Concordia Plus Schedule of Benefits Plan TX IMPORTANT INFORMATION ABOUT YOUR PLAN The pays a $ office visit Copayment per visit in addition to the Copayments listed on this Schedule of Benefits. This schedule of benefits provides a listing of procedures covered by your plan. For procedures that require a copayment, the amount to be paid is shown in the column titled. You pay these copayments to the dental office at the time of service. You must select a United Concordia Primary Dental Office (PDO) to receive covered services. Your PDO will perform the below procedures or refer you to a specialty care dentist for further care. Treatment by an Out-of-Network dentist is not covered, except as described in the Certificate of Coverage. Only procedures listed on this Schedule of Benefits are Covered Services. For services not listed (not covered), the is responsible for the full fee charged by the dentist less 2%. Procedure codes and member Copayments may be updated to meet American Dental Association () Current Dental Terminology (CDT) in accordance with national standards. For a complete description of your plan, please refer to the Certificate of Coverage and the Schedule of Exclusions and Limitations in addition to this Schedule of Benefits. CLINICAL ORAL EVALUATIONS ORAL PATHOLOGY LABORATORY D12 Periodic Oral Evaluation - Established Patient D14 Limited Oral Evaluation - Problem Focused D14 Oral Evaluation For A Patient Under 3 Years Of Age And Counseling With Primary Caregiver D Comprehensive Oral Evaluation - New Or Established Patient D16 Detailed And Extensive Oral Evaluation - Problem Focused, By Report D17 Re-Evaluation-Limited, Problem Focused (Established Patient; Not Post-Operative Visit) D171 ReEvaluation Post-Operative Office Visit D18 Comprehensive Periodontal Evaluation RADIOGRAPHS/DIAGNOSTIC IMAGING (including interpretation) D21 Intraoral - Complete Series Of Radiographic Images D22 Intraoral- Periapical First Radiographic Image D23 Intraoral- Periapical Each Additional Radiographic Image D24 Intraoral - Occlusal Radiographic Image D2 Extra-oral - 2D Projection Radiographic Image Created Using A Stationary Radiation Source, And Detector D21 Extra-oral Posterior Dental Radiographic Image D27 Bitewing - Single Radiographic Image D272 Bitewings - Two Radiographic Images D273 Bitewings - Three Radiographic Images D274 Bitewings - Four Radiographic Images D277 Vertical Bitewings - 7 To 8 Radiographic Images D322 Tomographic Survey D33 Panoramic Radiographic Image TESTS AND EXAMINATIONS D46 Pulp Vitality Tests D47 Diagnostic Casts D61 Caries Risk Assessment And Documentation, With A Finding Of Low Risk D62 Caries Risk Assessment And Documentation, With A Finding Of Moderate Risk D63 Caries Risk Assessment And Documentation, With A Finding Of High Risk DENTAL PROPHYLAXIS D111 Prophylaxis, Adult D112 Prophylaxis, Child TOPICAL FLUORIDE TREATMENT (office procedure) D126 Topical Application Of Fluoride Varnish D128 Topical Application Of Flouride Excluding Varnish OTHER PREVENTIVE SERVICES D131 Sealant - Per Tooth D133 Sealant Repair - Per Tooth D134 Interim Caries Arresting Medicament Application - Per Tooth SPACE MAINTENANCE (passive appliances) D1 Space Maintainer - Fixed, Unilateral (Tooth Numbers Or Tooth Area Required) D Space Maintainer - Fixed, Bilateral 2 D2 Space Maintainer - Removable, Unilateral 2 D2 Space Maintainer - Removable, Bilateral 3 D ReCement Or ReBond Space Maintainer D Removal Of Fixed Space Maintainer D7 Distal shoe space maintainers - fixed - unilateral AMALGAM RESTORATIONS (including polishing) D214 Amalgam - One Surface, Primary Or D2 Amalgam - Two Surfaces, Primary Or D216 Amalgam - Three Surfaces, Primary Or Base 16 (1/12) TX Current Dental Terminology 217 American Dental Association. All rights reserved. TX
AMALGAM RESTORATIONS (including polishing) D2161 Amalgam - Four Or More Surfaces, Primary Or RESIN-BASED COMPOSITE RESTORATIONS - DIRECT D233 Resin-Based Composite - One Surface, Anterior D2331 Resin-Based Composite - Two Surfaces, Anterior D2332 Resin-Based Composite - Three Surfaces, Anterior D233 Resin-Based Composite - Four Or More Surfaces Or Involving Incisal Angle (Anterior) D239 Resin-Based Composite Crown, Anterior 1 D2391 Resin-Based Composite - One Surface, Posterior D2392 Resin-Based Composite - Two Surfaces, Posterior 1 D2393 Resin-Based Composite - Three Surfaces, Posterior 2 D2394 Resin-Based Composite - Four Or More Surfaces, Posterior 3 CROWNS - SINGLE RESTORATIONS ONLY D27 Crown, Porcelain Fused To High Noble Metal 17 D271 Crown-Porcelain Fused To Predominantly 17 Base Metal D272 Crown, Porcelain Fused To Noble Metal 17 D278 Crown - 3/4 Cast High Noble Metal 17 D2781 Crown - 3/4 Cast Predominantly Base Metal 17 D2782 Crown - 3/4 Cast Noble Metal 17 D279 Crown, Full Cast High Noble Metal 17 D2791 Crown - Full Cast Predominantly Base Metal 17 D2792 Crown, Full Cast Noble Metal 17 D2794 Crown-Titanium 17 OTHER RESTORATIVE SERVICES D291 Re-Cement Or ReBond Inlay, Onlay, Veneer Or Partial Coverage Restoration D29 ReCement Or Rebond Indirectly Fabricated Or Prefabricated Post And Core D292 Re-Cement Or ReBond Crown D293 Prefabricated Stainless Steel Crown - Primary Tooth 1 D2931 Prefabricated Stainless Steel Crown - Tooth 1 D294 Protective Restoration D2949 Restorative Foundation For An Indirect Restoration D29 Core Buildup Including Any Pins When Required 3 D291 Pin Retention - Per Tooth, In Addition To Restoration D292 Post And Core In Addition To Crown, Indirectly Fabricated D293 Each Additional Indirectly Fabricated Post - Same Tooth D294 Prefabricated Post And Core In Addition To 4 Crown D297 Each Additional Prefabricated Post - Same 2 Tooth D2971 Additional Procedures To Construct New 3 Crown Under Existing Partial Denture Framework PULP CAPPING PULP CAPPING D311 Pulp Cap - Direct (Excluding Final Restoration) D312 Pulp Cap - Indirect (Excluding Final Restoration) PULPOTOMY D322 Therapeutic Pulpotomy (Excluding Final Restoration) 2 D3221 Pulpal Debridement, Primary And Teeth 4 D3222 Partial Pulpotomy For Apexogenesis- Tooth With Incomplete Root Development 2 ENDODONTIC THERAPY ON PRIMARY TEETH D323 Pulpal Therapy (Resorbable Filling)-Anterior, Primary Tooth (Excluding Final Restoration) 1 D324 Pulpal Therapy (Resorbable Filling)-Posterior, Primary Tooth (Excluding Final Restoration) 1 ENDODONTIC THERAPY (including treatment plan, clinical procedures and follow-up care) D331 Endodontic Therapy, Anterior Tooth (Excluding Final Restoration) 2 D332 Endodontic Therapy, Premolar Tooth (Excluding Final Restoration) 24 D333 Endodontic Therapy, Molar Tooth (Excluding Final Restoration) 32 APICOECTOMY/PERIRADICULAR SERVICES D341 Apicoectomy - Anterior 1 D3421 Apicoectomy - Premolar (First Root) 1 D342 Apicoectomy - Molar (First Root) 12 D3426 Apicoectomy (Each Additional Root) D3427 Periradicular Surgery Without Apicoectomy 12 D343 Retrograde Filling - Per Root SURGICAL SERVICES (including usual postoperative care) D421 Gingivectomy Or Gingivoplasty - Four Or More Contiguous Teeth Or Tooth Bounded Spaces Per Quadrant 7 D4211 Gingivectomy Or Gingivoplasty - One To Three Contiguous Teeth Or Tooth Bounded Spaces Per Quadrant 2 D4212 Gingivectomy Or Gingivoplasty To Allow Access For Restorative Procedure, Per Tooth D424 Gingival Flap Procedure, Including Root Planing - Four Or More Contiguous Teeth Or Tooth Bounded Spaces Per Quadrant 13 D4241 Gingival Flap Procedure, Including Root Planing - One To Three Contiguous Teeth Or Tooth Bounded Spaces Per Quadrant 7 D426 Osseous Surgery (Including Elevation Of A Full Thickness Flap And Closure) Four Or More Contiguous Teeth Or Tooth Bounded Spaces Per Quadrant 19 D4261 Osseous Surgery (Including Elevation Of A Full Thickness Flap And Closure) One To Three Contiguous Teeth Or Tooth Bounded Spaces Per Quadrant NON-SURGICAL PERIODONTAL SERVICES 12 D4341 Periodontal Scaling And Root Planing - Four Or More Teeth Per Quadrant 3 D4342 Periodontal Scaling And Root Planing - One To Three Teeth Per Quadrant 2 Base 16 (1/12) TX Current Dental Terminology 217 American Dental Association. All rights reserved. TX
NON-SURGICAL PERIODONTAL SERVICES REPAIRS TO PARTIAL DENTURES D4346 Scaling In Presence Of Generalized Moderate Or Severe Gingival Inflammation - Full Mouth, After Oral Evaluation D43 Full Mouth Debridement To Enable a Comprehensive Oral Evaluation And Diagnosis on a Subsequent Visit OTHER PERIODONTAL SERVICES D491 Periodontal Maintenance D4921 Gingival Irrigation - Per Quadrant 2 COMPLETE DENTURES (including routine post delivery care) D63 Repair Or Replace Broken Clasp - Per Tooth 1 D64 Replace Broken Teeth-Per Tooth 1 D6 Add Tooth To Existing Partial Denture 1 D66 Add Clasp To Existing Partial Denture - Per Tooth D67 Replace All Teeth And Acrylic On Cast Metal 22 Framework (Maxillary) D671 Replace All Teeth And Acrylic On Cast Metal 2 Framework (Mandibular) DENTURE REBASE PROCEDURES D11 Complete Denture - Maxillary 33 D71 Rebase Complete Maxillary Denture 3 D12 Complete Denture - Mandibular 33 D711 Rebase Complete Mandibular Denture 3 D13 Immediate Denture - Maxillary 33 D72 Rebase Maxillary Partial Denture 3 D14 Immediate Denture - Mandibular 33 D721 Rebase Mandibular Partial Denture 3 PARTIAL DENTURES (including routine post-delivery care) DENTURE RELINE PROCEDURES D211 Maxillary Partial Denture - Resin Base 26 D212 Mandibular Partial Denture - Resin Base 26 D213 Maxillary Partial Denture - Cast Metal 38 Framework With Resin Denture Bases D73 Reline Complete Maxillary Denture (Chairside) D731 Reline Complete Mandibular Denture (Chairside) D74 Reline Maxillary Partial Denture (Chairside) D741 Reline Mandibular Partial Denture (Chairside) D7 Reline Complete Maxillary Denture (Laboratory) 3 D71 Reline Complete Mandibular Denture 3 (Laboratory) D214 Mandibular Partial Denture - Cast Metal Framework With Resin Denture Bases (Including Any Conventional Clasps, Rest And Teeth) 38 D221 Immediate Maxillary Partial Denture - Resin 26 Base (Including Any Conventional Clasps, Rests and Teeth) D222 Immediate Mandibular Partial Denture - Resin 26 Base (Including Any Conventional Clasps, Rests and Teeth) D76 Reline Maxillary Partial Denture (Laboratory) 3 D761 Reline Mandibular Partial Denture (Laboratory) 3 OTHER REMOVABLE PROSTHETIC SERVICES D8 Tissue Conditioning, Maxillary 1 D81 Tissue Conditioning, Mandibular 1 D863 Overdenture - Complete Maxillary 33 D864 Overdenture - Partial Maxillary 38 D223 Immediate Maxillary Partial Denture - Case Metal Framework With Resin Denture Bases 38 D86 Overdenture - Complete Mandibular 33 D866 Overdenture - Partial Mandibular 38 FIXED PARTIAL DENTURE PONTICS D224 Immediate Mandibular Partial Denture - Case Metal Framework With Resin Denture Bases 38 D621 Pontic-Cast High Noble Metal D6211 Pontic-Cast Predominatly Base Metal D6212 Pontic-Cast Noble Metal ADJUSTMENTS TO DENTURES D6214 Pontic - Titanium D41 Adjust Complete Denture - Maxillary 1 D411 Adjust Complete Denture - Mandibular 1 D421 Adjust Partial Denture - Maxillary 1 D422 Adjust Partial Denture - Mandibular 1 REPAIRS TO COMPLETE DENTURES D11 Repair Broken Complete Denture Base, Mandibular 1 D12 Repair Broken Complete Denture Base, 1 Maxillary D2 Replace Missing Or Broken Teeth-Complete 1 Denture (Each Tooth) REPAIRS TO PARTIAL DENTURES D611 Repair Resin Partial Denture Base, Mandibular 1 D612 Repair Resin Partial Denture Base, Maxillary 1 D621 Repair Cast Partial Framework, Mandibular 1 D622 Repair Cast Partial Framework, Maxillary 1 D624 Pontic-Porcelain Fused To High Noble Metal D6241 Pontic-Porcelain Fused To Predominantly Base Metal D6242 Pontic-Porcelain Fused To Noble Metal FIXED PARTIAL DENTURE RETAINERS - CROWNS D67 Retainer Crown, Porcelain Fused To High Noble Metal 18 D671 Retainer Crown - Porcelain Fused To 18 Predominantly Base Metal D672 Retainer Crown, Porcelain Fused To Noble 18 Metal D678 Retainer Crown, 3/4 Cast High Noble Metal 18 D6781 Retainer Crown - 3/4 Cast Predominantly Base 18 Metal D6782 Retainer Crown - 3/4 Cast Noble Metal 18 D6783 Retainer Crown - 3/4 Porcelain/Ceramic 18 D679 Retainer Crown, Full Cast High Noble Metal 16 Base 16 (1/12) TX Current Dental Terminology 217 American Dental Association. All rights reserved. TX
FIXED PARTIAL DENTURE RETAINERS - CROWNS D6791 Retainer Crown, Full Cast Predominantly Base Metal 16 D6792 Retainer Crown, Full Cast Noble Metal 16 D6794 Retainer Crown - Titanium 16 OTHER FIXED PARTIAL DENTURE SERVICES D693 ReCement Or Re-Bond Fixed Partial Denture EXTRACTIONS (includes local anesthesia, suturing, if needed, and routine postoperative care) D7111 Extraction, Coronal Remnants - Primary Tooth D714 Extraction, Erupted Tooth Or Exposed Root (Elevation And/Or Forceps Removal) SURGICAL EXTRACTIONS (includes local anesthesia, suturing, if needed, and routine postoperative care) D721 Extraction, Erupted Tooth Requiring Removal Of Bone And/Or Sectioning Of Tooth, And Including Elevation Of Mucoperiosteal Flap If Indicated 6 D722 Removal Of Impacted Tooth - Soft Tissue D723 Removal Of Impacted Tooth - Partially Bony 7 D724 Removal Of Impacted Tooth - Completely Bony 8 D7241 Removal Of Impacted Tooth - Completely Bony, With Unusual Surgical Complications 8 D72 Removal Of Residual Tooth Roots (Cutting Procedure) 4 D721 Coronectomy-Intentional Partial Tooth Removal 8 OTHER SURGICAL PROCEDURES D728 Exposure Of An Unerupted Tooth 9 ALVEOLOPLASTY (surgical preparation of ridge for dentures) D731 Alveoloplasty In Conjunction With Extractions - Four Or More Teeth Or Tooth Spaces, Per Quadrant 3 D732 Alveoloplasty Not In Conjunction With Extractions - Four Or More Teeth Or Tooth Spaces, Per Quadrant 4 D7321 Alveoloplasty Not In Conjunction With Extractions - One To Three Teeth Or Tooth Spaces, Per Quadrant 3 SURGICAL INCISION D71 Incision And Drainage Of Abscess - Intraoral 2 Soft Tissue OTHER REPAIR PROCEDURES D796 Frenulectomy - Also Known As Frenectomy Or 6 Frenotomy - Separate Procedure Not Incidental To Another Procedure LIMITED ORTHODONTIC TREATMENT D81 Limited Orthodontic Treatment Of Primary 77 D82 Limited Orthodontic Treatment Of Transitional 77 D83 Limited Orthodontic Treatment Of Adolescent 77 D84 Limited Orthodontic Treatment Of The Adult 77 INTERCEPTIVE ORTHODONTIC TREATMENT D8 Interceptive Orthodontic Treatment Of Primary 11 D86 Interceptive Orthodontic Treatment Of Transitional 11 COMPREHENSIVE ORTHODONTIC TREATMENT D87 Comprehensive Orthodontic Treatment Of Transitional 18 D88 Comprehensive Orthodontic Treatment Of Adolescent 18 D89 Comprehensive Orthodontic Treatment Of Adult 2 MINOR TREATMENT TO CONTROL HARMFUL HABITS D821 Removable Appliance Therapy For Control Of Harmful Habits 6 D822 Fixed Appliance Therapy For Control Of 6 Harmful Habits OTHER ORTHODONTIC SERVICES D866 PreOrthodontic Treatment Examination To Monitor Growth And Development 9 D868 Orthodontic Retention (Removal Of Appliances, Construction And Placement Of Retainer(S) 9 UNCLASSIFIED TREATMENT D911 Palliative (Emergency) Treatment Of Dental Pain, Minor Procedures PROFESSIONAL CONSULTATION D931 Consultation - Diagnostic Service Provided By Dentist Or Physician Other Than Requesting Dentist Or Physician D9311 Consultation With A Medical Health Care Professional PROFESSIONAL VISITS D943 Office Visit For Observation (During Regularly Scheduled Hours) - No Other Services Performed D944 Office Visit After Regularly Scheduled Hours 3 MISCELLANEOUS SERVICES D9932 Cleaning And Inspection Of Removable Complete Denture, Maxillary D9933 Cleaning And Inspection Of Removable Complete Denture, Mandibular D9934 Cleaning And Inspection Of Removable Partial Denture, Maxillary D993 Cleaning And Inspection Of Removable Partial Denture, Mandibular D9991 Dental Case Management - Addressing Appointment Compliance Barriers D9992 Dental Case Management - Care Coordination D9993 Dental Case Management - Motivational Interviewing D9994 Dental Case Management - Patient Education To Improve Oral Health Literacy D999 Teledentistry - Synchronous; Real-Time Encounter D9996 Teledentistry - Asynchronous; Information Stored and Forwarded to Dentist for Subsequent Review FOOTNOTES Base 16 (1/12) TX Current Dental Terminology 217 American Dental Association. All rights reserved. TX
FOOTNOTES Charges for lab fees or the use of precious (high noble) or semi precious (noble) metal are not covered and therefore are not included in the copayment for crowns, bridges, pontics, inlays and onlays. The total patient charge for high noble metal and the applicable dental lab fees may not exceed the primary care dentist's actual charge or $22, which ever is lower Base 16 (1/12) TX Current Dental Terminology 217 American Dental Association. All rights reserved. TX
SCHEDULE OF EXCLUSIONS AND LIMITATIONS EXCLUSIONS Except as specifically provided in this Certificate, Schedules of Benefits, or Riders to the Certificate, no coverage will be provided for devices, supplies or charges: 1. Not specifically listed in the Schedule of Benefits as a Covered Service. 2. Provided to s outside of the Primary Dental Office in which the is enrolled and services provided by a Specialty Care Dentist without a referral except for emergency services as specified in the Certificate. 3. Which in the opinion of the treating dentist, or the Company, are not clinically necessary, or do not have a reasonable, favorable prognosis. 4. That are necessary due to lack of cooperation with the treating dentist, or failure to comply with a professionally prescribed Treatment Plan.. Started or incurred prior to the s Effective Date with the Company or after the Termination Date of Coverage with the Company. 6. For consultations by a Specialty Care Dentist for services not specifically listed on the Schedule of Benefits as a Covered Service. 7. Services or supplies that are not deemed generally accepted standards of dental treatment. 8. That are the responsibility of employer s liability insurance, or for treatment of any automobile related injury in which the is entitled to payment under an automobile insurance policy. The Company s benefits would be in excess to the third party benefits and therefore, the Company would have right of recovery for any benefits paid in excess. 9. For services and/or appliances that alter the vertical dimension or alter, restore or maintain the occlusion, including, but not limited to, full mouth rehabilitation, splinting, appliances or any other method. 1. That restore tooth structure lost due to attrition, erosion or abrasion. 11. Periodontal splinting of teeth by any method. 12. For replacement of lost, missing, stolen or damaged prosthetic device or orthodontic appliance or for duplicate dentures, prosthetic devices or any duplicative device. 13. For diagnostic services and treatment of jaw joint problems by any method. These jaw joint problems include but are not limited to such conditions as temporomandibular joint disorder (TMD and/or TMJ) and craniomandibular disorders or other conditions of the joint linking the jaw bone and the complex of muscles, nerves and other tissues related to that joint. 14. For implants, surgical insertion and/or removal of, and any appliances and/or crowns attached to implants.. For the following, which are not included as orthodontic benefits: retreatment of orthodontic cases, changes in orthodontic treatment necessitated by patient noncooperation, repair of orthodontic appliances, replacement of lost or stolen appliances, special appliances (including, but not limited to, headgear, orthopedic appliances, bite planes, functional appliances or palatal expanders), myofunctional therapy, cases involving orthognathic surgery, extractions for orthodontic purposes, and treatment in excess of 24 months. 16. For prescription or non-prescription drugs, home care items, vitamins or dietary supplements. 17. For hospitalization and associated costs for rendering services in a hospital. 18. Which are Cosmetic in nature as determined by the Company, including, but not limited to bleaching, veneer facings, personalization or characterization of crowns, bridges and/or dentures. 19. For any condition caused by or resulting from declared or undeclared war or act thereof, or resulting from service in the national guard or in the armed forces of any country or international authority. TXNPEL (6/3)