Guaranty Assurance Company d/b/a Dina Dental Peoples Health Secure Health Effective January 1, 2019
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1 Guaranty Assurance Company d/b/a Dina Dental Peoples Health Secure Health Effective January 1, 2019 Benefits: Annual Deductible $2,000 Annual Benefit Maximum per Calendar Year Preventive procedures do not count towards the Annual Benefit Maximum No Out-of-Network Benefits Code Description Frequency Copay DIAGNOSTIC PROCEDURES D0120 Periodic oral evaluation 1/6 months D0140 Limit oral evaluation problem focus 1/12 months D0150 Comprehensive oral evaluation 1/12 months D0160 Extensive oral evaluation problem focus 1/12 months D0170 Re-evaluation established patient, problem focus 1/12 months D0171 Re-evaluation - post-operative office visit 1/12 months D0180 Comp periodontal evaluation 1/12 months D0210 Intraoral complete film series 1/12 months D0220 Intraoral periapical first 1/12 months D0230 Intraoral periapical each additional 1/12 months D0240 Intraoral occlusal film 1/12 months D0250 Extraoral first film 1/12 months D0251 Intraoral-complete series 1/12 months D0270 Dental bitewing single image 1/12 months D0272 Dental bitewings two images 1/12 months D0273 Bitewings - three images 1/12 months D0274 Bitewings four images 1/12 months D0277 Vert bitewings 7 to 8 images 1/12 months D0310 Dental sialography 1/12 months D0320 Dental TMJ arthrogram included 1/12 months D0321 Other TMJ images by report 1/12 months D0322 Dental tomographic survey 1/12 months D0330 Panoramic image 1/12 months D0340 Cephalometric image 1/12 months D0350 Oral/facial photo images 1/12 months D0414 Laboratory processing of microbial specimen 1/12 months D0415 Collection of microorganisms 1/12 months D0416 Viral culture 1/12 months D0425 Caries susceptibility test 1/12 months D0431 Diagnostic test detect mucosal abnormalities 1/12 months D0460 Pulp vitality test 1/12 months Page 1 of 9
2 D0470 Diagnostic casts 1/12 months D0472 Gross exam, prep & report 1/12 months D0473 Micro exam, prep & report 1/12 months D0474 Micro w exam of surgical margins 1/12 months D0475 Decalcification procedure 1/12 months D0476 Spec stains for microorganism 1/12 months D0477 Spec stains not for microorganisms 1/12 months D0502 Other oral pathology proc 1/12 months *Panoramic Film (D0330) may be taken in place of Intraoral-Complete Series (D0210) PREVENTIVE PROCEDURES D1110 Dental prophylaxis adult 1/6 months D1208 Topical app of fluoride 1/12 months RESTORATIVE PROCEDURES D2140 Amalgam one surface perm 1/36 months D2150 Amalgam two surfaces perm 1/36 months D2160 Amalgam three surfaces perm 1/36 months D2161 Amalgam 4 or > surfaces perm 1/36 months D2330 Resin one surface-anterior 1/36 months D2331 Resin two surfaces-anterior 1/36 months D2332 Resin three surfaces-anterior 1/36 months D2335 Resin 4/> surf or w incisal angle 1/36 months D2390 Ant resin-based composite crown 1/36 months D2391 Post 1 surface resin based composite 1/36 months D2392 Post 2 surface resin based composite 1/36 months D2393 Post 3 surface resin based composite 1/36 months D2394 Post >=4srfc resin base composite 1/36 months D2510 Dental inlay metallic 1 surface 1/60 months D2520 Dental inlay metallic 2 surface 1/60 months D2530 Dental inlay metallic 3/more surface 1/60 months D2542 Dental onlay metallic 2 surface 1/60 months D2543 Dental onlay metallic 3 surface 1/60 months D2544 Dental onlay metallic 4/more surface 1/60 months D2610 Inlay porcelain/ceramic 1 surface 1/60 months D2620 Inlay porcelain/ceramic 2 surface 1/60 months D2630 Dental onlay porcelain 3/more surface 1/60 months D2642 Dental onlay porcelain 2 surface 1/60 months D2643 Dental onlay porcelain 3 surface 1/60 months D2644 Dental onlay porcelain 4/more surface 1/60 months D2650 Inlay composite/resin one surface 1/60 months D2651 Inlay composite/resin two surface 1/60 months D2652 Dental inlay resin 3/more surface 1/60 months D2662 Dental onlay resin 2 surface 1/60 months D2663 Dental onlay resin 3 surface 1/60 months D2664 Dental onlay resin 4/more surface 1/60 months D2710 Crown resin-based indirect 1/60 months D2712 Crown 3/4 resin-based composite 1/60 months Page 2 of 9
3 D2721 Crown resin w/ base metal 1/60 months D2722 Crown resin w/ noble metal 1/60 months D2740 Crown porcelain/ceramic subs 1/60 months D2750 Crown porcelain w/ h noble metal 1/60 months D2751 Crown porcelain fused base metal 1/60 months D2752 Crown porcelain w/ noble metal 1/60 months D2781 Crown 3/4 cast base metal 1/60 months D2782 Crown 3/4 cast noble metal 1/60 months D2783 Crown 3/4 porcelain/ceramic 1/60 months D2790 Crown full cast high noble m 1/60 months D2791 Crown full cast base metal 1/60 months D2792 Crown full cast noble metal 1/60 months D2910 Recement inlay onlay or part 1/60 months D2915 Recement cast or prefab post 1/60 months D2920 Dental re-cement crown 1/60 months D2930 Prefab stainless steel crown primary D2931 Prefab stainless steel crown permanent tooth D2932 Prefabricated resin crown D2933 Prefab stainless steel crown D2934 Prefab steel crown primary D2940 Protective restoration D2950 Core build-up included any pins D2951 Tooth pin retention D2952 Post and core cast + crown D2953 Each additional cast post D2954 Prefab post/core + crown D2955 Post removal D2957 Each additional prefab post D2971 Add proc construct new crown D2975 Coping D2980 Crown repair *Crowns Single Restorations Only One (1) Crown procedure code is covered every Sixty (60) months per Member ENDODONTICS D3110 Pulp cap direct D3120 Pulp cap indirect D3220 Therapeutic pulpotomy D3221 Gross pulpal debridement D3230 Pulpal therapy anterior primary D3240 Pulpal therapy posterior primary D3310 End therapy, anterior tooth 1/lifetime D3320 End therapy, bicuspid tooth 1/lifetime D3330 End therapy, molar 1/lifetime D3331 Non-surgical treatment root canal obstruction 1/lifetime D3332 Incomplete endodontic therapy D3333 Internal root repair Page 3 of 9
4 D3346 Retreat root canal anterior D3347 Retreat root canal bicuspid D3348 Retreat root canal molar D3351 Apexification/recalcification initial D3352 Apexification/ recalcification interim D3353 Apexification/ recalcification final D3410 Apicoectomy - anterior D3421 Root surgery bicuspid D3425 Root surgery molar D3426 Root surgery each add root D3430 Retrograde filling D3450 Root amputation D3460 Endodontic end osseous implant D3470 Intentional replantation D3910 Isolation- tooth w rubber dam D3920 Tooth splitting D3950 Canal prep/fitting of dowel PERIODONTICS D4210 Gingivectomy/gingivoplasty 4 or more D4211 Gingivectomy/gingivoplasty 1 to 3 D4230 Ana crown exposure 4 or> per quad D4231 Ana crown exposure 1-3 per quad D4240 Gingival flap proc w/ Planing D4241 Gingival flap w root Planing 1-3 teeth or tooth D4245 Apically positioned flap D4249 Crown lengthen hard tissue D4260 Osseous surgery 4 or more D4261 Osseous surgery 1 to 3 teeth D4263 Bone replace graft first site D4264 Bone replace graft each add D4265 Bio materials to aid soft/osseous tissue regeneration D4266 Guided tissue regen resorbable D4267 Guided tissue regen non-resorbable D4268 Surgical revision procedure D4270 Pedicle soft tissue graft procedure D4273 Autogenous connective tissue graft procedure D4274 Distal/proximal wedge proc D4275 Soft tissue allograft D4276 Combined connective tissue double pedicle graft D4277 Soft tissue graft first tooth D4278 Soft tissue graft additional tooth D4283 Auto Connective Tissue Graft D4285 Non-Auto Connective Tissue Graft D4320 Provision splinting intracoronal D4321 Provisional splinting extracoronal D4341 Periodontal scaling & root 1/24 months Page 4 of 9
5 D4342 Periodontal scaling 1-3teeth 1/24 months D4346 Scaling presence of generalized moderate/severe ging inflam 1/24 months D4355 Full mouth debridement 1/36 months D4381 Localized delivery antimicrobial agents D4910 Periodontal maintenance procedures 1/6 months D4920 Unscheduled dressing change PROSTHODONTICS (REMOVEABLE) D5110 Dentures complete maxillary 1/60 months D5120 Dentures complete mandible 1/60 months D5130 Dentures immediate maxillary 1/60 months D5140 Dentures immediate mandible 1/60 months D5211 Dentures maxillary part resin 1/60 months D5212 Dentures mandible part resin 1/60 months D5213 Dentures maxillary part metal 1/60 months D5214 Dentures mandible part metal 1/60 months D5221 Immediate maxillary partial denture - resin base 1/60 months D5222 Immediate mandibular partial denture - resin base 1/60 months D5223 Immediate max partial denture cast metal framework with resin denture bases 1/60 months D5224 Immediate man partial denture - cast metal framework with resin denture bases 1/60 months D5225 Maxillary part denture flex 1/60 months D5226 Mandibular part denture flex 1/60 months D5281 Removable partial denture D5410 Dentures adjust complete maxillary D5411 Dentures adjust complete mandible D5421 Dentures adjust part maxillary D5422 Dentures adjust part mandible D5510 Dentures repair broken complete bas D5520 Replace denture teeth complete D5610 Dentures repair resin base D5620 Rep part denture cast frame D5630 Rep partial denture clasp D5640 Replace part denture teeth D5650 Add tooth to partial denture D5660 Add clasp to partial denture D5670 Replace all teeth & acrylic on cast metal framework maxillary D5671 Replace all teeth & acrylic on cast metal framework mandibular D5710 Dentures rebase complete maxillary D5711 Dentures rebase complete mandibular D5720 Dentures rebase part maxillary D5721 Dentures rebase part mandibular D5730 Denture reline complete maxillary denture D5731 Denture reline complete mandibular denture D5740 Denture reline maxillary partial denture chairside Page 5 of 9
6 D5741 Denture reline mandibular partial denture chairside D5750 Denture reline complete maxillary denture chairside D5751 Denture reline complete mandibular denture chairside D5760 Denture reline partial maxillary lab D5761 Denture reline partial mandibular lab D5810 Denture interim complete denture maxillary D5811 Denture interim complete denture mandibular D5820 Denture interim partial maxillary D5821 Denture interim partial mandibular D5850 Denture tissue conditioning maxillary D5851 Denture tissue conditioning mandibular D5863 Overdenture complete maxillary D5864 Overdenture partial maxillary D5865 Overdenture complete mandibular D5866 Overdenture partial mandibular D5867 Replacement of replaceable part of semi-precision or precision D5875 Prosthesis modification PROSTHODONTICS (FIXED) D6205 Pontic-indirect resin based D6210 Prosthodontic high noble metal D6211 Bridge base metal cast 1/60 months D6212 Bridge noble metal cast 1/60 months D6241 Bridge porcelain base metal 1/60 months D6242 Bridge porcelain noble metal 1/60 months D6245 Bridge porcelain/ceramic 1/60 months D6251 Bridge resin base metal 1/60 months D6252 Bridge resin w/noble metal 1/60 months D6253 Provisional pontic D6545 Dental retainer cast metal D6548 Porcelain/ceramic retainer D6549 Resin retainer - for resin bonded fixed prosthesis D6600 Porcelain/ceramic inlay 2srf D6601 Porcelain/ceramic inlay >= 3 surfaces D6602 Cast high noble metal inlay 2 surfaces D6603 Cast high noble metal inlay >=3 surfaces D6604 Cast base metal inlay 2 surfaces D6605 Cast base metal inlay >= 3 surfaces D6606 Cast noble metal inlay 2 sur D6607 Cast noble metal inlay >=3 surf D6608 Onlay porcelain/ceramic 2 surfaces D6609 Onlay porcelain/ceramic >=3 surfaces D6612 Onlay cast base metal 2 surfaces D6613 Onlay cast base metal >=3 surfaces D6614 Onlay cast noble metal 2 surfaces D6615 Onlay cast noble metal >=3 surface D6710 Crown-indirect resin based 1/60 months Page 6 of 9
7 D6721 Crown resin w/base metal 1/60 months D6722 Crown resin w/noble metal 1/60 months D6740 Crown porcelain/ceramic 1/60 months D6751 Crown porcelain base metal 1/60 months D6752 Crown porcelain noble metal 1/60 months D6781 Crown 3/4 high noble metal 1/60 months D6782 Crown 3/4 cast based metal 1/60 months D6783 Crown 3/4 cast noble metal 1/60 months D6791 Crown 3/4 porcelain/ceramic 1/60 months D6792 Crown full noble metal cast 1/60 months D6793 Provisional retainer crown D6920 Dental connector bar D6930 Dental re-cement bridge D6940 Stress breaker D6950 Precision attachment D6980 Fixed partial repair ORAL & MAXILLOFACIAL SURGERY D7140 Extraction erupted tooth/exposed root 1/lifetime D7210 Rem imp tooth w Mucoperiosteal flap 1/lifetime D7220 Impact tooth remove soft tissue 1/lifetime D7230 Impact tooth remove part bony 1/lifetime D7240 Impact tooth remove comp bony 1/lifetime D7241 Impact tooth rem bony w/comp 1/lifetime D7250 Tooth root removal 1/lifetime D7260 Oral antral fistula closure D7261 Primary closure sinus perf D7270 Tooth reimplantation D7272 Tooth transplantation D7280 Exposure of an unerupted tooth D7282 Mobilize erupted/malpositioned tooth D7283 Place device impacted tooth D7285 Biopsy of oral tissue hard D7286 Biopsy of oral tissue soft D7287 Exfoliative cytological collect D7288 Brush biopsy D7290 Repositioning of teeth D7291 Transseptal fiberotomy/supra crestal fiberotomy D7292 Screw retained plate D7293 Temp anchorage dev w flap D7294 Temp anchorage dev w/o flap D7310 Alveoloplasty w/ extraction D7311 Alveoloplasty w/extract 1-3 D7320 Alveoloplasty w/o extraction D7321 Alveoloplasty not w/extracts D7340 Vestibuloplasty ridge extension D7350 Vestibuloplasty extension graft Page 7 of 9
8 D7410 Excision benign lesion up to 1.25cm D7411 Excision benign lesion>1.25cm D7412 Excision benign lesion complete D7413 Excision malignant lesion<=1.25cm D7414 Excision malignant lesion>1.25cm D7415 Excision malignant lesion complications D7440 Malignant tumor excision to 1.25cm D7441 Malignant tumor > 1.25cm D7450 Removal benign odontogenic cyst to 1.25cm D7451 Removal benign odontogenic cyst > 1.25cm D7460 Removal benign non-odontogenic cyst to 1.25cm D7461 Removal benign non-odontogenic cyst > 1.25cm D7471 Rem exostosis any site D7472 Removal of torus palatinus D7473 Remove torus mandibularis D7485 Surgical reduction osseous tuberosity D7510 Incision/drain abscess intraoral soft tissue D7511 Incision/drain abscess intra D7520 Incision/drain abscess extraoral D7521 Incision/drain abscess extra D7530 Removal fb skin/areolar tissue D7540 Removal of fb reaction D7960 Frenulectomy or frenotomy D7963 Frenuloplasty D7970 Excision hyperplastic tissue D7971 Excision pericoronal gingiva D7972 Surgical reduction fibrous tuberosity D7997 Appliance removal *Extractions (includes local anesthesia, suturing, if needed, and routine post-operative care) ADJUNCTIVE GENERAL SERVICES D9110 Treatment dental pain minor proc D9120 Fix partial denture section D9210 Dent anesthesia w/o surgery D9211 Regional block anesthesia D9212 Trigeminal block anesthesia D9215 Local anesthesia D9219 Evaluation for deep sedation or general anesthesia D9223 Deep sedation/general anesthesia - each 15 minute increment D9230 Analgesia D9243 Intravenous moderate (conscious) sedation/analgesia - each 15 minute increment D9248 Sedation (non-iv) D9310 Dental consultation D9311 Consultation with a medical health care professional D9410 Dental house call D9420 Hospital/ASC call Page 8 of 9
9 D9430 Office visit during hours D9440 Office visit after hours D9450 Case presentation treatment plan D9610 Dent therapeutic drug inject D9612 Thera par drugs 2 or > admin D9630 Other drugs/medicaments D9910 Application of desensitizing medicament D9911 Application desensitizing resin D9920 Behavior management D9930 Treatment of complications D9940 Dental occlusal guard D9942 Repair/reline occlusal guard D9950 Occlusion analysis D9951 Limited occlusal adjustment D9952 Complete occlusal adjustment *Total Reimbursement does not include lab costs. Lab fees are the Member s responsibility Claims Submission: Mail: DINA Dental (Attention: Claims Department) 101 Parklane Boulevard, Suite 301 Sugar Land, Texas Fax: (281) Electronic: Third Party Clearinghouse: Emdeon (Payer ID #CX090) Page 9 of 9
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