The purpose of our Dental Reimbursement Policy Manual is to document the sources and principles used in writing our Dental Policies. This information is to be used as a general reference resource regarding our Dental Policies and not intended to address every aspect of a dental situation. Reasonable discretion may be used in applying our Dental Policies to individual situations.
The following national source, the American Dental Association (ADA) Code on Dental Procedures and Nomenclature (CDT), is consulted in the development of our health plan Dental Policies.
Comments from dental providers regarding dental policies are welcome. If you have a question or comment regarding a dental policy, please contact your provider relations representative.
Your use of this Dental Policy constitutes your agreement to be bound by and comply with the terms and conditions of the Dental Policy Disclaimer.
Adjunctive general services
- Assessment of Salivary Flow by Measurement
- Bacteriologic Studies, Culture - 2/2020
- Blood Glucose Level Test, in-office using a glucose meter
- Cone Beam Computed Tomography (CT) - 2/2020 - new policy
- HbA1C In-office Point of Service Testing
- Oral Pathology Laboratory
Oral and maxillofacial surgery
- Biopsy of Oral Tissue
- Cytology Sample Collection
- Oraantral Fistual Closure, Primary Closure of a Sinus Infection
- Removal of Tumors, Cysts, Neoplasms
- Repair of Orthodontic Appliance
- Replacement of Lost or Broken Retainer
- Apically Positioned Flap
- Autogenous Connective Tissue Graft
- Bone Replacement Graft
- Chemotherapeutic Agents
- Combined Connective Tissue and Double Pedicle Graft
- Distal or Proximal Wedge Procedure
- Free Soft Tissue Graft
- Full Mouth Debridement
- Non-autogenous Connective Tissue Graft
- Pedicle Soft Tissue Graft
- Interim Prosthesis
- Partial Dentures
- Provisional Retainer Crown
- Surgical Placement of Implant Body, Endosteal