Effective Date:

a)    This policy will apply to all services performed on or after the above revision date which will become the new effective date.

b)    For all services referred to in this policy that were performed before the revision date, contact customer service for the rules that would apply.

This benefit does not apply to most plans issued by QualChoice. 

1)    A small number of plans issued and/or administered by QualChoice include some preventive dental care.

2)    This policy does not address the application of pediatric dental benefits in those metallic level plans that are required to have a pediatric dental benefit in order to be a Qualified Health Plan under the requirements of the Affordable Care Act; for those policies, refer to BI432.  Please refer to your Evidence of Coverage and your Benefit Summary to determine if this policy applies to you.

3)    This medical policy defines what services are covered as being part of “preventive dental care.”

4)    Please consult your coverage documents; if preventive dental care is not explicitly included in your coverage, you do not have this coverage.

5)    If you do have preventive dental care included in your policy, please ask your dentist to check the policy statement in this medical policy to know what will be covered.

1)    A small number of QualChoice administered plans include preventive dental coverage. As of this writing, this includes primarily some policies issued under the Chamber Alliance Program. The only way to know will be to check eligibility on line, or call customer service and ask if the member has preventive dental coverage.

a)    Included services that will be paid on our fee schedule are:

i)           D0120 – Periodic oral evaluation

ii)         D0150 – Comprehensive oral evaluation

iii)        D0210 – Intraoral complete film series

iv)        D0220 – Intraoral periapical first film

v)         D0230 – Intraoral periapical each additional film

vi)        D0270 – Dental bitewing single film

vii)      D0272 – Dental bitewings two films

viii)     D0274 – Dental Bitewings four films

ix)        D1110 – Dental Prophylaxis, adult

x)         D1120 – Dental Prophylaxis, child

b)    No other services are covered.

Codes Used In This BI:

This policy applies to all health plans and products administered by QualChoice, both those insured by QualChoice and those that are self-funded by the sponsoring employer, unless there is indication in this policy otherwise or a stated exclusion in your medical plan booklet.  Consult the individual plan sponsor Summary Plan Description (SPD) for self-insured plans or the specific Evidence of Coverage (EOC) or Certificate of Coverage (COC) for those plans or products insured by QualChoice.  In the event of a discrepancy between this policy and a self-insured customer’s SPD or the specific QualChoice EOC or COC, the SPD,  EOC, or COC, as applicable, will prevail.  State and federal mandates will be followed as they apply.