTES Documents Min Count Length N/A Month Only one exam every 6 Months provider or provider billing group. Only one exam (D0120, D0140, D0145, D0150, D0170) date of service, beneficiary, provider or provider billing group. (D0140 is not limited to 1x every 6 Months) N/A Only one exam (D0120, D0140, D0145, D0150, D0170) date of service, beneficiary, provider or provider billing group. Limited oral evaluation is only covered when formed in conjunction with treatment to address an emergency situation. An emergency is defined as treatment medically necessary to treat pain, infection, swelling, uncontrolled bleeding, or traumatic injury. (D0140 is not limited to 1x every 6 Months) N/A Month One comprehensive exam beneficiary, provider or provider billing group lifetime. Only one exam (D0120, D0145, or D0150) every six Months beneficiary, provider or provider billing group. N/A Month One 12 Months. Established beneficiary to access the status of a previously existing condition (not post-oative visit). t covered with any other procedure other than radiographs. N/A Month One 36 Months. The following are also considered an Intraoral Complete Series (D0210), D0330 and D0272, D0330 and D0273, D0330 and D0274, D0330 and D0277 N/A Days One day. Any additional films (D D0340) formed on the same date of service as a complete intraoral series, or its equivalent, are considered content of service of the complete series and will not be reimbursed. N/A Any additional films (D D0340) formed on the same date of service as a complete intraoral series, or its equivalent, are considered content of service of the complete series and are not reimbursed. D0240 Intraoral - Occlusal Film N/A Any additional films (D D0340) formed on the same date of service as a complete intraoral series, or its equivalent, are considered content of service of the complete series and are not reimbursed. D0250 Extraoral - First Film N/A Any additional films (D D0340) formed on the same date of service as a complete intraoral series, or its equivalent, are considered content of service of the complete series and are not reimbursed. Type , Scion Dental, Inc. PROPRIETARY AND CONFIDENTIAL Dental Health & Wellness 87

94 Benefit Plan Details and Requirements ICF/MR Adults s 21 and Over ICF/MR Adults s 21 and Over AUTHORIZATION REQUIREMENT BENEFIT DETAILS ADDITIONAL NOTES Code Code Description Documents Min Count Length Type D0260 Extraoral - Each Additional Film N/A Any additional films (D D0340) formed on the same date of service as a complete intraoral series, or its equivalent, are considered content of service of the complete series and are not reimbursed. D0270 Bitewing - Single Film N/A Any additional films (D D0340) formed on the same date of service as a complete intraoral series, or its equivalent, are considered content of service of the complete series and are not reimbursed. Only one bitewing code (D0270, D0272, D0273, D0274, D0277) date of service, beneficiary, provider or provider billing group. D0272 Bitewings - Two Films N/A Any additional films (D D0340) formed on the same date of service as a complete intraoral series, or its equivalent, are considered content of service of the complete series and are not reimbursed. Only one bitewing code (D0270, D0272, D0273, D0274, D0277) date of service, beneficiary, provider or provider billing group. D0273 Bitewings - Three Films N/A Any additional films (D D0340) formed on the same date of service as a complete intraoral series, or its equivalent, are considered content of service of the complete series and are not reimbursed. Only one bitewing code (D0270, D0272, D0273, D0274, D0277) date of service, beneficiary, provider or provider billing group. D0274 Bitewings - Four Films N/A Any additional films (D D0340) formed on the same date of service as a complete intraoral series, or its equivalent, are considered content of service of the complete series and are not reimbursed. Only one bitewing code (D0270, D0272, D0273, D0274, D0277) date of service, beneficiary, provider or provider billing group. D0277 Vertical Bitewings - 7 To 8 Films D0290 D0321 Posterior - Anterior Or Lateral Skull And Facial Bone Survey Film Other Temporomandibular Joint Films, By Report N/A Any additional films (D D0340) formed on the same date of service as a complete intraoral series, or its equivalent, are considered content of service of the complete series and are not reimbursed. Only one bitewing code (D0270, D0272, D0273, D0274, D0277) date of service, beneficiary, provider or provider billing group. N/A Any additional films (D D0340) formed on the same date of service as a complete intraoral series, or its equivalent, are considered content of service of the complete series and are not reimbursed. N/A Any additional films (D D0340) formed on the same date of service as a complete intraoral series, or its equivalent, are considered content of service of the complete series and are not reimbursed. D0330 Panoramic Film N/A Month One 36 Months. The following are also considered an Intraoral Complete Series (D0210), D0330 and D0272, D0330 and D0273, D0330 and D0274, D0330 and D , Scion Dental, Inc. PROPRIETARY AND CONFIDENTIAL Dental Health & Wellness

95 Benefit Plan Details and Requirements ICF/MR Adults s 21 and Over Code Code Description ICF/MR Adults s 21 and Over AUTHORIZATION REQUIREMENT BENEFIT DETAILS ADDITIONAL NOTES Documents Min D0460 Pulp Vitality Tests N/A Days imum of three teeth visit. Covered teeth are: 1-32, (SN), A T, AS - TS (SN) D1110 Prophylaxis - Adult N/A Month One six Months. Includes scaling and polishing procedures to remove coronal plaque, calculus, and stains. D2140 D2150 D2160 D2161 Amalgam - One Surface, Primary Or Permanent Amalgam - Two Surfaces, Primary Or Permanent Amalgam - Three Surfaces, Primary Or Permanent Amalgam - Four Or More Surfaces, Primary Or Permanent D2330 Resin-Based Composite - One Surface, Anterior D2331 Resin-Based Composite - Two Surfaces, Anterior D2332 Resin-Based Composite - Three Surfaces, Anterior D2335 Resin-Based Composite - Four Or More Surfaces, anterior Or Involving Incisal Angle D2390 Resin-Based Composite Crown, Anterior D2391 Resin-Based Composite - One Surface, Posterior D2392 Resin-Based Composite - Two Surfaces, Posterior D2393 Resin-Based Composite - Three Surfaces, Posterior D2394 Resin-Based Composite - Four Or More Surfaces, Posterior D2710 Crown - Resin-Based Composite (Indirect) Count N/A Month Teeth Covered:1-32,51-82 (SN),A - T,AS - TS (SN) N/A Month Teeth Covered:1-32,51-82 (SN),A - T,AS - TS (SN) N/A Month Teeth Covered:1-32,51-82 (SN),A - T,AS - TS (SN) N/A Month Teeth Covered:1-32,51-82 (SN),A - T,AS - TS (SN) Length N/A Month Teeth Covered:6-11, 22-27, (SN), (SN), C-H, M-R, CS-HS (SN), MS-RS (SN) N/A Month Teeth Covered:6-11, 22-27, (SN), (SN), C-H, M-R, CS-HS (SN), MS-RS (SN) N/A Month Teeth Covered:6-11, 22-27, (SN), (SN), C-H, M-R, CS-HS (SN), MS-RS (SN) N/A Month Teeth Covered:6-11, 22-27, (SN), (SN), C-H, M-R, CS-HS (SN), MS-RS (SN) N/A Month Teeth Covered:6-11, 22-27, (SN), (SN), C-H, M-R, CS-HS (SN), MS-RS (SN) N/A Month Teeth Covered:1-5, 12-21, 28-32, (SN), (SN), (SN,) A, B, I-L, S, T, AS (SN), BS (SN), IS-LS (SN), SS (SN),TS (SN) N/A Month Teeth Covered:1-5, 12-21, 28-32, (SN), (SN), (SN,) A, B, I - L, S, T, AS (SN), BS (SN), IS-LS (SN), SS (SN),TS (SN) N/A Month Teeth Covered:1-5, 12-21, 28-32, (SN), (SN), (SN,) A, B, I-L, S, T, AS (SN), BS (SN), IS-LS (SN), SS (SN),TS (SN) N/A Month Teeth Covered:1-5, 12-21, 28-32, (SN), (SN), (SN,) A, B, I - L, S, T, AS (SN), BS (SN), IS-LS (SN), SS (SN),TS (SN) Preoative radiographs of adjacent and opposing teeth. If a tooth has had RCT, a postendodontic radiograph is also required showing the entire tooth,. Type Month Teeth Covered: 6 11, 22 27, (SN), (SN) , Scion Dental, Inc. PROPRIETARY AND CONFIDENTIAL Dental Health & Wellness 89

96 Benefit Plan Details and Requirements ICF/MR Adults s 21 and Over Code D2740 D2751 D2752 Code Description Crown - Porcelain/Ceramic Substrate Crown - Porcelain Fused To Predominantly Base Metal Crown - Porcelain Fused To ble Metal D2783 Crown - 3/4 Porcelain/Ceramic D2791 D2792 D2910 Crown - Full Cast Predominantly Base Metal Crown - Full Cast ble Metal Recement Inlay, Onlay, Or Partial Coverage Restoration ICF/MR Adults s 21 and Over AUTHORIZATION REQUIREMENT BENEFIT DETAILS ADDITIONAL NOTES Documents Preoative radiographs of adjacent and opposing teeth. If a tooth has had RCT, a postendodontic radiograph is also required showing the entire tooth, Preoative radiographs of adjacent and opposing teeth. If a tooth has had RCT, a postendodontic radiograph is also required showing the entire tooth, Preoative radiographs of adjacent and opposing teeth. If a tooth has had RCT, a postendodontic radiograph is also required showing the entire tooth, Preoative radiographs of adjacent and opposing teeth. If a tooth has had RCT, a postendodontic radiograph is also required showing the entire tooth, Preoative radiographs of adjacent and opposing teeth. If a tooth has had RCT, a postendodontic radiograph is also required showing the entire tooth, Preoative radiographs of adjacent and opposing teeth. If a tooth has had RCT, a postendodontic radiograph is also required showing the entire tooth, Min Count Length Type Month Teeth Covered: (SN) Month Teeth Covered: 1-32, 51-82(SN) Month Teeth Covered:1-32, 51-82(SN) Month Teeth Covered: 1-32, 51-82(SN) Month Teeth Covered: 1-32, 51-82(SN) Month Teeth Covered:1-32, 51-82(SN) N/A Teeth Covered: 1-32, 51-82(SN) D2920 Recement Crown N/A Teeth Covered: 1-32, 51-82(SN) D2921 D2930 Reattachment of tooth fragment, incisal edge or cusp Prefabricated Stainless Steel Crown - Primary Pre- and post-oative radiographic images shall be maintained in beneficiary records Teeth Covered: 1 32, (SN), t allowed same tooth, same surface(s), same DOS as D2140, D2150, D2160, D2161, D2330, D2331, D2332, D2335, D2391, D2392 D2393 D2394. N/A Month Teeth Covered: A - T, AS - TS (SN) , Scion Dental, Inc. PROPRIETARY AND CONFIDENTIAL Dental Health & Wellness

97 Benefit Plan Details and Requirements ICF/MR Adults s 21 and Over Code D2931 Code Description Prefabricated Stainless Steel Crown - Permanent ICF/MR Adults s 21 and Over AUTHORIZATION REQUIREMENT BENEFIT DETAILS ADDITIONAL NOTES Documents Min Count Length N/A Month Teeth Covered: 1 32, (SN) D2940 Sedative Filling N/A Temporary restoration intended to relieve pain. t to be used as a base or liner under a restoration. Teeth Covered: 1-32, 51-82(SN) D2951 D2954 D2957 D3110 D3220 Pin Retention - Per, In Addition To Restoration Prefabricated Post And Core In Addition To Crown Each Additional Prefabricated Post - Same Pulp Cap - Direct (Excluding Final Restoration) Therapeutic Pulpotomy (excluding final restoration) - removal of pulp coronal to the dentinocemental junction and application of medicament D3221 Pulpal Debridement - Primary And Permanent Teeth D3222 D3310 D3320 D3330 D3331 Partial Pulpotomy For Apexogenesis - Permanent with incomplete root development Endodontic Therapy, Anterior (Excluding Final Restoration) Endodontic Therapy, Bicuspid (Excluding Final Restoration) Endodontic Therapy, Molar (Excluding Final Restoration) Treatment Of Root Canal Obstruction; n-surgical Access N/A Teeth Covered: 1-32, 51-82(SN) Pre-op x-rays of adj and opposing teeth, fill x-ray Pre-op x-rays of adj and opposing teeth, fill x-ray and narrative of medical necessity submitted with claim Type Month Teeth Covered: 1-32, 51-82(SN) Month Teeth Covered: 1-3, 14-19, 30-32, 51-53(SN), 64-69(SN), 80-82(SN) N/A Teeth Covered: 1-32, 51-82(SN) N/A Lifetime N/A Lifetime Pre-oative x-rays (excluding bitewings) submitted Lifetime N/A Lifetime N/A Lifetime N/A Lifetime Pre-oative x-rays (excluding bitewings) and narrative of medical necessity, submitted with claim Teeth Covered: 1 32, (SN), A T, AS TS t covered within 30 days of D3310-D3331 on same tooth. Teeth Covered: 1-32, 51-82(SN), A -T, AS - TS(SN). t covered within 30 days of D D3331 on same tooth. Teeth Covered:1-32, 51-82(SN). Should only be formed as preparation for endodontic treatment. Teeth Covered: 6 11, 22 27, (SN), (SN) Teeth Covered: 4, 5, 12, 13, 20, 21, 28, 29, 54 (SN), 55 (SN), 62 (SN), 63 (SN), 70 (SN), 71 (SN), 78 (SN), 79 (SN) Teeth Covered: 1-3, 14 19, 30 32, (SN), (SN), (SN) , Scion Dental, Inc. PROPRIETARY AND CONFIDENTIAL Dental Health & Wellness 91

98 Benefit Plan Details and Requirements ICF/MR Adults s 21 and Over ICF/MR Adults s 21 and Over Code Code Description D3351 Apexification / Recalcification / Pulpal Regeneration - Initial Visit D3352 Apexification / Recalcification / Pulpal Regeneration - Interim D3353 Apexification / Recalcification / Pulpal Regeneration - Final Visit D3410 D3421 D3425 D3426 D3427 D3430 D4210 D4211 D4230 D4231 D4268 Apicoectomy / Periradicular Surgery - Anterior Apicoectomy / Periradicular Surgery - Bicuspid (First Root) Apicoectomy / Periradicular Surgery - Molar (First Root) Apicoectomy / Periradicular Surgery - Each Additional Root) Periradicular surgery without apicoectomy Retrograde Filling - Per Root Gingivectomy Or Gingivoplasty - Four Or More Contiguous Teeth Gingivectomy Or Gingivoplasty - One To Three Contiguous Teeth Anatomical Crown Exposure - Four Or More Contiguous Teeth Per Quadrant Anatomical Crown Exposure - One To Three Teeth Per Quadrant Surgical Revision Procedure, Per AUTHORIZATION REQUIREMENT BENEFIT DETAILS ADDITIONAL NOTES Documents Pre- and postoative radiographs shall be maintained in beneficiary records Pre- and postoative radiographs shall be maintained in beneficiary records Pre- and postoative radiographs shall be maintained in beneficiary records Pre- and postoative radiographs shall be maintained in beneficiary records Min Count Length Type Teeth Covered:1-32, 51-82(SN) Teeth Covered:1-32, 51-82(SN) Teeth Covered:1-32, 51-82(SN) Teeth Covered: 6 11, 22 27, (SN), (SN) N/A Teeth Covered: 4, 5, 12, 13, 20, 21, 28, 29, 54(SN), 55(SN), 62(SN), 63(SN), 70(SN), 71(SN), 78(SN), 79(SN) N/A Teeth Covered: 1-3, 14-19, 30-32, 51-53(SN),64-69(SN), 80-82(SN) N/A Teeth Covered:1-5, 12-21, 28-32, 51-55(SN), 62-71(SN), 78-82(SN) Pre- and post-oative radiographs shall be maintained in beneficiary records Teeth Covered: 1-32, (SN), t allowed same tooth, same DOS as D3410, D3421, D3425, D3426 N/A Teeth Covered: 1 32, (SN) Pre-op x-rays, io charting, treatment plan and narrative of medical necessity, submitted with claim. Pre-op x-rays, io charting, treatment plan and narrative of medical necessity, submitted with claim. Pre-op x-rays, io charting, and narrative of medical necessity, photo (optional), submitted with claim. Pre-op x-rays, io charting, and narrative of medical necessity, photo (optional), submitted with claim. Pre-oative x-rays and narrative of medical necessity submitted Per quadrant:10 (UR), 20 (UL), 30 (LL), 40 (LR) A minimum of four affected teeth in the quadrant Per quadrant:10 (UR), 20 (UL), 30 (LL), 40 (LR) One to three affected teeth in the quadrant Per quadrant:10 (UR), 20 (UL), 30 (LL), 40 (LR) Must be billed same date same tooth in conjunction with the restorative codes (D D2957) Per quadrant:10 (UR), 20 (UL), 30 (LL), 40 (LR) Same date and same tooth in conjunction with the restorative code Teeth Covered: 1 32, (SN) Only covered after D , Scion Dental, Inc. PROPRIETARY AND CONFIDENTIAL Dental Health & Wellness

99 Benefit Plan Details and Requirements ICF/MR Adults s 21 and Over Code D4341 D4342 Code Description ontal Scaling And Root Planing - Four Or More Teeth Per Quadrant ontal Scaling And Root Planing - One To Three Teeth Per Quadrant ICF/MR Adults s 21 and Over AUTHORIZATION REQUIREMENT BENEFIT DETAILS ADDITIONAL NOTES Documents ontal charting and pre-op x-rays, and treatment plan submitted. There must be radiographic evidence of root calculus or noticeable loss of bone support. ontal charting and pre-op x-rays, and treatment plan submitted. There must be radiographic evidence of root calculus or noticeable loss of bone support. D4355 Full Mouth Debridement Documentation of medical necessity shall be maintained in beneficiary records. D5110 Complete Denture - illary D5120 Complete Denture - Mandibular D5211 illary Partial Denture - Resin Base D5212 Mandibular Partial Denture - Resin Base D5213 illary Partial Denture - Cast Metal Framework With Resin Denture Bases D5214 Mandibular Partial Denture - Cast Metal Framework With Resin Denture Bases D5225 illary Partial Denture - Flexible Base D5226 Mandibular Partial Denture - Flexible Base D5281 Removable Unilateral Partial Denture - One Piece Cast Metal D5410 Adjust Complete Denture - illary D5411 Adjust Complete Denture - Mandibular D5421 Adjust Partial Denture - illary Pre op x-rays, treatment plan with claim Pre op x-rays, treatment plan with claim Pre-op x-rays of adj and opposing teeth, trmt plan. Pre-op x-rays of adj and opposing teeth, trmt plan Pre-op x-rays of adj and opposing teeth, trmt plan Pre-op x-rays of adj and opposing teeth, trmt plan Pre-op x-rays of adj and opposing teeth, trmt plan Pre-op x-rays of adj and opposing teeth, trmt plan Pre-op x-rays of adj and opposing teeth, trmt plan Min Count Length Type Month Per quadrant:10 (UR), 20 (UL), 30 (LL), 40 (LR)A minimum of four affected teeth in the quadrant Month Per quadrant:10 (UR), 20 (UL), 30 (LL), 40 (LR) One to three affected teeth in the quadrant Month Month Month Month Beneficiaries ages 21 and over require: Preoative radiographs of adjacent and opposing teeth along with narrative of medical necessity should be retained in beneficiary's chart Month Month Month Month Month Month Per quadrant:10 (UR), 20 (UL), 30 (LL), 40 (LR) N/A t covered within 6 Months of placement. N/A t covered within 6 Months of placement. N/A t covered within 6 Months of placement , Scion Dental, Inc. PROPRIETARY AND CONFIDENTIAL Dental Health & Wellness 93

100 Benefit Plan Details and Requirements ICF/MR Adults s 21 and Over Code Code Description D5422 Adjust Partial Denture - Mandibular D5510 D5520 Repair Broken Complete Denture Base Replace Missing Or Broken Teeth - Complete Denture (Each ) ICF/MR Adults s 21 and Over AUTHORIZATION REQUIREMENT BENEFIT DETAILS ADDITIONAL NOTES Documents Min Count N/A t covered within 6 Months of placement. Length N/A Area covered:01 (UA), 02 (LA) N/A Teeth Covered:1-32 D5610 Repair Resin Denture Base N/A Area covered: 01 (UA), 02 (LA), 10 (UR), 20 (UL), 30 (LL), 40 (LR) D5620 Repair Cast Framework N/A Area covered: 01 (UA), 02 (LA), 10 (UR), 20 (UL), 30 (LL), 40 (LR) D5630 D5640 D5650 D5660 D5670 D5671 D5750 D5751 D5760 D5761 D5850 D5851 Repair Or Replace Broken Clasp Replace Broken Teeth - Per Add To Existing Partial Denture Add Clasp To Existing Partial Denture Replace All Teeth And Acrylic On Cast Metal Framework (illary) Replace All Teeth And Acrylic On Cast Metal Framework (Mandibular) Reline Complete illary Denture (Laboratory) Reline Complete Mandibular Denture (Laboratory) Reline illary Partial Denture (Laboratory) Reline Mandibular Partial Denture (Laboratory) Tissue Conditioning, illary Tissue Conditioning, Mandibular D6100 Implant Removal, By Report D6930 Recement Fixed Partial Denture N/A Area covered: 01 (UA), 02 (LA), 10 (UR), 20 (UL), 30 (LL), 40 (LR) N/A Teeth Covered: 1-32 N/A Teeth Covered:1-32 N/A Area covered: 01 (UA), 02 (LA), 10 (UR), 20 (UL), 30 (LL), 40 (LR) N/A N/A N/A Month t covered within 24 Months of placement N/A Month t covered within 24 Months of placement N/A Month t covered within 24 Months of placement N/A Month t covered within 24 Months of placement N/A N/A Pre-op & post-op x-rays, narr of med nec Type Teeth Covered: 1 32, (SN) N/A Area covered: 01 (UA), 02 (LA), 10 (UR), 20 (UL), 30 (LL), 40 (LR) , Scion Dental, Inc. PROPRIETARY AND CONFIDENTIAL Dental Health & Wellness

101 Benefit Plan Details and Requirements ICF/MR Adults s 21 and Over Code D7140 D7210 D7220 D7230 D7240 D7241 D7250 Code Description Extraction, Erupted Or Exposed Root Surgical Removal Or Erupted Removal Of Impacted - Soft Tissue Removal Of Impacted - Partially Bony Removal Of Impacted - Completely Bony Removal Of Impacted - Completely Bony, Unusual Surgical Complications Surgical Removal Of Residual (Cutting Procedure) ICF/MR Adults s 21 and Over AUTHORIZATION REQUIREMENT BENEFIT DETAILS ADDITIONAL NOTES Documents Min Count Length Type N/A Lifetime N/A Lifetime Pre-op x-rays (excluding bitewings) and narr of med nec Pre-op x-rays (excluding bitewings) and narr of med neck Pre-op x-rays (excluding bitewings) and narr of med neck Lifetime Lifetime Lifetime N/A Lifetime N/A Lifetime D7260 Oroantral Fistula Closure Pre- and postoative radiographs and narrative of medical necessity submitted with claim. D7270 D7280 Reimplantation And/Or Stabilization Of Accidentally Evulsed / Displaced Surgical Access Of An Unerupted D7285 Biopsy Of Oral Tissue - Hard (Bone, ) Lifetime N/A Lifetime Pre-op x-rays, narr of med neck Pathology report should be kept in beneficiary record. D7286 Biopsy Of Oral Tissue - Soft Pathology report should be kept in beneficiary record. D7320 Alveoloplasty t In Conjunction With Extractions - Four Or More Teeth Pre-op x-rays, narr of med nec Lifetime Teeth Covered: 1 32, (SN), A T, AS - TS (SN) Removal of asymptomic tooth not covered. Teeth Covered: 1 32, (SN), A T, AS - TS (SN) Removal of asymptomic tooth not covered. Includes cutting of gingiva and bone, removal of tooth structure, and closure. Teeth Covered: 1 32, (SN) Removal of asymptomic tooth not covered. Includes cutting of gingiva and bone, removal of tooth structure, and closure. Teeth Covered: 1 32, (SN) Removal of asymptomic tooth not covered. Includes cutting of gingiva and bone, removal of tooth structure, and closure. Teeth Covered: 1 32, (SN) Removal of asymptomic tooth not covered. Includes cutting of gingiva and bone, removal of tooth structure, and closure. Teeth Covered: 1 32, (SN) Removal of asymptomic tooth not covered. Includes cutting of gingiva and bone, removal of tooth structure, and closure. Unusual complications such as nerve dissection, separate closure of the maxillary sinus, or aberrant tooth position. Teeth Covered: 1 32, (SN), A T, AS - TS (SN) Includes cutting of gingiva and bone, removal of tooth structure, and closure. Will not be paid to the providers or group that originally removed the tooth. Teeth Covered: 1 32, (SN), A T, AS - TS (SN) Includes splinting and/or stabilization. Teeth Covered: 1 32, (SN) Will not be payable unless the orthodontic treatment has been authorized as a covered benefit for beneficiaries Removal of asymptomic tooth not covered Per quadrant: 10 (UR), 20 (UL), 30 (LL), 40 (LR) extractions formed in an edentulous area. t covered when formed on the same day as an extraction for the same tooth , Scion Dental, Inc. PROPRIETARY AND CONFIDENTIAL Dental Health & Wellness 95

102 Benefit Plan Details and Requirements ICF/MR Adults s 21 and Over Code D7350 D7410 D7411 D7412 D7413 D7414 D7415 D7440 D7441 D7450 D7451 D7460 D7461 D7471 Code Description Vesibuloplasty - Ridge Extension (Including Soft Tissue Grafts) Excision Of Benign Lesion Up To 1.25 Cm Excision Of Benign Lesion Greater Than 1.25 Cm Excision Of Benign Lesion, Complicated Excision Of Malignant Lesion Up To 1.25 Cm Excision Of Malignant Lesion Greater Than 1.25 Cm Excision Of Malignant Lesion, Complicated Excision Of Malignant Tumor - Lesion Diameter Up To 1.25 Cm Excision Of Malignant Tumor - Lesion Diameter Greater Than 1.25 Cm Removal Of Benign Odontogenic Cyst Or Tumor Dia Up To 1.25 Cm Removal Of Benign Odontogenic Cyst Or Tumor Dia Greater Than 1.25 Cm Removal Of Benign nodontogenic Cyst Or Tumor - Dia Up To 1.25 Cm Removal Of Benign nodontogenic Cyst Or Tumor - Dia Greater Than 1.25 Cm Removal Of Lateral Exostosis (illa Or Mandible) ICF/MR Adults s 21 and Over AUTHORIZATION REQUIREMENT BENEFIT DETAILS ADDITIONAL NOTES Documents Pre-op x-rays, narr of med nec Min N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A Pre-op x-rays, narr of med nec D7472 Removal Of Torus Palatinus Pre-op x-rays, narr of med nec D7473 Removal Of Torus Mandibularis Pre-op x-rays, narr of med nec Count Length Type Per quadrant:10 (UR), 20 (UL), 30 (LL), 40 (LR) Once Lifetime Once Lifetime Once Lifetime 01(UA), 02(LA) , Scion Dental, Inc. PROPRIETARY AND CONFIDENTIAL Dental Health & Wellness

103 Benefit Plan Details and Requirements ICF/MR Adults s 21 and Over Code D7490 D7510 D7511 D7520 D7521 D7530 D7540 D7550 D7560 D7610 D7620 D7630 D7640 D7650 D7660 Code Description Radical Resection Of illa Or Mandible Incision And Drainage Of Abscess - Intraoral Soft Tissue Incision And Drainage Of Abscess - Intraoral Soft Tissue - Complicated Incision And Drainage Of Abscess - Extraoral Soft Tissue Incision And Drainage Of Abscess - Extraoral Soft Tissue - Complicated Removal Of Foreign Body From Mucosa Removal Of Reaction Producing Foreign Bodies Partial Ostectomy /Sequestrectomy For Removal Of n-vital Bone illary Sinusotomy For Removal Of Fragment Or Foreign Body illa - Open Reduction (Teeth Immobilized, If Present) illa - Closed Reduction (Teeth Immobilized, If Present) Mandible - Open Reduction (Teeth Immobilized, If Present) Mandible - Closed Reduction (Teeth Immobilized, If Present) Malar And/Or Zygomatic Arch - Open Reduction Malar And/Or Zygomatic Arch - Closed Reduction ICF/MR Adults s 21 and Over AUTHORIZATION REQUIREMENT BENEFIT DETAILS ADDITIONAL NOTES Documents Pre-op x-rays, narr of med nec Min Count Length Type Area Covered:01 (UA), 02 (LA) N/A t covered same date of service as D7511 N/A N/A t covered same date of service as D7521 N/A N/A N/A N/A Pre- and postoative radiographs along with narrative of medical necessity must be submitted N/A N/A N/A N/A N/A N/A , Scion Dental, Inc. PROPRIETARY AND CONFIDENTIAL Dental Health & Wellness 97

104 Benefit Plan Details and Requirements ICF/MR Adults s 21 and Over Code D7670 D7680 Code Description Alveolus - Closed Reduction, May Include Stabilization Of Teeth Facial Bones - Complicated Reduction With Fixation And Multiple Surgical ICF/MR Adults s 21 and Over AUTHORIZATION REQUIREMENT BENEFIT DETAILS ADDITIONAL NOTES Documents Min Count Length N/A Teeth Covered: 1-32 May include stabilization. Pre- and postoative radiographs along with narrative of medical necessity must be submitted D7710 illa - Open Reduction N/A D7720 illa - Closed Reduction N/A D7730 Mandible - Open Reduction Postoative radiographs must be available in the beneficiary records. D7740 D7750 D7760 D7770 D7780 D7820 Mandible - Closed Reduction Malar And/Or Zygomatic Arch - Open Reduction Malar And/Or Zygomatic Arch - Closed Reduction Alveolus - Open Reduction Stabilization Of Teeth Facial Bones - Complicated Reduction With Fixation And Multiple Surgical Closed Reduction Of Dislocation N/A N/A N/A N/A N/A N/A D7860 Arthrotomy Pre-op & post-op x-rays, narr of med nec D7865 Arthroplasty D7910 D7911 Suture Of Recent Small Wounds Up To 5 Cm Complicated Suture - Up To 5 Cm D7912 Complicated Suture - Greater Than 5 Cm D7920 Skin Graft (Identify Defect Covered, Location And Type Of Graft) Pre- and postoative radiographs along with narrative of medical necessity must be submitted N/A t covered on dame day as D7140, D7210, D7220, D7230, D7240, D7241, or D7250. N/A t covered on dame day as D7140, D7210, D7220, D7230, D7240, D7241, or D7250. N/A t covered on dame day as D7140, D7210, D7220, D7230, D7240, D7241, or D7250. Pre-op & post-op x-rays, narr of med nec Type Area covered: 01 (UA), 02 (LA), 10 (UR), 20 (UL), 30 (LL), 40 (LR) , Scion Dental, Inc. PROPRIETARY AND CONFIDENTIAL Dental Health & Wellness

105 Benefit Plan Details and Requirements ICF/MR Adults s 21 and Over Code D7955 D7960 Code Description Repair Of illofacial Soft And/Or Hard Tissue Defect Frenulectomy - Also Known As Frenectomy Or Frenotomy - Separate Procedure ICF/MR Adults s 21 and Over AUTHORIZATION REQUIREMENT BENEFIT DETAILS ADDITIONAL NOTES Documents Pre- and postoative radiographs along with narrative of medical necessity must be submitted. Min Count Length N/A Lifetime Area Covered: 01 (UA), 02 (LA) Once Lifetime. Per location. Lingual, Buccal or Labial. t covered same date of service as D7963. The frenum may be excised when the tongue has limited mobility; for large diastemas between teeth, or when the frenum interferes with a prosthetic appliance; or when it is the etiology of iodontal tissue disease. D7963 Frenuloplasty N/A Excision of frenum with excision or repositioning of abervant muscle and z-plasty or other local flap closure D7971 Excision Of Pericoronal Gingiva N/A Teeth Covered: 1-32 D7980 Sialolithotomy N/A D7981 Excision Of Salivary Gland, By Report N/A D7982 Sialodochoplasty N/A D7983 Closure Of Salivary Fistula Narrative of medical necessity, x-rays or photos optional, submitted D7990 Emergency Tracheotomy N/A Type D9212 D9220 D9221 D9230 D9241 D9242 Trigeminal Division Block Anesthesia Deep Sedation/General Anesthesia-First 30 Minutes Deep Sedation/General Anesthesia-Each Additional 15 Minutes Inhalation Of Nitrous /Analgesia, Anxiolysis Intravenous Conscious Sedation/Analgesia - First 30 Minutes Intravenous Conscious Sedation/Analgesia - Each Additional 15 Minutes Narrative of medical necessity shall be maintained in beneficiary records. Narrative of medical necessity and treatment plan Narrative of medical necessity and treatment plan Narrative of medical necessity shall be maintained in beneficiary records Narrative of medical necessity and treatment plan Narrative of medical necessity and treatment plan D9220 and D9221 are only billable when dental services other then ONLY diagnostic are provided on the same date of service D9220 and D9221 are only billable when dental services other then ONLY diagnostic are provided on the same date of service t covered when billed with only diagnostic and/or preventative services (D0120 through D1208. D1515 through D1150, D9410, D9420) , Scion Dental, Inc. PROPRIETARY AND CONFIDENTIAL Dental Health & Wellness 99

106 Benefit Plan Details and Requirements ICF/MR Adults s 21 and Over ICF/MR Adults s 21 and Over Code D9310 D9410 D9420 D9610 D9920 D9999 Code Description Consultation - Diagnostic Service Provided By Dentist Or Physician House/Extended Care Facility Call Hospital Or Ambulatory Surgical Center Call Therapeutic Parenteral Drug, Single Administration Behavior Management, By Report Unspecified Adjunctive Procedure, By Report AUTHORIZATION REQUIREMENT BENEFIT DETAILS ADDITIONAL NOTES Documents Narrative of the consultation for dental services shall be maintained in beneficiary records' Narrative of medical necessity shall be maintained in beneficiary records Narrative of medical necessity shall be maintained in beneficiary records Description of drugs and parental administration Narrative of medical necessity Description of procedure and narrative of medical necessity Min Count Length Type Month D9310 is billable when ONLY diagnostic services are provided on the same date of service. One 12 Months by same provider. One inpatient follow up beneficiary within a 10 day iod by same provider. t covered on the same date of service as D0120-D0170, D9410, D Extended care facilities only Hospital facilities only , Scion Dental, Inc. PROPRIETARY AND CONFIDENTIAL Dental Health & Wellness

107 Benefit Plan Details and Requirements Money Follows Person (MFP) Adults s 21 and Over (IDD, TB(HI) and PD Waivers) Money Follows Person (MFP) Adults s 21 and Over (IDD, TB(HI) and PD Waivers) Code Code Description D0120 ic Oral Evaluation - Established Patient D0140 Limited Oral Evaluation - Problem Focused D0150 D0170 D0210 D0220 D0230 Comprehensive Oral Evaluation - New Or Established Patient Re-Evaluation - Limited, Problem Focused Intraoral - Complete Series (Including Bitewings) Intraoral - Periapical First Film Intraoral - Periapical Each Additional Film Money Follows Person (MFP) Adults s 21 and Over (IDD, TB(HI) and PD Waivers) AUTHORIZATION REQUIREMENTS BENEFIT DETAILS ADDITIONAL NOTES Docs Min Count Length N/A Month Only one exam every 6 Months provider or provider billing group. Only one exam (D0120, D0140, D0145, D0150, D0170) date of service, beneficiary, provider or provider billing group. (D0140 is not limited to 1x every 6 Months) N/A Only one exam (D0120, D0140, D0145, D0150, D0170) date of service, beneficiary, provider or provider billing group. Limited oral evaluation only covered when formed in conjunction with treatment to address an emergency situation. An emergency is defined as treatment medically necessary to treat pain, infection, swelling, uncontrolled bleeding or traumatic injury.(d0140 is not limited to 1x every 6 Months) N/A Month One comprehensive exam beneficiary, provider or provider billing group lifetime. Only one exam (D0120, D0145, or D0150) every six Months beneficiary, provider or provider billing group. N/A Month One 12 Months. Established beneficiary to access the status of a previously existing condition (not post-oative visit). t covered with any other procedure other than radiographs. N/A Month One 36 Months. The following are also considered an Intraoral Complete Series (D0210), D0330 and D0272 D0330 and D0273, D0330 and D0274, D0330 and D0277 N/A Days One day. Any additional films (D D0340) formed on the same date of service as a complete intraoral series, or its equivalent, are considered content of service of the complete series and will not be reimbursed. N/A Any additional films (D D0340) formed on the same date of service as a complete intraoral series, or its equivalent, are considered content of service of the complete series and are not reimbursed. D0240 Intraoral - Occlusal Film N/A Any additional films (D D0340) formed on the same date of service as a complete intraoral series, or its equivalent, are considered content of service of the complete series and are not reimbursed. D0250 Extraoral - First Film N/A Any additional films (D D0340) formed on the same date of service as a complete intraoral series, or its equivalent, are considered content of service of the complete series and are not reimbursed. D0260 Extraoral - Each Additional Film N/A Any additional films (D D0340) formed on the same date of service as a complete intraoral series, or its equivalent, are considered content of service of the complete series and are not reimbursed. Type , Scion Dental, Inc. PROPRIETARY AND CONFIDENTIAL Dental Health & Wellness 101

108 Benefit Plan Details and Requirements Money Follows Person (MFP) Adults s 21 and Over (IDD, TB(HI) and PD Waivers) Code Code Description Money Follows Person (MFP) Adults s 21 and Over (IDD, TB(HI) and PD Waivers) AUTHORIZATION REQUIREMENTS BENEFIT DETAILS ADDITIONAL NOTES Docs Min D0270 Bitewing - Single Film N/A Any additional films (D D0340) formed on the same date of service as a complete intraoral series, or its equivalent, are considered content of service of the complete series and are not reimbursed. Only one bitewing code (D0270, D0272, D0273, D0274, D0277) date of service, beneficiary, provider or provider billing group. D0272 Bitewings - Two Films N/A Any additional films (D D0340) formed on the same date of service as a complete intraoral series, or its equivalent, are considered content of service of the complete series and are not reimbursed. Only one bitewing code (D0270, D0272, D0273, D0274, D0277) date of service, beneficiary, provider or provider billing group. D0273 Bitewings - Three Films N/A Any additional films (D D0340) formed on the same date of service as a complete intraoral series, or its equivalent, are considered content of service of the complete series and are not reimbursed. Only one bitewing code (D0270, D0272, D0273, D0274, D0277) date of service, beneficiary, provider or provider billing group. D0274 Bitewings - Four Films N/A Any additional films (D D0340) formed on the same date of service as a complete intraoral series, or its equivalent, are considered content of service of the complete series and are not reimbursed. Only one bitewing code (D0270, D0272, D0273, D0274, D0277) date of service, beneficiary, provider or provider billing group. D0277 Vertical Bitewings - 7 To 8 Films D0290 D0321 Posterior - Anterior Or Lateral Skull And Facial Bone Survey Film Other Temporomandibular Joint Films, By Report Count Length N/A Any additional films (D D0340) formed on the same date of service as a complete intraoral series, or its equivalent, are considered content of service of the complete series and are not reimbursed. Only one bitewing code (D0270, D0272, D0273, D0274, D0277) date of service, beneficiary, provider or provider billing group. N/A Any additional films (D D0340) formed on the same date of service as a complete intraoral series, or its equivalent, are considered content of service of the complete series and are not reimbursed. N/A Any additional films (D D0340) formed on the same date of service as a complete intraoral series, or its equivalent, are considered content of service of the complete series and are not reimbursed. D0330 Panoramic Film N/A Month One 36 Months. The following are also considered an Intraoral Complete Series (D0210), D0330 and D0272 D0330 and D0273, D0330 and D0274, D0330 and D0277 D0460 Pulp Vitality Tests N/A Days imum of three teeth visit. Covered teeth are: 1-32, (SN), A - T, AS - TS (SN) D1110 Prophylaxis - Adult N/A Month One six Months. Includes scaling and polishing procedures to remove coronal plaque, calculus, and stains. Type , Scion Dental, Inc. PROPRIETARY AND CONFIDENTIAL Dental Health & Wellness

109 Benefit Plan Details and Requirements Money Follows Person (MFP) Adults s 21 and Over (IDD, TB(HI) and PD Waivers) Money Follows Person (MFP) Adults s 21 and Over (IDD, TB(HI) and PD Waivers) Code D2140 D2150 D2160 D2161 Code Description Amalgam - One Surface, Primary Or Permanent Amalgam - Two Surfaces, Primary Or Permanent Amalgam - Three Surfaces, Primary Or Permanent Amalgam - Four Or More Surfaces, Primary Or Permanent D2330 Resin-Based Composite - One Surface, Anterior D2331 Resin-Based Composite - Two Surfaces, Anterior D2332 Resin-Based Composite - Three Surfaces, Anterior D2335 Resin-Based Composite - Four Or More Surfaces Or Involving Incisal Angle D2390 Resin-Based Composite Crown, Anterior D2391 Resin-Based Composite - One Surface, Posterior D2392 Resin-Based Composite - Two Surfaces, Posterior D2393 Resin-Based Composite - Three Surfaces, Posterior D2394 Resin-Based Composite - Four Or More Surfaces, Posterior D2710 D2740 D2751 D2752 Crown - Resin-Based Composite (Indirect) Crown - Porcelain/Ceramic Substrate Crown - Porcelain Fused To Predominantly Base Metal Crown - Porcelain Fused To ble Metal D2783 Crown - 3/4 Porcelain/Ceramic AUTHORIZATION REQUIREMENTS BENEFIT DETAILS ADDITIONAL NOTES Docs Min Count N/A Month Teeth Covered:1-32,51-82 (SN),A - T,AS - TS (SN) N/A Month Teeth Covered:1-32,51-82 (SN),A - T,AS - TS (SN) N/A Month Teeth Covered:1-32,51-82 (SN),A - T,AS - TS (SN) N/A Month Teeth Covered:1-32,51-82 (SN),A - T,AS - TS (SN) Length N/A Month Teeth Covered:6-11, 22-27, (SN), (SN), C - H, M - R, CS - HS (SN), MS - RS (SN) N/A Month Teeth Covered:6-11, 22-27, (SN), (SN), C - H, M - R, CS - HS (SN), MS - RS (SN) N/A Month Teeth Covered:6-11, 22-27, (SN), (SN), C - H, M - R, CS - HS (SN), MS - RS (SN) N/A Month Teeth Covered:6-11, 22-27, (SN), (SN), C - H, M - R, CS - HS (SN), MS - RS (SN) N/A Month Teeth Covered:6-11, 22-27, (SN), (SN), C - H, M - R, CS - HS (SN), MS - RS (SN) N/A Month Teeth Covered:1-5, 12-21, 28-32, (SN), (SN), (SN,) A, B, I - L, S, T, AS (SN), BS (SN), IS - LS (SN), SS (SN),TS (SN) N/A Month Teeth Covered:1-5, 12-21, 28-32, (SN), (SN), (SN,) A, B, I - L, S, T, AS (SN), BS (SN), IS - LS (SN), SS (SN),TS (SN) N/A Month Teeth Covered:1-5, 12-21, 28-32, (SN), (SN), (SN,) A, B, I - L, S, T, AS (SN), BS (SN), IS - LS (SN), SS (SN),TS (SN) N/A Month Teeth Covered:1-5, 12-21, 28-32, (SN), (SN), (SN,) A, B, I - L, S, T, AS (SN), BS (SN), IS - LS (SN), SS (SN),TS (SN) N/A Month Teeth Covered: 6 11, 22 27, (SN), (SN) N/A Month Teeth Covered: 1 31, 51 82(SN) N/A Month Teeth Covered: 1 32, (SN) N/A Month Teeth Covered: 1 32, (SN) N/A Month Teeth Covered: 1 32, (SN) Type , Scion Dental, Inc. PROPRIETARY AND CONFIDENTIAL Dental Health & Wellness 103

110 Benefit Plan Details and Requirements Money Follows Person (MFP) Adults s 21 and Over (IDD, TB(HI) and PD Waivers) Code D2791 D2792 D2910 Code Description Crown - Full Cast Predominantly Base Metal Crown - Full Cast ble Metal Recement Inlay, Onlay, Or Partial Coverage Restoration Money Follows Person (MFP) Adults s 21 and Over (IDD, TB(HI) and PD Waivers) AUTHORIZATION REQUIREMENTS BENEFIT DETAILS ADDITIONAL NOTES Docs Min Count Length N/A Month Teeth Covered: 1 32, (SN) N/A Month Teeth Covered: 1 32, (SN) N/A Teeth Covered: 1 32, (SN) D2920 Recement Crown N/A Teeth Covered: 1 32, (SN) D2921 D2930 D2931 Reattachment of tooth fragment, incisal edge or cusp Prefabricated Stainless Steel Crown - Primary Prefabricated Stainless Steel Crown - Permanent Pre- and post-oative radiographic images shall be maintained in beneficiary records. Type Teeth Covered: 1 32, (SN), t allowed same tooth, same surface(s), same DOS as D2140, D2150, D2160, D2161, D2330, D2331, D2332, D2335, D2391, D2392 D2393 D2394. N/A Month Teeth Covered: A T, AS - TS (SN) D2930 and D2934 cannot be placed on the same tooth during a 24-Month iod. N/A Month Teeth Covered: 1 32, (SN) D2940 Protective Restoration N/A Teeth Covered: 1 32, (SN) Temporary restoration intended to relieve pain. t to be used as a base or liner under a restoration. D2951 D2954 D2957 D3110 Pin Retention - Per, In Addition To Restoration Prefabricated Post And Core In Addition To Crown Each Additional Prefabricated Post - Same Pulp Cap - Direct (Excluding Final Restoration) N/A Teeth Covered: 1 32, (SN) N/A Month Teeth Covered: 1 32, (SN) N/A Month Teeth Covered: 1 3, 14 19, 30 32, (SN), (SN), (SN) N/A Teeth Covered: 1 32, (SN) D3220 Therapeutic Pulpotomy N/A Lifetime D3221 Pulpal Debridement - Primary And Permanent Teeth D3222 D3310 Partial Pulpotomy For Apexogenesis - Permanent Endodontic Therapy, Anterior (Excluding Final Restoration) N/A Lifetime Pre-oative x-rays (excluding bitewings), submitted Lifetime N/A Lifetime Teeth Covered: 1 32, (SN), A - T, AS TS t covered within 30 days of D3310-D3331 on same tooth. Teeth Covered: 1 32, (SN), A T, AS TS t covered within 30 days of D3310-D3331 on same tooth. Teeth Covered: 1 32, (SN) Should only be formed as preparation for endodontic treatment. Teeth Covered: 6 11, 22 27, (SN), (SN) , Scion Dental, Inc. PROPRIETARY AND CONFIDENTIAL Dental Health & Wellness

111 Benefit Plan Details and Requirements Money Follows Person (MFP) Adults s 21 and Over (IDD, TB(HI) and PD Waivers) Money Follows Person (MFP) Adults s 21 and Over (IDD, TB(HI) and PD Waivers) Code D3320 D3330 D3331 Code Description Endodontic Therapy, Bicuspid (Excluding Final Restoration) Endodontic Therapy, Molar (Excluding Final Restoration) Treatment Of Root Canal Obstruction; n-surgical Access D3351 Apexification / Recalcification / Pulpal Regeneration - Initial Visit D3352 Apexification / Recalcification / Pulpal Regeneration - Interim D3353 Apexification / Recalcification / Pulpal Regeneration - Final Visit D3410 D3421 D3425 D3426 D3427 D3430 D4210 D4211 Apicoectomy / Periradicular Surgery - Anterior Apicoectomy / Periradicular Surgery - Bicuspid (First Root) Apicoectomy / Periradicular Surgery - Molar (First Root) Apicoectomy / Periradicular Surgery - Each Additional Root) Periradicular surgery without apicoectomy Retrograde Filling - Per Root Gingivectomy Or Gingivoplasty - Four Or More Contiguous Teeth Gingivectomy Or Gingivoplasty - One To Three Contiguous Teeth AUTHORIZATION REQUIREMENTS BENEFIT DETAILS ADDITIONAL NOTES Docs Min Count Length Type N/A Lifetime N/A Lifetime Teeth Covered: 4, 5, 12, 13, 20, 21, 28, 29, 54 (SN), 55 (SN), 62 (SN), 63 (SN), 70 (SN), 71 (SN),78 (SN), 79 (SN) Teeth Covered: 1-3, 14 19, 30 32, (SN), (SN), (SN) N/A Teeth Covered: 1 32, (SN) N/A Teeth Covered: 1 32, (SN) Pre- and post-oative radiographs shall be maintained in beneficiary records Pre- and post-oative radiographs shall be maintained in beneficiary records Pre- and post-oative radiographs shall be maintained in beneficiary records Teeth Covered: 1 32, (SN) Teeth Covered: 1 32, (SN) Teeth Covered: 6 11, 22 27, (SN), (SN) N/A Teeth Covered: 4, 5, 12, 13, 20, 21, 28, 29, 54 (SN), 55 (SN), 62 (SN), 63 (SN),70 (SN), 71 (SN), 78 (SN), 79 (SN) N/A Teeth Covered: 1-3, 14 19, 30 32, (SN), (SN), (SN) N/A Teeth Covered: 1-5, 12 21, 28 32, (SN), (SN), (SN) Pre- and post-oative radiographs shall be maintained in beneficiary records. Pre- and post-oative radiographs shall be maintained in beneficiary records 0 18 Teeth Covered: 1-32, (SN), t allowed same tooth, same DOS as D3410, D3421, D3425, D Teeth Covered: 1 32, (SN) N/A Per quadrant:10 (UR), 20 (UL), 30 (LL), 40 (LR) A minimum of four affected teeth in the quadrant. N/A Per quadrant:10 (UR), 20 (UL), 30 (LL), 40 (LR) One to three affected teeth in the quadrant , Scion Dental, Inc. PROPRIETARY AND CONFIDENTIAL Dental Health & Wellness 105

112 Benefit Plan Details and Requirements Money Follows Person (MFP) Adults s 21 and Over (IDD, TB(HI) and PD Waivers) Code D4230 D4231 D4268 D4341 D4342 Code Description Anatomical Crown Exposure - Four Or More Contiguous Teeth Per Quadrant Anatomical Crown Exposure - One To Three Teeth Per Quadrant Surgical Revision Procedure, Per ontal Scaling And Root Planing - Four Or More Teeth Per Quadrant ontal Scaling And Root Planing - One To Three Teeth Per Quadrant Money Follows Person (MFP) Adults s 21 and Over (IDD, TB(HI) and PD Waivers) AUTHORIZATION REQUIREMENTS BENEFIT DETAILS ADDITIONAL NOTES Docs Min Count Length N/A Per quadrant:10 (UR), 20 (UL), 30 (LL), 40 (LR) Must be billed same date same tooth in conjunction with the restorative codes (D D2957). N/A Per quadrant:10 (UR), 20 (UL), 30 (LL), 40 (LR) Same date and same tooth in conjunction with the restorative code. N/A Teeth Covered: 1 32, (SN) Only covered after D4210. N/A Month Per quadrant:10 (UR), 20 (UL), 30 (LL), 40 (LR) A minimum of four affected teeth in the quadrant. N/A Month Per quadrant:,10 (UR), 20 (UL), 30 (LL), 40 (LR) One to three affected teeth in the quadrant. D4355 Full Mouth Debridement N/A Month D6100 Implant Removal, By Report D6930 D7140 D7210 D7220 D7230 D7240 D7241 Recement Fixed Partial Denture Extraction, Erupted Or Exposed Root Surgical Removal Or Erupted Removal Of Impacted - Soft Tissue Removal Of Impacted - Partially Bony Removal Of Impacted - Completely Bony Removal Of Impacted - Completely Bony, Unusual Surgical Complications Pre-op & post-op x-rays, narr of med nec Type Teeth Covered: 1 32, (SN) N/A Area covered:01 (UA), 02 (LA), 10 (UR), 20 (UL), 30 (LL), 40 (LR) N/A Lifetime N/A Lifetime Pre-op x-rays (excluding bitewings) and narr of med nec Pre-op x-rays (excluding bitewings) and narr of med nec Pre-op x-rays (excluding bitewings) and narr of med nec Pre-op x-rays (excluding bitewings) and narr of med nec Lifetime Lifetime Lifetime Lifetime Teeth Covered: 1 32, (SN), A T, AS - TS (SN) Removal of asymptomic tooth not covered. Teeth Covered: 1 32, (SN), A T, AS - TS (SN) Removal of asymptomic tooth not covered. Includes cutting of gingiva and bone, removal of tooth structure, and closure. Teeth Covered: 1 32, (SN) Removal of asymptomic tooth not covered. Includes cutting of gingiva and bone, removal of tooth structure, and closure. Teeth Covered: 1 32, (SN) Removal of asymptomic tooth not covered. Includes cutting of gingiva and bone, removal of tooth structure, and closure. Teeth Covered: 1 32, (SN) Removal of asymptomic tooth not covered. Includes cutting of gingiva and bone, removal of tooth structure, and closure. Teeth Covered: 1 32, (SN) Removal of asymptomic tooth not covered. Includes cutting of gingiva and bone, removal of tooth structure, and closure. Unusual complications such as nerve dissection, separate closure of the maxillary sinus, or aberrant tooth position , Scion Dental, Inc. PROPRIETARY AND CONFIDENTIAL Dental Health & Wellness

113 Benefit Plan Details and Requirements Money Follows Person (MFP) Adults s 21 and Over (IDD, TB(HI) and PD Waivers) Code D7250 Code Description Surgical Removal Of Residual (Cutting Procedure) Money Follows Person (MFP) Adults s 21 and Over (IDD, TB(HI) and PD Waivers) D7260 Oroantral Fistula Closure D7270 D7280 Reimplantation And/Or Stabilization Of Accidentally Evulsed / Displaced Surgical Access Of An Unerupted D7285 Biopsy Of Oral Tissue - Hard (Bone, ) AUTHORIZATION REQUIREMENTS BENEFIT DETAILS ADDITIONAL NOTES Docs Min Count Length Type N/A Lifetime Pre- and post-oative radiographs and narrative of medical necessity submitted with claim Lifetime N/A Lifetime N/A Lifetime Pathology report should be kept in beneficiary record. D7286 Biopsy Of Oral Tissue - Soft Pathology report should be kept in beneficiary record. D7320 D7350 D7410 D7411 D7412 D7413 D7414 D7415 D7440 Alveoloplasty t In Conjunction With Extractions - Four Or More Teeth Vesibuloplasty - Ridge Extension (Including Soft Tissue Grafts) Excision Of Benign Lesion Up To 1.25 Cm Excision Of Benign Lesion Greater Than 1.25 Cm Excision Of Benign Lesion, Complicated Excision Of Malignant Lesion Up To 1.25 Cm Excision Of Malignant Lesion Greater Than 1.25 Cm Excision Of Malignant Lesion, complicated Excision Of Malignant Tumor Lesion Diameter Up To 1.25 Cm Teeth Covered: 1 32, (SN), A T, AS - TS (SN) Includes cutting of gingiva and bone, removal of tooth structure, and closure. Will not be paid to the providers or group that originally removed the tooth. Teeth Covered: 1 32, (SN), A T, AS - TS (SN) Includes splinting and/or stabilization. Teeth Covered: 1 32, (SN) Will not be payable unless the orthodontic treatment has been authorized as a covered benefit for beneficiaries Removal of asymptomic tooth not covered. N/A Per quadrant:10 (UR), 20 (UL), 30 (LL), 40 (LR) extractions formed in an edentulous area. t covered when formed on the same day as an extraction for the same tooth. N/A Per quadrant:10 (UR), 20 (UL), 30 (LL), 40 (LR) N/A N/A N/A N/A N/A N/A N/A , Scion Dental, Inc. PROPRIETARY AND CONFIDENTIAL Dental Health & Wellness 107

114 Benefit Plan Details and Requirements Money Follows Person (MFP) Adults s 21 and Over (IDD, TB(HI) and PD Waivers) Code D7441 D7450 D7451 D7460 D7461 D7471 Code Description Excision Of Malignant Tumor Lesion Diameter Greater Than 1.25 Cm Removal Of Benign Odontogenic Cyst Or Tumor - Dia Up To 1.25 Cm Removal Of Benign Odontogenic cyst Or Tumor-Dia Greater Than 1.25 Cm Removal Of Benign nodontogenic Cyst Or Tumor - Dia Up To 1.25 Cm Removal Of Benign nodontogenic Cyst Or Tumor - Dia Greater Than 1.25 Cm Removal Of Lateral Exostosis (illa Or Mandible) Money Follows Person (MFP) Adults s 21 and Over (IDD, TB(HI) and PD Waivers) AUTHORIZATION REQUIREMENTS BENEFIT DETAILS ADDITIONAL NOTES Docs Min N/A N/A N/A N/A N/A D7472 Removal Of Torus Palatinus D7473 D7490 D7510 D7511 D7520 D7521 D7530 D7540 Removal Of Torus Mandibularis Radical Resection Of illa Or Mandible Incision And Drainage Of Abscess - Intraoral Soft Tissue Incision And Drainage Of Abscess - Intraoral Soft Tissue - Complicated Incision And Drainage Of Abscess - Extraoral Soft Tissue Incision And Drainage Of Abscess - Extraoral Soft Tissue - Complicated Removal Of Foreign Body From Mucosa Removal Of Reaction Producing Foreign Bodies Pre-op x-rays, narr of med nec Pre-op x-rays, narr of med nec Pre-op x-rays, narr of med nec Pre-op x-rays, narr of med nec Count Length Type Once Lifetime Once Lifetime Once Lifetime Area Covered:01 (UA), 02 (LA) Area Covered:01 (UA), 02 (LA) N/A t covered on same date of service as D7511 N/A N/A t covered same date of service as D7521. N/A N/A N/A , Scion Dental, Inc. PROPRIETARY AND CONFIDENTIAL Dental Health & Wellness

115 Benefit Plan Details and Requirements Money Follows Person (MFP) Adults s 21 and Over (IDD, TB(HI) and PD Waivers) Code D7550 D7560 D7610 D7620 D7630 D7640 D7650 D7660 D7670 D7680 Code Description Partial Ostectomy/ Sequestrectomy For Removal Of n-vital Bone illary Sinusotomy For Removal Of Fragment Or Foreign Body illa - Open Reduction (Teeth Immobilized, If Present) illa - Closed Reduction (Teeth Immobilized, If Present) Mandible - Open Reduction (Teeth Immobilized, If Present) Mandible - Closed Reduction (Teeth Immobilized, If Present) Malar And/Or Zygomatic Arch - Open Reduction Malar And/Or Zygomatic Arch - Closed Reduction Alveolus - Closed Reduction, May Include Stabilization Of Teeth Facial Bones - Complicated Reduction With Fixation And Multiple Surgical Money Follows Person (MFP) Adults s 21 and Over (IDD, TB(HI) and PD Waivers) AUTHORIZATION REQUIREMENTS BENEFIT DETAILS ADDITIONAL NOTES Docs Min N/A Pre- and postoative radiographs along with narrative of medical necessity must be submitted N/A N/A N/A N/A N/A N/A Count Length N/A Teeth Covered: 1-32 May include stabilization. Pre- and postoative radiographs along with narrative of medical necessity must be submitted D7710 illa - Open Reduction N/A D7720 illa - Closed Reduction N/A D7730 Mandible - Open Reduction N/A D7740 Mandible- Closed Reduction N/A Type D7750 D7760 D7770 Malar And/Or Zygomatic Arch - Open Reduction Malar And/Or Zygomatic Arch - Closed Reduction Alveolus - Open Reduction Stabilization Of Teeth N/A N/A N/A , Scion Dental, Inc. PROPRIETARY AND CONFIDENTIAL Dental Health & Wellness 109

116 Benefit Plan Details and Requirements Money Follows Person (MFP) Adults s 21 and Over (IDD, TB(HI) and PD Waivers) Code D7780 D7820 Code Description Facial Bones - Complicated Reduction With Fixation And Multiple Surgical Closed Reduction Of Dislocation Money Follows Person (MFP) Adults s 21 and Over (IDD, TB(HI) and PD Waivers) D7860 Arthrotomy D7865 Arthroplasty D7910 D7911 Suture Of Recent Small Wounds Up To 5 Cm Complicated Suture - Up To 5 Cm D7912 Complicated Suture - Greater Than 5 Cm D7920 D7955 D7960 Skin Graft (Identify Defect Covered, Location And Type Of Graft) Repair Of illofacial Soft And/Or Hard Tissue Defect Frenulectomy - Also Known As Frenectomy Or Frenotomy - Separate Procedure AUTHORIZATION REQUIREMENTS BENEFIT DETAILS ADDITIONAL NOTES Docs Min N/A N/A Pre-op & post-op x-rays, narr of med nec Pre- and postoative radiographs along with narrative of medical necessity must be submitted Count Length N/A t covered on dame day as D7140, D7210, D7220, D7230, D7240, D7241, or D7250. N/A t covered on dame day as D7140, D7210, D7220, D7230, D7240, D7241, or D7250. N/A t covered on dame day as D7140, D7210, D7220, D7230, D7240, D7241, or D7250. Pre-op & post-op x-rays, narr of med nec Pre- and postoative radiographs along with narrative of medical necessity must be submitted. Type Area covered:01 (UA), 02 (LA), 10 (UR), 20 (UL), 30 (LL), 40 (LR) N/A Lifetime Area Covered:01 (UA), 02 (LA) Once Lifetime. Per location. Lingual, Buccal or Labial. t covered same date of service as D7963. The frenum may be excised when the tongue has limited mobility; for large diastemas between teeth, or when the frenum interferes with a prosthetic appliance; or when it is the etiology of iodontal tissue disease. D7963 Frenuloplasty N/A Excision of frenum with the excision or repositioning of abervant muscle and z-plasty or other local flap closure. D7971 Excision Of Pericoronal Gingiva N/A Teeth Covered: 1-32 D7980 Sialolithotomy N/A D7981 Excision Of Salivary Gland, By Report N/A D7982 Sialodochoplasty N/A D7983 Closure Of Salivary Fistula Narrative of medical necessity, x-rays or photos optional, submitted , Scion Dental, Inc. PROPRIETARY AND CONFIDENTIAL Dental Health & Wellness

117 Benefit Plan Details and Requirements Money Follows Person (MFP) Adults s 21 and Over (IDD, TB(HI) and PD Waivers) Code Code Description Money Follows Person (MFP) Adults s 21 and Over (IDD, TB(HI) and PD Waivers) AUTHORIZATION REQUIREMENTS BENEFIT DETAILS ADDITIONAL NOTES Docs D7990 Emergency Tracheotomy N/A Min Count Length Type D9212 Trigeminal Division Block Anesthesia Narrative of medical necessity D9220 Deep Sedation/General Anesthesia - First 30 Minutes Narrative of medical necessity and treatment plan D9220 and D9221 are only billable when dental services other then ONLY diagnostic are provided on the same date of service. D9221 Deep Sedation/General Anesthesia - Each Additional 15 Minutes Narrative of medical necessity and treatment plan D9220 and D9221 are only billable when dental services other then ONLY diagnostic are provided on the same date of service. D9230 Inhalation Of Nitrous/Analgesia, Anxiolysis Narrative of medical necessity shall be maintained in beneficiary records t covered when billed with only diagnostic and/or preventative services (D0120 through D1208, D1515 through D1550, D9410, D9420). D9241 Intravenous Conscious Sedation/Analgesia - First 30 Minutes Narrative of medical necessity and treatment plan D9242 Intravenous Conscious Sedation/Analgesia - Each Additional 15 Minutes Narrative of medical necessity and treatment plan D9310 Consultation - Diagnostic Service Provided By Dentist Or Physician Narrative of the consultation for dental services shall be maintained in beneficiary records Month D9310 is billable when ONLY diagnostic services are provided on the same date of service. One 12 Months by same provider. One inpatient follow up beneficiary within a 10 day iod by same provider. t covered on the same date of service as D0120-D0170, D9410, D9420. D9410 House/Extended Care Facility Call Narrative of medical necessity shall be maintained in beneficiary records Extended Care Facilities only. D9420 Hospital Or Ambulatory Surgical Center Call Narrative of medical necessity shall be maintained in beneficiary records Hospital Facilities only. D9610 Therapeutic Parenteral Drug, Single Administration Narrative of medical necessity and description and dosage of drug submitted D9920 Behavior Management, By Report Narrative of medical necessity D9999 Unspecified Adjunctive Procedure, By Report Description of procedure and narrative of medical necessity, submitted , Scion Dental, Inc. PROPRIETARY AND CONFIDENTIAL Dental Health & Wellness 111

118 Benefit Plan Details and Requirements Money Follows Person (MFP) Frail and Elderly Money Follows Person (MFP) Frail and Elderly Code Code Description D0120 ic Oral Evaluation - Established Patient D0140 Limited Oral Evaluation - Problem Focused D0150 D0170 D0210 D0220 D0230 Comprehensive Oral Evaluation - New Or Established Patient Re-Evaluation - Limited, Problem Focused Intraoral - Complete Series (Including Bitewings) Intraoral - Periapical First Film Intraoral - Periapical Each Additional Film Money Follow Person (MFP) Frail and Elderly AUTHORIZATION REQUIREMENTS BENEFIT DETAILS ADDITIONAL NOTES Documents Min Count Length N/A Month Only one exam every 6 Months provider or provider billing group. Only one exam (D0120, D0140, D0145, D0150, D0170) date of service, beneficiary, provider or provider billing group. (D0140 is not limited to 1x every 6 Months) N/A Only one exam (D0120, D0140, D0145, D0150, D0170) date of service, beneficiary, provider or provider billing group. Limited oral evaluation is only covered when formed in conjunction with treatment to address an emergency situation. An emergency is defined as treatment medically necessary to treat pain, infection, swelling, uncontrolled bleeding, or traumatic injury. (D0140 is not limited to 1x every 6 Months) N/A Month One comprehensive exam beneficiary, provider or provider billing group lifetime. Only one exam (D0120, D0145, or D0150) every six Months beneficiary, provider or provider billing group. N/A Month One 12 Months. Established beneficiary to access the status of a previously existing condition (not post-oative visit). t covered with any other procedure other than radiographs. N/A Month One 36 Months. The following are also considered an Intraoral Complete Series (D0210), D0330 and D0272 D0330 and D0273, D0330 and D0274, D0330 and D0277 N/A Days One day. Any additional films (D D0340) formed on the same date of service as a complete intraoral series, or its equivalent, are considered content of service of the complete series and will not be reimbursed. N/A Any additional films (D D0340) formed on the same date of service as a complete intraoral series, or its equivalent, are considered content of service of the complete series and are not reimbursed. D0240 Intraoral - Occlusal Film N/A Any additional films (D D0340) formed on the same date of service as a complete intraoral series, or its equivalent, are considered content of service of the complete series and are not reimbursed. D0250 Extraoral - First Film N/A Any additional films (D D0340) formed on the same date of service as a complete intraoral series, or its equivalent, are considered content of service of the complete series and are not reimbursed. D0260 Extraoral - Each Additional Film N/A Any additional films (D D0340) formed on the same date of service as a complete intraoral series, or its equivalent, are considered content of service of the complete series and are not reimbursed. Type , Scion Dental, Inc. PROPRIETARY AND CONFIDENTIAL Dental Health & Wellness

119 Benefit Plan Details and Requirements Money Follows Person (MFP) Frail and Elderly Code Code Description Money Follow Person (MFP) Frail and Elderly AUTHORIZATION REQUIREMENTS BENEFIT DETAILS ADDITIONAL NOTES Documents Min D0270 Bitewing - Single Film N/A Any additional films (D D0340) formed on the same date of service as a complete intraoral series, or its equivalent, are considered content of service of the complete series and are not reimbursed. Only one bitewing code (D0270, D0272, D0273, D0274, D0277) date of service, beneficiary, provider or provider billing group. D0272 Bitewings - Two Films N/A Any additional films (D D0340) formed on the same date of service as a complete intraoral series, or its equivalent, are considered content of service of the complete series and are not reimbursed. Only one bitewing code (D0270, D0272, D0273, D0274, D0277) date of service, beneficiary, provider or provider billing group. D0273 Bitewings - Three Films N/A Any additional films (D D0340) formed on the same date of service as a complete intraoral series, or its equivalent, are considered content of service of the complete series and are not reimbursed. Only one bitewing code (D0270, D0272, D0273, D0274, D0277) date of service, beneficiary, provider or provider billing group. D0274 Bitewings - Four Films N/A Any additional films (D D0340) formed on the same date of service as a complete intraoral series, or its equivalent, are considered content of service of the complete series and are not reimbursed. Only one bitewing code (D0270, D0272, D0273, D0274, D0277) date of service, beneficiary, provider or provider billing group. D0277 Vertical Bitewings - 7 To 8 Films D0290 D0321 Posterior - Anterior Or Lateral Skull And Facial Bone Survey Film Other Temporomandibular Joint Films, By Report Count Length N/A Any additional films (D D0340) formed on the same date of service as a complete intraoral series, or its equivalent, are considered content of service of the complete series and are not reimbursed. Only one bitewing code (D0270, D0272, D0273, D0274, D0277) date of service, beneficiary, provider or provider billing group. N/A Any additional films (D D0340) formed on the same date of service as a complete intraoral series, or its equivalent, are considered content of service of the complete series and are not reimbursed. N/A Any additional films (D D0340) formed on the same date of service as a complete intraoral series, or its equivalent, are considered content of service of the complete series and are not reimbursed. D0330 Panoramic Film N/A Month One 36 Months. The following are also considered an Intraoral Complete Series (D0210), D0330 and D0272 D0330 and D0273, D0330 and D0274, D0330 and D0277 D0460 Pulp Vitality Tests N/A Days imum of three teeth visit. Covered teeth are: 1-32, (SN), A - T, AS - TS (SN) D1110 Prophylaxis - Adult N/A Month One six Months. Includes scaling and polishing procedures to remove coronal plaque, calculus, and stains. Type , Scion Dental, Inc. PROPRIETARY AND CONFIDENTIAL Dental Health & Wellness 113

120 Benefit Plan Details and Requirements Money Follows Person (MFP) Frail and Elderly Money Follow Person (MFP) Frail and Elderly Code D2140 D2150 D2160 D2161 Code Description Amalgam - One Surface, Primary Or Permanent Amalgam - Two Surfaces, Primary Or Permanent Amalgam - Three Surfaces, Primary Or Permanent Amalgam - Four Or More Surfaces, Primary Or Permanent D2330 Resin-Based Composite - One Surface, Anterior D2331 Resin-Based Composite - Two Surfaces, Anterior D2332 Resin-Based Composite - Three Surfaces, Anterior D2335 Resin-Based Composite - Four Or More Surfaces Or Involving Incisal Angle D2390 Resin-Based Composite Crown, Anterior D2391 Resin-Based Composite - One Surface, Posterior D2392 Resin-Based Composite - Two Surfaces, Posterior D2393 Resin-Based Composite - Three Surfaces, Posterior D2394 Resin-Based Composite - Four Or More Surfaces, Posterior D2710 D2740 D2751 D2752 Crown - Resin-Based Composite (Indirect) Crown - Porcelain/Ceramic Substrate Crown - Porcelain Fused To Predominantly Base Metal Crown - Porcelain Fused To ble Metal D2783 Crown - 3/4 Porcelain/Ceramic AUTHORIZATION REQUIREMENTS BENEFIT DETAILS ADDITIONAL NOTES Documents Min Count N/A Month Teeth Covered:1-32,51-82 (SN),A - T,AS - TS (SN) N/A Month Teeth Covered:1-32,51-82 (SN),A - T,AS - TS (SN) N/A Month Teeth Covered:1-32,51-82 (SN),A - T,AS - TS (SN) N/A Month Teeth Covered:1-32,51-82 (SN),A - T,AS - TS (SN) Length N/A Month Teeth Covered:6-11, 22-27, (SN), (SN), C - H, M - R, CS - HS (SN), MS - RS (SN) N/A Month Teeth Covered:6-11, 22-27, (SN), (SN), C - H, M - R, CS - HS (SN), MS - RS (SN) N/A Month Teeth Covered:6-11, 22-27, (SN), (SN), C - H, M - R, CS - HS (SN), MS - RS (SN) N/A Month Teeth Covered:6-11, 22-27, (SN), (SN), C - H, M - R, CS - HS (SN), MS - RS (SN) N/A Month Teeth Covered:6-11, 22-27, (SN), (SN), C - H, M - R, CS - HS (SN), MS - RS (SN) N/A Month Teeth Covered:1-5, 12-21, 28-32, (SN), (SN), (SN,) A, B, I - L, S, T, AS (SN), BS (SN), IS - LS (SN), SS (SN),TS (SN) N/A Month Teeth Covered:1-5, 12-21, 28-32, (SN), (SN), (SN,) A, B, I - L, S, T, AS (SN), BS (SN), IS - LS (SN), SS (SN),TS (SN) N/A Month Teeth Covered:1-5, 12-21, 28-32, (SN), (SN), (SN,) A, B, I - L, S, T, AS (SN), BS (SN), IS - LS (SN), SS (SN),TS (SN) N/A Month Teeth Covered:1-5, 12-21, 28-32, (SN), (SN), (SN,) A, B, I - L, S, T, AS (SN), BS (SN), IS - LS (SN), SS (SN),TS (SN) N/A Month Teeth Covered: 6 11, 22 27, (SN), (SN) N/A Month Teeth Covered: 1 32, 51 82(SN) N/A Month Teeth Covered: 1 32, (SN) N/A Month Teeth Covered: 1 32, (SN) N/A Month Teeth Covered: 1 32, (SN) Type , Scion Dental, Inc. PROPRIETARY AND CONFIDENTIAL Dental Health & Wellness

121 Benefit Plan Details and Requirements Money Follows Person (MFP) Frail and Elderly Code D2791 D2792 D2910 Code Description Crown - Full Cast Predominantly Base Metal Crown - Full Cast ble Metal Recement Inlay, Onlay, Or Partial Coverage Restoration Money Follow Person (MFP) Frail and Elderly AUTHORIZATION REQUIREMENTS BENEFIT DETAILS ADDITIONAL NOTES Documents Min Count Length N/A Month Teeth Covered: 1 32, (SN) N/A Month Teeth Covered: 1 32, (SN) N/A Teeth Covered: 1 32, (SN) D2920 Recement Crown N/A Teeth Covered: 1 32, (SN) D2921 D2930 D2931 Reattachment of tooth fragment, incisal edge or cusp Prefabricated Stainless Steel Crown - Primary Prefabricated Stainless Steel Crown - Permanent Pre- and post-oative radiographic images shall be maintained in beneficiary records. Type Teeth Covered: 1 32, (SN), t allowed same tooth, same surface(s), same DOS as D2140, D2150, D2160, D2161, D2330, D2331, D2332, D2335, D2391, D2392 D2393 D2394. N/A Month Teeth Covered: A T, AS - TS (SN) D2930 and D2934 cannot be placed on the same tooth during a 24-Month iod. N/A Month Teeth Covered: 1 32, (SN) D2940 Protective Restoration N/A Teeth Covered: (SN) Temporary restoration intended to relieve pain. t to be used as a base or liner under a restoration. D2951 D2954 D2957 D3110 Pin Retention - Per, In Addition To Restoration Prefabricated Post And Core In Addition To Crown Each Additional Prefabricated Post - Same Pulp Cap - Direct (Excluding Final Restoration) N/A Teeth Covered: 1 32, (SN) Pre-op x-rays of adj and opposing teeth, fill x-ray and narrative of medical necessity submitted Month Teeth Covered: 1 32, (SN) N/A Month Teeth Covered: 1 3, 14 19, 30 32, (SN), (SN), (SN) N/A Teeth Covered: 1 32, (SN) D3220 Therapeutic Pulpotomy N/A Lifetime D3221 Pulpal Debridement - Primary And Permanent Teeth D3222 Partial Pulpotomy For Apexogenesis - Permanent N/A Lifetime Pre-oative x-rays (excluding bitewings) Lifetime Teeth Covered: 1 32, (SN), A T, AS TS t covered within 30 days of D3310-D3331 on same tooth. Teeth Covered: 1 32, (SN), A T, AS TS, t covered within 30 days of D3310-D3331 on same tooth. Teeth Covered: 1 32, (SN) Should only be formed as preparation for endodontic treatment , Scion Dental, Inc. PROPRIETARY AND CONFIDENTIAL Dental Health & Wellness 115

122 Benefit Plan Details and Requirements Money Follows Person (MFP) Frail and Elderly Money Follow Person (MFP) Frail and Elderly Code D3310 D3320 D3330 D3331 Code Description Endodontic Therapy, Anterior (Excluding Final Restoration) Endodontic Therapy, Bicuspid (Excluding Final Restoration) Endodontic Therapy, Molar (Excluding Final Restoration) Treatment Of Root Canal Obstruction; n-surgical Access D3351 Apexification / Recalcification / Pulpal Regeneration - Initial Visit D3352 Apexification / Recalcification / Pulpal Regeneration - Interim D3353 Apexification / Recalcification / Pulpal Regeneration - Final Visit D3410 D3421 D3425 D3426 D3427 D3430 D4210 Apicoectomy / Periradicular Surgery - Anterior Apicoectomy / Periradicular Surgery - Bicuspid (First Root) Apicoectomy / Periradicular Surgery - Molar (First Root) Apicoectomy / Periradicular Surgery - Each Additional Root) Periradicular surgery without apicoectomy Retrograde Filling - Per Root Gingivectomy Or Gingivoplasty - Four Or More Contiguous Teeth AUTHORIZATION REQUIREMENTS BENEFIT DETAILS ADDITIONAL NOTES Documents Min Count Length Type N/A Lifetime N/A Lifetime N/A Lifetime Teeth Covered: 6 11, 22 27, (SN), (SN) Teeth Covered: 4, 5, 12, 13, 20, 21, 28, 29, 54 (SN), 55 (SN), 62 (SN), 63 (SN) 70 (SN), 71 (SN), 78 (SN), 79 (SN) Teeth Covered: 1-3, 14 19, 30 32, (SN),64-69 (SN), (SN) N/A Teeth Covered: 1 32, (SN) Pre- and postoative radiographs shall be maintained in beneficiary records Pre- and postoative radiographs shall be maintained in beneficiary records Pre- and postoative radiographs shall be maintained in beneficiary records Pre- and postoative radiographs shall be maintained in beneficiary records Teeth Covered: 1 32, (SN) Teeth Covered: 1 32, (SN) Teeth Covered: 1 32, (SN) Teeth Covered: 6 11, 22 27, (SN), (SN) N/A Teeth Covered: 4, 5, 12, 13, 20, 21, 28, 29, 54 (SN), 55 (SN),62 (SN), 63 (SN), 70 (SN), 71 (SN), 78 (SN), 79 (SN) N/A Teeth Covered: 1-3, 14 19, 30 32, (SN), (SN),80-82 (SN) N/A Teeth Covered: 1-5, 12 21, 28 32, (SN), (SN), (SN) Pre- and post-oative radiographs shall be maintained in beneficiary records. Pre- and postoative radiographs shall be maintained in beneficiary records Teeth Covered: 1-32, (SN), t allowed same tooth, same DOS as D3410, D3421, D3425, D Teeth Covered: 1 32, (SN) N/A Per quadrant:10 (UR), 20 (UL), 30 (LL), 40 (LR) A minimum of four affected teeth in the quadrant , Scion Dental, Inc. PROPRIETARY AND CONFIDENTIAL Dental Health & Wellness

123 Benefit Plan Details and Requirements Money Follows Person (MFP) Frail and Elderly Code D4211 D4230 D4231 D4268 D4341 D4342 Code Description Gingivectomy Or Gingivoplasty - One To Three Contiguous Teeth Anatomical Crown Exposure - Four Or More Contiguous Teeth Per Quadrant Anatomical Crown Exposure - One To Three Teeth Per Quadrant Surgical Revision Procedure, Per ontal Scaling And Root Planing - Four Or More Teeth Per Quadrant ontal Scaling And Root Planing - One To Three Teeth Per Quadrant Money Follow Person (MFP) Frail and Elderly AUTHORIZATION REQUIREMENTS BENEFIT DETAILS ADDITIONAL NOTES Documents Min Count Length N/A Per quadrant:10 (UR), 20 (UL), 30 (LL), 40 (LR) One to three affected teeth in the quadrant. N/A Per quadrant:10 (UR), 20 (UL), 30 (LL), 40 (LR) Must be billed same date same tooth in conjunction with the restorative codes (D D2957). N/A Per quadrant:10 (UR), 20 (UL), 30 (LL), 40 (LR)Must be billed same date same tooth in conjunction with the restorative codes (D D2957). N/A Teeth Covered: 1 32, (SN), Only covered after D4210. N/A Month Per quadrant:10 (UR), 20 (UL), 30 (LL), 40 (LR) A minimum of four affected teeth in the quadrant. ontal charting and pre-op x-rays, and treatment plan submitted. There must be radiographic evidence of root calculus or noticeable loss of bone support. D4355 Full Mouth Debridement Documentation of medical necessity shall be maintained in beneficiary records. D5110 Complete Denture - illary D5120 Complete Denture - Mandibular D5211 illary Partial Denture - Resin Base D5212 Mandibular Partial Denture - Resin Base D5213 illary Partial Denture - Cast Metal Framework With Resin Denture Bases D5214 Mandibular Partial Denture - Cast Metal Framework With Resin Denture Bases D5225 illary Partial Denture - Flexible Base Type Month Per quadrant:10 (UR), 20 (UL), 30 (LL), 40 (LR) One to three affected teeth in the quadrant Month N/A Month N/A Month Preoative radiographs of adjacent and opposing teeth along with narrative of medical necessity should be retained in beneficiary's chart Month N/A Month N/A Month N/A Month N/A Month , Scion Dental, Inc. PROPRIETARY AND CONFIDENTIAL Dental Health & Wellness 117

124 Benefit Plan Details and Requirements Money Follows Person (MFP) Frail and Elderly Code Code Description D5226 Mandibular Partial Denture - Flexible Base D5281 Removable Unilateral Partial Denture - One Piece Cast Metal D5410 Adjust Complete Denture - illary D5411 Adjust Complete Denture - Mandibular D5421 Adjust Partial Denture - illary D5422 Adjust Partial Denture - Mandibular D5510 D5520 Repair Broken Complete Denture Base Replace Missing Or Broken Teeth - Complete Denture (Each ) Money Follow Person (MFP) Frail and Elderly AUTHORIZATION REQUIREMENTS BENEFIT DETAILS ADDITIONAL NOTES Documents Min Count Length Type N/A Month N/A Month Per quadrant:10 (UR), 20 (UL), 30 (LL), 40 (LR) N/A t covered within 6 Months of placement. N/A t covered within 6 Months of placement. N/A t covered within 6 Months of placement. N/A t covered within 6 Months of placement. N/A Area covered:01 (UA), 02 (LA) N/A Teeth Covered: 1-32 D5610 Repair Resin Denture Base N/A Area covered:01 (UA), 02 (LA), 10 (UR), 20 (UL), 30 (LL), 40 (LR) D5620 Repair Cast Framework N/A Area covered:01 (UA), 02 (LA), 10 (UR), 20 (UL), 30 (LL), 40 (LR) D5630 D5640 D5650 D5660 D5670 D5671 D5730 D5731 Repair Or Replace Broken Clasp Replace Broken Teeth - Per Add To Existing Partial Denture Add Clasp To Existing Partial Denture Replace All Teeth And Acrylic On Cast Metal Framework (illary) Replace All Teeth And Acrylic On Cast Metal Framework (Mandibular) Reline Complete illary Denture (Chairside) Reline Complete Mandibular Denture (Chairside) N/A Area covered:01 (UA), 02 (LA), 10 (UR), 20 (UL), 30 (LL), 40 (LR) N/A Teeth Covered: 1-32 N/A Teeth Covered: 1-32 N/A Area covered:01 (UA), 02 (LA), 10 (UR), 20 (UL), 30 (LL), 40 (LR) N/A N/A N/A Month One 24 Months. t covered within 24 Months of placement. Covered for Frail Elderly benefit plan only. N/A Month One 24 Months. t covered within 24 Months of placement. Covered for Frail Elderly benefit plan only , Scion Dental, Inc. PROPRIETARY AND CONFIDENTIAL Dental Health & Wellness

125 Benefit Plan Details and Requirements Money Follows Person (MFP) Frail and Elderly Code D5750 D5751 D5760 D5761 D5850 D5851 Code Description Reline Complete illary Denture (Laboratory) Reline Complete Mandibular Denture (Laboratory) Reline illary Partial Denture (Laboratory) Reline Mandibular Partial Denture (Laboratory) Tissue Conditioning, illary Tissue Conditioning, Mandibular D6100 Implant Removal, By Report D6930 D7140 D7210 D7220 D7230 D7240 D7241 D7250 Recement Fixed Partial Denture Extraction, Erupted Or Exposed Root Surgical Removal Or Erupted Removal Of Impacted - Soft Tissue Removal Of Impacted - Partially Bony Removal Of Impacted - Completely Bony Removal Of Impacted - Completely Bony, Unusual Surgical Complications Surgical Removal Of Residual (Cutting Procedure) Money Follow Person (MFP) Frail and Elderly AUTHORIZATION REQUIREMENTS BENEFIT DETAILS ADDITIONAL NOTES Documents Min Count N/A Month t covered within 24 Months of placement. N/A Month t covered within 24 Months of placement. N/A Month t covered within 24 Months of placement. N/A Month t covered within 24 Months of placement. N/A N/A Pre-op & post-op x-rays, narr of med nec Length Type Teeth Covered: 1 32, (SN) N/A Area covered:01 (UA), 02 (LA), 10 (UR), 20 (UL), 30 (LL), 40 (LR) N/A Lifetime Preoative radiographs must be available Pre-op x-rays (excluding bitewings) and narr of med nec Pre-op x-rays (excluding bitewings) and narr of med nec Pre-op x-rays (excluding bitewings) and narr of med nec Pre-op x-rays (excluding bitewings) and narr of med nec Preoative radiographs and narrative of medical necessity shall be maintained in beneficiary records Lifetime Lifetime Lifetime Lifetime Lifetime Lifetime Teeth Covered: 1 32, (SN), A T, AS - TS (SN) Removal of asymptomic tooth not covered. Teeth Covered: 1 32, (SN), A T, AS - TS (SN) Removal of asymptomic tooth not covered. Includes cutting of gingiva and bone, removal of tooth structure, and closure. Teeth Covered: 1 32, (SN) Removal of asymptomic tooth not covered. Includes cutting of gingiva and bone, removal of tooth structure, and closure. Teeth Covered: 1 32, (SN) Removal of asymptomic tooth not covered. Includes cutting of gingiva and bone, removal of tooth structure, and closure. Teeth Covered: 1 32, (SN) Removal of asymptomic tooth not covered. Includes cutting of gingiva and bone, removal of tooth structure, and closure. Teeth Covered: 1 32, (SN) Removal of asymptomic tooth not covered. Includes cutting of gingiva and bone, removal of tooth structure, and closure. Unusual complications such as nerve dissection, separate closure of the maxillary sinus, or aberrant tooth position. Teeth Covered: 1 32, (SN), A T, AS - TS (SN) Includes cutting of gingiva and bone, removal of tooth structure, and closure. Will not be paid to the providers or group that originally removed the tooth. Removal of asymptomic tooth not covered , Scion Dental, Inc. PROPRIETARY AND CONFIDENTIAL Dental Health & Wellness 119

126 Benefit Plan Details and Requirements Money Follows Person (MFP) Frail and Elderly Code Code Description D7260 Oroantral Fistula Closure D7270 D7280 Reimplantation And/Or Stabilization Of Accidentally Evulsed / Displaced Surgical Access Of An Unerupted D7285 Biopsy Of Oral Tissue - Hard (Bone, ) Money Follow Person (MFP) Frail and Elderly AUTHORIZATION REQUIREMENTS BENEFIT DETAILS ADDITIONAL NOTES Documents Pre- and postoative radiographs and narrative of medical necessity submitted with claim. Min , Scion Dental, Inc. PROPRIETARY AND CONFIDENTIAL Dental Health & Wellness Count Length Type Lifetime N/A Lifetime N/A Lifetime Pathology report should be kept in beneficiary record. D7286 Biopsy Of Oral Tissue - Soft Pathology report should be kept in beneficiary record. D7310 D7320 D7350 D7410 D7411 D7412 D7413 D7414 D7415 D7440 D7441 Alveoloplasty In Conjunction With Extractions - Four Or More Teeth Alveoloplasty t In Conjunction With Extractions - Four Or More Teeth Vesibuloplasty - Ridge Extension (Including Soft Tissue Grafts) Excision Of Benign Lesion Up To 1.25 Cm Excision Of Benign Lesion Greater Than 1.25 Cm Excision Of Benign Lesion, Complicated Excision Of Malignant Lesion Up To 1.25 Cm Excision Of Malignant Lesion Greater Than 1.25 Cm Excision Of Malignant Lesion, Complicated Excision Of Malignant Tumor - Lesion Diameter Up To 1.25 Cm Excision Of Malignant Tumor - Lesion Diameter Greater Than 1.25 Cm Teeth Covered: 1 32, (SN), A T, AS - TS (SN) Includes splinting and/or stabilization. Teeth Covered: 1 32, (SN) Removal of asymptomic tooth not covered. N/A Per quadrant:10 (UR), 20 (UL), 30 (LL), 40 (LR) Covered for Frail Elderly benefit plan only. N/A Per quadrant:10 (UR), 20 (UL), 30 (LL), 40 (LR) extractions formed in an edentulous area. t covered when formed on the same day as an extraction for the same tooth. N/A Per quadrant:10 (UR), 20 (UL), 30 (LL), 40 (LR) N/A N/A N/A N/A N/A N/A N/A N/A

127 Benefit Plan Details and Requirements Money Follows Person (MFP) Frail and Elderly Code D7450 D7451 D7460 D7461 D7471 Code Description Removal Of Benign Odontogenic Cyst Or Tumor - Dia Up To 1.25 Cm Removal Of Benign Odontogenic Cyst Or Tumor Dia Greater Than 1.25 Cm Removal Of Benign nodontogenic Cyst Or Tumor - Dia Up To 1.25 Cm Removal Of Benign nodontogenic Cyst Or Tumor Dia Greater Than 1.25 Cm Removal Of Lateral Exostosis (illa Or Mandible) Money Follow Person (MFP) Frail and Elderly AUTHORIZATION REQUIREMENTS BENEFIT DETAILS ADDITIONAL NOTES Documents Min N/A N/A N/A N/A D7472 Removal Of Torus Palatinus D7473 D7490 D7510 D7511 D7520 D7521 D7530 D7540 D7550 Removal Of Torus Mandibularis Radical Resection Of illa Or Mandible Incision And Drainage Of Abscess - Intraoral Soft Tissue Incision And Drainage Of Abscess - Intraoral Soft Tissue - Complicated Incision And Drainage Of Abscess - Extraoral Soft Tissue Incision And Drainage Of Abscess - Extraoral Soft Tissue - Complicated Removal Of Foreign Body From Mucosa Removal Of Reaction Producing Foreign Bodies Partial Ostectomy/ Sequestrectomy For Removal Of n-vital Bone Pre-op x-rays, narr of med nec Pre-op x-rays, narr of med nec Pre-op x-rays, narr of med nec Pre-op x-rays, narr of med nec Count Length Type Once Lifetime Once Lifetime Once Lifetime Area Covered:01 (UA), 02 (LA) Area Covered:01 (UA), 02 (LA) N/A t covered on same date of service as D7511 N/A N/A t covered same date of service as D721 N/A N/A N/A N/A , Scion Dental, Inc. PROPRIETARY AND CONFIDENTIAL Dental Health & Wellness 121

128 Benefit Plan Details and Requirements Money Follows Person (MFP) Frail and Elderly Code D7560 D7610 D7620 D7630 D7640 D7650 D7660 D7670 D7680 Code Description illary Sinusotomy For Removal Of Fragment Or Foreign Body illa - Open Reduction (Teeth Immobilized, If Present) illa - Closed Reduction (Teeth Immobilized, If Present) Mandible - Open Reduction (Teeth Immobilized, If Present) Mandible - Closed Reduction (Teeth Immobilized, If Present) Malar And/Or Zygomatic Arch - Open Reduction Malar And/Or Zygomatic Arch - Closed Reduction Alveolus - Closed Reduction, May Include Stabilization Of Teeth Facial Bones - Complicated Reduction With Fixation And Multiple Surgical Money Follow Person (MFP) Frail and Elderly AUTHORIZATION REQUIREMENTS BENEFIT DETAILS ADDITIONAL NOTES Documents Pre- and postoative radiographs along with narrative of medical necessity must be submitted. Min N/A N/A N/A N/A N/A N/A Count N/A Teeth Covered: 1 32 May include stabilization. Pre- and postoative radiographs along with narrative of medical necessity must be submitted D7710 illa - Open Reduction N/A D7720 illa - Closed Reduction N/A D7730 Mandible - Open Reduction Postoative radiographs must be available in the beneficiary records. D7740 D7750 D7760 D7770 Mandible - Closed Reduction Malar And/Or Zygomatic Arch - Open Reduction Malar And/Or Zygomatic Arch - Closed Reduction Alveolus - Open Reduction Stabilization Of Teeth N/A N/A N/A N/A Length Type , Scion Dental, Inc. PROPRIETARY AND CONFIDENTIAL Dental Health & Wellness

129 Benefit Plan Details and Requirements Money Follows Person (MFP) Frail and Elderly Code D7780 D7820 Code Description Facial Bones - Complicated Reduction With Fixation And Multiple Surgical Closed Reduction Of Dislocation D7860 Arthrotomy D7865 Arthroplasty D7910 D7911 Suture Of Recent Small Wounds Up To 5 Cm Complicated Suture - Up To 5 Cm D7912 Complicated Suture - Greater Than 5 Cm D7920 D7955 D7960 Skin Graft (Identify Defect Covered, Location And Type Of Graft) Repair Of illofacial Soft And/Or Hard Tissue Defect Frenulectomy - Also Known As Frenectomy Or Frenotomy - Separate Procedure Money Follow Person (MFP) Frail and Elderly AUTHORIZATION REQUIREMENTS BENEFIT DETAILS ADDITIONAL NOTES Documents Min N/A N/A Pre-op & post-op x-rays, narr of med nec Pre- and postoative radiographs along with narrative of medical necessity must be submitted Count Length N/A t covered on dame day as D7140, D7210, D7220, D7230, D7240, D7241, or D7250. N/A t covered on dame day as D7140, D7210, D7220, D7230, D7240, D7241, or D7250. N/A t covered on dame day as D7140, D7210, D7220, D7230, D7240, D7241, or D7250. Pre-op & post-op x-rays, narr of med nec Pre- and postoative radiographs along with narrative of medical necessity must be submitted. Type Area covered:01 (UA), 02 (LA), 10 (UR), 20 (UL), 30 (LL), 40 (LR) N/A Lifetime Area Covered:01 (UA), 02 (LA) Once Lifetime. Per location. Lingual, Buccal or Labial. t covered same date of service as D7963. The frenum may be excised when the tongue has limited mobility; for large diastemas between teeth, or when the frenum interferes with a prosthetic appliance; or when it is the etiology of iodontal tissue disease. D7963 Frenuloplasty N/A Excision of frenum with the excision or repositioning of abervant muscle and z-plasty or other local flap closure. D7971 Excision Of Pericoronal Gingiva N/A Teeth Covered: 1-32 D7980 Sialolithotomy N/A D7981 Excision Of Salivary Gland, By Report N/A D7982 Sialodochoplasty N/A D7983 Closure Of Salivary Fistula Narrative of medical necessity, x-rays or photos optional, submitted , Scion Dental, Inc. PROPRIETARY AND CONFIDENTIAL Dental Health & Wellness 123

130 Benefit Plan Details and Requirements Money Follows Person (MFP) Frail and Elderly Code Code Description Money Follow Person (MFP) Frail and Elderly AUTHORIZATION REQUIREMENTS BENEFIT DETAILS ADDITIONAL NOTES Documents D7990 Emergency Tracheotomy N/A Min Count Length Type D9212 D9220 D9221 D9230 D9241 D9242 D9310 D9410 D9420 D9610 D9920 D9999 Trigeminal Division Block Anesthesia Deep Sedation/General Anesthesia-First 30 Minutes Deep Sedation/General Anesthesia-Each Additional 15 Minutes Inhalation Of Nitrous/ Analgesia, Anxiolysis Intravenous Conscious Sedation/Analgesia-First 30 Minutes Intravenous Conscious Sedation/Analgesia - Each Additional 15 Minutes Consultation - Diagnostic Service Provided By Dentist Or Physician House/Extended Care Facility Call Hospital Or Ambulatory Surgical Center Call Therapeutic Parenteral Drug, Single Administration Behavior Management, By Report Unspecified Adjunctive Procedure, By Report Narrative of medical necessity Narrative of medical necessity and treatment plan Narrative of medical necessity and treatment plan Narrative of medical necessity shall be maintained in beneficiary records Narrative of medical necessity and treatment plan Narrative of medical necessity and treatment plan Narrative of the consultation for dental services shall be maintained in beneficiary records. Narrative of the consultation for dental services shall be maintained in beneficiary records. Narrative of the consultation for dental services shall be maintained in beneficiary records. Narrative of medical necessity and description and dosage of drug submitted. Narrative of medical necessity Description of procedure and narrative of medical necessity D9220 and D9221 are only billable when dental services other then ONLY diagnostic are provided on the same date of service D9220 and D9221 are only billable when dental services other then ONLY diagnostic are provided on the same date of service t covered when billed with only diagnostic and/or preventative services (D0120 through D1208, D1515 through D1550, D9410, D9420) Month D9310 is billable when ONLY diagnostic services are provided on the same date of service. One 12 Months by same provider. One inpatient follow up beneficiary within a 10 day iod by same provider. t covered on the same date of service as D0120-D0170, D9410, D Extended Care Facilities only Hospital Facilities only , Scion Dental, Inc. PROPRIETARY AND CONFIDENTIAL Dental Health & Wellness

131 Benefit Plan Details and Requirements HCBS Adults s 65 and Over (not ICF/MR) HCBS Adults s 65 and Over (not ICF/MR) HCBS Adults s 65 and Over (not ICF/MR) HCBS beneficiaries covered under the HCBS Frail Elderly (FE) waiver will have additional coverage for the dental services listed in this benefit plan with an approved 'Crisis ' authorization. Refer to the Title 19 adult benefit plan for a list of covered benefits. Code Code Description AUTHORIZATION REQUIREMENTS BENEFIT DETAILS ADDITIONAL NOTES Documents Min Count Length Type D0120 ic Oral Evaluation - Established Patient D0140 Limited Oral Evaluation - Problem Focused D0150 D0170 D0210 D0220 D0230 Comprehensive Oral Evaluation - New Or Established Patient Re-Evaluation - Limited, Problem Focused Intraoral - Complete Series (Including Bitewings) Intraoral - Periapical First Film Intraoral - Periapical Each Additional Film N/A Month Only one exam every 6 Months provider or provider billing group. Only one exam (D0120, D0140, D0145, D0150, D0170) date of service, beneficiary, provider or provider billing group. (D0140 is not limited to 1x every 6 Months) N/A Only one exam (D0120, D0140, D0145, D0150, D0170) date of service, beneficiary, provider or provider billing group. Limited oral evaluation is only covered when formed in conjunction with treatment to address an emergency situation. An emergency is defined as treatment medically necessary to treat pain, infection, swelling, uncontrolled bleeding, or traumatic injury. (D0140 is not limited to 1x every 6 Months) N/A Month One comprehensive exam beneficiary, provider or provider billing group lifetime. Only one exam (D0120, D0145, or D0150) every six Months beneficiary, provider or provider billing group. N/A Month One 12 Months. Established beneficiary to access the status of a previously existing condition (not post-oative visit). t covered with any other procedure other than radiographs. N/A Month One 36 Months. The following are also considered an Intraoral Complete Series (D0210), D0330 and D0272 D0330 and D0273, D0330 and D0274, D0330 and D0277 N/A Days One day. Any additional films (D D0340) formed on the same date of service as a complete intraoral series, or its equivalent, are considered content of service of the complete series and will not be reimbursed. N/A Any additional films (D D0340) formed on the same date of service as a complete intraoral series, or its equivalent, are considered content of service of the complete series and are not reimbursed. D0240 Intraoral - Occlusal Film N/A Any additional films (D D0340) formed on the same date of service as a complete intraoral series, or its equivalent, are considered content of service of the complete series and are not reimbursed. D0250 Extraoral - First Film N/A Any additional films (D D0340) formed on the same date of service as a complete intraoral series, or its equivalent, are considered content of service of the complete series and are not reimbursed , Scion Dental, Inc. PROPRIETARY AND CONFIDENTIAL Dental Health & Wellness 125

132 Benefit Plan Details and Requirements HCBS Adults s 65 and Over (not ICF/MR) HCBS Adults s 65 and Over (not ICF/MR) HCBS beneficiaries covered under the HCBS Frail Elderly (FE) waiver will have additional coverage for the dental services listed in this benefit plan with an approved 'Crisis ' authorization. Refer to the Title 19 adult benefit plan for a list of covered benefits. Code Code Description AUTHORIZATION REQUIREMENTS BENEFIT DETAILS ADDITIONAL NOTES Documents Min Count Length Type D0260 Extraoral - Each Additional Film N/A Any additional films (D D0340) formed on the same date of service as a complete intraoral series, or its equivalent, are considered content of service of the complete series and are not reimbursed. D0270 Bitewing - Single Film N/A Any additional films (D D0340) formed on the same date of service as a complete intraoral series, or its equivalent, are considered content of service of the complete series and are not reimbursed. Only one bitewing code (D0270, D0272, D0273, D0274, D0277) date of service, beneficiary, provider or provider billing group. D0272 Bitewings - Two Films N/A Any additional films (D D0340) formed on the same date of service as a complete intraoral series, or its equivalent, are considered content of service of the complete series and are not reimbursed. Only one bitewing code (D0270, D0272, D0273, D0274, D0277) date of service, beneficiary, provider or provider billing group. D0273 Bitewings - Three Films N/A Any additional films (D D0340) formed on the same date of service as a complete intraoral series, or its equivalent, are considered content of service of the complete series and are not reimbursed. Only one bitewing code (D0270, D0272, D0273, D0274, D0277) date of service, beneficiary, provider or provider billing group. D0274 Bitewings - Four Films N/A Any additional films (D D0340) formed on the same date of service as a complete intraoral series, or its equivalent, are considered content of service of the complete series and are not reimbursed. Only one bitewing code (D0270, D0272, D0273, D0274, D0277) date of service, beneficiary, provider or provider billing group. D0277 Vertical Bitewings - 7 To 8 Films D0290 D0321 Posterior - Anterior Or Lateral Skull And Facial Bone Survey Film Other Temporomandibular Joint Films, By Report HCBS Crisis Narrative Any additional films (D D0340) formed on the same date of service as a complete intraoral series, or its equivalent, are considered content of service of the complete series and are not reimbursed. Only one bitewing code (D0270, D0272, D0273, D0274, D0277) date of service, beneficiary, provider or provider billing group. HCBS Crisis Narrative Any additional films (D D0340) formed on the same date of service as a complete intraoral series, or its equivalent, are considered content of service of the complete series and are not reimbursed. HCBS Crisis Narrative Any additional films (D D0340) formed on the same date of service as a complete intraoral series, or its equivalent, are considered content of service of the complete series and are not reimbursed , Scion Dental, Inc. PROPRIETARY AND CONFIDENTIAL Dental Health & Wellness

133 Benefit Plan Details and Requirements HCBS Adults s 65 and Over (not ICF/MR) HCBS Adults s 65 and Over (not ICF/MR) HCBS beneficiaries covered under the HCBS Frail Elderly (FE) waiver will have additional coverage for the dental services listed in this benefit plan with an approved 'Crisis ' authorization. Refer to the Title 19 adult benefit plan for a list of covered benefits. Code Code Description AUTHORIZATION REQUIREMENTS BENEFIT DETAILS ADDITIONAL NOTES Documents Min Count Length Type D0330 Panoramic Film N/A Month One 36 Months. The following are also considered an Intraoral Complete Series (D0210), D0330 and D0272 D0330 and D0273, D0330 and D0274, D0330 and D0277 D0460 Pulp Vitality Tests HCBS Crisis Narrative Days imum of three teeth visit. Covered teeth are: 1-32, (SN), A - T, AS - TS (SN) D1110 Prophylaxis - Adult N/A Month One six Months. Includes scaling and polishing procedures to remove coronal plaque, calculus, and stains. D2140 D2150 D2160 D2161 Amalgam - One Surface, Primary Or Permanent Amalgam - Two Surfaces, Primary Or Permanent Amalgam - Three Surfaces, Primary Or Permanent Amalgam - Four Or More Surfaces, Primary Or Permanent D2330 Resin-Based Composite - One Surface, Anterior D2331 Resin-Based Composite - Two Surfaces, Anterior D2332 Resin-Based Composite - Three Surfaces, Anterior D2335 Resin-Based Composite - Four Or More Surfaces Or Involving Incisal Angle D2390 Resin-Based Composite Crown, Anterior D2391 Resin-Based Composite - One Surface, Posterior D2392 Resin-Based Composite - Two Surfaces, Posterior D2393 Resin-Based Composite - Three Surfaces, Posterior D2394 Resin-Based Composite - Four Or More Surfaces, Posterior HCBS Crisis Narrative Month Teeth Covered:1-32,51-82 (SN),A - T,AS - TS (SN) HCBS Crisis Narrative Month Teeth Covered:1-32,51-82 (SN),A - T,AS - TS (SN) HCBS Crisis Narrative Month Teeth Covered:1-32,51-82 (SN),A - T,AS - TS (SN) HCBS Crisis Narrative Month Teeth Covered:1-32,51-82 (SN),A - T,AS - TS (SN) HCBS Crisis Narrative Month Teeth Covered:6-11, 22-27, (SN), (SN), C - H, M - R, CS - HS (SN), MS - RS (SN) HCBS Crisis Narrative Month Teeth Covered:6-11, 22-27, (SN), (SN), C - H, M - R, CS - HS (SN), MS - RS (SN) HCBS Crisis Narrative Month Teeth Covered:6-11, 22-27, (SN), (SN), C - H, M - R, CS - HS (SN), MS - RS (SN) HCBS Crisis Narrative Month Teeth Covered:6-11, 22-27, (SN), (SN), C - H, M - R, CS - HS (SN), MS - RS (SN) HCBS Crisis Narrative Month Teeth Covered:6-11, 22-27, (SN), (SN), C - H, M - R, CS - HS (SN), MS - RS (SN) HCBS Crisis Narrative Month Teeth Covered:1-5, 12-21, 28-32, (SN), (SN), (SN,) A, B, I - L, S, T, AS (SN), BS (SN), IS - LS (SN), SS (SN),TS (SN) HCBS Crisis Narrative Month Teeth Covered:1-5, 12-21, 28-32, (SN), (SN), (SN,) A, B, I - L, S, T, AS (SN), BS (SN), IS - LS (SN), SS (SN),TS (SN) HCBS Crisis Narrative Month Teeth Covered:1-5, 12-21, 28-32, (SN), (SN), (SN,) A, B, I - L, S, T, AS (SN), BS (SN), IS - LS (SN), SS (SN),TS (SN) HCBS Crisis Narrative Month Teeth Covered:1-5, 12-21, 28-32, (SN), (SN), (SN,) A, B, I - L, S, T, AS (SN), BS (SN), IS - LS (SN), SS (SN),TS (SN) , Scion Dental, Inc. PROPRIETARY AND CONFIDENTIAL Dental Health & Wellness 127

134 Benefit Plan Details and Requirements HCBS Adults s 65 and Over (not ICF/MR) HCBS Adults s 65 and Over (not ICF/MR) HCBS beneficiaries covered under the HCBS Frail Elderly (FE) waiver will have additional coverage for the dental services listed in this benefit plan with an approved 'Crisis ' authorization. Refer to the Title 19 adult benefit plan for a list of covered benefits. Code Code Description D2710 D2740 D2751 D2752 Crown - Resin-Based Composite (Indirect) Crown - Porcelain/Ceramic Substrate Crown - Porcelain Fused To Predominantly Base Metal Crown - Porcelain Fused To ble Metal D2783 Crown - 3/4 Porcelain/Ceramic D2791 D2792 D2910 Crown - Full Cast Predominantly Base Metal Crown-Full Cast ble Metal Recement Inlay, Onlay, Or Partial Coverage Restoration D2920 Recement Crown D2921 D2930 D2931 Reattachment of tooth fragment, incisal edge or cusp Prefabricated Stainless Steel Crown - Primary Prefabricated Stainless Steel Crown - Permanent D2940 Protective Restoration D2951 Pin Retention - Per, In Addition To Restoration AUTHORIZATION REQUIREMENTS BENEFIT DETAILS ADDITIONAL NOTES Documents Min Count Length Type HCBS Crisis Narrative and Pre-op x-rays of adj and opposing teeth, fill x-ray. HCBS Crisis Narrative and Pre-op x-rays of adj and opposing teeth, fill x-ray HCBS Crisis Narrative and Pre-op x-rays of adj and opposing teeth, fill x-ray HCBS Crisis Narrative and Pre-op x-rays of adj and opposing teeth, fill x-ray HCBS Crisis Narrative and Pre-op x-rays of adj and opposing teeth, fill x-ray HCBS Crisis Narrative and Pre-op x-rays of adj and opposing teeth, fill x-ray HCBS Crisis Narrative and Pre-op x-rays of adj and opposing teeth, fill x-ray Month Teeth Covered: 6 11, 22 27, (SN), (SN) Month Teeth Covered: 1 31, 51 82(SN) Month Teeth Covered: 1 32, (SN) Month Teeth Covered: 1 32, (SN) Month Teeth Covered: 1 32, (SN) Month Teeth Covered: 1 32, (SN) Month Teeth Covered: 1 32, (SN) HCBS Crisis Narrative Teeth Covered: 1 32, (SN) HCBS Crisis Narrative Teeth Covered: 1 32, (SN) HCBS Crisis Narrative and Pre- and post-oative radiographic images shall be maintained in beneficiary records Teeth Covered: 1 32, (SN), t allowed same tooth, same surface(s), same DOS as D2140, D2150, D2160, D2161, D2330, D2331, D2332, D2335, D2391, D2392 D2393 D2394. HCBS Crisis Narrative Month Teeth Covered: A T, AS - TS (SN) D2930 and D2934 cannot be placed on the same tooth during a 24-Month iod. HCBS Crisis Narrative Month Teeth Covered: 1 32, (SN) HCBS Crisis Narrative Teeth Covered: 1 32, (SN) Temporary restoration intended to relieve pain. t to be used as a base or liner under a restoration. HCBS Crisis Narrative Teeth Covered: 1 32, (SN) , Scion Dental, Inc. PROPRIETARY AND CONFIDENTIAL Dental Health & Wellness

135 Benefit Plan Details and Requirements HCBS Adults s 65 and Over (not ICF/MR) HCBS Adults s 65 and Over (not ICF/MR) HCBS beneficiaries covered under the HCBS Frail Elderly (FE) waiver will have additional coverage for the dental services listed in this benefit plan with an approved 'Crisis ' authorization. Refer to the Title 19 adult benefit plan for a list of covered benefits. Code Code Description D2954 D2957 D3110 Prefabricated Post And Core In Addition To Crown Each Additional Prefabricated Post - Same Pulp Cap - Direct (Excluding Final Restoration) D3220 Therapeutic Pulpotomy D3221 Pulpal Debridement - Primary And Permanent Teeth D3222 D3310 D3320 D3330 D3331 Partial Pulpotomy For Apexogenesis - Permanent Endodontic Therapy, Anterior (Excluding Final Restoration) Endodontic Therapy, Bicuspid (Excluding Final Restoration) Endodontic Therapy, Molar (Excluding Final Restoration) Treatment Of Root Canal Obstruction; n-surgical Access D3351 Apexification / Recalcification / Pulpal Regeneration - Initial Visit D3352 Apexification / Recalcification / Pulpal Regeneration - Interim D3353 Apexification / Recalcification / Pulpal Regeneration - Final Visit D3410 Apicoectomy / Periradicular Surgery - Anterior AUTHORIZATION REQUIREMENTS BENEFIT DETAILS ADDITIONAL NOTES Documents Min Count Length Type HCBS Crisis Narrative and Pre-op x-rays of adj and opposing teeth, fill x-ray HCBS Crisis Narrative and Pre-op x-rays of adj and opposing teeth, fill x-ray Month Teeth Covered: 1 32, (SN) Month Teeth Covered: 1 3, 14 19, 30 32, (SN), (SN), (SN) HCBS Crisis Narrative Teeth Covered: 1 32, (SN) HCBS Crisis Narrative Lifetime HCBS Crisis Narrative Lifetime HCBS Crisis Narrative and Pre-oative x-rays (excluding bitewings) Lifetime HCBS Crisis Narrative Lifetime HCBS Crisis Narrative Lifetime HCBS Crisis Narrative Lifetime HCBS Crisis Narrative and Pre-oative x-rays (excluding bitewings) Teeth Covered: 1 32, (SN), A T, AS TS t covered within 30 days of D3310-D3331 on same tooth. Teeth Covered: 1 32, (SN), A T, AS TS t covered within 30 days of D3310-D3331 on same tooth. Teeth Covered: 1 32, (SN) Should only be formed as preparation for endodontic treatment. Teeth Covered: 6 11, 22 27, (SN), (SN) Teeth Covered: 4, 5, 12, 13, 20, 21, 28, 29, 54 (SN), 55 (SN), 62 (SN), 63 (SN), 70 (SN), 71 (SN), 78 (SN), 79 (SN) Teeth Covered: 1-3, 14 19, 30 32, (SN), (SN), (SN) Teeth Covered: 1 32, (SN) HCBS Crisis Narrative Teeth Covered: 1 32, (SN) HCBS Crisis Narrative Teeth Covered: 1 32, (SN) HCBS Crisis Narrative Teeth Covered: 1 32, (SN) HCBS Crisis Narrative Teeth Covered: 6 11, 22 27, (SN), (SN) , Scion Dental, Inc. PROPRIETARY AND CONFIDENTIAL Dental Health & Wellness 129

136 Benefit Plan Details and Requirements HCBS Adults s 65 and Over (not ICF/MR) HCBS Adults s 65 and Over (not ICF/MR) HCBS beneficiaries covered under the HCBS Frail Elderly (FE) waiver will have additional coverage for the dental services listed in this benefit plan with an approved 'Crisis ' authorization. Refer to the Title 19 adult benefit plan for a list of covered benefits. Code Code Description D3421 D3425 D3426 D3427 D3430 D4210 D4211 D4230 D4231 D4268 D4341 D4342 Apicoectomy / Periradicular Surgery - Bicuspid (First Root) Apicoectomy / Periradicular Surgery - Molar (First Root) Apicoectomy / Periradicular Surgery - Each Additional Root) Periradicular surgery without apicoectomy Retrograde Filling - Per Root Gingivectomy Or Gingivoplasty - Four Or More Contiguous Teeth Gingivectomy Or Gingivoplasty - One To Three Contiguous Teeth Anatomical Crown Exposure - Four Or More Contiguous Teeth Per Quadrant Anatomical Crown Exposure - One To Three Teeth Per Quadrant Surgical Revision Procedure, Per ontal Scaling And Root Planing - Four Or More Teeth Per Quadrant ontal Scaling And Root Planing - One To Three Teeth Per Quadrant D4355 Full Mouth Debridement AUTHORIZATION REQUIREMENTS BENEFIT DETAILS ADDITIONAL NOTES Documents Min Count Length Type HCBS Crisis Narrative Teeth Covered: 4, 5, 12, 13, 20, 21, 28, 29, 54 (SN), 55 (SN), 62 (SN), 63 (SN),70 (SN), 71 (SN), 78 (SN), 79 (SN) HCBS Crisis Narrative Teeth Covered: 1-3, 14 19, 30 32, (SN),64-69 (SN), (SN) HCBS Crisis Narrative Teeth Covered: 1-5, 12 21, 28 32, (SN), (SN), (SN) HCBS Crisis Narrative and Pre- and post-oative radiographs shall be maintained in beneficiary records Teeth Covered: 1-32, (SN), t allowed same tooth, same DOS as D3410, D3421, D3425, D3426 HCBS Crisis Narrative Teeth Covered: 1 32, (SN) HCBS Crisis Narrative and Pre-op x-rays, io charting, narrative of medical necessity, photo (optional) HCBS Crisis Narrative and Pre-op x-rays, io charting, narrative of medical necessity, photo (optional) HCBS Crisis Narrative and Pre-oative x-rays with claim HCBS Crisis Narrative and Pre-oative x-rays with claim Per quadrant:10 (UR), 20 (UL), 30 (LL), 40 (LR) A minimum of four affected teeth in the quadrant Per quadrant:10 (UR), 20 (UL), 30 (LL), 40 (LR) One to three affected teeth in the quadrant Per quadrant:10 (UR), 20 (UL), 30 (LL), 40 (LR) Must be billed same date same tooth in conjunction with the restorative codes (D D2957) Per quadrant: 10 (UR), 20 (UL), 30 (LL), 40 (LR) Same date and same tooth in conjunction with the restorative code. HCBS Crisis Narrative Teeth Covered: 1 32, (SN), Only covered after D4210. HCBS Crisis Narrative and ontal charting and preop x-rays HCBS Crisis Narrative and ontal charting and preop x-rays HCBS Crisis Narrative and ontal charting and preop x-rays Month Per quadrant: 10 (UR), 20 (UL), 30 (LL), 40 (LR) A minimum of four affected teeth in the quadrant Month Per quadrant:10 (UR), 20 (UL), 30 (LL), 40 (LR) One to three affected teeth in the quadrant Month , Scion Dental, Inc. PROPRIETARY AND CONFIDENTIAL Dental Health & Wellness

137 Benefit Plan Details and Requirements HCBS Adults s 65 and Over (not ICF/MR) HCBS Adults s 65 and Over (not ICF/MR) HCBS beneficiaries covered under the HCBS Frail Elderly (FE) waiver will have additional coverage for the dental services listed in this benefit plan with an approved 'Crisis ' authorization. Refer to the Title 19 adult benefit plan for a list of covered benefits. Code Code Description AUTHORIZATION REQUIREMENTS BENEFIT DETAILS ADDITIONAL NOTES Documents Min Count Length Type D5110 Complete Denture - illary D5120 Complete Denture - Mandibular D5211 illary Partial Denture - Resin Base D5212 Mandibular Partial Denture - Resin Base D5213 illary Partial Denture - Cast Metal Framework With Resin Denture Bases D5214 Mandibular Partial Denture - Cast Metal Framework With Resin Denture Bases D5225 illary Partial Denture - Flexible Base D5226 Mandibular Partial Denture - Flexible Base D5281 Removable Unilateral Partial Denture - One Piece Cast Metal D5410 Adjust Complete Denture - illary D5411 Adjust Complete Denture - Mandibular D5421 Adjust Partial Denture - illary D5422 Adjust Partial Denture - Mandibular D5510 D5520 Repair Broken Complete Denture Base Replace Missing Or Broken Teeth - Complete Denture (Each ) HCBS Crisis Narrative and Pre-op x-rays of adj and opposing teeth, trmt plan HCBS Crisis Narrative and Pre-op x-rays of adj and opposing teeth, trmt plan HCBS Crisis Narrative and Pre-op x-rays of adj and opposing teeth, trmt plan HCBS Crisis Narrative and Pre-op x-rays of adj and opposing teeth, trmt plan HCBS Crisis Narrative and Pre-op x-rays of adj and opposing teeth, trmt plan HCBS Crisis Narrative and Pre-op x-rays of adj and opposing teeth, trmt plan HCBS Crisis Narrative and Pre-op x-rays of adj and opposing teeth, trmt plan HCBS Crisis Narrative and Pre-op x-rays of adj and opposing teeth, trmt plan HCBS Crisis Narrative and Pre-op x-rays of adj and opposing teeth, trmt plan Month Month Month Month Month Month Month Month Month Per quadrant:10 (UR), 20 (UL), 30 (LL), 40 (LR) HCBS Crisis Narrative t covered within 6 Months of placement. HCBS Crisis Narrative t covered within 6 Months of placement. HCBS Crisis Narrative t covered within 6 Months of placement. HCBS Crisis Narrative t covered within 6 Months of placement. HCBS Crisis Narrative Area covered:01 (UA), 02 (LA) HCBS Crisis Narrative Teeth Covered: , Scion Dental, Inc. PROPRIETARY AND CONFIDENTIAL Dental Health & Wellness 131

138 Benefit Plan Details and Requirements HCBS Adults s 65 and Over (not ICF/MR) HCBS Adults s 65 and Over (not ICF/MR) HCBS beneficiaries covered under the HCBS Frail Elderly (FE) waiver will have additional coverage for the dental services listed in this benefit plan with an approved 'Crisis ' authorization. Refer to the Title 19 adult benefit plan for a list of covered benefits. Code Code Description D5610 Repair Resin Denture Base D5620 Repair Cast Framework D5630 D5640 D5650 D5660 D5670 D5671 D5730 D5731 D5750 D5751 D5760 D5761 D5850 Repair Or Replace Broken Clasp Replace Broken Teeth - Per Add To Existing Partial Denture Add Clasp To Existing Partial Denture Replace All Teeth And Acrylic On Cast Metal Framework (illary) Replace All Teeth And Acrylic On Cast Metal Framework (Mandibular) Reline Complete illary Denture (Chairside) Reline Complete Mandibular Denture (Chairside) Reline Complete illary Denture (Laboratory) Reline Complete Mandibular Denture (Laboratory) Reline illary Partial Denture (Laboratory) Reline Mandibular Partial Denture (Laboratory) Tissue Conditioning, illary D5851 Tissue Conditioning, Mandibular D6100 Implant Removal, By Report D6930 Recement Fixed Partial Denture AUTHORIZATION REQUIREMENTS BENEFIT DETAILS ADDITIONAL NOTES Documents Min Count Length Type HCBS Crisis Narrative Area covered:01 (UA), 02 (LA), 10 (UR), 20 (UL), 30 (LL), 40 (LR) HCBS Crisis Narrative Area covered:01 (UA), 02 (LA), 10 (UR), 20 (UL), 30 (LL),40 (LR) HCBS Crisis Narrative Area covered:01 (UA), 02 (LA), 10 (UR), 20 (UL), 30 (LL),40 (LR) HCBS Crisis Narrative Teeth Covered: 1-32 HCBS Crisis Narrative Teeth Covered: 1-32 HCBS Crisis Narrative Area covered: 01 (UA), 02 (LA), 10 (UR), 20 (UL), 30 (LL),40 (LR) HCBS Crisis Narrative HCBS Crisis Narrative HCBS Crisis Narrative Month One 24 Months. t covered within 24 Months of placement. Covered for Frail Elderly benefit plan only. HCBS Crisis Narrative Month One 24 Months. t covered within 24 Months of placement. Covered for Frail Elderly benefit plan only. HCBS Crisis Narrative Month t covered within 24 Months of placement. HCBS Crisis Narrative Month t covered within 24 Months of placement. HCBS Crisis Narrative Month t covered within 24 Months of placement. HCBS Crisis Narrative Month t covered within 24 Months of placement. HCBS Crisis Narrative HCBS Crisis Narrative Pre-op & post-op x-rays, narr of med neck Teeth Covered: 1 32, (SN) HCBS Crisis Narrative Area covered:01 (UA), 02 (LA), 10 (UR), 20 (UL), 30 (LL),40 (LR) , Scion Dental, Inc. PROPRIETARY AND CONFIDENTIAL Dental Health & Wellness

139 Benefit Plan Details and Requirements HCBS Adults s 65 and Over (not ICF/MR) HCBS Adults s 65 and Over (not ICF/MR) HCBS beneficiaries covered under the HCBS Frail Elderly (FE) waiver will have additional coverage for the dental services listed in this benefit plan with an approved 'Crisis ' authorization. Refer to the Title 19 adult benefit plan for a list of covered benefits. Code Code Description AUTHORIZATION REQUIREMENTS BENEFIT DETAILS ADDITIONAL NOTES Documents Min Count Length Type D7140 D7210 D7220 D7230 D7240 D7241 D7250 Extraction, Erupted Or Exposed Root Surgical Removal Or Erupted Removal Of Impacted - Soft Tissue Removal Of Impacted - Partially Bony Removal Of Impacted - Completely Bony Removal Of Impacted - Completely Bony, Unusual Surgical Complications Surgical Removal Of Residual (Cutting Procedure) N/A Lifetime N/A Lifetime D7260 Oroantral Fistula Closure D7270 D7280 Reimplantation And/Or Stabilization Of Accidentally Evulsed / Displaced Surgical Access Of An Unerupted D7285 Biopsy Of Oral Tissue - Hard (Bone, ) Pre-op x-rays (excluding bitewings) and narr of med neck Pre-op x-rays (excluding bitewings) and narr of med neck Pre-op x-rays (excluding bitewings) and narr of med neck Pre-op x-rays (excluding bitewings) and narr of med nec Preoative radiographs and narrative of medical necessity shall be maintained in beneficiary records. Pre- and postoative radiographs and narrative of medical necessity submitted with claim Lifetime Lifetime Lifetime Lifetime Lifetime Lifetime HCBS Crisis Narrative Lifetime HCBS Crisis Narrative with Pre-op x-rays, narr of med nec Pathology report should be kept in beneficiary record. D7286 Biopsy Of Oral Tissue - Soft Pathology report should be kept in beneficiary record. D7310 Alveoloplasty In Conjunction With Extractions - Four Or More Teeth Lifetime Teeth Covered: 1 32, (SN), A T, AS - TS (SN) Removal of asymptomic tooth not covered. Teeth Covered: 1 32, (SN), A T, AS - TS (SN) Removal of asymptomic tooth not covered. Includes cutting of gingiva and bone, removal of tooth structure, and closure. Teeth Covered: 1 32, (SN) Removal of asymptomic tooth not covered. Includes cutting of gingiva and bone, removal of tooth structure, and closure. Teeth Covered: 1 32, (SN) Removal of asymptomic tooth not covered. Includes cutting of gingiva and bone, removal of tooth structure, and closure. Teeth Covered: 1 32, (SN) Removal of asymptomic tooth not covered. Includes cutting of gingiva and bone, removal of tooth structure, and closure. Teeth Covered: 1 32, (SN) Removal of asymptomic tooth not covered. Includes cutting of gingiva and bone, removal of tooth structure, and closure. Unusual complications such as nerve dissection, separate closure of the maxillary sinus, or aberrant tooth position. Teeth Covered: 1 32, (SN), A T, AS-TS (SN) Includes cutting of gingiva and bone, removal of tooth structure, and closure. Will not be paid to the providers or group that originally removed the tooth. Teeth Covered: 1 32, (SN), A T, AS - TS (SN) Includes splinting and/or stabilization. Teeth Covered: 1 32, (SN), Removal of asymptomic tooth not covered. HCBS Crisis Narrative Per quadrant:10 (UR), 20 (UL), 30 (LL), 40 (LR) Covered for Frail Elderly benefit plan only , Scion Dental, Inc. PROPRIETARY AND CONFIDENTIAL Dental Health & Wellness 133

140 Benefit Plan Details and Requirements HCBS Adults s 65 and Over (not ICF/MR) HCBS Adults s 65 and Over (not ICF/MR) HCBS beneficiaries covered under the HCBS Frail Elderly (FE) waiver will have additional coverage for the dental services listed in this benefit plan with an approved 'Crisis ' authorization. Refer to the Title 19 adult benefit plan for a list of covered benefits. Code Code Description AUTHORIZATION REQUIREMENTS BENEFIT DETAILS ADDITIONAL NOTES Documents Min Count Length Type D7320 D7350 D7410 D7411 D7412 D7413 D7414 D7415 D7440 D7441 D7450 D7451 D7460 D7461 Alveoloplasty t In Conjunction With Extractions - Four Or More Teeth Vesibuloplasty - Ridge Extension (Including Soft Tissue Grafts) Excision Of Benign Lesion Up To 1.25 Cm Excision Of Benign Lesion Greater Than 1.25 Cm Excision Of Benign Lesion, Complicated Excision Of Malignant Lesion Up To 1.25 Cm Excision Of Malignant Lesion Greater Than 1.25 Cm Excision Of Malignant Lesion, Complicated Excision Of Malignant Tumor - Lesion Diameter Up To 1.25 Cm Excision Of Malignant Tumor - Lesion Diameter Greater Than 1.25 Cm Removal Of Benign Odontogenic Cyst Or Tumor Dia Up To 1.25 Cm Removal Of Benign Odontogenic Cyst Or Tumor Dia Greater Than 1.25 Cm Removal Of Benign nodontogenic Cyst Or Tumor - Dia Up To 1.25 Cm Removal Of Benign nodontogenic Cyst Or Tumor - Dia Greater Than 1.25 Cm HCBS Crisis Narrative with Pre-op x-rays, narr of med nec HCBS Crisis Narrative with Pre-op x-rays, narr of med nec N/A N/A N/A Days N/A N/A N/A N/A N/A N/A N/A N/A N/A Per quadrant: 10 (UR), 20 (UL), 30 (LL), 40 (LR) extractions formed in an edentulous area. t covered when formed on the same day as an extraction for the same tooth Per quadrant: 10 (UR), 20 (UL), 30 (LL), 40 (LR) , Scion Dental, Inc. PROPRIETARY AND CONFIDENTIAL Dental Health & Wellness

141 Benefit Plan Details and Requirements HCBS Adults s 65 and Over (not ICF/MR) HCBS Adults s 65 and Over (not ICF/MR) HCBS beneficiaries covered under the HCBS Frail Elderly (FE) waiver will have additional coverage for the dental services listed in this benefit plan with an approved 'Crisis ' authorization. Refer to the Title 19 adult benefit plan for a list of covered benefits. Code Code Description AUTHORIZATION REQUIREMENTS BENEFIT DETAILS ADDITIONAL NOTES Documents Min Count Length Type D7471 Removal Of Lateral Exostosis (illa Or Mandible) D7472 Removal Of Torus Palatinus D7473 D7490 D7510 D7511 D7520 D7521 D7530 D7540 D7550 D7560 D7610 D7620 Removal Of Torus Mandibularis Radical Resection Of illa Or Mandible Incision And Drainage Of Abscess - Intraoral Soft Tissue Incision And Drainage Of Abscess - Intraoral Soft Tissue - Complicated Incision And Drainage Of Abscess - Extraoral Soft Tissue Incision And Drainage Of Abscess - Extraoral Soft Tissue - Complicated Removal Of Foreign Body From Mucosa Removal Of Reaction Producing Foreign Bodies Partial Ostectomy/ Sequestrectomy For Removal Of n-vital Bone illary Sinusotomy For Removal Of Fragment Or Foreign Body illa - Open Reduction (Teeth Immobilized, If Present) illa - Closed Reduction (Teeth Immobilized, If Present) Pre-op x-rays, narr of med nec Pre-op x-rays, narr of med nec Pre-op x-rays, narr of med neck Pre-op x-rays, narr of med nec Once Lifetime Once Lifetime Once Lifetime Area Covered: 01 (UA), 02 (LA) Area Covered: 01 (UA), 02 (LA) N/A t covered same date of service as D7511 N/A N/A t covered same date of service as D7521. N/A N/A N/A N/A Pre- and postoative radiographs along with narrative of medical necessity must be submitted N/A N/A , Scion Dental, Inc. PROPRIETARY AND CONFIDENTIAL Dental Health & Wellness 135

142 Benefit Plan Details and Requirements HCBS Adults s 65 and Over (not ICF/MR) HCBS Adults s 65 and Over (not ICF/MR) HCBS beneficiaries covered under the HCBS Frail Elderly (FE) waiver will have additional coverage for the dental services listed in this benefit plan with an approved 'Crisis ' authorization. Refer to the Title 19 adult benefit plan for a list of covered benefits. Code Code Description AUTHORIZATION REQUIREMENTS BENEFIT DETAILS ADDITIONAL NOTES Documents Min Count Length Type D7630 D7640 D7650 D7660 D7670 D7680 Mandible - Open Reduction (Teeth Immobilized, If Present) Mandible - Closed Reduction (Teeth Immobilized, If Present) Malar And/Or Zygomatic Arch - Open Reduction Malar And/Or Zygomatic Arch - Closed Reduction Alveolus - Closed Reduction, May Include Stabilization Of Teeth Facial Bones - Complicated Reduction With Fixation And Multiple Surgical N/A N/A N/A N/A N/A Teeth Covered: 1 32 May include stabilization. Pre- and postoative radiographs along with narrative of medical necessity must be submitted D7710 illa - Open Reduction N/A D7720 illa - Closed Reduction N/A D7730 Mandible - Open Reduction Postoative radiographs must be available in the beneficiary records D7740 D7750 D7760 D7770 D7780 D7820 Mandible - Closed Reduction Malar And/Or Zygomatic Arch - Open Reduction Malar And/Or Zygomatic Arch - Closed Reduction Alveolus - Open Reduction Stabilization Of Teeth Facial Bones - Complicated Reduction With Fixation And Multiple Surgical Closed Reduction Of Dislocation D7860 Arthrotomy N/A N/A N/A N/A N/A N/A Pre-op & post-op x-rays, narr of med nec , Scion Dental, Inc. PROPRIETARY AND CONFIDENTIAL Dental Health & Wellness

143 Benefit Plan Details and Requirements HCBS Adults s 65 and Over (not ICF/MR) HCBS Adults s 65 and Over (not ICF/MR) HCBS beneficiaries covered under the HCBS Frail Elderly (FE) waiver will have additional coverage for the dental services listed in this benefit plan with an approved 'Crisis ' authorization. Refer to the Title 19 adult benefit plan for a list of covered benefits. Code Code Description AUTHORIZATION REQUIREMENTS BENEFIT DETAILS ADDITIONAL NOTES Documents Min Count Length Type D7865 Arthroplasty D7910 D7911 Suture Of Recent Small Wounds Up To 5 Cm Complicated Suture - Up To 5 Cm D7912 Complicated Suture - Greater Than 5 Cm D7920 D7955 D7960 Skin Graft (Identify Defect Covered, Location And Type Of Graft) Repair Of illofacial Soft And/Or Hard Tissue Defect Frenulectomy - Also Known As Frenectomy Or Frenotomy - Separate Procedure Pre- and postoative radiographs along with narrative of medical necessity must be submitted N/A t covered on dame day as D7140, D7210, D7220, D7230, D7240, D7241, or D7250. N/A t covered on dame day as D7140, D7210, D7220, D7230, D7240, D7241, or D7250. N/A t covered on dame day as D7140, D7210, D7220, D7230, D7240, D7241, or D7250. Pre-op & post-op x-rays, narr of med nec HCBS Crisis Narrative with Pre-op x-rays, narr of med nec Area covered: 01 (UA), 02 (LA), 10 (UR), 20 (UL), 30 (LL), 40 (LR) N/A Lifetime Area Covered:01 (UA), 02 (LA) Once Lifetime. Per location. Lingual, Buccal or Labial. t covered same date of service as D7963. The frenum may be excised when the tongue has limited mobility; for large diastemas between teeth, or when the frenum interferes with a prosthetic appliance; or when it is the etiology of iodontal tissue disease. D7963 Frenuloplasty N/A Excision of frenum with the excision or repositioning of abervant muscle and z-plasty or other local flap closure. D7971 Excision Of Pericoronal Gingiva N/A Teeth Covered: 1-32 D7980 Sialolithotomy N/A D7981 Excision Of Salivary Gland, By Report N/A D7982 Sialodochoplasty N/A D7983 Closure Of Salivary Fistula Narrative of medical necessity, x-rays or photos optional, submitted D7990 Emergency Tracheotomy N/A D9212 Trigeminal Division Block Anesthesia Narrative of medical necessity D9220 Deep Sedation/General Anesthesia - First 30 Minutes Narrative of medical necessity and treatment plan D9220 and D9221 are only billable when dental services other then ONLY diagnostic are provided on the same date of service , Scion Dental, Inc. PROPRIETARY AND CONFIDENTIAL Dental Health & Wellness 137

144 Benefit Plan Details and Requirements HCBS Adults s 65 and Over (not ICF/MR) HCBS Adults s 65 and Over (not ICF/MR) HCBS beneficiaries covered under the HCBS Frail Elderly (FE) waiver will have additional coverage for the dental services listed in this benefit plan with an approved 'Crisis ' authorization. Refer to the Title 19 adult benefit plan for a list of covered benefits. Code Code Description AUTHORIZATION REQUIREMENTS BENEFIT DETAILS ADDITIONAL NOTES Documents Min Count Length Type D9221 Deep Sedation/General Anesthesia - Each Additional 15 Minutes Narrative of medical necessity and treatment plan D9220 and D9221 are only billable when dental services other then ONLY diagnostic are provided on the same date of service. D9230 Inhalation Of Nitrous/Analgesia, Anxiolysis Narrative of medical necessity shall be maintained in beneficiary records t covered when billed with only diagnostic and/or preventative services (D0120 through D1208, D1515 through D1550, D9410, D9420). D9241 Intravenous Conscious Sedation/Analgesia - First 30 Minutes Narrative of medical necessity and treatment plan D9242 Intravenous Conscious Sedation/Analgesia - Each Additional 15 Minutes Narrative of medical necessity and treatment plan D9310 Consultation - Diagnostic Service Provided By Dentist Or Physician Narrative of the consultation for dental services shall be maintained in beneficiary records Month D9310 is billable when ONLY diagnostic services are provided on the same date of service. One 12 Months by same provider. One inpatient follow up beneficiary within a 10 day iod by same provider. t covered on the same date of service as D0120-D0170, D9410, D9420. D9410 House/Extended Care Facility Call Narrative of medical necessity shall be maintained in beneficiary records Extended Care Facilities only. D9420 Hospital Or Ambulatory Surgical Center Call Narrative of medical necessity shall be maintained in beneficiary records Hospital Facilities only. D9610 Therapeutic Parenteral Drug, Single Administration Narrative of medical necessity and description and dosage of drug submitted D9920 Behavior Management, By Report Narrative of medical necessity D9999 Unspecified Adjunctive Procedure, By Report HCBS Crisis Narrative. Description of procedure and narrative of medical necessity , Scion Dental, Inc. PROPRIETARY AND CONFIDENTIAL Dental Health & Wellness