VA Cardinal Care Smiles Office Reference Manual

DentaQuest LLC July 1, 2024

DentaQuest, LLC

Office Reference Manual

Cardinal Care Smiles

Commonwealth of Virginia Medicaid, FAMIS, FAMIS Plus, Dental Program

11100 W Liberty Dr.

Milwaukee, WI 53224

888.912.3456

www.dentaquest.com

DentaQuest LLC July 1, 2024

This document contains proprietary and confidential information and

DentaQuest, LLC

Address and Telephone Numbers

Provider Services/Standard Updates

PO Box 2906

Milwaukee, WI 53201-2906

Fax: 262.241.4077

Cardinal Care Smiles: 888.912.3456

Network Development

Fax numbers:

Claims/payment issues: 262.241.7379

Claims to be processed: 262.834.3589

All other: 262.834.3450

edentialing

PO Box 2906

Milwaukee, WI 53201-2906

Credentialing Hotline: 800.233.1468

Fax: 262.241.7401

Customer Service/Member Services

PO Box 2906

Milwaukee, WI 53201-2906

888.912.3456

TDD (Hearing Impaired)

800.466.7566

Special Needs Member Services

800.660.3397

Fraud Hotline

800.237.9139

DentaQuest’s Virginia Office

866.853.0657

Prior authorizations for Hospital Operating

Room Cases should be sent to:

DentaQuest, LLC-OR Authorizations

PO Box 2906

Milwaukee, WI 53201-2906

Authorizations should be sent to:

DentaQuest, LLC–VA Authorizations

PO Box 2906

Milwaukee, WI 53201-2906

Dental claims should be mailed to:

DentaQuest, LLC-VA Claims

PO Box 2906

Milwaukee, WI 53201-2906

Electronic Claims should be sent:

Direct entry on the web – www.dentaquest.com

Via Clearinghouse – Payer ID CX014

Include address on electronic claims –

DentaQuest, LLC

PO Box 2906

Milwaukee, WI 53201-2906

Provider Appeals should be sent to:

DentaQuest, LLC

Utilization Management/Provider Appeals

PO Box 2906

Milwaukee, WI 53201-2906

Member Grievance and Appeals

888.912.3456

DentaQuest, LLC

Cardinal Care Smiles

Complaints and Appeals

PO Box 2906

Milwaukee, WI 53201-2906

DentaQuest LLC July 1, 2024

Cardinal Care Smiles

Statement of Members Rights and Responsibilities

The mission of Cardinal Care Smiles is to expand access to high-quality, compassionate oral health

services within the allocated resources. Cardinal Care Smiles is committed to ensuring that all Members are

treated in a manner that respects their rights and acknowledges its expectations of Member’s responsibilities.

As a member of the Cardinal Care Smiles program, your child has the right to:

 Be treated with respect, dignity, and privacy

 Receive information about Cardinal Care Smiles and the services available

 Be able to choose a dental care provider from the Cardinal Care Smiles directory

 Be able to refuse care from a specific dentist

 Make decisions about your child's dental care

 File a complaint or appeal about a dental care provider or Cardinal Care Smiles

 Have access to your child's dental records

 Not be discriminated against by the health care provider on the basis of age, sex, race, color, physical

or mental handicap, national origin, ethnicity, religion, sexual orientation, genetic information, economic

status, source of payment or type, or degree of illness or condition

 Have your health information kept private pursuant to state and federal laws

 Be told of changes in services or if your dentist leaves Cardinal Care Smiles within (15) calendar days

from the date that DentaQuest becomes aware that your dentist will no longer be available to render

services.

 Request an interpreter when you call Cardinal Care Smiles Member Services

 Have any printed materials translated into your primary language or to request an alternative format

 Request an interpreter when translation is needed to understand treatment received from a Cardinal

Care Smiles dentist.

As a member of the Cardinal Care Smiles program you are responsible for:

 Using the Cardinal Care Smiles dental program

 Knowing, understanding, and following the terms and conditions of this handbook

 Listening to the dentist and following instructions about the care of your child's teeth

 Making and keeping appointments, and being on time for your appointment

 Canceling appointments and scheduled transportation as early as possible

 Showing your child's identification card and any other insurance card every time you go to the dentist

 Making sure you are the only person who uses your identification card and letting your local Department

of Social Services or your MCO know if it is lost or stolen

 Answering questions about your child's health that will help your dentist take care of your child

 Letting your dentist know if your child has had care in an emergency room within 24 hours or been to

another dentist recently

 Notifying Member Services when you believe someone has purposely misused Cardinal Care Smiles

benefits or services.

 Treating the dentist with dignity and respect.

 Immediately informing your local Department of Social Services or the FAMIS CPU of any of these

things:

 An address change each and every time you move

 A phone number change each and every time you change phone numbers

 If you have a new baby or have a family size change

 A name change

DentaQuest LLC July 1, 2024

Cardinal Care Smiles

Statement of Provider Rights and Responsibilities

Providers shall have the right to:

1. Communicate with patients, including Members regarding dental treatment options.

2. Recommend a course of treatment to a Member, even if the course of treatment is not a covered benefit,

or approved by the Cardinal Care Smiles program.

3. File an appeal or complaint pursuant to the procedures of Cardinal Care Smiles.

4. Supply accurate, relevant, and factual information to any Member in connection with an appeal or

complaint filed by the Member.

5. Object to policies, procedures, or decisions made by Cardinal Care Smiles.

6. Charge an eligible Cardinal Care Smiles Member for dental services that are not covered services only if

the Member knowingly elects to receive the services as a private-pay patient and enters into an agreement

in writing to pay for such services prior to receiving them. Non-covered services include: services not

covered under the Cardinal Care Smiles plan; services for which pre-authorization has been denied

and

deemed not medically necessary; and services which are provided out-of-network.

7. Be informed timely of the status of their credentialing or re-credentialing application, upon request.

8. To determine to what extent they will participate in the Cardinal Care Smiles program (i.e. set patient

panel size).

Providers have the responsibility to:

1. Protect the patients’/members’ rights to privacy.

2. Comply with any applicable Federal and State laws that pertain to members rights and not to discriminate

against a member on the basis of age, sex, race, physical or mental handicap, national origin, ethnicity,

religion, sexual orientation, genetic information, economic status, source of payment or type, or degree of

illness or condition.

3. Notify DentaQuest of any changes in their practice information, including: location, telephone number,

limits to participation, providers joining or leaving the practice, etc. All changes must be submitted in writing

by completing the Provider Change Form. The Provider Change Form is available on the Provider Web

Portal (PWP) at www.dentaquestgov.com

4. Hold the Cardinal Care Smiles Members harmless and shall not bill any Member for services if the

services are not covered as a result of any error or omission by Provider.

5. Adhere to the Cardinal Care Smiles Provider Participation Agreement.

DentaQuest makes every effort to maintain accurate information in this manual; however, DentaQuest will not

be held liable for any damages directly or indirectly due to typographical errors. Please contact us should you

discover an error.

DentaQuest LLC July 1, 2024

Office Reference Manual

Table of Contents

Section P

age

1.00 What is Cardinal Care Smiles............................................................................................................................... 7

1.01 Dedicated Call Center for Providers ................................................................................................................... 8

1.02 Provider Training .................................................................................................................................................. 8

1.03 Provider Newsletters ............................................................................................................................................ 8

1.04 DentaQuest Website ............................................................................................................................................. 8

1.05 Other Value-Added Provider Benefits ................................................................................................................. 8

2.00 Patient Eligibility Verification Procedures .......................................................................................................... 9

2.01 Cardinal Care Smiles Eligibility ........................................................................................................................... 9

2.02 Pregnant Women Eligibility – Dental Services ................................................................................................... 9

2.03 DentaQuest Eligibility Systems ........................................................................................................................... 9

2.04 Specialist Referral Process ............................................................................................................................... 10

2.05 Provider Directory .............................................................................................................................................. 11

2.06 Member Transportation ...................................................................................................................................... 11

2.07 Tips for Reducing Broken Appointments ......................................................................................................... 11

2.08 Broken/Cancelled/Missed Appointment ........................................................................................................... 12

3.00 Authorization for Treatment ............................................................................................................................... 12

3.01 Dental Treatment Requiring Authorization ....................................................................................................... 12

3.02 Authorization for Operating Room (OR) Cases ................................................................................................ 14

3.03 Payment for Non-Covered Services .................................................................................................................. 14

3.04 Electronic Attachments ...................................................................................................................................... 14

4.00 Claim Submission Procedures (claim filing options ........................................................................................ 16

4.01 Claim Submission for Pregnant Women ........................................................................................................... 16

4.02 Claim Submission for VA CCS IMD Me

mbers ……………………………………………………………… 16

4.03 Electronic Claim Submission Utilizing DentaQuest’s Internet Website ......................................................... 16

4.04

Electronic Authorization Submission Utilizing DentaQuest’s Internet Website ............................................ 16

DentaQuest LLC July 1, 2024

4.05 Electronic Claim Submission via Clearinghouse ............................................................................................. 16

4.06 HIPAA Compliant 837D File ............................................................................................................................... 17

4.07 NPI Requirements for Submission of Electronic Claims ................................................................................. 17

4.08 Paper Claim Submission .................................................................................................................................... 17

4.09 Coordination of Benefits (COB) ......................................................................................................................... 18

4.10 Filing Limits ........................................................................................................................................................ 18

4.11 Claims Appeals ................................................................................................................................................... 19

4.12 Receipt and Audit of Claims .............................................................................................................................. 19

4.13 Claim Submission and Payment for Operating Room (OR) Cases ................................................................. 19

4.14 Direct Deposit and Electronic Remittance Statements .................................................................................... 20

5.00 Health Insurance Portability and Accountability Act (HIPAA) ......................................................................... 21

5.01 HIPAA Companion Guide ................................................................................................................................... 21

6.00 Grievances and Appeals .................................................................................................................................... 21

6.01 Provider Grievances and Appeals ..................................................................................................................... 21

6.02 Member Grievances and Appeals ..................................................................................................................... 22

7.00 Utilization Management Program ...................................................................................................................... 24

7.01 Introduction ........................................................................................................................................................ 24

7.02 Community Practice Patterns ............................................................................................................................ 24

7.03 Evaluation ........................................................................................................................................................... 24

7.04 Results ................................................................................................................................................................ 24

7.05 Fraud and Abuse (Policies 700 Series) ............................................................................................................. 25

8.00 Quality Improvement Program (Policies 200 Series) ....................................................................................... 25

9.00 Credentialing (Policies - 300 Series ................................................................................................................... 27

9.01 Reporting Requirements for Exclusion from Federal Programs ………………………………………………... 28

10.00 The Patient Record ............................................................................................................................................. 28

11.00 Patient Recall System ......................................................................................................................................... 31

12.00 Member Communication .................................................................................................................................... 32

13.00 Radiology Requirements .................................................................................................................................... 33

14.00 Health Guidelines – Ages 0-18 Years ................................................................................................................ 36

15.00 Clinical Criteria .................................................................................................................................................... 37

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15.01 Criteria for Dental Extractions ........................................................................................................................... 38

15.02 Criteria for Cast Crowns ..................................................................................................................................... 38

15.03 Criteria for Endodontics ..................................................................................................................................... 39

15.04 Criteria for Stainless Steel Crowns ................................................................................................................... 40

15.05 Criteria for Authorization of Operating Room (OR) Cases .............................................................................. 41

15.06 Criteria for Removable Prosthodontics (Full and Partial Dentures) ............................................................... 43

15.07 Criteria for the Determination of a Non-Restorable Tooth .............................................................................. 44

15.08 Criteria for General Anesthesia and Intravenous (IV) Sedation ...................................................................... 45

15.09 Criteria for Periodontal Treatment .................................................................................................................... 45

16.00 Orthodontia Documentation .............................................................................................................................. 46

APPENDIX A .................................................................................................................................................................... 47

Attachments .................................................................................................................................................................... 47

General Definitions .................................................................................................................................... 47

Additional Resources .................................................................................................................................................. 48

APPENDIX B .................................................................................................................................................................... 49

Covered Benefits (See Exhibits A, B and C) .............................................................................................................. 49

1.00 What is Cardinal Care Smiles

Cardinal Care Smiles is the dental program for members enrolled in Medicaid, FAMIS or FAMIS Plus.

All dental services for Medicaid, FAMIS or FAMIS Plus Members will be provided through Cardinal Care

Smiles. Cardinal Care Smiles is provided by the Commonwealth of Virginia’s Department of Medical

Assistance Services (DMAS) in collaboration with the Virginia Dental Association (VDA) and the Old

Dominion Dental Society (ODDS) and is administered by DentaQuest, LLC on an administrative services

only (ASO) basis. This means that DentaQuest will process and pay claims to providers on a fee-for-

service basis, based on the Cardinal Care Smiles fee schedule, and DMAS retains responsibility for

reimbursement to DentaQuest for the cost of the claim payments made to providers. Reimbursement to

providers outside of the Cardinal Care Smiles network is not available.

Cardinal Care Smiles provides coverage for Medicaid and FAMIS Plus children under 21 years of age

and under age 19 for FAMIS children. Covered services are defined as any medically necessary

diagnostic, preventive, restorative, and surgical procedures, as well as orthodontic procedures,

administered by, or under the direct supervision of, a dentist. Comprehesive dental coverage for adults,

age 21 years and over, who are receivng full Medicaid benefits are covered by the Cardinal Care Smiles

program. Comprehensive dental coverage, with the exception of orthndontia, for pregnant women ages

21 years and over are covered by the Cardinal Care Smiles program. Reference Exhibits A, B and C

of this manual for detailed coverage criteria and guidelines.

The goals of the Cardinal Care Smiles program are to:

• Increase provider participation in the Cardinal Care Smiles network

• Streamline program administration, making it easier for provider to participate

• Create a partnership between DMAS, DentaQuest and Organized Dentistry

• Improve Member access to quality dental care

• Improve oral health and wellness for Virginia’s children

DentaQuest LLC July 1, 2024

Value-A

dded Provider Benefits

1.01 Dedicated Call Center for Providers

DentaQuest offers Participating Cardinal Care Smiles Providers access to call center

representatives who specialize in areas such as:

• Eligibility, benefits and authorizations,

• Member placements, and

• Claims

You can reach these specialists by calling 888.912.3456.

1.02 Provider Training

DentaQuest offers free Provider training sessions periodically throughout the Commonwealth

of Virginia. These sessions include important information such as: claims submission

procedures, pre-payment and prior-authorization criteria, how to access DentaQuest’s clinical

personnel, etc. As a tool, all Provider training aids are available on the Provider Web Portal

(PWP) at www.dentaquestgov.com

. In addition, Providers can contact the Virginia Provider

Engagement Representative for assistance, or to request a personal, in-office visit, by calling:

866.853.0657.

1.03 P

rovider Newsletters

DentaQuest publishes quarterly Participating Provider newsletters that include helpful

information of interest to providers. To request a copy of the DentaQuest provider newsletter,

you may call our Virginia Provider Engagement Representative at 866.853.0657, or call

888.912.3456.

1.04 DentaQuest Website

DentaQuest’s website includes a “For Provider’s Only” section, that allows Participating

Cardinal Care Smiles Providers access to several helpful options including:

• Member eligibility verification

• Claims submission

• Authorization Submission

• View claim status

• Create claim tracking reports

• Member treatment history

• Explanation of Benefits

• Contact DentaQuest via the Provider Web Portal

• Obtain program documents (such as ORM, Provider Change Form, Interpreter Service

Form, Continuation of Care Form)

For more information, contact DentaQuest’s Systems Operations Department via email at

[email protected]

1.05 Other Value-Added Provider Benefits

Other value-added provider benefits (detailed in other sections of this manual) include:

 Dedicated Virginia Project Director, Provider Engagement Representative, Outreac

oordinator, and Dental Director

 Streamlined Credentialing

 Minimal Prior Authorization Requirements

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2.00 P

atient Eligibility Verification Procedures

2.01 Cardinal Care Smiles Eligibility

Any eligible Medicaid, FAMIS or FAMIS Plus person is eligible for dental benefits under the

Cardinal Care Smiles Program. Please note that when calling DMAS to verify member

eligibility, members indicated as enrolled ONLY in the Family Planning Waiver Program (Aid

Category 80) are not eligible for dental benefits under the Cardinal Care Smiles Program.

Dental providers must call DentaQuest to verify member eligibility. Recipients will not receive

a separate Cardinal Care Smiles ID card for dental services. Medicaid, FAMIS and FAMIS

Plus eligible recipients will receive dental coverage under Cardinal Care Smiles regardless of

their MCO enrollment status. Therefore, recipients may use their Commonwealth of Virginia

(blue and white) plastic identification card or any of the following MCO cards: Virginia Premier

Health Plan, Optima Family Care, CareNet by Southern Health, AMERIGROUP (as of

September 1, 2005), Anthem HealthKeepers Plus, Anthem HealthKeepers Plus by Peninsula,

and Anthem HealthKeepers Plus by Priority. Aetna Better health of Virginia, Anthem

healthKeepers Plus, Molina Complete Care, Optima Family Care, United Healthcare

Community Plan. (Although dental services have been carved out from the MCO contracts, all

MCO ID cards list the 12-digit Medicaid, FAMIS, and FAMIS Plus ID number for eligibility

verification purposes.)

2.02 Pregnant Women Eligibility – Dental Services

Pregnant women in Medicaid and FAMIS MOMS who are 21 years of age and older are

eligible to receive dental benefits (excluding Orthodontia) through Virginia’s dental program,

Cardinal Care Smiles (CCS). Covered services are listed in Exhibit C.

Eligibility should be verified prior to each appointment.

• Members in the VA Cardinal Care Smiles Over 21 Pregnant Member subgroup:Dental

benefits will be discontinued at the end of the month following 12 months postpartum.

• Members in the VA Cardinal Care Smiles Over 21 Pregnant Member – 60 Days

subgroup: Dental benefits will be discontinued at the end of the month following their 60

day

postpartum.

2.03 DentaQuest Eligibility Systems

Participating Cardinal Care Smiles Providers may access Member eligibility information

through DentaQuest’s Interactive Voice Response (IVR) system or through the “Dentist” section

of DentaQuest’s website at www.dentaquestgov.com

. T

he eligibility information received from

either system will be the same information you would receive by calling DentaQuest’s Customer

Service department; however, by utilizing either system you can get information 24 hours a day,

7 days a week without having to wait for an available Customer Service Representative.

Access to eligibility information via the Internet:

he DentaQuest website allows Providers to verify a Member’s eligibility as well as submit

claims directly to DentaQuest. You can verify the Member’s eligibility on-line by entering the

Member’s date of birth, the expected date of service and the Member’s identification number or

last name and first initial. To access the eligibility information via DentaQuest’s website, simply

log on to the website at www.dentaquestgov.com

. O

nce you have entered the website, click on

“Dentist”. From there choose ‘Virginia” and press go. You will then be able to log in using your

password and ID. First time users will have to register by utilizing the Business’s NPI or TIN,

State and Zip Code. If you have not received instruction on how to complete Provider Self

Registration contact DentaQuest’s Customer Service Department at 888.912.3456. Once

logged in, select “eligibility look up” and enter the applicable information for each Member you

are inquiring about. You are able to check on an unlimited number of patients and can print off

the summary of eligibility given by the system for your records.

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Access to eligibility information via the Interactive Voice Response IVR line:

o access the IVR, simply call DentaQuest’s Customer Service department at 888.912.3456

and press 1 for eligibility. The IVR system will be able to answer all of your eligibility questions

for as many Members as you wish to check. Once you have completed your eligibility checks,

you will have the option to transfer to a Customer Service Representative to answer any

additional questions, i.e. Member history, which you may have. Using your telephone keypad,

you can request eligibility information on a Cardinal Care Smiles Member by entering your NPI

Number, Tax Identification Number, and the Member’s identification number. Specific directions

for utilizing the IVR to check eligibility are listed below. After our system analyzes the

information, the patient’s eligibility for coverage of dental services will be verified. If the system

is unable to verify the Member information you entered, you will be transferred to a Customer

Service Representative.

Members must be eligible on the date of service for payment to be made. However,

please note that due to possible eligibility status changes, the information provided by

either system does not guarantee payment.

If you are having difficulty accessing either the IVR or website, please contact the Customer

Service Department at 888.912.3456. They will be able to assist you in utilizing either system.

2.04 Specialist Referral Process

A patient requiring a referral to a dental specialist can be referred directly to any specialist

participating in the Cardinal Care Smiles program without authorization from DentaQuest. The

dental specialist is responsible for obtaining prior authorization if necessary, for services

according to Exhibits A, B and C of this manual. If you are unfamiliar with the DentaQuest

contracted specialty network or need assistance locating a certain specialty, please contact

DentaQuest’s Customer Service Department at the telephone number found on page 2 of this

manual.

Directions for using DentaQuest’s IVR to verify eligibility:

Entering system with the National Provider Identification number (NPI) and Tax Identification (TIN) number

1. C

all DentaQuest Provider Service at 888.912.3456.

2. If you are a Provider Press 1. If you are a Cardinal Care Smiles Member Press 2

3. After the greeting, stay on the line for English or press 1 for Spanish.

4. When prompted, enter or say you’re NPI (National Provider Identification number).

5. When prompted, enter the last 4 digits of your Tax ID number.

6. IVR validates caller:

• If provider is found – continues to enter member information

• If provider is not found – continues to limited options

7. When prompted, enter the members information

• Member ID (12 digit number only)

• DOB

8. IVR validates member information:

• If member is found – continues to main menu

• If member is not found – prompted to re-enter information

9. Main Menu (when both provider and member are found in the system)

• Eligibility, Claims, Authorizations, Benefit Summary, Benefit Detail, Procedure History,

Web Support and all other inquiries.

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2.05 Provider Directory

DentaQuest publishes a provider directory to Cardinal Care Smiles Members. The directory is

updated periodically and includes: provider name, practice name (if applicable), office

addresses(s), telephone number(s), provider specialty, panel status (for example, providers

limiting their practice to existing patients only), office hours (if available), and any other panel

limitations that DentaQuest is aware of, such as patient age minimum and maximum, etc.

It is very important that you notify DentaQuest of any change in your practice information.

Please complete the Provider Change Form found on the Provider Web Portal (PWP) at

www.dentaquestgov.com

and fax it to DentaQuest at 262.241.4077.

2.06 Member Transportation

Transportation may be available for Cardinal Care Smiles Members through their MCO or

through DMAS if the member is not enrolled in a MCO. DentaQuest will refer Cardinal Care

Smiles Members to the appropriate transportation vendor for assistance. Cardinal Care

Smiles Member transportation assistance can be arranged by contacting the transportation

vendor.

Dental Providers, Medicaid members, facilities, and agencies are encouraged to visit

https://www.dmas.virginia.gov/for-members/benefits-and-services/transportation-services/ and

select “Transportation Contacts.” Here you will be able to locate Medicaid Member

Transportation Reservation and Ride Assist telephone numbers. Ride Assist is to be contacted

to ask questions about your patient’s transportation or report complaints. Please refer to the

website listed above as they are updated frequently.

2.07 Tips for Reducing Broken Appointments

Broken appointments are a major concern for the Department of Medical Assistance Services,

the Virginia Dental Association, the Old Dominion Dental Society, and DentaQuest. We

recognize that broken appointments are a costly and unnecessary expense for providers. Our

goal is to remove any barriers that prevent dentists from participating in the Cardinal Care

Smiles program as well as barriers that prevent our members for utilizing their benefits.

As a result of your feedback, we have developed several Broken Appointment Best Practice

guidelines. We encourage you to implement these practices in your office.

The following list contains office policies which have helped to reduce broken

appointments and the effects of broken appointments in other dental practices.

• Develop a Broken Appointment policy that is for ALL patients.

• Have a contract that patients sign that spells out their rights and responsibilities.

• Confirm appointments after hours when the patient is likely to be home to answer the call.

• Confirm all appointments, including recall and hygiene appointments, the day before the

appointment.

• Consider telling patients they must confirm their own appointment the day before the visit,

or their appointment slot will be lost.

• If a patient has a broken appointment history or is a new patient, it is recommended that

you attempt to speak directly with the patient for the appointment confirmation.

• Continuing care appointments made for three to six months ahead should be reserved for

patients of record with no history of broken appointments.

• Patients with a history of broken appointments or that did not schedule a continuing care

appointment, should receive a postcard asking them to call to schedule an appointment.

• Many emergency patients will not keep future appointments if scheduled on the day of

emergency treatment. These patients should be called later during the week to schedul

ollow-up treatment.

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• When a procedure needs to be completed at a subsequent appointment, send information

hom

e with patients about that next appointment. The information should stress t

mportance of such a procedure and indicate possible outcomes if it is not completed within

the designated timeframe.

• Maintain a list of patients that can be contacted to come in on short notice; this will allow

you to fill gaps when late notice cancellations occur.

• Many patients site daytime obligations such as work or childcare as significant contributing

factors to missing appointments. Having extended hours on selected days of the week or

occasional weekend hours can alleviate this barrier to accessing dental care.

2.08 Broken/Cancelled/Missed Appointment

The Centers for Medicare and Medicaid Services (CMS) prohibit billing Medicaid beneficiaries

for broken, missed or cancelled appointments. Medicaid programs are State designed and

administered with Federal policy established by CMS. Federal requirements mandate that

providers who participate in the Medicaid program must accept the payment of the agency as

payment in full. Providers cannot bill for scheduling appointments or holding appointment

blocks. For more information, please refer to 42 USC § 1396a(a)(25)(c) (which is the United

States Code) or 42 CFR § 447.15 (which is the United States regulation).

Broken Appointment Program

Providers are encouraged to report broken appointments to DentaQuest via the Provider Portal

or on an ADA claim form using codes D9986 or D9987. This is used for reporting purposes only.

No payment will be made for broken appointments. DentaQuest will use this information to

educate members on the importance of keeping appointments and to assist with rescheduling

appointments.

3.00 Authorization for Treatment

3.01 Dental Treatment Requiring Authorization

Under Cardinal Care Smiles, the number of services requiring prior authorization or pre-

payment review is significantly reduced. Authorization is a utilization tool that requires

Participating Cardinal Care Smiles Providers to submit “documentation” associated with

certain dental services for a Member. Participating Providers will not be paid if this

“documentation” is not furnished to DentaQuest. Participating Providers must hold the Member,

DentaQuest, and DMAS harmless as set forth in the Provider Participation Agreement if

coverage is denied for failure to obtain authorization (either before or after service is rendered).

DentaQuest utilizes specific dental utilization criteria as well as an authorization process to

manage utilization of services. DentaQuest’s operational focus is to assure compliance with its

utilization criteria. The criteria are included in this manual (see Clinical Criteria section 14.00).

Please review these criteria as well as the Benefits covered to understand the decision making

process used to determine payment for services rendered.

A. Authorization and documentation submitted before treatment begins. (Prior

Authorization) and Documentation submitted with claim (Pre-payment Review).

Services that require prior-authorization should not be started prior to the determination

coverage (approval or denial of the authorization). Treatment requiring prior-

authorization started prior to the determination of coverage will be performed at t

inancial risk of the dental office.

Services that require pre-payment review, but not prior authorization will require proper

documentation prior to consideration for payment. The dentist also has the option of

requesting prior authorization (instead of pre-payment review) if a Cardinal Care

Smiles decision regarding coverage is desired prior to rendering treatment services.

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Your submission of “documentation” should include:

1. Radiographs, narrative, or other information where requested (See Exhibit A, B

and C for specifics by code)

2. CDT codes on the claim form

Your submission should be sent on an ADA approved claim form. The tables of

Covered Services (Exhibit A, B and C) contain a column marked “Authorization

Required”. A “Yes” in this column indicates that the service listed requires either prior-

authorization or documentation submitted with the claim for pre-payment review in

order to be considered for reimbursement. The “Documentation Required” column will

describe what information is necessary for review, and whether it must be submitted

on a prior-authorization basis, or with a claim following treatment for pre-payment

review.

After the DentaQuest director reviews the documentation, the submitting office shall be

provided an authorization number. The authorization number will be provided within

two business days from the date the documentation is received. The authorization

number will be issued to the submitting office by mail and must be submitted with the

other required claim information after the treatment is rendered. (For prior authorization

only)

B. Submitting Authorization Requests and X-Rays

• Electronic submission using National Electronic Attachment (NEA) is

recommended. For more information, please visit www.nea-fast.com and click

the “Learn More” button. To register, click the “Provider Registration” button in

the middle of the home page.

• Submission of duplicate radiographs (which we will recycle and not return)

• Submission of original radiographs with a self addressed stamped envel

ope

(

SASE) so that we may return the original radiographs. Note that

determinations will be sent separately and any radiographs received without

a SASE will not be returned to the sender.

Please note we also require radiographs be mounted when there are 5 or more

radiographs submitted at one time. If 5 or more radiographs are submitted and not

mounted, they will be returned to you and your request for prior authorization and/or

claims will not be processed. You will need to resubmit a copy of the 2006 or newer

ADA form that was originally submitted, along with mounted radiographs so that we

may process the claim correctly.

Acceptable methods of mounted radiographs are:

• Radiographs duplicated and displayed in proper order on a piece of

duplicating film.

• Radiographs mounted in a radiograph holder or mount designed for this

purpose.

Unacceptable methods of mounted radiographs are:

• Cut out radiographs taped or stapled together

• Cut out radiographs placed in a coin envelope.

• Multiple radiographs placed in the same slot of a radiograph holder or mount.

All radiographs should include member’s name, identification number and office name

to ensure proper handling.

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3.02 Authorization for Operating Room (OR) Cases

All operating room (OR) cases must be prior-authorized. The Participating Cardinal Care

Smiles Provider should submit the prior authorization to DentaQuest. DentaQuest will serve as

the central point of contact for the dental provider, medical facility, medical anesthesiologist,

MCO, DMAS and any other required provider. DentaQuest’s dental director will review the case

for medical necessity, and render an approval or denial of the services. Once DentaQuest has

approved the case, DentaQuest will coordinate authorization for non-dental services (example:

facility and anesthesia) with DMAS and the MCO as appropriate, within the MCO provider

network.

The Participating Cardinal Care Smiles Provider may contact DentaQuest for a list of

participating hospitals and facilities.

Please see section 4.08 for information on submitting claims for services performed in a

non-dental setting.

3.03 Payment for Non-Covered Services

Participating Providers shall hold Members, DentaQuest, and DMAS harmless for the payment

of non-Covered Services except as provided in this paragraph. A provider may charge an

eligible Cardinal Care Smiles Member for dental services which are not covered services only

if the Member knowingly elects to receive the services and enters into an agreement in writing

to pay for such services prior to receiving them. Non-covered services include:

• Services not covered under the Cardinal Care Smiles plan,

• Services for which prior-authorization has been denied and deemed not

medically necessary,

• Services which are provided out-of-network

3.04 Electronic Attachments

A. Fast Attach™

DentaQuest accepts dental radiographs electronically via FastAttach™ for prior-authorization

requests and pre-payment review. DentaQuest, in conjunction with National Electronic

Attachment, LLC (NEA), allows Participating Cardinal Care Smiles Providers the opportunity

to submit all claims electronically, even those that require attachments. This program allows

transmissions via secure Internet lines for radiographs, periodontic charts, intraoral pictures,

narratives and EOBs.

FastAttach™ is inexpensive and easy to use, reduces administrative costs, eliminates lost or

damaged attachments and accelerates claims and prior authorization processing. It is

compatible with most claims clearinghouse or practice management systems.

For more information or to sign up for FastAttach go to www.nea-fast.com

or call NEA at:

800.782.5150

B. OrthoCAD™

OrthoCAD™ - DentaQuest accepts orthodontic models electronically via OrthoCAD™ for

authorization requests. DentaQuest allows Participating Providers the opportunity to submit all

orthodontic models electronically. This program allows transmissions via secure Internet lines

for orthodontic models. OrthoCAD™ is inexpensive and easy to use, reduces administrative

costs, eliminates lost or damaged models and accelerates claims and prior authorization

processing. It is compatible with most claims clearinghouse or practice management systems.

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For more information or to sign up for OrthoCAD™ go to www.orthocad.com or call

OrthoCAD™ at:800.577.8767

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4.00 Claim Submission Procedures (claim filing options

DentaQuest receives dental claims in four possible formats. These formats include:

• Electronic claims via DentaQuest’s website (www.dentaquestgov.com

• Electronic submission via clearinghouses.

• HIPAA Compliant 837D File.

• Paper claims.

4.01 Claim Submission for Pregnant Women

Prepayment review will be conducted on all claims for pregnant women. Appropriate

documentation must include: Narrative indicating member is pregnant with estimated date of

delivery (must be noted in box 35 of ADA claim form); Narrative demonstrating medical

necessity for those services where additional documentation is required for review (i.e.

diagnostic x-rays, perio charting).

4.02 Claim Submission for VA CCS IMD Members

Dental claims submitted for IMD Members must have a referring NPI Number (Referring NPI

Number is the NPI Number of the facility where the Member resides, not the office or provider

NPI) in Box 35 of the ADA Claim Form. Any claim that does not include the referring NPI number

in Box 35 of the form will be denied.

4.03 Electronic Claim Submission Utilizing DentaQuest’s Internet Website

Participating Providers may submit claims directly to DentaQuest by utilizing the “Dentist”

section of our website. Submitting claims via the website is very quick and easy. It is

especially easy if you have already accessed the site to check a Member’s eligibility prior to

providing the service.

To submit claims via the website, simply log on to www.dentaquestgov.com

. Once you have

entered the website, click on the “Dentist” icon. From there choose ‘Virginia” and press go.

You will then be able to log in using your password and ID. First time users will have to

instruction on how to complete Provider Self Registration, contact Customer Service

Department at 888.912.3456. Once logged in, select “Claims/Pre-Authorizations” and then

“Dental Claim Entry“. The Dentist Portal allows you to attach electronic files (such as x-rays in

jpeg format, reports and charts) to the claim.

If you have questions on submitting claims or accessing the website, please contact our

ystems Operations via e-mail at: [email protected].

4.04 Electronic Authorization Submission Utilizing DentaQuest’s Website

Participating Providers may submit Pre-Authorizations directly to DentaQuest by utilizing the

“Dentist” section of our website. To submit pre-authorizations via the website, simply log on to

www.dentaquestgov.com. Once you have entered the website, click on the “Dentist” icon.

From there choose “Virginia” and press go. You will then be able to log in using your

password and ID. Once logged in, select “Claims/Pre-Authorizations” and then “Dental Pre-

Auth Entry“. The Dentist Portal also allows you to attach electronic files (such as x-rays in jpeg

format, reports and charts) to the pre-authorization.

4.05 E

lectronic Claim Submission via Clearinghouse

Participating Providers may submit Pre-Authorizations directly to DentaQuest by utilizing the

“Dentist” section of our website. To submit pre-authorizations via the website, simply log on to

www.dentaquestgov.com. Once you have entered the website, click on the “Dentist” icon.

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From there choose “Virginia” and press go. You will then be able to log in using your

password and ID. Once logged in, select “Claims/Pre-Authorizations” and then “Dental Pre-

Auth Entry“. The Dentist Portal also allows you to attach electronic files (such as x-rays in jpeg

format, reports and charts) to the pre-authorization.

DentaQuest works directly with Emdeon 1-888-255-7293, EDI Health Group (DentalXChange)

1-877-932-2567, Secure EDI (now InMediata ) 1-877-466-9656 and Claim Remedi 1-800-763-

8484, for claim submissions to DentaQuest.

You can contact your software vendor and make certain that they have DentaQuest listed as

the payer and claim mailing address on your electronic claim. Your software vendor will be

able to provide you with any information you may need to ensure that submitted claims are

forwarded to DentaQuest. Dentaquest’s Payor ID is CX014.

4.06 HIPAA Compliant 837D File

For Providers who are unable to submit electronically via the Internet or a clearinghouse,

DentaQuest will work directly with the Provider to receive their claims electronically via a

HIPAA compliant 837D or 837P file from the Provider’s practice management system. Please

email [email protected]

to inquire about this option for electronic claim

submission.

4.07 N

PI Requirements for Submission of Electronic Claims

In accordance with the HIPAA guidelines, DentaQuest has adopted the following NPI standards

in order to simplify the submission of claims from all of our providers, conform to industry

required standards and increase the accuracy and efficiency of claims administered by

DentaQuest.

• Providers must register for the appropriate NPI classification at the following website

https://nppes.cms.hhs.gov/NPPES/Welcome.do

and pr

ovide this information to DentaQuest in

its entirety.

• A

ll providers must register for an Individual (Type 1) NPI. You may also be required to register

for a group (Type 2) NPI (or as part of a group) dependant upon your designation.

• When submitting claims to DentaQuest you must submit all forms of NPI properly and in their

entirety for claims to be accepted and processed accurately. If you registered as part of a group,

your claims must be submitted with both the Group (Type 2) and Individual (Type 1) NPI’s.

These numbers are not interchangeable and could cause your claims to be returned to you as

non-compliant.

• If you are presently submitting claims to DentaQuest through a clearinghouse or through a direct

integration you need to review your integration to assure that it is in compliance with the revised

HIPAA compliant 837D format. This information can be found on the 837D Companion Gui

ocated on the Provider Web Portal.

4.08 Paper Claim Submission

• Claims must be submitted on ADA approved claim forms or other forms approved in advanc

DentaQuest.

• Member name, identification number, and date of birth must be listed on all claims submitted. If

the Member identification number is missing or miscoded on the claim form, the patient cannot

be identified. This could result in the claim being returned to the submitting Provider office,

causing a delay in payment.

• The paper claim must contain an acceptable provider signature.

• The Provider and office location information must be clearly identified on the claim. Frequently,

if only the dentist signature is used for identification, the dentist’s name cannot be clearly

identified. Please include either a typed dentist (practice) name or the DentaQuest Provider

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identification number.

• The paper claim form must contain a valid provider NPI (National Provider Identification)

number. In the event of not having this box on the claim form, the NPI must still be included

the form. The ADA claim form only supplies 2 fields to enter NPI. On paper claims, the Type 2

PI identifies the payee, and may be submitted in conjunction with a Type 1 NPI to identify the

dentist who provided the treatment. For example, on a standard ADA Dental Claim Form, the

treating dentist’s NPI is entered in field 54 and the billing entity’s NPI is entered in field 49.

• The date of service must be provided on the claim form for each service line submitted.

• Approved ADA dental codes as published in the current CDT book or as defined in this manual

must be used to define all services.

• List all quadrants, tooth numbers and surfaces for dental codes that necessitate identification

(extractions, root canals, amalgams and resin fillings). Missing tooth and surface identification

codes can result in the delay or denial of claim payment.

• Affix the proper postage when mailing bulk documentation. DentaQuest does not accept

postage due mail. This mail will be returned to the sender and will result in delay of payment.

Claims should be mailed to the following address:

DentaQuest, LLC-Claims

PO Box 2906

Milwaukee, WI 53201-2906

4.09 Coordination of Benefits (COB)

When DentaQuest is the secondary insurance carrier, a copy of the primary carrier's

Explanation of Benefits (EOB) must be submitted with the claim. For electronic claim

submissions, the payment made by the primary carrier must be indicated in the appropriate

COB field. When a primary carrier's payment meets or exceeds a provider's contracted rate or

fee schedule, DentaQuest will consider the claim paid in full and no further payment will be

made on the claim. The Provider may not bill the Member for any difference between

DentaQuest’s payment and the Provider’s billed amount, or request to share in the cost through

a co-payment or similar charge. Providers are expected to take reasonable measures to

ascertain any third party resource available to the Member and to file a claim with that party.

In accident cases where dental services are needed, the provider may either bill DentaQuest or

wait for a settlement from the responsible liable third party. However, all claims for dental

services in accident cases must be billed to DentaQuest within 6 months from the date of the

service. If the provider decides to wait for the settlement before billing DentaQuest and the wait

extends beyond 6 months from the date of the service, DentaQuest cannot reimburse the

provider if the time limit for filing a claim related to an accident case has expired.

4.10 Filing Limits

The timely filing requirement for the Cardinal Care Smiles program is 180 calendar days from

the date of service and receipt of claim. DentaQuest determines whether a claim has been filed

timely by comparing the date of service to the receipt date applied to the claim when the claim

is received. If the span between these two dates exceeds the time limitation, the claim is

considered to have not been filed timely.

Resubmissions: Adjustment Claims and Claims for Reconsideration of Payment

Adjustment claims or claims that are resubmitted for reconsideration of payment are handled

as follows:

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• If the original claim was processed and paid and an adjustment is requested, the

adj

ustment claim must be submitted and received within 12 months from the dat

he original claim was paid.

• I

f the original claim was processed and denied and a reconsideration of the

denied claim is requested, the denied claim must be resubmitted and received

ithin 12 months from the date the original claim was denied provided that t

claim was not initially denied for timely filing.

• “

Corrected Claim” must be noted in box 35 of the ADA claim form.

Timely Filing and Coordination of Benefits

When a member has other coverage, the timely filing limit begins with the date of payment or

denial from the primary carrier.

4.11 Claims Appeals

A provider may appeal any adverse decision DentaQuest has made to deny, reduce, terminate,

delay or suspend covered dental services. Provider may appeal in writing to DentaQuest within

30 days from the date of the denial. Upon completion of the DentaQuest appeal process,

providers may appeal to the Department of Medical Assistance Services (DMAS). The

Grievances and Appeals processes are outlined in Section 6.00.

4.12 Receipt and Audit of Claims

In order to ensure timely, accurate remittances to each Participating Cardinal Care Smiles

Provider, DentaQuest performs an audit of all claims upon receipt. This audit validates Member

eligibility, procedure codes and dentist identifying information. A DentaQuest Benefit Analyst

analyzes any claim conditions that would result in non-payment. When potential problems are

identified, your office may be contacted and asked to assist in resolving this problem. Please

contact our Customer Service Department at 888.912.3456 with any questions you may have

regarding claim submission or your remittance.

Each DentaQuest Participating Cardinal Care Smiles Provider office receives an “explanation

of benefit” report with their remittance. This report includes patient information and the allowable

fee for each service rendered.

4.13 Claim Submission and Payment for Operating Room (OR) Cases

Facility and anesthesia services for operating room cases require pre-authorization.

Authorization requirements are outlined in Section 3.02.

Claims related to the facility and anesthesia services rendered in a non-dental setting will be

handled as follows:

A. Managed Care Organization (MCO) Members

1. If the dental provider performs the anesthesia services in a non-dental setting, all

dental and anesthesia services should be submitted to and are paid by

DentaQuest. In such cases, facility charges should be submitted directly to t

CO.

2. If the dental provider does not perform the anesthesia services for dental

services provided in a non-dental setting, the dental services should

ubmitted to and are paid by DentaQuest. In such cases, both facility

and

anes

thesia charges should be billed directly to the MCO and within the MCO

provider network.

B. Fee For Service (FFS) Members

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1. For Medicaid/FAMIS Plus and FAMIS eligible individuals who are not enrolled in

an M

CO on the date of service (served by the FFS program), facility, anesthesia

and any required medical providers must participate in the FFS Medicaid

program. If the dental provider performs the anesthesia services in a non-dental

setting, all dental and anesthesia services should be submitted to and are paid

by DentaQuest. In such cases, facility charges should be submitted directly to

DMAS.

2. If the dental provider does not perform the anesthesia services for dental services

provided in a non-dental setting, the dental services should be submitted to and

are paid by DentaQuest. In such cases, both facility and anesthesia charges

should be billed directly to DMAS and within the DMAS provider network.

4.14 Direct Deposit and Electronic Remittance Statements

As a benefit to participating Providers, DentaQuest offers Direct Deposit for claims payments. This

process improves payment turnaround times as funds are directly deposited into the Provider’s banking

account.

To receive claims payments through the Direct Deposit Program, Providers must:

• Complete and sign the Direct Deposit Authorization Form found on the website

• Attach a voided check to the form. The authorization cannot be processed without a voided

check.

• Return the Direct Deposit Authorization Form and voided check to DentaQuest.

ia Fax – 262.241.4077

Via Mail –

DentaQuest, LLC

Attn: Provider Enrollment & Credentialing

PO Box 2906

Milwaukee, WI 53201-2906

The Direct Deposit Authorization Form must be legible to prevent delays in processing. Providers should

allow up to six weeks after the receipt of completed paperwork for the Direct Deposit Program to be

implemented. Providers will receive a bank note one check cycle prior to the first Direct Deposit payment.

Providers enrolled in the Direct Deposit Program must notify DentaQuest of any changes to bank

accounts such as: changes in routing or account numbers, a switch to a different bank or any other

relevant information. All changes must be submitted via the Direct Deposit Authorization Form (which

can be found on the website). Providers should allow 2-3 weeks’ notice to implement new banking

information. DentaQuest cannot be held responsible for delays in funding if Providers do not

notify DentaQuest in writing of any banking changes.

As a condition of acceptance of the Direct Deposit Program, Providers are also required to access their

remittance statements online and will no longer receive paper remittance statements. Electronic

remittance statements are located on DentaQuest’s Provider Web Portal (PWP). Providers may access

their remittance statements by following these steps:

1. Go to www.dentaquestgov.com

2. Once you have entered the website, click on the “Dentist” icon. From there choose your

‘State” and press go.

3. Log in using your password and ID.

4. Once logged in, select “Claims/Pre-Authorizations” and then “Remittance Advice Search“.

5. The remittance will display on the screen

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5.00 Health Insurance Portability and Accountability Act (HIPAA)

As a healthcare provider, your office is required to comply with all aspects of the HIPAA regulations in

effect as indicated in the final publications of the various rules covered by HIPAA.

DentaQuest has implemented various operational policies and procedures to ensure that it is compliant

with the Privacy, Administrative Simplification and Security Standards of HIIPAA. One aspect of our

compliance plan is working cooperatively with our providers to comply with the HIPAA regulations. In

relation to the Privacy Standards, DentaQuest has previously modified its provider contracts to reflect

the appropriate HIPAA compliance language. These contractual updates include the following in regard

to record handling and HIPAA requirements:

• Maintenance of adequate dental/medical, financial and administrative records related to covered dental

services rendered by Provider in accordance with federal and state law.

• Safeguarding of all information about Members according to applicable state and federal laws and

regulations. All material and information, in particular information relating to Members or potential

Members, which is provided to or obtained by or through a Provider, whether verbal, written, tape, or

otherwise, shall be reported as confidential information to the extent confidential treatment is provi

ded

under state and feral laws.

• Neither DentaQuest nor Provider shall share confidential information with a Member’s employer absent

the Member’s consent for such disclosure.

• Provider agrees to comply with the requirements of the Health Insurance Portability and Accountability

Act (“HIPAA”) relating to the exchange of information and shall cooperate with DentaQuest in its efforts

to ensure compliance with the privacy regulations promulgated under HIPAA and other related privacy

laws.

Provider and DentaQuest agree to conduct their respective activities in accordance with the

applicable provisions of HIPAA and such implementing regulations.

In relation to the Administrative Simplification Standards, you will note that the benefit tables included

in this ORM reflect the most current coding standards (CDT-2007-2008) recognized by the ADA.

Effective the date of this manual, DentaQuest will require providers to submit all claims with the

proper CDT-2007-2008 codes listed in this manual. In addition, all paper claims must be submitted

on the current approved ADA claim form.

Note: Copies of DentaQuest’s HIPAA policies are available upon request by contacting DentaQuest’s

Customer Service department at 888.912.3456 or via e-mail at [email protected]

5.01 HIPAA Companion Guide

To view a copy of the most recent Companion Guide please visit our website at

www.dentaquestgov.com. Once you have entered the website, click on the “Dentist” icon. From there

choose ‘Virginia” and press go. You will then be able to log in using your password and ID. Once you

have logged in, click on the link named “Related Documents’ (located under the picture on the right hand

side of the screen).

6.00 G

rievances and Appeals

6.01 Provider Grievances and Appeals

Participating Cardinal Care Smiles Providers that disagree with determinations made by the

DentaQuest directors may submit a written Notice of Appeal to DentaQuest that specifies the

nature and rationale of the disagreement. Please complete the Provider Appeals Form, which

can be found on the website and follow the instructions on the form. This notice and additional

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support information must be sent to DentaQuest at the address below within 30 days from the

date of the original determination to be reconsidered by DentaQuest’s Virginia Peer Review

Committee.

DentaQuest, LLC

Attention: Utilization Management/Provider Appeals

PO Box 2906

Milwaukee, WI 53201-2906

Certified and overnight requests can be sent to the following address:

DentaQuest, LLC

Attention: Utilization Management/Provider Appeals

11100 W Liberty Dr.

Milwaukee, WI 53224

All notices received shall be submitted to DentaQuest’s Virginia Peer Review Committee for

review and reconsideration. The Committee will respond in writing with its decision to the

Provider. Upon completion of the DentaQuest appeal process the Participating provider may

appeal to the Department of Medical Assistance Services (DMAS). The appeal must be in

writing and sent to DMAS within 30 days from the final appeal decision letter from DentaQuest.

Appeals to DMAS must be sent to the following address:

Director

Appeals Division

Department of Medical Assistance Services

600 East Broad Street

Suite 1300

Richmond, VA 23219

6.02 Member Grievances and Appeals

Complaints (Grievances)

Members may submit complaints to DentaQuest telephonically or in writing on any Cardinal

Care Smiles program issue other than decisions that deny, delay, reduce, or terminate dental

services. Some examples of complaints include: the quality of care or services received, access

to dental care services, provider care and treatment, or administrative issues. Member

complaints should be directed to:

DentaQuest, LLC

Cardinal Care Smiles

Attention: Complaints and Appeals

PO Box 2906

Milwaukee, WI 53201-2906

1-888-912-3456

DentaQuest will respond to member complaints immediately if possible but within no more than

30 working days from the date the complaint (grievance) is received.

Member Appeals

Members have the right to appeal any adverse decision DentaQuest has made to deny, reduce,

delay or terminate dental services. Members may request assistance with filing an appeal by

contacting DentaQuest at 1-888-912-3456. Members may send appeal requests to DentaQuest

at the address listed above within 30 days receipt of the adverse decision notice. DentaQuest

will respond in writing to member appeals within 30 days of the date of receipt, or within 3 days

if the condition needs immediate attention.

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State of Virginia Fair Hearing Process

Members also have the right to appeal directly to DMAS at the same time, after, or instead of

appealing to DentaQuest. Appeal requests to DMAS must be sent in writing and must be sent

within 30 days receipt of DentaQuest’s adverse decision to:

ppeals Division

Department of Medical Assistance Services

600 E. Broad Street

Richmond, Virginia 23219

(804) 371-8488

Appeal/review requests may also be faxed to:

(804) 452-5454

Note: Copies of DentaQuest policies and procedures can be requested by contacting

Customer Service at 888.912.3456.

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7.00 Utilization Management Program

7.01 Introduction

Under the provisions of federal regulations, the Cardinal Care Smiles Program must provide

for continuing review and evaluation of the care and services paid through Medicaid and FAMIS,

including review of utilization of the services by providers and by recipients. These reviews are

mandated by Title 42 Code of Federal Regulations, Parts 455 and 456. Cardinal Care Smiles

conducts periodic utilization reviews on all providers. In addition, Cardinal Care Smiles

conducts compliance reviews on providers that are found to provide services in excess of

established norms, or by referrals and complaints from agencies or individuals. Participating

providers are responsible for ensuring that requirements for services rendered are met in order

to receive payment from DentaQuest. Under the Cardinal Care Smiles Participation

Agreement the provider also agrees to give access to records and facilities to Cardinal Care

Smiles program representatives upon reasonable request. This section provides information

on utilization review and control requirement procedures conducted by Cardinal Care Smiles

program personnel.

7.02 Community Practice Patterns

In following with the requirements described in Section 7.01 above, DentaQuest has developed

a philosophy of Utilization Management that recognizes the fact that there exists, as in all

healthcare services, a relationship between the dentist’s treatment planning, treatment costs

and treatment outcomes. The dynamics of these relationships, in any region, are reflected by

the “community practice patterns” of local dentists and their peers. With this in mind,

DentaQuest’s Utilization Management Programs are designed to ensure the fair and

appropriate use of Federal and State program dollars as defined by the regionally based

community practice patterns of local dentists and their peers.

All utilization management analysis, evaluations and outcomes are related to these patterns.

DentaQuest’s Utilization Management Programs recognize that there exists a normal individual

dentist variance within these patterns among a community of dentists and accounts for such

variance. Also, specialty dentists are evaluated as a separate group and not with general

dentists since the types and nature of treatment may differ.

DentaQuest will monitor the quality of services delivered under the Provider Agreement and

initiate corrective action where necessary to improve quality of care, in accordance with that

level of dental care which is recognized as acceptable professional practice in the respective

community in which the Provider practices and/or the standards established by DMAS for the

Cardinal Care Smiles program.

7.03 Evaluation

DentaQuest’s Utilization Management Programs evaluate claims submissions in such areas as:

• Diagnostic and preventive treatment;

• Patient treatment planning and sequencing;

• Types of treatment;

• Treatment outcomes; and

• Treatment cost effectiveness.

7.04 Results

With the objective of ensuring the fair and appropriate distribution of these “budgeted” Medicaid

Assistance Dental Program dollars to dentists, DentaQuest’s Utilization Management Programs

will help identify those dentists whose patterns show significant deviation from the normal

practice patterns of the community of their peer dentists (typically less than 5% of all dentists).

When presented with such information, dentists may be asked to implement slight modification

DentaQuest LLC July 1, 2024

of their diagnosis and treatment processes that bring their practices back within the normal

range. However, in some isolated instances, it may be necessary to recover reimbursement.

Providers will be required to refund payments if they are found to have billed contrary to law,

regulation, or DMAS/DentaQuest policy or failed to maintain adequate documentation to

support their claims. DentaQuest reserves the right to utilize extrapolation methodology in the

determination of the amount(s) Providers are required to refund. Providers have the right to

appeal these review findings in accordance with the procedures described in Section 14.(b) of

the Cardinal Care Smiles provider agreement.

7.05 Fraud and Abuse (Policies 700 Series)

DentaQuest is committed to detecting, reporting and preventing potential fraud, waste and

abuse. Fraud, waste and abuse for the Cardinal Care Smiles are defined as:

Fraud: In insurance fraud, “fraud” is the intentional submission of a “document or statement”

that contains a material misrepresentation made by an individual/entity knowing that the

document/statement contains false or misleading information for the purpose of receiving

benefits to which they would not have otherwise been entitled.

Waste: Is defined as a loss through carelessness, inefficiency, or ignorance.

Abuse: Is considered an action that is not consistent with generally accepted standards and

practices related to that industry.

Member Abuse: Intentional infliction of physical harm, injury caused by negligent acts or

omissions, unreasonable confinement, sexual abuse or sexual assault.

Provider Fraud: Provider practices that are inconsistent with sound fiscal, business or

medical practices, and result in unnecessary cost to the program, or in reimbursement for

services that are not medically necessary or that fail to meet professionally recognized

standards for health care may be referred to the appropriate state regulatory agency.

Suspected fraudulent behavior should be reported to DentaQuest.

Member Fraud: If a Provider suspects a member of ID fraud, drug-seeking behavior, or any

other fraudulent behavior should be reported to DentaQuest.

It is the responsibility of everyone to report suspected Fraud, Waste and Abuse. The

avenues for reporting are:

• DentaQuest Fraud Hotline - 800.237.9139

• http://www.dentaquest.com/report-fraud/

8.00 Quality Improvement Program (Policies 200 Series)

DentaQuest currently administers a Quality Improvement Program. The Quality Improvement Program

includes but is not limited to:

• Provider credentialing and recredentialing

• Member satisfaction surveys

• Provider satisfaction surveys

• Random Chart Audits

• Member Grievance Monitoring and Trending

• Peer Review Process

• Utilization Management and practice patterns

• Quarterly Quality Indicator tracking (i.e. member complaint rate, appointment waiting

ime, access to care, etc.)

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A copy of DentaQuest’s QI Program, is available upon request by contacting DentaQuest’s Customer

Service department at 888.912.3456 or via e-mail at:

[email protected]

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9.00 Credentialing (Policies - 300 Series

DentaQuest in conjunction with DMAS has the sole right to determine which dentists (DDS or DMD) it

shall accept and continue as Participating Providers. The purpose of the credentialing plan is to provide

a general guide for the acceptance, discipline and termination of Participating Providers. DentaQuest

considers each Provider’s potential contribution to the objective of providing effective and efficient dental

services to Cardinal Care Smiles Members.

Upon receipt from a potential new provider of a signed Agreement and application for participation in the

Cardinal Care Smiles program, DentaQuest will verify the following credentialing criteria:

• National Provider Identifier number

• Current licensure status

• History of State licensing sanctions or reprimands

• Medicare/Medicaid sanction history

• Malpractice claims history

Following successful verification, the Provider will be enrolled as a Participating Provider in the Cardinal

Care Smiles program.

Nothing in this Credentialing Plan limits DentaQuest’s sole discretion to accept and discipline

Participating Providers. No portion of this Credentialing Plan limits DentaQuest’s right to permit restricted

participation by a dental office or DentaQuest’s ability to terminate a Provider’s participation in

accordance with the Participating Provider’s written agreement, instead of this Credentialing Plan.

DMAS has the final decision-making power regarding network participation. DentaQuest will notify

DMAS of all disciplinary actions enacted upon Participating Providers.

ATTENTION ORAL SURGEONS:

Oral surgeons who currently submit, or wish to submit medical claims for Fee For Service Medicaid

Members using CPT codes on a HCFA 1500 form to DMAS, must be enrolled with DMAS as a medical

provider.

Oral surgeons submitting medical claims for Fee For Service Medicaid Members to DMAS, and dental

claims to DentaQuest, must be enrolled in both DMAS and DentaQuest.

Please address questions regarding contracting with DMAS for medical claims reimbursement, to the

DMAS Enrollment Provider Unit (PEU) at 1.888.829.5373, or visit the DMAS web site at:

http://www.dmas.virginia.gov.

Appeal of Credentialing Committee Recommendations. (Policy 300.017)

If the Credentialing Committee recommends acceptance with restrictions or the denial of an application,

the Committee will offer the applicant an opportunity to appeal the recommendation.

The applicant must request a reconsideration/appeal in writing and the request must be received by

DentaQuest within 30 days of the date the Committee gave notice of its decision to the applicant.

Discipline of Providers (Policy 300.019)

Procedures for Discipline and Termination (Policies 300.017-300.021)

Recredentialing (Policy 300.016)

Network providers are recredentialed at least every 36 months as required by DMAS.

Note: The aforementioned policies are available upon request by contacting DentaQuest’s Customer

Service at 888.912.3456 or via e-mail at: [email protected]

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9.01 Reporting Requirements for Exclusion from Federal Programs

Providers and subcontractors who are performing services under the DMAS Agreement

(“Subcontractors”) are required to report excluded from participation in Federal health care

programs.

Providers and Subcontractors can screen managing employees through the Federal Health and

Human Services – Office of Inspector General (HHS-OIG) online exclusions database, available

at http://exclusions.oig.hhs.gov/

, updating DentaQuest, minimally, on a monthly basis. The

HHS-OIG website shall be checked on a monthly basis to determine whether any of them have

been excluded from participating in Federal health care programs.

Providers and Subcontractors are advised to immediately report any exclusion information

scovered. DentaQuest also require that Subcontractor(s) it has contracted Network

Development out to shall have written policies and procedures outlining provider enrollment

and/or credentialing process

10.00 The Patient Record

A. Organization

1. The record must have areas for documentation of the following information:

a. Registration data including a complete health history

b. Medical alert predominantly displayed inside chart jacket

c. Initial examination data

d. Radiographs

e. Periodontal and Occlusion status

f. Treatment plan/Alternative treatment plan

g. Progress notes to include diagnosis, preventive services, treatment rendered, and

medical/dental consultations

h. Miscellaneous items (correspondence, referrals, and clinical laboratory reports)

2. The design of the record must provide the capability or periodic update, without the

loss of documentation of the previous status, of the following information.

a. Health history

b. Medical alert

c. Examination/Recall data

d. Periodontal status

e. Treatment plan

3. The design of the record must ensure that all permanent components of the record ar

tached or secured within the record.

4. The design of the record must ensure that all components must be readily identified to

the patient, i.e., patient name, and identification number on each page.

5. The organization of the record system must require that individual records be assigned

to each patient.

B. Content-The patient record must contain the following:

1. Adequate documentation of registration information which requires entry of these

items:

a. Patient’s first and last name

b. Date of birth

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c. Sex

d. Address

e. Telephone number

f. Name and telephone number of the person to contact in case of emergency

2. An adequate health history that requires documentation of these items:

a. Current medical treatment

b. Significant past illnesses

c. Current medications

d. Drug allergies

e. Hematologic disorders

f. Cardiovascular disorders

g. Respiratory disorders

h. Endocrine disorders

i. Communicable diseases

j. Neurologic disorders

k. Signature and date by patient

l. Signature and date by reviewing dentist

m. History of alcohol and/or tobacco usage including smokeless tobacco

3. An adequate update of health history at subsequent recall examinations which requires

documentation of these items:

a. Significant changes in health status

b. Current medical treatment

c. Current medications

d. Dental problems/concerns

e. Signature and date by reviewing dentist

4. A conspicuously placed medical alert inside chart jacket that documents highly

significant terms from health history. These items are:

a. Health problems which contraindicate certain types of dental treatment

b. Health problems that require precautions or pre-medication prior to dental

treatment

c. Current medications that may contraindicate the use of certain types of drugs

or dental treatment

d. Drug sensitivities

e. Infectious diseases that may endanger personnel or other patients

5. Adequate documentation of the initial clinical examination which is dated and requires

descriptions of findings in these items:

a. Blood pressure. (Recommended)

b. Head/neck examination

c. Soft tissue examination

d. Periodontal assessment

e. Occlusion classification

f. Dentition charting

6. Adequate documentation of the patient’s status at subsequent Periodic/Recall

examinations which is dated and requires descriptions of changes/new findings in

these items:

a. Blood pressure (Recommended)

b. Head/neck examination

c. Soft tissue examination

d. Periodontal assessment

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e. Dentition charting

7. Radiographs which are:

a. Identified by patient name

b. Dated

c. Designated by patient’s left and right side

d. Mounted (if intraoral films)

8. An indication of the patient’s clinical problems/diagnosis

9. Adequate documentation of the treatment plan (including any alternate treatment

options) that specifically describes all the services planned for the patient by entry of

these items:

a. Procedure

b. Localization (area of mouth, tooth number, surface)

10. An adequate documentation of the periodontal status, if necessary, which is dated and

requires charting of the location and severity of these items:

a. Periodontal pocket depth

b. Furcation involvement

c. Mobility

d. Recession

e. Adequacy of attached gingiva

f. Missing teeth

11. An adequate documentation of the patient’s oral hygiene status and preventive efforts

which requires entry of these items:

a. Gingival status

b. Amount of plaque

c. Amount of calculus

d. Education provided to the patient

e. Patient receptiveness/compliance

f. Recall interval

g. Date

12. An adequate documentation of medical and dental consultations within and outside the

practice which requires entry of these items:

a. Provider to whom consultation is directed

b. Information/services requested

c. Consultant’s response

13. Adequate documentation of treatment rendered which requires entry of these items:

a. Date of service/procedure

b. Description of service, procedure and observation

c. Type and dosage of anesthetics and medications given or prescribed

d. Localization of procedure/observation, (tooth #, quadrant etc.)

e. Signature of the provider who rendered the service

14. Adequate documentation of the specialty care performed by another dentist that

includes:

a. Patient examination

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b. Treatment plan

c. Treatment status

C. Compliance

1. The patient record has one explicitly defined format that is currently in use

2. There is consistent use of each component of the patient record by all staff

3. The components of the record that are required for complete documentation of each

patient’s status and care are present

4. Entries in the records are legible

5. Entries of symbols and abbreviations in the records are uniform, easily interpreted and

are commonly understood in the practice

D. Electronic Signatures

An electronic signature may be used for clinical documentation, and will be as effective as a

paper signature, as provided by applicable law and this ORM. An “electronic signature” is an

electronic sound, symbol, or process, attached to or logically associated with the clinical record,

and executed or adopted by a person with the intent to sign the record. See 15 U.S.C. § 7001

et seq.; Va. Code § 59.1-479 et seq.

Providers using electronic signatures shall maintain written policies and procedures regarding

the use of electronic signatures. Such policies shall include a policy that individuals shall not log

into another individual’s account for accessing clinical records, use another individual’s user

name when accessing clinical records, or share passwords associated with logging into clinical

records. Such procedures shall include procedures designed to prevent the unauthorized use

of logon information for clinical records and the unauthorized use of electronic signatures.

If a Provider uses electronic signatures, it is the Provider’s responsibility to ensure that

electronic signatures are created only by the individual whose name is associated with that

electronic signature

11.00 Patient Recall System

A. Recall System Recommendation

Each participating DentaQuest Provider office may maintain and document, a formal system for

patient recall. The system can utilize either written or phone contact. Any system should

encompass routine patient check-ups, cleaning appointments, follow-up treatment

appointments, and missed appointments for any Cardinal Care Smiles Member that has

sought dental treatment.

If a written process is utilized, the following or similar language is s

uggested for missed

appointments:

• “

We missed you when you did not come for your dental appointment on

month/date. Regular check-ups are needed to keep your teeth healthy.”

• “Please call to reschedule another appointment. Call us ahead of time if you cannot

keep the appointment. Missed appointments are very costly to us. Thank you for

your help.”

Dental offices indicate that patients sometimes fail to show up for appointments. DentaQuest

fers the following suggestions to decrease the “no show” rate.

• Contact the Member by phone or postcard prior to the appointment to remind the

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individual of the time and place of the appointment.

B. DentaQuest Appointment Assistance

DentaQuest’s Customer Service Department uses technology to link Cardinal Care Smiles

Members to the closest and most appropriate dental provider. On occasion, Members requir

special assistance making appointments due to geographic or special physical needs.

DentaQuest’s Customer Service department includes Member Placement Specialists,

responsible for locating providers for Members in emergency or difficult situations. These

Member Placement Specialists will assist Members with making appointments wit

h a

articipating Provider. DentaQuest will also place reminder phone calls prior to the

appointment, to any Member for which DentaQuest’s Member Placement Specialist has

assisted in scheduling the appointment.

C. Non-Compliant Members

DentaQuest will proactively educate Members on the importance of keeping appointments

through various outreach and educational materials, including member newsletters, member

handbook, and outreach. DentaQuest will contact and educate Cardinal Care Smiles Members

who have been identified by providers as non-compliant.

Providers and dental offices are not allowed to charge members for missed appointments.

D. Office Compliance Verification Procedures

• Participating Cardinal Care Smiles Dentists are expected to meet minimum

standards with regards to appointment availability. The standards are:

• Emergency care – As quickly as the situation warrants

• Urgent care – Within 48 hours

• Routine care – Not to exceed 6 week

12.00 Member Communication

A. Effective Communication

DentaQuest expects that participating Cardinal Care Smiles dentists will provide contracted services

without discrimination to Medicaid enrollees with special needs. This includes providing or arranging

for communication assistance, such as interpreter services, for persons with communication and

language barriers.

B. Reimbursement for Professional Interpreter Services

Title XIX of the Social Security Act requires Medicaid providers to provide nondiscriminatory services

to its clients including those with limited English proficiency. In order to help providers with this

requirement, DMAS has implemented a provision for reimbursement of interpreter services under the

CCS program when there is a need and it relates to the treatment. DMAS maintains an Interpreter

Resource list located at https://www.dmas.virginia.gov/for-providers/dental/for-dentists

. To

access the resource list, select Cardinal Care Smiles Provider Information and go to Interpreter

Service Information. Select the resource list. If you do not have an interpreter resource, you may select

one from the Interpreter Resource List.

D9990 (Certified translation or sign-l

anguage services – per visit) can only be used for the provision of

interpreter services.

In order for the CCS dentist to be reimbursed for interpreter services performed at the dental office

using D9990, the provider must submit the following with the ADA claim for pre-payment review:

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• CCS Professional Interpreter Service Form documenting the services provided by and paid to an

interpreter that is proficient in the specific language and that holds a Virginia business license

allowing a fee for their service.

• A copy of the paid invoice/receipt to DentaQuest to include the following information:

o Date and Time of Interpreter service (including beginning and ending time).

o Patient Name and Medicaid ID number

o Interpreter name, address, telephone number, language used, duration of service

and

interpreter’s charge for the service.

o If the interpreter is not listed on the DMAS Interpreter Resource list, the provider must attach

a copy of the professional interpreter's business license with the invoice.

o The patient’s chart must document that the patient needed and received interpreter services

on a specific date. If ongoing interpreter services are required, the provider must incl

ude an

annual assessment and attestation in the patient’s chart confirming need. Payment for that

service acknowledges DentaQuest’s ability to audit the use of the service at any time.

To be eligible for reimbursement, services must be rendered in conjunction with an eligible CCS dental

service and the ADA claim for these services must be reflected in DentaQuest’s claim system.

Charges incurred for a missed or broken appointment are not eligible for reimbursement. The CCS

Professional Interpreter Invoice Form must be completed and submitted to DentaQuest within 180

days from the date the interpreter service is utilized.

Mail the CCS Professional Interpreter Service Invoice Form (which can be found on the DMAS and

DentaQuest websites) along with the above documentation to:

DentaQuest - Cardinal Care Smiles

PO Box 2906

Milwaukee, WI 53201-2906

Fax: 262-834-3589

Provider reimbursement will be processed by DentaQuest within 30 days of receipt. Go to

https://www.dmas.virginia.gov/for-providers/dental/for-dentists/

elect Cardinal Care Smiles Provider

Information and go to Interpreter Service Information for additional guidance.

13.00 R

adiology Requirements

Note: Please refer to benefit tables for radiograph benefit limitations

DentaQuest utilizes the guidelines published by the Department of Health and Human Services, Center

for Devices and Radiological Health Panel (the Panel). These guidelines were developed in conjunction

with the Food and Drug Administration.

A. Radiographic Examination of the New Patient

1. Child – Primary Dentition

The Panel recommends Posterior Bitewing radiographs for a new patient, with

a primary dentition and closed proximal contacts.

2. Child – Transitional Dentition

The Panel recommends an individualized Periapical/Occlusal examination

with Posterior Bitewings OR a Panoramic Radiograph and Posterior

Bitewings, for a new patient with a transitional dentition.

3. Adolescent – Permanent Dentition Prior to the eruption of the third molars

The Panel recommends an individualized radiographic examination consisting

of selected Periapicals with posterior Bitewings for a new adolescent patient.

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4. Adult – Dentulous

The Panel recommends an individualized radiographic examination consisting

of selected Periapicals with posterior Bitewings for a new dentulous adult

patient.

5. Adult – Edentulous

The Panel recommends a Full-Mouth Intraoral Radiographic Survey OR a

Panoramic Radiograph for the new edentulous adult patient.

B. Radiographic Examination of the Recall Patient

1. Patients with clinical caries or other high – risk factors for caries

a. Child – Primary and Transitional Dentition

The Panel recommends that Posterior Bitewings be performed at

6-12

month interval for those children with clinical caries or who ar

increased risk for the development of caries in either the primary

or transitional dentition.

b. Adolescent

The Panel recommends that Posterior Bitewings be performed at

6-12 m

onth interval for adolescents with clinical caries or who are at

increased risk for the development of caries.

c. Adult – Dentulous

The Panel recommends that Posterior Bitewings be performed at

6-12

month interval for adults with clinical caries or who are at

increased risk for the development of caries.

d. Adult – Edentulous

The Panel found that an examination for occult disease in this group

cannot be justified on the basis of prevalence, morbidity, mortality,

radiation dose and cost. Therefore, the Panel recommends that no

radiographs be performed for edentulous recall patients without

clinical signs or symptoms.

2. Patients with no clinical caries and no other high risk factors for caries

a. Child – Primary Dentition

The Panel recommends that Posterior Bitewings be performed at an

interval of 12-24 months for children with a primary dentition with

closed posterior contacts that show no clinical caries and are not at

increased risk for the development of caries.

b. Adolescent

The Panel recommends that Posterior Bitewings be performed at

intervals of 12-24 months for patients with a transitional dentition

who show no clinical caries and are not at an increased risk for the

development of caries.

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c. Adult – Dentulous

The Panel recommends that Posterior Bitewings be performed at

intervals of 24-36 months for dentulous adult patients who show no

clinical caries and are not at an increased risk for the development

of caries.

3. Patients with periodontal disease, or a history of periodontal treatment for

Child – Primary and Transitional Dentition, Adolescent and Dentulous Adult

The Panel recommends an individualized radiographic survey consisted of

selected Periapicals and/or Bitewing radiographs of areas with clinical

evidence or a history of periodontal disease, (except nonspecific gingivitis).

4. Growth and Development Assessment

a. Child – Primary Dentition

The panel recommends that prior to the eruption of the first

permanent tooth, no radiographs be performed to assess growth and

development at recall visits in the absence of clinical signs or

symptoms.

b. Child – Transitional Dentition

The Panel recommended an individualized Periapical/Occlusal

series OR a Panoramic Radiograph to assess growth and

development at the first recall visit for a child after the eruption of t

first permanent tooth.

c. Adolescent

The Panel recommended that for the adolescent (age 16-19 years

of age) recall patient, a single set of Periapicals of the wisdom teeth

OR a Panoramic Radiograph.

d. Adult

The Panel recommends that no radiographs be performed

adul

ts to assess growth and development in the absence of clinical

signs or symptoms.

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14.00 Health Guidelines – Ages 0-18 Years

NOTE: Please refer to benefit tables for benefits and limitations

Recommendations for Preventive Pediatric Dental Care (AAPD Reference Manual 2007)

Periodicity and Anticipatory Guidance Recommendations

PERIODICITY RECOMMENDATIONS

Age

Infancy

6 – 12

`Months

Late

Infancy

12 – 24

Months

Preschool

2 – 6 Years

School Aged

6 – 12 Years

Adolescence

12 – 18 Years

Clinical oral exam (1,2)

Assess oral growth and

development (3)

X X X X X

Caries-risk assessment (4)

Radiographic assessment

(5)

X X X X X

Prophylaxis and topical fluoride

treatment (4,5)

X X X X X

Fluoride Supplementation (6,7)

Anticipatory

guidance/counseling (8)

X X X X X

Oral Hygiene Counseling (9) Parents/

guardians/

caregivers

Parents/

guardians/

caregivers

Patient/parents/

guardians/

caregivers

Patient/parents/

caregivers

Patient

Dietary Counseling (10)

Injury, Prevention Counseling

(11)

X X X X X

Counseling for non-nutritive

habits (12)

X X X X X

Counseling for

speech/language development

X X X X X

Substance abuse counseling

Blank

Counseling for

intraoral/perioral piercing

Blank Blank Blank Blank X

Assessment and treatment of

developing malocclusion

Blank Blank X X X

Assessment for pit and fissure

sealants (13)

Blank Blank X X X

Assessment and/or removal of

third molars

Blank Blank Blank Blank X

Transition to adult dental care

Blank

1. First examination at the eruption of the first tooth and no later than 12 months. Repeat every 6 months or as indicated by

child’s risk status/susceptibility to disease.

2. Includes assessment of pathology and injuries.

3. By clinical examination.

4. Must be repeated regularly and frequently to maximize effectiveness.

5. Timing, selection, and frequency determined by child’s history, clinical findings, and susceptibility to oral disease.

6. Consider when systemic fluoride exposure is suboptimal.

7. Up to at least 16 years.

8. Appropriate discussion and counseling should be an integral part of each visit for care.

9. Initially, responsibility of parent: as child develops, jointly with parent; then, when indicated, only child.

10. At every appointment; initially discuss appropriate feeding practices, then the role of refined carbohydrates and frequency of

snacking in caries development and childhood obesity.

11. Initially play objects, pacifiers, car seats; then when learning to walk, sports and routine playing, including the importance of

mouthguards.

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PERIODICITY RECOMMENDATIONS

Age

Infancy

6 – 12

`Months

Late

Infancy

12 – 24

Months

Preschool

2 – 6 Years

School Aged

6 – 12 Years

Adolescence

12 – 18 Years

12. At first, discuss the need for additional sucking: digits vs pacifiers; then the need to wean from the habit before malocclusion

or skeletal dysplasia occurs. For school-aged children and adolescent patients, counsel regarding any existing habits such

s fingernail biting, clenching, or bruxism.

13. For caries-susceptible primary molars, permanent molars, premolars, and anterior teeth with deep pits and fissures; placed

as soon as possible after eruption.

15.00 Clinical Criteria

The criteria outlined in DentaQuest’s Provider Office Reference Manual are based around procedure

odes as defined in the American Dental Association’s Code Manuals. Documentation requests for

information regarding treatment using these codes are determined by generally accepted dental

standards for authorization, such as radiographs, periodontal charting, treatment plans, or descriptive

narratives. In some instances, the State legislature will define the requirements for dental procedures.

These criteria were formulated from information gathered from practicing dentists, dental schools, ADA

inical articles and guidelines, insurance companies, as well as other dental related organizations.

These criteria and policies must meet and satisfy specific DMAS requirements as well. They are

designed as guidelines for authorization and payment decisions and are not intended to be all-inclusive

or absolute. Additional narrative information is appreciated when there may be a special situation.

These clinical criteria will be used for making medical necessity determinations for prior authorizations,

post payment review and retrospective review. Failure to submit the required documentation may

result in a disallowed request and/or a denied payment of a claim related to that request. Some

services require prior authorization and some services require pre-payment review, this is detailed in

the Benefits Covered Section(s) in the “Review Required” column.

For all procedures, every Provider in the DentaQuest program is subject to random chart audits.

Providers are required to comply with any request for records. These audits may occur in the

Provider’s office as well as in the office of DentaQuest. The Provider will be notified in writing of the

results and findings of the audit.

DentaQuest providers are required to maintain comprehensive treatment records that meet

professional standards for risk management. Please refer to the “Patient Record” section for additional

detail.

Documentation in the treatment record must justify the need for the procedure performed due to

medical necessity, for all procedures rendered. Appropriate diagnostic pre‐operative radiographs

clearly showing the adjacent and opposing teeth and substantiating any pathology or caries present

are required. Post-operative radiographs are required for endodontic procedures and permanent crown

placement to confirm quality of care. In the event that radiographs are not available or cannot be

obtained, diagnostic quality intraoral photographs must substantiate the need for procedures rendered.

• Prosthetic appliances, whether removable or fixed, cannot be billed until completion/final delivery date.

This completion date is when the member leaves with the crown, bridge, denture, or partial in the mouth

and it is functioning properly. The completion date for immediate dentures and immediate partials is the

date that the remaining teeth are removed and the partial or denture is inserted. When the remaining

teeth are removed by an oral surgeon or dentist other than the dentist who fabricated the appliance, the

completion date for billing purposes is the date after all necessary extractions are done. The dentist

fabricating the appliance cannot bill in front of the dentist removing the teeth. Immediate appliances

require the extraction dental codes to be submitted first, which allows the billing process to recogniz

and

allow payment for the immediate prosthesis.

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The completion date for fixed appliances, such as bridges, crowns, onlays, and inlays is the cementation

date for the final cement being used. Fixed prosthetics that are cemented in a temporary way for further

evaluation is not considered a final cementation.

The completion date for endodontic treatment is the date all the canals are permanently filled.

Failure to provide the required documentation, adverse audit findings, or the failure to maintain

acceptable practice standards may result in sanctions including, but not limited to, recoupment of

benefits on paid claims, follow‐up audits, or removal of the Provider from the DentaQuest Provider Panel.

We hope that the enclosed criteria will provide a better understanding of the decision-making process

for reviews. We also recognize that “local community standards of care” may vary from region to region

and will continue our goal of incorporating generally accepted criteria that will be consistent with both

the concept of local community standards and the current ADA concept of national community

standards. Your feedback and input regarding the constant evolution of these criteria is both essential

and welcome. DentaQuest shares your commitment and belief to provide quality care to Cardinal Care

Smiles Members and we appreciate your participation in the program.

15.01 Criteria for Dental Extractions

Some procedures require pre-payment review documentation. Please refer to the benefit tables

for specific information needed by code.

Documentation needed for procedure:

• Appropriate pre-operative radiographs showing clearly the adjacent and opposing teeth

should be submitted: bitewings, periapicals or panorex.

• Narrative demonstrating medical necessity.

Criteria

The prophylactic removal of asymptomatic teeth (i.e. third molars) or teeth exhibiting no overt

clinical pathology (for orthodontics) may be covered subject to consultant review.

• The removal of primary teeth whose exfoliation is imminent does not meet criteria.

• Alveoloplasty (code D7310) in conjunction with three or more extractions in the same

quadrant will be covered.

15.02 Criteria for Cast Crowns

Some procedures require pre-payment review documentation. Please refer to the benefit tables

for specific information needed by code.

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Documentation needed for procedure:

• Appropriate pre-operative radiographs showing clearly the adjacent and opposing teeth

should be submitted: bitewings, periapicals or panorex.

Criteria

• In general, criteria for crowns will be met only for permanent teeth needing multi-surfac

estorations where other restorative materials have a poor prognosis.

• Permanent molar teeth must have pathologic destruction to the tooth by caries or trauma,

and should involve four or more surfaces and two or more cusps.

• Permanent bicuspid teeth must have pathologic destruction to the tooth by caries or

trauma, and should involve three or more surfaces and at least one cusp.

• Permanent anterior teeth must have pathologic destruction to the tooth by caries or

trauma, and must involve four or more surfaces and at least 50% of the incisal edge.

A request for a crown following root canal therapy must meet the following criteria:

• Request should include a dated post-endodontic radiograph.

• Tooth should be filled sufficiently close to the radiological apex to ensure that an apical

seal is achieved, unless there is a curvature or calcification of the canal that limits the

ability to fill the canal to the apex.

• The filling must be properly condensed/obturated. Filling material does not extend

excessively beyond the apex.

To meet criteria, a crown must be opposed by a tooth or denture in the opposite arch or be an

abutment for a partial denture.

• The patient must be free from active and advanced periodontal disease.

• The fee for crowns includes the temporary crown that is placed on the prepared tooth and

worn while the permanent crown is being fabricated for permanent teeth.

• Cast Crowns on permanent teeth are expected to last, at a minimum, five years.

Payment for Crowns will not meet criteria if:

• A lesser means of restoration is possible.

• Tooth has subosseous and/or furcation caries.

• Tooth has advanced periodontal disease.

• Tooth is a primary tooth.

• Crowns are being planned to alter vertical dimension.

15.03 Criteria for Endodontics

Some procedures require pre-payment review documentation. Please refer to the benefit tables

for specific information needed by code.

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Documentation needed for procedure:

• Sufficient and appropriate pre-operative radiographs showing clearly the adjacent

and

oppos

ing teeth and a pre-operative radiograph of the tooth to be treated; bitewings,

periapicals or panorex.

Criteria

Root canal therapy is performed in order to maintain teeth that have been damaged through

trauma or carious exposure.

Root canal therapy must meet the following criteria:

• Fill should be sufficiently close to the radiological apex to ensure that an apical seal is

achieved, unless there is a curvature or calcification of the canal that limits the dentist’s

ability to fill the canal to the apex.

• Fill must be properly condensed/obturated. Filling material does not extend excessively

beyond the apex.

Payment for Root Canal therapy will not meet criteria if:

• Gross periapical or periodontal pathosis is demonstrated radiographically (caries

subcrestal or to the furcation, deeming the tooth non-restorable).

• The general oral condition does not justify root canal therapy due to loss of arch integrity.

• Root canal therapy is for third molars, unless they are an abutment for a partial denture.

• Tooth does not demonstrate 50% bone support.

• Root canal therapy is in anticipation of placement of an overdenture.

• A filling material not accepted by the Federal Food and Drug Administration (e.g. Sargenti

filling material) is used.

Other Considerations

• Root canal therapy for permanent teeth includes diagnosis, extirpation of the pulp, shaping

and enlarging the canals, temporary fillings, filling and obliteration of root canal(s), and

progress radiographs, including a root canal fill radiograph.

• In cases where the root canal filling does not meet DentaQuest’s treatment standards,

DentaQuest can require the procedure to be redone at no additional cost. Any

reimbursement already made for an inadequate service may be recouped after

DentaQuest reviews the circumstances.

15.04 Criteria for Stainless Steel Crowns

Authorization or pre-payment review is not required.

Criteria

• In general, criteria for stainless steel crowns will be met only for teeth needing multi-

surface restorations where amalgams and other materials have a poor prognosis.

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• Permanent molar teeth must have pathologic destruction to the tooth by caries or trauma,

and should involve four or more surfaces and two or more cusps.

• Permanent bicuspid teeth must have pathologic destruction to the tooth by caries or

trauma, and should involve three or more surfaces and at least one cusp.

• Permanent anterior teeth must have pathologic destruction to the tooth by caries or

trauma, and should involve four or more surfaces and at least 50% of the incisal edge.

• Primary molars must have pathologic destruction to the tooth by caries or trauma, an

hould involve two or more surfaces or substantial occlusal decay resulting in an enamel

shell.

A crown on a permanent tooth following root canal therapy must meet the following criteria:

• Tooth should be filled sufficiently close to the radiological apex to ensure that an apical

seal is achieved, unless there is a curvature or calcification of the canal that limits the

dent

ist’s ability to fill the canal to the apex.

• The filling must be properly condensed/obturated. Filling material does not extend

excessively beyond the apex.

To meet criteria, a crown must be opposed by a tooth or denture in the opposite arch or be an

abutment for a partial denture.

• The patient must be free from active and advanced periodontal disease.

• The permanent tooth must be at least 50% supported in bone.

• Stainless Steel Crowns on permanent teeth are expected to last five years.

Treatment using Stainless Steel Crowns will not meet criteria if:

• A lesser means of restoration is possible.

• Tooth has subosseous and/or furcation caries.

• Tooth has advanced periodontal disease.

• Tooth is a primary tooth with exfoliation imminent.

• Crowns are being planned to alter vertical dimension.

15.05 Criteria for Authorization of Operating Room (OR) Cases

Documentation needed for authorization of procedure:

• Treatment Plan (prior-authorized, if necessary)

• D9999 must be submitted for all for Operating Room cases

• Notes in box 35 of the ADA claim form should identify the full name of the facility

– NO ABBREVIATIONS

• Notes in box 35 of the ADA claim form should identify the full date of servic

(

MM/DD/YYY) for the OR Case

• Include narrative describing medical necessity for OR

• MUST have “Medical Necessity” clearly written in box 35 of the ADA claim

• If a letter of medical necessity is submitted, a notation in box 35 shoul

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indicate “See attachment of medical necessity”

Prior authorization requests not containing this information will be denied.

Please mail requests for OR authorization to:

DentaQuest, LLC-OR Authorizations

PO Box 2906

Milwaukee, WI 53201-2906

All Operating Room (OR) Cases Must be Prior-

Authorized.

The Participating Cardinal Care Smiles Provider should submit the prior authorization to

DentaQuest. DentaQuest will serve as the central point of contact for the dental provider,

medical facility, medical anesthesiologist, MCO, DMAS and any other required provider.

DentaQuest’s dental director will review the case for medical necessity for members eleven

years and older and render an approval or denial of the services. Once DentaQuest has

approved the case, DentaQuest will coordinate authorization for non-dental services (example:

facility and anesthesia) with the MCO as appropriate. DentaQuest will not review cases for

medical necessity for members age ten or younger where a determination has been made by a

licensed dentist in consultation with the enrollee’s treating physician to require general

anesthesia and admission to a hospital or outpatient surgery facility to effectively and safely

provide dental care. DentaQuest will coordinate authorization for non-dental services (example:

facility and anesthesia) with the MCO as appropriate. Providers will need to continue submitting

treatment plans for review for all OR cases.

Criteria

In most cases, OR will be authorized (for procedures covered by Cardinal Care Smiles) if the

following is (are) involved:

• Young children requiring extensive operative procedures such as multiple restorations,

treatment of multiple abscesses, and/or oral surgical procedures if authorization

documentation indicates that in-office treatment (nitrous oxide or IV sedation) is not

appropriate and hospitalization is not solely based upon reducing, avoiding or controlli

appr

ehension, or upon Provider or Member convenience.

• Patients requiring extensive dental procedures and classified as American Society of

Anesthesiologists (ASA) class III and ASA class IV (Class III – patients with uncontroll

sease or significant systemic disease; for recent MI, resent stroke, new chest pain, etc.

Class IV – patient with severe systemic disease that is a constant threat to life).

• Medically compromised patients whose medical history indicates that the monitoring of

vital signs or the availability of resuscitative equipment is necessary during extensive

dental procedures.

• Patients requiring extensive dental procedures with a medical history of uncontrolled

bleeding, severe cerebral palsy, or other medical condition that renders in-office treatment

not medically appropriate.

• Patients requiring extensive dental procedures who have documentation of

psychosomatic disorders that require special treatment.

• Cognitively disabled individuals requiring extensive dental procedures whose prior history

indicates hospitalization is appropriate.

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15.06 Criteria for Removable Prosthodontics (Full and Partial Dentures)

Some procedures require pre-payment review or prior authorization documentation. Please

refer to the benefit tables for specific information needed by code.

Documentation needed for procedure:

• Appropriate pre-operative radiographs showing clearly the adjacent and opposing teeth:

bitewings, periapicals or panorex.

Criteria

Prosthetic services are intended to restore oral form and function due to premature loss of

permanent teeth that would result in significant occlusal dysfunction.

• A denture is determined to be an initial placement if the patient has never wor

n a

prosthesis. This does not refer to just the time a patient has been receiving treatment

from a certain Provider.

• Partial dentures are covered only for recipients with good oral health and hygiene, goo

periodontal health (AAP Type I or II), and a favorable prognosis where continuous

deterioration is not expected.

• Radiographs must show no untreated cavities or active periodontal disease in the

abutment teeth, and abutments must be at least 50% supported in bone.

• As part of any removable prosthetic service, dentists are expected to instruct the patient

in the proper care of the prosthesis.

• In general, if there is a pre-existing removable prosthesis (includes partial and full

dentures), it must be at least 5 years old and unserviceable to qualify for replacement.

• In general, a partial denture will be approved for benefits for if it replaces one or more

anterior teeth, or replaces two or more posterior teeth unilaterally or replaces three or

more posterior teeth bilaterally, excluding third molars, and it can be demonstrated that

masticatory function has been severely impaired. The replacement teeth should be

anatomically full sized teeth.

Removable prosthesis will not meet criteria:

• If there is a pre-existing prosthesis which is not at least 5 years old and unserviceable.

• If good oral health and hygiene, good periodontal health, and a favorable prognosis ar

not

present.

• If there are untreated cavities or active periodontal disease in the abutment teeth.

• If abutment teeth are less than 50% supported in bone.

• If the recipient cannot accommodate and properly maintain the prosthesis (i.e.. G

eflex, potential for swallowing the prosthesis, severely handicapped).

• If the recipient has a history or an inability to wear a prosthesis due to psychological or

physiological reasons.

• If a partial denture, less than five years old, is converted to a temporary or permanent

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complete denture.

• If extensive repairs are performed on marginally functional partial dentures, or whe

n a

new

partial denture would be better for the health of the recipient. However, adding teet

and/or a clasp to a partial denture is a covered benefit if the addition makes the denture

unctional.

Criteria

• If there is a pre-existing prosthesis, it must be at least 5 years old and unserviceable t

qualify for replacement.

• Adjustments, repairs and relines are included with the denture fee within the first 6

months after insertion. After that time has elapsed:

• Adjustments will be reimbursed at one per calendar year per denture.

• Repairs will be reimbursed. Reference appropriate exhibit (A, B, C) based on

member eligibilty.

• Relines will be reimbursed. Reference appropriate exhibit (A, B, C) based on

member eligibility.

• A new prosthesis will not be reimbursed unless adequate documentation has

been presented that all procedures to render the denture serviceable have

been

hausted. Reference appropriate exhibit (A, B, C) based on member eligibility

• Replacement of lost, stolen, or broken dentures less than 5 years of age usually

will not meet criteria for pre-authorization of a new denture.

• The use of Preformed Dentures with teeth already mounted (that is, teeth set in acrylic

before the initial impression) cannot be used for the fabrication of a new denture.

• All prosthetic appliances shall be inserted in the mouth and adjusted before a claim is

submitted for payment.

• When billing for partial and complete dentures, dentists must list the date that the dentures

or partials were inserted as the date of service. Recipients must be eligible on that date in

order for the denture service to be covered.

15.07 Criteria for the Determination of a Non-Restorable Tooth

In the application of clinical criteria for benefit determination, dental consultants must consider

the overall dental health. A tooth that is determined to be non-restorable may be subject to an

alternative treatment plan.

A tooth may be deemed non-restorable if one or more of the following criteria are present:

• The tooth presents with greater than a 75% loss of the clinical crown

• The tooth has less than 50% bone support

• The tooth has subosseous and/or furcation caries

• The tooth is a primary tooth with exfoliation imminent

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• The tooth apex is surrounded by severe pathologic destruction of the bone

• The overall dental condition (i.e. periodontal) of the patient is such that an alternative

treatment plan would be better suited to meet the patient’s needs

15.08 Criteria for General Anesthesia and Intravenous (IV) Sedation

Authorization or pre-payment review is not required.

Criteria

General anesthesia or IV sedation may be performed in conjunction with procedures covered

by the Cardinal Care Smiles program if any of the following criteria are met:

Extensive or complex oral surgical procedures such as:

• Impacted wisdom teeth

• Surgical root recovery from maxillary antrum

• Surgical exposure of impacted or unerupted cuspids

• Radical excision of lesions in excess of 1.25 cm

• Extraction of four or more teeth, excluding coronal remnants

• Multiple quadrants of alveoloplasty

• Removal of bilateral exostosis or bilateral tuberosities

And/or one of the following medical conditions:

• Medical condition(s) which require monitoring (e.g. cardiac problems, severe

hypertension).

• Underlying hazardous medical condition (cerebral palsy, epilepsy, mental retardation,

including Down’s syndrome) which would render patient non-compliant.

• Documented failed local anesthesia/nitrous or a condition where severe periapical

infection would render local anesthesia ineffective.

• Combative or behavioral issues that preclude use of local/nitrous for completion of

treatment

• Patients 9 years old and younger with extensive procedures to be accomplished.

15.09 Criteria for Periodontal Treatment

Some procedures require pre-payment review documentation. Please refer to the benefit tables

for specific information needed by code.

Documentation needed for procedure:

• Radiographs – periapicals or bitewings preferred.

• Complete periodontal charting with AAP Case Type.

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Periodontal scaling and root planing, per quadrant involves instrumentation of the crown and

root surfaces of the teeth to remove plaque and calculus from these surfaces. It is indicated for

patients with periodontal disease and is therapeutic, not prophylactic in nature. Root planing is

the definitive procedure designed for the removal of cementum and dentin that is rough, and/or

permeated by calculus or contaminated with toxins or microorganisms. Some soft tissue

removal occurs. This procedure may be used as a definitive treatment in some stages of

periodontal disease and as a part of pre-surgical procedures in others.

It is anticipated that this procedure would be requested in cases of severe periodontal conditions

(i.e. late Type II, III, IV periodontitis) where definitive comprehensive root planing requiring

local/regional block anesthesia and several appointments would be indicated.

From the American Academy of Periodontology (AAP) Policy on Scaling and Root Planing:

“Periodontal scaling is a treatment procedure involving instrumentation of the crown and root

surfaces of the teeth to remove plaque, calculus, and stains from these surfaces. It is performed

on patients with periodontal disease and is therapeutic, not prophylactic, in nature. Periodontal

scaling may precede root planing, which is the definitive, meticulous treatment procedure to

remove cementum and/or dentin that is rough and may be permeated by calculus, or

contaminated with toxins or microorganisms. Periodontal scaling and root planing are arduous

and time consuming. They may need to be repeated and may require local anesthetic.”

Criteria

• Periodontal charting indicating abnormal pocket depths in multiple sites.

• Additionally at least one of the following should be present:

1) Radiographic evidence of root surface calculus.

2) Radiographic evidence of noticeable loss of bone support.

16.00 Orthodontia Documentation

DentaQuest has always required the submission of plaster models, along with other required

documentation such as x-rays, to review and approve treatment necessity for an orthodontic

case. DentaQuest will now accept a complete series of intra-oral photographs instead of the

plaster models. All other previously required documentation, including panoramic and

cepholometric films, tracings, score sheets, and narratives; will also need to be submitted with

the photographs. This change will reduce postage costs for providers, increase the speed with

which records are returned, and eliminate the possibility of models being damaged in transit. If

your office is unable to submit intra-oral photos, plaster models will still be accepted.

The photographs must be of good clinical quality and should include:

• Facial photographs (right and left profiles in addition to a straight-on facial

view)

• Frontal view, in occlusion, straight-on view

• Frontal view, in occlusion, from a low angle to evaluate overjet. Please note:

This photo is only necessary when there is a significant overjet that will affect the

results of the review.

• Right buccal view, in occlusion

• Left buccal view, in occlusion

• Maxillary Occlusal view

• Mandibular Occlusal view

Orthodontic treatment requests, must include photographs, or models and all pertinent

measurement information including overjet. All other required documentation, including

panoramic and cepholometric x-rays, tracings, narratives, and scoring forms are still required

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for review.

If your office currently submits digital models through OrthoCad, these will continue to be

accepted. OrthoCAD case submissions do not require models or photographs

APPENDIX A

Attachments

General Definitions

The following definitions apply to this Office Reference Manual:

A. “Agreement” means the contract between DentaQuest acting on behalf of the

Cardinal Care Smiles program and Provider.

B. “Covered Services” means a dental health care service or supply, including those

services covered through the Early and Periodic, Screening, Diagnosis, and

Treatment (EPSDT) program that satisfies all of the following criteria:

• Is medically necessary;

• Is covered under the Cardinal Care Smiles program;

• Is provided to an enrolled member by a Participating Provider

• Is the most appropriate supply or level of care that is consistent with

professionally recognized standards of dental practice within t

ervice area and applicable policies and procedures.

C. “DMAS” means the Virginia Department of Medical Assistance Services.

D. “DentaQuest” shall refer to DentaQuest, LLC

E. "DentaQuest Service Area" shall be defined as the Commonwealth of Virginia.

F. “Emergency Services” means covered dental services furnished by a qualified provider

that are needed to evaluate or stabilize an emergency medical condition that is found to

exist using the prudent layperson standard.

G. “EPSDT” means the Early and Periodic Screening, Diagnosis and Treatment program

for persons (under age 21) made pursuant to 42 U.S.C. Sections 1396a(a)43, 1396d(a)

and (r) and 42 C.F.R. Part 441, Subpart B to ascertain children’s individual physical and

mental illness and conditions discovered by the screening services, whether or not suc

ervices are covered.

H. “Medically Necessary” means covered medical, dental, behavioral, rehabilitative or

other health care services which:

• are reasonable and necessary to prevent illness or medical conditions, or

provide early screening, interventions, and/or treatment for conditions that cause

suffering or pain, cause physical deformity or limitation in function, cause illness

or infirmity, endanger life, or worsen a disability:

• are provided at appropriate facilities and at the appropriate levels of care for the

treatment of a member’s medical conditions;

• are consistent with the diagnoses of the conditions;

• are no more intrusive or restrictive than necessary to provide a proper balanc

safety, effectiveness, efficiency and independence; and

• will assist the individual to achieve or maintain maximum functional capacity in

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performing daily activities, taking into account both the functional capacity of the

individual, and those functional capacities that are appropriate for individuals of

the same age.

I. “Member or Enrollee” means any individual who is eligible to receive Covered Services

provided for under the Cardinal Care Smiles program.

J. “Participating Provider or Provider” is a dental professional or facility, including a Provider

Dentist, that has a written participation agreement in effect with DMAS and DentaQuest,

to provide dental services to Members of the Cardinal Care Smiles program.

K. “Claim” means any bill or claim made by or on behalf of an enrollee or the Dentist to

DentaQuest under the agreement for payment for Dental Services under the Cardinal

Care Smiles program.

L. “Clean Claim” means a claim that can be processed without obtaining additional

information from the provider of the service or from a third party. It does not include a

claim form a provider who is under investigation for fraud or abuse, or a claim under

review for medical necessity.

M. "Provider" means the undersigned health professional or any other entity that has enter

into a written agreement with DentaQuest to provide certain health services to Members.

Each Provider shall have its own distinct tax identification number.

N. “Provider Dentist” is a Doctor of dentistry, duly licensed and qualified under the laws of

the Commonwealth of Virginia, who practices as a shareholder, partner, or employee of

Provider.

O. “Cardinal Care Smiles” is the name of the dental program provided to Virginia Medicaid,

FAMIS and FAMIS Plus enrollees, administered by DentaQuest, under the direction of

DMAS.

P. “FAMIS” is the DMAS program for members under the age of 19 who are eligible t

eceive services under the State Child Health Insurance Plan under Title XXI, as

amended.

Q. “FAMIS Plus” is the DMAS program for members under the age of 19 who meet

“medically indigent” criteria under Medicaid program rules, and who are assigned an ai

category code of 90;90 (under 6 years of age);92 and 94. FAMIS Plus children receive

he full Medicaid benefit package and have no cost-sharing responsibilities.

Additional Resources

Welcome to the DentaQuest provider forms and attachment resource page. The links below provide methods to

access and acquire both electronic and printable forms addressed within this document. To view copies please

visit our website at www.dentaquestgov.com

. Once you have entered the website, click on the “Dentist” icon.

From there choose your ‘State” and press go. You will then be able to log in using your password and User ID.

Once logged in, select the link “Related Documents” to access the following resources:

• O

rthodontic Criteria Index Form

• Malocclusion Severity Assessment

• Malocclusion Severity Assessment Instructions

• Orthodontic Continuation of Care Form

• OrthoCAD Submission Form

• Orthodontic Pre-Authorization Checklist

• Dental Claim Form

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• Instructions for Dental Claim Form

• Initial Clinical Exam

• Recall Examination Form

• Authorization for Dental Treatment

• Medical and Dental History

• Provider Change Form

• CCS Transportation Complaint Form

• Professional Interpreter Service Invoice Form

• Provider Appeal Form

• Authorization to Honor Direct Automated Clearinghouse (ACH) Credits Disbursed by

DentaQuest Services of Virginia, LLC

• ANSI Companion Gui

f you do not have internet access, to have a copy mailed, you may also contact DentaQuest Customer Service

at 888.912.3456

APPENDIX B

Covered Benefits (See Exhibits A, B and C)

This section identifies covered benefits, provides specific criteria for coverage and defines individual age

and benefit limitations for Cardinal Care Smiles members Providers with benefit questions should

contact DentaQuest’s Customer Service Department directly at:

888.912.3456

DentaQuest recognizes tooth letters “A” through “T” for primary teeth and tooth numbers “1” to “32” for

permanent teeth. Supernumerary teeth should be designated by “AS through TS” for primary teeth and

tooth numbers “51” to “82” for permanent teeth. These codes must be referenced in the patient’s file for

record retention and review. All dental services performed must be recorded in the patient record,

which must be available as required by your Participating Provider Agreement.

The DentaQuest claim system can only recognize dental services described using the current American

Dental Association CDT code list or those as defined as a Covered Benefit. All other service codes not

contained in the following tables will be rejected when submitted for payment. A complete, copy of the

CDT book can be purchased from the American Dental Association at the following address:

American Dental Association

211 East Chicago Avenue

Chicago, IL 60611

800.947.4746

Furthermore, DentaQuest subscribes to the definition of services performed as described in the CDT

manual.

The benefit tables (Exhibits A, B, & C) are all inclusive for covered services. Each category of service is

contained in a separate table and lists:

1. the ADA approved service code to submit when billing,

2. brief description of the covered service,

3. any age limits imposed on coverage,

4. a description of documentation, in addition to a completed ADA claim form, that must be submitted

when a claim or request for prior authorization is submitted,

5. an indicator of whether or not the service is subject to prior authorization, pre-payment review, or

any other applicable benefit limitations.

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Exhibit A Benefits Covered for

VA Cardinal Care Smiles - Under 21

Diagnostic services include the oral examination, and selected radiographs needed to assess the oral health, diagnose oral pathology, and develop an

adequate treatment plan for the member's oral health.

Reimbursement for some or multiple radiographs of the same tooth or area may be denied if DentaQuest determines the number to be redundant, excessive

or not in keeping with the federal guidelines relating to radiation exposure. The maximum amount paid for individual radiographs taken on the same day will

be limited to the allowance for a full mouth series.

Reimbursement for radiographs is limited to those films required for proper treatment and/or diagnosis.

DentaQuest utilizes the guidelines published by the Department of Health and Human Services Center for Devices and Radiological Health. However,

please consult the following benefit tables for benefit limitations.

All radiographs must be of good diagnostic quality properly mounted, dated and identified with the recipient's name and date of birth. Substandard

radiographs will not be reimbursed for, or if already paid for, DentaQuest will recoup the funds previously paid.

Diagnostic

Code Description Age Limitation Teeth Covered Authorization

Required

Benefit Limitations Documentation

Required

D0120 periodic oral evaluation -

established patient

0-20 No One of (D0120) per 6 Month(s) Per

Provider OR Location. One of (D0120,

D0145, D0150) per 6 Month(s) Per

Provider OR Location.

D0140 limited oral evaluation-problem

focused

0-20 No

D0145 oral evaluation for a patient under

three years of age and counseling

with primary caregiver

0-2 No One of (D0145) per 6 Month(s) Per

Provider OR Location. One of (D0120,

D0145, D0150) per 6 Month(s) Per

Provider OR Location.

D0150 comprehensive oral evaluation -

new or established patient

0-20 No One of (D0150) per 6 Month(s) Per

Provider OR Location. One of (D0120,

D0145, D0150) per 6 Month(s) Per

Provider OR Location.

D0170 re-evaluation, limited problem

focused

0-20 No

D0210 intraoral - comprehensive series of

radiographic images

6 - 20 No One of (D0210, D0330) per 60 Month(s)

Per Provider OR Location. Frequency of

service or age deviation must be

supported by Medical Necessity.

D0220 intraoral - periapical first

radiographic image

0-20 No

D0230 intraoral - periapical each additional

radiographic image

0-20 No

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Exhibit A Benefits Covered for

VA Cardinal Care Smiles - Under 21

Diagnostic

Code Description Age Limitation Teeth Covered Authorization

Required

Benefit Limitations Documentation

Required

D0240 intraoral - occlusal radiographic

image

0-20 No Two of (D0240) per 12 Month(s) Per

patient.

D0250 extra-oral – 2D projection

radiographic image created using a

stationary radiation source, and

detector

0-20 No

D0251 extra-oral posterior dental

radiographic image

0-20 No

D0270 bitewing - single radiographic image 0-20 No

D0272 bitewings - two radiographic images 0-20 No One of (D0272, D0273, D0274) per 12

Month(s) Per Provider OR Location.

D0273 bitewings - three radiographic

images

0-20 No One of (D0272, D0273, D0274) per 12

Month(s) Per Provider OR Location.

D0274 bitewings - four radiographic

images

0-20 No One of (D0272, D0273, D0274) per 12

Month(s) Per Provider OR Location.

D0330 panoramic radiographic image 6 - 20 No One of (D0210, D0330) per 60 Month(s)

Per Provider OR Location. Frequency of

service or age deviation must be

supported by Medical Necessity.

D0340 cephalometric radiographic image 0-20 No Non-orthodontic procedures.

D0372 intraoral tomosynthesis –

comprehensive series of

radiographic images

0-20 No

D0373 intraoral tomosynthesis – bitewing

radiographic image

0-20 No

D0374 intraoral tomosynthesis – periapical

radiographic image

0-20 No

D0470 diagnostic casts 0-20 No Non-orthodontic procedures.

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Exhibit A Benefits Covered for

VA Cardinal Care Smiles - Under 21

Sealants may be placed on the occlusal or occlusal-buccal surfaces of lower molars or occlusal or occlusal-lingual surfaces of upper molars once per tooth,

per lifetime.

Space maintainers are a covered service when medically indicated due to the premature loss of posterior primary tooth. A lower lingual holding arch placed

where there is not premature loss of the primary molar is considered a transitional orthodontic appliance and not covered by this Plan.

The application of topical fluoride treatment is allowed for Members up to age 21 once every 6 months when provided in conjunction with a prophylaxis.

Treatment that incorporates fluoride with the polishing compound is considered part of the prophylaxis procedure and not a separate topical fluoride

treatment.

BILLING AND REIMBURSEMENT FOR SPACE MAINTAINERS SHALL BE BASED ON THE CEMENTATION DATE.

Preventative

Code Description Age Limitation Teeth Covered Authorization

Required

Benefit Limitations Documentation

Required

D1110 prophylaxis - adult 13-20 No One of (D1110, D1120) per 6 Month(s) Per

Provider OR Location. Includes minor

scaling procedures.

D1120 prophylaxis - child 0-12 No One of (D1110, D1120) per 6 Month(s) Per

Provider OR Location.

D1206 topical application of fluoride

varnish

0-20 No One of (D1206, D1208) per 6 Month(s) Per

Provider OR Location.

D1208 topical application of fluoride -

excluding varnish

0-20 No One of (D1206, D1208) per 6 Month(s) Per

Provider OR Location.

D1351 sealant - per tooth 5-20 Teeth 2, 3, 14, 15, 18, 19,

30, 31

No One of (D1351) per 1 Lifetime Per patient

per tooth for First and Second Molars. for

First and Second Molars. Occlusal

sealants are permissible if teeth 2, 3, 14,

15, 18, 19, 30, 31 (1st and 2nd molars)

have a lingual or buccal pit filling but no

occlusal restoration.

D1354 application of caries arresting

medicament- per tooth

0-20 Teeth 1 - 32, A - T No Two of (D1354) per 1 Lifetime Per patient

per tooth.

D1510 space maintainer-fixed, unilateral-

per quadrant

0-20 Per Quadrant (10, 20, 30,

40, LL, LR, UL, UR)

No One of (D1510, D1520) per 24 Month(s)

Per patient per quadrant.

D1516 space maintainer --fixed--bilateral,

maxillary

0-20 No One of (D1516, D1526) per 24 Month(s)

Per patient per arch.

D1517 space maintainer --fixed--bilateral,

mandibular

0-20 No One of (D1517, D1527) per 24 Month(s)

Per patient per arch.

D1520 space

maintainer-removable-unilateral

0-20 Per Quadrant (10, 20, 30,

40, LL, LR, UL, UR)

No One of (D1510, D1520) per 24 Month(s)

Per patient per quadrant.

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Exhibit A Benefits Covered for

VA Cardinal Care Smiles - Under 21

Preventative

Code Description Age Limitation Teeth Covered Authorization

Required

Benefit Limitations Documentation

Required

D1526 space maintainer

--removable--bilateral, maxillary

0-20 No One of (D1516, D1526) per 24 Month(s)

Per patient per arch.

D1527 space maintainer

--removable--bilateral, mandibular

0-20 No One of (D1517, D1527) per 24 Month(s)

Per patient per arch.

D1551 re-cement or re-bond bilateral

space maintainer- Maxillary

0-20 No

D1552 re-cement or re-bond bilateral

space maintainer- Mandibular

0-20 No

D1553 re-cement or re-bond unilateral

space maintainer- Per Quadrant

0-20 Per Quadrant (10, 20, 30,

40, LL, LR, UL, UR)

D1556 Removal of fixed unilateral space

maintainer- Per Quadrant

0-20 Per Quadrant (10, 20, 30,

40, LL, LR, UL, UR)

D1557 Removal of fixed bilateral space

maintainer- Maxillary

0-20 No

D1558 Removal of fixed bilateral space

maintainer- Mandibular

0-20 No

D1575 distal shoe space maintainer - fixed

- unilateral- Per Quadrant

0-20 Per Quadrant (10, 20, 30,

40, LL, LR, UL, UR)

No One of (D1510, D1520, D1575) per 24

Month(s) Per patient per quadrant.

DentaQuest LLC 54 of 136

July 1, 2024

Exhibit A Benefits Covered for

VA Cardinal Care Smiles - Under 21

Generally, once a particular restoration is placed in a tooth, a similar restoration will not be covered for at least twelve months, unless there is recurrent

decay or material failure. Payment will be made for only one single surface restoration per tooth surface. For example, two separate occlusal (O)

restorations on the same tooth are to be billed as one occlusal restoration. However, for example it is permissible to bill for multiple, but separate

restorations involving the same tooth surface, such as a mesial-facial (MF) and a distal-facial (DF) restoration on the same anterior tooth.

The acid etching procedure is considered part of the restoration and is not billed as a separate procedure.

Local anesthetic is included in the restorative service or surgical fee and is not separately reimbursed.

A sedative restoration is considered a temporary restoration only and not a base under a restoration.

Bases, copalite, or calcium hydroxide liners placed under a restoration are considered part of the restorations and are not billable as separate procedures.

BILLING AND REIMBURSEMENT FOR CAST CROWNS, CAST POST & CORES AND LAMINATE VENEERS OR ANY OTHER FIXED PROSTHETICS

SHALL BE BASED ON THE CEMENTATION DATE.

Restorative pins are reimbursed on a per tooth basis, regardless of the number of pins placed.

Only full labial veneers porcelain (lab) are a covered service.

For all services that require pre-payment review, Providers have the option of requesting prior authorization.When restorations involving multiple surfaces

are requested or performed, that are outside the usual anatomical expectation, the allowance is limited to that of a one-surface restoration. Any fee charged

in excess of the allowance for the one-surface restoration is DISALLOWED.

Restorative

Code Description Age Limitation Teeth Covered Authorization

Required

Benefit Limitations Documentation

Required

D2140 Amalgam - one surface, primary or

permanent

0-20 Teeth 1 - 32, A - T No One of (D2140, D2150, D2160, D2161,

D2330, D2331, D2332, D2335, D2390,

D2391, D2392, D2393, D2394) per 12

Month(s) Per patient per tooth, per

surface.

D2150 Amalgam - two surfaces, primary or

permanent

0-20 Teeth 1 - 32, A - T No One of (D2140, D2150, D2160, D2161,

D2330, D2331, D2332, D2335, D2390,

D2391, D2392, D2393, D2394) per 12

Month(s) Per patient per tooth, per

surface.

D2160 amalgam - three surfaces, primary

or permanent

0-20 Teeth 1 - 32, A - T No One of (D2140, D2150, D2160, D2161,

D2330, D2331, D2332, D2335, D2390,

D2391, D2392, D2393, D2394) per 12

Month(s) Per patient per tooth, per

surface.

DentaQuest LLC 55 of 136

July 1, 2024

Exhibit A Benefits Covered for

VA Cardinal Care Smiles - Under 21

Restorative

Code Description Age Limitation Teeth Covered Authorization

Required

Benefit Limitations Documentation

Required

D2161 amalgam - four or more surfaces,

primary or permanent

0-20 Teeth 1 - 32, A - T No One of (D2140, D2150, D2160, D2161,

D2330, D2331, D2332, D2335, D2390,

D2391, D2392, D2393, D2394) per 12

Month(s) Per patient per tooth, per

surface.

D2330 resin-based composite - one

surface, anterior

0-20 Teeth 6 - 11, 22 - 27, C - H,

M - R

No One of (D2140, D2150, D2160, D2161,

D2330, D2331, D2332, D2335, D2390,

D2391, D2392, D2393, D2394) per 12

Month(s) Per patient per tooth, per

surface.

D2331 resin-based composite - two

surfaces, anterior

0-20 Teeth 6 - 11, 22 - 27, C - H,

M - R

No One of (D2140, D2150, D2160, D2161,

D2330, D2331, D2332, D2335, D2390,

D2391, D2392, D2393, D2394) per 12

Month(s) Per patient per tooth, per

surface.

D2332 resin-based composite - three

surfaces, anterior

0-20 Teeth 6 - 11, 22 - 27, C - H,

M - R

No One of (D2140, D2150, D2160, D2161,

D2330, D2331, D2332, D2335, D2390,

D2391, D2392, D2393, D2394) per 12

Month(s) Per patient per tooth, per

surface.

D2335 resin-based composite - four or

more surfaces (anterior)

0-20 Teeth 6 - 11, 22 - 27, C - H,

M - R

No One of (D2140, D2150, D2160, D2161,

D2330, D2331, D2332, D2335, D2390,

D2391, D2392, D2393, D2394) per 12

Month(s) Per patient per tooth, per

surface.

D2390 resin-based composite crown,

0-20 Teeth 6 - 11, 22 - 27, C - H,

M - R

No One of (D2140, D2150, D2160, D2161,

D2330, D2331, D2332, D2335, D2390,

D2391, D2392, D2393, D2394) per 12

Month(s) Per patient per tooth, per

surface.

D2391 resin-based composite - one

surface, posterior

0-20 Teeth 1 - 5, 12 - 21, 28 - 32,

A, B, I - L, S, T

No One of (D2140, D2150, D2160, D2161,

D2330, D2331, D2332, D2335, D2390,

D2391, D2392, D2393, D2394) per 12

Month(s) Per patient per tooth, per

surface.

D2392 resin-based composite - two

surfaces, posterior

0-20 Teeth 1 - 5, 12 - 21, 28 - 32,

A, B, I - L, S, T

No One of (D2140, D2150, D2160, D2161,

D2330, D2331, D2332, D2335, D2390,

D2391, D2392, D2393, D2394) per 12

Month(s) Per patient per tooth, per

surface.

DentaQuest LLC 56 of 136

July 1, 2024

Exhibit A Benefits Covered for

VA Cardinal Care Smiles - Under 21

Restorative

Code Description Age Limitation Teeth Covered Authorization

Required

Benefit Limitations Documentation

Required

D2393 resin-based composite - three

surfaces, posterior

0-20 Teeth 1 - 5, 12 - 21, 28 - 32,

A, B, I - L, S, T

No One of (D2140, D2150, D2160, D2161,

D2330, D2331, D2332, D2335, D2390,

D2391, D2392, D2393, D2394) per 12

Month(s) Per patient per tooth, per

surface.

D2394 resin-based composite - four or

more surfaces, posterior

0-20 Teeth 1 - 5, 12 - 21, 28 - 32,

A, B, I - L, S, T

No One of (D2140, D2150, D2160, D2161,

D2330, D2331, D2332, D2335, D2390,

D2391, D2392, D2393, D2394) per 12

Month(s) Per patient per tooth, per

surface.

D2644 onlay-porcelain/ceramic-4+

surfaces

0-20 Teeth 1 - 32 Yes One of (D2644) per 60 Month(s) Per

patient per tooth.

narr. of med. necessity,

pre-op x-ray(s)

D2710 crown - resin-based composite

(indirect)

0-20 Teeth 1 - 32 Yes One of (D2710, D2720, D2721, D2722,

D2740, D2750, D2751, D2752, D2753,

D2790, D2791, D2792, D2794, D2962) per

60 Month(s) Per patient per tooth.

Pre-operative radiographs with claim for

pre-payment review.

pre-operative x-ray(s)

D2720 crown-resin with high noble metal 0-20 Teeth 1 - 32 Yes One of (D2710, D2720, D2721, D2722,

D2740, D2750, D2751, D2752, D2753,

D2790, D2791, D2792, D2794, D2962) per

60 Month(s) Per patient per tooth.

Pre-operative radiographs with claim for

pre-payment review.

pre-operative x-ray(s)

D2721 crown - resin with predominantly

base metal

0-20 Teeth 1 - 32 Yes One of (D2710, D2720, D2721, D2722,

D2740, D2750, D2751, D2752, D2753,

D2790, D2791, D2792, D2794, D2962) per

60 Month(s) Per patient per tooth.

Pre-operative radiographs with claim for

pre-payment review.

pre-operative x-ray(s)

D2722 crown - resin with noble metal 0-20 Teeth 1 - 32 Yes One of (D2710, D2720, D2721, D2722,

D2740, D2750, D2751, D2752, D2753,

D2790, D2791, D2792, D2794, D2962) per

60 Month(s) Per patient per tooth.

Pre-operative radiographs with claim for

pre-payment review.

pre-operative x-ray(s)

D2740 crown - porcelain/ceramic 0-20 Teeth 1 - 32 Yes One of (D2710, D2720, D2721, D2722,

D2740, D2750, D2751, D2752, D2753,

D2790, D2791, D2792, D2794, D2962) per

60 Month(s) Per patient per tooth.

Pre-operative radiographs with claim for

pre-payment review.

pre-operative x-ray(s)

DentaQuest LLC 57 of 136

July 1, 2024

Exhibit A Benefits Covered for

VA Cardinal Care Smiles - Under 21

Restorative

Code Description Age Limitation Teeth Covered Authorization

Required

Benefit Limitations Documentation

Required

D2750 crown - porcelain fused to high

noble metal

0-20 Teeth 1 - 32 Yes One of (D2710, D2720, D2721, D2722,

D2740, D2750, D2751, D2752, D2753,

D2790, D2791, D2792, D2794, D2962) per

60 Month(s) Per patient per tooth.

Pre-operative radiographs with claim for

pre-payment review.

pre-operative x-ray(s)

D2751 crown - porcelain fused to

predominantly base metal

0-20 Teeth 1 - 32 Yes One of (D2710, D2720, D2721, D2722,

D2740, D2750, D2751, D2752, D2753,

D2790, D2791, D2792, D2794, D2962) per

60 Month(s) Per patient per tooth.

Pre-operative radiographs with claim for

pre-payment review.

pre-operative x-ray(s)

D2752 crown - porcelain fused to noble

metal

0-20 Teeth 1 - 32 Yes One of (D2710, D2720, D2721, D2722,

D2740, D2750, D2751, D2752, D2753,

D2790, D2791, D2792, D2794, D2962) per

60 Month(s) Per patient per tooth.

Pre-operative radiographs with claim for

pre-payment review.

pre-operative x-ray(s)

D2753 Crown- Porcelain Fused to Titanium

and Titanium Alloys

0-20 Teeth 1 - 32 Yes One of (D2710, D2720, D2721, D2722,

D2740, D2750, D2751, D2752, D2753,

D2790, D2791, D2792, D2794, D2962) per

60 Month(s) Per patient per tooth.

Pre-operative radiographs with claim for

pre-payment review.

pre-operative x-ray(s)

D2790 crown - full cast high noble metal 0-20 Teeth 1 - 32 Yes One of (D2710, D2720, D2721, D2722,

D2740, D2750, D2751, D2752, D2753,

D2790, D2791, D2792, D2794, D2962) per

60 Month(s) Per patient per tooth.

Pre-operative radiographs with claim for

pre-payment review.

pre-operative x-ray(s)

D2791 crown - full cast predominantly

base metal

0-20 Teeth 1 - 32 Yes One of (D2710, D2720, D2721, D2722,

D2740, D2750, D2751, D2752, D2753,

D2790, D2791, D2792, D2794, D2962) per

60 Month(s) Per patient per tooth.

Pre-operative radiographs with claim for

pre-payment review.

pre-operative x-ray(s)

D2792 crown - full cast noble metal 0-20 Teeth 1 - 32 Yes One of (D2710, D2720, D2721, D2722,

D2740, D2750, D2751, D2752, D2753,

D2790, D2791, D2792, D2794, D2962) per

60 Month(s) Per patient per tooth.

Pre-operative radiographs with claim for

pre-payment review.

pre-operative x-ray(s)

DentaQuest LLC 58 of 136

July 1, 2024

Exhibit A Benefits Covered for

VA Cardinal Care Smiles - Under 21

Restorative

Code Description Age Limitation Teeth Covered Authorization

Required

Benefit Limitations Documentation

Required

D2794 Crown- Titanium and Titanium

Alloys

0-20 Teeth 1 - 32 Yes One of (D2710, D2720, D2721, D2722,

D2740, D2750, D2751, D2752, D2753,

D2790, D2791, D2792, D2794, D2962) per

60 Month(s) Per patient per tooth.

Pre-operative radiographs with claim for

pre-payment review.

pre-operative x-ray(s)

D2915 re-cement or re-bond indirectly

fabricated or prefabricated post and

core

0-20 Teeth 1 - 32 No

D2920 re-cement or re-bond crown 0-20 Teeth 1 - 32, A - T No

D2928 prefabricated porcelain/ceramic

crown – permanent tooth

0-20 Teeth 1 - 32 No

D2929 Prefabricated porcelain/ceramic

crown – primary tooth

0-20 Teeth A - T No

D2930 prefabricated stainless steel crown

- primary tooth

0-20 Teeth A - T No

D2931 prefabricated stainless steel

crown-permanent tooth

0-20 Teeth 1 - 32 No

D2932 prefabricated resin crown 0-20 Teeth 1 - 32, A - T No

D2933 prefabricated stainless steel crown

with resin window

0-20 Teeth C - H, M - R No

D2934 prefabricated esthetic coated

stainless steel crown - primary

tooth

0-20 Teeth C - H, M - R No

D2940 protective restoration 0-20 Teeth 1 - 32, A - T No

D2950 core buildup, including any pins

when required

0-20 Teeth 1 - 32 No One of (D2950, D2952, D2954) per 1

Day(s) Per patient per tooth. One of

(D2950, D2952, D2954) per 60 Month(s)

Per patient per tooth.

D2951 pin retention - per tooth, in addition

to restoration

0-20 Teeth 1 - 32 No

D2952 cast post and core in addition to

crown

0-20 Teeth 1 - 32 No One of (D2950, D2952, D2954) per 1

Day(s) Per patient per tooth. One of

(D2950, D2952, D2954) per 60 Month(s)

Per patient per tooth.

DentaQuest LLC 59 of 136

July 1, 2024

Exhibit A Benefits Covered for

VA Cardinal Care Smiles - Under 21

Restorative

Code Description Age Limitation Teeth Covered Authorization

Required

Benefit Limitations Documentation

Required

D2954 prefabricated post and core in

addition to crown

0-20 Teeth 1 - 32 No One of (D2950, D2952, D2954) per 1

Day(s) Per patient per tooth. One of

(D2950, D2952, D2954) per 60 Month(s)

Per patient per tooth.

D2962 labial veneer (porc laminate) -

laboratory

0-20 Teeth 1 - 32 Yes One of (D2710, D2720, D2721, D2722,

D2740, D2750, D2751, D2752, D2753,

D2790, D2791, D2792, D2794, D2962) per

60 Month(s) Per patient per tooth. Will be

considered as an alternative to a full

restoration for an endodontically treated

tooth. Pre-operative radiographs with

claim for pre-payment review.

pre-operative x-ray(s)

D2991 application of hydroxyapatite

regeneration medicament – per

tooth

0-20 Teeth 1 - 32, 51 - 82, A - T,

AS, BS, CS, DS, ES, FS,

GS, HS, IS, JS, KS, LS,

MS, NS, OS, PS, QS, RS,

SS, TS

No One of (D2991) per 1 Lifetime Per patient

per tooth. Caries risk assessment shall be

performed and documentation maintained

in the patient record. Documentation in

the file to support the use of the code.

Photograph for smooth surface white spot

lesions or radiographic for interproximal

surfaces, or combination if one or the other

does not clearly demonstrate medical

necessity. Product used must be a

hydroxyapatite regeneration medicament

designed for regenerative purpose.

DentaQuest LLC 60 of 136

July 1, 2024

Exhibit A Benefits Covered for

VA Cardinal Care Smiles - Under 21

Payment for conventional root canal treatment is limited to treatment of permanent teeth.

Root canal therapy may be performed to prevent or treat apical periodontitis. Teeth may need endodontic therapy due to caries, trauma, or developmental

anomalies.

Examiners and providers may observe a completed root canal procedure differently. To be consistent, examiners follow specific guidelines and criteria.

Providers encountering canal obstructions [stones, calcifications] could be performing clinically acceptable procedures and should include a

narrative/radiograph when necessary. The finished radiograph may not fully detail what the clinician encountered. Variations in root anatomy, tooth condition,

and microscopic findings may affect root canal therapy. Apex locators and other technical instruments available can and may support final fill radiographs.

It is recommended providers submit a final fill radiograph and narrative simultaneously with request for payment. A provider narrative allows the examiner to

simultaneously review radiographs with the provider explanation and reduce payment denials. The submitted verbiage can also be helpful when an extended

amount of time has occurred between root canal and crown treatments.

Note: This is optional for providers. Please include in box 35 any additional relevant information. The treating clinician's judgement is relevant and important

and these comments should be included.

In cases where the root canal filling does not meet DentaQuest's treatment standards, DentaQuest can require the procedure to be redone at no additional

cost. Any reimbursement already made for an inadequate service may be recouped after any post payment review by the DentaQuest Consultants. A

pulpotomy or palliative treatment cannot be billed on the same date of service as root canal treatment. Filling material not accepted by the Federal Food and

Drug Administration (FDA) (e.g. Sargenti filling material) is not covered. Pulpotomies will be limited to primary teeth or permanent teeth with incomplete root

development. The fee for root canal therapy for permanent teeth includes diagnosis, extirpation treatment, temporary fillings, filling and obturation of root

canals, and progress radiographs. A completed fill radiograph is also included.

For all services that require pre-payment review, Providers have the option of requesting prior authorization.

Endodontics

Code Description Age Limitation Teeth Covered Authorization

Required

Benefit Limitations Documentation

Required

D3110 pulp cap - direct (exluding final

restoration)

0-20 Teeth 1 - 32 No

D3120 pulp cap - indirect (excluding final

restoration)

0-20 Teeth 1 - 32, A - T No

D3220 therapeutic pulpotomy (excluding

final restoration) - removal of pulp

coronal to the dentinocemental

junction and application of

medicament

0-20 Teeth 1 - 32, A - T No Cannot be billed on same date of service

as (D3310, D3320 and D3330)

D3221 pulpal debridement, primary and

permanent teeth

0-20 Teeth 1 - 32, A - T No Cannot be billed on same date of service

as (D3310, D3320 and D3330)

DentaQuest LLC 61 of 136

July 1, 2024

Exhibit A Benefits Covered for

VA Cardinal Care Smiles - Under 21

Endodontics

Code Description Age Limitation Teeth Covered Authorization

Required

Benefit Limitations Documentation

Required

D3230 pulpal therapy (resorbable filling) -

anterior, primary tooth (excluding

final restoration)

0-20 Teeth C - H, M - R No

D3240 pulpal therapy (resorbable filling) -

posterior, primary tooth (excluding

final restoration)

0-20 Teeth A, B, I - L, S, T No

D3310 endodontic therapy, anterior tooth

(excluding final restoration)

0-20 Teeth 6 - 11, 22 - 27 No One of (D3310) per 1 Lifetime Per patient

per tooth.

D3320 endodontic therapy, premolar tooth

(excluding final restoration)

0-20 Teeth 4, 5, 12, 13, 20, 21,

28, 29

No One of (D3320) per 1 Lifetime Per patient

per tooth.

D3330 endodontic therapy, molar tooth

(excluding final restoration)

0-20 Teeth 1 - 3, 14 - 19, 30 - 32 No One of (D3330) per 1 Lifetime Per patient

per tooth.

D3346 retreatment of previous root canal

therapy-anterior

0-20 Teeth 6 - 11, 22 - 27 Yes One of (D3346) per 1 Lifetime Per patient

per tooth. Pre-operative radiographs and

narrative of medical necessity with claim

for pre-payment review.

narr. of med. necessity,

pre-op x-ray(s)

D3347 retreatment of previous root canal

therapy - premolar

0-20 Teeth 4, 5, 12, 13, 20, 21,

28, 29

Yes One of (D3347) per 1 Lifetime Per patient

per tooth. Pre-operative radiographs and

narrative of medical necessity with claim

for pre-payment review.

narr. of med. necessity,

pre-op x-ray(s)

D3348 retreatment of previous root canal

therapy-molar

0-20 Teeth 1 - 3, 14 - 19, 30 - 32 Yes One of (D3348) per 1 Lifetime Per Provider

per tooth. Pre-operative radiographs and

narrative of medical necessity with claim

for pre-payment review.

narr. of med. necessity,

pre-op x-ray(s)

D3351 apexification/recalcification - initial

visit (apical closure / calcific repair

of perforations, root resorption, etc.)

0-20 Teeth 1 - 32 No

D3352 apexification/recalcification - interim

medication replacement

0-20 Teeth 1 - 32 No Limited three (3) treatments.

D3353 apexification/recalcification - final

visit (includes completed root canal

therapy - apical closure/calcific

repair of perforations, root

resorption, etc.)

0-20 Teeth 1 - 32 No One of (D3353) per 1 Lifetime Per Provider

per tooth.

D3410 apicoectomy - anterior 0-20 Teeth 6 - 11, 22 - 27 Yes One of (D3410) per 1 Lifetime Per patient

per tooth. Pre-operative radiographs with

claim for pre-payment review.

pre-operative x-ray(s)

DentaQuest LLC 62 of 136

July 1, 2024

Exhibit A Benefits Covered for

VA Cardinal Care Smiles - Under 21

Endodontics

Code Description Age Limitation Teeth Covered Authorization

Required

Benefit Limitations Documentation

Required

D3421 apicoectomy - premolar (first root) 0-20 Teeth 4, 5, 12, 13, 20, 21,

28, 29

Yes One of (D3421) per 1 Lifetime Per patient

per tooth. Pre-operative radiographs with

claim for pre-payment review.

pre-operative x-ray(s)

D3425 apicoectomy - molar (first root) 0-20 Teeth 1 - 3, 14 - 19, 30 - 32 Yes One of (D3425) per 1 Lifetime Per patient

per tooth. Pre-operative radiographs with

claim for pre-payment review.

pre-operative x-ray(s)

D3426 apicoectomy (each additional root) 0-20 Teeth 1 - 5, 12 - 21, 28 - 32 Yes Pre-operative radiographs with claim for

pre-payment review.

pre-operative x-ray(s)

D3430 retrograde filling - per root 0-20 Teeth 1 - 32 Yes One of (D3430) per 1 Lifetime Per patient

per tooth. Pre-operative radiographs with

claim for pre-payment review.

pre-operative x-ray(s)

DentaQuest LLC 63 of 136

July 1, 2024

Exhibit A Benefits Covered for

VA Cardinal Care Smiles - Under 21

For all services that require pre-payment review, Providers have the option of requesting prior authorization.

Periodontics

Code Description Age Limitation Teeth Covered Authorization

Required

Benefit Limitations Documentation

Required

D4210 gingivectomy or gingivoplasty - four

or more contiguous teeth or tooth

bounded spaces per quadrant

0-20 Per Quadrant (10, 20, 30,

40, LL, LR, UL, UR)

No One of (D4210) per 24 Month(s) Per

patient per quadrant. One of (D4210,

D4211) per 24 Month(s) Per patient per

quadrant. A min of 4 affected teeth in the

quadrant. Gingivectomies for the removal

of hyperplasic tissue to reduce pocket

depth. Request only when non-surgical

treatment has not been effective or when

the patient is taking medications that

cause such conditions.

pre-op x-ray(s), perio

charting

D4211 gingivectomy or gingivoplasty - one

to three contiguous teeth or tooth

bounded spaces per quadrant

0-20 Per Quadrant (10, 20, 30,

40, LL, LR, UL, UR)

No One of (D4211) per 24 Month(s) Per

patient per quadrant. One of (D4210,

D4211) per 24 Month(s) Per patient per

quadrant. 1 to 3 affected teeth in the

quadrant. For removal of hyperplastic

tissue. Should be only requested when

non-surgical treatment does not achieve

the desired results or when the patient is

being treated with medications that result

in such conditions.

pre-op x-ray(s), perio

charting

D4249 clinical crown lengthening - hard

tissue

0-20 Teeth 1 - 32 Yes One of (D4249) per 1 Lifetime Per patient

per tooth. Periodontal charting and

preoperative radiographs with claim for

pre-payment review.

pre-op x-ray(s), perio

charting

D4260 osseous surgery (including

elevation of a full thickness flap and

closure) - four or more contiguous

teeth or tooth bounded spaces per

quadrant

0-20 Per Quadrant (10, 20, 30,

40, LL, LR, UL, UR)

Yes One of (D4260) per 60 Month(s) Per

patient per quadrant. One of (D4260,

D4261) per 60 Month(s) Per patient per

quadrant. A minimum of four (4) affected

teeth in the quadrant. Periodontal charting

and pre-operative radiographs with claim

for pre-payment review.

pre-op x-ray(s), perio

charting

D4261 osseous surgery (including

elevation of a full thickness flap and

closure) - one to three contiguous

teeth or tooth bounded spaces per

quadrant

0-20 Per Quadrant (10, 20, 30,

40, LL, LR, UL, UR)

Yes One of (D4261) per 60 Month(s) Per

patient per quadrant. One of (D4260,

D4261) per 60 Month(s) Per patient per

quadrant. One (1) to three (3) affected

teeth in the quadrant. Periodontal charting

and pre-operative radiographs with claim

for pre-payment review.

pre-op x-ray(s), perio

charting

D4263 bone replacement graft - first site in

quadrant

0-20 Teeth 1 - 32 Yes Periodontal charting and pre-operative

radiographs with claim for pre-payment

review.

pre-op x-ray(s), perio

charting

DentaQuest LLC 64 of 136

July 1, 2024

Exhibit A Benefits Covered for

VA Cardinal Care Smiles - Under 21

Periodontics

Code Description Age Limitation Teeth Covered Authorization

Required

Benefit Limitations Documentation

Required

D4264 bone replacement graft - each

additional site in quadrant

0-20 Teeth 1 - 32 Yes Periodontal charting and pre-operative

radiographs with claim for pre-payment

review.

pre-op x-ray(s), perio

charting

D4270 pedicle soft tissue graft procedure 0-20 Teeth 1 - 32 No

D4273 subepithelial connective tissue graft

procedure

0-20 Teeth 1 - 32 No

D4277 Free soft tissue graft procedure

(including donor site surgery), first

tooth or edentulous tooth position in

graft

0-20 Teeth 1 - 32 No One of (D4277) per 1 Lifetime Per patient

per quadrant.

D4278 Free soft tissue graft procedure

(including donor site surgery), each

additional contiguous tooth or

edentulous tooth position in same

graft site

0-20 Teeth 1 - 32 No One of (D4278) per 1 Lifetime Per patient

per quadrant.

D4283 autogenous connective tissue graft

procedure (including donor and

recipient surgical sites) – each

additional contiguous tooth, implant

or edentulous tooth position in

same graft site

0-20 Per Quadrant (10, 20, 30,

40, LL, LR, UL, UR)

No One of (D4283) per 1 Lifetime Per patient

per quadrant.

D4322 splint – intra-coronal; natural teeth

or prosthetic crowns

0-20 Teeth 1 - 32 No

D4323 splint – extra-coronal; natural teeth

or prosthetic crowns

0-20 Teeth 1 - 32 No

D4341 periodontal scaling and root planing

- four or more teeth per quadrant

0-20 Per Quadrant (10, 20, 30,

40, LL, LR, UL, UR)

Yes One of (D4341, D4342) per 24 Month(s)

Per patient per quadrant. Either D4341 or

D4342. A minimum of four (4) affected

teeth in the quadrant. Periodontal charting

and pre-operative radiographs with claim

for pre-payment review.

pre-op x-ray(s), perio

charting

D4342 periodontal scaling and root planing

- one to three teeth per quadrant

0-20 Per Quadrant (10, 20, 30,

40, LL, LR, UL, UR)

No One of (D4341, D4342) per 24 Month(s)

Per patient per quadrant. Either D4341 or

D4342. One (1) to three (3) affected teeth

in the quadrant. Check service limit.

Periodontal charting and pre-operative

radiographs with claim for pre-payment

review.

DentaQuest LLC 65 of 136

July 1, 2024

Exhibit A Benefits Covered for

VA Cardinal Care Smiles - Under 21

Periodontics

Code Description Age Limitation Teeth Covered Authorization

Required

Benefit Limitations Documentation

Required

D4346 scaling in presence of generalized

moderate or severe gingival

inflammation, full mouth, after oral

evaluation

0-20 No One of (D1110, D1120, D4346) per 6

Month(s) Per patient. Not allowed on

same day as D1110 or D1120.

D4355 full mouth debridement to enable a

comprehensive periodontal

evaluation and diagnosis on a

subsequent visit

0-20 No One of (D4355) per 12 Month(s) Per

patient. Only covered when there is

substantial gingival inflammation

(gingivitis) in all four quadrants.Cannot be

billed on same day with D0150, D1110 or

D1120. Not covered within 12 months

following D1110, D1120, D4341 or D4342.

D4910 periodontal maintenance

procedures

0-20 No Four of (D4910) per 12 Month(s) Per

patient. Any combination of D1110, D1120

and D4910 up to four (4) per 12 months.

Covered following active treatment only

(D4210, D4211, D4260, D4261, D4341,

D4342).

DentaQuest LLC 66 of 136

July 1, 2024

Exhibit A Benefits Covered for

VA Cardinal Care Smiles - Under 21

Provision for removable prostheses when masticatory function is impaired, or when existing prostheses is unserviceable and when evidence is submitted

that indicates that the masticatory insufficiencies are likely to impair the general health of the member.

Authorization for partial dentures to replace posterior teeth will not be allowed if there are in each quadrant at least three (3) peridontially sound posterior

teeth in fairly good position and occlusion with opposing dentition. For partial dentures, two or more posterior teeth must be missing in a quadrant or at least

one posterior tooth in each quadrant of the same arch.

Authorization for cast partial dentures for anterior teeth generally will not be given unless two or more anterior teeth in the same arch are missing. A modified

space maintainer is to be considered when only one anterior tooth is missing in an arch, Exceptions may be made on a per case basis.

Dentures will not be preauthorized when:

Dental history reveals that any or all dentures made in recent years have been unsatisfactory for reasons that are not remediable because of physiological or

psychological reasons, or repair, relining or rebasing of the patient's present dentures will make them serviceable.

A preformed denture with teeth already mounted forming a denture module is not a covered service.

BILLING AND REIMBURSEMENT FOR CAST CROWNS AND POST & CORES OR REMOVABLE PROSTHETICS SHALL BE BASED ON THE

CEMENTATION OR INSERTION DATE.

For all services that require pre-payment review, Providers have the option of requesting prior authorization.

Prosthodontics, removable

Code Description Age Limitation Teeth Covered Authorization

Required

Benefit Limitations Documentation

Required

D5110 complete denture - maxillary 0-20 Per Arch (01, UA) No One of (D5110) per 60 Month(s) Per

patient.

D5120 complete denture - mandibular 0-20 Per Arch (02, LA) No One of (D5120) per 60 Month(s) Per

patient.

D5130 immediate denture - maxillary 0-20 Per Arch (01, UA) No One of (D5130) per 1 Lifetime Per patient.

D5140 immediate denture - mandibular 0-20 Per Arch (02, LA) No One of (D5140) per 1 Lifetime Per patient.

D5211 maxillary partial denture, resin base

(including retentive/clasping

materials, rests, and teeth)

0-20 Yes One of (D5211, D5213, D5221, D5223,

D5225) per 60 Month(s) Per patient.

Pre-operative radiographs of all teeth in

arch with claim for pre-payment review.

pre-operative x-ray(s)

D5212 mandibular partial denture, resin

base (including retentive/clasping

materials, rests, and teeth)

0-20 Yes One of (D5212, D5214, D5222, D5224,

D5226) per 60 Month(s) Per patient.

Pre-operative radiographs of all teeth in

arch with claim for pre-payment review.

pre-operative x-ray(s)

DentaQuest LLC 67 of 136

July 1, 2024

Exhibit A Benefits Covered for

VA Cardinal Care Smiles - Under 21

Prosthodontics, removable

Code Description Age Limitation Teeth Covered Authorization

Required

Benefit Limitations Documentation

Required

D5213 maxillary partial denture - cast

metal framework with resin denture

bases (including retentive/clasping

materials, rests and teeth)

0-20 Yes One of (D5211, D5213, D5221, D5223,

D5225) per 60 Month(s) Per patient.

Pre-operative radiographs of all teeth in

arch with claim for pre-payment review.

pre-operative x-ray(s)

D5214 mandibular partial denture - cast

metal framework with resin denture

bases (including retentive/clasping

materials, rests and teeth)

0-20 Yes One of (D5212, D5214, D5222, D5224,

D5226) per 60 Month(s) Per patient.

Pre-operative radiographs of all teeth in

arch with claim for pre-payment review.

pre-operative x-ray(s)

D5221 immediate maxillary partial denture

– resin base (including any

conventional clasps, rests and

teeth)

0-20 Yes One of (D5211, D5213, D5221, D5223,

D5225) per 60 Month(s) Per patient.

Pre-operative radiographs of all teeth in

arch with claim for pre-payment review.

pre-operative x-ray(s)

D5222 immediate mandibular partial

denture - resin base (including any

conventional clasps, rests and

teeth)

0-20 Yes One of (D5212, D5214, D5222, D5224,

D5226) per 60 Month(s) Per patient.

Pre-operative radiographs of all teeth in

arch with claim for pre-payment review.

pre-operative x-ray(s)

D5223 immediate maxillary partial denture

– cast metal framework with resin

denture bases (including any

conventional clasps, rests and

teeth)

0-20 Yes One of (D5211, D5213, D5221, D5223,

D5225) per 60 Month(s) Per patient.

Pre-operative radiographs of all teeth in

arch with claim for pre-payment review.

pre-operative x-ray(s)

D5224 immediate mandibular partial

denture – cast metal framework

with resin denture bases (including

any conventional clasps, rests and

teeth)

0-20 Yes One of (D5212, D5214, D5222, D5224,

D5226) per 60 Month(s) Per patient.

Pre-operative radiographs of all teeth in

arch with claim for pre-payment review.

pre-operative x-ray(s)

D5225 maxillary partial denture-flexible

base

0-20 Yes One of (D5211, D5213, D5221, D5223,

D5225) per 60 Month(s) Per patient.

Pre-operative radiographs of all teeth in

arch with claim for pre-payment review.

pre-operative x-ray(s)

D5226 mandibular partial denture-flexible

base

0-20 Yes One of (D5212, D5214, D5222, D5224,

D5226) per 60 Month(s) Per patient.

Pre-operative radiographs of all teeth in

arch with claim for pre-payment review.

pre-operative x-ray(s)

D5227 immediate maxillary partial denture

- flexible base (including any

clasps, rests and teeth)

0-20 No One of (D5211, D5213, D5221, D5223,

D5225, D5227, D5282, D5284, D5286) per

60 Month(s) Per patient. Pre-operative

radiographs of all teeth in arch with claim

for pre-payment review.

DentaQuest LLC 68 of 136

July 1, 2024

Exhibit A Benefits Covered for

VA Cardinal Care Smiles - Under 21

Prosthodontics, removable

Code Description Age Limitation Teeth Covered Authorization

Required

Benefit Limitations Documentation

Required

D5228 immediate mandibular partial

denture - flexible base (including

any clasps, rests and teeth)

0-20 No One of (D5212, D5214, D5222, D5224,

D5226, D5228, D5283, D5284, D5286) per

60 Month(s) Per patient. Pre-operative

radiographs of all teeth in arch with claim

for pre-payment review.

D5282 Removable unilateral partial

denture--one piececast metal

(including clasps and teeth),

maxillary

0-20 No One of (D5282) per 60 Month(s) Per

patient per arch. Pre-operative

radiographs of all teeth in arch with claim

for pre-payment review.

D5283 Removable unilateral partial

denture--one piececast metal

(including clasps and teeth),

mandibular

0-20 No One of (D5283) per 60 Month(s) Per

patient per arch. Pre-operative

radiographs of all teeth in arch with claim

for pre-payment review.

D5284 Removeable Unilateral Partial

Denture- One Piece Flexible Base-

Per Quadrant

0-20 Per Quadrant (10, 20, 30,

40, LL, LR, UL, UR)

D5286 Removeable Unilateral Partial

Denture- One Piece Resin Base-

Per Quadrant

0-20 Per Quadrant (10, 20, 30,

40, LL, LR, UL, UR)

D5410 adjust complete denture - maxillary 0-20 No Not covered within 6 months of placement.

D5411 adjust complete denture -

mandibular

0-20 No Not covered within 6 months of placement.

D5421 adjust partial denture-maxillary 0-20 No Not covered within 6 months of placement.

D5422 adjust partial denture - mandibular 0-20 No Not covered within 6 months of placement.

D5511 repair broken complete denture

base, mandibular

0-20 No One of (D5511) per 12 Month(s) Per

patient. Not covered within 6 months of

placement.

D5512 repair broken complete denture

base, maxillary

0-20 No One of (D5512) per 12 Month(s) Per

patient. Not covered within 6 months of

placement.

D5520 replace missing or broken teeth -

complete denture (each tooth)

0-20 Teeth 1 - 32 No

D5611 repair resin partial denture base,

mandibular

0-20 No One of (D5611) per 12 Month(s) Per

patient. Not covered within 6 months of

placement.

D5612 repair resin partial denture base,

maxillary

0-20 No One of (D5612) per 12 Month(s) Per

patient. Not covered within 6 months of

placement.

DentaQuest LLC 69 of 136

July 1, 2024

Exhibit A Benefits Covered for

VA Cardinal Care Smiles - Under 21

Prosthodontics, removable

Code Description Age Limitation Teeth Covered Authorization

Required

Benefit Limitations Documentation

Required

D5621 repair cast partial framework,

mandibular

0-20 No One of (D5621) per 12 Month(s) Per

patient. Not covered within 6 months of

placement.

D5622 repair cast partial framework,

maxillary

0-20 No One of (D5622) per 12 Month(s) Per

patient. Not covered within 6 months of

placement.

D5630 repair or replace broken

retentive/clasping materials per

tooth

0-20 Teeth 1 - 32 No One of (D5630) Per patient per tooth.

D5640 replace broken teeth-per tooth 0-20 Teeth 1 - 32 No

D5650 add tooth to existing partial denture 0-20 Teeth 1 - 32 No

D5660 add clasp to existing partial denture 0-20 Teeth 1 - 32 No

D5725 rebase hybrid prosthesis 0-20 Per Arch (01, 02, LA, UA) No

D5730 reline complete maxillary denture

(chairside)

0-20 No One of (D5730, D5750) per 24 Month(s)

Per patient. Not covered within 6 months

of placement.

D5731 reline complete mandibular denture

(chairside)

0-20 No One of (D5731, D5751) per 24 Month(s)

Per patient. Not covered within 6 months

of placement.

D5740 reline maxillary partial denture

(chairside)

0-20 No One of (D5740, D5760) per 24 Month(s)

Per patient. Not covered within 6 months

of placement.

D5741 reline mandibular partial denture

(chairside)

0-20 No One of (D5741, D5761) per 24 Month(s)

Per patient. Not covered within 6 months

of placement.

D5750 reline complete maxillary denture

(laboratory)

0-20 No One of (D5730, D5750) per 24 Month(s)

Per patient. Not covered within 6 months

of placement.

D5751 reline complete mandibular denture

(laboratory)

0-20 No One of (D5731, D5751) per 24 Month(s)

Per patient. Not covered within 6 months

of placement.

D5760 reline maxillary partial denture

(laboratory)

0-20 No One of (D5740, D5760) per 24 Month(s)

Per patient. Not covered within 6 months

of placement.

D5761 reline mandibular partial denture

(laboratory)

0-20 No One of (D5741, D5761) per 24 Month(s)

Per patient. Not covered within 6 months

of placement.

DentaQuest LLC 70 of 136

July 1, 2024

Exhibit A Benefits Covered for

VA Cardinal Care Smiles - Under 21

Prosthodontics, removable

Code Description Age Limitation Teeth Covered Authorization

Required

Benefit Limitations Documentation

Required

D5765 soft liner for complete or partial

removable denture – indirect

0-20 Per Arch (01, 02, LA, UA) No Pre-operative radiographs of all teeth in

arch with claim for pre-payment review.

D5850 tissue conditioning, maxillary 0-20 No Not covered within 6 months of placement.

D5851 tissue conditioning,mandibular 0-20 Yes Narrative of medical necessity with

claimfor prepayment review. Not covered

within 6 months of placement.

narrative of medical

necessity

DentaQuest LLC 71 of 136

July 1, 2024

Exhibit A Benefits Covered for

VA Cardinal Care Smiles - Under 21

Maxillofacial Prosthetics

Code Description Age Limitation Teeth Covered Authorization

Required

Benefit Limitations Documentation

Required

D5951 feeding aid 0-20 No

DentaQuest LLC 72 of 136

July 1, 2024

Exhibit A Benefits Covered for

VA Cardinal Care Smiles - Under 21

Implant Services

Code Description Age Limitation Teeth Covered Authorization

Required

Benefit Limitations Documentation

Required

D6096 remove broken implant retaining

screw

0-20 Teeth 1 - 32 No One of (D6096) per 60 Month(s) Per

patient per tooth for All Permanent Teeth.

DentaQuest LLC 73 of 136

July 1, 2024

Exhibit A Benefits Covered for

VA Cardinal Care Smiles - Under 21

Fixed prosthetics will only be covered under special circumstances when no other acceptable less expensive dental service will adequately accomplish the

treatment objectives.

Acid etch bonded bridges should be considered as less expensive alternate treatment if circumstances permit. Candidates for fixed prosthetics must have

demonstrated very good to excellent oral hygiene and dental health awareness.

A fixed prosthetic will generally only be approved when it replaces a maximum of 2 missing anterior teeth or 1 posterior tooth. Exceptions can be made on a

per case basis.

BILLING AND REIMBURSEMENT FOR CROWNS AND POST & CORES OR ANY OTHER FIXED PROSTHETIC SHALL BE BASED UPON THE

CEMENTATION DATE.

For all services that require pre-payment review, Providers have the option of requesting prior authorization.

Prosthodontics, fixed

Code Description Age Limitation Teeth Covered Authorization

Required

Benefit Limitations Documentation

Required

D6205 pontic - indirect resin based

composite

0-20 Teeth 1 - 32 Yes One of (D6205, D6211, D6212, D6214,

D6240, D6241, D6242, D6243, D6245,

D6250, D6251, D6252, D6710, D6720,

D6721, D6722, D6740, D6750, D6751,

D6752, D6753, D6790, D6791, D6792,

D6794) per 60 Month(s) Per patient per

tooth. Pre-operative radiographs of all

teeth in arch with claim for pre-payment

review.

pre-operative x-ray(s)

D6211 pontic-cast base metal 0-20 Teeth 1 - 32 Yes One of (D6205, D6211, D6212, D6214,

D6240, D6241, D6242, D6243, D6245,

D6250, D6251, D6252, D6710, D6720,

D6721, D6722, D6740, D6750, D6751,

D6752, D6753, D6790, D6791, D6792,

D6794) per 60 Month(s) Per patient per

tooth. Pre-operative radiographs of all

teeth in arch with claim for pre-payment

review.

pre-operative x-ray(s)

D6212 pontic - cast noble metal 0-20 Teeth 1 - 32 Yes One of (D6205, D6211, D6212, D6214,

D6240, D6241, D6242, D6243, D6245,

D6250, D6251, D6252, D6710, D6720,

D6721, D6722, D6740, D6750, D6751,

D6752, D6753, D6790, D6791, D6792,

D6794) per 60 Month(s) Per patient per

tooth. Pre-operative radiographs of all

teeth in arch with claim for pre-payment

review.

pre-operative x-ray(s)

DentaQuest LLC 74 of 136

July 1, 2024

Exhibit A Benefits Covered for

VA Cardinal Care Smiles - Under 21

Prosthodontics, fixed

Code Description Age Limitation Teeth Covered Authorization

Required

Benefit Limitations Documentation

Required

D6214 Pontic - titanium and titanium alloys 0-20 Teeth 1 - 32 Yes One of (D6205, D6211, D6212, D6214,

D6240, D6241, D6242, D6243, D6245,

D6250, D6251, D6252, D6710, D6720,

D6721, D6722, D6740, D6750, D6751,

D6752, D6753, D6790, D6791, D6792,

D6794) per 60 Month(s) Per patient per

tooth. Pre-operative radiographs of all

teeth in arch with claim for pre-payment

review.

pre-operative x-ray(s)

D6240 pontic-porcelain fused-high noble 0-20 Teeth 1 - 32 Yes One of (D6205, D6211, D6212, D6214,

D6240, D6241, D6242, D6243, D6245,

D6250, D6251, D6252, D6710, D6720,

D6721, D6722, D6740, D6750, D6751,

D6752, D6753, D6790, D6791, D6792,

D6794) per 60 Month(s) Per patient per

tooth. Pre-operative radiographs of all

teeth in arch with claim for pre-payment

review.

pre-operative x-ray(s)

D6241 pontic-porcelain fused to base

metal

0-20 Teeth 1 - 32 Yes One of (D6205, D6211, D6212, D6214,

D6240, D6241, D6242, D6243, D6245,

D6250, D6251, D6252, D6710, D6720,

D6721, D6722, D6740, D6750, D6751,

D6752, D6753, D6790, D6791, D6792,

D6794) per 60 Month(s) Per patient per

tooth. Pre-operative radiographs of all

teeth in arch with claim for pre-payment

review.

pre-operative x-ray(s)

D6242 pontic-porcelain fused-noble metal 0-20 Teeth 1 - 32 Yes One of (D6205, D6211, D6212, D6214,

D6240, D6241, D6242, D6243, D6245,

D6250, D6251, D6252, D6710, D6720,

D6721, D6722, D6740, D6750, D6751,

D6752, D6753, D6790, D6791, D6792,

D6794) per 60 Month(s) Per patient per

tooth. Pre-operative radiographs of all

teeth in arch with claim for pre-payment

review.

pre-operative x-ray(s)

D6243 Pontic - Porcelain fused to titanium

and titanium alloys

0-20 Teeth 1 - 32 Yes One of (D6205, D6211, D6212, D6214,

D6240, D6241, D6242, D6243, D6245,

D6250, D6251, D6252, D6710, D6720,

D6721, D6722, D6740, D6750, D6751,

D6752, D6753, D6790, D6791, D6792,

D6794) per 60 Month(s) Per patient per

tooth. Pre-operative radiographs of all

teeth in arch with claim for pre-payment

review.

pre-operative x-ray(s)

DentaQuest LLC 75 of 136

July 1, 2024

Exhibit A Benefits Covered for

VA Cardinal Care Smiles - Under 21

Prosthodontics, fixed

Code Description Age Limitation Teeth Covered Authorization

Required

Benefit Limitations Documentation

Required

D6245 prosthodontics fixed, pontic -

porcelain/ceramic

0-20 Teeth 1 - 32 Yes One of (D6205, D6211, D6212, D6214,

D6240, D6241, D6242, D6243, D6245,

D6250, D6251, D6252, D6710, D6720,

D6721, D6722, D6740, D6750, D6751,

D6752, D6753, D6790, D6791, D6792,

D6794) per 60 Month(s) Per patient per

tooth. Pre-operative radiographs of all

teeth in arch with claim for pre-payment

review.

pre-operative x-ray(s)

D6250 pontic-resin with high noble metal 0-20 Teeth 1 - 32 Yes One of (D6205, D6211, D6212, D6214,

D6240, D6241, D6242, D6243, D6245,

D6250, D6251, D6252, D6710, D6720,

D6721, D6722, D6740, D6750, D6751,

D6752, D6753, D6790, D6791, D6792,

D6794) per 60 Month(s) Per patient per

tooth. Pre-operative radiographs of all

teeth in arch with claim for pre-payment

review.

pre-operative x-ray(s)

D6251 pontic-resin with base metal 0-20 Teeth 1 - 32 Yes One of (D6205, D6211, D6212, D6214,

D6240, D6241, D6242, D6243, D6245,

D6250, D6251, D6252, D6710, D6720,

D6721, D6722, D6740, D6750, D6751,

D6752, D6753, D6790, D6791, D6792,

D6794) per 60 Month(s) Per patient per

tooth. Pre-operative radiographs of all

teeth in arch with claim for pre-payment

review.

pre-operative x-ray(s)

D6252 pontic-resin with noble metal 0-20 Teeth 1 - 32 Yes One of (D6205, D6211, D6212, D6214,

D6240, D6241, D6242, D6243, D6245,

D6250, D6251, D6252, D6710, D6720,

D6721, D6722, D6740, D6750, D6751,

D6752, D6753, D6790, D6791, D6792,

D6794) per 60 Month(s) Per patient per

tooth. Pre-operative radiographs of all

teeth in arch with claim for pre-payment

review.

pre-operative x-ray(s)

D6545 retainer - cast metal fixed 0-20 Teeth 1 - 32 Yes One of (D6545, D6548) per 60 Month(s)

Per patient per tooth. Pre-operative

radiographs of all teeth in arch with claim

for pre-payment review.

pre-operative x-ray(s)

D6548 prosthodontics fixed, retainer -

porcelain/ceramic for resin bonded

fixed prosthodontic

0-20 Teeth 1 - 32 Yes One of (D6545, D6548) per 60 Month(s)

Per patient per tooth. Pre-operative

radiographs of all teeth in arch with claim

for pre-payment review.

pre-operative x-ray(s)

DentaQuest LLC 76 of 136

July 1, 2024

Exhibit A Benefits Covered for

VA Cardinal Care Smiles - Under 21

Prosthodontics, fixed

Code Description Age Limitation Teeth Covered Authorization

Required

Benefit Limitations Documentation

Required

D6710 crown - indirect resin based

composite

0-20 Teeth 1 - 32 Yes One of (D6205, D6211, D6212, D6214,

D6240, D6241, D6242, D6243, D6245,

D6250, D6251, D6252, D6710, D6720,

D6721, D6722, D6740, D6750, D6751,

D6752, D6753, D6790, D6791, D6792,

D6794) per 60 Month(s) Per patient per

tooth. Pre-operative radiographs of all

teeth in arch with claim for pre-payment

review.

pre-operative x-ray(s)

D6720 crown-resin with high noble metal 0-20 Teeth 1 - 32 Yes One of (D6205, D6211, D6212, D6214,

D6240, D6241, D6242, D6243, D6245,

D6250, D6251, D6252, D6710, D6720,

D6721, D6722, D6740, D6750, D6751,

D6752, D6753, D6790, D6791, D6792,

D6794) per 60 Month(s) Per patient per

tooth. Pre-operative radiographs of all

teeth in arch with claim for pre-payment

review.

pre-operative x-ray(s)

D6721 crown-resin with base metal 0-20 Teeth 1 - 32 Yes One of (D6205, D6211, D6212, D6214,

D6240, D6241, D6242, D6243, D6245,

D6250, D6251, D6252, D6710, D6720,

D6721, D6722, D6740, D6750, D6751,

D6752, D6753, D6790, D6791, D6792,

D6794) per 60 Month(s) Per patient per

tooth. Pre-operative radiographs of all

teeth in arch with claim for pre-payment

review.

pre-operative x-ray(s)

D6722 crown-resin with noble metal 0-20 Teeth 1 - 32 Yes One of (D6205, D6211, D6212, D6214,

D6240, D6241, D6242, D6243, D6245,

D6250, D6251, D6252, D6710, D6720,

D6721, D6722, D6740, D6750, D6751,

D6752, D6753, D6790, D6791, D6792,

D6794) per 60 Month(s) Per patient per

tooth. Pre-operative radiographs of all

teeth in arch with claim for pre-payment

review.

pre-operative x-ray(s)

D6740 retainer crown, porcelain/ceramic 0-20 Teeth 1 - 32 Yes One of (D6205, D6211, D6212, D6214,

D6240, D6241, D6242, D6243, D6245,

D6250, D6251, D6252, D6710, D6720,

D6721, D6722, D6740, D6750, D6751,

D6752, D6753, D6790, D6791, D6792,

D6794) per 60 Month(s) Per patient per

tooth. Pre-operative radiographs of all

teeth in arch with claim for pre-payment

review.

pre-operative x-ray(s)

DentaQuest LLC 77 of 136

July 1, 2024

Exhibit A Benefits Covered for

VA Cardinal Care Smiles - Under 21

Prosthodontics, fixed

Code Description Age Limitation Teeth Covered Authorization

Required

Benefit Limitations Documentation

Required

D6750 crown-porcelain fused high noble 0-20 Teeth 1 - 32 Yes One of (D6205, D6211, D6212, D6214,

D6240, D6241, D6242, D6243, D6245,

D6250, D6251, D6252, D6710, D6720,

D6721, D6722, D6740, D6750, D6751,

D6752, D6753, D6790, D6791, D6792,

D6794) per 60 Month(s) Per patient per

tooth. Pre-operative radiographs of all

teeth in arch with claim for pre-payment

review.

pre-operative x-ray(s)

D6751 crown-porcelain fused to base

metal

0-20 Teeth 1 - 32 Yes One of (D6205, D6211, D6212, D6214,

D6240, D6241, D6242, D6243, D6245,

D6250, D6251, D6252, D6710, D6720,

D6721, D6722, D6740, D6750, D6751,

D6752, D6753, D6790, D6791, D6792,

D6794) per 60 Month(s) Per patient per

tooth. Pre-operative radiographs of all

teeth in arch with claim for pre-payment

review.

pre-operative x-ray(s)

D6752 crown-porcelain fused noble metal 0-20 Teeth 1 - 32 Yes One of (D6205, D6211, D6212, D6214,

D6240, D6241, D6242, D6243, D6245,

D6250, D6251, D6252, D6710, D6720,

D6721, D6722, D6740, D6750, D6751,

D6752, D6753, D6790, D6791, D6792,

D6794) per 60 Month(s) Per patient per

tooth. Pre-operative radiographs of all

teeth in arch with claim for pre-payment

review.

pre-operative x-ray(s)

D6753 Retainer Crown- Porcelain fused to

titanium and titanium alloys

0-20 Teeth 1 - 32 Yes One of (D6205, D6211, D6212, D6214,

D6240, D6241, D6242, D6243, D6245,

D6250, D6251, D6252, D6710, D6720,

D6721, D6722, D6740, D6750, D6751,

D6752, D6753, D6790, D6791, D6792,

D6794) per 60 Month(s) Per patient per

tooth. Pre-operative radiographs of all

teeth in arch with claim for pre-payment

review.

pre-operative x-ray(s)

D6784 Retainer Crown 3/4- Titanium and

Titanium Alloys

0-20 Teeth 1 - 32 No

DentaQuest LLC 78 of 136

July 1, 2024

Exhibit A Benefits Covered for

VA Cardinal Care Smiles - Under 21

Prosthodontics, fixed

Code Description Age Limitation Teeth Covered Authorization

Required

Benefit Limitations Documentation

Required

D6790 crown-full cast high noble 0-20 Teeth 1 - 32 Yes One of (D6205, D6211, D6212, D6214,

D6240, D6241, D6242, D6243, D6245,

D6250, D6251, D6252, D6710, D6720,

D6721, D6722, D6740, D6750, D6751,

D6752, D6753, D6790, D6791, D6792,

D6794) per 60 Month(s) Per patient per

tooth. Pre-operative radiographs of all

teeth in arch with claim for pre-payment

review.

pre-operative x-ray(s)

D6791 crown - full cast base metal 0-20 Teeth 1 - 32 Yes One of (D6205, D6211, D6212, D6214,

D6240, D6241, D6242, D6243, D6245,

D6250, D6251, D6252, D6710, D6720,

D6721, D6722, D6740, D6750, D6751,

D6752, D6753, D6790, D6791, D6792,

D6794) per 60 Month(s) Per patient per

tooth. Pre-operative radiographs of all

teeth in arch with claim for pre-payment

review.

pre-operative x-ray(s)

D6792 crown - full cast noble metal 0-20 Teeth 1 - 32 Yes One of (D6205, D6211, D6212, D6214,

D6240, D6241, D6242, D6243, D6245,

D6250, D6251, D6252, D6710, D6720,

D6721, D6722, D6740, D6750, D6751,

D6752, D6753, D6790, D6791, D6792,

D6794) per 60 Month(s) Per patient per

tooth. Pre-operative radiographs of all

teeth in arch with claim for pre-payment

review.

pre-operative x-ray(s)

D6794 Retainer crown - titanium and

titanium alloys

0-20 Teeth 1 - 32 Yes One of (D6205, D6211, D6212, D6214,

D6240, D6241, D6242, D6243, D6245,

D6250, D6251, D6252, D6710, D6720,

D6721, D6722, D6740, D6750, D6751,

D6752, D6753, D6790, D6791, D6792,

D6794) per 60 Month(s) Per patient per

tooth. Pre-operative radiographs of all

teeth in arch with claim for pre-payment

review.

pre-operative x-ray(s)

D6930 re-cement or re-bond fixed partial

denture

0-20 No

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July 1, 2024

Exhibit A Benefits Covered for

VA Cardinal Care Smiles - Under 21

Reimbursement includes local anesthesia and routine post-operative care.

The extraction of asymptomatic impacted teeth is not a covered benefit. Symptomatic conditions would include pain and/or infection or demonstrated

malocclusion causing a shifting of existing dentition.

Oral surgery procedures not listed in Exhibit A may be covered under the member's medical benefits through the Medicaid, FAMIS, or FAMIS Plus

fee-for-service or managed care organization (MCO) program.

For all services that require pre-payment review, Providers have the option of requesting prior authorization.

Oral and Maxillofacial Surgery

Code Description Age Limitation Teeth Covered Authorization

Required

Benefit Limitations Documentation

Required

D7111 extraction, coronal remnants -

primary tooth

0-20 Teeth A - T, AS, BS, CS,

DS, ES, FS, GS, HS, IS,

JS, KS, LS, MS, NS, OS,

PS, QS, RS, SS, TS

D7140 extraction, erupted tooth or

exposed root (elevation and/or

forceps removal)

0-20 Teeth 1 - 32, 51 - 82, A - T,

AS, BS, CS, DS, ES, FS,

GS, HS, IS, JS, KS, LS,

MS, NS, OS, PS, QS, RS,

SS, TS

D7210 surgical removal of erupted tooth

requiring removal of bone and/or

sectioning of tooth, and including

elevation of mucoperiosteal flap if

indicated

0-20 Teeth 1 - 32, 51 - 82, A - T,

AS, BS, CS, DS, ES, FS,

GS, HS, IS, JS, KS, LS,

MS, NS, OS, PS, QS, RS,

SS, TS

No Erupted surgical extractions are defined as

extractions requiring elevation of a

mucoperiosteal flap and removal of bone

and/or section of the tooth and closure.

D7220 removal of impacted tooth-soft

tissue

0-20 Teeth 1 - 32, 51 - 82, A - T,

AS, BS, CS, DS, ES, FS,

GS, HS, IS, JS, KS, LS,

MS, NS, OS, PS, QS, RS,

SS, TS

No Removal of asymptomatic tooth not

covered.

D7230 removal of impacted tooth-partially

bony

0-20 Teeth 1 - 32, 51 - 82, A - T,

AS, BS, CS, DS, ES, FS,

GS, HS, IS, JS, KS, LS,

MS, NS, OS, PS, QS, RS,

SS, TS

No Removal of asymptomatic tooth not

covered.

D7240 removal of impacted

tooth-completely bony

0-20 Teeth 1 - 32, 51 - 82, A - T,

AS, BS, CS, DS, ES, FS,

GS, HS, IS, JS, KS, LS,

MS, NS, OS, PS, QS, RS,

SS, TS

No Removal of asymptomatic tooth not

covered.

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July 1, 2024

Exhibit A Benefits Covered for

VA Cardinal Care Smiles - Under 21

Oral and Maxillofacial Surgery

Code Description Age Limitation Teeth Covered Authorization

Required

Benefit Limitations Documentation

Required

D7241 removal of impacted

tooth-completely bony, with unusual

surgical complications

0-20 Teeth 1 - 32, 51 - 82, A - T,

AS, BS, CS, DS, ES, FS,

GS, HS, IS, JS, KS, LS,

MS, NS, OS, PS, QS, RS,

SS, TS

Yes Unusually difficult or complicated due to

factors such as nerve dissection required,

separate closure of maxillary sinus

required, aberrant tooth position, or

unusual depth of impaction. Pre-operative

radiographs with claim for pre-payment

review.

pre-operative x-ray(s)

D7250 surgical removal of residual tooth

roots (cutting procedure)

0-20 Teeth 1 - 32, 51 - 82, A - T,

AS, BS, CS, DS, ES, FS,

GS, HS, IS, JS, KS, LS,

MS, NS, OS, PS, QS, RS,

SS, TS

No Will not be paid to the dentist or dental

group that removed the tooth. Removal of

asymptomatic tooth not covered.

D7260 oroantral fistula closure 0-20 No

D7261 primary closure of a sinus

perforation

0-20 No

D7270 tooth reimplantation and/or

stabilization of accidentally evulsed

or displaced tooth

0-20 Teeth 1 - 32 Yes Narrative with claim for prepayment

review.

narrative of medical

necessity

D7280 Surgical access of an unerupted

tooth

0-20 Teeth 1 - 32 Yes Pre-operative radiographs and narrative

with claim for pre-payment review.

narr. of med. necessity,

pre-op x-ray(s)

D7282 mobilization of erupted or

malpositioned tooth to aid eruption

0-20 Teeth 1 - 32 No

D7283 placement of device to facilitate

eruption of impacted tooth

0-20 Teeth 1 - 32 Yes Will not be payable unless orthodontic

treatment has been proposed or is in

progress. Orthodontic approval is not

required. Pre-operative radiographs and

narrative with claim for pre-payment

review.

narr. of med. necessity,

pre-op x-ray(s)

D7284 excisional biopsy of minor salivary

glands

0-20 No

D7285 incisional biopsy of oral tissue-hard

(bone, tooth)

0-20 No

D7286 incisional biopsy of oral tissue-soft 0-20 No

D7288 brush biopsy - transepithelial

sample collection

0-20 No

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July 1, 2024

Exhibit A Benefits Covered for

VA Cardinal Care Smiles - Under 21

Oral and Maxillofacial Surgery

Code Description Age Limitation Teeth Covered Authorization

Required

Benefit Limitations Documentation

Required

D7310 alveoloplasty in conjunction with

extractions - four or more teeth or

tooth spaces, per quadrant

0-20 Per Quadrant (10, 20, 30,

40, LL, LR, UL, UR)

No One of (D7310) per 1 Lifetime Per patient

per quadrant. One of (D7310, D7311) per

1 Day(s) Per patient per quadrant. Either

D7310 or D7311. Minimum of three (3)

extractions per quadrant. Not allowed with

a surgical extraction in same quadrant.

Pre-operative radiographs and narrative of

medical necessity with claim for

pre-payment review.

D7311 alveoloplasty in conjunction with

extractions - one to three teeth or

tooth spaces, per quadrant

0-20 Per Quadrant (10, 20, 30,

40, LL, LR, UL, UR)

No One of (D7311) per 1 Lifetime Per patient

per quadrant. One of (D7310, D7311) per

1 Day(s) Per patient per quadrant. Either

D7310 or D7311. Minimum of three (3)

extractions per quadrant. Not allowed with

a surgical extraction in same quadrant.

Pre-operative radiographs and narrative of

medical necessity with claim for

pre-payment review.

D7320 alveoloplasty not in conjunction with

extractions - four or more teeth or

tooth spaces, per quadrant

0-20 Per Quadrant (10, 20, 30,

40, LL, LR, UL, UR)

No One of (D7320) per 1 Lifetime Per patient

per quadrant. One of (D7320, D7321) per

1 Day(s) Per patient per quadrant. No

extractions performed in edentulous area.

D7321 alveoloplasty not in conjunction with

extractions - one to three teeth or

tooth spaces, per quadrant

0-20 Per Quadrant (10, 20, 30,

40, LL, LR, UL, UR)

No One of (D7321) per 1 Lifetime Per patient

per quadrant. One of (D7320, D7321) per

1 Day(s) Per patient per quadrant. No

extractions performed on edentulous area.

D7450 removal of odontogenic cyst or

tumor - lesion diameter up to

1.25cm

0-20 Yes Pathology report

D7451 removal of odontogenic cyst or

tumor - lesion greater than 1.25cm

0-20 Yes Pathology report

D7471 removal of exostosis - per site 0-20 Per Arch (01, 02, LA, UA) No

D7472 removal of torus palatinus 0-20 No

D7473 removal of torus mandibularis 0-20 No

D7485 surgical reduction of osseous

tuberosity

0-20 No

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July 1, 2024

Exhibit A Benefits Covered for

VA Cardinal Care Smiles - Under 21

Oral and Maxillofacial Surgery

Code Description Age Limitation Teeth Covered Authorization

Required

Benefit Limitations Documentation

Required

D7510 incision and drainage of abscess -

intraoral soft tissue

0-20 Teeth 1 - 32, 51 - 82, A - T,

AS, BS, CS, DS, ES, FS,

GS, HS, IS, JS, KS, LS,

MS, NS, OS, PS, QS, RS,

SS, TS

No One of (D7510, D7511) per 1 Day(s) Per

patient per tooth. Either D7510 or D7511.

D7511 incision and drainage of abscess -

intraoral soft tissue - complicated

(includes drainage of multiple

fascial spaces)

0-20 No One of (D7510, D7511) per 1 Day(s) Per

patient. Either D7510 or D7511.

D7880 occlusal orthotic device, by report 0-20 No Covered only for temporomandbular pain,

dysfunction or assoc. musculature.

D7961 buccal / labial frenectomy

(frenulectomy)

0-20 No The frenum may be excised when the

tongue has limited mobility, causing

inability to eat, speak or breathe and

supported by narrative of referring

physician. For large diastemas between

teeth, in conjunction with approved

orthodontic treatment. Or when frenum

interferes with a prosthetic appliance, or

when it is the etiology of recession of

periodontal tissue. Midsagittal removal

only.

D7962 lingual frenectomy (frenulectomy) 0-20 No The frenum may be excised when the

tongue has limited mobility, causing

inability to eat, speak or breathe and

supported by narrative of referring

physician. For large diastemas between

teeth, in conjunction with approved

orthodontic treatment. Or when frenum

interferes with a prosthetic appliance, or

when it is the etiology of recession of

periodontal tissue. Midsagittal removal

only.

D7963 frenuloplasty 0-20 No One of (D7960, D7963) per 1 Lifetime Per

patient. Excision of frenum with excision

or repositioning of abervant muscle and

z-plasty or other local flap closure. The

frenum may be excised when the tongue

has limited mobility, for large diastemas

between teeth, or when frenum interferes

with a prosthetic appliance, or when it is

the etiology of periodontal tissue disease.

Midsagittal removal only.

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July 1, 2024

Exhibit A Benefits Covered for

VA Cardinal Care Smiles - Under 21

Oral and Maxillofacial Surgery

Code Description Age Limitation Teeth Covered Authorization

Required

Benefit Limitations Documentation

Required

D7970 excision of hyperplastic tissue - per

arch

0-20 Per Arch (01, 02, LA, UA) No

D7971 excision of pericoronal gingiva 0-20 Teeth 1 - 32 No

D7972 surgical reduction of fibrous

tuberosity

0-20 No

DentaQuest LLC 84 of 136

July 1, 2024

Exhibit A Benefits Covered for

VA Cardinal Care Smiles - Under 21

Medicaid Members age 20 and under may qualify for orthodontic care under the program. Members must have a severe, dysfunctional, handicapping

malocclusion.

Since a case must be dysfunctional to be accepted for treatment, Members whose molars and bicuspids are in good occlusion seldom qualify. Crowding

alone is not usually dysfunctional in spite of the aesthetic considerations.

Limited tooth guidance, if a covered benefit, will be authorized on a selective basis to help prevent the future necessity for full-banded treatment. All

appliance adjustments are incidental and included in the allowance for the tooth guidance appliance. With the exception of situations involving gingival

stripping or other nonreversible damage, appliances for minor tooth guidance (codes D8020 through D8040) will be approved when they are the only

treatment necessary. If treatment is not definitive, the movement will only be covered as part of a comprehensive orthodontic treatment plan.

All comprehensive orthodontic services require prior authorization by one of DentaQuest's Dental Consultants. The Member should present with a fully

erupted set of permanent teeth. At least 1/2 to 3/4 of the clinical crown should be exposed, unless the tooth is impacted or congenitally missing.

In evaluating requests for orthodontic coverage, medical necessity/handicapping criteria (which can be found on the website) are used as the first level

review to determine coverage as applied to the permanent dentition. If the requested orthodontic treatment meets one of the listed criteria, DentaQuest will

approve the request for coverage as meeting medically necessary handicapping criteria. Please note, a complete series of intra-oral photographs and all

required documentation to support medical necessity should be submitted along with the Orthodontic Criteria Index Form. If the request does not meet any

of the listed criteria, then DentaQuest will proceed in evaluating the request by applying the Salzmann Malocclusion Severity Assessment (which can be

found on the website).

The Salzmann Evaluation Criteria Index Form is also used as the basis for determining whether a Member qualifies for orthodontic treatment. A member

must score a minimum of 25 points to qualify for coverage – points are not awarded for esthetics, therefore additional points for handicapping esthetics will

not be considered as part of the determination.

For cases that may not meet the Salzmann criteria, medical necessity documentation to support any of the following impaired functions must be submitted

along with all other required documentation, including intra-oral photos or models, panoramic and cepholometric films, tracings, score sheets, and narratives:

* Speech disorder – Documented by a physician or speech therapist,

* Eating disorder – Problems documented by a physician,

* Emotional mental distress to impair school participation – Documented by a teacher, a counselor, or a School psychologist All documentation will be

reviewed together and an appropriate determination made.

Diagnostic study models (trimmed) with waxbites or OrthoCad electronic equivalent and treatment plan must be submitted with the request for prior

authorization of services. Treatment should not begin prior to receiving notification from DentaQuest indicating coverage or non-coverage for the proposed

treatment plan. Providers cannot bill prior to services being performed.

If the case is denied, the prior authorization will be returned to the Provider indicating that DentaQuest will not cover the orthodontic treatment. In order to

receive payment of records for cases that are denied, a claim must be submitted on an ADA form for D8660. The date of service will be the date the

treatment plan, radiographs and/or photos, records and diagnostic models were performed by the provider.

In cases where the member has been approved for comprehensive Orthodontic benefits, and the parent has decided they do not wish to have the child

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July 1, 2024

begin treatment at this time or any time in the near future, the provider may bill for their records, to include the treatment plan, radiographs, models, photos,

etc. using D8999 and explaining the situation on the claim for payment. The reimbursement for these records is the same.

General Billing Information for Orthodontics:

The start and billing date of orthodontic services is defined as the date when the bands, brackets, or appliances are placed in the Member’s mouth. The

Member must be eligible on this date of service.

If a member becomes ineligible during treatment and before full payment is made, DentaQuest will pay the balance of any remaining treatment up to the

approved case rate. To receive the remaining balance for members that are ineligible but remain in treatment, providers must submit the claim using D8999

with the last service date the patient was eligible.

To guarantee proper and prompt payment of orthodontic cases, please follow the steps below:

Electronically file, fax or mail a copy of the completed ADA form with the date of service (banding date) filled in. Our fax number is 262. 241.7150.

Initial payments for orthodontics (code D8080) includes pre-orthodontic visit, radiographs, treatment plan, records, diagnostic models, initial banding, 1 set

of retainers, and 12 months of retainer adjustments (If retainer fees are not separate).

Once DentaQuest receives the banding date, the initial payment for code D8080 will be set to pay out. Providers must submit claims for 5 quarterly

payments (Code D8670) and de-banding (D8680). The member must be eligible on the date of the claim.

The maximum case payment for orthodontic treatment will be 1 initial payment (D8080), 5 quarterly periodic billed orthodontic treatments (D8670) and 1

payment for de-banding (D8680).

Members may not be billed for broken, repaired, or replacement of brackets or wires. Payment for up to one set of lost/unrepairable retainers may be

considered on a medically necessary basis.

In order to receive payment of records for cases that are denied, a claim must be submitted on an ADA form for D8660. The date of service will be the date

the treatment plan, radiographs and/or photos, records and diagnostic models were performed by the provider.

***Please notify DentaQuest should the Member discontinue treatment for any reason*** Continuation of Treatment:

DentaQuest, LLC requires the following information for possible payment of continuation of care cases:

* Completed "Orthodontic Continuation of Care Form" - See Appendix A.

* Completed ADA claim form listing services to be rendered.

* A copy of Member’s prior approval including the total approved case fee,

banding fee, and periodic orthodontic treatment fees.

* If the member is private pay or transferring from a commercial insurance program: Original diagnostic models (or OrthoCad equivalent), radiographs

(optional).

Orthodontics

Code Description Age Limitation Teeth Covered Authorization

Required

Benefit Limitations Documentation

Required

D8010 limited orthodontic treatment of the

primary dentition

0-20 No

DentaQuest LLC 86 of 136

July 1, 2024

Exhibit A Benefits Covered for

VA Cardinal Care Smiles - Under 21

Orthodontics

Code Description Age Limitation Teeth Covered Authorization

Required

Benefit Limitations Documentation

Required

D8020 limited orthodontic treatment of the

transitional dentition

0-20 Yes narrative of medical

necessity

D8030 limited orthodontic treatment of the

adolescent dentition

0-20 Yes Narrative of medical need with claim for

prepayment review.

narrative of medical

necessity

D8040 limited orthodontic treatment of the

adult dentition

0-20 Yes Narrative of medical need with claim for

prepayment review.

narrative of medical

necessity

D8080 comprehensive orthodontic

treatment of the adolescent

dentition

0-20 Yes One of (D8080) per 1 Lifetime Per patient.

Panoramic or periapical radiogprahs.

Cephalogram and/or photos or OrthoCad

equivalent. PRIOR AUTHORIZATION IS

REQUIRED.

Panoramic x-ray, Study

model

D8210 removable appliance therapy

(includes appliances for thumb

sucking and tongue thrusting)

0-20 No

D8220 fixed appliance therapy (includes

appliances for thumb sucking and

tongue thrusting)

0-20 No One of (D8220) per 1 Lifetime Per patient.

D8660 pre-orthodontic treatment

examination to monitor growth and

development

0-20 Yes One of (D8660) per 1 Year(s) Per Provider.

For denied cases only An internal

authorization will be issued for the

payment of the pre-orthodontic visit (code

D8660)

D8670 periodic orthodontic treatment visit 0-20 Yes One of (D8670) per 90 Day(s) Per patient.

Maximum of five (5) quarterly payments.

This code (D8670) cannot be billed prior to

91 days after the date of service of the

D8080 (comprehensive orthodontic

treatment of the adolescent dentition).

D8680 orthodontic retention (removal of

appliances)

0-20 Yes One of (D8680) per 1 Lifetime Per patient.

D8703 Replacement of lost or broken

retainer - maxillary

0-20 Yes One of (D8703) per 1 Lifetime Per patient.

Narrative of medical necessity with claim

for prepayment review.

narrative of medical

necessity

D8704 Replacement of lost or broken

retainer - mandibular

0-20 Yes One of (D8704) per 1 Lifetime Per patient.

Narrative of medical necessity with claim

for prepayment review.

narrative of medical

necessity

DentaQuest LLC 87 of 136

July 1, 2024

Exhibit A Benefits Covered for

VA Cardinal Care Smiles - Under 21

Orthodontics

Code Description Age Limitation Teeth Covered Authorization

Required

Benefit Limitations Documentation

Required

D8999 unspecified orthodontic procedure,

by report

0-20 Yes Debanding by dentist other than dentist

who initially banded case is one example.

Narrative of medical need with claim for

prepayment review.

narrative of medical

necessity

DentaQuest LLC 88 of 136

July 1, 2024

Exhibit A Benefits Covered for

VA Cardinal Care Smiles - Under 21

Local anesthesia is considered part of the treatment procedure, and no additional payment will be made for it. Adjunctive general services include: IV

sedation and emergency services provided for relief of dental pain.

Use of IV sedation and general anesthesia will be reviewed on a periodic basis. The service is not routinely used for the apprehensive dental patient. Medical

necessity must be demonstrated. Use of nitrous oxide and conscious sedation will also be reviewed on a periodic basis, and patient medical records must

include documentation of medical necessity.

For all services that require pre-payment review, Providers have the option of requesting prior authorization.

Qualified Dental network providers are the only providers who can submit claims for general anesthesia/deep sedation or intravenous conscious sedation

services and be paid by DentaQuest. For the claim to be paid the service must be delivered by that same provider. A dental provider not qualified to deliver

general anesthesia/deep sedation or intravenous conscious sedation procuring this service from a general anesthesiologist, can not submit a dental claim for

that service.

Use procedure code D9999 for all services connected with same day surgery. This includes the initial hospital care, history examination, initiation of

diagnostic and treatment programs, prepartion of hospital records, consults with anesthesia and/or pediatrician and others, day surgery visit, and hospital

discharge day management including the discharge summary.

Adjunctive General Services

Code Description Age Limitation Teeth Covered Authorization

Required

Benefit Limitations Documentation

Required

D9110 palliative treatment of dental pain -

per visit

0-20 No Not allowed with any other services other

than radiographs and emergency exam.

D9219 evaluation for moderate sedation,

deep sedation or general

anesthesia

0-20 No Three of (D9219) per 12 Month(s) Per

Provider OR Location.

D9222 deep sedation/general anesthesia

first 15 minutes

0-20 No

D9223 deep sedation/general anesthesia -

each subsequent 15 minute

increment

0-20 No Ten of (D9223, D9243) per 1 Day(s) Per

patient. Maximum of 150 minutes (10

units). Either D9223 or D9243. D9230

and/or D9248 are not allowed in

conjunction with D9223.

D9230 inhalation of nitrous

oxide/analgesia, anxiolysis

0-20 No The routine administration of inhalation

analgesia or oral sedation is generally

considered part of the treatment

procedure, unless its use is documented in

the patient record as necessary to

complete treatment. Cannot be used in

conjunction with D9223 and/or D9243 on

the same date of service.

D9239 intravenous moderate (conscious)

sedation/analgesia- first 15 minutes

0-20 No

DentaQuest LLC 89 of 136

July 1, 2024

Exhibit A Benefits Covered for

VA Cardinal Care Smiles - Under 21

Adjunctive General Services

Code Description Age Limitation Teeth Covered Authorization

Required

Benefit Limitations Documentation

Required

D9243 intravenous moderate (conscious)

sedation/analgesia - each

subsequent 15 minute increment

0-20 No Ten of (D9223, D9243) per 1 Day(s) Per

patient. Maximum of 150 minutes (10

units). Either D9223 or D9243. D9230

and/or D9248 are not allowed in

conjunction with D9243.

D9248 non-intravenous moderate sedation 0-20 No Must be documented as a medically

necessity in the patient records. Cannot be

used in conjunction with D9223 and/or

D9243 on the same date of service.

D9310 consultation - diagnostic service

provided by dentist or physician

other than requesting dentist or

physician

0-20 No One of (D9310) per 1 Day(s) Per Provider

OR Location. Not to be billed on the same

day or within 6 months of another exam

code by the same provider. Oral

evaluations and any consulting services

are inclusive in the code. Must be a

consult request from a health care

provider, excludes placement from

DentaQuest.

D9420 hospital or ambulatory surgical

center call

0-20 No Maximum of three (3) for the same day.

Cannot be billed with D9999 for hospital

care on the same date of service.

D9440 office visit - after regularly

scheduled hours

0-20 No

D9610 therapeutic drug injection, by report 0-20 No Either D9610 or D9612.

D9612 therapeutic drug injection - 2 or

more medications by report

0-20 No Either D9610 or D9612.

D9630 other drugs and/or medicaments,

by report

0-20 Yes Two of (D9630) per 6 Month(s) Per

Provider. Drug or medicament must be

documented on claim and in the patient

record.

narrative of medical

necessity

D9910 application of desensitizing

medicament

0-20 No

DentaQuest LLC 90 of 136

July 1, 2024

Exhibit A Benefits Covered for

VA Cardinal Care Smiles - Under 21

Adjunctive General Services

Code Description Age Limitation Teeth Covered Authorization

Required

Benefit Limitations Documentation

Required

D9920 behavior management, by report 0-20 No Four of (D9920) per 365 Day(s) Per

Location. One of (D9920) per 1 Day(s) Per

patient. Patient record must indicate the

additional staffing required to complete the

treatment. Patient record must indicate the

type and/or types of behavior management

techniques used.D9920 can be used up to

four (4) times per 365 day period. D9920

shall be used once per member per date

of service. D9920 can be used in

conjunction with D9230 on the same date

of service. It cannot be used in conjunction

with D9223, D9243 and/or D9248 on the

same date of service. If additional use of

D9920 is required in a 365 day period the

service must be preauthorized.

D9930 treatment of complications

(post-surgical) - unusual

circumstances, by report

0-20 No

D9944 occlusal guard--hard appliance, full

arch

0-20 Per Arch (01, 02, LA, UA) No One of (D9944, D9945, D9946) per 24

Month(s) Per patient.

D9945 occlusal guard--soft appliance full

arch

0-20 Per Arch (01, 02, LA, UA) No One of (D9944, D9945, D9946) per 24

Month(s) Per patient.

D9946 occlusal guard--hard appliance,

partial arch

0-20 Per Arch (01, 02, LA, UA) No One of (D9944, D9945, D9946) per 24

Month(s) Per patient.

D9990 certified translation or

sign-language services per visit

0-20 No Can only be used for language

interpretation services. Documentation

required: SFC Professional Interpreter

Service Form and a copy of the paid

Interpreter Service invoice/receipt.

D9992 dental case management – care

coordination

0-20 No Two of (D9992) per 6 Month(s) Per

Provider. Documentation of encounter

shall be maintained in the patient chart.

D9994 dental case management – patient

education to improve oral health

literacy

0-20 No Two of (D9994) per 6 Month(s) Per

Provider. Documentation of encounter

shall be maintained in the patient chart.

D9995 teledentistry – synchronous;

real-time encounter

0-20 No Four of (D9995) per 6 Month(s) Per

Provider. Documentation of encounter

shall be maintained in the patient chart.

DentaQuest LLC 91 of 136

July 1, 2024

Exhibit A Benefits Covered for

VA Cardinal Care Smiles - Under 21

Adjunctive General Services

Code Description Age Limitation Teeth Covered Authorization

Required

Benefit Limitations Documentation

Required

D9996 teledentistry – asynchronous;

information stored and forwarded to

dentist for subsequent review

0-20 No Four of (D9996) per 6 Month(s) Per

Provider. Documentation of encounter

shall be maintained in the patient chart.

D9999 unspecified adjunctive procedure,

by report

0-20 Yes For hospital operating room cases.

Includes all workups, same day surgery

visit, and discharge summary, etc. Cannot

be billed with D9420. Requires prior

approval.

DentaQuest LLC 92 of 136

July 1, 2024

Exhibit B Benefits Covered for

VA Cardinal Care Smiles - Over 21

Diagnostic services include the oral examination, and selected radiographs, needed to assess the oral health, diagnose oral pathology, and develop an

adequate treatment plan for the member's oral health.

Reimbursement for some or multiple radiographs of the same tooth or area may be denied if DentaQuest determines the number to be redundant, excessive

or not in keeping with the federal guidelines relating to radiation exposure. The maximum amount paid for individual radiographs taken on the same day will

be limited to the allowance for a full mouth series.

Reimbursement for radiographs is limited to those films required for proper treatment and/or diagnosis.

DentaQuest utilizes the guidelines published by the Department of Health and Human Services Center for Devices and Radiological Health. However, please

consult the following benefit tables for benefit limitations.

All radiographs must be of good diagnostic quality properly mounted, dated and identified with the recipient's name and date of birth. Substandard

radiographs will not be reimbursed for, or if already paid for, DentaQuest will recoup the funds previously paid.

Diagnostic

Code Description Age Limitation Teeth Covered Authorization

Required

Benefit Limitations Documentation

Required

D0120 periodic oral evaluation -

established patient

21 and older No

D0140 limited oral evaluation-problem

focused

21 and older No

D0150 comprehensive oral evaluation -

new or established patient

21 and older No One comprehensive exam per patient per

dentist or dental group. Not covered with

D0140, D9310 on same day.

D0170 re-evaluation, limited problem

focused

21 and older No

D0210 intraoral - comprehensive series of

radiographic images

21 and older No One of (D0210, D0330) per 60 Month(s)

Per Provider OR Location.

D0220 intraoral - periapical first

radiographic image

21 and older No One of (D0220) per 1 Day(s) Per patient.

D0230 intraoral - periapical each additional

radiographic image

21 and older No Four of (D0230) per 1 Day(s) Per patient.

D0240 intraoral - occlusal radiographic

image

21 and older No

D0250 extra-oral – 2D projection

radiographic image created using a

stationary radiation source, and

detector

21 and older No These images include, but are not limited

to: Lateral Skull; Posterior-Anterior Skull;

Submentovertex; Waters; Reverse Tomes;

Oblique Mandibular Body; Lateral Ramus.

D0251 extra-oral posterior dental

radiographic image

21 and older No

DentaQuest LLC 93 of 136

July 1, 2024

Exhibit B Benefits Covered for

VA Cardinal Care Smiles - Over 21

Diagnostic

Code Description Age Limitation Teeth Covered Authorization

Required

Benefit Limitations Documentation

Required

D0270 bitewing - single radiographic image 21 and older No

D0272 bitewings - two radiographic images 21 and older No

D0274 bitewings - four radiographic

images

21 and older No

D0330 panoramic radiographic image 21 and older No One of (D0330) per 60 Month(s) Per

Provider OR Location.

D0372 intraoral tomosynthesis –

comprehensive series of

radiographic images

21 and older No

D0373 intraoral tomosynthesis – bitewing

radiographic image

21 and older No

D0374 intraoral tomosynthesis – periapical

radiographic image

21 and older No

DentaQuest LLC 94 of 136

July 1, 2024

Exhibit B Benefits Covered for

VA Cardinal Care Smiles - Over 21

Preventative

Code Description Age Limitation Teeth Covered Authorization

Required

Benefit Limitations Documentation

Required

D1110 prophylaxis - adult 21 and older No Three of (D1110) per 12 Month(s) Per

Provider OR Location. Includes scaling

and polishing procedures to remove

coronal plaque, calculus and stains.

D1354 application of caries arresting

medicament- per tooth

21 and older Teeth 1 - 32, 51 - 82, A - T,

AS, BS, CS, DS, ES, FS,

GS, HS, IS, JS, KS, LS,

MS, NS, OS, PS, QS, RS,

SS, TS

No Two of (D1354) per 1 Lifetime Per patient

per tooth. D1354 is allowable for up to two

applications per tooth per lifetime for the

primary and permanent dentition. The first

and second application of D1354 must be

seperated by no less than 91 days.

Restorative, endodontic, and extraction

procedures cannot be billed within 180

days of D1354. If restorative, endodontic,

and/or extraction services are medically

necessary prior to 180 days, the fee for

those services will be reduced by $12.00.

DentaQuest LLC 95 of 136

July 1, 2024

Exhibit B Benefits Covered for

VA Cardinal Care Smiles - Over 21

Generally, once a particular restoration is placed in a tooth, a similar restoration will not be covered for at least twelve months, unless there is recurrent

decay or material failure. Payment will be made for only one single surface restoration per tooth surface. For example, two separate occlusal (O) restorations

on the same tooth are to be billed as one occlusal restoration. However, for example it is permissible to bill for multiple, but separate restorations involving

the same tooth surface, such as a mesial-facial (MF) and a distal-facial (DF) restoration on the same anterior tooth.

The acid etching procedure is considered part of the restoration and is not billed as a separate procedure. Local anesthetic is included in the restorative

service or surgical fee and is not separately reimbursed.

A sedative restoration is considered a temporary restoration only and not a base under a restoration.

Bases, copalite, or calcium hydroxide liners placed under a restoration are considered part of the restorations and are not billable as separate procedures.

BILLING AND REIMBURSEMENT FOR CAST CROWNS, CAST POST & CORES OR ANY OTHER FIXED PROSTHETICS SHALL BE BASED ON THE

CEMENTATION DATE.

Restorative pins are reimbursed on a per tooth basis, regardless of the number of pins placed.

For all services that require pre-payment review, providers have the option of requesting prior authorization.

When restorations involving multiple surfaces are requested or performed, that are outside the usual anatomical expectation, the allowance is limited to that

of a one-surface restoration. Any fee charged in excess of the allowance for the one-surface restoration is DISALLOWED.

Restorative

Code Description Age Limitation Teeth Covered Authorization

Required

Benefit Limitations Documentation

Required

D2140 Amalgam - one surface, primary or

permanent

21 and older Teeth 1 - 32, A - T No One of (D2140, D2150, D2160, D2161,

D2330, D2331, D2332, D2335, D2390,

D2391, D2392, D2393, D2394) per 12

Month(s) Per patient per tooth, per

surface. One of (D2140, D2150, D2160,

D2161, D2330, D2331, D2332, D2335,

D2390, D2391, D2392, D2393, D2394) per

12 Month(s) Per patient per tooth, per

surface.

D2150 Amalgam - two surfaces, primary or

permanent

21 and older Teeth 1 - 32, A - T No One of (D2140, D2150, D2160, D2161,

D2330, D2331, D2332, D2335, D2390,

D2391, D2392, D2393, D2394) per 12

Month(s) Per patient per tooth, per

surface. One of (D2140, D2150, D2160,

D2161, D2330, D2331, D2332, D2335,

D2390, D2391, D2392, D2393, D2394) per

12 Month(s) Per patient per tooth, per

surface.

DentaQuest LLC 96 of 136

July 1, 2024

Exhibit B Benefits Covered for

VA Cardinal Care Smiles - Over 21

Restorative

Code Description Age Limitation Teeth Covered Authorization

Required

Benefit Limitations Documentation

Required

D2160 amalgam - three surfaces, primary

or permanent

21 and older Teeth 1 - 32, A - T No One of (D2140, D2150, D2160, D2161,

D2330, D2331, D2332, D2335, D2390,

D2391, D2392, D2393, D2394) per 12

Month(s) Per patient per tooth, per

surface. One of (D2140, D2150, D2160,

D2161, D2330, D2331, D2332, D2335,

D2390, D2391, D2392, D2393, D2394) per

12 Month(s) Per patient per tooth, per

surface.

D2161 amalgam - four or more surfaces,

primary or permanent

21 and older Teeth 1 - 32, A - T No One of (D2140, D2150, D2160, D2161,

D2330, D2331, D2332, D2335, D2390,

D2391, D2392, D2393, D2394) per 12

Month(s) Per patient per tooth, per

surface. One of (D2140, D2150, D2160,

D2161, D2330, D2331, D2332, D2335,

D2390, D2391, D2392, D2393, D2394) per

12 Month(s) Per patient per tooth, per

surface.

D2330 resin-based composite - one

surface, anterior

21 and older Teeth 6 - 11, 22 - 27, C - H,

M - R

No One of (D2140, D2150, D2160, D2161,

D2330, D2331, D2332, D2335, D2390,

D2391, D2392, D2393, D2394) per 12

Month(s) Per patient per tooth, per

surface. One of (D2140, D2150, D2160,

D2161, D2330, D2331, D2332, D2335,

D2390, D2391, D2392, D2393, D2394) per

12 Month(s) Per patient per tooth, per

surface.

D2331 resin-based composite - two

surfaces, anterior

21 and older Teeth 6 - 11, 22 - 27, C - H,

M - R

No One of (D2140, D2150, D2160, D2161,

D2330, D2331, D2332, D2335, D2390,

D2391, D2392, D2393, D2394) per 12

Month(s) Per patient per tooth, per

surface. One of (D2140, D2150, D2160,

D2161, D2330, D2331, D2332, D2335,

D2390, D2391, D2392, D2393, D2394) per

12 Month(s) Per patient per tooth, per

surface.

D2332 resin-based composite - three

surfaces, anterior

21 and older Teeth 6 - 11, 22 - 27, C - H,

M - R

No One of (D2140, D2150, D2160, D2161,

D2330, D2331, D2332, D2335, D2390,

D2391, D2392, D2393, D2394) per 12

Month(s) Per patient per tooth, per

surface. One of (D2140, D2150, D2160,

D2161, D2330, D2331, D2332, D2335,

D2390, D2391, D2392, D2393, D2394) per

12 Month(s) Per patient per tooth, per

surface.

DentaQuest LLC 97 of 136

July 1, 2024

Exhibit B Benefits Covered for

VA Cardinal Care Smiles - Over 21

Restorative

Code Description Age Limitation Teeth Covered Authorization

Required

Benefit Limitations Documentation

Required

D2335 resin-based composite - four or

more surfaces (anterior)

21 and older Teeth 6 - 11, 22 - 27, C - H,

M - R

No One of (D2140, D2150, D2160, D2161,

D2330, D2331, D2332, D2335, D2390,

D2391, D2392, D2393, D2394) per 12

Month(s) Per patient per tooth, per

surface. One of (D2140, D2150, D2160,

D2161, D2330, D2331, D2332, D2335,

D2390, D2391, D2392, D2393, D2394) per

12 Month(s) Per patient per tooth, per

surface.

D2391 resin-based composite - one

surface, posterior

21 and older Teeth 1 - 5, 12 - 21, 28 - 32,

A, B, I - L, S, T

No One of (D2140, D2150, D2160, D2161,

D2330, D2331, D2332, D2335, D2390,

D2391, D2392, D2393, D2394) per 12

Month(s) Per patient per tooth, per

surface. One of (D2140, D2150, D2160,

D2161, D2330, D2331, D2332, D2335,

D2390, D2391, D2392, D2393, D2394) per

12 Month(s) Per patient per tooth, per

surface.

D2392 resin-based composite - two

surfaces, posterior

21 and older Teeth 1 - 5, 12 - 21, 28 - 32,

A, B, I - L, S, T

No One of (D2140, D2150, D2160, D2161,

D2330, D2331, D2332, D2335, D2390,

D2391, D2392, D2393, D2394) per 12

Month(s) Per patient per tooth, per

surface. One of (D2140, D2150, D2160,

D2161, D2330, D2331, D2332, D2335,

D2390, D2391, D2392, D2393, D2394) per

12 Month(s) Per patient per tooth, per

surface.

D2393 resin-based composite - three

surfaces, posterior

21 and older Teeth 1 - 5, 12 - 21, 28 - 32,

A, B, I - L, S, T

No One of (D2140, D2150, D2160, D2161,

D2330, D2331, D2332, D2335, D2390,

D2391, D2392, D2393, D2394) per 12

Month(s) Per patient per tooth, per

surface. One of (D2140, D2150, D2160,

D2161, D2330, D2331, D2332, D2335,

D2390, D2391, D2392, D2393, D2394) per

12 Month(s) Per patient per tooth, per

surface.

D2394 resin-based composite - four or

more surfaces, posterior

21 and older Teeth 1 - 5, 12 - 21, 28 - 32,

A, B, I - L, S, T

No One of (D2140, D2150, D2160, D2161,

D2330, D2331, D2332, D2335, D2390,

D2391, D2392, D2393, D2394) per 12

Month(s) Per patient per tooth, per

surface. One of (D2140, D2150, D2160,

D2161, D2330, D2331, D2332, D2335,

D2390, D2391, D2392, D2393, D2394) per

12 Month(s) Per patient per tooth, per

surface.

DentaQuest LLC 98 of 136

July 1, 2024

Exhibit B Benefits Covered for

VA Cardinal Care Smiles - Over 21

Restorative

Code Description Age Limitation Teeth Covered Authorization

Required

Benefit Limitations Documentation

Required

D2740 crown - porcelain/ceramic 21 and older Teeth 1 - 32 Yes One of (D2740) per 60 Month(s) Per

patient per tooth. PRIOR

AUTHORIZATION REQUIRED. Tooth

must have evidence of endodontic

treatment while covered by a Virginia

Medicaid dental program.

narrative of medical

necessity

D2750 crown - porcelain fused to high

noble metal

21 and older Teeth 1 - 32 Yes One of (D2750) per 60 Month(s) Per

patient per tooth. PRIOR

AUTHORIZATION REQUIRED. Tooth

must have evidence of endodontic

treatment while covered by a Virginia

Medicaid dental program.

narrative of medical

necessity

D2751 crown - porcelain fused to

predominantly base metal

21 and older Teeth 1 - 32 Yes One of (D2751) per 60 Month(s) Per

patient per tooth. PRIOR

AUTHORIZATION REQUIRED. Tooth

must have evidence of endodontic

treatment while covered by a Virginia

Medicaid dental program.

narrative of medical

necessity

D2752 crown - porcelain fused to noble

metal

21 and older Teeth 1 - 32 Yes One of (D2752) per 60 Month(s) Per

patient per tooth. PRIOR

AUTHORIZATION REQUIRED. Tooth

must have evidence of endodontic

treatment while covered by a Virginia

Medicaid dental program.

narrative of medical

necessity

D2780 crown - ¾ cast high noble metal 21 and older Teeth 1 - 32 Yes One of (D2780) per 60 Month(s) Per

patient per tooth. PRIOR

AUTHORIZATION REQUIRED. Tooth

must have evidence of endodontic

treatment while covered by a Virginia

Medicaid dental program.

narrative of medical

necessity

D2781 crown - ¾ cast predominantly base

metal

21 and older Teeth 1 - 32 Yes One of (D2781) per 60 Month(s) Per

patient per tooth. PRIOR

AUTHORIZATION REQUIRED. Tooth

must have evidence of endodontic

treatment while covered by a Virginia

Medicaid dental program.

narrative of medical

necessity

D2782 crown - ¾ cast noble metal 21 and older Teeth 1 - 32 Yes One of (D2782) per 60 Month(s) Per

patient per tooth. PRIOR

AUTHORIZATION REQUIRED. Tooth

must have evidence of endodontic

treatment while covered by a Virginia

Medicaid dental program.

narrative of medical

necessity

DentaQuest LLC 99 of 136

July 1, 2024

Exhibit B Benefits Covered for

VA Cardinal Care Smiles - Over 21

Restorative

Code Description Age Limitation Teeth Covered Authorization

Required

Benefit Limitations Documentation

Required

D2783 crown - ¾ porcelain/ceramic 21 and older Teeth 1 - 32 Yes One of (D2783) per 60 Month(s) Per

patient per tooth. PRIOR

AUTHORIZATION REQUIRED. Tooth

must have evidence of endodontic

treatment while covered by a Virginia

Medicaid dental program.

narrative of medical

necessity

D2790 crown - full cast high noble metal 21 and older Teeth 1 - 32 Yes One of (D2790) per 60 Month(s) Per

patient per tooth. PRIOR

AUTHORIZATION REQUIRED. Tooth

must have evidence of endodontic

treatment while covered by a Virginia

Medicaid dental program.

narrative of medical

necessity

D2791 crown - full cast predominantly

base metal

21 and older Teeth 1 - 32 Yes One of (D2791) per 60 Month(s) Per

patient per tooth. PRIOR

AUTHORIZATION REQUIRED. Tooth

must have evidence of endodontic

treatment while covered by a Virginia

Medicaid dental program.

narrative of medical

necessity

D2792 crown - full cast noble metal 21 and older Teeth 1 - 32 Yes One of (D2792) per 60 Month(s) Per

patient per tooth. PRIOR

AUTHORIZATION REQUIRED. Tooth

must have evidence of endodontic

treatment while covered by a Virginia

Medicaid dental program.

narrative of medical

necessity

D2794 Crown- Titanium and Titanium

Alloys

21 and older Teeth 1 - 32 Yes One of (D2794) per 60 Month(s) Per

patient per tooth. PRIOR

AUTHORIZATION REQUIRED. Tooth

must have evidence of endodontic

treatment while covered by a Virginia

Medicaid dental program.

narrative of medical

necessity

D2920 re-cement or re-bond crown 21 and older Teeth 1 - 32, A - T No Not allowed within 6 months of placement.

D2931 prefabricated stainless steel

crown-permanent tooth

21 and older Teeth 1 - 32 No

D2932 prefabricated resin crown 21 and older Teeth 1 - 32, A - T No

D2940 protective restoration 21 and older Teeth 1 - 32, A - T No One of (D2940) per 12 Month(s) Per

patient per tooth. Not allowed in

conjunction with root canal therapy,

pulpotomy, pulpectomy, or on the same

date of service as a restoration.

DentaQuest LLC 100 of 136

July 1, 2024

Exhibit B Benefits Covered for

VA Cardinal Care Smiles - Over 21

Restorative

Code Description Age Limitation Teeth Covered Authorization

Required

Benefit Limitations Documentation

Required

D2950 core buildup, including any pins

when required

21 and older Teeth 1 - 32 No One of (D2950, D2952, D2954) per 60

Month(s) Per patient per tooth. Limit one

per tooth.

D2951 pin retention - per tooth, in addition

to restoration

21 and older Teeth 1 - 32 No One of (D2951) per 1 Lifetime Per patient

per tooth. Limit one per tooth.

D2952 cast post and core in addition to

crown

21 and older Teeth 1 - 32 No One of (D2950, D2952, D2954) per 60

Month(s) Per patient per tooth. Limit one

per tooth.

D2954 prefabricated post and core in

addition to crown

21 and older Teeth 1 - 32 No One of (D2950, D2952, D2954) per 60

Month(s) Per patient per tooth. Limit one

per tooth.

D2991 application of hydroxyapatite

regeneration medicament – per

tooth

21 and older Teeth 1 - 32, 51 - 82, A - T,

AS, BS, CS, DS, ES, FS,

GS, HS, IS, JS, KS, LS,

MS, NS, OS, PS, QS, RS,

SS, TS

No One of (D2991) per 1 Lifetime Per patient

per tooth. Caries risk assessment shall be

performed and documentation maintained

in the patient record. Documentation in

the file to support the use of the code.

Photograph for smooth surface white spot

lesions or radiographic for interproximal

surfaces, or combination if one or the other

does not clearly demonstrate medical

necessity. Product used must be a

hydroxyapatite regeneration medicament

designed for regenerative purpose.

DentaQuest LLC 101 of 136