Transcription
Dental Benefits MatrixImportant information X‐rays and chart notes must accompany your requestfor Prior Authorization. Emergency dental services do not requirePriorAuthorization. Please refer to the AHCCCS Uniform Warranty Listlocated under AHCCCS’ Guides and Manuals todetermine the frequency a restoration or otherservices can be replaced. All NON‐PAR providers require Prior Authorizationforany services, except emergency services. Post‐op treatment for services rendered within3months of original service is not billable. Members age 21 and older have a 1k emergentbenefit and prior authorization is not needed ifitmeets AHCCCS criteria. Members age 21 and older that qualify for anemergent root canal may have a crown placed tocomplete the care. Otherwise, permanent crowns arenot a covered benefit. Prior authorization is not a guarantee of payment.C‐ Covered ServiceMercy Care RBHA Dental Benefits Matrix 1/2020ProprietaryN‐Non‐covered ServiceMail Prior Authorization to:Mercy Care RBHA Dental Prior Authorization4755 S. 44th PlacePhoenix, AZ 85040Email Prior Authorizations: dental@mercycareaz.orgFax: 602‐431‐7155Most dental claims will not require X‐rays with submission.However, if your claim requires additional attachments andyou need to submit X‐rays, chart notes, etc., the claimmustbe mailed to Mercy Care RBHA. These claims cannot besubmitted electronically to us. Please mail these claims tothe address below:DENTAL CLAIMS – MAIL TO:Mercy Care RBHA dental claimsPO Box 62978Phoenix, AZ 85082‐2979C‐PA ‐ Covered only with prior authorization1 of 21
MERCY CARE – REGIONAL BEHAVIORAL HEALTH AUTHORITY (MC RBHA)CDT 2020ProcedureCodeD0120ProcedureDescriptionCoverage Category(0 ‐20 years)AdditionalDocumentationRequired forPrior Authorization(0‐20 years)Emergent Benefit‐Policy 310‐D1‐covered if it meet AHCCCS criteria(21 years & older)Periodic oral examination(2 per year; 6 months plus 1 day apart)Limited oral evaluation‐problem focused** May not be billed with D0120,D0150,D0160 or D0170CCC‐policy 310‐D1‐covered if it meetscriteriaCND0160Comprehensive oral evaluation – new or establishedpatient(only billable one time per member/per provider)Detailed and extensive oral evaluation ‐ problem basedD0171Re‐evaluation post‐operative office visitCD0180Comprehensive periodontal evaluation – new orestablished patientC‐PAInclude NarrativeND0190Screening of a patientC‐ One of (D0190,Include NarrativeND0191Assessment of a patientC ‐‐One of (D0190,Include NarrativeC‐ policy 310‐D1‐covered if it meetscriteriaD0210Intraoral ‐ complete series (including bitewings)C1 series in a 3 year periodND0220Intraoral ‐ periapical ‐ first filmCD0230Intraoral ‐ periapical ‐ each additional filmCD0240Intraoral ‐ occlusal filmCD0140D0150Include NarrativeD0191) per 12Month(s)Mercy Care RBHA Dental Benefits Matrix 1/2020N‐Non‐covered ServiceNND0191) per 12Month(s)C‐ Covered ServiceProprietaryCNC policy 310‐D1‐covered if it meetscriteriaC‐ policy 310‐D1‐covered if it meetscriteriaNC‐PA ‐ Covered only with prior authorization2 of 21
D0250C‐PANCND0270Extra‐oral – 2D projectionradiographic image created usinga stationary radiation source, anddetectorExtra‐oral posterior dentalradiographicBitewing ‐ single filmC2 per year; 6 months plus 1 day apartD0272Bitewings ‐ two filmsC2 per year; 6 months plus 1 day apartD0273Bitewings – three filmsCD0274Bitewings ‐ four filmsC2 per year; 6 months plus 1 day apartD0277Vertical bitewings 7 – 8 filmsC1 per 36 ibular joint arthrogram, including injectionOther temporomandibular joint films, by reportPanoramic filmC‐PAC‐PAC‐PACInclude NarrativeInclude NarrativeInclude Narrative1 in a 3 year periodD0340D0350D0367Cephalometric filmOral/facial images (includes intra and extra oral images)Cone beam CT capture and interpretation with fieldof view of both jaws; with or without craniumTreatment simulation using 3D image volumeDiagnostic castsOther oral pathology procedures, by reportC‐PAC‐PAC‐PAInclude NarrativeC‐PAC‐PAC‐PAInclude NarrativeInclude NarrativeInclude NarrativeNNNC‐PACInclude Narrative2 per year; 6 months plus 1 day apartNNC2 per year; 6 months plus 1 day ed diagnostic procedure, by reportProphylaxis ‐ adult (ages 14 )(2 per year; 6 months plus 1 day apart)Topical Application of Fluoride VarnishC‐ Covered ServiceMercy Care RBHA Dental Benefits Matrix 1/2020ProprietaryN‐Non‐covered ServiceC‐ policy 310‐D1‐covered if it meetscriteriaC‐ policy 310‐D1‐covered if it meetscriteriaC‐ policy 310‐D1‐covered if it meetscriteriaC‐ policy 310‐D1‐covered if it meetscriteriaC‐ policy 310‐D1‐covered if it meetscriteriaNNNC‐ policy 310‐D1‐covered if it meetscriteriaNNNC‐PA ‐ Covered only with prior authorization3 of 21
D1208Topical Application of nterim caries arresting medicament application‐ per toothSpace maintainer‐fixed‐unilateralSpace maintainer‐ fixed‐bilateral, maxillarySpace maintainer‐ fixed‐bilateral, mandibularSpace maintainer‐ removable‐ unilateralSpace maintainer‐ removable‐bilateral, maxillarySpace maintainer‐ removable‐bilateral, mandibularRe‐cementation of bilateral space maintainer, 52Re‐cement of bilateral space maintainer, mandibularCD1553Re‐cement unilateral space maintainer‐per quadrantCD1556Removal of fixed unilateral space maintainer‐perquadrantC2 per year; 6 months plus 1 day apartInclude NarrativeInclude NarrativeInclude NarrativeInclude NarrativeInclude NarrativeInclude NarrativeInclude Narrative‐ with claimssubmissionInclude Narrative‐ with claimssubmissionInclude Narrative‐ with claimssubmissionInclude Narrative‐ with claimssubmissionNNNNNNNNNNNND1557Removal of fixed bilateral space maintainer, maxillary (doneby dentist or practice that did not place appliance)CInclude Narrative‐ with claimssubmissionND1558Removal of fixed bilateral space maintainer, mandibular(done by dentist or practice that did not place appliance)CInclude Narrative‐ with claimssubmissionNInclude NarrativeInclude NarrativeNNNNNNC‐ policy 310‐D1‐covered if it stal shoe space maintainer‐fixed‐unilateralUnspecified preventive procedure, by reportAmalgam ‐ one surface, primary or permanentAmalgam ‐ two surfaces, primary or permanentAmalgam ‐ three surfaces, primary or permanentAmalgam ‐ four or more surfaces, primary or permanentResin ‐ one surface, anteriorC‐PAC‐PACCCCCD2331Resin ‐ two surfaces, anteriorCD2332Resin ‐ three surfaces, anteriorCC‐ Covered ServiceMercy Care RBHA Dental Benefits Matrix 1/2020ProprietaryN‐Non‐covered ServiceC‐ policy 310‐D1‐covered if it meetscriteriaC‐ policy 310‐D1‐covered if it meetscriteriaC‐PA ‐ Covered only with prior authorization4 of 21
D2335CD2390Resin ‐ four or more surfaces OR involving the incisal angle,anteriorResin – based composite crown, anteriorC‐PAInclude NarrativeD2391D2392D2393D2394D2740Resin – based composite – 1 surface, posteriorResin – based composite – 2 surfaces, posteriorResin – based composite – 3 surfaces, posteriorResin – based composite – 4 or more surfaces, posteriorCrown‐‐‐porcelain/ceramic substrateCCCCC‐PA ‐ Ages 18‐20Endo Tx Teeth OnlyDocumentation of seated crown and x‐ray required with claimD2750Crown – porcelain fused to high noble metalC‐PA ‐ Ages 18‐20Endo Tx Teeth OnlyDocumentation of seated crown and x‐ray required with claimD2751Crown – porcelain fused to predominantly base metalC‐PA ‐ Ages 18‐20Endo Tx Teeth OnlyDocumentation of seated crown and x‐ray required with claimD2752Crown – porcelain fused to noble metalC‐PA ‐ Ages 18‐20Endo Tx Teeth OnlyDocumentation of seated crown and x‐ray required with claimD2753Crown‐porcelain fused to titanium and titanium alloysC‐PA ‐ Ages 18‐20Endo Tx Teeth OnlyDocumentation of seated crown and x‐ray required with claimD2790Crown – full cast high noble metalC‐PA ‐ Ages 18‐20Endo Tx Teeth OnlyDocumentation of seated crown and x‐ray required with claimD2791Crown – full cast predominantly base metalC‐PA ‐ Ages 18‐20Endo Tx Teeth OnlyDocumentation of seated crown and x‐ray required with claimD2792Crown – Full cast noble metalC‐PA ‐ Ages 18‐20Endo Tx Teeth OnlyDocumentation of seated crown and x‐ray required with claimD2794Crown‐ titaniumC‐PA ‐ Ages 18‐20Endo Tx Teeth OnlyDocumentation of seated crown and x‐ray required with claimD2910Re‐cement inlay, onlay, or partial coverage restorationCInclude NarrativeD2915Re‐cement cast or prefabricated post and coreCInclude NarrativeC‐ Covered ServiceMercy Care RBHA Dental Benefits Matrix 1/2020ProprietaryN‐Non‐covered ServiceC‐ policy 310‐D1‐covered if it meetscriteriaC‐ policy 310‐D1‐covered if it meetscriteriaNNNNC‐ policy 310‐D1‐covered if it meetscriteria‐narrative with pre and post opx‐raysC‐ policy 310‐D1‐covered if it meetscriteria‐narrative with pre and post opx‐raysC‐ policy 310‐D1‐covered if it meetscriteria‐narrative with pre and post opx‐raysC‐ policy 310‐D1‐covered if it meetscriteria‐narrative with pre and post opx‐raysC‐ policy 310‐D1‐covered if it meetscriteria‐narrative with pre and post opx‐raysC‐ policy 310‐D1‐covered if it meetscriteria‐narrative with pre and post opx‐raysC‐ policy 310‐D1‐covered if it meetscriteria‐narrative with pre and post opx‐raysC‐ policy 310‐D1‐covered if it meetscriteria‐narrative with pre and post opx‐raysC‐ policy 310‐D1‐covered if it meetscriteria‐narrative with pre and post opx‐raysC‐ Policy 310‐D1‐covered if it meetscriteriaC‐ policy 310‐D1‐covered if it meetscriteriaC‐PA ‐ Covered only with prior authorization5 of 21
D2920Re‐cement crownCInclude NarrativeD2921Reattachment of tooth fragment, incisial edge or cuspCInclude NarrativeD2929D2930D2931Prefabricated porcelain/ceramic crown‐primary toothPrefabricated stainless steel crown ‐ primary toothPrefabricated stainless steel crown ‐ permanent toothC‐PAC‐PAC‐PAInclude NarrativeInclude NarrativeInclude NarrativeD2932Prefabricated resin crownC‐PAInclude NarrativeD2933Prefabricated stainless steel crown with resin windowInclude NarrativeD2934D2940Prefabricated esthetic coated stainless steel crown –primary toothProtective restoration –Sedative fillingC‐PAAnterior teeth onlyC‐PAAnterior teeth onlyC‐PAD2941D2950Interim therapeutic restoration‐‐‐primary dentitionCore build‐up, including any pinsC‐PAC‐PAD2951D2952Pin retention ‐ per tooth, in addition to restorationPost and core in addition to crownD2954D2999NNC‐ policy 310‐D1‐covered if it meetscriteriaC‐ policy 310‐D1‐covered if it meetscriteriaC‐ policy 310‐D1‐covered if it meetscriteriaNC‐ policy 310‐D1‐covered if it meetscriteriaC‐PAC‐PASedative fillings and permanentrestorations on the same tooth may notbe billed on the same date of service.Sedative fillings and pulpotomy or RCTmay not be billed on the same tooth(primary or permanent) for the samedate of service.Sedative fillings not covered onprimary teeth without narrative.Include NarrativeClaims for core build‐ups must beaccompanied by a narrative describingthat greater than ½ of the toothstructure is absent.Not covered on primary teeth.Include NarrativeInclude NarrativePrefabricated post and core in addition to crownC‐PAInclude NarrativeUnspecified restorative procedure, by reportC‐PAInclude NarrativeC‐ policy 310‐D1‐covered if it meetscriteriaNC‐ Covered ServiceMercy Care RBHA Dental Benefits Matrix 1/2020ProprietaryInclude NarrativeC‐ policy 310‐D1‐covered if it meetscriteriaNN‐Non‐covered ServiceNC‐ policy 310‐D1‐covered if it meetscriteriaNC‐ policy 310‐D1‐covered if it meetscriteriaC‐PA ‐ Covered only with prior authorization6 of 21
D3110Pulp cap – direct (excluding final restoration)CD3120Pulp cap ‐ indirect (excluding final restoration)CD3220Therapeutic pulpotomy (excluding final restoration),primary and permanent teethPulpal debridement, primary and permanent teethC‐PAD3222Partial Pulpotomy for apexogenesis‐‐permanent tooth withincomplete root developmentC‐PAInclude X‐ray & narrativeD3230D3240D3310Pulpal therapy (restorable filling)‐anterior, primary toothPulpal therapy (restorable filling)‐posterior, primary toothAnteriorC‐PAC‐PAC‐PAExcluding final restorationExcluding final restorationExcluding final restorationD3320BicuspidC‐PAExcluding final restorationD3330MolarC‐PAExcluding final restorationD3331Treatment of root canal obstruction; non‐surgical accessC‐PAInclude X‐ray & NarrativeD3332D3333D3346Incomplete endodontic therapy; inoperable or fractured.Internal root repair or perforation defects.Retreatment of previous root canal therapy ‐ anteriorC‐PAC‐PAC‐PAInclude X‐ray & narrativeInclude X‐ray & narrativeInclude X‐ray & narrativeD3347Retreatment of previous root canal therapy – bicuspidC‐PAInclude X‐ray & narrativeD3348Retreatment of previous root canal therapy ‐ molarC‐PAInclude X‐ray & narrativeD3221C‐ Covered ServiceMercy Care RBHA Dental Benefits Matrix 1/2020ProprietaryDirect pulp caps are covered only onpermanent teeth.Direct pulp caps and permanent fillingsmay not be billed on the same tooth onthe same date of service. This isconsidered part of the restoration fee.Indirect pulp caps are covered only onpermanent teeth.Indirect pulp caps and permanentfillings may not be billed on the sametooth on the same date of service. Thisis considered part of the restorationfee.not to be used for apexogenesisCN‐Non‐covered ServiceC‐ policy 310‐D1‐covered if it meetscriteriaC‐ policy 310‐D1‐covered if it meetscriteriaC‐ policy 310‐D1‐covered if it meetscriteriaC‐ policy 310‐D1‐covered if it meetscriteriaNNNC‐ policy 310‐D1‐covered if it meetscriteriaC‐ policy 310‐D1‐covered if it meetscriteriaC‐ policy 310‐D1‐covered if it meetscriteriaC‐ policy 310‐D1‐covered if it meetscriteriaNNC‐ policy 310‐D1‐covered if it meetscriteriaC‐ policy 310‐D1‐covered if it meetscriteriaC‐ policy 310‐D1‐covered if it meetscriteriaC‐PA ‐ Covered only with prior authorization7 of 21
D3351D3410Apexification/recalcification ‐ initial visit (apicalclosure/calcific repair of perforations, root resorption, etc.)Apexification/recalcification ‐ interim medication (apicalclosure/calcific repair of perforations, root resorption, etc.)Apexification/recalcification ‐ final visit (includescompleted root canal therapy)Apicoectomy/periradicular surgery ‐ anteriorD3421Apicoectomy/periradicular surgery ‐ bicuspid (first root)C‐PAInclude X‐rayD3425Apicoectomy/periradicular surgery ‐ molar (first root)C‐PAInclude X‐rayD3426Apicoectomy/periradicular surgery ‐ each additional rootC‐PAInclude X‐rayD3430Retrograde filling ‐ per rootC‐PAInclude X‐ray & narrativeD3450D3920Root amputation ‐ per rootHemisection (including any root removal), not includingroot canal therapyUnspecified endodontic procedure, by reportGingivectomy or gingivoplasty – 4 or more contiguousteeth or tooth bounded spaces per quadrantC‐PAC‐PAInclude X‐rayInclude X‐rayC‐ policy 310‐D1‐covered if it meetscriteriaC‐ policy 310‐D1‐covered if it meetscriteriaC‐ policy 310‐D1‐covered if it meetscriteriaC‐ policy 310‐D1‐covered if it meetscriteriaC‐ policy 310‐D1‐covered if it meetscriteriaNNC‐PAC‐PAInclude NarrativeInclude Narrative, Perio ChartNNC‐PAInclude Narrative,Perio ChartInclude Narrative, Perio Chart, medicalnecessityInclude Narrative, Perio ChartNC‐PAC‐PAInclude Narrative, Perio ChartInclude Narrative,Perio ChartNNC‐PAC‐PAInclude Narrative,Perio ChartInclude NarrativeND4263Gingivectomy or gingivoplasty – 1 to 3 contiguous teeth ortooth bounded spaces per quadrantGingival flap procedure, including root planing – 4 or morecontiguous teeth or tooth bounded spaces per quadrantGingival flap procedure, including root planing – 1 to 3contiguous teeth or tooth bounded spaces per quadrantClinical crown lengthening – hard tissueOsseous surgery (including flap entry and closure) ‐ 4 ormore contiguous teeth or bounded teeth spaces perquadrantOsseous surgery (including flap entry and closure) – 1 to 3teeth per quadrantBone replacement graft‐‐‐first site in quadrantD4264Bone replacement graft—each additional site in quadrantC‐PAInclude D4260D4261C‐ Covered ServiceMercy Care RBHA Dental Benefits Matrix 1/2020ProprietaryC‐PAInclude X‐ray & narrativeNC‐PAInclude X‐ray & narrativeNC‐PAInclude X‐ray & narrativeNC‐PAInclude X‐rayC‐PAC‐PAN‐Non‐covered ServiceNNNC‐PA ‐ Covered only with prior authorization8 of 21
D5140D5211D5212Biologic materials to aid in soft and osseous tissueregenerationGuided tissue regeneration—restorable barrier—per siteGuided tissue regeneration—Non‐restorable barrier—persitePedicle soft tissue graft procedureSub‐epithelial connective tissue graft procedures, pertoothDistal or proximal wedge procedure (when not performedin conjunction with surgicalprocedures in the same anatomical areaSoft tissue allograftCombined connective tissue and double pedicle graft‐‐‐ per toothProvisional splinting‐‐‐intra‐coronalProvisional splinting‐‐‐extra‐coronalPeriodontal scaling and root planing – 4 or more teeth perquadrantPeriodontal scaling and root planing – 1 to 3 teeth, perquadrantScaling in the presence of generalized moderate or severegingival inflammation – full mouth after evaluationFull mouth debridement to enable comprehensiveevaluation and diagnosisPeriodontal maintenance procedures ‐following activeperiodontal therapy—Unscheduled dressing change (by someone other than thetreating dentist)Unspecified periodontal procedure, by reportComplete denture maxillaryComplete denture mandibularImmediate denture maxillaryImmediate denture mandibularMaxillary partial denture ‐ resin base (including anyconventional clasps, rests and teeth)Mandibular partial denture ‐ resin base (including anyconventional clasps, rests and teeth)C‐ Covered ServiceMercy Care RBHA Dental Benefits Matrix 1/2020ProprietaryC‐PAInclude NarrativeNC‐PAC‐PAInclude NarrativeInclude NarrativeNNC‐PAC‐PAInclude NarrativeInclude NarrativeNNC‐PAInclude NarrativeNC‐PAC‐PAInclude NarrativeInclude NarrativeNNC‐PAC‐PAC‐PAInclude NarrativeInclude NarrativeInclude Narrative, Perio Chart, X‐raysNNNC‐PAInclude Narrative, Perio Chart, X‐raysNC‐PAInclude Narrative, Perio Chart, X‐raysNC‐PAInclude Narrative, Perio chartNC‐PAInclude Narrative & Perio nclude NarrativeInclude NarrativeInclude NarrativeInclude NarrativeInclude NarrativeInclude NarrativeNNNNNNC‐PAInclude NarrativeNN‐Non‐covered ServiceC‐PA ‐ Covered only with prior authorization9 of 21
D5621D5622Maxillary partial denture ‐ cast metal framework with resindenture bases (including any conventional clasps, rests andteethMandibular partial denture ‐ cast metal framework withresin denture bases (including any conventional clasps,rests and teeth)Immediate maxillary partial denture‐resin base(includingany conventional clasps, rests and teeth)Immediate mandibular partial denture‐ resinbase(including any conventional clasps, rests and teeth)Immediate maxillary partial denture‐ cast metal frameworkwith resin denture bases (including any conventionalclasps, rests and teeth)Immediate mandibular partial denture‐cast metalframework with resin dentures bases (including anyconventional clasps, rests and teeth)Removable unilateral partial denture, one‐piece castmetal, (including clasp and teeth), maxillaryRemovable unilateral partial denture, one‐piece castmetal, (including clasp and teeth), mandibularRemovable unilateral partial denture‐one‐piece flexible base(including clasps and teeth) ‐per quadrantRemovable unilateral partial denture‐one‐piece resin(including clasps and teeth)‐per quadrantInclude NarrativeNC‐PAInclude NarrativeNC‐PAInclude NarrativeNC‐PAInclude NarrativeNC‐PAInclude NarrativeNC‐PAInclude NarrativeNC‐PAInclude NarrativeNC‐PAInclude NarrativeNC‐PAInclude NarrativeNC‐PAInclude NarrativeNInclude NarrativeInclude NarrativeInclude NarrativeInclude NarrativeInclude NarrativeInclude NarrativeInclude NarrativeNNNNNNNAdjust complete denture ‐ maxillaryC‐PAAdjust complete denture ‐ mandibularC‐PAAdjust partial denture ‐ maxillaryC‐PAAdjust partial denture ‐ mandibularC‐PARepair broken complete denture base, mandibularC‐PARepair broken complete denture base, maxillaryC‐PAReplace missing or broken teeth ‐ complete denture (eachC‐PAtooth)Repair resin denture base, mandibularC‐PARepair resin denture base, maxillaryC‐PARepair cast frameworkC‐PARepair cast metal framework, mandibularC‐PARepair cast metal framework, maxillaryC‐PAC‐ Covered ServiceN‐Non‐covered ServiceMercy Care RBHA Dental Benefits Matrix 1/2020ProprietaryC‐PAInclude NarrativeInclude narrativeInclude NarrativeInclude NarrativeInclude NarrativeC‐PA ‐ Covered only with prior authorizationNNNNN10 of 21
clude NarrativeInclude NarrativeInclude NarrativeInclude NarrativeInclude NarrativeInclude NarrativeInclude NarrativeInclude NarrativeInclude NarrativeInclude NarrativeInclude NarrativeInclude NarrativeInclude NarrativeInclude NarrativeInclude NarrativeInclude NarrativeInclude Narrative & X‐rayInclude Narrative & X‐rayNNNNNNNNNNNNNNNNNND5850D5851D5876Repair or replace broken claspReplace broken teethAdd tooth to existing partial dentureAdd clasp to existing partial dentureRebase complete maxillary dentureRebase complete mandibular C224 dentureRebase maxillary partial dentureRebase mandibular partial dentureReline maxillary complete denture (chairside)Reline mandibular complete denture (chairside)Reline maxillary partial denture (chairside)Reline mandibular partial denture (chairside)Reline maxillary complete denture (laboratory)Reline mandibular complete denture (laboratory)Reline maxillary partial denture (laboratory)Reline mandibular partial denture (laboratory)Maxillary Interim Partial Denture (use for anterior flipper)Mandibular Interim Partial Denture (use for anteriorflipper)Maxillary Tissue conditioningMandibular Tissue conditioningAdd metal substructure to acrylic full denture (per arch)C‐PAC‐PAC‐PAInclude NarrativeInclude NarrativeInclude NarrativeNNND5899Unspecified removable prosthodontic procedureC‐PAInclude D5923D5924D5925D5926D5927Facial moulage (sectional)Facial moulage (complete)Nasal prosthesisAuricular prosthesisOrbital prosthesisOcular prosthesisFacial prosthesisNasal septal prosthesisOcular prosthesis, interimCranial prosthesisFacial augmentation implant prosthesisNasal prosthesis, replacementAuricular prosthesis, �PAC‐PAC‐PAC‐PAC‐PAC‐PAC‐PAInclude NarrativeInclude NarrativeInclude NarrativeInclude NarrativeInclude NarrativeInclude NarrativeInclude NarrativeInclude NarrativeInclude NarrativeInclude NarrativeInclude NarrativeInclude NarrativeInclude NarrativeNNNNNNNNNNNNNC‐ Covered ServiceMercy Care RBHA Dental Benefits Matrix 1/2020ProprietaryN‐Non‐covered ServiceC‐PA ‐ Covered only with prior authorization11 of 21
D5985D5986D5987D5988D5991D5999D6081Orbital prosthesis, replacementFacial prosthesis, replacementObturator prosthesis, surgicalObturator prosthesis, definitiveObturator prosthesis, modificationMandibular resection prosthesis with guide flangeMandibular resection prosthesis without guide flangeObturator/prosthesis, interimTrismus appliance (not for TMD treatment)Feeding aidSpeech aid prosthesis, pediatricSpeech aid prosthesis, adultPalatal augmentation prosthesisPalatal life prosthesis, definitivePalatal lift prosthesis, interimPalatal lift prosthesis, modificationSpeech aid prosthesis, modificationSurgical stentRadiation carrierRadiation shieldRadiation cone locatorFluoride gel carrierCommissure splintSurgical splintVesiculobullous disease medicament carrierUnspecified maxillofacial prosthesis, by reportScaling and debridement in the presence of inflammationor mucositis of a single implant, including cleaning of theimplant surfaces, without flap entry and AC‐PAC‐PAC‐PAD6930Re‐cement fixed partial dentureC‐PAD6999Unspecified fixed prosthodontic procedure, by reportC‐PAC‐ Covered ServiceMercy Care RBHA Dental Benefits Matrix 1/2020ProprietaryN‐Non‐covered ServiceInclude NarrativeInclude NarrativeInclude NarrativeInclude NarrativeInclude NarrativeInclude NarrativeInclude NarrativeInclude NarrativeInclude NarrativeInclude NarrativeInclude NarrativeInclude NarrativeInclude NarrativeInclude NarrativeInclude NarrativeInclude NarrativeInclude NarrativeInclude NarrativeInclude NarrativeInclude NarrativeInclude NarrativeInclude NarrativeInclude NarrativeInclude NarrativeInclude NarrativeInclude NarrativeInclude narrative, pre‐op x‐ray(s), periocharting(Not to be performed in conjunction ofD1110, D4910, D4346)Narrative required with claimssubmissionInclude narrativeNNNNNNNNNNNNNNNNNNNNNNNNNNNNNC‐PA ‐ Covered only with prior authorization12 of 21
*Extractions of naturally exfoliating teeth are not a covered benefit.**Extractions are covered for ages 0‐20 if:1. Tooth (teeth) is symptomatic and/or exhibits pathology.2. Extraction (s) in NOT for orthodontic purposes3. Extraction (s) is NOT for the prophylactic extraction of 3rd molars4. Prior Authorization is submitted for ALL 3rd molar extractions**Claims for ALL extractions must be accompanied by X‐ray and/or treatment notes.D7111Coronal remnants – deciduous toothC‐PAC‐ policy 310‐D1‐covered if it meetscriteriaD7140Extraction, erupted tooth or exposed root (elevationand/or forceps removal)Surgical removal of erupted tooth requiring elevation ofmucoperiosteal flap and removal of bone and/or section oftooth including cutting of gingiva and bone, removal oftooth structure, minor smoothing of socket bone andclosureRemoval of impacted tooth ‐ soft tissue – occlusal surfaceof tooth covered by soft tissue; requires mucoperiostealflap elevationRemoval of impacted tooth ‐ partially bony – part of crowncovered by bone; requires mucoperiosteal flap elevationand bone removalRemoval of impacted tooth ‐ completely bony – most or allof crown covered by bone; requires mucoperiosteal flapelevation and bone removalRemoval of impacted tooth ‐ completely bony, withunusual surgical complications – most or all of crowncovered by bone; unusually difficult or complicated due tofactors such as nerve dissection required, separate closureof maxillary sinus required or aberrant tooth positionSurgical removal of residual tooth roots (cuttingprocedure) includes cutting of soft tissue and bone,removal of tooth surface and closure (completelysubmerged in bone)C‐PAC‐ policy 310‐D1‐covered if it meetscriteriaC‐ policy 310‐D1‐covered if it meetscriteriaCoronectomy—intentional partial tooth removalD7210D7220D7230D7240D7241D7250D7251C‐ Covered ServiceMercy Care RBHA Dental Benefits Matrix 1/2020ProprietaryC‐PAC‐PAInclude X‐ray, NarrativeC‐ policy 310‐D1‐covered if it meetscriteriaC‐PAInclude X‐ray, NarrativeC‐ policy 310‐D1‐covered if it meetscriteriaC‐PAInclude X‐ray, NarrativeC‐ policy 310‐D1‐covered if it meetscriteriaC‐PAInclude X‐ray, NarrativeC‐ policy 310‐D1‐covered if it meetscriteriaC‐PAInclude X‐ray, NarrativeC‐ policy 310‐D1‐covered if it meetscriteriaC‐PAInclude NarrativeC‐ policy 310‐D1‐covered if it meetscriteriaN‐Non‐covered ServiceC‐PA ‐ Covered only with prior authorization13 of 21
D7260Oral antral fistula closureC‐PAD7261Primary closure of a sinus perforationC‐PAD7270Tooth reimplantation and/or stabilization of accidentallyevulsed or displaced toothC‐PANarrative required with claimssubmissionC‐ policy 310‐D1‐covered if it meetscriteriaC‐ policy 310‐D1‐covered if it meetscriteriaC‐ policy 310‐D1‐covered if it meetscriteriaD7280D7282C‐PAC‐PAInclude X‐ray, NarrativeInclude X‐ray, NarrativeNNC‐PAInclude X‐ray, NarrativeND7285Surgical access of an unerupted toothMobilization of erupted or malpositioned tooth to aideruptionPlacement of device to facilitate eruption of impactedtoothBiopsy of oral tissue – hardC‐PAInclude NarrativeD7286Biopsy of oral tissue – softC‐PAInclude NarrativeD7292Surgical placement: Temporary anchorage device (screwretained plate requiring surgical flap)Surgical placement: Temporary anchorage devicerequiring surgical flapSurgical placement: Temporary anchorage device withoutsurgical flapC‐PAInclude X‐ray, NarrativeC‐ policy 310‐D1‐covered if it meetscriteriaC‐ policy 310‐D1‐covered if it meetscriteriaNC‐PAInclude X‐ray, NarrativeNC‐PAInclude X‐ray, NarrativeNAlveoloplasty in conjunction with extractions – four ormore teeth or tooth spaces per quadrantAlveoloplasty in conjunction with extractions – 1 to 3 teethor tooth spaces per quadrantC‐PAInclude X‐ray ,NarrativeInclude X‐ray ,NarrativeC‐ policy 310‐D1‐covered if it meetscriteriaC‐ policy 310‐D1‐covered if it meetscriteriaC‐PAD7410Alveoloplasty not in conjunction with extractions – four ormore teeth or tooth spaces per quadrantAlveoloplasty not in conjunction with extractions – 1 to 3teeth or tooth spaces per quadrantExcision of benign lesion up to 1.25 cmC‐PAInclude X‐ray ,NarrativeInclude X‐ray ,NarrativeInclude NarrativeD7411Excision of benign lesion greater than 1.25 cmC‐PAInclude NarrativeD7412D7413D7414Excision of benign lesion – complicatedExcision of malignant lesion up to 1.25 cmExcision of malignant lesion greater than 1.25 cmC‐PAC‐PAC‐PAInclude NarrativeInclude NarrativeInclude NarrativeC‐ policy 310‐D1‐covered if it meetscriteriaC‐ policy 310‐D1‐covered if it meetscriteriaC‐ policy 310‐D1‐covered if it meetscriteriaC‐ policy 310‐D1‐covered if it 1C‐ Covered ServiceMercy Care RBHA Dental Benefits Matrix 1/2020Proprieta
meets AHCCCS criteria. Members age 21 and older that qualify for an emergent root canal may have a crown placed to complete the care. Otherwise, permanent crown sare not a covered benefit. Prior authorization is not a guarantee of payment. Mail Prior Authorization to: Mercy Care RBHA Dental Prior Authorization 4755 S. 44. th . Place
