Schedule of Covered Services and Copayments Classic SmartSmile (WA-D)

Transcription

1 Schedule of Covered Services and Copayments Classic SmartSmile (WA-D) D943 Office Visit D9986 missed appointment Per office policy D9987 cancelled appointment Per office policy Services when performed by a Dental Health Services participating dentist. Specialty Services are not a covered benefit (except orthodontia). If you need dental services that your general dentist cannot perform, contact Member Services to discuss options. Diagnostic D1 D1 D14 D1 D16 D17 D171 D18 D2 D2 D2 D2 D D27 D272 D273 D274 D277 D3 D3 D D391 D41 D42 D431 D46 D47 periodic oral evaluation - established patient limited oral evaluation - problem focused oral evaluation for a patient under three years of age and counseling with primary caregiver comprehensive oral evaluation - new or established patient detailed and extensive oral evaluation - problem focused, by report re-evaluation - limited, problem focused (established patient; not post-operative visit) re-evaluation post-operative office visit comprehensive periodontal evaluation - new or established patient intraoral - complete series of radiographic images intraoral - periapical first radiographic image intraoral - periapical each additional radiographic image intraoral - occlusal radiographic image extra-oral 2D projection radiographic image created using a stationary radiation source, and detector bitewing - single radiographic image bitewings - two radiographic images bitewings - three radiographic images bitewings - four radiographic images vertical bitewings - 7 to 8 radiographic images panoramic radiographic image 2D cephalometric radiographic image acquisition, measurement and analysis 2D oral/facial photographic image obtained intra-orally or extra-orally interpretation of diagnostic image by a practitioner not associated with capture of the image, including report collection of microorganisms for culture and sensitivity caries susceptibility tests adjunctive pre-diagnostic test that aids in detection of mucosal abnormalities including premalignant and malignant lesions, not to include cytology or biopsy procedures pulp vitality tests diagnostic casts D61 D62 D63 Preventive D11 D11 D11AX D11CX D16 D18 D13 D13 D13 D131 D132 D133 D134 Space Maintainers D1 D11 D1 D12 D1 D1 D17 caries risk assessment and documentation, with a finding of low risk caries risk assessment and documentation, with a finding of moderate risk caries risk assessment and documentation, with a finding of high risk prophylaxis - adult (limited to 1 every 6 months) prophylaxis - child (limited to 1 every 6 months) prophylaxis - adult (additional beyond 1 in 6 months) prophylaxis - child (additional beyond 1 in 6 months) topical application of fluoride varnish topical application of fluoride excluding varnish nutritional counseling for control of dental disease tobacco counseling for the control and prevention of oral disease oral hygiene instructions sealant - per tooth preventive resin restoration in a moderate to high caries risk patient permanent tooth sealant repair per tooth interim caries arresting medicament application- per tooth space maintainer - fixed - unilateral space maintainer - fixed - bilateral space maintainer - removable - unilateral space maintainer - removable - bilateral re-cement or re-bond space maintainer removal of fixed space maintainer distal shoe space maintainer fixed unilateral Amalgam Restorations - Primary or Permanent D21 D21 D216 D2161 amalgam - one surface, primary or permanent amalgam - two, primary or permanent amalgam - three, primary or permanent amalgam - four or more, primary or permanent Resin-Based Composite Restorations D23 D2331 D2332 D233 D239 resin-based composite - one surface, anterior resin-based composite - two, anterior resin-based composite - three, anterior resin-based composite - four or more or involving incisal angle (anterior) resin-based composite crown, anterior WA1i Current Dental Terminology 18 American Dental Association. All rights reserved Effective Date: 1/1/18

2 D2391 D2392 D2393 D2394 resin-based composite - one surface, posterior resin-based composite - two, posterior resin-based composite - three, posterior resin-based composite - four or more, posterior 8 1 Crowns - Single Restoration Only D27SP, D27HP, and D27NP are allowable upgrade charges for specialized porcelain such as Lava, Captek, Cercon, etc. It is charged in addition to the type of crown billed. D2 D2 D2 D242 D243 D244 D26 D26 D26 D2642 D2643 D2644 D26 D261 D262 D2662 D2663 D2664 D27 D2712 D27 D2721 D2722 D27 D27 D271 D272 D278 D2781 D2782 D2783 D279 D2791 D2792 D2794 D2799 D27HP D27NP D27SP inlay - metallic - one surface inlay - metallic - two inlay - metallic - three or more onlay - metallic - two onlay - metallic - three onlay - metallic - four or more inlay - porcelain/ceramic - one surface inlay - porcelain/ceramic - two inlay - porcelain/ceramic - three or more onlay - porcelain/ceramic - two onlay - porcelain/ceramic - three onlay - porcelain/ceramic - four or more inlay - resin-based composite - one surface inlay - resin-based composite - two inlay - resin-based composite - three or more onlay - resin-based composite - two onlay - resin-based composite - three onlay - resin-based composite - four or more crown - resin-based composite (indirect) crown - ¾ resin-based composite (indirect) crown - resin with high noble metal crown - resin with predominantly base metal crown - resin with noble metal crown - porcelain/ceramic crown - porcelain fused to high noble metal crown - porcelain fused to predominantly base metal crown - porcelain fused to noble metal crown - 3/4 cast high noble metal crown - 3/4 cast predominantly base metal crown - 3/4 cast noble metal crown - 3/4 porcelain/ceramic crown - full cast high noble metal crown - full cast predominantly base metal crown - full cast noble metal crown - titanium provisional crown further treatment or completion of diagnosis necessary prior to final impression specialized porcelain- high noble/titanium crown specialized porcelain- noble metal crown specialized porcelain-all porcelain crown Other Restorative Services D29 re-cement or re-bond inlay, onlay, veneer or partial coverage restoration D291 D29 D2921 D2929 D29 D2931 D2932 D2933 D2934 D29 D2941 D2949 D29 D291 D292 D293 D294 D29 D297 D296 D2961 D2962 D2971 D297 D299 re-cement or re-bond indirectly fabricated or prefabricated post and core re-cement or re-bond crown reattachment of tooth fragment, incisal edge or cusp prefabricated porcelain/ceramic crown primary tooth prefabricated stainless steel crown - primary tooth prefabricated stainless steel crown - permanent tooth prefabricated resin crown prefabricated stainless steel crown with resin window prefabricated esthetic coated stainless steel crown - primary tooth protective restoration interim therapeutic restoration primary dentition restorative foundation for an indirect restoration core buildup, including any pins when required pin retention - per tooth, in addition to restoration post and core in addition to crown, indirectly fabricated each additional indirectly fabricated post - same tooth prefabricated post and core in addition to crown post removal each additional prefabricated post - same tooth labial veneer (resin laminate) - chairside labial veneer (resin laminate) - laboratory labial veneer (porcelain laminate) - laboratory additional procedures to construct new crown under existing partial denture framework coping resin infiltration of incipient smooth surface lesions Endodontics (root canal therapy) D31 D31 D32 D3221 D3222 D32 D32 D33 D33 D33 pulp cap - direct (excluding final restoration) pulp cap - indirect (excluding final restoration) therapeutic pulpotomy (excluding final restoration) - removal of pulp coronal to the dentinocemental junction and application of medicament pulpal debridement, primary and permanent teeth partial pulpotomy for apexogenesis - permanent tooth with incomplete root development pulpal therapy (resorbable filling) - anterior, primary tooth (excluding final restoration) pulpal therapy (resorbable filling) - posterior, primary tooth (excluding final restoration) endodontic therapy, anterior tooth (excluding final restoration) endodontic therapy, premolar tooth (excluding final restoration) endodontic therapy, molar tooth (excluding final restoration) WA1i Current Dental Terminology 18 American Dental Association. All rights reserved Effective Date: 1/1/18

3 D3331 D3332 D3333 D3346 D3347 D3348 D333 D33 D336 D337 D3421 D342 D3426 D3427 D34 D3 D39 D39 Periodontics D42 D4211 D4212 D42 D4231 D42 D4241 D424 D4249 D426 D4261 D4263 D4264 treatment of root canal obstruction; nonsurgical access incomplete endodontic therapy; inoperable, unrestorable or fractured tooth internal root repair of perforation defects retreatment of previous root canal therapy - anterior retreatment of previous root canal therapy - premolar retreatment of previous root canal therapy - molar apexification/recalcification - final visit (includes completed root canal therapy - apical closure/calcific repair of perforations, root resorption, etc.) pulpal regeneration - initial visit pulpal regeneration - interim medication replacement pulpal regeneration - completion of treatment apicoectomy - premolar (first root) apicoectomy - molar (first root) apicoectomy (each additional root) periradicular surgery without apicoectomy retrograde filling - per root root amputation - per root hemisection (including any root removal), not including root canal therapy canal preparation and fitting of preformed dowel or post gingivectomy or gingivoplasty - four or more contiguous teeth or tooth bounded spaces per gingivectomy or gingivoplasty - one to three contiguous teeth or tooth bounded spaces per gingivectomy or gingivoplasty to allow access for restorative procedure, per tooth anatomical crown exposure - four or more contiguous teeth or bounded spaces per anatomical crown exposure - one to three teeth or bounded spaces per gingival flap procedure, including root planing - four or more contiguous teeth or tooth bounded spaces per gingival flap procedure, including root planing - one to three contiguous teeth or tooth bounded spaces per apically positioned flap clinical crown lengthening hard tissue osseous surgery (including elevation of a full thickness flap and closure) four or more contiguous teeth or tooth bounded spaces per osseous surgery (including elevation of a full thickness flap and closure) one to three contiguous teeth or tooth bounded spaces per bone replacement graft retained natural tooth first site in bone replacement graft retained natural tooth each additional site in D4266 D4267 D4268 D427 D4274 D4277 D4278 D4341 D4342 D4346 D43 D4381 D49 D4921 D49XC guided tissue regeneration - resorbable barrier, per site guided tissue regeneration - nonresorbable barrier, per site (includes membrane removal) surgical revision procedure, per tooth pedicle soft tissue graft procedure mesial/distal wedge procedure, single tooth (when not performed in conjunction with surgical procedures in the same anatomical area) free soft tissue graft procedure (including recipient and donor surgical sites) first tooth, implant or edentulous tooth position in graft free soft tissue graft procedure (including recipient and donor surgical sites) each additional contiguous tooth, implant or edentulous tooth position in same graft site periodontal scaling and root planing - four or more teeth per periodontal scaling and root planing - one to three teeth per scaling in presence of generalized moderate or severe gingival inflammation full mouth, after oral evaluation full mouth debridement to enable a comprehensive oral evaluation and diagnosis on a subsequent visit localized delivery of antimicrobial agents via a controlled release vehicle into diseased crevicular tissue, per tooth periodontal maintenance (1st and 2nd in year) gingival irrigation per periodontal maintenance (3rd and 4th in year) Dentures Full/partial dentures (upper and/or lower) - one per five year period. Replacement will be provided where casing is unsatisfactory and cannot be made satisfactory. Lost or stolen appliances are the responsibility of the patient. Unilateral partials (Nesbitt) are not a recommended treatment. D1 D1 D1 D1 D211 D212 D213 D214 complete denture - maxillary complete denture - mandibular immediate denture - maxillary immediate denture - mandibular maxillary partial denture - resin base mandibular partial denture - resin base maxillary partial denture - cast metal framework with resin denture bases (including any conventional clasps, rests and mandibular partial denture - cast metal framework with resin denture bases (including any conventional clasps, rests and immediate maxillary partial denture resin base (including any conventional clasps, rests and immediate mandibular partial denture resin base (including any conventional clasps, rests and immediate maxillary partial denture cast metal framework with resin denture bases 8.12WA1i Current Dental Terminology 18 American Dental Association. All rights reserved Effective Date: 1/1/18 D221 D222 D

4 D224 D22 D226 D281 immediate mandibular partial denture cast metal framework with resin denture bases maxillary partial denture - flexible base (including any clasps, rests and mandibular partial denture - flexible base (including any clasps, rests and removable unilateral partial denture - one piece cast metal (including clasps and Denture Adjustments & Repairs D4 D411 D421 D422 D11 D12 D D611 D612 D621 D622 D6 D6 D6 D66 D67 D671 D7 D711 D7 D721 D7 D731 D7 D741 D7 D71 D76 D761 D8 D811 D8 D821 D8 D81 D863 D864 D86 D866 adjust complete denture - maxillary adjust complete denture - mandibular adjust partial denture - maxillary adjust partial denture - mandibular repair broken complete denture base, mandibular repair broken complete denture base, maxillary replace missing or broken teeth - complete denture (each tooth) repair resin partial denture base, mandibular repair resin partial denture base, maxillary repair cast partial framework, mandibular repair cast partial framework, maxillary repair or replace broken clasp - per tooth replace broken teeth - per tooth add tooth to existing partial denture add clasp to existing partial denture - per tooth replace all teeth and acrylic on cast metal framework (maxillary) replace all teeth and acrylic on cast metal framework (mandibular) rebase complete maxillary denture rebase complete mandibular denture rebase maxillary partial denture rebase mandibular partial denture reline complete maxillary denture (chairside) reline complete mandibular denture (chairside) reline maxillary partial denture (chairside) reline mandibular partial denture (chairside) reline complete maxillary denture (laboratory) reline complete mandibular denture (laboratory) reline maxillary partial denture (laboratory) reline mandibular partial denture (laboratory) interim complete denture (maxillary) interim complete denture (mandibular) interim partial denture (maxillary) interim partial denture (mandibular) tissue conditioning, maxillary tissue conditioning, mandibular overdenture complete maxillary overdenture partial maxillary overdenture complete mandibular overdenture partial mandibular Implants Implants are only available at specific particpating dental offices. Check to locate participating dental offices which offer this service. D6SP, D6HP, and D6NP are allowable upgrade charges for specialized porcelain such as Lava, Captek, Cercon, etc. It is charged in addition to the type of abutment retainer billed. ***Standard x-rays include periapical, bitewing and occlusal films. There are additional fees for panoramic, cephalometric, CT or other films. ****There are additional fees for any replacement parts, screws, etc. D6 D66 D67 D68 D69 D66 D661 D662 D663 D664 D66 D666 D667 D668 D669 D67 D671 D672 D673 surgical placement of implant body: endosteal implant prefabricated abutment includes modification and placement custom fabricated abutment includes placement abutment supported porcelain/ceramic crown abutment supported porcelain fused to metal crown (high noble metal) abutment supported porcelain fused to metal crown (predominantly base metal) abutment supported porcelain fused to metal crown (noble metal) abutment supported cast metal crown (high noble metal) abutment supported cast metal crown (predominantly base metal) abutment supported cast metal crown (noble metal) implant supported porcelain/ceramic crown implant supported porcelain fused to metal crown (titanium, titanium alloy, high noble metal) implant supported metal crown (titanium, titanium alloy, high noble metal) abutment supported retainer for porcelain/ceramic FPD abutment supported retainer for porcelain fused to metal FPD (high noble metal) abutment supported retainer for porcelain fused to metal FPD (predominantly base metal) abutment supported retainer for porcelain fused to metal FPD (noble metal) abutment supported retainer for cast metal FPD (high noble metal) abutment supported retainer for cast metal FPD (predominantly base metal) abutment supported retainer for cast metal FPD (noble metal) implant supported retainer for ceramic FPD implant supported retainer for porcelain fused to metal FPD (titanium, titanium alloy, or high noble metal) implant supported retainer for cast metal FPD (titanium, titanium alloy, or high noble metal) scaling and debridement in the presence of inflammation or mucositis of a single implant, including cleaning of the implant, without flap entry and closure provisional implant crown re-cement or re-bond implant/abutment supported crown re-cement or re-bond implant/abutment supported fixed partial denture 8.12WA1i Current Dental Terminology 18 American Dental Association. All rights reserved Effective Date: 1/1/18 D674 D67 D676 D677 D681 D68 D692 D

5 D694 D6HP D6NP D6SP D61 D6111 D6112 D6113 D6194 abutment supported crown - (titanium) specialized porcelain- high noble/titanium abutment retainer specialized porcelain- noble metal abutment retainer specialized porcelain- all porcelain abutment retainer implant /abutment supported removable denture for edentulous arch maxillary implant /abutment supported removable denture for edentulous arch mandibular implant /abutment supported removable denture for partially edentulous arch maxillary implant /abutment supported removable denture for partially edentulous arch mandibular abutment supported retainer crown for FPD (titanium) Bridges D62SP, D62HP, D62NP, D67SP, D67HP, and D67NP are allowable upgrade charges for specialized porcelain such as Lava, Captek, Cercon, etc. It is charged in addition to the type of abutment or pontic billed. D6 D62 D6211 D6212 D6214 D62 D6241 D6242 D624 D6 D621 D622 D623 D62HP D62NP D62SP D64 D648 D649 D66 D661 D662 D663 D664 D66 D666 pontic - indirect resin based composite pontic - cast high noble metal pontic - cast predominantly base metal pontic - cast noble metal pontic - titanium pontic - porcelain fused to high noble metal pontic - porcelain fused to predominantly base metal pontic - porcelain fused to noble metal pontic - porcelain/ceramic pontic - resin with high noble metal pontic - resin with predominantly base metal pontic - resin with noble metal provisional pontic - further treatment or completion of diagnosis necessary prior to final impression specialized porcelain- high noble/titanium pontic specialized porcelain- noble metal pontic specialized porcelain- all porcelain pontic retainer - cast metal for resin bonded fixed prosthesis retainer - porcelain/ceramic for resin bonded fixed prosthesis resin retainer for resin bonded fixed prosthesis inlay - porcelain/ceramic, two retainer inlay - porcelain/ceramic, three or more retainer inlay - cast high noble metal, two retainer inlay - cast high noble metal, three or more retainer inlay - cast predominantly base metal, two retainer inlay - cast predominantly base metal, three or more retainer inlay - cast noble metal, two D667 D668 D669 D66 D6611 D6612 D6613 D6614 D661 D6624 D6634 D67 D67 D6721 D6722 D67 D67 D671 D672 D678 D6781 D6782 D6783 D679 D6791 D6792 D6793 D6794 D67HP D67NP D67SP D69 Oral Surgery D7111 D71 D72 D72 D72 D72 D7241 retainer inlay - cast noble metal, three or more retainer onlay - porcelain/ceramic, two retainer onlay - porcelain/ceramic, three or more retainer onlay - cast high noble metal, two retainer onlay - cast high noble metal, three or more retainer onlay - cast predominantly base metal, two retainer onlay - cast predominantly base metal, three or more retainer onlay - cast noble metal, two retainer onlay - cast noble metal, three or more retainer inlay - titanium retainer onlay - titanium retainer crown - indirect resin based composite retainer crown - resin with high noble metal retainer crown - resin with predominantly base metal retainer crown - resin with noble metal retainer crown - porcelain/ceramic retainer crown - porcelain fused to high noble metal retainer crown - porcelain fused to predominantly base metal retainer crown - porcelain fused to noble metal retainer crown - 3/4 cast high noble metal retainer crown - 3/4 cast predominantly base metal retainer crown - 3/4 cast noble metal retainer crown - 3/4 porcelain/ceramic retainer crown - full cast high noble metal retainer crown - full cast predominantly base metal retainer crown - full cast noble metal provisional retainer crown - further treatment or completion of diagnosis necessary prior to final impression retainer crown - titanium specialized porcelain- high noble/titanium abutment specialized porcelain- noble metal abutment specialized procelain- all porcelain abutment re-cement or re-bond fixed partial denture extraction, coronal remnants - primary tooth extraction, erupted tooth or exposed root (elevation and/or forceps removal) extraction, erupted tooth requiring removal of bone and/or sectioning of tooth, and including elevation of mucoperiosteal flap if indicated removal of impacted tooth - soft tissue removal of impacted tooth - partially bony removal of impacted tooth - completely bony removal of impacted tooth - completely bony, with unusual surgical complications WA1i Current Dental Terminology 18 American Dental Association. All rights reserved Effective Date: 1/1/18

6 D7 D721 D727 D728 D7282 D728 D7286 D7288 D73 D7311 D73 D7321 D7 D711 D796 D7963 D797 D7971 removal of residual tooth roots (cutting procedure) coronectomy intentional partial tooth removal tooth reimplantation and/or stabilization of accidentally evulsed or displaced tooth exposure of an unerupted tooth mobilization of erupted or malpositioned tooth to aid eruption incisional biopsy of oral tissue-hard (bone, tooth) incisional biopsy of oral tissue-soft brush biopsy - transepithelial sample collection alveoloplasty in conjunction with extractions - four or more teeth or tooth spaces, per alveoloplasty in conjunction with extractions - one to three teeth or tooth spaces, per alveoloplasty not in conjunction with extractions - four or more teeth or tooth spaces, per alveoloplasty not in conjunction with extractions - one to three teeth or tooth spaces, per incision and drainage of abscess - intraoral soft tissue incision and drainage of abscess - intraoral soft tissue - complicated (includes drainage of multiple fascial spaces) frenulectomy - also known as frenectomy or frenotomy - separate procedure not incidental to another procedure frenuloplasty excision of hyperplastic tissue - per arch excision of pericoronal gingiva Other Services General Anesthesia is covered soley for dependent children under the age of seven (7) or the physically or developmentally disabled, only when medically necessary and in conjunction with a covered dental procedure performed at a participating provider. D91 D91 D92 D9211 D9212 D921 D9219 D9222 D9223 D92 D9239 D9243 D9248 palliative (emergency) treatment of dental pain - minor procedure fixed partial denture sectioning local anesthesia not in conjunction with operative or surgical procedures regional block anesthesia trigeminal division block anesthesia local anesthesia in conjunction with operative or surgical procedures evaluation for deep sedation or general anesthesia deep sedation/general anesthesia first 1 minutes deep sedation/general anesthesia each subsequent 1 minute increment inhalation of nitrous oxide/analgesia, anxiolysis intravenous moderate (conscious) sedation/analgesia first 1 minutes intravenous moderate (conscious) sedation/analgesia each subsequent 1 minute increment non-intravenous conscious sedation D93 D94 D94 D9 D96 D9612 D96 D99 D9911 D9932 D9933 D9934 D993 D99 D9941 D9942 D9943 D991 D992 D997 D9971 D9972 D9973 D9974 D997 D9991 D9992 D9993 D9994 consultation - diagnostic service provided by dentist or physician other than requesting dentist or physician office visit for observation (during regularly scheduled hours) - no other services performed office visit - after regularly scheduled hours case presentation, detailed and extensive treatment planning therapeutic parenteral drug, single administration therapeutic parenteral drugs, two or more administrations, different medications drugs or medicaments dispensed in the office for home use application of desensitizing medicament application of desensitizing resin for cervical and/or root surface, per tooth cleaning and inspection of removable complete denture, maxillary cleaning and inspection of removable complete denture, mandibular cleaning and inspection of removable partial denture, maxillary cleaning and inspection of removable partial denture, mandibular occlusal guard, by report fabrication of athletic mouthguard repair and/or reline of occlusal guard occlusal guard adjustment occlusal adjustment - limited occlusal adjustment - complete enamel microabrasion odontoplasty 1-2 teeth; includes removal of enamel projections external bleaching - per arch - performed in office external bleaching - per tooth internal bleaching - per tooth external bleaching for home application, per arch; includes materials and fabrication of custom trays dental case management addressing appointment compliance barriers dental case management care coordination dental case management motivational interviewing dental case management patient education to improve oral health literacy Orthodontics When performed by a Dental Health Services participating orthodontist. D8 D8 D8 D8 D8 Limited orthodontic treatment of the primary dentition Limited orthodontic treatment of the transitional dentition Limited orthodontic treatment of the adolescent dentition Limited orthodontic treatment of the adult dentition Interceptive orthodontic treatment of the primary dentition D87 D87 D88 D89 D WA1i Current Dental Terminology 18 American Dental Association. All rights reserved Effective Date: 1/1/18

7 D86 Interceptive orthodontic treatment of the D87 transitional dentition D87 Comprehensive orthodontic treatment of the 339 transitional dentition D88 Comprehensive orthodontic treatment of the 339 adolescent dentition D89 Comprehensive orthodontic treatment of the 349 adult dentition D82 Removable appliance therapy D82 Fixed appliance therapy D866 Pre-orthodontic treatment examination to monitor growth and development D867 Periodic orthodontic treatment visit D868 Orthodontic retention (removal of appliances, 31 construction and placement of retainer(s)) D869 Orthodontic treatment (alternative billing to a included contract fee) D8693 Re-cement or re-bond fixed retainer 4 Comprehensive orthodontic treatment copayment amounts (D87, D88, D89) are based on a typical 24-month case. If case extends beyond 24 months, additional months are according to the number of extra months of treatment. Denturists Covered Denturist Services and Copayments when services are received from a licensed Dental Health Services' Denturist. Only Plastic Teeth will be covered by Dental Health Services. Upgrades on dentures will be the member's responsibility (at a % discount). D1 D1 D1 D1 D211 D212 D213 D214 D221 D222 D223 D224 D22 D226 D281 D4 Complete denture - maxillary Complete denture - mandibular Immediate denture - maxillary Immediate denture - mandibular Maxillary partial denture - resin base Mandibular partial denture - resin base Maxillary partial denture - cast metal framework with resin denture bases (including any conventional clasps, rests and Mandibular partial denture - cast metal framework with resin denture bases (including any conventional clasps, rests and immediate maxillary partial denture resin base (including any conventional clasps, rests and immediate mandibular partial denture resin base (including any conventional clasps, rests and immediate maxillary partial denture cast metal framework with resin denture bases immediate mandibular partial denture cast metal framework with resin denture bases Maxillary partial denture - flexible base (including any clasps, rests and Mandibular partial denture - flexible base (including any clasps, rests and Removable unilateral partial denture - one piece cast metal (including clasps and Adjust complete denture - maxillary D411 D421 D422 D11 D12 D D611 D612 D621 D622 D6 D6 D6 D66 D67 D671 D7 D711 D7 D721 D7 D731 D7 D741 D7 D71 D76 D761 D8 D811 D8 D821 D8 D81 D863 D864 D86 D866 Adjust complete denture - mandibular Adjust partial denture - maxillary Adjust partial denture - mandibular Repair broken complete denture base, mandibular Repair broken complete denture base, maxillary Replace missing or broken teeth - complete denture (each tooth) repair resin partial denture base, mandibular repair resin partial denture base, maxillary repair cast partial framework, mandibular repair cast partial framework, maxillary repair or replace broken clasp - per tooth Replace broken teeth - per tooth Add tooth to existing partial denture add clasp to existing partial denture - per tooth Replace all teeth and acrylic on cast metal framework (maxillary) Replace all teeth and acrylic on cast metal framework (mandibular) Rebase complete maxillary denture Rebase complete mandibular denture Rebase maxillary partial denture Rebase mandibular partial denture Reline complete maxillary denture (chairside) Reline complete mandibular denture (chairside) Reline maxillary partial denture (chairside) Reline mandibular partial denture (chairside) Reline complete maxillary denture (laboratory) Reline complete mandibular denture (laboratory) Reline maxillary partial denture (laboratory) Reline mandibular partial denture (laboratory) Interim complete denture (maxillary) Interim complete denture (mandibular) Interim partial denture (maxillary) Interim partial denture (mandibular) Tissue conditioning, maxillary Tissue conditioning, mandibular Overdenture complete maxillary Overdenture partial maxillary Overdenture complete mandibular Overdenture partial mandibular WA1i Current Dental Terminology 18 American Dental Association. All rights reserved Effective Date: 1/1/18

8 Exclusions & Limitations of Coverage SmartSmile - Plan WA-D Dental Limitations The following are limitations on covered benefits. A. Authorized treatment is rendered only by your selected participating provider. Services provided by a dentist other than the enrollee s designated participating provider, except for emergency dental conditions, are not covered. (See item C. below) B. Limitation on the frequency and appropriateness of services: 1. D2 and D3 Intraoral complete series films and panoramic films limited to once every three years. 2. D1 Periodic oral evaluation: D16 and D18 Fluoride are limited to one per six months. 3. Caries risk assessments (D61-D63) are covered for members 18 years of age and younger. a. D61 & D62 are covered once every 6 months. b. D63 is covered once every 3 months. 4. D11 Prophylaxis (removal of plaque, calculus and stains from the tooth structures in the permanent and transitional dentition) or D49 Periodontal Maintenance limited to one per six month period, with any additional at additional copayment.. D4341 or D4342 Periodontal scaling and root planing limited to four s per six months; and two s per day. 6. D1 through D281 Full/partial dentures (upper and/or lower) limited to one per five year period. New dentures are covered only if the existing denture cannot be made satisfactory by either a reline or repair. Lost or stolen appliances are the responsibility of the patient. 7. Fixed bridges are optional and not covered for patients under the age of 16. C. Emergency dental condition is the emergent and acute onset of a symptom or symptoms, including severe pain that would lead a prudent layperson acting reasonably to believe that dental condition exists that requires immediate, palliative care by a licensed dentist for the relief of pain, swelling or bleeding. This does not include routine, extensive or postponable treatment. Emergency dental care is limited to palliative treatment. D. The additional cost to the enrollee for laboratory charges, unless specified in the Schedule of Covered Services and Copayments, will be charged at the provider s actual cost. E. Optional services all cases in which the enrollee selects a plan of treatment that is considered unnecessary by the provider the enrollee is responsible for fee-for-service rates. This does not apply to standard covered restorative procedures which offer a choice of material. F. Upgraded services cases in which the enrollee selects a plan of treatment that is considered an upgraded procedure Dental Health Services upgrade charges would apply. G. Cosmetic dentistry services for appearance only may be available at a discount off full fees. This includes such services as the replacement of clinically acceptable amalgam fillings, Veneers and Bonding. H. Crowns and Bridges limited to in a 12 month period. Additional Crowns and Bridges are subject to a $ copayment increase per procedure. I. Unsatisfactory patient-doctor relationship Dental Health Services providers reserve the right to limit or deny services to an enrollee who fails to follow the prescribed course of treatment, repeatedly fails to keep appointments, fails to pay applicable copayments, is abusive to the participating provider or their staff, or obtains services by fraud or deception. J. Submit claims within 6 days. Dental Health Services shall not be liable to pay a claim for emergency care or for any Dental Health Services authorized treatment provided by a dentist other than a participating provider unless the enrollee submits the claim to Dental Health Services within 6 days after treatment. K. Denturist benefit subject to existence and availability of a licensed denturist within a mile radius. Enrollees may elect to travel to the nearest participating denturist for services. L. Benefits are only available if work is completed in enrollee s participating provider s office. M. Not all participating dentists can perform all dental procedures. Please verify what services your selected provider can perform for you. Some complicated extractions, periodontal treatment, osseous surgery and root canal treatment may be referred to a specialist at the discretion of the general dentist. N. Coverage for services only available during period of enrollment. O. Implants only available at specific participating dental offices. Check to locate participating provider offices which offer implant services. Dental Exclusions The following are not covered by your dental plan. A. Services not specifically listed in the Schedule of Covered Services and Copayments. B. Treatment at a specialist is not covered, but may be available at a discount unless your specific plan contains specialty copayments. C. Work in progress non-emergency/temporary procedures started but not finished prior to the date of eligibility is not covered. This includes crown preps prepared and temporized but not cemented, root canals in mid treatment, prosthetic cases post final impression stage (sent to the lab), etc. This does not include teeth slated for root canal treatment and/or canals filled during an emergency visit. D. Temporomandibular joint (TMJ) disorders and related disease including myofunctional therapy. Procedures for training, treating or developing muscles in and around the jaw of the mouth (unless provided by a separate, supplemental Dental Health Services program.) E. Any dental procedure that cannot be performed in the dental office due to the general health and/or physical limitations of the enrollee. F. Services that are reimbursed by a third party such as the medical portion of a health insurance plan or any other third party indemnification. (The member may be responsible for the payment of usual and customary charges to his/her dentist for services that are reimbursed by a third party.) Orthodontic Limitations The following are limitations on covered benefits. A. Changes in treatment necessitated by accident of any kind. B. Services which are compensable under Worker s Compensation or employer liability laws. C. Malocclusions too severe or mutilated which are not amenable to ideal orthodontic therapy. Orthodontic Exclusions The following are not covered by your dental plan. A. Cephalometric x-rays, dental x-rays for orthodontic purposes. B. Tracings and photographs. C. Study Models. D. Replacement of lost or broken appliances. E. Retreatment of orthodontic cases. F. Treatment of a case in progress at inception of eligibility. G. Treatment and/or surgical procedures related to cleft palate, micrognathia or microdontia. H. Treatment related to temporomandibular joint disturbances and/or hormonal imbalances. I. Any dental procedures considered to be within the field of general dentistry, including but not limited to: 1. Myofunctional therapy. 2. General anesthetics including intravenous and inhalation sedation. 3. Dental services of any nature performed in a hospital. 4. Services which are compensable under Worker s Compensation or employer liability laws W. Harrison Street, Suite S-4, South Tower, Seattle, WA WA1ie&l 18 Dental Health Services