Coverage Policies

Important! Please note:

Current policies effective through April 30, 2024.

Use the index below to search for coverage information on specific medical conditions.

High-Tech Imaging: High-Tech Imaging services are administered by Evolent. For coverage information and authorizations, click here.

Medical Providers: Payment for care or services is based on eligibility, medical necessity and available benefits at time of service and is subject to all contractual exclusions and limitations, including pre-existing conditions if applicable.

Future eligibility cannot be guaranteed and should be rechecked at time of service. Verify benefits by signing into My Account or calling Customer Service at 800.235.7111 or 501.228.7111.

QualChoice follows care guidelines published by MCG Health.

Clinical Practice Guidelines for Providers (PDF)

QualChoice reserves the right to alter, amend, change or supplement medical policies as needed. QualChoice reviews and authorizes services and substances. CPT and HCPCS codes are listed as a convenience and any absent, new or changed codes do not alter the intent of the policy.


Effective Date: 07/29/2005 Title: Preventive Dental Care
Revision Date: 08/28/2008 Document: BI105:00
CPT Code(s): D0120, D0150, D0210, D0220, D0230, D0270, D0272, D0274. D1110, D1120
Public Statement

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.

Medical Statement

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:


Periodic oral evaluation


Comprehensve oral evaluation


Intraor complete film series


Intraoral periapical first f


Intraoral periapical ea add


Dental bitewing single film


Dental bitewings two films


Dental bitewings four films


Dental prophylaxis adult


Dental prophylaxis child

Application to Products

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.

Changes: QualChoice reserves the right to alter, amend, change or supplement benefit interpretations as needed.
This policy has recently been updated. Please use the index above or enter policy title in search bar for the latest version.