2017 Provider Quick Reference Guide for Medicare Advantage Plans
UnitedHealthcareAttn: Provider Quick Reference Guidec/o PCA15 W. Aylesbury Road, Suite 200Timonium, MD 21093
Presorted StandardUS Postage
PaidWaldorf, MD
Permit No. 144
SAMPLE
September 22, 2016 Dear Valued Provider: UnitedHealthcare thanks you for your participation in the UnitedHealthcare (UHC) Medicare dental network. We are pleased to provide you with our new 2017 Provider Quick Reference Guide for Medicare Advantage plans, which includes the state specific Quick Reference Guides (QRGs) for all Medicare products, and a Frequently Asked Questions (FAQ) reference sheet. As a reminder, members will be referencing or showing their medical ID card as they do not have a separate dental ID card. A sample card, showing the format, is below. Many of the medical cards may display the acronym “HMO” (example 1). However, the dental plan for this member is not an HMO plan, but rather it is our UHC Medicare plan in which you participate. On the back of the card, please use the Dental Provider phone number that is located in the lower right hand corner.
While the above is just a sample, please refer to the state specific QRG which reflects a copy of the ID card that corresponds to the member’s plan. This copy will display the actual plan name and dental provider phone number. Should you have any questions, please contact us by dialing our dedicated toll free customer service number found on the Quick Reference Guide for your state. We look forward to continuing a long and mutually rewarding relationship. Sincerely,
Vice President, Network Development UnitedHealthcare Dental
Example 1 Dental Provider Phone Number
1
22
2017 Provider Quick Reference Guide For Medicare Advantage Plans
UnitedHealthcare FAQ
Q. What is a Quick Reference Guide (QRG)? A. QRG is a 2 to 3 page reference document that shows the following:
Plan name A sample member ID card that is plan name specific. Phone numbers for eligibility/benefit verification and claims questions. Addresses for claims/prior authorization submission. Summary of covered ADA codes/services and corresponding frequency. Web site for online services
Q. How do I use this book?
A. The book will include an index showing QRGs in alphabetical order by state.
Q. How will I know which QRG goes with what member? A. The members ID card will reflect the name of their Plan. Refer to the Index; locate the state and the Plan name.
Q. Are the Quick Reference Guides for all Medicare Advantage products in this book?
A. Yes, all Medicare Advantage Plans are included in this booklet. QRGs for Medicaid lines of business are not included except for some Medicaid plans in Florida.
Q. What fee schedule is used for covered services?
A. Covered services will be reimbursed according to your contracted commercial PPO fee schedule.
Q. Who can help me with questions about my participation? A. To obtain a copy of your fee schedule, contractual questions, dentist changes or office updates; please call provider Services at (800) 822-5353.
2017 M&R FAQ
3
44
2017 Provider Quick Reference Guide (QRG) Index for Medicare Advantage Plans Sectioned by State & National Level Plans
State Plans Alabama
AARP MedicareComplete Plan ( $1,000 Annual Max/ Product D0015896) UnitedHealthcare Community Plan Dual Complete ($2,500 Annual Max/Product 409) National AARP MedicareComplete & UnitedHealthcare MedicareComplete Plans (See national plan section) National UnitedHealthcare Dental Platinum Rider (See national plan section) National UnitedHealthcare Nursing Home & Assisted Living Plans (See national plan section)
Arkansas
National AARP MedicareComplete & UnitedHealthcare MedicareComplete Plans (See national plan section) National AARP MedicareComplete Plans (See national plan section) National UnitedHealthcare Care Improvement Plus Gold Rx (See national plan section) National UnitedHealthcare Care Improvement Plus Silver Rx, Dual Advantage (See national plan section) National UnitedHealthcare Dental Platinum Rider (See national plan section)
Arizona UnitedHealthcare Community Plan Dual Complete ($2,500 Annual Max/Products 67 & 365) UnitedHealthcare Medicare Nursing Home Plan ($2,400 Annual Max/D0018585) National UnitedHealthcare Dental Platinum Rider (See national plan section) National UnitedHealthcare Nursing Home & Assisted Living Plan (See national plan section)
California
AARP MedicareComplete DHMO (No Annual Max/Product D0012660) High Option Rider-DHMO ($1,000 Annual Max/Product D0012025) Optional Rider-DHMO (No Annual Max/Product D00012024) National UnitedHealthcare Dental Platinum Rider (See national plan section)
Colorado High Option Rider 260 DHMO ($1,000 Annual Max/Product D0012026) UnitedHealthcare Medicare Nursing Home Plan ($2,400 Annual Max/D0018585) National AARP MedicareComplete & UnitedHealthcare MedicareComplete Plans (See national plan section) National Erickson Advantage Medicare (See national plan section) National UnitedHealthcare Nursing Home & Assisted Living Plan (See national plan section) National UnitedHealthcare Nursing Home & Assisted Living Plans (See national plan section)
5
2017 Provider Quick Reference Guide (QRG) Index for Medicare Advantage Plans Sectioned by State & National Level Plans
Connecticut
UnitedHealthcare AARP MedicareComplete Plans (formally Oxford DHMO) (No Annual Max/Product 143) National AARP MedicareComplete & UnitedHealthcare MedicareComplete Plans (See national plan section) National UnitedHealthcare Dental Platinum Rider (See national plan section) National UnitedHealthcare Nursing Home & Assisted Living Plans (See national plan section)
District of Columbia UnitedHealthcare Community Plan Dual Complete ($1,000 Annual Max/Product 193) National UnitedHealthcare Nursing Home & Assisted Living Plans (See national plan section)
Delaware UnitedHealthcare Community Plan Dual Complete ($1,000 Annual Max/Product 400) National UnitedHealthcare Nursing Home & Assisted Living Plans (See national plan section)
Florida AARP MedicareComplete Choice Plan (No Annual Max/Product D0007383) UnitedHealthcare Community Plan/UnitedHealthcare of Florida Dual Complete LP ($1,500 Annual Max/Product 364) UnitedHealthcare Community Plan/UnitedHealthcare of Florida Dual Complete Medicaid Wrap (No Annual Max/Product 289) UnitedHealthcare Community Plan/UnitedHealthcare of Florida Dual Complete RP ($1,500 Annual Max/Product 288) UnitedHealthcare the Villages MedicareComplete, AARP MedicareComplete Focus, AARP MedicareComplete Plus, AARP MedicareComplete Plans (No Annual Max/Product D0007381) National UnitedHealthcare Nursing Home & Assisted Living Plan (See national plan section) National UnitedHealthcare Nursing Home & Assisted Living Plans (See national plan section)
Georgia
AARP MedicareComplete Plans ($500 Annual Max/Product D0015895) UnitedHealthcare Care Improvement Plus Medicare Advantage ($500 Annual Max/Product 402) UnitedHealthcare Care Improvement Plus Silver Rx ($1,000 Annual Max/Product 367) UnitedHealthcare Community Plan Dual Complete ($1,000 Annual Max/Product 168) UnitedHealthcare Community Plan Dual Complete ($1,000 Annual Max/Product 169) National AARP MedicareComplete & UnitedHealthcare MedicareComplete Plans (See national plan section) National UnitedHealthcare Care Improvement Plus Gold Rx (See national plan section) National UnitedHealthcare Care Improvement Plus Silver Rx (See national plan section) National UnitedHealthcare Dental Platinum Rider (See national plan section)
66
2017 Provider Quick Reference Guide (QRG) Index for Medicare Advantage Plans Sectioned by State & National Level Plans
Hawaii
UnitedHealthcare Community Plan Dual Complete ($2,000 Annual Max/Product 170) UnitedHealthcare Community Plan Medicare Dual SNP ($1,000 Annual Max/Product 357) National UnitedHealthcare Dental Platinum Rider (See national plan section)
Idaho AARP MedicareComplete Choice Plan 2 (No Annual Max/Product D0013571)
Illinois
AARP MedicareComplete Plan ($1,000 Annual Max/Product D0010299) National AARP MedicareComplete & UnitedHealthcare MedicareComplete Plans (See national plan section) National AARP MedicareComplete Choice Plans (See national plan section) National UnitedHealthcare Dental Platinum Rider (See national plan section)
Indiana
AARP MedicareComplete Plan 2 ($1,000 Annual Max/Product D0018539) National AARP MedicareComplete & UnitedHealthcare MedicareComplete Plans (See national plan section) National AARP MedicareComplete Choice Plans (See national plan section) National UnitedHealthcare Dental Platinum Rider (See national plan section)
Iowa
National AARP MedicareComplete & UnitedHealthcare MedicareComplete Plans (See national plan section)
Kansas
AARP MedicareComplete Plans & UnitedHealthcare Chronic Complete ($1000 Annual Max/Product D0018548) UnitedHealthcare Community Plan Dual Complete ($2,000 Annual Max/Product 398) National AARP MedicareComplete & UnitedHealthcare MedicareComplete Plans (See national plan section) National AARP MedicareComplete Choice Plans (See national plan section) National UnitedHealthcare Dental Platinum Rider (See national plan section)
Kentucky
National AARP MedicareComplete & UnitedHealthcare MedicareComplete Plans (See national plan section) National AARP MedicareComplete Plans (See national plan section) National UnitedHealthcare Dental Platinum Rider (See national plan section)
7
2017 Provider Quick Reference Guide (QRG) Index for Medicare Advantage Plans Sectioned by State & National Level Plans
Louisiana
UnitedHealthcare Community Plan Dual Complete ($2,000 Annual Max/Product 399) Massachusetts
National AARP MedicareComplete & UnitedHealthcare MedicareComplete Plans (See national plan section) National Erickson Advantage Medicare (See national plan section)
Maryland
National Erickson Advantage Medicare (See national plan section) National UnitedHealthcare Nursing Home & Assisted Living Plans (See national plan section)
Maine
National AARP MedicareComplete Choice Plans (See national plan section) National UnitedHealthcare Nursing Home & Assisted Living Plans (See national plan section)
Michigan
National AARP MedicareComplete Choice Plans (See national plan section) Missouri
National AARP MedicareComplete & UnitedHealthcare MedicareComplete Plans (See national plan section) National AARP MedicareComplete Choice Plans (See national plan section) National UnitedHealthcare Care Improvement Plus Gold Rx (See national plan section) National UnitedHealthcare Care Improvement Plus Silver Rx, Dual Advantage (See national plan section) National UnitedHealthcare Dental Platinum Rider (See national plan section)
Mississippi UnitedHealthcare Community Plan Dual Complete ($2,000 Annual Max/Product 401)
Nebraska
National AARP MedicareComplete & UnitedHealthcare MedicareComplete Plans (See national plan section)
New Hampshire
National AARP MedicareComplete & UnitedHealthcare MedicareComplete Plans (See national plan section) National AARP MedicareComplete Choice Plans (See national plan section) National UnitedHealthcare Nursing Home & Assisted Living Plans (See national plan section)
88
2017 Provider Quick Reference Guide (QRG) Index for Medicare Advantage Plans Sectioned by State & National Level Plans
New Jersey
UnitedHealthcare AARP MedicareComplete Plans (formally Oxford DHMO) (No Annual Max/Product 143) National Erickson Advantage Medicare (See national plan section)
New Mexico UnitedHealthcare Community Plan Dual Complete ($2,000 Annual Max/Product 172) UnitedHealthcare Community Plan Dual Complete ($2,000 Annual Max/Product 403) National UnitedHealthcare Dental Platinum Rider (See national plan section)
New York UnitedHealthcare AARP MedicareComplete Plans (formally Oxford DHMO) (No Annual Max/Product 143) UnitedHealthcare Community Plan Dual Complete ($2,500 Annual Max/Product 20) UnitedHealthcare MedicareComplete Choice Plans ($1,000 Annual Max/Product D0015893) National AARP MedicareComplete & UnitedHealthcare MedicareComplete Plans (See national plan section) National UnitedHealthcare Dental Platinum Rider (See national plan section)
Nevada AARP MedicareComplete & AARP MedicareComplete SecureHorizons (No Annual Max/Product D0011527) National AARP MedicareComplete & UnitedHealthcare MedicareComplete Plans (See national plan section)
North Carolina
UnitedHealthcare Community Plan Dual Complete ($2,500 Annual Max/Product 408) National AARP MedicareComplete & UnitedHealthcare MedicareComplete Plans (See national plan section) National UnitedHealthcare Dental Platinum Rider (See national plan section) National UnitedHealthcare Nursing Home & Assisted Living Plans (See national plan section)
Ohio UnitedHealthcare Community Plan Dual Complete ($2,000 Annual Max/Product 369) National AARP MedicareComplete & UnitedHealthcare MedicareComplete Plans (See national plan section) National AARP MedicareComplete Plans (See national plan section) National UnitedHealthcare Dental Platinum Rider (See national plan section) National UnitedHealthcare Nursing Home & Assisted Living Plans (See national plan section) National UnitedHealthcare Nursing Home Plan (See national plan section)
9
2017 Provider Quick Reference Guide (QRG) Index for Medicare Advantage Plans Sectioned by State & National Level Plans
Oklahoma
AARP MedicareComplete & AARP MedicareComplete SecureHorizons (No Annual Max/Product D0011527) National AARP MedicareComplete & UnitedHealthcare MedicareComplete Plans (See national plan section) National UnitedHealthcare Dental Platinum Rider (See national plan section)
Oregon
UnitedHealthcare Nursing Home and Assisted Living Plans ($1,000 Annual Max/Product D0012657) National AARP MedicareComplete & UnitedHealthcare MedicareComplete Plans (See national plan section) National UnitedHealthcare Dental Platinum Rider (See national plan section) National UnitedHealthcare Nursing Home & Assisted Living Plans (See national plan section)
Pennsylvania
UnitedHealthcare Community Plan Dual Complete ($2,500 Annual Max/Product 368) National AARP MedicareComplete & UnitedHealthcare MedicareComplete Plans (See national plan section) National AARP MedicareComplete Choice Plans (See national plan section) National Erickson Advantage Medicare (See national plan section) National UnitedHealthcare Nursing Home & Assisted Living Plans (See national plan section)
Rhode Island
UnitedHealthcare Community Plan Dual Complete ($2,000 Annual Max/Product 397) National AARP MedicareComplete & UnitedHealthcare MedicareComplete Plans (See national plan section) National UnitedHealthcare Dental Platinum Rider (See national plan section)
South Carolina UnitedHealthcare Care Improvement Plus Silver Rx ($1,000 Annual Max/Product 367) National AARP MedicareComplete & UnitedHealthcare MedicareComplete Plans (See national plan section) National UnitedHealthcare Care Improvement Plus Gold Rx (See national plan section) National UnitedHealthcare Care Improvement Plus Silver Rx (See national plan section) National UnitedHealthcare Dental Platinum Rider (See national plan section)
Tennessee UnitedHealthcare Community Plan Dual Complete ($1,000 Annual Max/Product 23) National AARP MedicareComplete & UnitedHealthcare MedicareComplete Plans (See national plan section) National UnitedHealthcare Nursing Home & Assisted Living Plans (See national plan section)
1010
2017 Provider Quick Reference Guide (QRG) Index for Medicare Advantage Plans Sectioned by State & National Level Plans
Texas
AARP MedicareComplete Focus ($500 Annual Max/Product D0012666) AARP MedicareComplete Focus Essential (No Annual Max/Product D0012703) AARP MedicareComplete Plans & UnitedHealthcare Chronic Complete ($1000 Annual Max/Product D0018551) AARP MedicareComplete SecureHorizons Essential (No Annual Max/Product D1000068) UnitedHealthcare Community Plan Dual Complete ($1,000 Annual Max/Product 173) UnitedHealthcare Community Plan Dual Complete ($1,250 Annual Max/Product 396) UnitedHealthcare Community Plan Dual Complete ($2,000 Annual Max/Product 191) UnitedHealthcare Community Plan Dual Complete ($2,000 Annual Max/Product 394) UnitedHealthcare Community Plan Dual Complete ($2,500 Annual Max/Product 192) UnitedHealthcare Community Plan Dual Complete ($2,500 Annual Max/Product 395) National AARP MedicareComplete & UnitedHealthcare MedicareComplete Plans (See national plan section) National Erickson Advantage Medicare (See national plan section) National UnitedHealthcare Care Improvement Plus Gold Rx (See national plan section) National UnitedHealthcare Care Improvement Plus Silver Rx (See national plan section) National UnitedHealthcare Dental Platinum Rider (See national plan section)
Utah AARP MedicareComplete Plan 2 (No Annual Max/Product D0018584) National AARP MedicareComplete & UnitedHealthcare MedicareComplete Plans (See national plan section)
Virginia
National AARP MedicareComplete & UnitedHealthcare MedicareComplete Plans (See national plan section) National UnitedHealthcare Dental Platinum Rider (See national plan section) National Erickson Advantage Medicare (See national plan section) National UnitedHealthcare Nursing Home & Assisted Living Plans (See national plan section)
Washington
UnitedHealthcare Community Plan Dual Complete ($1,250 Annual Max/Product 194) UnitedHealthcare Nursing Home and Assisted Living Plans ($1,000 Annual Max/ Product D0012657) National AARP MedicareComplete & UnitedHealthcare MedicareComplete Plans (See national plan section) National UnitedHealthcare Dental Platinum Rider (See national plan section) National UnitedHealthcare Nursing Home & Assisted Living Plans (See national plan section)
11
2017 Provider Quick Reference Guide (QRG) Index for Medicare Advantage Plans Sectioned by State & National Level Plans
Wisconsin
UnitedHealthcare Community Plan Dual Complete ($1,500 Annual Max/Product 363) UnitedHealthcare Nursing Home Plan ($1,000 Annual Max/Product D0013573) National AARP MedicareComplete & UnitedHealthcare MedicareComplete Plans (See national plan section) National UnitedHealthcare Care Improvement Plus Gold Rx (See national plan section) National UnitedHealthcare Dental Platinum Rider (See national plan section) National UnitedHealthcare Nursing Home & Assisted Living Plans (See national plan section)
National Plans
AARP MedicareComplete & UnitedHealthcare MedicareComplete Plans (No Annual Max/Products D0011451 & D0015219) AARP MedicareComplete Choice Plans 1 & 2 (No Annual Max/Product D0011530) AARP MedicareComplete Plans ($1,000 Annual Max/Product D0015894) Erickson Advantage Medicare (No Annual Max/Product D0005183) UnitedHealthcare Care Improvement Plus Gold Rx (No Annual Max/Product 283) UnitedHealthcare Care Improvement Plus Silver Rx (No Annual Max/Product 284) UnitedHealthcare Care Improvement Plus Silver Rx, Dual Advantage ($500 Annual Max/Product 366) UnitedHealthcare Dental Platinum Rider ($1,000 Annual Max/Products D001337 & D0015067) UnitedHealthcare Nursing Home & Assisted Living Plans ($250 Annual Max/Product D0003398) UnitedHealthcare Nursing Home & Assisted Living Plans ($500 Annual Max/Product D0007296) UnitedHealthcare Nursing Home & Assisted Living Plans ($500 Annual Max/Product D0012658) UnitedHealthcare Nursing Home & Assisted Living Plan ($1,800 Annual Max/Product D0014777) UnitedHealthcare Nursing Home Plan ($250 Annual Max/Product D0011452)
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bric
ated
pos
t and
cor
ere
cem
ent o
r re-
bond
cro
wn
crow
n, 3
/4 c
ast n
oble
met
alcr
own,
3/4
por
cela
in/c
eram
iccr
own
- ful
l cas
t hig
h no
ble
met
alcr
own
- ful
l cas
t pre
dom
inan
tly b
ase
met
alcr
own
- ful
l cas
t nob
le m
etal
crow
n - p
orce
lain
fuse
d to
hig
h no
ble
met
alcr
own
- por
cela
in fu
sed
to p
redo
min
antly
bas
e m
etal
crow
n - p
orce
lain
fuse
d to
nob
le m
etal
crow
n, 3
/4 c
ast h
igh
nobl
e m
etal
crow
n, 3
/4 c
ast p
redo
min
atel
y ba
se m
etal
crow
n - 3
/4 re
sin-
base
d co
mpo
site
(ind
irect
)cr
own
- res
in w
ith h
igh
nobl
e m
etal
crow
n - r
esin
with
pre
dom
inan
tly b
ase
met
alcr
own
- res
in w
ith n
oble
met
alcr
own
- por
cela
in/c
eram
ic su
bstr
ate
resi
n-ba
sed
com
posi
te -
one
surf
ace,
pos
terio
rre
sin-
base
d co
mpo
site
- tw
o su
rfac
es, p
oste
rior
resi
n-ba
sed
com
posi
te -
thre
e su
rfac
es, p
oste
rior
resi
n-ba
sed
com
posi
te -
four
or m
ore
surf
aces
, pos
terio
rcr
own,
resi
n-ba
sed
com
posi
te (i
ndire
ct)
pulp
vita
lity
test
s
amal
gam
- fo
ur o
r mor
e su
rfac
es, p
rimar
y or
per
man
ent
resi
n-ba
sed
com
posi
te -
one
surf
ace,
ant
erio
rre
sin-
base
d co
mpo
site
- tw
o su
rfac
es, a
nter
ior
resi
n-ba
sed
com
posi
te -
thre
e su
rfac
es, a
nter
ior
resi
n-ba
sed
com
posi
te -
four
or m
ore
surf
aces
or i
nvol
ving
inci
sal a
ngle
(ant
erio
r)
Topi
cal a
pplic
atio
n of
fluo
ride
- exc
ludi
ng v
arni
shor
al h
ygie
ne in
stru
ctio
nsam
alga
m -
one
surf
ace,
prim
ary
or p
erm
anen
tam
alga
m -
two
surf
aces
, prim
ary
or p
erm
anen
tam
alga
m -
thre
e su
rfac
es, p
rimar
y or
per
man
ent
intr
aora
l - o
cclu
sal r
adio
grap
hic
imag
ebi
tew
ing
- sin
gle
radi
ogra
phic
imag
ebi
tew
ings
- tw
o ra
diog
raph
ic im
ages
deta
iled
and
exte
nsiv
e or
al e
valu
atio
n - p
robl
em-fo
cuse
d, b
y re
port
re-e
valu
atio
n, li
mite
d, p
robl
em fo
cuse
dre
-eva
luat
ion
- pos
t-op
erat
ive
offic
e vi
sit
com
preh
ensi
ve p
erio
dont
al e
valu
atio
n - n
ew o
r est
ablis
hed
patie
ntin
trao
ral -
com
plet
e se
ries o
f rad
iogr
aphi
c im
ages
intr
aora
l - p
eria
pica
l firs
t rad
iogr
aphi
c im
age
intr
aora
l - p
eria
pica
l eac
h ad
ditio
nal r
adio
grap
hic
imag
e
prop
hyla
xis -
adu
lt
bite
win
gs -
four
radi
ogra
phic
imag
espa
nora
mic
radi
ogra
phic
imag
e
D279
1D2
792
D279
4D2
915
D292
0
D278
0D2
781
D278
2D2
783
D279
0
D272
2D2
740
D275
0D2
751
D275
2
D239
4D2
710
D271
2D2
720
D272
1
D233
2D2
335
D239
1D2
392
D239
3
D215
0D2
160
D216
1D2
330
D233
1
D111
0D1
208
D133
0D2
140
D046
0
D027
0D0
272
D027
4D0
330
D021
0D0
220
D023
0D0
240
D016
0D0
170
D017
1D0
180
No
Freq
uenc
y/Li
mita
tions
unlim
ited
perio
dic
oral
eva
luat
ion
No
limite
d or
al e
valu
atio
n - p
robl
em fo
cuse
d
unlim
ited
No
No
unlim
ited
Cove
red
Den
tal S
ervi
ces:
Proc
edur
e Co
dePr
oced
ure
Des
crip
tion
Prio
r Aut
horiz
atio
n Re
quire
d?D0
120
D014
0
D014
5D0
150
oral
eva
luat
ion
for a
pat
ient
und
er th
ree
year
s of a
ge a
nd c
ouns
elin
g w
ith p
rimar
y ca
regi
ver
com
preh
ensi
ve o
ral e
valu
atio
n - n
ew o
r est
ablis
hed
patie
nt
unlim
ited
unlim
ited
3232
unlim
ited
unlim
ited
unlim
ited
unlim
ited
unlim
ited
unlim
ited
unlim
ited
unlim
ited
unlim
ited
unlim
ited
unlim
ited
unlim
ited
unlim
ited
unlim
ited
unlim
ited
unlim
ited
unlim
ited
unlim
ited
unlim
ited
unlim
ited
unlim
ited
unlim
ited
unlim
ited
unlim
ited
unlim
ited
unlim
ited
unlim
ited
unlim
ited
unlim
ited
unlim
ited
unlim
ited
unlim
ited
unlim
ited
unlim
ited
unlim
ited
4 ev
ery
year
unlim
ited
unlim
ited
unlim
ited
unlim
ited
unlim
ited
unlim
ited
unlim
ited
unlim
ited
unlim
ited
unlim
ited
unlim
ited
unlim
ited
unlim
ited
unlim
ited
unlim
ited
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
Yes
Yes
Yes
No
No
No
No
No
No
No
Yes
Yes
Yes
Yes
Yes
No
No
No
No
repl
ace
all t
eeth
and
acr
ylic
on
cast
met
al fr
amew
ork
(max
illar
y)re
plac
e al
l tee
th a
nd a
cryl
ic o
n ca
st m
etal
fram
ewor
k (m
andi
bula
r)re
line
com
plet
e m
axill
ary
dent
ure
(cha
irsid
e)re
line
com
plet
e m
andi
bula
r den
ture
(cha
irsid
e)
repa
ir ca
st fr
amew
ork
repa
ir or
repl
ace
brok
en c
lasp
- pe
r too
thre
plac
e br
oken
teet
h - p
er to
oth
add
toot
h to
exi
stin
g pa
rtia
l den
ture
add
clas
p to
exi
stin
g pa
rtia
l den
ture
- pe
r too
th
adju
st p
artia
l den
ture
- m
axill
ary
adju
st p
artia
l den
ture
- m
andi
bula
rre
pair
brok
en c
ompl
ete
dent
ure
base
repl
ace
mis
sing
or b
roke
n te
eth
- com
plet
e de
ntur
e (e
ach
toot
h)re
pair
resi
n de
ntur
e ba
se
max
illar
y pa
rtia
l den
ture
- fle
xibl
e ba
se (i
nclu
ding
any
cla
sps,
rest
s and
teet
h)m
andi
bula
r par
tial d
entu
re -
flexi
ble
base
(inc
ludi
ng a
ny c
lasp
s, re
sts a
nd te
eth)
rem
ovab
le u
nila
tera
l par
tial d
entu
re -
one
piec
e ca
st m
etal
(inc
ludi
ng c
lasp
s and
teet
h)ad
just
com
plet
e de
ntur
e - m
axill
ary
adju
st c
ompl
ete
dent
ure
- man
dibu
lar
imm
edia
te d
entu
re -
man
dibu
lar
max
illar
y pa
rtia
l den
ture
- re
sin b
ase
(incl
udin
g an
y co
nven
tiona
l cla
sps,
rest
s and
teet
h)
man
dibu
lar p
artia
l den
ture
- re
sin
base
(inc
ludi
ng a
ny c
onve
ntio
nal c
lasp
s, re
sts a
nd te
eth)
max
illar
y pa
rtia
l den
ture
- ca
st m
etal
fram
ewor
k w
ith re
sin d
entu
re b
ases
(inc
ludi
ng a
ny c
onve
ntio
nal
clas
ps, r
ests
and
man
dibu
lar p
artia
l den
ture
- ca
st m
etal
fram
ewor
k w
ith re
sin
dent
ure
base
s (in
clud
ing
any
conv
entio
nal c
lasp
s, re
sts a
nd
perio
dont
al m
aint
enan
cegi
ngiv
al ir
rigat
ion
- per
qua
dran
tco
mpl
ete
dent
ure
- max
illar
yco
mpl
ete
dent
ure
- man
dibu
lar
imm
edia
te d
entu
re -
max
illar
y
inco
mpl
ete
endo
dont
ic th
erap
y; in
oper
able
, unr
esto
rabl
e or
frac
ture
d to
oth
cana
l pre
para
tion
and
fittin
g of
pre
form
ed d
owel
or p
ost
perio
dont
al sc
alin
g an
d ro
ot p
lann
ing
- fou
r or m
ore
teet
h pe
r qua
dran
tpe
riodo
ntal
scal
ing
and
root
pla
nnin
g - o
ne -
thre
e te
eth,
per
qua
dran
tfu
ll m
outh
deb
ridem
ent t
o en
able
com
preh
ensi
ve e
valu
atio
n an
d di
agno
sis
pulp
cap
- in
dire
ct (e
xclu
ding
fina
l res
tora
tion)
ther
apeu
tic p
ulpo
tom
y (e
xclu
ding
fina
l res
tora
tion)
endo
dont
ic th
erap
y, a
nter
ior t
ooth
(exc
ludi
ng fi
nal r
esto
ratio
n)en
dodo
ntic
ther
apy,
bic
uspi
d to
oth
(exc
ludi
ng fi
nal r
esto
ratio
n)en
dodo
ntic
ther
apy,
mol
ar (e
xclu
ding
fina
l res
tora
tion)
pref
abric
ated
pos
t and
cor
e in
add
ition
to c
row
nea
ch a
dditi
onal
pre
fabr
icat
ed p
ost,
sam
e to
oth
addi
tiona
l pro
cedu
res t
o co
nstr
uct n
ew c
row
n un
der e
xist
ing
part
ial d
entu
re fr
amew
ork
(to
be
repo
rted
in a
dditi
on to
cro
wn
resi
n in
filtr
atio
n of
inci
pien
t sm
ooth
surf
ace
lesi
ons
pulp
cap
- di
rect
(exc
ludi
ng fi
nal r
esto
ratio
n)
prot
ectiv
e re
stor
atio
nin
terim
ther
apeu
tic re
stor
atio
n-pr
imar
y de
ntiti
onpi
n re
tent
ion
- per
toot
h, in
add
ition
to re
stor
atio
nca
st p
ost a
nd c
ore
in a
dditi
on to
cro
wn
each
add
ition
al in
dire
ctly
fabr
icat
ed p
ost,
sam
e to
oth
pref
abric
ated
stai
nles
s ste
el c
row
n - p
erm
anen
t too
thpr
efab
ricat
ed re
sin
crow
n
D573
1
D565
0D5
660
D567
0D5
671
D573
0
D552
0D5
610
D562
0D5
630
D564
0
D541
0D5
411
D542
1D5
422
D551
0
D521
3
D521
4D5
225
D522
6
D528
1
D512
0D5
130
D514
0
D521
1
D521
2
D434
2D4
355
D491
0D4
921
D511
0
D332
0D3
330
D333
2D3
950
D434
1
D299
0D3
110
D312
0D3
220
D331
0
D295
2D2
953
D295
4D2
957
D297
1
D293
1D2
932
D294
0D2
941
D295
1
33
unlim
ited
unlim
ited
unlim
ited
unlim
ited
4 ev
ery
24 m
onth
s fro
m la
st d
ate
of se
rvic
e
unlim
ited
unlim
ited
unlim
ited
unlim
ited
unlim
ited
unlim
ited
unlim
ited
1 pe
r life
time
per t
ooth
1 pe
r life
time
per t
ooth
unlim
ited
unlim
ited
unlim
ited
unlim
ited
unlim
ited
unlim
ited
unlim
ited
unlim
ited
unlim
ited
unlim
ited
unlim
ited
unlim
ited
unlim
ited
unlim
ited
unlim
ited
unlim
ited
unlim
ited
unlim
ited
unlim
ited
unlim
ited
unlim
ited
unlim
ited
unlim
ited
unlim
ited
unlim
ited
unlim
ited
unlim
ited
unlim
ited
unlim
ited
unlim
ited
unlim
ited
unlim
ited
unlim
ited
unlim
ited
No
No
No
No
No
No
No
No
No
No
Yes
Yes
No
No
No
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
No
Yes
Yes
No
Yes
Yes
Yes
No
No
No
Yes
Yes
Yes
No
No
No
No
No
No
No
No
case
pre
sent
atio
n, d
etai
led
and
exte
nsiv
e tr
eatm
ent p
lann
ing
occl
usal
adj
ustm
ent
occl
usal
adj
ustm
ent -
lim
ited
palli
ativ
e (e
mer
genc
y) tr
eatm
ent o
f den
tal p
ain
- min
or p
roce
dure
loca
l ane
sthe
sia
in c
onju
nctio
n w
ith o
pera
tive
or su
rgic
al p
roce
dure
s
offic
e vi
sit f
or o
bser
vatio
n (d
urin
g re
gula
rly sc
hedu
led
hour
s) -
no o
ther
serv
ices
per
form
edof
fice
visi
t - a
fter
regu
larly
sche
dule
d ho
urs
rece
men
t or r
e-bo
nd fi
xed
part
ial d
entu
reex
trac
tion,
cor
onal
rem
nant
s - d
ecid
uous
toot
hex
trac
tion,
eru
pted
toot
h or
exp
osed
root
(ele
vatio
n an
d/or
forc
eps r
emov
al)
inci
sion
and
dra
inag
e of
abs
cess
- in
trao
ral s
oft t
issu
e
inci
sion
and
dra
inag
e of
abs
cess
- in
trao
ral s
oft t
issu
e - c
ompl
icat
ed (i
nclu
des d
rain
age
of m
ultip
le
fasc
ial s
pace
s)
reta
iner
cro
wn-
3/4
porc
elai
n/ce
ram
icre
tain
er c
row
n - f
ull c
ast h
igh
nobl
e m
etal
reta
iner
cro
wn
- ful
l cas
t pre
dom
inan
tly b
ase
met
alre
tain
er c
row
n - f
ull c
ast n
oble
met
alre
tain
er c
row
n - t
itani
um
reta
iner
cro
wn
- por
cela
in fu
sed
to p
redo
min
antly
bas
e m
etal
reta
iner
cro
wn
- por
cela
in fu
sed
to n
oble
met
alre
tain
er c
row
n - 3
/4 c
ast h
igh
nobl
e m
etal
reta
iner
cro
wn-
3/4
cast
pre
dom
inat
ely
base
d m
etal
reta
iner
cro
wn-
3/4
cast
nob
le m
etal
reta
iner
cro
wn
- res
in w
ith h
igh
nobl
e m
etal
reta
iner
cro
wn
- res
in w
ith p
redo
min
antly
bas
e m
etal
reta
iner
cro
wn
- res
in w
ith n
oble
met
alre
tain
er c
row
n-po
rcel
ain/
cera
mic
reta
iner
cro
wn
- por
cela
in fu
sed
to h
igh
nobl
e m
etal
pont
ic -
porc
elai
n fu
sed
to n
oble
met
alpo
ntic
-por
cela
in/c
eram
icpo
ntic
- re
sin
with
hig
h no
ble
met
alpo
ntic
- re
sin
with
pre
dom
inan
tly b
ase
met
alpo
ntic
- re
sin
with
nob
le m
etal
pont
ic -
cast
pre
dom
inan
tly b
ase
met
alpo
ntic
- ca
st n
oble
met
alpo
ntic
- tit
aniu
mpo
ntic
- po
rcel
ain
fuse
d to
hig
h no
ble
met
alpo
ntic
- po
rcel
ain
fuse
d to
pre
dom
inan
tly b
ase
met
al
Ove
rden
ture
-com
plet
e m
axill
ary
Ove
rden
ture
-par
tial m
axill
ary
Ove
rden
ture
- co
mpl
ete
man
dibu
lar
Ove
rden
ture
-par
tial m
andi
bula
rpo
ntic
- ca
st h
igh
nobl
e m
etal
relin
e m
andi
bula
r par
tial d
entu
re (c
hairs
ide)
relin
e co
mpl
ete
max
illar
y de
ntur
e (la
bora
tory
)re
line
com
plet
e m
andi
bula
r den
ture
(lab
orat
ory)
relin
e m
axill
ary
part
ial d
entu
re (l
abor
ator
y)re
line
man
dibu
lar p
artia
l den
ture
(lab
orat
ory)
relin
e m
axill
ary
part
ial d
entu
re (c
hairs
ide)
D943
0D9
440
D945
0D9
943
D995
1
D751
0
D751
1D9
110
D921
5
D679
2D6
794
D693
0D7
111
D714
0
D678
1D6
782
D678
3D6
790
D679
1
D674
0D6
750
D675
1D6
752
D678
0
D625
1D6
252
D672
0D6
721
D672
2
D624
0D6
241
D624
2D6
245
D625
0
D586
6D6
210
D621
1D6
212
D621
4
D576
0D5
761
D586
3D5
864
D586
5
D574
0D5
741
D575
0D5
751
3434
Prov
ider
Cla
im D
ispu
tes
Mem
ber A
ppea
ls &
Grie
vanc
es
In a
n ef
fort
to c
ompl
y w
ith th
e Ce
nter
s for
Med
icar
e an
d M
edic
aid
(CM
S) st
ate
man
date
d re
quire
men
ts, p
leas
e be
adv
ised
that
DHM
O E
ncou
nter
Dat
a Su
bmis
sion
s are
now
requ
ired.
CM
S no
w re
quire
s tha
t w
e re
port
100
% o
f util
izatio
n da
ta fo
r our
AAR
P M
edic
are
Com
plet
e DH
MO
mem
bers
. To
ens
ure
that
we
mee
t CM
S re
quire
men
t of r
epor
ting
100%
util
izatio
n, w
e ar
e ha
ppy
to re
-intr
oduc
e ou
r Den
tal
Ince
ntiv
e Pr
ogra
m e
ffect
ive
imm
edia
tely
. De
ntal
Ben
efit
Prov
ider
s will
reim
burs
e ou
r pro
vide
rs $
2.00
for e
ach
enco
unte
r cla
im su
bmitt
ed fo
r AAR
P M
edic
are
Com
plet
e D
HM
O m
embe
rs o
nly
for a
ll pr
oced
ures
(cov
ered
und
er th
e m
embe
r's p
lan)
per
form
ed o
n th
ose
mem
bers
, for
eac
h da
te o
f ser
vice
. Al
l pro
cedu
res p
erfo
rmed
MU
ST b
e re
port
ed in
clud
ing
proc
edur
es w
heth
er o
r not
the
mem
ber h
as a
co
paym
ent.
Thi
s is a
requ
irem
ent f
or a
ll co
ntra
cted
pro
vide
rs to
subm
it ut
iliza
tion
for e
ach
patie
nt tr
eate
d.
Her
e ar
e a
few
way
s the
Enc
ount
er In
form
atio
n ca
n be
subm
itted
:
1)
Electronically
- As
you
wou
ld a
PPO
or I
ndem
nity
Cla
im
2)
Web
Site
- Cl
aim
s can
be
subm
itted
indi
vidu
ally
on
our w
ebsi
te a
t ww
w.u
hcpr
ovid
ers.
com
3)
By
Mai
l - A
s you
wou
ld a
PPO
or I
ndem
nity
Cla
im
4)
Util
izat
ion
Repo
rts -
Mus
t con
tain
ALL
requ
ired
info
rmat
ion:
• Su
bscr
iber
ID•
Subs
crib
er D
ate
of B
irth
• G
roup
Nam
e or
Num
ber
• Pa
tient
’s F
ull N
ame
• Pa
tient
’s D
ate
of B
irth
• Re
latio
nshi
p to
Sub
scrib
er•
Phys
ical
Add
ress
• AD
A Co
de P
erfo
rmed
• To
oth#
/ Q
uadr
ant
• Su
rfac
e•
Trea
ting
Dent
ist N
ame
• De
ntist
Tax
I.D.
for B
illin
g
Enco
unte
r/U
tiliza
tion
Repo
rtin
g - W
hen
subm
ittin
g En
coun
ter/
Util
izat
ion
clai
ms,
you
mus
t inc
lude
Cod
e D0
999
alon
g w
ith a
ll co
vere
d se
rvic
e pr
oced
ure
code
s you
per
form
on
each
AAR
P M
edic
are
Com
plet
e DH
MO
mem
ber.
Plea
se n
ote
the
follo
win
g:
1)
If y
ou su
bmit
D099
9 al
one
no a
dditi
onal
$2.
00 re
imbu
rsem
ent w
ill n
ot b
e pa
id.
Addi
tiona
lly, c
laim
subm
issio
n w
ould
be
cons
ider
ed n
on-c
ompl
iant
.
2) If
you
subm
it al
l ser
vice
pro
cedu
re se
rvic
e co
des b
ut d
on't
incl
ude
D099
9 as
wel
l as y
ou w
on't
be re
imbu
rsed
the
addi
tiona
l $2.
00.
In a
dditi
on, t
he c
laim
will
be
cons
ider
ed n
on-c
ompl
iant
.
Mai
l mem
ber a
ppea
ls to
: Uni
tedH
ealth
care
, Att
n: A
ppea
ls a
nd G
rieva
nce
Depa
rtm
ent,
PO B
ox 6
106,
MS
CA12
4-01
57, C
ypre
ss, C
A 90
630
AARP
Med
icar
e Co
mpl
ete
San
Dieg
o DH
MO
Pla
n co
ver t
he d
enta
l cod
es li
sted
abo
ve. P
rovi
der p
aym
ent i
s mad
e on
a F
ee-fo
r-Se
rvic
e ba
sis.
Mem
bers
hav
e In
-Net
wor
k on
ly b
enef
its a
nd th
ere
is n
o an
nual
be
nefit
max
imum
, coi
nsur
ance
or d
educ
tible
. The
mem
ber c
opay
s var
y fo
r cov
ered
serv
ices
from
$3
- $65
0. S
ome
serv
ices
requ
ire p
rior a
utho
rizat
ion.
Dent
al P
rovi
ders
with
com
plai
nts a
re to
con
tact
Uni
tedH
ealth
care
Den
tal’s
Pro
vide
r Ser
vice
dep
artm
ent a
t 877
-816
-359
6. N
etw
ork
Prov
ider
con
trac
tual
dis
pute
s, O
ut-o
f-Net
wor
k pr
ovid
er d
ispu
tes,
and
re
proc
essi
ng re
ques
ts w
ill b
e lo
gged
into
the
appe
als d
atab
ase.
Ple
ase
mai
l to
the
Appe
als &
Grie
vanc
es P
O B
ox li
sted
abo
ve. R
esea
rch
and
reso
lutio
n w
ill b
e co
mpl
eted
with
in 3
0 ca
lend
ar d
ays.
Mem
ber a
ppea
ls a
re re
view
ed b
y th
e he
alth
pla
n, a
nd a
re n
ot d
eleg
ated
to U
HC D
enta
l. Al
l Mem
ber a
ppea
ls (i
nclu
des P
re-S
ervi
ce a
ppea
ls, I
n N
etw
ork
Prov
ider
app
eals
, and
Out
of N
etw
ork
prov
ider
app
eals
) re
ceiv
ed b
y U
HC D
enta
l will
be
forw
arde
d to
the
heal
th p
lan
via
over
nigh
t mai
l, w
ithin
7 d
ays o
f rec
eipt
of t
he a
ppea
l.
35
CA_F
ACET
S D0
0126
60_P
kg D
T035
_DT0
35-H
0000
a-DM
O75
09/2
016
“Prio
r Aut
horiz
atio
n re
quire
d” m
eans
the
prac
titio
ner m
ust s
ubm
it th
ose
proc
edur
es fo
r app
rova
l with
clin
ical
doc
umen
tatio
n su
ppor
ting
nece
ssity
bef
ore
perf
orm
ing
thos
e pr
oced
ures
. To
do th
is c
ompl
ete
a st
anda
rd A
DA c
laim
form
and
che
ck th
e bo
x m
arke
d “P
re-T
reat
men
t EST
IMAT
E.”
Prio
r aut
horiz
atio
n re
ques
t can
be
subm
itted
via
the
prov
ider
web
por
tal (
at w
ww
.myu
hcpr
ovid
ers.
com
), su
bmitt
ed
elec
tron
ical
ly v
ia y
our c
lear
ingh
ouse
, or s
impl
y m
ail t
he fo
rm, t
o th
e be
low
add
ress
, alo
ng w
ith a
ny re
quire
d su
pple
men
tal i
nfor
mat
ion
(film
s, n
arra
tive,
per
io-c
hart
ing,
etc
.). Y
our o
ffice
will
then
rece
ive
an
Expl
anat
ion
of B
enef
its (E
OB)
out
linin
g th
e de
nial
or a
ppro
val o
f req
uest
ed tr
eatm
ent a
nd p
lan
paym
ent a
mou
nts w
hen
appl
icab
le.
Prio
r Aut
horiz
atio
n Re
ques
ts
3636
Iden
tific
atio
n Ca
rds
Sam
ple
Mem
ber I
D C
ard*
Fron
t of c
ard
Back
of c
ard
Fron
t of c
ard
Back
of c
ard
Impo
rtan
t Tel
epho
ne N
umbe
rs &
Web
site
s
Prov
ider
Qui
ck R
efer
ence
Gui
de -
Effe
ctiv
e 1/
1/20
17Ca
lifor
nia
Hig
h O
ptio
n Ri
der -
DH
MO
- $1
000
Annu
al M
axim
umAA
RP M
edic
areC
ompl
ete
Secu
re H
oriz
ons P
lans
1, 2
, 4 a
nd V
alue
Pla
ns
*Ple
ase
note
that
the
Med
ical
ID C
ard
is un
iver
sal a
nd in
clud
es a
ll lin
es o
f cov
erag
e. T
he M
edic
al p
lan
can
be H
MO
or P
PO a
nd th
is d
oes n
ot re
flect
the
Dent
al P
lan
Bene
fits.
Ple
ase
flip
the
ID C
ard
over
to se
e th
e De
ntal
Pro
vide
r in
form
atio
n on
the
back
(i.e
. car
rier w
ebsi
te a
nd to
ll-fr
ee n
umbe
r). T
his i
nfor
mat
ion
can
be u
sed
to c
onfir
m p
rovi
der p
artic
ipat
ion,
mem
ber e
ligib
ility
and
ben
efits
. Thi
s is a
SAM
PLE
ID C
ard
and
may
diff
er fr
om th
e m
embe
r's ID
Ca
rd.
Elig
ibili
ty,
Bene
fits,
Cla
im(s
) and
Aut
horiz
atio
ns87
7-81
6-35
96Li
ve A
gent
: Mon
day
- Frid
ay, 8
:00A
M -
6:00
PM, E
STIV
R: 2
4 ho
urs a
day
Call
to In
quire
Abo
utTe
leph
one
Num
ber
Hou
rs o
f Ope
ratio
n
Emai
l to
Inqu
ire A
bout
Web
site
Hou
rs o
f Ope
ratio
nTo
dis
cuss
you
r par
ticip
atio
n, c
ontr
actu
al is
sues
, den
tist c
hang
es o
r offi
ce u
pdat
es80
0-82
2-53
53Li
ve A
gent
: Mon
day
- Frid
ay, 8
:00A
M -
11:0
0PM
, EST
37
Impo
rtan
t Add
ress
es
Impo
rtan
t Ele
ctro
nic
Clai
ms &
Prio
r Aut
horiz
atio
n Su
bmis
sion
Info
rmat
ion
unlim
ited
unlim
ited
unlim
ited
unlim
ited
unlim
ited
unlim
ited
unlim
ited
unlim
ited
unlim
ited
unlim
ited
unlim
ited
unlim
ited
unlim
ited
unlim
ited
unlim
ited
unlim
ited
unlim
ited
unlim
ited
unlim
ited
unlim
ited
unlim
ited
unlim
ited
unlim
ited
unlim
ited
unlim
ited
unlim
ited
unlim
ited
No
D046
0pu
lp v
italit
y te
sts
No
D111
0pr
ophy
laxi
s - a
dult
No
D099
9un
spec
ified
dia
gnos
tic p
roce
dure
, by
repo
rtN
o
No
D214
0am
alga
m -
one
surf
ace,
prim
ary
or p
erm
anen
tN
oD2
150
D023
0in
trao
ral -
per
iapi
cal e
ach
addi
tiona
l rad
iogr
aphi
c im
age
No
D024
0in
trao
ral -
occ
lusa
l rad
iogr
aphi
c im
age
No
D021
0D0
220
5213
3
D012
0D0
140
D014
5D0
150
perio
dic
oral
eva
luat
ion
limite
d or
al e
valu
atio
n - p
robl
em fo
cuse
d
oral
eva
luat
ion
for a
pat
ient
und
er th
ree
year
s of a
ge a
nd c
ouns
elin
g w
ith p
rimar
y ca
regi
ver
com
preh
ensi
ve o
ral e
valu
atio
n - n
ew o
r est
ablis
hed
patie
ntN
o
Cove
red
Den
tal S
ervi
ces:
Prio
r Aut
horiz
atio
n Re
quire
d?Pr
oced
ure
Code
Freq
uenc
y/Li
mita
tions
24 h
ours
a d
ay
Proc
edur
e D
escr
iptio
n
24 h
ours
a d
ay
Clai
ms
D017
0D0
171
D018
0
deta
iled
and
exte
nsiv
e or
al e
valu
atio
n - p
robl
em-fo
cuse
d, b
y re
port
unlim
ited
2 ev
ery
year
No
No
No
No
No
re-e
valu
atio
n, li
mite
d, p
robl
em fo
cuse
dre
-eva
luat
ion
- pos
t-op
erat
ive
offic
e vi
sit
com
preh
ensi
ve p
erio
dont
al e
valu
atio
n - n
ew o
r est
ablis
hed
patie
nt
D016
0
intr
aora
l - c
ompl
ete
serie
s of r
adio
grap
hic
imag
esin
trao
ral -
per
iapi
cal f
irst r
adio
grap
hic
imag
eN
o
unlim
ited
unlim
ited
unlim
ited
unlim
ited
unlim
ited
Med
icar
ew
ww
.med
icar
e.go
v24
hou
rs a
day
Elig
ibili
ty,
Bene
fits,
Cla
im(s
) and
Aut
horiz
atio
nsw
ww
.dbp
.com
Cent
ers f
or M
edic
aid
and
Med
icar
e Se
rvic
esw
ww
.cm
s.hh
s.go
v
Prov
ider
Rea
son
for M
ailin
g
EDI P
ayer
Num
ber f
or C
laim
s Sub
mitt
ed
D027
4bi
tew
ings
- fo
ur ra
diog
raph
ic im
ages
No
D033
0pa
nora
mic
radi
ogra
phic
imag
eN
o
D027
0bi
tew
ing
- sin
gle
radi
ogra
phic
imag
eN
oD0
272
bite
win
gs -
two
radi
ogra
phic
imag
esN
o
Prio
r Aut
horiz
atio
nAp
peal
s & G
rieva
nces
Uni
tedH
ealth
care
Den
tal,
PO B
ox 3
0567
, Sal
t Lak
e Ci
ty, U
T 84
130-
0567
Uni
tedH
ealth
care
Den
tal,
PO B
ox 3
0552
, Sal
t Lak
e Ci
ty, U
T 8
4130
-055
2U
nite
dHea
lthca
re D
enta
l, Ap
peal
s Disp
utes
, PO
Box
305
69, S
alt L
ake
City
, UT
8413
0-05
69
No
No
amal
gam
- tw
o su
rfac
es, p
rimar
y or
per
man
ent
No
D120
8To
pica
l app
licat
ion
of fl
uorid
e - e
xclu
ding
var
nish
No
D133
0or
al h
ygie
ne in
stru
ctio
nsN
o
No
D252
0in
lay
- met
allic
- tw
o su
rfac
esN
o
D239
3re
sin-
base
d co
mpo
site
- th
ree
surf
aces
, pos
terio
rN
oD2
394
resi
n-ba
sed
com
posi
te -
four
or m
ore
surf
aces
, pos
terio
rN
oun
limite
dun
limite
d
D233
2re
sin-
base
d co
mpo
site
- th
ree
surf
aces
, ant
erio
rN
oD2
335
resi
n-ba
sed
com
posi
te -
four
or m
ore
surf
aces
or i
nvol
ving
inci
sal a
ngle
(ant
erio
r)N
o
D233
0re
sin-
base
d co
mpo
site
- on
e su
rfac
e, a
nter
ior
No
D233
1re
sin-
base
d co
mpo
site
- tw
o su
rfac
es, a
nter
ior
No
unlim
ited
D216
0am
alga
m -
thre
e su
rfac
es, p
rimar
y or
per
man
ent
No
D216
1am
alga
m -
four
or m
ore
surf
aces
, prim
ary
or p
erm
anen
t
D251
0in
lay
- met
allic
- on
e su
rfac
e
D239
1re
sin-
base
d co
mpo
site
- on
e su
rfac
e, p
oste
rior
No
D239
2re
sin-
base
d co
mpo
site
- tw
o su
rfac
es, p
oste
rior
No
D253
0in
lay
- met
allic
- th
ree
or m
ore
surf
aces
No
D254
2on
lay
met
allic
, tw
o su
rfac
esN
o
3838
unlim
ited
unlim
ited
unlim
ited
unlim
ited
D279
1
D271
2cr
own
- 3/4
resi
n-ba
sed
com
posi
te (i
ndire
ct)
No
D272
0D2
721
D272
2
D254
4on
lay-
met
allic
-four
or m
ore
surf
aces
No
crow
n - r
esin
with
hig
h no
ble
met
alcr
own
- res
in w
ith p
redo
min
antly
bas
e m
etal
crow
n - r
esin
with
nob
le m
etal
No
No
No
D279
2D2
794
D274
0D2
750
D275
1D2
752
D278
0D2
781
D278
2D2
783
D279
0
D271
0cr
own,
resi
n-ba
sed
com
posi
te (i
ndire
ct)
No
D254
3on
lay-
met
allic
-thr
ee su
rfac
esN
o
D291
5D2
920
D293
1D2
932
D294
0D2
941
D295
0D2
951
D295
2D2
953
D295
4D2
957
D297
1D3
110
D312
0D3
220
D331
0D3
320
D333
0D3
332
D334
6D3
347
D334
8D3
410
D342
1D3
425
D342
6D3
427
D343
0D3
950
D421
0
D421
1
D424
0
crow
n - p
orce
lain
/cer
amic
subs
trat
ecr
own
- por
cela
in fu
sed
to h
igh
nobl
e m
etal
crow
n - p
orce
lain
fuse
d to
pre
dom
inan
tly b
ase
met
alcr
own
- por
cela
in fu
sed
to n
oble
met
alcr
own,
3/4
cas
t hig
h no
ble
met
alcr
own,
3/4
cas
t pre
dom
inat
ely
base
met
al
pin
rete
ntio
n - p
er to
oth,
in a
dditi
on to
rest
orat
ion
cast
pos
t and
cor
e in
add
ition
to c
row
nea
ch a
dditi
onal
indi
rect
ly fa
bric
ated
pos
t, sa
me
toot
h
crow
n, 3
/4 c
ast n
oble
met
alcr
own,
3/4
por
cela
in/c
eram
iccr
own
- ful
l cas
t hig
h no
ble
met
alcr
own
- ful
l cas
t pre
dom
inan
tly b
ase
met
alcr
own
- ful
l cas
t nob
le m
etal
crow
n - t
itani
umre
cem
ent o
r re-
bond
cas
t ind
irect
ly fa
bric
ated
or p
refa
bric
ated
pos
t and
cor
ere
cem
ent o
r re-
bond
cro
wn
pref
abric
ated
stai
nles
s ste
el c
row
n - p
erm
anen
t too
thpr
efab
ricat
ed re
sin
crow
npr
otec
tive
rest
orat
ion
inte
rim th
erap
eutic
rest
orat
ion-
prim
ary
dent
ition
Core
bui
ldup
, inc
ludi
ng a
ny p
ins w
hen
requ
ired
pref
abric
ated
pos
t and
cor
e in
add
ition
to c
row
nea
ch a
dditi
onal
pre
fabr
icat
ed p
ost,
sam
e to
oth
addi
tiona
l pro
cedu
res t
o co
nstr
uct n
ew c
row
n un
der e
xist
ing
part
ial d
entu
re fr
amew
ork
(to
be
repo
rted
in a
dditi
on to
cro
wn
pulp
cap
- di
rect
(exc
ludi
ng fi
nal r
esto
ratio
n)pu
lp c
ap -
indi
rect
(exc
ludi
ng fi
nal r
esto
ratio
n)th
erap
eutic
pul
poto
my
(exc
ludi
ng fi
nal r
esto
ratio
n)en
dodo
ntic
ther
apy,
ant
erio
r too
th (e
xclu
ding
fina
l res
tora
tion)
endo
dont
ic th
erap
y, b
icus
pid
toot
h (e
xclu
ding
fina
l res
tora
tion)
endo
dont
ic th
erap
y, m
olar
(exc
ludi
ng fi
nal r
esto
ratio
n)in
com
plet
e en
dodo
ntic
ther
apy;
inop
erab
le, u
nres
tora
ble
or fr
actu
red
toot
hre
trea
tmen
t of p
revi
ous r
oot c
anal
ther
apy
- ant
erio
rre
trea
tmen
t of p
revi
ous r
oot c
anal
ther
apy
- bic
uspi
dre
trea
tmen
t of p
revi
ous r
oot c
anal
ther
apy
- mol
arAp
icoe
ctom
y - a
nter
ior
Apic
oect
omy
- bic
uspi
d (fi
rst r
oot)
Apic
oect
omy
- mol
ar (f
irst r
oot)
Apic
oect
omy
(eac
h ad
ditio
nal r
oot)
perir
adic
ular
surg
ery
with
out a
pico
ecto
my
retr
ogra
de fi
lling
- pe
r roo
tca
nal p
repa
ratio
n an
d fit
ting
of p
refo
rmed
dow
el o
r pos
t
ging
ivec
tom
y or
gin
givo
plas
ty -
four
or m
ore
cont
iguo
us te
eth
or to
oth
boun
ded
spac
es p
er q
uadr
ant
ging
ivec
tom
y or
gin
givo
plas
ty -
one
to th
ree
cont
iguo
us te
eth
or to
oth
boun
ded
spac
es p
er q
uadr
ant
ging
ival
flap
pro
cedu
re, i
nclu
ding
root
pla
nnin
g - f
our o
r mor
e co
ntig
uous
teet
h or
toot
h bo
unde
d sp
aces
per
qua
dran
t
Yes
Yes
Yes
Yes
No
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
No
No
No
No
No
No
No
Yes
Yes
Yes
No
No
No
No
Yes
Yes
Yes
No
Yes
Yes
Yes
No
No
No
No
No
No
No
No
No
No
unlim
ited
unlim
ited
unlim
ited
unlim
ited
unlim
ited
unlim
ited
unlim
ited
unlim
ited
unlim
ited
unlim
ited
unlim
ited
unlim
ited
unlim
ited
unlim
ited
unlim
ited
unlim
ited
unlim
ited
unlim
ited
unlim
ited
unlim
ited
unlim
ited
unlim
ited
unlim
ited
unlim
ited
unlim
ited
unlim
ited
unlim
ited
unlim
ited
unlim
ited
unlim
ited
unlim
ited
unlim
ited
unlim
ited
unlim
ited
unlim
ited
unlim
ited
unlim
ited
unlim
ited
unlim
ited
unlim
ited
unlim
ited
unlim
ited
unlim
ited
unlim
ited
unlim
ited
unlim
ited
unlim
ited
unlim
ited
39
D424
1
D426
0
D426
1D4
341
D434
2D4
355
D491
0D4
921
D511
0D5
120
D513
0D5
140
D521
1
D521
2
D521
3
D521
4D5
225
D522
6
D528
1D5
410
D541
1D5
421
D542
2
D551
0D5
520
D561
0D5
620
D563
0D5
640
D565
0D5
660
D567
0D5
671
D573
0D5
731
D574
0D5
741
D575
0D5
751
D576
0D5
761
D585
0D5
851
D586
3D5
864
D586
5D5
866
ging
ival
flap
pro
cedu
re -
incl
udin
g ro
ot p
lann
ing
-one
to th
ree
cont
iguo
us te
eth
or to
oth
boun
ded
spac
es p
er q
uadr
ant
osse
ous s
urge
ry (i
nclu
ding
flap
ent
ry a
nd c
losu
re) -
four
or m
ore
cont
iguo
us te
eth
or to
oth
boun
ded
spac
es p
er q
uadr
ant
osse
ous s
urge
ry (i
nclu
ding
flap
ent
ry a
nd c
losu
re) -
one
to th
ree
cont
iguo
us te
eth
or to
oth
boun
ded
spac
es p
er q
uadr
ant
perio
dont
al sc
alin
g an
d ro
ot p
lann
ing
- fou
r or m
ore
teet
h pe
r qua
dran
tpe
riodo
ntal
scal
ing
and
root
pla
nnin
g - o
ne -
thre
e te
eth,
per
qua
dran
tfu
ll m
outh
deb
ridem
ent t
o en
able
com
preh
ensi
ve e
valu
atio
n an
d di
agno
sis
perio
dont
al m
aint
enan
cegi
ngiv
al ir
rigat
ion
- per
qua
dran
tco
mpl
ete
dent
ure
- max
illar
yco
mpl
ete
dent
ure
- man
dibu
lar
imm
edia
te d
entu
re -
max
illar
yim
med
iate
den
ture
- m
andi
bula
r
max
illar
y pa
rtia
l den
ture
- re
sin b
ase
(incl
udin
g an
y co
nven
tiona
l cla
sps,
rest
s and
teet
h)
man
dibu
lar p
artia
l den
ture
- re
sin
base
(inc
ludi
ng a
ny c
onve
ntio
nal c
lasp
s, re
sts a
nd te
eth)
max
illar
y pa
rtia
l den
ture
- ca
st m
etal
fram
ewor
k w
ith re
sin d
entu
re b
ases
(inc
ludi
ng a
ny c
onve
ntio
nal
clas
ps, r
ests
and
man
dibu
lar p
artia
l den
ture
- ca
st m
etal
fram
ewor
k w
ith re
sin
dent
ure
base
s (in
clud
ing
any
conv
entio
nal c
lasp
s, re
sts a
ndm
axill
ary
part
ial d
entu
re -
flexi
ble
base
(inc
ludi
ng a
ny c
lasp
s, re
sts a
nd te
eth)
man
dibu
lar p
artia
l den
ture
- fle
xibl
e ba
se (i
nclu
ding
any
cla
sps,
rest
s and
teet
h)
rem
ovab
le u
nila
tera
l par
tial d
entu
re -
one
piec
e ca
st m
etal
(inc
ludi
ng c
lasp
s and
teet
h)ad
just
com
plet
e de
ntur
e - m
axill
ary
adju
st c
ompl
ete
dent
ure
- man
dibu
lar
adju
st p
artia
l den
ture
- m
axill
ary
adju
st p
artia
l den
ture
- m
andi
bula
r
repa
ir br
oken
com
plet
e de
ntur
e ba
sere
plac
e m
issi
ng o
r bro
ken
teet
h - c
ompl
ete
dent
ure
(eac
h to
oth)
repa
ir re
sin
dent
ure
base
repa
ir ca
st fr
amew
ork
repa
ir or
repl
ace
brok
en c
lasp
- pe
r too
thre
plac
e br
oken
teet
h - p
er to
oth
add
toot
h to
exi
stin
g pa
rtia
l den
ture
add
clas
p to
exi
stin
g pa
rtia
l den
ture
- pe
r too
thre
plac
e al
l tee
th a
nd a
cryl
ic o
n ca
st m
etal
fram
ewor
k (m
axill
ary)
repl
ace
all t
eeth
and
acr
ylic
on
cast
met
al fr
amew
ork
(man
dibu
lar)
relin
e co
mpl
ete
max
illar
y de
ntur
e (c
hairs
ide)
relin
e co
mpl
ete
man
dibu
lar d
entu
re (c
hairs
ide)
relin
e m
axill
ary
part
ial d
entu
re (c
hairs
ide)
relin
e m
andi
bula
r par
tial d
entu
re (c
hairs
ide)
relin
e co
mpl
ete
max
illar
y de
ntur
e (la
bora
tory
)re
line
com
plet
e m
andi
bula
r den
ture
(lab
orat
ory)
relin
e m
axill
ary
part
ial d
entu
re (l
abor
ator
y)re
line
man
dibu
lar p
artia
l den
ture
(lab
orat
ory)
tissu
e co
nditi
onin
g, m
axill
ary
tissu
e co
nditi
onin
g, m
andi
bula
rO
verd
entu
re-c
ompl
ete
max
illar
yO
verd
entu
re-p
artia
l max
illar
yO
verd
entu
re -
com
plet
e m
andi
bula
rO
verd
entu
re-p
artia
l man
dibu
lar
No
Yes
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
unlim
ited
unlim
ited
unlim
ited
4 ev
ery
year
unlim
ited
unlim
ited
unlim
ited
unlim
ited
unlim
ited
unlim
ited
unlim
ited
unlim
ited
unlim
ited
unlim
ited
unlim
ited
unlim
ited
unlim
ited
unlim
ited
unlim
ited
unlim
ited
unlim
ited
unlim
ited
unlim
ited
unlim
ited
unlim
ited
unlim
ited
unlim
ited
unlim
ited
unlim
ited
unlim
ited
unlim
ited
unlim
ited
unlim
ited
unlim
ited
unlim
ited
unlim
ited
unlim
ited
unlim
ited
unlim
ited
unlim
ited
unlim
ited
unlim
ited
unlim
ited
unlim
ited
unlim
ited
unlim
ited
unlim
ited
4040
D621
0D6
211
D621
2D6
214
D624
0D6
241
D624
2D6
245
D625
0D6
251
D625
2D6
602
D660
3D6
604
D660
5D6
606
D660
7D6
624
D672
0D6
721
D672
2
D674
0D6
750
D675
1D6
752
D678
0D6
781
D678
2D6
783
D679
0D6
791
D679
2D6
794
D693
0
D711
1D7
140
D721
0D7
220
D723
0D7
240
D725
0D7
285
D728
6
D731
0
D731
1
D732
0
D747
2D7
473
D748
5
pont
ic -
cast
hig
h no
ble
met
alpo
ntic
- ca
st p
redo
min
antly
bas
e m
etal
pont
ic -
cast
nob
le m
etal
pont
ic -
titan
ium
pont
ic -
porc
elai
n fu
sed
to h
igh
nobl
e m
etal
pont
ic -
porc
elai
n fu
sed
to p
redo
min
antly
bas
e m
etal
pont
ic -
porc
elai
n fu
sed
to n
oble
met
alpo
ntic
-por
cela
in/c
eram
icpo
ntic
- re
sin
with
hig
h no
ble
met
alpo
ntic
- re
sin
with
pre
dom
inan
tly b
ase
met
alpo
ntic
- re
sin
with
nob
le m
etal
reta
iner
inla
y - c
ast h
igh
nobl
e m
etal
, tw
o su
rfac
esre
tain
er in
lay
- cas
t hig
h no
ble
met
al, t
hree
or m
ore
surf
aces
reta
iner
inla
y - c
ast p
redo
min
antly
bas
e m
etal
, tw
o su
rfac
esre
tain
er in
lay
- cas
t pre
dom
inan
tly b
ase
met
al, t
hree
or m
ore
surf
aces
reta
iner
inla
y - c
ast n
oble
met
al, t
wo
surf
aces
reta
iner
inla
y - c
ast n
oble
met
al, t
hree
or m
ore
surf
aces
reta
iner
inla
y - t
itani
umre
tain
er c
row
n - r
esin
with
hig
h no
ble
met
alre
tain
er c
row
n - r
esin
with
pre
dom
inan
tly b
ase
met
alre
tain
er c
row
n - r
esin
with
nob
le m
etal
reta
iner
cro
wn-
porc
elai
n/ce
ram
icre
tain
er c
row
n - p
orce
lain
fuse
d to
hig
h no
ble
met
alre
tain
er c
row
n - p
orce
lain
fuse
d to
pre
dom
inan
tly b
ase
met
alre
tain
er c
row
n - p
orce
lain
fuse
d to
nob
le m
etal
reta
iner
cro
wn
- 3/4
cas
t hig
h no
ble
met
alre
tain
er c
row
n-3/
4 ca
st p
redo
min
atel
y ba
sed
met
alre
tain
er c
row
n-3/
4 ca
st n
oble
met
alre
tain
er c
row
n-3/
4 po
rcel
ain/
cera
mic
reta
iner
cro
wn
- ful
l cas
t hig
h no
ble
met
alre
tain
er c
row
n - f
ull c
ast p
redo
min
antly
bas
e m
etal
reta
iner
cro
wn
- ful
l cas
t nob
le m
etal
reta
iner
cro
wn
- tita
nium
rece
men
t or r
e-bo
nd fi
xed
part
ial d
entu
re
extr
actio
n, c
oron
al re
mna
nts -
dec
iduo
us to
oth
extr
actio
n, e
rupt
ed to
oth
or e
xpos
ed ro
ot (e
leva
tion
and/
or fo
rcep
s rem
oval
)su
rgic
al re
mov
al o
f eru
pted
toot
h re
q re
mov
al o
f bon
e, se
ctio
ning
of t
ooth
and
incl
udin
g el
evat
ion
of
muc
oper
iost
eal f
lap
rem
oval
of i
mpa
cted
toot
h - s
oft t
issue
rem
oval
of i
mpa
cted
toot
h - p
artia
lly b
ony
rem
oval
of i
mpa
cted
toot
h - c
ompl
etel
y bo
ny
surg
ical
rem
oval
of r
esid
ual t
ooth
root
s (cu
ttin
g pr
oced
ure)
inci
sion
al b
iops
y of
ora
l tis
sue
- har
d (b
one,
toot
h)in
cisi
onal
bio
psy
of o
ral t
issu
e - s
oft (
all o
ther
s)
Yes
Yes
Yes
No
Yes
Yes
Yes
No
Yes
Yes
No
No
No
No
No
No
No
No
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
No
No
No
No
No
Yes
Yes
Yes
Yes
Yes
No
No
No
No
No
No
No
No
No
unlim
ited
unlim
ited
unlim
ited
unlim
ited
unlim
ited
unlim
ited
unlim
ited
unlim
ited
unlim
ited
unlim
ited
unlim
ited
unlim
ited
unlim
ited
unlim
ited
unlim
ited
unlim
ited
unlim
ited
unlim
ited
unlim
ited
unlim
ited
unlim
ited
unlim
ited
unlim
ited
unlim
ited
unlim
ited
unlim
ited
unlim
ited
unlim
ited
unlim
ited
unlim
ited
unlim
ited
unlim
ited
unlim
ited
unlim
ited
1 pe
r too
th1
per t
ooth
1 pe
r too
th1
per t
ooth
1 pe
r too
th1
per t
ooth
1 pe
r too
thun
limite
dun
limite
d
unlim
ited
unlim
ited
unlim
ited
unlim
ited
unlim
ited
unlim
ited
unlim
ited
alve
olop
last
y in
con
junc
tion
with
ext
ract
ions
- fo
ur o
r mor
e te
eth
or to
oth
spac
es, p
er q
uadr
ant
alve
opla
sty
in c
onju
nctio
n w
ith e
xtra
ctio
n - o
ne to
thre
e te
eth
or to
oth
spac
es, p
er q
uadr
ant
alve
olop
last
y no
t in
conj
unct
ion
with
ext
ract
ions
- fo
ur o
r mor
e te
eth
or to
oth
spac
es, p
er q
uadr
ant
alve
opla
sty
not i
n co
njun
ctio
n w
ith e
xtra
ctio
n - o
ne to
thre
e te
eth
or to
oth
spac
es, p
er q
uadr
ant
rem
oval
of l
ater
al e
xost
osis
(max
illa
or m
andi
ble)
rem
oval
of t
orus
pal
atin
usre
mov
al o
f tor
us m
andi
bula
rissu
rgic
al re
duct
ion
of o
sseo
us tu
bero
sity
D732
1D7
471
unlim
ited
41
The
Calif
orni
a Hi
gh O
ptio
n Ri
der D
HMO
supp
lem
enta
l ben
efit
plan
cov
ers t
he d
enta
l cod
es li
sted
abo
ve. T
his s
uppl
emen
tal b
enef
it is
offe
red
to m
embe
rs th
at a
re e
nrol
led
in A
ARP
Med
icar
eCom
plet
e Se
cure
Horiz
ons p
lans
. Pr
ovid
er p
aym
ent i
s mad
e on
a F
ee-fo
r-Se
rvic
e ba
sis.
Mem
bers
hav
e In
-net
wor
k on
ly b
enef
its. S
ome
serv
ices
requ
ire p
rior a
utho
rizat
ion.
The
$10
00 a
nnua
l max
imum
app
lies t
o co
vere
d pr
even
tive
and
com
preh
ensi
ve
bene
fits.
Mem
ber c
an b
e bi
lled
for s
ervi
ces o
ver t
he $
1000
ann
ual m
axim
um b
enef
it. T
he m
embe
r cop
ays v
ary
for c
over
ed se
rvic
es fr
om $
0 - $
500.
The
re is
no
coin
sura
nce
or d
educ
tible
.
D751
0
D751
1
D995
1
D752
1D7
881
D911
0D9
215
D921
9D9
310
D943
0D9
440
D945
0
inci
sion
and
dra
inag
e of
abs
cess
- in
trao
ral s
oft t
issu
e
No
No
No
No
No
No
No
No
No
No
No
No
In a
n ef
fort
to c
ompl
y w
ith th
e Ce
nter
s for
Med
icar
e an
d M
edic
aid
(CM
S) st
ate
man
date
d re
quire
men
ts, p
leas
e be
adv
ised
that
DHM
O E
ncou
nter
Dat
a Su
bmis
sion
s are
now
requ
ired.
CM
S no
w re
quire
s tha
t we
repo
rt 1
00%
of
util
izat
ion
data
for o
ur C
alifo
rnia
Hig
h O
ptio
n Ri
der D
HMO
mem
bers
. To
ens
ure
that
we
mee
t CM
S re
quire
men
t of r
epor
ting
100%
util
izatio
n, w
e ar
e ha
ppy
to re
-intr
oduc
e ou
r Den
tal I
ncen
tive
Prog
ram
effe
ctiv
e im
med
iate
ly.
Dent
al B
enef
it Pr
ovid
ers w
ill re
imbu
rse
our p
rovi
ders
$2.
00 fo
r eac
h en
coun
ter c
laim
subm
itted
for C
alifo
rnia
Hig
h O
ptio
n Ri
der D
HM
O m
embe
rs o
nly
for a
ll pr
oced
ures
(cov
ered
und
er th
e m
embe
r's p
lan)
pe
rfor
med
on
thos
e m
embe
rs, f
or e
ach
date
of s
ervi
ce.
All p
roce
dure
s per
form
ed M
UST
be
repo
rted
incl
udin
g pr
oced
ures
whe
ther
or n
ot th
e m
embe
r has
a c
opay
men
t. T
his i
s a re
quire
men
t for
all
cont
ract
ed p
rovi
ders
to
subm
it ut
iliza
tion
for e
ach
patie
nt tr
eate
d.
Her
e ar
e a
few
way
s the
Enc
ount
er In
form
atio
n ca
n be
subm
itted
:
1) Electronically
- As
you
wou
ld a
PPO
or I
ndem
nity
Cla
im
2) W
eb S
ite -
Clai
ms c
an b
e su
bmitt
ed in
divi
dual
ly o
n ou
r web
site
at w
ww
.uhc
prov
ider
s.co
m
3)
By
Mai
l - A
s you
wou
ld a
PPO
or I
ndem
nity
Cla
im
4) U
tiliz
atio
n Re
port
s - M
ust c
onta
in A
LL re
quire
d in
form
atio
n:
•
Subs
crib
er ID
• Su
bscr
iber
Dat
e of
Birt
h •
Gro
up N
ame
or N
umbe
r•
Patie
nt’s
Ful
l Nam
e•
Patie
nt’s
Dat
e of
Birt
h•
Rela
tions
hip
to S
ubsc
riber
• Ph
ysic
al A
ddre
ss•
ADA
Code
Per
form
ed•
Toot
h# /
Qua
dran
t•
Surf
ace
• Tr
eatin
g De
ntis
t Nam
e•
Dent
ist T
ax I.
D. fo
r Bill
ingloca
l ane
sthe
sia
in c
onju
nctio
n w
ith o
pera
tive
or su
rgic
al p
roce
dure
sev
alua
tion
for d
eep
seda
tion
or g
ener
al a
nest
hesi
aco
nsul
tatio
n (d
iagn
ostic
serv
ice
prov
ided
by
dent
ist o
r phy
sici
an o
ther
than
pra
ctiti
oner
pro
vidi
ng
offic
e vi
sit f
or o
bser
vatio
n (d
urin
g re
gula
rly sc
hedu
led
hour
s) -
no o
ther
serv
ices
per
form
edof
fice
visi
t - a
fter
regu
larly
sche
dule
d ho
urs
Enco
unte
r/U
tiliza
tion
Repo
rtin
g - W
hen
subm
ittin
g En
coun
ter/
Util
izat
ion
clai
ms,
you
mus
t inc
lude
Cod
e D0
999
alon
g w
ith a
ll co
vere
d se
rvic
e pr
oced
ure
code
s you
per
form
on
each
AAR
P M
edic
are
Com
plet
e DH
MO
mem
ber.
Pl
ease
not
e th
e fo
llow
ing:
1)
If y
ou su
bmit
D099
9 al
one
no a
dditi
onal
$2.
00 re
imbu
rsem
ent w
ill n
ot b
e pa
id.
Addi
tiona
lly, c
laim
subm
issio
n w
ould
be
cons
ider
ed n
on-c
ompl
iant
.
2)
If y
ou su
bmit
all s
ervi
ce p
roce
dure
serv
ice
code
s but
don
't in
clud
e D0
999
as w
ell a
s you
won
't be
reim
burs
ed th
e ad
ditio
nal $
2.00
. In
add
ition
, the
cla
im w
ill b
e co
nsid
ered
non
-com
plia
nt,
unlim
ited
unlim
ited
unlim
ited
4 ev
ery
24 m
onth
s
unlim
ited
unlim
ited
unlim
ited
unlim
ited
unlim
ited
unlim
ited
unlim
ited
unlim
ited
case
pre
sent
atio
n, d
etai
led
and
exte
nsiv
e tr
eatm
ent p
lann
ing
occl
usal
adj
ustm
ent -
lim
ited
inci
sion
and
dra
inag
e of
abs
cess
- in
trao
ral s
oft t
issu
e - c
ompl
icat
ed (i
nclu
des d
rain
age
of m
ultip
le
fasc
ial s
pace
s)in
cisi
on a
nd d
rain
age
of a
bsce
ss -
extr
aora
l sof
t tis
sue
- com
plic
ated
(inc
lude
s dra
inag
e of
mul
tiple
fa
scia
l spa
ces)
occl
usal
ort
hotic
dev
ice
adju
stm
ent
palli
ativ
e (e
mer
genc
y) tr
eatm
ent o
f den
tal p
ain
- min
or p
roce
dure
4242
Prov
ider
Cla
im D
ispu
tes
Mem
ber A
ppea
ls &
Grie
vanc
es
Prio
r Aut
horiz
atio
n Re
ques
ts
CA_F
ACET
S D0
0120
25_P
kg D
N04
8, 6
0_Hi
gh O
ptio
n De
ntal
-DM
O77
09/2
016
“Prio
r Aut
horiz
atio
n re
quire
d” m
eans
the
prac
titio
ner m
ust s
ubm
it th
ose
proc
edur
es fo
r app
rova
l with
clin
ical
doc
umen
tatio
n su
ppor
ting
nece
ssity
bef
ore
perf
orm
ing
thos
e pr
oced
ures
. To
do th
is c
ompl
ete
a st
anda
rd A
DA
clai
m fo
rm a
nd c
heck
the
box
mar
ked
“Pre
-Tre
atm
ent E
STIM
ATE.
” Pr
ior a
utho
rizat
ion
requ
est c
an b
e su
bmitt
ed v
ia th
e pr
ovid
er w
eb p
orta
l (at
ww
w.m
yuhc
prov
ider
s.co
m),
subm
itted
ele
ctro
nica
lly v
ia y
our c
lear
ingh
ouse
, or
simpl
y m
ail t
he fo
rm, t
o th
e be
low
add
ress
, alo
ng w
ith a
ny re
quire
d su
pple
men
tal i
nfor
mat
ion
(film
s, n
arra
tive,
per
io-c
hart
ing,
etc
.). Y
our o
ffice
will
then
rece
ive
an E
xpla
natio
n of
Ben
efits
(EO
B) o
utlin
ing
the
deni
al o
r app
rova
l of
requ
este
d tr
eatm
ent a
nd p
lan
paym
ent a
mou
nts w
hen
appl
icab
le.
Dent
al P
rovi
ders
with
com
plai
nts a
re to
con
tact
Uni
tedH
ealth
care
Den
tal’s
Pro
vide
r Ser
vice
dep
artm
ent a
t (87
7) 8
16-3
596.
Net
wor
k Pr
ovid
er c
ontr
actu
al d
ispu
tes,
Out
-of-N
etw
ork
prov
ider
dis
pute
s, a
nd re
proc
essi
ng re
ques
ts
will
be
logg
ed in
to th
e ap
peal
s dat
abas
e. P
leas
e m
ail t
o th
e Ap
peal
s & G
rieva
nces
PO
Box
list
ed a
bove
. Res
earc
h an
d re
solu
tion
will
be
com
plet
ed w
ithin
30
cale
ndar
day
s.
Mem
ber a
ppea
ls a
re re
view
ed b
y th
e he
alth
pla
n, a
nd a
re n
ot d
eleg
ated
to U
HC D
enta
l. Al
l Mem
ber a
ppea
ls (i
nclu
des P
re-S
ervi
ce a
ppea
ls, I
n N
etw
ork
Prov
ider
app
eals
, and
Out
of N
etw
ork
prov
ider
app
eals
) rec
eive
d by
UHC
De
ntal
will
be
forw
arde
d to
the
heal
th p
lan
via
over
nigh
t mai
l, w
ithin
7 d
ays o
f rec
eipt
of t
he a
ppea
l.
Mai
l mem
ber a
ppea
ls to
: Uni
tedH
ealth
care
, Att
n: A
ppea
l Dep
artm
ent,
MS
CA12
4-01
57, P
O B
ox 6
106,
Cyp
ress
, CA
9063
0
43
Iden
tific
atio
n Ca
rds
Sam
ple
Mem
ber I
D C
ard*
Fron
t of c
ard
Back
of c
ard
Fron
t of c
ard
Back
of c
ard
Impo
rtan
t Tel
epho
ne N
umbe
rs &
Web
site
s
Prov
ider
Qui
ck R
efer
ence
Gui
de -
Effe
ctiv
e 1/
1/20
17Ca
lifor
nia
Opt
iona
l Rid
er -
DH
MO
AARP
Med
icar
eCom
plet
e Se
cure
Hor
izon
s Pla
ns
*Ple
ase
note
that
the
Med
ical
ID C
ard
is un
iver
sal a
nd in
clud
es a
ll lin
es o
f cov
erag
e. T
he M
edic
al p
lan
can
be H
MO
or P
PO a
nd th
is d
oes n
ot re
flect
the
Dent
al P
lan
Bene
fits.
Ple
ase
flip
the
ID C
ard
over
to se
e th
e De
ntal
Pro
vide
r in
form
atio
n on
the
back
(i.e
. car
rier w
ebsi
te a
nd to
ll-fr
ee n
umbe
r). T
his i
nfor
mat
ion
can
be u
sed
to c
onfir
m p
rovi
der p
artic
ipat
ion,
mem
ber e
ligib
ility
and
ben
efits
. Thi
s is a
SAM
PLE
ID C
ard
and
may
diff
er fr
om th
e m
embe
r's ID
Ca
rd.
Elig
ibili
ty,
Bene
fits,
Cla
im(s
) and
Aut
horiz
atio
ns87
7-81
6-35
96Li
ve A
gent
: Mon
day
- Frid
ay, 8
:00A
M -
6:00
PM, E
STIV
R: 2
4 ho
urs a
day
Call
to In
quire
Abo
utTe
leph
one
Num
ber
Hou
rs o
f Ope
ratio
n
Emai
l to
Inqu
ire A
bout
Web
site
Hou
rs o
f Ope
ratio
nTo
dis
cuss
you
r par
ticip
atio
n, c
ontr
actu
al is
sues
, den
tist c
hang
es o
r offi
ce u
pdat
es80
0-82
2-53
53Li
ve A
gent
: Mon
day
- Frid
ay, 8
:00A
M -
11:0
0PM
, EST
4444
Impo
rtan
t Add
ress
es
Impo
rtan
t Ele
ctro
nic
Clai
ms &
Prio
r Aut
horiz
atio
n Su
bmis
sion
Info
rmat
ion
unlim
ited
1 ev
ery
6 m
onth
s fro
m la
st d
ate
of se
rvic
eun
limite
dun
limite
d
unlim
ited
unlim
ited
unlim
ited
unlim
ited
unlim
ited
unlim
ited
unlim
ited
unlim
ited
unlim
ited
unlim
ited
unlim
ited
unlim
ited
unlim
ited
unlim
ited
unlim
ited
unlim
ited
unlim
ited
unlim
ited
unlim
ited
unlim
ited
unlim
ited
unlim
ited
unlim
ited
unlim
ited
unlim
ited
unlim
ited
unlim
ited
unlim
ited
unlim
ited
unlim
ited
No
D023
0in
trao
ral -
per
iapi
cal e
ach
addi
tiona
l rad
iogr
aphi
c im
age
No
D024
0in
trao
ral -
occ
lusa
l rad
iogr
aphi
c im
age
No
D021
0D0
220
Asse
ssm
ent o
f a p
atie
ntin
trao
ral -
com
plet
e se
ries o
f rad
iogr
aphi
c im
ages
intr
aora
l - p
eria
pica
l firs
t rad
iogr
aphi
c im
age
No
D012
0D0
140
D014
5D0
150
perio
dic
oral
eva
luat
ion
limite
d or
al e
valu
atio
n - p
robl
em fo
cuse
d
oral
eva
luat
ion
for a
pat
ient
und
er th
ree
year
s of a
ge a
nd c
ouns
elin
g w
ith p
rimar
y ca
regi
ver
com
preh
ensi
ve o
ral e
valu
atio
n - n
ew o
r est
ablis
hed
patie
nt
D019
1Sc
reen
ing
of a
pat
ient
Cove
red
Den
tal S
ervi
ces:
Prio
r Aut
horiz
atio
n Re
quire
d?Pr
oced
ure
Code
Freq
uenc
y/Li
mita
tions
24 h
ours
a d
ay
Proc
edur
e D
escr
iptio
n
24 h
ours
a d
ay
Clai
ms
D017
0D0
171
5213
3
Prio
r Aut
horiz
atio
nAp
peal
s & G
rieva
nces
Uni
tedH
ealth
care
Den
tal,
PO B
ox 3
0567
, Sal
t Lak
e Ci
ty, U
T 84
130-
0567
Uni
tedH
ealth
care
Den
tal,
PO B
ox 3
0552
, Sal
t Lak
e Ci
ty, U
T 8
4130
-055
2U
nite
dHea
lthca
re D
enta
l, Ap
peal
s Disp
utes
, PO
Box
305
69, S
alt L
ake
City
, UT
8413
0-05
69
D018
0
deta
iled
and
exte
nsiv
e or
al e
valu
atio
n - p
robl
em-fo
cuse
d, b
y re
port
unlim
ited
2 ev
ery
year
No
No
D019
0
No
No
No
No
re-e
valu
atio
n, li
mite
d, p
robl
em fo
cuse
dre
-eva
luat
ion
- pos
t-op
erat
ive
offic
e vi
sit
com
preh
ensi
ve p
erio
dont
al e
valu
atio
n - n
ew o
r est
ablis
hed
patie
nt
D016
0
No
No
No
No
Med
icar
ew
ww
.med
icar
e.go
v24
hou
rs a
day
Elig
ibili
ty,
Bene
fits,
Cla
im(s
) and
Aut
horiz
atio
nsw
ww
.dbp
.com
Cent
ers f
or M
edic
aid
and
Med
icar
e Se
rvic
esw
ww
.cm
s.hh
s.go
v
Prov
ider
Rea
son
for M
ailin
g
EDI P
ayer
Num
ber f
or C
laim
s Sub
mitt
ed
D027
4bi
tew
ings
- fo
ur ra
diog
raph
ic im
ages
No
D033
0pa
nora
mic
radi
ogra
phic
imag
eN
o
D027
0bi
tew
ing
- sin
gle
radi
ogra
phic
imag
eN
oD0
272
bite
win
gs -
two
radi
ogra
phic
imag
esN
o
D046
0pu
lp v
italit
y te
sts
No
D111
0pr
ophy
laxi
s - a
dult
No
No
D214
0am
alga
m -
one
surf
ace,
prim
ary
or p
erm
anen
tN
oD2
150
amal
gam
- tw
o su
rfac
es, p
rimar
y or
per
man
ent
No
D120
8To
pica
l app
licat
ion
of fl
uorid
e - e
xclu
ding
var
nish
No
D133
0or
al h
ygie
ne in
stru
ctio
nsN
o
D216
0am
alga
m -
thre
e su
rfac
es, p
rimar
y or
per
man
ent
No
D216
1am
alga
m -
four
or m
ore
surf
aces
, prim
ary
or p
erm
anen
t
No
D271
2cr
own
- 3/4
resi
n-ba
sed
com
posi
te (i
ndire
ct)
No
D239
3re
sin-
base
d co
mpo
site
- th
ree
surf
aces
, pos
terio
rN
oD2
394
resi
n-ba
sed
com
posi
te -
four
or m
ore
surf
aces
, pos
terio
rN
o
unlim
ited
D233
2re
sin-
base
d co
mpo
site
- th
ree
surf
aces
, ant
erio
rN
oD2
335
resi
n-ba
sed
com
posi
te -
four
or m
ore
surf
aces
or i
nvol
ving
inci
sal a
ngle
(ant
erio
r)N
o
D233
0re
sin-
base
d co
mpo
site
- on
e su
rfac
e, a
nter
ior
No
D233
1re
sin-
base
d co
mpo
site
- tw
o su
rfac
es, a
nter
ior
No
D271
0cr
own,
resi
n-ba
sed
com
posi
te (i
ndire
ct)
D239
1re
sin-
base
d co
mpo
site
- on
e su
rfac
e, p
oste
rior
No
D239
2re
sin-
base
d co
mpo
site
- tw
o su
rfac
es, p
oste
rior
No
D272
0cr
own
- res
in w
ith h
igh
nobl
e m
etal
No
45
unlim
ited
unlim
ited
unlim
ited
unlim
ited
unlim
ited
D293
2D2
940
D294
1
D278
2D2
783
D279
0D2
791
D279
2D2
794
D291
5D2
920
D293
1
D275
0cr
own
- por
cela
in fu
sed
to h
igh
nobl
e m
etal
Yes
D275
1cr
own
- por
cela
in fu
sed
to p
redo
min
antly
bas
e m
etal
Yes
D275
2D2
780
D278
1
D274
0cr
own
- por
cela
in/c
eram
ic su
bstr
ate
Yes
crow
n - p
orce
lain
fuse
d to
nob
le m
etal
crow
n, 3
/4 c
ast h
igh
nobl
e m
etal
crow
n, 3
/4 c
ast p
redo
min
atel
y ba
se m
etal
Yes
No
Yes
D272
2cr
own
- res
in w
ith n
oble
met
alN
oD2
721
crow
n - r
esin
with
pre
dom
inan
tly b
ase
met
alN
o
D295
1D2
952
D295
3D2
954
D295
7D2
971
D299
0D3
110
D312
0D3
220
D331
0D3
320
D333
0D3
332
D395
0D4
341
D434
2D4
355
D491
0D4
921
D511
0D5
120
D513
0D5
140
D521
1
D521
2
D521
3
D521
4D5
225
D522
6
D528
1D5
410
crow
n, 3
/4 c
ast n
oble
met
alcr
own,
3/4
por
cela
in/c
eram
iccr
own
- ful
l cas
t hig
h no
ble
met
alcr
own
- ful
l cas
t pre
dom
inan
tly b
ase
met
alcr
own
- ful
l cas
t nob
le m
etal
crow
n - t
itani
um
pulp
cap
- in
dire
ct (e
xclu
ding
fina
l res
tora
tion)
ther
apeu
tic p
ulpo
tom
y (e
xclu
ding
fina
l res
tora
tion)
endo
dont
ic th
erap
y, a
nter
ior t
ooth
(exc
ludi
ng fi
nal r
esto
ratio
n)
rece
men
t or r
e-bo
nd c
ast i
ndire
ctly
fabr
icat
ed o
r pre
fabr
icat
ed p
ost a
nd c
ore
rece
men
t or r
e-bo
nd c
row
npr
efab
ricat
ed st
ainl
ess s
teel
cro
wn
- per
man
ent t
ooth
pref
abric
ated
resi
n cr
own
prot
ectiv
e re
stor
atio
nin
terim
ther
apeu
tic re
stor
atio
n-pr
imar
y de
ntiti
onpi
n re
tent
ion
- per
toot
h, in
add
ition
to re
stor
atio
nca
st p
ost a
nd c
ore
in a
dditi
on to
cro
wn
each
add
ition
al in
dire
ctly
fabr
icat
ed p
ost,
sam
e to
oth
pref
abric
ated
pos
t and
cor
e in
add
ition
to c
row
nea
ch a
dditi
onal
pre
fabr
icat
ed p
ost,
sam
e to
oth
addi
tiona
l pro
cedu
res t
o co
nstr
uct n
ew c
row
n un
der e
xist
ing
part
ial d
entu
re fr
amew
ork
(to
be
resi
n in
filtr
atio
n of
inci
pien
t sm
ooth
surf
ace
lesi
ons
pulp
cap
- di
rect
(exc
ludi
ng fi
nal r
esto
ratio
n)
endo
dont
ic th
erap
y, b
icus
pid
toot
h (e
xclu
ding
fina
l res
tora
tion)
endo
dont
ic th
erap
y, m
olar
(exc
ludi
ng fi
nal r
esto
ratio
n)in
com
plet
e en
dodo
ntic
ther
apy;
inop
erab
le, u
nres
tora
ble
or fr
actu
red
toot
hca
nal p
repa
ratio
n an
d fit
ting
of p
refo
rmed
dow
el o
r pos
tpe
riodo
ntal
scal
ing
and
root
pla
nnin
g - f
our o
r mor
e te
eth
per q
uadr
ant
perio
dont
al sc
alin
g an
d ro
ot p
lann
ing
- one
- th
ree
teet
h, p
er q
uadr
ant
full
mou
th d
ebrid
emen
t to
enab
le c
ompr
ehen
sive
eva
luat
ion
and
diag
nosi
spe
riodo
ntal
mai
nten
ance
ging
ival
irrig
atio
n - p
er q
uadr
ant
com
plet
e de
ntur
e - m
axill
ary
com
plet
e de
ntur
e - m
andi
bula
rim
med
iate
den
ture
- m
axill
ary
imm
edia
te d
entu
re -
man
dibu
lar
max
illar
y pa
rtia
l den
ture
- re
sin b
ase
(incl
udin
g an
y co
nven
tiona
l cla
sps,
rest
s and
teet
h)
man
dibu
lar p
artia
l den
ture
- re
sin
base
(inc
ludi
ng a
ny c
onve
ntio
nal c
lasp
s, re
sts a
nd te
eth)
max
illar
y pa
rtia
l den
ture
- ca
st m
etal
fram
ewor
k w
ith re
sin d
entu
re b
ases
(inc
ludi
ng a
ny c
onve
ntio
nal
clas
ps, r
ests
and
man
dibu
lar p
artia
l den
ture
- ca
st m
etal
fram
ewor
k w
ith re
sin
dent
ure
base
s (in
clud
ing
any
conv
entio
nal c
lasp
s, re
sts a
ndm
axill
ary
part
ial d
entu
re -
flexi
ble
base
(inc
ludi
ng a
ny c
lasp
s, re
sts a
nd te
eth)
man
dibu
lar p
artia
l den
ture
- fle
xibl
e ba
se (i
nclu
ding
any
cla
sps,
rest
s and
teet
h)
rem
ovab
le u
nila
tera
l par
tial d
entu
re -
one
piec
e ca
st m
etal
(inc
ludi
ng c
lasp
s and
teet
h)ad
just
com
plet
e de
ntur
e - m
axill
ary
Yes
Yes
Yes
Yes
Yes
No
No
No
No
No
No
No
No
No
No
Yes
Yes
Yes
Yes
Yes
No
No
Yes
Yes
Yes
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
unlim
ited
unlim
ited
unlim
ited
unlim
ited
unlim
ited
unlim
ited
unlim
ited
unlim
ited
unlim
ited
unlim
ited
unlim
ited
unlim
ited
unlim
ited
unlim
ited
unlim
ited
unlim
ited
unlim
ited
unlim
ited
unlim
ited
unlim
ited
unlim
ited
unlim
ited
unlim
ited
unlim
ited
unlim
ited
unlim
ited
unlim
ited
unlim
ited
unlim
ited
unlim
ited
4 ev
ery
year
unlim
ited
unlim
ited
unlim
ited
unlim
ited
unlim
ited
unlim
ited
unlim
ited
unlim
ited
unlim
ited
unlim
ited
unlim
ited
unlim
ited
unlim
ited
unlim
ited
unlim
ited
unlim
ited
4646
D541
1D5
421
D542
2D5
510
D552
0D5
610
D562
0D5
630
D564
0D5
650
D566
0D5
670
D567
1D5
730
D573
1D5
740
D574
1D5
750
D575
1D5
760
D576
1D5
863
D586
4D5
865
D586
6D6
210
D621
1D6
212
D621
4D6
240
D624
1D6
242
D624
5D6
250
D625
1D6
252
D672
0
D679
2D6
794
D693
0D7
111
D714
0D7
510
D751
1
D672
1D6
722
D674
0D6
750
D675
1D6
752
D678
0D6
781
D678
2D6
783
D679
0D6
791
adju
st c
ompl
ete
dent
ure
- man
dibu
lar
adju
st p
artia
l den
ture
- m
axill
ary
adju
st p
artia
l den
ture
- m
andi
bula
rre
pair
brok
en c
ompl
ete
dent
ure
base
repl
ace
mis
sing
or b
roke
n te
eth
- com
plet
e de
ntur
e (e
ach
toot
h)re
pair
resi
n de
ntur
e ba
sere
pair
cast
fram
ewor
kre
pair
or re
plac
e br
oken
cla
sp -
per t
ooth
repl
ace
brok
en te
eth
- per
toot
had
d to
oth
to e
xist
ing
part
ial d
entu
read
d cl
asp
to e
xist
ing
part
ial d
entu
re -
per t
ooth
repl
ace
all t
eeth
and
acr
ylic
on
cast
met
al fr
amew
ork
(max
illar
y)re
plac
e al
l tee
th a
nd a
cryl
ic o
n ca
st m
etal
fram
ewor
k (m
andi
bula
r)re
line
com
plet
e m
axill
ary
dent
ure
(cha
irsid
e)re
line
com
plet
e m
andi
bula
r den
ture
(cha
irsid
e)re
line
max
illar
y pa
rtia
l den
ture
(cha
irsid
e)re
line
man
dibu
lar p
artia
l den
ture
(cha
irsid
e)re
line
com
plet
e m
axill
ary
dent
ure
(labo
rato
ry)
relin
e co
mpl
ete
man
dibu
lar d
entu
re (l
abor
ator
y)re
line
max
illar
y pa
rtia
l den
ture
(lab
orat
ory)
relin
e m
andi
bula
r par
tial d
entu
re (l
abor
ator
y)
reta
iner
cro
wn
- res
in w
ith h
igh
nobl
e m
etal
reta
iner
cro
wn
- res
in w
ith p
redo
min
antly
bas
e m
etal
reta
iner
cro
wn
- res
in w
ith n
oble
met
al
Ove
rden
ture
-com
plet
e m
axill
ary
Ove
rden
ture
-par
tial m
axill
ary
Ove
rden
ture
- co
mpl
ete
man
dibu
lar
Ove
rden
ture
-par
tial m
andi
bula
rpo
ntic
- ca
st h
igh
nobl
e m
etal
pont
ic -
cast
pre
dom
inan
tly b
ase
met
alpo
ntic
- ca
st n
oble
met
alpo
ntic
- tit
aniu
mpo
ntic
- po
rcel
ain
fuse
d to
hig
h no
ble
met
alpo
ntic
- po
rcel
ain
fuse
d to
pre
dom
inan
tly b
ase
met
alpo
ntic
- po
rcel
ain
fuse
d to
nob
le m
etal
pont
ic-p
orce
lain
/cer
amic
pont
ic -
resi
n w
ith h
igh
nobl
e m
etal
pont
ic -
resi
n w
ith p
redo
min
antly
bas
e m
etal
pont
ic -
resi
n w
ith n
oble
met
al
reta
iner
cro
wn
- ful
l cas
t pre
dom
inan
tly b
ase
met
alre
tain
er c
row
n - f
ull c
ast n
oble
met
alre
tain
er c
row
n - t
itani
umre
cem
ent o
r re-
bond
fixe
d pa
rtia
l den
ture
extr
actio
n, c
oron
al re
mna
nts -
dec
iduo
us to
oth
extr
actio
n, e
rupt
ed to
oth
or e
xpos
ed ro
ot (e
leva
tion
and/
or fo
rcep
s rem
oval
)in
cisi
on a
nd d
rain
age
of a
bsce
ss -
intr
aora
l sof
t tis
sue
inci
sion
and
dra
inag
e of
abs
cess
- in
trao
ral s
oft t
issu
e - c
ompl
icat
ed (i
nclu
des d
rain
age
of m
ultip
le
fasc
ial s
pace
s)
reta
iner
cro
wn-
porc
elai
n/ce
ram
icre
tain
er c
row
n - p
orce
lain
fuse
d to
hig
h no
ble
met
alre
tain
er c
row
n - p
orce
lain
fuse
d to
pre
dom
inan
tly b
ase
met
alre
tain
er c
row
n - p
orce
lain
fuse
d to
nob
le m
etal
reta
iner
cro
wn
- 3/4
cas
t hig
h no
ble
met
alre
tain
er c
row
n-3/
4 ca
st p
redo
min
atel
y ba
sed
met
alre
tain
er c
row
n-3/
4 ca
st n
oble
met
alre
tain
er c
row
n-3/
4 po
rcel
ain/
cera
mic
reta
iner
cro
wn
- ful
l cas
t hig
h no
ble
met
al
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
Yes
Yes
No
No
No
No
No
Yes
Yes
Yes
No
Yes
Yes
Yes
No
No
No
No
No
No
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
No
Yes
Yes
unlim
ited
unlim
ited
unlim
ited
unlim
ited
unlim
ited
unlim
ited
unlim
ited
unlim
ited
unlim
ited
unlim
ited
unlim
ited
unlim
ited
unlim
ited
unlim
ited
unlim
ited
unlim
ited
unlim
ited
unlim
ited
unlim
ited
unlim
ited
unlim
ited
unlim
ited
unlim
ited
unlim
ited
unlim
ited
unlim
ited
unlim
ited
unlim
ited
unlim
ited
unlim
ited
unlim
ited
unlim
ited
unlim
ited
unlim
ited
unlim
ited
unlim
ited
unlim
ited
unlim
ited
unlim
ited
unlim
ited
unlim
ited
unlim
ited
unlim
ited
unlim
ited
unlim
ited
unlim
ited
unlim
ited
unlim
ited
unlim
ited
unlim
ited
unlim
ited
unlim
ited
1 pe
r too
th1
per t
ooth
unlim
ited
unlim
ited
47
Prov
ider
Cla
im D
ispu
tes
The
Calif
orni
a O
ptio
nal R
ider
DHM
O D
enta
l sup
plem
enta
l ben
efit
plan
cov
ers t
he d
enta
l cod
es li
sted
abo
ve. T
his s
uppl
emen
tal b
enef
it is
offe
red
to m
embe
rs th
at a
re e
nrol
led
in A
ARP
Med
icar
eCom
plet
e Se
cure
Horiz
ons a
nd
Shar
p Se
cure
Horiz
ons P
lans
. Pro
vide
r pay
men
t is m
ade
on a
Fee
-for-
Serv
ice
basi
s. M
embe
rs h
ave
In-n
etw
ork
only
ben
efits
. Som
e se
rvic
es re
quire
prio
r aut
horiz
atio
n. T
he m
embe
r cop
ays v
ary
for c
over
ed se
rvic
es fr
om $
3 -
$650
. The
re is
no
annu
al m
axim
um, c
oins
uran
ce o
r ded
uctib
le.
Dent
al P
rovi
ders
with
com
plai
nts a
re to
con
tact
Uni
tedH
ealth
care
Den
tal’s
Pro
vide
r Ser
vice
dep
artm
ent a
t (87
7) 8
16-3
596.
Net
wor
k Pr
ovid
er c
ontr
actu
al d
ispu
tes,
Out
-of-N
etw
ork
prov
ider
dis
pute
s, a
nd re
proc
essi
ng re
ques
ts
will
be
logg
ed in
to th
e ap
peal
s dat
abas
e. P
leas
e m
ail t
o th
e Ap
peal
s & G
rieva
nces
PO
Box
list
ed a
bove
. Res
earc
h an
d re
solu
tion
will
be
com
plet
ed w
ithin
30
cale
ndar
day
s.
D995
1
D788
1D9
110
occl
usal
ort
hotic
dev
ice
adju
stm
ent
No
No
No
No
No
No
In a
n ef
fort
to c
ompl
y w
ith th
e Ce
nter
s for
Med
icar
e an
d M
edic
aid
(CM
S) st
ate
man
date
d re
quire
men
ts, p
leas
e be
adv
ised
that
DHM
O E
ncou
nter
Dat
a Su
bmis
sion
s are
now
requ
ired.
CM
S no
w re
quire
s tha
t we
repo
rt 1
00%
of
util
izat
ion
data
for o
ur C
alifo
rnia
Opt
iona
l Rid
er D
HMO
mem
bers
. To
ens
ure
that
we
mee
t CM
S re
quire
men
t of r
epor
ting
100%
util
izatio
n, w
e ar
e ha
ppy
to re
-intr
oduc
e ou
r Den
tal I
ncen
tive
Prog
ram
effe
ctiv
e im
med
iate
ly.
Dent
al B
enef
it Pr
ovid
ers w
ill re
imbu
rse
our p
rovi
ders
$2.
00 fo
r eac
h en
coun
ter c
laim
subm
itted
for C
alifo
rnia
Opt
iona
l Rid
er D
HM
O m
embe
rs o
nly
for a
ll pr
oced
ures
(cov
ered
und
er th
e m
embe
r's p
lan)
per
form
ed o
n th
ose
mem
bers
, for
eac
h da
te o
f ser
vice
. Al
l pro
cedu
res p
erfo
rmed
MU
ST b
e re
port
ed in
clud
ing
proc
edur
es w
heth
er o
r not
the
mem
ber h
as a
cop
aym
ent.
Thi
s is a
requ
irem
ent f
or a
ll co
ntra
cted
pro
vide
rs to
subm
it ut
iliza
tion
for
each
pat
ient
trea
ted.
Her
e ar
e a
few
way
s the
Enc
ount
er In
form
atio
n ca
n be
subm
itted
:
1)
Electronically
- As
you
wou
ld a
PPO
or I
ndem
nity
Cla
im
2) W
eb S
ite -
Clai
ms c
an b
e su
bmitt
ed in
divi
dual
ly o
n ou
r web
site
at w
ww
.uhc
prov
ider
s.co
m
3) B
y M
ail -
As y
ou w
ould
a P
PO o
r Ind
emni
ty C
laim
4)
Util
izat
ion
Repo
rts -
Mus
t con
tain
ALL
requ
ired
info
rmat
ion:
• Su
bscr
iber
ID•
Subs
crib
er D
ate
of B
irth
• G
roup
Nam
e or
Num
ber
• Pa
tient
’s F
ull N
ame
• Pa
tient
’s D
ate
of B
irth
• Re
latio
nshi
p to
Sub
scrib
er•
Phys
ical
Add
ress
• AD
A Co
de P
erfo
rmed
• To
oth#
/ Q
uadr
ant
• Su
rfac
e•
Trea
ting
Dent
ist N
ame
• De
ntist
Tax
I.D.
for B
illin
g
Enco
unte
r/U
tiliza
tion
Repo
rtin
g - W
hen
subm
ittin
g En
coun
ter/
Util
izat
ion
clai
ms,
you
mus
t inc
lude
Cod
e D0
999
alon
g w
ith a
ll co
vere
d se
rvic
e pr
oced
ure
code
s you
per
form
on
each
Opt
iona
l Cal
iforn
ia D
HMO
mem
ber.
Pl
ease
not
e th
e fo
llow
ing:
1)
If y
ou su
bmit
D099
9 al
one
no a
dditi
onal
$2.
00 re
imbu
rsem
ent w
ill n
ot b
e pa
id.
Addi
tiona
lly, c
laim
subm
issio
n w
ould
be
cons
ider
ed n
on-c
ompl
iant
.
2) If
yo
u su
bmit
all s
ervi
ce p
roce
dure
serv
ice
code
s but
don
't in
clud
e D0
999
as w
ell a
s you
won
't be
reim
burs
ed th
e ad
ditio
nal $
2.00
. In
add
ition
, the
cla
im w
ill b
e co
nsid
ered
non
-com
plia
nt.
unlim
ited
unlim
ited
unlim
ited
unlim
ited
unlim
ited
unlim
ited
4 ev
ery
24 m
onth
s fro
m la
st d
ate
of se
rvic
eN
o
palli
ativ
e (e
mer
genc
y) tr
eatm
ent o
f den
tal p
ain
- min
or p
roce
dure
loca
l ane
sthe
sia
in c
onju
nctio
n w
ith o
pera
tive
or su
rgic
al p
roce
dure
s
offic
e vi
sit f
or o
bser
vatio
n (d
urin
g re
gula
rly sc
hedu
led
hour
s) -
no o
ther
serv
ices
per
form
edof
fice
visi
t - a
fter
regu
larly
sche
dule
d ho
urs
case
pre
sent
atio
n, d
etai
led
and
exte
nsiv
e tr
eatm
ent p
lann
ing
D921
5
D943
0D9
440
D945
0oc
clus
al a
djus
tmen
t - li
mite
d
4848
Mem
ber A
ppea
ls &
Grie
vanc
es
Prio
r Aut
horiz
atio
n Re
ques
ts
CA_F
ACET
S D0
0120
24_P
kg D
N05
4_O
ptio
nal D
enta
l-DM
O75
09/2
016
“Prio
r Aut
horiz
atio
n re
quire
d” m
eans
the
prac
titio
ner m
ust s
ubm
it th
ose
proc
edur
es fo
r app
rova
l with
clin
ical
doc
umen
tatio
n su
ppor
ting
nece
ssity
bef
ore
perf
orm
ing
thos
e pr
oced
ures
. To
do th
is c
ompl
ete
a st
anda
rd A
DA
clai
m fo
rm a
nd c
heck
the
box
mar
ked
“Pre
-Tre
atm
ent E
STIM
ATE.
” Pr
ior a
utho
rizat
ion
requ
est c
an b
e su
bmitt
ed v
ia th
e pr
ovid
er w
eb p
orta
l (at
ww
w.m
yuhc
prov
ider
s.co
m),
subm
itted
ele
ctro
nica
lly v
ia y
our c
lear
ingh
ouse
, or
simpl
y m
ail t
he fo
rm, t
o th
e be
low
add
ress
, alo
ng w
ith a
ny re
quire
d su
pple
men
tal i
nfor
mat
ion
(film
s, n
arra
tive,
per
io-c
hart
ing,
etc
.). Y
our o
ffice
will
then
rece
ive
an E
xpla
natio
n of
Ben
efits
(EO
B) o
utlin
ing
the
deni
al o
r app
rova
l of
requ
este
d tr
eatm
ent a
nd p
lan
paym
ent a
mou
nts w
hen
appl
icab
le.
Mem
ber a
ppea
ls a
re re
view
ed b
y th
e he
alth
pla
n, a
nd a
re n
ot d
eleg
ated
to U
HC D
enta
l. Al
l Mem
ber a
ppea
ls (i
nclu
des P
re-S
ervi
ce a
ppea
ls, I
n N
etw
ork
Prov
ider
app
eals
, and
Out
of N
etw
ork
prov
ider
app
eals
) rec
eive
d by
UHC
De
ntal
will
be
forw
arde
d to
the
heal
th p
lan
via
over
nigh
t mai
l, w
ithin
7 d
ays o
f rec
eipt
of t
he a
ppea
l.
Mai
l mem
ber a
ppea
ls to
: Uni
tedH
ealth
care
, Att
n: A
ppea
l Dep
artm
ent,
MS
CA12
4-01
57, P
O B
ox 6
106,
Cyp
ress
, CA
9063
0
49
5050
Iden
tific
atio
n Ca
rds
Sam
ple
Mem
ber I
D C
ard*
Fron
t of c
ard
Back
of c
ard
Fron
t of c
ard
Back
of c
ard
Impo
rtan
t Tel
epho
ne N
umbe
rs &
Web
site
s
Call
to In
quire
Abo
utTe
leph
one
Num
ber
Hou
rs o
f Ope
ratio
n
Emai
l to
Inqu
ire A
bout
Web
site
Hou
rs o
f Ope
ratio
nTo
dis
cuss
you
r par
ticip
atio
n, c
ontr
actu
al is
sues
, den
tist c
hang
es o
r offi
ce u
pdat
es80
0-82
2-53
53Li
ve A
gent
: Mon
day
- Frid
ay, 8
:00A
M -
11:0
0PM
, EST
Prov
ider
Qui
ck R
efer
ence
Gui
de -
Effe
ctiv
e 1/
1/20
17Co
lora
do H
igh
Opt
ion
Ride
r 260
DH
MO
- $1
000
Annu
al M
axim
umAA
RP M
edic
areC
ompl
ete
Secu
reH
oriz
ons P
lans
1, 2
, and
Ess
entia
l Pla
ns
*Ple
ase
note
that
the
Med
ical
ID C
ard
is un
iver
sal a
nd in
clud
es a
ll lin
es o
f cov
erag
e. T
he M
edic
al p
lan
can
be H
MO
or P
PO a
nd th
is d
oes n
ot re
flect
the
Dent
al P
lan
Bene
fits.
Ple
ase
flip
the
ID C
ard
over
to se
e th
e De
ntal
Pro
vide
r in
form
atio
n on
the
back
(i.e
. car
rier w
ebsi
te a
nd to
ll-fr
ee n
umbe
r). T
his i
nfor
mat
ion
can
be u
sed
to c
onfir
m p
rovi
der p
artic
ipat
ion,
mem
ber e
ligib
ility
and
ben
efits
. Thi
s is a
SAM
PLE
ID C
ard
and
may
diff
er fr
om th
e m
embe
r's ID
Ca
rd.
Elig
ibili
ty,
Bene
fits,
Cla
im(s
) and
Aut
horiz
atio
ns87
7-81
6-35
96Li
ve A
gent
: Mon
day
- Frid
ay, 8
:00A
M -
6:00
PM, E
STIV
R: 2
4 ho
urs a
day
51
Impo
rtan
t Add
ress
es
Impo
rtan
t Ele
ctro
nic
Clai
ms &
Prio
r Aut
horiz
atio
n Su
bmis
sion
Info
rmat
ion
D233
0re
sin-
base
d co
mpo
site
- on
e su
rfac
e, a
nter
ior
No
D216
0am
alga
m -
thre
e su
rfac
es, p
rimar
y or
per
man
ent
No
D216
1am
alga
m -
four
or m
ore
surf
aces
, prim
ary
or p
erm
anen
tN
o
D214
0am
alga
m -
one
surf
ace,
prim
ary
or p
erm
anen
tN
oD2
150
amal
gam
- tw
o su
rfac
es, p
rimar
y or
per
man
ent
No
D155
0re
cem
ent o
r re-
bond
of s
pace
mai
ntai
ner
No
D155
5re
mov
al o
f fix
ed sp
ace
mai
ntai
ner
No
D152
5sp
ace
mai
ntai
ner -
rem
ovab
le -
bila
tera
lN
o
D151
0sp
ace
mai
ntai
ner -
fixe
d - u
nila
tera
lN
oD1
515
spac
e m
aint
aine
r - fi
xed
- bila
tera
lN
o
pano
ram
ic ra
diog
raph
ic im
age
No
D047
0di
agno
stic
cas
tsN
o
D112
0pr
ophy
laxi
s - c
hild
No
D120
6to
pica
l app
licat
ion
of fl
uorid
e va
rnis
hN
o
D060
3ca
ries r
isk
asse
ssm
ent a
nd d
ocum
enta
tion,
with
a fi
ndin
g of
hig
h ris
kN
oD1
110
prop
hyla
xis -
adu
ltN
o
Med
icar
ew
ww
.med
icar
e.go
v24
hou
rs a
day
Elig
ibili
ty,
Bene
fits,
Cla
im(s
) and
Aut
horiz
atio
nsw
ww
.dbp
.com
Cent
ers f
or M
edic
aid
and
Med
icar
e Se
rvic
esw
ww
.cm
s.hh
s.go
v
Prov
ider
Rea
son
for M
ailin
g
Uni
tedH
ealth
care
Den
tal,
PO B
ox 3
0552
, Sal
t Lak
e Ci
ty, U
T 8
4130
-055
2U
nite
dHea
lthca
re D
enta
l, Ap
peal
s Disp
utes
, PO
Box
305
69, S
alt L
ake
City
, UT
8413
0-05
69
D021
0
deta
iled
and
exte
nsiv
e or
al e
valu
atio
n - p
robl
em-fo
cuse
d, b
y re
port
unlim
ited
unlim
ited
No
No
D022
0
No
No
No
No
re-e
valu
atio
n, li
mite
d, p
robl
em fo
cuse
dco
mpr
ehen
sive
per
iodo
ntal
eva
luat
ion
- new
or e
stab
lishe
d pa
tient
intr
aora
l - c
ompl
ete
serie
s of r
adio
grap
hic
imag
es
D016
0
No
No
No
No
EDI P
ayer
Num
ber f
or C
laim
s Sub
mitt
ed
D060
1ca
ries r
isk
asse
ssm
ent a
nd d
ocum
enta
tion,
with
a fi
ndin
g of
low
risk
No
D060
2ca
ries r
isk
asse
ssm
ent a
nd d
ocum
enta
tion,
with
a fi
ndin
g of
mod
erat
e ris
kN
o
D033
0
com
preh
ensi
ve o
ral e
valu
atio
n - n
ew o
r est
ablis
hed
patie
nt
D023
0in
trao
ral -
per
iapi
cal f
irst r
adio
grap
hic
imag
e
Cove
red
Den
tal S
ervi
ces:
Prio
r Aut
horiz
atio
n Re
quire
d?Pr
oced
ure
Code
Freq
uenc
y/Li
mita
tions
24 h
ours
a d
ay
Proc
edur
e D
escr
iptio
n
24 h
ours
a d
ay
Clai
ms
D017
0D0
180
5213
3
Prio
r Aut
horiz
atio
nAp
peal
s & G
rieva
nces
Uni
tedH
ealth
care
Den
tal,
PO B
ox 3
0567
, Sal
t Lak
e Ci
ty, U
T 84
130-
0567
unlim
ited
unlim
ited
unlim
ited
unlim
ited
unlim
ited
unlim
ited
unlim
ited
unlim
ited
unlim
ited
unlim
ited
2 ev
ery
year
unlim
ited
No
D027
2bi
tew
ings
- tw
o ra
diog
raph
ic im
ages
No
D027
4bi
tew
ings
- fo
ur ra
diog
raph
ic im
ages
No
D024
0D0
270
intr
aora
l - p
eria
pica
l eac
h ad
ditio
nal r
adio
grap
hic
imag
ein
trao
ral -
occ
lusa
l rad
iogr
aphi
c im
age
bite
win
g - s
ingl
e ra
diog
raph
ic im
age
No
D012
0D0
140
D014
5D0
150
perio
dic
oral
eva
luat
ion
limite
d or
al e
valu
atio
n - p
robl
em fo
cuse
d
oral
eva
luat
ion
for a
pat
ient
und
er th
ree
year
s of a
ge a
nd c
ouns
elin
g w
ith p
rimar
y ca
regi
ver
unlim
ited
unlim
ited
unlim
ited
unlim
ited
unlim
ited
unlim
ited
unlim
ited
unlim
ited
unlim
ited
unlim
ited
unlim
ited
unlim
ited
unlim
ited
1 ev
ery
6 m
onth
s1
ever
y 6
mon
ths
unlim
ited
unlim
ited
unlim
ited
unlim
ited
unlim
ited
unlim
ited
unlim
ited
unlim
ited
D135
2pr
even
tive
resi
n re
stor
atio
n - p
erm
anen
t too
thN
oD1
353
seal
ant r
epai
r - p
er to
oth
No
D120
8To
pica
l app
licat
ion
of fl
uorid
e - e
xclu
ding
var
nish
No
D135
1se
alan
t - p
er to
oth
No
No
D152
0sp
ace
mai
ntai
ner -
rem
ovab
le -
unila
tera
l
5252
unlim
ited
unlim
ited
unlim
ited
unlim
ited
unlim
ited
unlim
ited
unlim
ited
unlim
ited
unlim
ited
unlim
ited
unlim
ited
unlim
ited
unlim
ited
unlim
ited
unlim
ited
unlim
ited
unlim
ited
unlim
ited
unlim
ited
unlim
ited
unlim
ited
unlim
ited
unlim
ited
unlim
ited
unlim
ited
unlim
ited
unlim
ited
unlim
ited
unlim
ited
unlim
ited
unlim
ited
unlim
ited
unlim
ited
unlim
ited
unlim
ited
unlim
ited
unlim
ited
unlim
ited
unlim
ited
unlim
ited
unlim
ited
unlim
ited
unlim
ited
unlim
ited
unlim
ited
unlim
ited
No
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
Yes
Yes
No
No
No
No
No
No
No
No
No
No
No
No
inte
rim th
erap
eutic
rest
orat
ion-
prim
ary
dent
ition
Core
bui
ldup
, inc
ludi
ng a
ny p
ins w
hen
requ
ired
pin
rete
ntio
n - p
er to
oth,
in a
dditi
on to
rest
orat
ion
cast
pos
t and
cor
e in
add
ition
to c
row
nea
ch a
dditi
onal
indi
rect
ly fa
bric
ated
pos
t, sa
me
toot
hpr
efab
ricat
ed p
ost a
nd c
ore
in a
dditi
on to
cro
wn
crow
n - p
orce
lain
/cer
amic
subs
trat
ecr
own
- por
cela
in fu
sed
to h
igh
nobl
e m
etal
crow
n - p
orce
lain
fuse
d to
pre
dom
inan
tly b
ase
met
al
crow
n, 3
/4 c
ast n
oble
met
alcr
own,
3/4
por
cela
in/c
eram
iccr
own
- ful
l cas
t hig
h no
ble
met
alcr
own
- ful
l cas
t pre
dom
inan
tly b
ase
met
alcr
own
- ful
l cas
t nob
le m
etal
crow
n - t
itani
umre
cem
ent o
r re-
bond
inla
y, o
nlay
, ven
eer o
r par
tial c
over
age
rest
orat
ion
rece
men
t or r
e-bo
nd c
ast i
ndire
ctly
fabr
icat
ed o
r pre
fabr
icat
ed p
ost a
nd c
ore
rece
men
t or r
e-bo
nd c
row
npr
efab
ricat
ed st
ainl
ess s
teel
cro
wn
- prim
ary
toot
hpr
efab
ricat
ed st
ainl
ess s
teel
cro
wn
- per
man
ent t
ooth
pref
abric
ated
resi
n cr
own
pref
abric
ated
stai
nles
s ste
el c
row
n w
ith re
sin
win
dow
prot
ectiv
e re
stor
atio
n
inla
y - p
orce
lain
/cer
amic
- on
e su
rfac
ein
lay
- por
cela
in/c
eram
ic -
two
surf
aces
inla
y - p
orce
lain
/cer
amic
- th
ree
or m
ore
surf
aces
onla
y - p
orce
lain
/cer
amic
- tw
o su
rfac
eson
lay
- por
cela
in/c
eram
ic -
thre
e su
rfac
eson
lay
- por
cela
in/c
eram
ic -
four
or m
ore
surf
aces
crow
n - p
orce
lain
fuse
d to
nob
le m
etal
crow
n, 3
/4 c
ast h
igh
nobl
e m
etal
crow
n, 3
/4 c
ast p
redo
min
atel
y ba
se m
etal
inla
y - c
ompo
site
/res
in -
one
surf
ace
inla
y - c
ompo
site
/res
in -
two
surf
aces
inla
y - c
ompo
site/
resi
n - t
hree
or m
ore
surf
aces
onla
y - c
ompo
site
/res
in -
two
surf
aces
onla
y - c
ompo
site
/res
in -
thre
e su
rfac
eson
lay
- com
posi
te/r
esin
- fo
ur o
r mor
e su
rfac
escr
own,
resi
n-ba
sed
com
posi
te (i
ndire
ct)
crow
n - 3
/4 re
sin-
base
d co
mpo
site
(ind
irect
)cr
own
- res
in w
ith h
igh
nobl
e m
etal
crow
n - r
esin
with
pre
dom
inan
tly b
ase
met
alcr
own
- res
in w
ith n
oble
met
al
D291
0D2
915
D292
0D2
930
D293
1D2
932
D293
3D2
940
D294
1D2
950
D295
1D2
952
D295
3D2
954
D271
0D2
712
D272
0D2
721
D272
2D2
740
D275
0D2
751
D275
2D2
780
D278
1D2
782
D278
3D2
790
D279
1D2
792
D279
4
D239
4re
sin-
base
d co
mpo
site
- fo
ur o
r mor
e su
rfac
es, p
oste
rior
No
D239
0re
sin-
base
d co
mpo
site
cro
wn,
ant
erio
r
D233
1re
sin-
base
d co
mpo
site
- tw
o su
rfac
es, a
nter
ior
No
D239
2re
sin-
base
d co
mpo
site
- tw
o su
rfac
es, p
oste
rior
No
D239
3re
sin-
base
d co
mpo
site
- th
ree
surf
aces
, pos
terio
rN
o
D252
0in
lay
- met
allic
- tw
o su
rfac
esN
oD2
530
inla
y - m
etal
lic -
thre
e or
mor
e su
rfac
esN
oD2
542
D254
3D2
544
D251
0in
lay
- met
allic
- on
e su
rfac
eN
o
onla
y m
etal
lic, t
wo
surf
aces
onla
y-m
etal
lic-t
hree
surf
aces
onla
y-m
etal
lic-fo
ur o
r mor
e su
rfac
es
No
No
No
D266
2D2
663
D266
4
No
D239
1re
sin-
base
d co
mpo
site
- on
e su
rfac
e, p
oste
rior
No
D233
2re
sin-
base
d co
mpo
site
- th
ree
surf
aces
, ant
erio
rN
oD2
335
resi
n-ba
sed
com
posi
te -
four
or m
ore
surf
aces
or i
nvol
ving
inci
sal a
ngle
(ant
erio
r)N
o
D261
0D2
620
D263
0D2
642
D264
3D2
644
D265
0D2
651
D265
2
unlim
ited
unlim
ited
unlim
ited
unlim
ited
unlim
ited
unlim
ited
unlim
ited
unlim
ited
unlim
ited
unlim
ited
unlim
ited
53
unlim
ited
unlim
ited
unlim
ited
unlim
ited
unlim
ited
unlim
ited
unlim
ited
unlim
ited
unlim
ited
unlim
ited
unlim
ited
unlim
ited
unlim
ited
unlim
ited
unlim
ited
unlim
ited
unlim
ited
unlim
ited
unlim
ited
unlim
ited
unlim
ited
unlim
ited
unlim
ited
unlim
ited
unlim
ited
unlim
ited
unlim
ited
unlim
ited
unlim
ited
unlim
ited
unlim
ited
unlim
ited
unlim
ited
unlim
ited
unlim
ited
unlim
ited
unlim
ited
unlim
ited
unlim
ited
unlim
ited
unlim
ited
unlim
ited
unlim
ited
unlim
ited
unlim
ited
unlim
ited
No
No
No
No
No
No
No
No
No
No
No
No
Yes
Yes
No
Yes
No
No
Yes
Yes
Yes
No
No
No
Yes
Yes
Yes
No
No
No
No
No
No
No
No
Yes
No
No
No
No
No
No
No
No
No
No
dist
al o
r pro
xim
al w
edge
pro
cedu
re (w
hen
not p
erfo
rmed
in c
onju
nctio
n w
ith su
rgic
al p
roce
dure
s in
the
sam
e an
atom
ical
are
a
Apic
oect
omy
- mol
ar (f
irst r
oot)
Apic
oect
omy
(eac
h ad
ditio
nal r
oot)
perir
adic
ular
surg
ery
with
out a
pico
ecto
my
retr
ogra
de fi
lling
- pe
r roo
tro
ot a
mpu
tatio
n - p
er ro
othe
mis
ectio
n (in
clud
ing
any
root
rem
oval
), no
t inc
ludi
ng ro
ot c
anal
ther
apy
ging
ivec
tom
y or
gin
givo
plas
ty -
four
or m
ore
cont
iguo
us te
eth
or to
oth
boun
ded
spac
es p
er q
uadr
ant
ging
ivec
tom
y or
gin
givo
plas
ty -
one
to th
ree
cont
iguo
us te
eth
or to
oth
boun
ded
spac
es p
er q
uadr
ant
ging
ival
flap
pro
cedu
re, i
nclu
ding
root
pla
nnin
g - f
our o
r mor
e co
ntig
uous
teet
h or
toot
h bo
unde
d sp
aces
per
qua
dran
t
ging
ival
flap
pro
cedu
re -
incl
udin
g ro
ot p
lann
ing
-one
to th
ree
cont
iguo
us te
eth
or to
oth
boun
ded
spac
es p
er q
uadr
ant
apic
ally
pos
ition
ed fl
ap
clin
ical
cro
wn
leng
then
ing
- har
d tis
sue
osse
ous s
urge
ry (i
nclu
ding
flap
ent
ry a
nd c
losu
re) -
four
or m
ore
cont
iguo
us te
eth
or to
oth
boun
ded
spac
es p
er q
uadr
ant
osse
ous s
urge
ry (i
nclu
ding
flap
ent
ry a
nd c
losu
re) -
one
to th
ree
cont
iguo
us te
eth
or to
oth
boun
ded
Bone
repl
acem
ent g
raft
- fir
st si
te in
qua
dran
tBo
ne re
plac
emen
t gra
ft -
each
add
ition
al si
te in
qua
dran
tpe
dicl
e so
ft tis
sue
graf
t pro
cedu
re
endo
dont
ic th
erap
y, a
nter
ior t
ooth
(exc
ludi
ng fi
nal r
esto
ratio
n)en
dodo
ntic
ther
apy,
bic
uspi
d to
oth
(exc
ludi
ng fi
nal r
esto
ratio
n)en
dodo
ntic
ther
apy,
mol
ar (e
xclu
ding
fina
l res
tora
tion)
trea
tmen
t of r
oot c
anal
obs
truc
tion,
non
-sur
gica
l acc
ess
inco
mpl
ete
endo
dont
ic th
erap
y; in
oper
able
, unr
esto
rabl
e or
frac
ture
d to
oth
inte
rnal
toot
h re
pair
of p
erfo
ratio
n de
fect
sre
trea
tmen
t of p
revi
ous r
oot c
anal
ther
apy
- ant
erio
rre
trea
tmen
t of p
revi
ous r
oot c
anal
ther
apy
- bic
uspi
dre
trea
tmen
t of p
revi
ous r
oot c
anal
ther
apy
- mol
arAp
exifi
catio
n/re
calc
ifica
tion-
initi
al v
isit (
apic
al c
losu
re/c
alci
fic re
pair
of p
erfo
ratio
ns, r
oot r
esor
ptio
n,
etc.
Apex
ifica
tion/
reca
lcifi
catio
n/pu
lpal
rege
nera
tion
- int
erim
med
icat
ion
repl
acem
ent
apex
ifica
tion/
reca
lcifi
catio
n - f
inal
visi
t (in
clud
es c
ompl
eted
root
Pupa
l reg
ener
atio
n-in
itial
vis
itPu
lpal
rege
nera
tion-
inte
rim m
edic
amen
t rep
lace
men
tPu
lpal
rege
nera
tion-
com
plet
ion
of tr
eatm
ent
Apic
oect
omy
- ant
erio
rAp
icoe
ctom
y - b
icus
pid
(firs
t roo
t)
each
add
ition
al p
refa
bric
ated
pos
t, sa
me
toot
hla
bial
ven
eer (
lam
inat
e) -
chai
rsid
ela
bial
ven
eer (
resi
n la
min
ate)
- la
bora
tory
labi
al v
enee
r (po
rcel
ain
lam
inat
e) -
labo
rato
ryve
neer
repa
ir ne
cess
itate
d by
rest
orat
ive
mat
eria
l fai
lure
pulp
cap
- di
rect
(exc
ludi
ng fi
nal r
esto
ratio
n)pu
lp c
ap -
indi
rect
(exc
ludi
ng fi
nal r
esto
ratio
n)th
erap
eutic
pul
poto
my
(exc
ludi
ng fi
nal r
esto
ratio
n)pu
lpal
deb
ridem
ent,
prim
ary
and
perm
anen
t tee
th
pulp
al th
erap
y (r
esto
rabl
e fil
ling)
- an
terio
r, pr
imar
y to
oth
(exc
ludi
ng fi
nal r
esto
ratio
n)
pulp
al th
erap
y (r
esto
rabl
e fil
ling)
- po
ster
ior,
prim
ary
toot
h (e
xclu
ding
fina
l res
tora
tion)
D424
1D4
245
D424
9
D426
0D4
261
D426
3D4
264
D427
0
D427
4
D335
1D3
352
D335
3D3
355
D335
6D3
357
D341
0D3
421
D342
5D3
426
D342
7D3
430
D345
0D3
920
D421
0
D421
1
D424
0
D296
2D2
983
D311
0D3
120
D322
0D3
221
D323
0
D324
0D3
310
D332
0D3
330
D333
1D3
332
D333
3D3
346
D334
7D3
348
D295
7D2
960
D296
1
5454
unlim
ited
unlim
ited
unlim
ited
unlim
ited
unlim
ited
unlim
ited
unlim
ited
unlim
ited
unlim
ited
unlim
ited
unlim
ited
unlim
ited
unlim
ited
unlim
ited
unlim
ited
unlim
ited
unlim
ited
unlim
ited
unlim
ited
unlim
ited
unlim
ited
unlim
ited
unlim
ited
unlim
ited
unlim
ited
unlim
ited
unlim
ited
unlim
ited
unlim
ited
unlim
ited
unlim
ited
unlim
ited
unlim
ited
unlim
ited
unlim
ited
unlim
ited
unlim
ited
4 ev
ery
year
unlim
ited
unlim
ited
unlim
ited
unlim
ited
unlim
ited
unlim
ited
unlim
ited
unlim
ited
unlim
ited
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
Yes
No
No
No
Yes
No
No
No
No
No
No
No
No
No
No
No
add
clas
p to
exi
stin
g pa
rtia
l den
ture
- pe
r too
thre
plac
e al
l tee
th a
nd a
cryl
ic o
n ca
st m
etal
fram
ewor
k (m
axill
ary)
repl
ace
all t
eeth
and
acr
ylic
on
cast
met
al fr
amew
ork
(man
dibu
lar)
reba
se c
ompl
ete
max
illar
y de
ntur
ere
base
com
plet
e m
andi
bula
r den
ture
reba
se m
axill
ary
part
ial d
entu
rere
base
man
dibu
lar p
artia
l den
ture
relin
e co
mpl
ete
max
illar
y de
ntur
e (c
hairs
ide)
relin
e co
mpl
ete
man
dibu
lar d
entu
re (c
hairs
ide)
relin
e m
axill
ary
part
ial d
entu
re (c
hairs
ide)
relin
e m
andi
bula
r par
tial d
entu
re (c
hairs
ide)
relin
e co
mpl
ete
max
illar
y de
ntur
e (la
bora
tory
)re
line
com
plet
e m
andi
bula
r den
ture
(lab
orat
ory)
relin
e m
axill
ary
part
ial d
entu
re (l
abor
ator
y)
imm
edia
te m
andi
bula
r par
tial d
entu
re -
resi
n ba
se
imm
edia
te m
axill
ary
part
ial d
entu
re -
cast
met
al fr
amew
ork
with
resin
den
ture
bas
es
imm
edia
te m
andi
bula
r par
tial d
entu
re-c
ast m
etal
fram
ewor
k w
ith re
sin
dent
ure
base
sm
axill
ary
part
ial d
entu
re -
flexi
ble
base
(inc
ludi
ng a
ny c
lasp
s, re
sts a
nd te
eth)
man
dibu
lar p
artia
l den
ture
- fle
xibl
e ba
se (i
nclu
ding
any
cla
sps,
rest
s and
teet
h)
rem
ovab
le u
nila
tera
l par
tial d
entu
re -
one
piec
e ca
st m
etal
(inc
ludi
ng c
lasp
s and
teet
h)ad
just
com
plet
e de
ntur
e - m
axill
ary
adju
st c
ompl
ete
dent
ure
- man
dibu
lar
adju
st p
artia
l den
ture
- m
axill
ary
adju
st p
artia
l den
ture
- m
andi
bula
rre
pair
brok
en c
ompl
ete
dent
ure
base
repl
ace
mis
sing
or b
roke
n te
eth
- com
plet
e de
ntur
e (e
ach
toot
h)re
pair
resi
n de
ntur
e ba
sere
pair
cast
fram
ewor
kre
pair
or re
plac
e br
oken
cla
sp -
per t
ooth
repl
ace
brok
en te
eth
- per
toot
had
d to
oth
to e
xist
ing
part
ial d
entu
re
free
soft
tiss
ue g
raft
pro
cedu
re e
ach
addi
tiona
l con
tiguo
us to
oth,
impl
ant o
r ede
ntul
ous t
ooth
perio
dont
al sc
alin
g an
d ro
ot p
lann
ing
- fou
r or m
ore
teet
h pe
r qua
dran
tpe
riodo
ntal
scal
ing
and
root
pla
nnin
g - o
ne -
thre
e te
eth,
per
qua
dran
tfu
ll m
outh
deb
ridem
ent t
o en
able
com
preh
ensi
ve e
valu
atio
n an
d di
agno
sis
loca
lized
del
iver
y of
ant
imic
robi
al a
gent
s via
a c
ontr
olle
d re
leas
e ve
hicl
e in
to d
isea
sed
crev
icul
ar
tissu
e, p
er to
oth
perio
dont
al m
aint
enan
ce
unsc
hedu
led
dres
sing
cha
nge
(by
som
eone
oth
er th
an tr
eatin
g de
ntis
t or t
heir
staf
f)co
mpl
ete
dent
ure
- max
illar
y
com
plet
e de
ntur
e - m
andi
bula
r
imm
edia
te d
entu
re -
max
illar
yim
med
iate
den
ture
- m
andi
bula
r
max
illar
y pa
rtia
l den
ture
- re
sin b
ase
(incl
udin
g an
y co
nven
tiona
l cla
sps,
rest
s and
teet
h)
man
dibu
lar p
artia
l den
ture
- re
sin
base
(inc
ludi
ng a
ny c
onve
ntio
nal c
lasp
s, re
sts a
nd te
eth)
max
illar
y pa
rtia
l den
ture
- ca
st m
etal
fram
ewor
k w
ith re
sin d
entu
re b
ases
(inc
ludi
ng a
ny c
onve
ntio
nal
clas
ps, r
ests
and
man
dibu
lar p
artia
l den
ture
- ca
st m
etal
fram
ewor
k w
ith re
sin
dent
ure
base
s (in
clud
ing
any
imm
edia
te m
axill
ary
part
ial d
entu
re -
resin
bas
e
D574
0D5
741
D575
0D5
751
D576
0
D542
2D5
510
D552
0D5
610
D562
0D5
630
D564
0D5
650
D566
0D5
670
D567
1D5
710
D571
1D5
720
D572
1D5
730
D573
1
D512
0
D513
0D5
140
D521
1
D521
2
D521
3D5
214
D522
1D5
222
D522
3
D522
4D5
225
D522
6
D528
1D5
410
D541
1D5
421
D427
7D4
341
D434
2D4
355
D438
1D4
910
D492
0D5
110
55
unlim
ited
unlim
ited
unlim
ited
unlim
ited
unlim
ited
unlim
ited
unlim
ited
unlim
ited
unlim
ited
unlim
ited
unlim
ited
unlim
ited
unlim
ited
unlim
ited
unlim
ited
unlim
ited
unlim
ited
unlim
ited
unlim
ited
unlim
ited
unlim
ited
pont
ic -
resi
n w
ith n
oble
met
alre
tain
er in
lay-
porc
elai
n/ce
ram
ic, t
wo
surf
aces
pont
ic -
cast
pre
dom
inan
tly b
ase
met
alpo
ntic
- ca
st n
oble
met
alpo
ntic
- tit
aniu
mpo
ntic
- po
rcel
ain
fuse
d to
hig
h no
ble
met
al
Yes
No
No
Yes
Yes
Yes
No
Yes
Yes
Yes
No
Yes
No
No
No
No
No
No
No
No
No
pont
ic -
porc
elai
n fu
sed
to n
oble
met
alpo
ntic
-por
cela
in/c
eram
icpo
ntic
- re
sin
with
hig
h no
ble
met
alpo
ntic
- re
sin
with
pre
dom
inan
tly b
ase
met
al
inte
rim p
artia
l den
ture
(max
illar
y)in
terim
par
tial d
entu
re (m
andi
bula
r)tis
sue
cond
ition
ing,
max
illar
ytis
sue
cond
ition
ing,
man
dibu
lar
Ove
rden
ture
-com
plet
e m
axill
ary
Ove
rden
ture
-par
tial m
axill
ary
Ove
rden
ture
- co
mpl
ete
man
dibu
lar
Ove
rden
ture
-par
tial m
andi
bula
rpo
ntic
- ca
st h
igh
nobl
e m
etal
relin
e m
andi
bula
r par
tial d
entu
re (l
abor
ator
y)
pont
ic -
porc
elai
n fu
sed
to p
redo
min
antly
bas
e m
etal
D660
1D6
602
D660
3D6
604
D660
5D6
606
D660
7D6
608
D660
9D6
610
D661
1D6
612
D576
1D5
820
D582
1D5
850
D585
1D5
863
D586
4D5
865
D586
6D6
210
D621
1
D660
0
D621
2D6
214
D624
0D6
241
D624
2D6
245
D625
0D6
251
D625
2
D661
3D6
614
D661
5D6
624
D663
4D6
720
D672
1D6
722
D674
0
D679
2D6
794
D693
0D7
111
D714
0
D675
0D6
751
D675
2D6
780
D678
1D6
782
D678
3D6
790
D679
1
reta
iner
cro
wn
- res
in w
ith h
igh
nobl
e m
etal
reta
iner
cro
wn
- res
in w
ith p
redo
min
antly
bas
e m
etal
reta
iner
cro
wn
- res
in w
ith n
oble
met
alre
tain
er c
row
n-po
rcel
ain/
cera
mic
reta
iner
cro
wn
- por
cela
in fu
sed
to h
igh
nobl
e m
etal
reta
iner
cro
wn
- por
cela
in fu
sed
to p
redo
min
antly
bas
e m
etal
reta
iner
cro
wn
- por
cela
in fu
sed
to n
oble
met
alre
tain
er c
row
n - 3
/4 c
ast h
igh
nobl
e m
etal
reta
iner
cro
wn-
3/4
cast
pre
dom
inat
ely
base
d m
etal
reta
iner
inla
y - p
orce
lain
/cer
amic
, thr
ee o
r mor
e su
rfac
esre
tain
er in
lay
- cas
t hig
h no
ble
met
al, t
wo
surf
aces
reta
iner
inla
y - c
ast h
igh
nobl
e m
etal
, thr
ee o
r mor
e su
rfac
esre
tain
er in
lay
- cas
t pre
dom
inan
tly b
ase
met
al, t
wo
surf
aces
reta
iner
inla
y - c
ast p
redo
min
antly
bas
e m
etal
, thr
ee o
r mor
e su
rfac
esre
tain
er in
lay
- cas
t nob
le m
etal
, tw
o su
rfac
esre
tain
er in
lay
- cas
t nob
le m
etal
, thr
ee o
r mor
e su
rfac
esre
tain
er o
nlay
- po
rcel
ain/
cera
mic
, tw
o su
rfac
esre
tain
er o
nlay
- po
rcel
ain/
cera
mic
, thr
ee o
r mor
e su
rfac
esre
tain
er o
nlay
- ca
st h
igh
nobl
e m
etal
, tw
o su
rfac
esre
tain
er o
nlay
- ca
st h
igh
nobl
e m
etal
, thr
ee o
r mor
e su
rfac
esre
tain
er o
nlay
- ca
st p
redo
min
antly
bas
e m
etal
, tw
o su
rfac
esre
tain
er o
nlay
- ca
st p
redo
min
antly
bas
e m
etal
, thr
ee o
r mor
e su
rfac
esre
tain
er o
nlay
- ca
st n
oble
met
al, t
wo
surf
aces
reta
iner
onl
ay -
cast
nob
le m
etal
, thr
ee o
r mor
e su
rfac
esre
tain
er in
lay
- tita
nium
reta
iner
onl
ay -
titan
ium
reta
iner
cro
wn-
3/4
cast
nob
le m
etal
reta
iner
cro
wn-
3/4
porc
elai
n/ce
ram
icre
tain
er c
row
n - f
ull c
ast h
igh
nobl
e m
etal
reta
iner
cro
wn
- ful
l cas
t pre
dom
inan
tly b
ase
met
alre
tain
er c
row
n - f
ull c
ast n
oble
met
alre
tain
er c
row
n - t
itani
umre
cem
ent o
r re-
bond
fixe
d pa
rtia
l den
ture
extr
actio
n, c
oron
al re
mna
nts -
dec
iduo
us to
oth
extr
actio
n, e
rupt
ed to
oth
or e
xpos
ed ro
ot (e
leva
tion
and/
or fo
rcep
s rem
oval
)
Yes
Yes
Yes
Yes
Yes
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
unlim
ited
unlim
ited
unlim
ited
unlim
ited
unlim
ited
unlim
ited
unlim
ited
unlim
ited
unlim
ited
unlim
ited
unlim
ited
unlim
ited
unlim
ited
unlim
ited
unlim
ited
unlim
ited
unlim
ited
unlim
ited
unlim
ited
unlim
ited
unlim
ited
unlim
ited
unlim
ited
unlim
ited
1 pe
r too
th1
per t
ooth
unlim
ited
unlim
ited
unlim
ited
unlim
ited
unlim
ited
unlim
ited
unlim
ited
unlim
ited
unlim
ited
5656
The
Colo
rado
Hig
h O
ptio
n Ri
der 2
60 D
HMO
supp
lem
enta
l ben
efit
plan
cov
ers t
he d
enta
l cod
es li
sted
abo
ve. T
his s
uppl
emen
tal b
enef
it is
offe
red
to m
embe
rs th
at a
re e
nrol
led
in A
ARP
Med
icar
eCom
plet
e pl
ans.
Pro
vide
r pay
men
t is
mad
e on
a F
ee-fo
r-Se
rvic
e ba
sis.
Mem
bers
hav
e In
-net
wor
k on
ly b
enef
its. S
ome
serv
ices
requ
ire p
rior a
utho
rizat
ion.
The
$10
00 a
nnua
l max
imum
app
lies t
o co
vere
d pr
even
tive
and
com
preh
ensi
ve b
enef
its. M
embe
r can
be
bille
d fo
r ser
vice
s ove
r the
$10
00 a
nnua
l max
imum
ben
efit.
The
mem
ber c
opay
s var
y fo
r cov
ered
serv
ices
from
$0
- $63
3. T
here
is n
o co
insu
ranc
e or
ded
uctib
le.
D721
0D7
220
D723
0D7
240
D732
0
D732
1D7
471
D751
0
D751
1D7
881
D796
0D7
963
D797
0
D724
1D7
250
D727
0D7
280
D728
2D7
285
D728
6
D731
0
D731
1
D922
3D9
243
D931
0D9
440
D994
0D9
943
D995
1D9
952
D797
1D7
972
D807
0D8
080
D809
0
D868
0D9
110
D921
5D9
219
rem
oval
of l
ater
al e
xost
osis
(max
illa
or m
andi
ble)
inci
sion
and
dra
inag
e of
abs
cess
- in
trao
ral s
oft t
issu
ein
cisi
on a
nd d
rain
age
of a
bsce
ss -
intr
aora
l sof
t tis
sue
- com
plic
ated
(inc
lude
s dra
inag
e of
mul
tiple
fa
scia
l spa
ces)
surg
ical
rem
oval
of e
rupt
ed to
oth
req
rem
oval
of b
one,
sect
ioni
ng o
f too
th a
nd in
clud
ing
elev
atio
n of
m
ucop
erio
stea
l fla
pre
mov
al o
f im
pact
ed to
oth
- sof
t tiss
uere
mov
al o
f im
pact
ed to
oth
- par
tially
bon
yre
mov
al o
f im
pact
ed to
oth
- com
plet
ely
bony
rem
oval
of i
mpa
cted
toot
h - c
ompl
etel
y bo
ny, w
ith u
nusu
al su
rgic
alsu
rgic
al re
mov
al o
f res
idua
l too
th ro
ots (
cutt
ing
proc
edur
e)
toot
h re
impl
anta
tion
and/
or st
abili
zatio
n of
acc
iden
tally
avu
lsed
or d
ispl
aced
toot
hsu
rgic
al a
cces
s of a
n un
erup
ted
toot
hm
obili
zatio
n of
eru
pted
or m
alpo
sitio
ned
toot
h to
aid
eru
ptio
n
occl
usal
adj
ustm
ent
occl
usal
adj
ustm
ent -
lim
ited
occl
usal
adj
ustm
ent -
com
plet
e
orth
odon
tic re
tent
ion
(rem
oval
of a
pplia
nces
, con
stru
ctio
n an
d pl
acem
ent o
f ret
aine
r(s)
)pa
lliat
ive
(em
erge
ncy)
trea
tmen
t of d
enta
l pai
n - m
inor
pro
cedu
relo
cal a
nest
hesi
a in
con
junc
tion
with
ope
rativ
e or
surg
ical
pro
cedu
res
eval
uatio
n fo
r dee
p se
datio
n or
gen
eral
ane
sthe
sia
deep
seda
tion/
gene
ral a
nest
hesi
a-ea
ch 1
5 m
inut
e in
crem
ent
intr
aven
ous m
oder
ate
(con
scio
us) s
edat
ion/
anal
gesi
a-ea
ch 1
5 m
inut
e in
crem
ent
cons
ulta
tion
(dia
gnos
tic se
rvic
e pr
ovid
ed b
y de
ntis
t or p
hysi
cian
oth
er th
an p
ract
ition
er p
rovi
ding
of
fice
visi
t - a
fter
regu
larly
sche
dule
d ho
urs
occl
usal
gua
rd, b
y re
port
occl
usal
ort
hotic
dev
ice
adju
stm
ent
fren
ulec
tom
y (fr
enec
tom
y or
fren
otom
y) -
sepa
rate
pro
cedu
re n
ot in
cide
ntal
to a
noth
er p
roce
dure
fren
ulop
last
yex
cisi
on o
f hyp
erpl
astic
tiss
ue -
per a
rch
exci
sion
of p
eric
oron
al g
ingi
vasu
rgic
al re
duct
ion
of fi
brou
s tub
eros
ityco
mpr
ehen
sive
ort
hodo
ntic
trea
tmen
t of t
he tr
ansi
tiona
l den
titio
nco
mpr
ehen
sive
ort
hodo
ntic
trea
tmen
t of t
he a
dole
scen
t den
titio
nco
mpr
ehen
sive
ort
hodo
ntic
trea
tmen
t of t
he a
dult
dent
ition
inci
sion
al b
iops
y of
ora
l tis
sue
- har
d (b
one,
toot
h)in
cisi
onal
bio
psy
of o
ral t
issu
e - s
oft (
all o
ther
s)
alve
olop
last
y in
con
junc
tion
with
ext
ract
ions
- fo
ur o
r mor
e te
eth
or to
oth
spac
es, p
er q
uadr
ant
alve
opla
sty
in c
onju
nctio
n w
ith e
xtra
ctio
n - o
ne to
thre
e te
eth
or to
oth
spac
es, p
er q
uadr
ant
alve
olop
last
y no
t in
conj
unct
ion
with
ext
ract
ions
- fo
ur o
r mor
e te
eth
or to
oth
spac
es, p
er q
uadr
ant
alve
opla
sty
not i
n co
njun
ctio
n w
ith e
xtra
ctio
n - o
ne to
thre
e te
eth
or to
oth
spac
es, p
er q
uadr
ant
No
No
No
Yes
Yes
Yes
Yes
Yes
Yes
No
No
No
No
No
No
No
No
No
No
No
No
No
No
Yes
No
No
No
No
No
No
No
No
No
Yes
No
Yes
No
No
No
1 pe
r too
th
unlim
ited
unlim
ited
unlim
ited
unlim
ited
unlim
ited
unlim
ited
unlim
ited
unlim
ited
unlim
ited
1 pe
r too
th1
per t
ooth
1 pe
r too
th1
per t
ooth
1 pe
r too
th
unlim
ited
unlim
ited
unlim
ited
unlim
ited
4 ev
ery
24 m
onth
s fro
m la
st d
ate
of se
rvic
e4
ever
y 24
mon
ths f
rom
last
dat
e of
serv
ice
unlim
ited
unlim
ited
unlim
ited
unlim
ited
unlim
ited
unlim
ited
unlim
ited
unlim
ited
unlim
ited
unlim
ited
unlim
ited
unlim
ited
unlim
ited
unlim
ited
unlim
ited
unlim
ited
unlim
ited
unlim
ited
57
Prov
ider
Cla
im D
ispu
tes
Mem
ber A
ppea
ls &
Grie
vanc
es
Prio
r Aut
horiz
atio
n Re
ques
ts
CO_F
ACET
S D0
0120
26_P
kg D
N04
8, D
enta
l 260
-DM
O80
09/2
016
In a
n ef
fort
to c
ompl
y w
ith th
e Ce
nter
s for
Med
icar
e an
d M
edic
aid
(CM
S) st
ate
man
date
d re
quire
men
ts, p
leas
e be
adv
ised
that
DHM
O E
ncou
nter
Dat
a Su
bmis
sion
s are
now
requ
ired.
CM
S no
w re
quire
s tha
t we
repo
rt 1
00%
of
utili
zatio
n da
ta fo
r our
Col
orad
o Hi
gh O
ptio
n Ri
der 2
60 D
HMO
mem
bers
. To
ens
ure
that
we
mee
t CM
S re
quire
men
t of r
epor
ting
100%
util
izatio
n, w
e ar
e ha
ppy
to re
-intr
oduc
e ou
r Den
tal I
ncen
tive
Prog
ram
effe
ctiv
e im
med
iate
ly.
Dent
al B
enef
it Pr
ovid
ers w
ill re
imbu
rse
our p
rovi
ders
$2.
00 fo
r eac
h en
coun
ter c
laim
subm
itted
for C
olor
ado
Hig
h O
ptio
n Ri
der 2
60 D
HM
O m
embe
rs o
nly
for a
ll pr
oced
ures
(cov
ered
und
er th
e m
embe
r's p
lan)
per
form
ed o
n th
ose
mem
bers
, for
eac
h da
te o
f ser
vice
. Al
l pro
cedu
res p
erfo
rmed
MU
ST b
e re
port
ed in
clud
ing
proc
edur
es w
heth
er o
r not
the
mem
ber h
as a
cop
aym
ent.
Thi
s is a
requ
irem
ent f
or a
ll co
ntra
cted
pro
vide
rs to
subm
it ut
iliza
tion
for e
ach
patie
nt tr
eate
d.
Her
e ar
e a
few
way
s the
Enc
ount
er In
form
atio
n ca
n be
subm
itted
:
1) Electronically
- As
you
wou
ld a
PPO
or I
ndem
nity
Cla
im
2)
Web
Site
- Cl
aim
s can
be
subm
itted
indi
vidu
ally
on
our w
ebsi
te a
t ww
w.u
hcpr
ovid
ers.
com
3)
By
Mai
l - A
s you
wou
ld a
PPO
or I
ndem
nity
Cla
im
4)
Util
izat
ion
Repo
rts -
Mus
t con
tain
ALL
requ
ired
info
rmat
ion:
• Su
bscr
iber
ID•
Subs
crib
er D
ate
of B
irth
• G
roup
Nam
e or
Num
ber
• Pa
tient
’s F
ull N
ame
• Pa
tient
’s D
ate
of B
irth
• Re
latio
nshi
p to
Sub
scrib
er•
Phys
ical
Add
ress
• AD
A Co
de P
erfo
rmed
• To
oth#
/ Q
uadr
ant
• Su
rfac
e•
Trea
ting
Dent
ist N
ame
• De
ntist
Tax
I.D.
for B
illin
g
Enco
unte
r/U
tiliza
tion
Repo
rtin
g - W
hen
subm
ittin
g En
coun
ter/
Util
izat
ion
clai
ms,
you
mus
t inc
lude
Cod
e D0
999
alon
g w
ith a
ll co
vere
d se
rvic
e pr
oced
ure
code
s you
per
form
on
each
AAR
P M
edic
are
Com
plet
e DH
MO
mem
ber.
Plea
se n
ote
the
follo
win
g:
1)
If y
ou su
bmit
D099
9 al
one
no a
dditi
onal
$2.
00 re
imbu
rsem
ent w
ill n
ot b
e pa
id.
Addi
tiona
lly, c
laim
subm
issio
n w
ould
be
cons
ider
ed n
on-c
ompl
iant
.
2)
If y
ou su
bmit
all s
ervi
ce p
roce
dure
serv
ice
code
s but
don
't in
clud
e D0
999
as w
ell a
s you
won
't be
reim
burs
ed th
e ad
ditio
nal $
2.00
. In
add
ition
, the
cla
im w
ill b
e co
nsid
ered
non
-com
plia
nt.
Mai
l mem
ber a
ppea
ls to
: Uni
tedH
ealth
care
, Att
n: A
ppea
l Dep
artm
ent,
MS
CA12
4-01
57, P
O B
ox 6
106,
Cyp
ress
, CA
9063
0
“Prio
r Aut
horiz
atio
n re
quire
d” m
eans
the
prac
titio
ner m
ust s
ubm
it th
ose
proc
edur
es fo
r app
rova
l with
clin
ical
doc
umen
tatio
n su
ppor
ting
nece
ssity
bef
ore
perf
orm
ing
thos
e pr
oced
ures
. To
do th
is c
ompl
ete
a st
anda
rd A
DA c
laim
fo
rm a
nd c
heck
the
box
mar
ked
“Pre
-Tre
atm
ent E
STIM
ATE.
” Pr
ior a
utho
rizat
ion
requ
est c
an b
e su
bmitt
ed v
ia th
e pr
ovid
er w
eb p
orta
l (at
ww
w.m
yuhc
prov
ider
s.co
m),
subm
itted
ele
ctro
nica
lly v
ia y
our c
lear
ingh
ouse
, or s
impl
y m
ail t
he fo
rm, t
o th
e be
low
add
ress
, alo
ng w
ith a
ny re
quire
d su
pple
men
tal i
nfor
mat
ion
(film
s, n
arra
tive,
per
io-c
hart
ing,
etc
.). Y
our o
ffice
will
then
rece
ive
an E
xpla
natio
n of
Ben
efits
(EO
B) o
utlin
ing
the
deni
al o
r app
rova
l of
requ
este
d tr
eatm
ent a
nd p
lan
paym
ent a
mou
nts w
hen
appl
icab
le.
Dent
al P
rovi
ders
with
com
plai
nts a
re to
con
tact
Uni
tedH
ealth
care
Den
tal’s
Pro
vide
r Ser
vice
dep
artm
ent a
t (87
7) 8
16-3
596.
Net
wor
k Pr
ovid
er c
ontr
actu
al d
ispu
tes,
Out
-of-N
etw
ork
prov
ider
dis
pute
s, a
nd re
proc
essi
ng re
ques
ts
will
be
logg
ed in
to th
e ap
peal
s dat
abas
e. P
leas
e m
ail t
o th
e Ap
peal
s & G
rieva
nces
PO
Box
list
ed a
bove
. Res
earc
h an
d re
solu
tion
will
be
com
plet
ed w
ithin
30
cale
ndar
day
s.
Mem
ber a
ppea
ls a
re re
view
ed b
y th
e he
alth
pla
n, a
nd a
re n
ot d
eleg
ated
to U
HC D
enta
l. Al
l Mem
ber a
ppea
ls (i
nclu
des P
re-S
ervi
ce a
ppea
ls, I
n N
etw
ork
Prov
ider
app
eals
, and
Out
of N
etw
ork
prov
ider
app
eals
) rec
eive
d by
UHC
De
ntal
will
be
forw
arde
d to
the
heal
th p
lan
via
over
nigh
t mai
l, w
ithin
7 d
ays o
f rec
eipt
of t
he a
ppea
l.
5858
59
6060
“Prio
r Aut
horiz
atio
n re
quire
d” m
eans
the
prac
titio
ner m
ust s
ubm
it th
ose
proc
edur
es fo
r app
rova
l with
clin
ical
doc
umen
tatio
n su
ppor
ting
nece
ssity
bef
ore
perf
orm
ing
thos
e pr
oced
ures
. To
do th
is c
ompl
ete
a st
anda
rd
ADA
clai
m fo
rm a
nd c
heck
the
box
mar
ked
“Pre
-Tre
atm
ent E
STIM
ATE.
” Pr
ior a
utho
rizat
ion
requ
est c
an b
e su
bmitt
ed v
ia th
e pr
ovid
er w
eb p
orta
l (at
ww
w.m
yuhc
prov
ider
s.co
m),
subm
itted
ele
ctro
nica
lly v
ia y
our
Dent
al P
rovi
ders
with
com
plai
nts a
re to
con
tact
Uni
tedH
ealth
care
Den
tal’s
Pro
vide
r Ser
vice
dep
artm
ent a
t
61
6262
Iden
tific
atio
n Ca
rds
Sam
ple
Mem
ber I
D C
ard*
Fron
t of c
ard
Back
of c
ard
Impo
rtan
t Tel
epho
ne N
umbe
rs &
Web
site
s
Impo
rtan
t Add
ress
es
Impo
rtan
t Ele
ctro
nic
Clai
ms &
Prio
r Aut
horiz
atio
n Su
bmis
sion
Info
rmat
ion
Prov
ider
Qui
ck R
efer
ence
Gui
de -
Effe
ctiv
e 1/
1/20
17U
nite
dHea
lthca
re A
ARP
Com
plet
e Pl
ans (
form
ally
Oxf
ord
DH
MO
)
CT, N
J, an
d N
Y
24 h
ours
a d
ay24
hou
rs a
day
*Ple
ase
note
that
the
Med
ical
ID C
ard
is un
iver
sal a
nd in
clud
es a
ll lin
es o
f cov
erag
e. T
he M
edic
al p
lan
can
be H
MO
or P
PO a
nd th
is d
oes n
ot re
flect
the
Dent
al P
lan
Bene
fits.
Ple
ase
flip
the
ID C
ard
over
to se
e th
e De
ntal
Pr
ovid
er in
form
atio
n on
the
back
(i.e
. car
rier w
ebsi
te a
nd to
ll-fr
ee n
umbe
r). T
his i
nfor
mat
ion
can
be u
sed
to c
onfir
m p
rovi
der p
artic
ipat
ion,
mem
ber e
ligib
ility
and
ben
efits
. Thi
s is a
SAM
PLE
ID C
ard
and
may
diff
er fr
om
the
mem
ber's
ID C
ard.
Elig
ibili
ty,
Bene
fits,
Cla
im(s
) and
Aut
horiz
atio
ns84
4-27
5-87
50Li
ve A
gent
: Mon
day
- Frid
ay, 8
:00A
M -
6:00
PM, E
STIV
R: 2
4 ho
urs a
day
Clai
ms
GP1
33
Prio
r Aut
horiz
atio
nAp
peal
s & G
rieva
nces
Uni
tedH
ealth
care
Den
tal,
PO B
ox 2
176,
Milw
auke
e, W
I 532
01U
nite
dHea
lthca
re D
enta
l, PO
Box
205
3, M
ilwau
kee,
WI 5
3201
Uni
tedH
ealth
care
Den
tal,
Appe
als D
isput
es, P
O B
ox 3
61, M
ilwau
kee,
WI 5
3201
Cove
red
Den
tal S
ervi
ces:
Prov
ider
Rea
son
for M
ailin
g
EDI P
ayer
Num
ber f
or C
laim
s Sub
mitt
ed
No
Annu
al M
axim
um
Call
to In
quire
Abo
utTe
leph
one
Num
ber
Hou
rs o
f Ope
ratio
n
Emai
l to
Inqu
ire A
bout
Web
site
Hou
rs o
f Ope
ratio
n
Med
icar
ew
ww
.med
icar
e.go
v24
hou
rs a
day
To d
iscu
ss y
our p
artic
ipat
ion,
con
trac
tual
issu
es, d
entis
t cha
nges
or o
ffice
upd
ates
800-
822-
5353
Live
Age
nt: M
onda
y - F
riday
, 8:0
0AM
- 11
:00P
M, E
ST
Elig
ibili
ty,
Bene
fits,
Cla
im(s
) and
Aut
horiz
atio
nsw
ww
.uhc
prov
ider
s.co
mCe
nter
s for
Med
icai
d an
d M
edic
are
Serv
ices
ww
w.c
ms.
hhs.
gov
63
No
No
1 ev
ery
6 M
onth
(s)
1 ev
ery
6 M
onth
(s)
1 ev
ery
6 M
onth
(s)
1 ev
ery
6 M
onth
(s)
1 ev
ery
6 M
onth
(s)
1 ev
ery
6 M
onth
(s)
1 ev
ery
6 M
onth
(s)
1 ev
ery
6 M
onth
(s)
1 ev
ery
3 Ye
ar(s
)1
ever
y Ye
ar1
ever
y Ye
ar1
ever
y Ye
ar1
ever
y Ye
ar1
ever
y Ye
ar1
ever
y Ye
ar1
ever
y Ye
ar1
ever
y 3
Year
(s)
1 ev
ery
Year
1 ev
ery
6 M
onth
(s)
Her
e ar
e a
few
way
s the
Enc
ount
er In
form
atio
n ca
n be
subm
itted
:
1)
Electronically
- As
you
wou
ld a
PPO
or I
ndem
nity
Cla
im
2) W
eb S
ite -
Clai
ms c
an b
e su
bmitt
ed in
divi
dual
ly o
n ou
r web
site
at w
ww
.uhc
prov
ider
s.co
m
3)
By
Mai
l - A
s you
wou
ld a
PPO
or I
ndem
nity
Cla
im
4) U
tiliz
atio
n Re
port
s - M
ust c
onta
in A
LL re
quire
d in
form
atio
n:
•
Subs
crib
er ID
• Su
bscr
iber
Dat
e of
Birt
h •
Gro
up N
ame
or N
umbe
r•
Patie
nt’s
Ful
l Nam
e•
Patie
nt’s
Dat
e of
Birt
h•
Rela
tions
hip
to S
ubsc
riber
• Ph
ysic
al A
ddre
ss•
ADA
Code
Per
form
ed•
Toot
h# /
Qua
dran
t•
Surf
ace
• Tr
eatin
g De
ntis
t Nam
e•
Dent
ist T
ax I.
D. fo
r Bill
ing
Enco
unte
r/U
tiliza
tion
Repo
rtin
g - W
hen
subm
ittin
g En
coun
ter/
Util
izat
ion
clai
ms,
you
mus
t inc
lude
Cod
e D0
999
alon
g w
ith a
ll co
vere
d se
rvic
e pr
oced
ure
code
s you
per
form
on
each
AAR
P M
edic
are
Com
plet
e DH
MO
m
embe
r.
Plea
se n
ote
the
follo
win
g:
1) If
you
subm
it D0
999
alon
e no
add
ition
al $
2.00
reim
burs
emen
t will
not
be
paid
. Ad
ditio
nally
, cla
im su
bmiss
ion
wou
ld b
e co
nsid
ered
non
-com
plia
nt.
2)
If y
ou su
bmit
all s
ervi
ce p
roce
dure
serv
ice
code
s but
don
't in
clud
e D0
999
as w
ell a
s you
won
't be
reim
burs
ed th
e ad
ditio
nal $
2.00
. In
add
ition
, the
cla
im w
ill b
e co
nsid
ered
non
-com
plia
nt.
D022
0
D012
0D0
140
D015
0D0
210
perio
dic
oral
eva
luat
ion
limite
d or
al e
valu
atio
n - p
robl
em fo
cuse
dco
mpr
ehen
sive
ora
l eva
luat
ion
- new
or e
stab
lishe
d pa
tient
intr
aora
l - c
ompl
ete
serie
s (in
clud
ing
bite
win
gs)
D027
2D0
273
bite
win
g - t
wo
film
sN
o
D111
0pr
ophy
laxi
s - a
dult
No
D131
0nu
triti
onal
cou
nsel
ing
for c
ontr
ol o
f den
tal d
isea
seN
o
D027
4D0
330
bite
win
g - t
hree
film
s
D132
0to
bacc
o co
unse
ling
for t
he c
ontr
ol a
nd p
reve
ntio
n of
ora
l dis
ease
No
D099
9un
spec
ified
dia
gnos
tic p
roce
dure
No
bite
win
g - f
our f
ilms
pano
ram
ic fi
lmN
oD0
470
diag
nost
ic c
asts
No
D112
0D1
206
D120
8
prop
hyla
xis -
chi
ldto
pica
l app
licat
ion
of fl
uorid
e va
rnis
hto
pica
l app
licat
ion
of fl
uorid
e
No
No
No
D133
0or
al h
ygie
ne in
stru
ctio
nsN
o
Prio
r Aut
horiz
atio
n Re
quire
d?Pr
oced
ure
Code
Freq
uenc
y/Li
mita
tions
Proc
edur
e D
escr
iptio
n
In a
n ef
fort
to c
ompl
y w
ith th
e Ce
nter
s for
Med
icar
e an
d M
edic
aid
(CM
S) st
ate
man
date
d re
quire
men
ts, p
leas
e be
adv
ised
that
DHM
O E
ncou
nter
Dat
a Su
bmis
sion
s are
now
requ
ired.
CM
S no
w re
quire
s tha
t we
repo
rt
100%
of u
tiliza
tion
data
for o
ur A
ARP
Med
icar
e Co
mpl
ete
DHM
O m
embe
rs.
To e
nsur
e th
at w
e m
eet C
MS
requ
irem
ent o
f rep
ortin
g 10
0% u
tiliza
tion,
we
are
happ
y to
re-in
trod
uce
our D
enta
l Inc
entiv
e Pr
ogra
m e
ffect
ive
imm
edia
tely
. De
ntal
Ben
efit
Prov
ider
s will
reim
burs
e ou
r pro
vide
rs $
2.00
for e
ach
enco
unte
r cla
im su
bmitt
ed fo
r AAR
P M
edic
are
Com
plet
e D
HM
O m
embe
rs o
nly
for a
ll pr
oced
ures
(cov
ered
und
er th
e m
embe
r's p
lan)
pe
rfor
med
on
thos
e m
embe
rs, f
or e
ach
date
of s
ervi
ce.
All p
roce
dure
s per
form
ed M
UST
be
repo
rted
incl
udin
g pr
oced
ures
whe
ther
or n
ot th
e m
embe
r has
a c
opay
men
t. T
his i
s a re
quire
men
t for
all
cont
ract
ed
prov
ider
s to
subm
it ut
iliza
tion
for e
ach
patie
nt tr
eate
d.
No
D023
0D0
250
D027
0
intr
aora
l - p
eria
pica
l - fi
rst f
ilm
1 ev
ery
6 M
onth
(s)
1 ev
ery
6 M
onth
(s)
No
No
No
No
No
No
No
intr
aora
l - p
eria
pica
l - e
ach
addi
tiona
l film
extr
aora
l firs
t rad
iogr
aphi
c im
age
bite
win
g - s
ingl
e fil
m
6464
Prov
ider
Cla
im D
ispu
tes
Mem
ber A
ppea
ls &
Grie
vanc
es
Prio
r Aut
horiz
atio
n Re
ques
ts
CT, N
J, N
Y_SC
ION
143
_Pkg
DT0
36_D
T036
-H00
00a-
Oxf
rd
09/2
016
“Prio
r Aut
horiz
atio
n re
quire
d” m
eans
the
prac
titio
ner m
ust s
ubm
it th
ose
proc
edur
es fo
r app
rova
l with
clin
ical
doc
umen
tatio
n su
ppor
ting
nece
ssity
bef
ore
perf
orm
ing
thos
e pr
oced
ures
. To
do th
is c
ompl
ete
a st
anda
rd
ADA
clai
m fo
rm a
nd c
heck
the
box
mar
ked
“Pre
-Tre
atm
ent E
STIM
ATE.
” Pr
ior a
utho
rizat
ion
requ
est c
an b
e su
bmitt
ed v
ia th
e pr
ovid
er w
eb p
orta
l (at
ww
w.m
yuhc
prov
ider
s.co
m),
subm
itted
ele
ctro
nica
lly v
ia y
our
clea
ringh
ouse
, or s
impl
y m
ail t
he fo
rm, t
o th
e be
low
add
ress
, alo
ng w
ith a
ny re
quire
d su
pple
men
tal i
nfor
mat
ion
(film
s, n
arra
tive,
per
io-c
hart
ing,
etc
.). Y
our o
ffice
will
then
rece
ive
an E
xpla
natio
n of
Ben
efits
(EO
B)
outli
ning
the
deni
al o
r app
rova
l of r
eque
sted
trea
tmen
t and
pla
n pa
ymen
t am
ount
s whe
n ap
plic
able
.
Dent
al P
rovi
ders
with
com
plai
nts a
re to
con
tact
Uni
tedH
ealth
care
Den
tal’s
Pro
vide
r Ser
vice
dep
artm
ent a
t (84
4) 2
75-8
750.
Net
wor
k Pr
ovid
er c
ontr
actu
al d
ispu
tes,
Out
-of-N
etw
ork
prov
ider
dis
pute
s, a
nd re
proc
essi
ng
requ
ests
will
be
logg
ed in
to th
e ap
peal
s dat
abas
e. P
leas
e m
ail t
o th
e Ap
peal
s & G
rieva
nces
PO
Box
list
ed a
bove
. Res
earc
h an
d re
solu
tion
will
be
com
plet
ed w
ithin
30
cale
ndar
day
s.
Mem
ber a
ppea
ls a
re re
view
ed b
y th
e he
alth
pla
n, a
nd a
re n
ot d
eleg
ated
to U
HC D
enta
l. Al
l Mem
ber a
ppea
ls (i
nclu
des P
re-S
ervi
ce a
ppea
ls, I
n N
etw
ork
Prov
ider
app
eals
, and
Out
of N
etw
ork
prov
ider
app
eals
) rec
eive
d by
U
HC D
enta
l will
be
forw
arde
d to
the
heal
th p
lan
via
over
nigh
t mai
l, w
ithin
7 d
ays o
f rec
eipt
of t
he a
ppea
l.
Mai
l mem
ber a
ppea
ls to
: Uni
tedH
ealth
care
, Att
n: A
ppea
l Dep
artm
ent,
MS
CA12
4-01
57, P
O B
ox 6
106,
Cyp
ress
, CA
9063
0
65
6666
67
6868
Dent
al P
rovi
ders
with
com
plai
nts a
re to
con
tact
Uni
tedH
ealth
care
Den
tal’s
Pro
vide
r Ser
vice
dep
artm
ent a
t
69
“Prio
r Aut
horiz
atio
n re
quire
d” m
eans
the
prac
titio
ner m
ust s
ubm
it th
ose
proc
edur
es fo
r app
rova
l with
clin
ical
doc
umen
tatio
n su
ppor
ting
nece
ssity
bef
ore
perf
orm
ing
thos
e pr
oced
ures
. To
do th
is
com
plet
e a
stan
dard
ADA
cla
im fo
rm a
nd c
heck
the
box
mar
ked
“Pre
-Tre
atm
ent E
STIM
ATE.
” Pr
ior a
utho
rizat
ion
requ
est c
an b
e su
bmitt
ed v
ia th
e pr
ovid
er w
eb p
orta
l (at
ww
w.m
yuhc
prov
ider
s.co
m),
7070
71
7272
“Prio
r Aut
horiz
atio
n re
quire
d” m
eans
the
prac
titio
ner m
ust s
ubm
it th
ose
proc
edur
es fo
r app
rova
l with
clin
ical
doc
umen
tatio
n su
ppor
ting
nece
ssity
bef
ore
perf
orm
ing
thos
e pr
oced
ures
. To
do th
is
com
plet
e a
stan
dard
ADA
cla
im fo
rm a
nd c
heck
the
box
mar
ked
“Pre
-Tre
atm
ent E
STIM
ATE.
” Pr
ior a
utho
rizat
ion
requ
est c
an b
e su
bmitt
ed v
ia th
e pr
ovid
er w
eb p
orta
l (at
ww
w.m
yuhc
prov
ider
s.co
m),
Dent
al P
rovi
ders
with
com
plai
nts a
re to
con
tact
Uni
tedH
ealth
care
Den
tal’s
Pro
vide
r Ser
vice
dep
artm
ent a
t
73
7474
75
1 ev
ery
year
1 ev
ery
36 m
onth
s fro
m la
st d
ate
of s
ervi
ce
2 ev
ery
day
2 ev
ery
year
7676
“Prio
r Aut
horiz
atio
n re
quire
d” m
eans
the
prac
titio
ner m
ust s
ubm
it th
ose
proc
edur
es fo
r app
rova
l with
clin
ical
doc
umen
tatio
n su
ppor
ting
nece
ssity
bef
ore
perf
orm
ing
thos
e pr
oced
ures
. To
do th
is c
ompl
ete
a st
anda
rd A
DA c
laim
form
and
che
ck th
e bo
x m
arke
d “P
re-T
reat
men
t EST
IMAT
E.”
Prio
r aut
horiz
atio
n re
ques
t can
be
subm
itted
via
the
prov
ider
web
por
tal (
at w
ww
.myu
hcpr
ovid
ers.
com
), su
bmitt
ed
Dent
al P
rovi
ders
with
com
plai
nts a
re to
con
tact
Uni
tedH
ealth
care
Den
tal’s
Pro
vide
r Ser
vice
dep
artm
ent a
t
77
Iden
tific
atio
n Ca
rds
Sam
ple
Mem
ber I
D C
ard*
Fron
t of c
ard
Back
of c
ard
Impo
rtan
t Tel
epho
ne N
umbe
rs &
Web
site
s
Prov
ider
Qui
ck R
efer
ence
Gui
de -
Effe
ctiv
e 1/
1/20
17U
nite
dHea
lthca
re C
omm
unity
Pla
n/U
nite
dHea
lthca
re o
f Flo
rida
Dua
l Com
plet
e LP
$1,5
00 A
nnua
l Max
Call
to In
quire
Abo
utTe
leph
one
Num
ber
Hou
rs o
f Ope
ratio
n
Emai
l to
Inqu
ire A
bout
Web
site
Hou
rs o
f Ope
ratio
n
Med
icar
ew
ww
.med
icar
e.go
v24
hou
rs a
day
Cent
ers f
or M
edic
aid
and
Med
icar
e Se
rvic
esw
ww
.cm
s.hh
s.go
v
*Ple
ase
note
that
the
Med
ical
ID C
ard
is un
iver
sal a
nd in
clud
es a
ll lin
es o
f cov
erag
e. T
he M
edic
al p
lan
can
be H
MO
or P
PO a
nd th
is d
oes n
ot re
flect
the
Dent
al P
lan
Bene
fits.
Ple
ase
flip
the
ID C
ard
over
to se
e th
e De
ntal
Pro
vide
r inf
orm
atio
n on
the
back
(i.e
. car
rier w
ebsi
te a
nd to
ll-fr
ee n
umbe
r). T
his i
nfor
mat
ion
can
be u
sed
to c
onfir
m p
rovi
der p
artic
ipat
ion,
mem
ber e
ligib
ility
and
ben
efits
. Th
is is
a S
AMPL
E ID
Car
d an
d m
ay d
iffer
from
the
mem
ber's
ID C
ard.
Elig
ibili
ty,
Bene
fits,
Cla
im(s
) and
Aut
horiz
atio
ns87
7-37
8-52
93Li
ve A
gent
: Mon
day
- Frid
ay, 8
:00A
M -
6:00
PM, E
STIV
R: 2
4 ho
urs a
day
24 h
ours
a d
ay
To d
iscu
ss y
our p
artic
ipat
ion,
con
trac
tual
issu
es, d
entis
t cha
nges
or o
ffice
up
date
s80
0-82
2-53
53Li
ve A
gent
: Mon
day
- Frid
ay, 8
:00A
M -
11:0
0PM
, EST
Elig
ibili
ty,
Bene
fits,
Cla
im(s
) and
Aut
horiz
atio
nsw
ww
.uhc
prov
ider
s.co
m24
hou
rs a
day
FL D
SNP
H104
5-03
9 an
d H1
045-
040
7878
Impo
rtan
t Add
ress
es
Impo
rtan
t Ele
ctro
nic
Clai
ms &
Prio
r Aut
horiz
atio
n Su
bmis
sion
Info
rmat
ion
D027
41
ever
y 6
Mon
th(s
)
1 ev
ery
6 M
onth
(s)
intr
aora
l - o
cclu
sal f
ilm
D216
0U
nlim
ited
Unl
imite
d
1 ev
ery
3 Ye
ar(s
)
EDI P
ayer
Num
ber f
or C
laim
s Sub
mitt
ed
Prov
ider
Rea
son
for M
ailin
g
No
No
GP1
33
Clai
ms
Prio
r Aut
horiz
atio
nAp
peal
s & G
rieva
nces
UHC
Med
icar
e Cl
aim
s, P
O B
ox 2
176,
Milw
auke
e, W
I 532
01U
HC M
edic
are
Auth
oriza
tions
, PO
Box
205
3, M
ilwau
kee,
WI 5
3201
UHC
Med
icar
e Co
mpl
aint
s, G
rieva
nces
& A
ppea
ls, P
O B
ox 3
61, M
ilwau
kee,
WI 5
3201
Yes
Yes
Yes
Yes
No
No
Unl
imite
d
Unl
imite
dU
nlim
ited
Unl
imite
dU
nlim
ited
Unl
imite
dU
nlim
ited
1 ev
ery
24 M
onth
(s)
1 ev
ery
24 M
onth
(s)
1 ev
ery
24 M
onth
(s)
No
No
No
No
Unl
imite
dU
nlim
ited
Unl
imite
d
Unl
imite
dN
oN
oN
oN
oN
o
D233
2D2
335
D239
0D2
391
D239
2
Unl
imite
d
Yes
Yes
Yes
Yes
resi
n-ba
sed
com
posi
te -
thre
e su
rfac
es, p
oste
rior
resi
n-ba
sed
com
posi
te -
four
or m
ore
surf
aces
, pos
terio
rcr
own
- res
in-b
ased
com
posi
te (i
ndire
ct)
crow
n - p
orce
lain
/cer
amic
subs
trat
ecr
own
- por
cela
in fu
sed
to h
igh
nobl
e m
etal
crow
n - p
orce
lain
fuse
d to
pre
dom
inan
tly b
ase
met
alcr
own
- por
cela
in fu
sed
to n
oble
met
alcr
own
- ful
l cas
t pre
dom
inan
tly b
ase
met
alcr
own
- ful
l cas
t nob
le m
etal
perio
dont
al m
aint
enan
cefu
ll m
outh
deb
ridem
ent t
o en
able
com
preh
ensi
ve e
valu
atio
n an
d di
agno
sis
core
bui
ldup
, inc
ludi
ng a
ny p
ins
pref
abric
ated
pos
t and
cor
e in
add
ition
to c
row
npe
riodo
ntal
scal
ing
and
root
pla
nnin
g - f
our o
r mor
e pe
r qua
dran
tpe
riodo
ntal
scal
ing
and
root
pla
nnin
g - o
ne to
thre
e te
eth
per q
uadr
ant
resi
n-ba
sed
com
posi
te -
thre
e su
rfac
es, a
nter
ior
resi
n-ba
sed
com
posi
te -
four
or m
ore
surf
aces
or i
nvol
ving
inci
sal a
ngle
(ant
erio
r)re
sin-
base
d co
mpo
site
cro
wn,
ant
erio
rre
sin-
base
d co
mpo
site
- on
e su
rfac
e, p
oste
rior
resi
n-ba
sed
com
posi
te -
two
surf
aces
, pos
terio
r
rece
men
t cro
wn
pref
abric
ated
stai
nles
s ste
el c
row
n - p
rimar
y to
oth
pref
abric
ated
stai
nles
s ste
el c
row
n - p
erm
anen
t too
thpr
otec
tive
rest
orat
ion
D293
0D2
931
D294
0D2
950
D295
4D4
341
D434
2D4
355
D491
0
1 ev
ery
6 M
onth
(s)
1 ev
ery
6 M
onth
(s)
1 ev
ery
6 M
onth
(s)
1 ev
ery
6 M
onth
(s)
1 ev
ery
6 M
onth
(s)
1 ev
ery
6 M
onth
(s)
1 ev
ery
6 M
onth
(s)
Unl
imite
dU
nlim
ited
1 ev
ery
6 M
onth
(s)
1 ev
ery
6 M
onth
(s)
Unl
imite
d1
ever
y 36
Mon
th(s
)1
ever
y 36
Mon
th(s
)1
ever
y 36
Mon
th(s
)1
ever
y 36
Mon
th(s
)1
ever
y 36
Mon
th(s
)1
ever
y 36
Mon
th(s
)1
ever
y 36
Mon
th(s
)
Unl
imite
dU
nlim
ited
D292
0
D233
1re
sin-
base
d co
mpo
site
- tw
o su
rfac
es, a
nter
ior
No
D216
1am
alga
m -
four
or m
ore
surf
aces
, prim
ary
or p
erm
anen
tN
oD2
330
resi
n-ba
sed
com
posi
te -
one
surf
ace,
ant
erio
rN
o
D239
3D2
394
D271
0D2
740
D275
0D2
751
D275
2D2
791
D279
2
No
No
Yes
Yes
Yes
D214
0am
alga
m -
one
surf
ace,
prim
ary
or p
erm
anen
tN
oD2
150
amal
gam
- tw
o su
rfac
es, p
rimar
y or
per
man
ent
No
D012
0D0
140
D015
0D0
210
No
No
D022
0in
trao
ral -
per
iapi
cal -
firs
t film
No
D027
0bi
tew
ing
- sin
gle
film
No
D033
0pa
nora
mic
film
No
D111
0
No
bite
win
g - f
our f
ilms
bite
win
g - t
hree
film
sN
o
Freq
uenc
y/Li
mita
tions
Proc
edur
e D
escr
iptio
npe
riodi
c or
al e
valu
atio
nlim
ited
oral
eva
luat
ion
- pro
blem
focu
sed
com
preh
ensi
ve o
ral e
valu
atio
n - n
ew o
r est
ablis
hed
patie
ntin
trao
ral -
com
plet
e se
ries (
incl
udin
g bi
tew
ings
)
amal
gam
- th
ree
surf
aces
, prim
ary
or p
erm
anen
tN
oU
nlim
ited
1 ev
ery
6 M
onth
(s)
Cove
red
Den
tal S
ervi
ces:
Prio
r Aut
horiz
atio
n Re
quire
d?Pr
oced
ure
Code
No
No
D027
2bi
tew
ing
- tw
o fil
ms
No
D023
0D0
240
intr
aora
l - p
eria
pica
l - e
ach
addi
tiona
l film
prop
hyla
xis -
adu
ltN
o
D027
3
FL D
SNP
H104
5-03
9 an
d H1
045-
040
79
Prov
ider
Cla
im D
ispu
tes
Mem
ber A
ppea
ls &
Grie
vanc
es
Prio
r Aut
horiz
atio
n Re
ques
ts
Foot
note
: FL_
SCIO
N 3
64_D
T100
_DT0
15-H
1500
B-FF
S73
09/2
016
Unl
imite
d
Unl
imite
d
Unl
imite
d
D731
1al
veol
opla
sty
in c
onju
nctio
n w
ith e
xtra
ctio
ns -
one
to th
ree
teet
h or
toot
h sp
aces
, per
qu
adra
ntN
oD9
110
palli
ativ
e (e
mer
genc
y) tr
eatm
ent o
f den
tal p
ain
- min
or p
roce
dure
No
D725
0su
rgic
al re
mov
al o
f res
idua
l too
th ro
ots (
cutt
ing
proc
edur
e)Ye
s
D731
0al
veol
opla
sty
in c
onju
nctio
n w
ith e
xtra
ctio
ns -
four
or m
ore
teet
h or
toot
h sp
aces
, per
qu
adra
ntN
o
D714
0ex
trac
tion,
eru
pted
toot
h or
exp
osed
root
(ele
vatio
n an
d/or
forc
eps)
No
D721
0su
rgic
al re
mov
al o
f eru
pted
toot
h re
q re
mov
al o
f bon
e, se
ctio
ning
of t
ooth
and
incl
udin
g el
evat
ion
of m
ucop
erio
stea
l fla
pN
o
D711
1ex
trac
tion,
cor
onal
rem
nant
s - d
ecid
uous
toot
hN
o
“Prio
r Aut
horiz
atio
n re
quire
d” m
eans
the
prac
titio
ner m
ust s
ubm
it th
ose
proc
edur
es fo
r app
rova
l with
clin
ical
doc
umen
tatio
n su
ppor
ting
nece
ssity
bef
ore
perf
orm
ing
thos
e pr
oced
ures
. To
do th
is
com
plet
e a
stan
dard
ADA
cla
im fo
rm a
nd c
heck
the
box
mar
ked
“Pre
-Tre
atm
ent E
STIM
ATE.
” Pr
ior a
utho
rizat
ion
requ
est c
an b
e su
bmitt
ed v
ia th
e pr
ovid
er w
eb p
orta
l (at
w
ww
.myu
hcpr
ovid
ers.
com
), su
bmitt
ed e
lect
roni
cally
via
you
r cle
arin
ghou
se, o
r sim
ply
mai
l the
form
, to
the
belo
w a
ddre
ss, a
long
with
any
requ
ired
supp
lem
enta
l inf
orm
atio
n (fi
lms,
nar
rativ
e,
perio
-cha
rtin
g, e
tc.).
You
r offi
ce w
ill th
en re
ceiv
e an
Exp
lana
tion
of B
enef
its (E
OB)
out
linin
g th
e de
nial
or a
ppro
val o
f req
uest
ed tr
eatm
ent a
nd p
lan
paym
ent a
mou
nts w
hen
appl
icab
le.
The
Uni
tedH
ealth
care
(UHC
) Com
mun
ity P
lan
for D
ual C
ompl
ete
mem
bers
cov
ers t
he d
enta
l cod
es li
sted
abo
ve. P
rovi
der p
aym
ent i
s mad
e on
a F
ee-fo
r-Se
rvic
e ba
sis.
Som
e se
rvic
es re
quire
prio
r au
thor
izatio
n. T
he d
enta
l pla
n ha
s a $
1,50
0 an
nual
max
that
app
lies t
o co
vere
d pr
even
tive
and
com
preh
ensi
ve b
enef
its. T
his p
lan
is o
ffere
d to
Uni
tedH
ealth
care
Dua
l Com
plet
e m
embe
rs in
Fl
orid
a. T
here
is n
o m
embe
r cop
ay, c
oins
uran
ce o
r ded
uctib
le fo
r IN
Net
wor
k Pr
ovid
ers.
Mem
ber c
an b
e bi
lled
for s
ervi
ces o
ver t
he $
1,50
0 an
nual
max
imum
ben
efit.
Dent
al P
rovi
ders
with
com
plai
nts a
re to
con
tact
Uni
tedH
ealth
care
Den
tal’s
Pro
vide
r Ser
vice
dep
artm
ent a
t (84
4) 2
75-8
750.
Net
wor
k Pr
ovid
er c
ontr
actu
al d
ispu
tes,
Out
-of-N
etw
ork
prov
ider
di
sput
es, a
nd re
proc
essin
g re
ques
ts w
ill b
e lo
gged
into
the
appe
als d
atab
ase.
Ple
ase
mai
l to
the
Appe
als &
Grie
vanc
es P
O B
ox li
sted
abo
ve. R
esea
rch
and
reso
lutio
n w
ill b
e co
mpl
eted
with
in 3
0 ca
lend
ar d
ays.
Mem
ber a
ppea
ls a
re re
view
ed b
y th
e he
alth
pla
n, a
nd a
re n
ot d
eleg
ated
to U
HC D
enta
l. Al
l Mem
ber a
ppea
ls (i
nclu
des P
re-S
ervi
ce a
ppea
ls, I
n N
etw
ork
Prov
ider
app
eals
, and
Out
of N
etw
ork
prov
ider
app
eals)
rece
ived
by
UHC
Den
tal w
ill b
e fo
rwar
ded
to th
e he
alth
pla
n vi
a ov
erni
ght m
ail,
with
in 7
day
s of r
ecei
pt o
f the
app
eal.
Unl
imite
d
Unl
imite
dU
nlim
ited
Unl
imite
d
Mai
l mem
ber a
ppea
ls to
: Uni
tedH
ealth
care
, Att
n: A
ppea
l Dep
artm
ent,
MS
CA12
4-01
57, P
O B
ox 6
106,
Cyp
ress
, CA
9063
0
FL D
SNP
H104
5-03
9 an
d H1
045-
040
8080
Iden
tific
atio
n Ca
rds
Sam
ple
Mem
ber I
D C
ard*
Prov
ider
Qui
ck R
efer
ence
Gui
de -
Effe
ctiv
e 1/
1/20
17U
nite
dHea
lthca
re C
omm
unity
Pla
n/U
nite
dHea
lthca
re o
f Flo
rida
Dua
l Com
plet
e M
edic
aid
Wra
p
FL W
rap
R744
4 PB
P 01
2 G
roup
#82
080,
R74
44 P
BP 0
13 G
roup
#82
981,
H10
45 P
BP 0
39 G
roup
#82
060,
H10
45 P
BP 0
40 G
roup
#82
941
81
Fron
t of C
ard
Back
of C
ard
Impo
rtan
t Tel
epho
ne N
umbe
rs &
Web
site
s
Impo
rtan
t Add
ress
es
Impo
rtan
t Ele
ctro
nic
Clai
ms &
Prio
r Aut
horiz
atio
n Su
bmis
sion
Info
rmat
ion
EDI P
ayer
Num
ber f
or C
laim
s Sub
mitt
ed
Prov
ider
Rea
son
for M
ailin
g
Call
to In
quire
Abo
utTe
leph
one
Num
ber
Hou
rs o
f Ope
ratio
n
Emai
l to
Inqu
ire A
bout
Web
site
Hou
rs o
f Ope
ratio
n
Med
icar
ew
ww
.med
icar
e.go
v24
hou
rs a
day
Cent
ers f
or M
edic
aid
and
Med
icar
e Se
rvic
esw
ww
.cm
s.hh
s.go
v24
hou
rs a
day
*Ple
ase
note
that
the
Med
ical
ID C
ard
is u
nive
rsal
and
incl
udes
all
lines
of c
over
age.
The
Med
ical
pla
n ca
n be
HM
O o
r PPO
and
this
doe
s not
refle
ct th
e De
ntal
Pla
n Be
nefit
s. P
leas
e fli
p th
e ID
Car
d ov
er to
see
the
Dent
al P
rovi
der i
nfor
mat
ion
on th
e ba
ck (i
.e. c
arrie
r web
site
and
toll-
free
num
ber)
. Thi
s inf
orm
atio
n ca
n be
use
d to
con
firm
pro
vide
r par
ticip
atio
n, m
embe
r elig
ibili
ty a
nd b
enef
its.
This
is a
SAM
PLE
ID C
ard
and
may
diff
er fr
om th
e m
embe
r's ID
Car
d. P
leas
e lo
ok in
the
bott
om le
ft h
and
corn
er fo
r the
Pla
n an
d PB
P# a
nd th
e up
per r
ight
han
d co
rner
for t
he c
orre
ct g
roup
num
ber.
Elig
ibili
ty,
Bene
fits,
Cla
im(s
) and
Aut
horiz
atio
ns87
7-37
8-52
93
GP1
33
Clai
ms
Prio
r Aut
horiz
atio
nAp
peal
s & G
rieva
nces
Uni
tedH
ealth
care
Den
tal F
L M
edic
aid
PO B
ox 1
167,
Milw
auke
e, W
I 532
01U
nite
dHea
lthca
re D
enta
l FL
Med
icai
d PO
Box
753
Uni
tedH
ealth
care
Den
tal F
L M
edic
aid
Attn
: App
eals
, PO
Box
667
D014
0D0
150
D021
0D0
220
Live
Age
nt: M
onda
y - F
riday
, 8:0
0AM
- 6:
00PM
, EST
IVR:
24
hour
s a d
ay
24 h
ours
a d
ay
To d
iscu
ss y
our p
artic
ipat
ion,
con
trac
tual
issu
es, d
entis
t cha
nges
or o
ffice
up
date
s80
0-82
2-53
53Li
ve A
gent
: Mon
day
- Frid
ay, 8
:00A
M -
11:0
0PM
, EST
Elig
ibili
ty,
Bene
fits,
Cla
im(s
) and
Aut
horiz
atio
nsw
ww
.uhc
prov
ider
s.co
m
2 ev
ery
12 M
onth
s2
ever
y 12
Mon
ths
2 ev
ery
12 M
onth
sun
limite
dun
limite
d1
ever
y 36
Mon
ths
Freq
uenc
y/Li
mita
tions
Proc
edur
e D
escr
iptio
nLi
mite
d O
ral E
valu
atio
n - P
robl
em F
ocus
edCo
mpr
ehen
sive
Ora
l Eva
luat
ion
- New
Or E
stab
lishe
d Pa
tient
Intr
aora
l - C
ompl
ete
Serie
s of R
adio
grap
hic
Imag
esIn
trao
ral -
Per
iapi
cal F
irst R
adio
grap
hic
Imag
e
Cove
red
Den
tal S
ervi
ces:
Prio
r Aut
horiz
atio
n Re
quire
d?Pr
oced
ure
Code
D024
0In
trao
ral -
Per
iapi
cal E
ach
Addi
tiona
l Im
age
No
No
No
No
No
No
Intr
aora
l - O
cclu
sal R
adio
grap
hic
Imag
eD0
230
FL W
rap
R744
4 PB
P 01
2 G
roup
#82
080,
R74
44 P
BP 0
13 G
roup
#82
981,
H10
45 P
BP 0
39 G
roup
#82
060,
H10
45 P
BP 0
40 G
roup
#82
941
8282
Prov
ider
Cla
im D
ispu
tes
Mem
ber A
ppea
ls &
Grie
vanc
es
3 ev
ery
12 M
ON
THS
2 ev
ery
12 M
ON
THS
2 ev
ery
12 M
ON
THS
unlim
ited
unlim
ited
1 ev
ery
LIFE
TIM
E
1 ev
ery
LIFE
TIM
E
Yes
Yes
Yes
D511
0D5
120
3 ev
ery
60 M
ON
THS
3 ev
ery
60 M
ON
THS
3 ev
ery
60 M
ON
THS
1 ev
ery
12 M
ON
THS
1 ev
ery
12 M
ON
THS
1 ev
ery
12 M
ON
THS
1 ev
ery
12 M
ON
THS
1 ev
ery
12 M
ON
THS
1 ev
ery
12 M
ON
THS
1 ev
ery
12 M
ON
THS
1 ev
ery
12 M
ON
THS
D589
9
unlim
ited
1 ev
ery
36 M
onth
s1
ever
y LI
FETI
ME
1 ev
ery
LIFE
TIM
E1
ever
y LI
FETI
ME
3 ev
ery
60 M
ON
THS
3 ev
ery
60 M
ON
THS
1 ev
ery
12 M
ON
THS
1 ev
ery
12 M
ON
THS
D714
0U
nspe
cifie
d Re
mov
able
Pro
stho
dont
ic P
roce
dure
, By
Repo
rtEx
trac
tion,
Eru
pted
Too
th O
r Exp
osed
Roo
t1
ever
y LI
FETI
ME
1 ev
ery
LIFE
TIM
EYe
sYe
s
Yes
1 ev
ery
LIFE
TIM
ERe
mov
al O
f Im
pact
ed T
ooth
- Co
mpl
etel
y Bo
nyD7
240
D723
0Re
mov
al O
f Im
pact
ed T
ooth
- Pa
rtia
lly B
ony
Yes
1 ev
ery
LIFE
TIM
E
1 ev
ery
LIFE
TIM
E1
ever
y LI
FETI
ME
D721
0Su
rgic
al R
emov
al O
f Eru
pted
Too
thYe
sD7
220
Rem
oval
Of I
mpa
cted
Too
th -
Soft
Tis
sue
Yes
D576
0Re
line
Max
illar
y Pa
rtia
l Den
ture
(Lab
orat
ory)
No
D576
1Re
line
Man
dibu
lar P
artia
l Den
ture
(Lab
orat
ory)
No
D575
0Re
line
Com
plet
e M
axill
ary
Dent
ure
(Lab
orat
ory)
No
D575
1Re
line
Com
plet
e M
andi
bula
r Den
ture
(Lab
orat
ory)
No
D574
0Re
line
Max
illar
y Pa
rtia
l Den
ture
(Cha
irsid
e)N
oD5
741
Relin
e M
axill
ary
Part
ial D
entu
re (C
hairs
ide)
No
D573
0Re
line
Com
plet
e M
axill
ary
Dent
ure
(Cha
irsid
e)N
oD5
731
Relin
e Co
mpl
ete
Man
dibu
lar D
entu
re (C
hairs
ide)
No
D565
0Ad
d To
oth
To E
xist
ing
Part
ial D
entu
reN
oD5
660
Add
Clas
p To
Exi
stin
g Pa
rtia
l Den
ture
No
D563
0Re
pair
Or R
epla
ce B
roke
n Cl
asp
No
D564
0Re
plac
e Br
oken
Tee
th -
Per T
ooth
No
Repa
ir Re
sin
Dent
ure
Base
No
D562
0Re
pair
Cast
Fra
mew
ork
No
D551
0Re
pair
Brok
en C
ompl
ete
Dent
ure
Base
No
D552
0Re
plac
e M
issi
ng O
r Bro
ken
Teet
h - C
ompl
ete
Dent
ure
(Eac
h To
oth)
No
Yes
D542
1Ad
just
Par
tial D
entu
re -
Max
illar
yN
oD5
422
Adju
st P
artia
l Den
ture
- M
andi
bula
rN
o
D541
0Ad
just
Com
plet
e De
ntur
e - M
axill
ary
No
Mai
l mem
ber a
ppea
ls to
: Uni
tedH
ealth
care
, Att
n: A
ppea
l Dep
artm
ent,
P.O
. Box
313
64, S
alt L
ake
City
, UT
8413
1
D029
0D0
330
D521
4M
andi
bula
r Par
tial D
entu
re -
Cast
Met
al F
ram
ewor
k W
ith R
esin
Den
ture
Bas
esYe
s
D521
1D5
212
Com
plet
e De
ntur
e - M
andi
bula
rM
axill
ary
Part
ial D
entu
re -
Resin
Bas
e
The
Uni
tedH
ealth
care
(UHC
) Com
mun
ity P
lan
cove
rs th
e de
ntal
cod
es li
sted
abo
ve. P
rovi
der p
aym
ent i
s mad
e on
a F
ee-fo
r-Se
rvic
e ba
sis.
Mem
bers
hav
e co
vera
ge w
ith p
artic
ipat
ing
prov
ider
s.
Som
e se
rvic
es re
quire
prio
r aut
horiz
atio
n. T
here
is n
o m
embe
r cop
ay, c
oins
uran
ce o
r ded
uctib
le.
Dent
al P
rovi
ders
with
com
plai
nts a
re to
con
tact
Uni
tedH
ealth
care
Den
tal’s
Pro
vide
r Ser
vice
dep
artm
ent a
t (87
7) 3
78-5
293.
Net
wor
k Pr
ovid
er c
ontr
actu
al d
ispu
tes,
Out
-of-N
etw
ork
prov
ider
di
sput
es, a
nd re
proc
essin
g re
ques
ts w
ill b
e lo
gged
into
the
appe
als d
atab
ase.
Ple
ase
mai
l to
the
Appe
als &
Grie
vanc
es P
O B
ox li
sted
abo
ve. R
esea
rch
and
reso
lutio
n w
ill b
e co
mpl
eted
with
in 3
0 ca
lend
ar d
ays.
Mem
ber a
ppea
ls a
re re
view
ed b
y th
e he
alth
pla
n, a
nd a
re n
ot d
eleg
ated
to U
HC D
enta
l. Al
l Mem
ber a
ppea
ls (i
nclu
des P
re-S
ervi
ce a
ppea
ls, I
n N
etw
ork
Prov
ider
app
eals
, and
Out
of N
etw
ork
prov
ider
app
eals)
rece
ived
by
UHC
Den
tal w
ill b
e fo
rwar
ded
to th
e he
alth
pla
n vi
a ov
erni
ght m
ail,
with
in 7
day
s of r
ecei
pt o
f the
app
eal.
No
No
Intr
aora
l - O
cclu
sal R
adio
grap
hic
Imag
ePa
nora
mic
Rad
iogr
aphi
c Im
age
1 ev
ery
LIFE
TIM
EM
andi
bula
r Par
tial D
entu
re -
Resi
n Ba
se
D541
1Ad
just
Com
plet
e De
ntur
e - M
andi
bula
rN
o
D561
0
Com
plet
e De
ntur
e - M
axill
ary
Yes
D521
3M
axill
ary
Part
ial D
entu
re -
Cast
Met
al F
ram
ewor
k W
ith R
esin
Den
ture
Bas
es
FL W
rap
R744
4 PB
P 01
2 G
roup
#82
080,
R74
44 P
BP 0
13 G
roup
#82
981,
H10
45 P
BP 0
39 G
roup
#82
060,
H10
45 P
BP 0
40 G
roup
#82
941
83
Prio
r Aut
horiz
atio
n Re
ques
ts
Foot
note
: FL_
SCIO
N 2
89_D
SNP
Med
icai
d W
rap
01/2
017
“Prio
r Aut
horiz
atio
n re
quire
d” m
eans
the
prac
titio
ner m
ust s
ubm
it th
ose
proc
edur
es fo
r app
rova
l with
clin
ical
doc
umen
tatio
n su
ppor
ting
nece
ssity
bef
ore
perf
orm
ing
thos
e pr
oced
ures
. To
do th
is
com
plet
e a
stan
dard
ADA
cla
im fo
rm a
nd c
heck
the
box
mar
ked
“Pre
-Tre
atm
ent E
STIM
ATE.
” Pr
ior a
utho
rizat
ion
requ
est c
an b
e su
bmitt
ed v
ia th
e pr
ovid
er w
eb p
orta
l (at
w
ww
.myu
hcpr
ovid
ers.
com
), su
bmitt
ed e
lect
roni
cally
via
you
r cle
arin
ghou
se, o
r sim
ply
mai
l the
form
, to
the
belo
w a
ddre
ss, a
long
with
any
requ
ired
supp
lem
enta
l inf
orm
atio
n (fi
lms,
nar
rativ
e,
perio
-cha
rtin
g, e
tc.).
You
r offi
ce w
ill th
en re
ceiv
e an
Exp
lana
tion
of B
enef
its (E
OB)
out
linin
g th
e de
nial
or a
ppro
val o
f req
uest
ed tr
eatm
ent a
nd p
lan
paym
ent a
mou
nts w
hen
appl
icab
le.
FL W
rap
R744
4 PB
P 01
2 G
roup
#82
080,
R74
44 P
BP 0
13 G
roup
#82
981,
H10
45 P
BP 0
39 G
roup
#82
060,
H10
45 P
BP 0
40 G
roup
#82
941
8484
Iden
tific
atio
n Ca
rds
Sam
ple
Mem
ber I
D C
ard*
Fron
t of c
ard
Back
of c
ard
Prov
ider
Qui
ck R
efer
ence
Gui
de -
Effe
ctiv
e 1/
1/20
17U
nite
dHea
lthca
re C
omm
unity
Pla
n/U
nite
dHea
lthca
re o
f Flo
rida
Dua
l Com
plet
e RP
$1,5
00 A
nnua
l Max
*Ple
ase
note
that
the
Med
ical
ID C
ard
is un
iver
sal a
nd in
clud
es a
ll lin
es o
f cov
erag
e. T
he M
edic
al p
lan
can
be H
MO
or P
PO a
nd th
is d
oes n
ot re
flect
the
Dent
al P
lan
Bene
fits.
Ple
ase
flip
the
ID C
ard
over
to se
e th
e De
ntal
Pro
vide
r inf
orm
atio
n on
the
back
(i.e
. car
rier w
ebsi
te a
nd to
ll-fr
ee n
umbe
r). T
his i
nfor
mat
ion
can
be u
sed
to c
onfir
m p
rovi
der p
artic
ipat
ion,
mem
ber e
ligib
ility
and
ben
efits
. Th
is is
a S
AMPL
E ID
Car
d an
d m
ay d
iffer
from
the
mem
ber's
ID C
ard.
FL D
NSP
R74
44-0
12 a
nd R
7444
-013
85
Impo
rtan
t Tel
epho
ne N
umbe
rs &
Web
site
s
Impo
rtan
t Add
ress
es
Impo
rtan
t Ele
ctro
nic
Clai
ms &
Prio
r Aut
horiz
atio
n Su
bmis
sion
Info
rmat
ion
EDI P
ayer
Num
ber f
or C
laim
s Sub
mitt
ed
Prov
ider
Rea
son
for M
ailin
g
Call
to In
quire
Abo
utTe
leph
one
Num
ber
Hou
rs o
f Ope
ratio
n
Emai
l to
Inqu
ire A
bout
Web
site
Hou
rs o
f Ope
ratio
n
Med
icar
ew
ww
.med
icar
e.go
v24
hou
rs a
day
Cent
ers f
or M
edic
aid
and
Med
icar
e Se
rvic
esw
ww
.cm
s.hh
s.go
v24
hou
rs a
day
Elig
ibili
ty,
Bene
fits,
Cla
im(s
) and
Aut
horiz
atio
ns84
4-27
5-87
50
Unl
imite
dU
nlim
ited
Unl
imite
dU
nlim
ited
GP1
33
Clai
ms
Prio
r Aut
horiz
atio
nAp
peal
s & G
rieva
nces
UHC
Med
icar
e Cl
aim
s, P
O B
ox 2
176,
Milw
auke
e, W
I 532
01U
HC M
edic
are
Auth
oriza
tions
, PO
Box
205
3, M
ilwau
kee,
WI 5
3201
UHC
Med
icar
e Co
mpl
aint
s, G
rieva
nces
& A
ppea
ls, P
O B
ox 3
61, M
ilwau
kee,
WI 5
3201
Unl
imite
d
No
No
D027
2D0
273
bite
win
g - t
wo
film
sN
o
D111
0pr
ophy
laxi
s - a
dult
No
Freq
uenc
y/Li
mita
tions
Proc
edur
e D
escr
iptio
npe
riodi
c or
al e
valu
atio
nlim
ited
oral
eva
luat
ion
- pro
blem
focu
sed
com
preh
ensi
ve o
ral e
valu
atio
n - n
ew o
r est
ablis
hed
patie
ntin
trao
ral -
com
plet
e se
ries (
incl
udin
g bi
tew
ings
)
Unl
imite
dU
nlim
ited
Live
Age
nt: M
onda
y - F
riday
, 8:0
0AM
- 6:
00PM
, EST
IVR:
24
hour
s a d
ay
24 h
ours
a d
ay
To d
iscu
ss y
our p
artic
ipat
ion,
con
trac
tual
issu
es, d
entis
t cha
nges
or o
ffice
up
date
s80
0-82
2-53
53Li
ve A
gent
: Mon
day
- Frid
ay, 8
:00A
M -
11:0
0PM
, EST
Elig
ibili
ty,
Bene
fits,
Cla
im(s
) and
Aut
horiz
atio
nsw
ww
.uhc
prov
ider
s.co
m
1 ev
ery
6 M
onth
(s)
1 ev
ery
6 M
onth
(s)
1 ev
ery
6 M
onth
(s)
1 ev
ery
6 M
onth
(s)
1 ev
ery
6 M
onth
(s)
1 ev
ery
6 M
onth
(s)
1 ev
ery
6 M
onth
(s)
1 ev
ery
6 M
onth
(s)
1 ev
ery
6 M
onth
(s)
D012
0D0
140
D015
0D0
210
No
1 ev
ery
6 M
onth
(s)
1 ev
ery
6 M
onth
(s)
Unl
imite
dU
nlim
ited
Unl
imite
dU
nlim
ited
1 ev
ery
36 M
onth
(s)
Unl
imite
d
1 ev
ery
6 M
onth
(s)
Unl
imite
d
D271
0cr
own
- res
in-b
ased
com
posi
te (i
ndire
ct)
Yes
D239
3re
sin-
base
d co
mpo
site
- th
ree
surf
aces
, pos
terio
rN
oD2
394
resi
n-ba
sed
com
posi
te -
four
or m
ore
surf
aces
, pos
terio
rN
o
D239
1re
sin-
base
d co
mpo
site
- on
e su
rfac
e, p
oste
rior
No
D239
2re
sin-
base
d co
mpo
site
- tw
o su
rfac
es, p
oste
rior
No
D215
0am
alga
m -
two
surf
aces
, prim
ary
or p
erm
anen
tN
o
No
D233
1re
sin-
base
d co
mpo
site
- tw
o su
rfac
es, a
nter
ior
No
D233
2re
sin-
base
d co
mpo
site
- th
ree
surf
aces
, ant
erio
rN
o
Cove
red
Den
tal S
ervi
ces:
Prio
r Aut
horiz
atio
n Re
quire
d?Pr
oced
ure
Code
D023
0D0
240
D027
0
intr
aora
l - p
eria
pica
l - fi
rst f
ilm
No
No
D214
0am
alga
m -
one
surf
ace,
prim
ary
or p
erm
anen
tN
o
D027
4D0
330
bite
win
g - t
hree
film
sbi
tew
ing
- fou
r film
s
D216
1am
alga
m -
four
or m
ore
surf
aces
, prim
ary
or p
erm
anen
tN
oD2
330
resi
n-ba
sed
com
posi
te -
one
surf
ace,
ant
erio
rN
o
No
No
No
No
No
No
intr
aora
l - p
eria
pica
l - e
ach
addi
tiona
l film
intr
aora
l - o
cclu
sal f
ilmbi
tew
ing
- sin
gle
film
1 ev
ery
3 Ye
ar(s
)
D022
0
pano
ram
ic fi
lm
D216
0am
alga
m -
thre
e su
rfac
es, p
rimar
y or
per
man
ent
No
D233
5re
sin-
base
d co
mpo
site
- fo
ur o
r mor
e su
rfac
es o
r inv
olvi
ng in
cisa
l ang
le (a
nter
ior)
No
D239
0re
sin-
base
d co
mpo
site
cro
wn,
ant
erio
r
FL D
NSP
R74
44-0
12 a
nd R
7444
-013
8686
Prov
ider
Cla
im D
ispu
tes
Mem
ber A
ppea
ls &
Grie
vanc
es
Prio
r Aut
horiz
atio
n Re
ques
ts
Foot
note
: SCI
ON
288
_DT0
99_D
T015
-P15
00A-
FFS7
3
09/2
016
Unl
imite
d
Unl
imite
d
1 ev
ery
24 M
onth
(s)
1 ev
ery
24 M
onth
(s)
1 ev
ery
36 M
onth
(s)
1 ev
ery
36 M
onth
(s)
1 ev
ery
36 M
onth
(s)
1 ev
ery
36 M
onth
(s)
1 ev
ery
36 M
onth
(s)
Unl
imite
d
Unl
imite
d
D293
0pr
efab
ricat
ed st
ainl
ess s
teel
cro
wn
- prim
ary
toot
hU
nlim
ited
No
Unl
imite
d
D279
2cr
own
- ful
l cas
t nob
le m
etal
Yes
D292
0re
cem
ent c
row
nN
o
D275
2cr
own
- por
cela
in fu
sed
to n
oble
met
alYe
sD2
791
crow
n - f
ull c
ast p
redo
min
antly
bas
e m
etal
Yes
surg
ical
rem
oval
of r
esid
ual t
ooth
root
s (cu
ttin
g pr
oced
ure)
Yes
pref
abric
ated
stai
nles
s ste
el c
row
n - p
erm
anen
t too
thU
nlim
ited
No
Yes
1 ev
ery
24 M
onth
(s)
perio
dont
al sc
alin
g an
d ro
ot p
lann
ing
- fou
r or m
ore
per q
uadr
ant
pref
abric
ated
pos
t and
cor
e in
add
ition
to c
row
nYe
s
Unl
imite
d
surg
ical
rem
oval
of e
rupt
ed to
oth
req
rem
oval
of b
one,
sect
ioni
ng o
f too
th a
nd in
clud
ing
elev
atio
n of
muc
oper
iost
eal f
lap
No
No
Unl
imite
dD7
250
D731
0
D731
1D9
110
1 ev
ery
36 M
onth
(s)
D721
0
Unl
imite
dU
nlim
ited
Unl
imite
d
Unl
imite
d
Unl
imite
d
alve
olop
last
y in
con
junc
tion
with
ext
ract
ions
- fo
ur o
r mor
e te
eth
or to
oth
spac
es, p
er
quad
rant
alve
olop
last
y in
con
junc
tion
with
ext
ract
ions
- on
e to
thre
e te
eth
or to
oth
spac
es, p
er
quad
rant
palli
ativ
e (e
mer
genc
y) tr
eatm
ent o
f den
tal p
ain
- min
or p
roce
dure
No
No
No
D293
1
D434
1
D711
1ex
trac
tion,
cor
onal
rem
nant
s - d
ecid
uous
toot
hD7
140
extr
actio
n, e
rupt
ed to
oth
or e
xpos
ed ro
ot (e
leva
tion
and/
or fo
rcep
s)N
o
D435
5fu
ll m
outh
deb
ridem
ent t
o en
able
com
preh
ensi
ve e
valu
atio
n an
d di
agno
sis
No
D491
0pe
riodo
ntal
mai
nten
ance
No
D434
2pe
riodo
ntal
scal
ing
and
root
pla
nnin
g - o
ne to
thre
e te
eth
per q
uadr
ant
Yes
D294
0pr
otec
tive
rest
orat
ion
No
D295
0co
re b
uild
up, i
nclu
ding
any
pin
sYe
sD2
954
D275
0cr
own
- por
cela
in fu
sed
to h
igh
nobl
e m
etal
Yes
D275
1cr
own
- por
cela
in fu
sed
to p
redo
min
antly
bas
e m
etal
Yes
D274
0cr
own
- por
cela
in/c
eram
ic su
bstr
ate
Yes
Mai
l mem
ber a
ppea
ls to
: Uni
tedH
ealth
care
, Att
n: A
ppea
l Dep
artm
ent,
MS
CA12
4-01
57, P
O B
ox 6
106,
Cyp
ress
, CA
9063
0
“Prio
r Aut
horiz
atio
n re
quire
d” m
eans
the
prac
titio
ner m
ust s
ubm
it th
ose
proc
edur
es fo
r app
rova
l with
clin
ical
doc
umen
tatio
n su
ppor
ting
nece
ssity
bef
ore
perf
orm
ing
thos
e pr
oced
ures
. To
do th
is
com
plet
e a
stan
dard
ADA
cla
im fo
rm a
nd c
heck
the
box
mar
ked
“Pre
-Tre
atm
ent E
STIM
ATE.
” Pr
ior a
utho
rizat
ion
requ
est c
an b
e su
bmitt
ed v
ia th
e pr
ovid
er w
eb p
orta
l (at
ww
w.m
yuhc
prov
ider
s.co
m),
subm
itted
ele
ctro
nica
lly v
ia y
our c
lear
ingh
ouse
, or s
impl
y m
ail t
he fo
rm, t
o th
e be
low
add
ress
, alo
ng w
ith a
ny re
quire
d su
pple
men
tal i
nfor
mat
ion
(film
s, n
arra
tive,
per
io-c
hart
ing,
etc
.). Y
our o
ffice
w
ill th
en re
ceiv
e an
Exp
lana
tion
of B
enef
its (E
OB)
out
linin
g th
e de
nial
or a
ppro
val o
f req
uest
ed tr
eatm
ent a
nd p
lan
paym
ent a
mou
nts w
hen
appl
icab
le.
The
Uni
tedH
ealth
care
(UHC
) Com
mun
ity P
lan
for D
ual C
ompl
ete
mem
bers
cov
ers t
he d
enta
l cod
es li
sted
abo
ve. P
rovi
der p
aym
ent i
s mad
e on
a F
ee-fo
r-Se
rvic
e ba
sis.
Som
e se
rvic
es re
quire
prio
r au
thor
izatio
n. T
he d
enta
l pla
n ha
s a $
1,50
0 an
nual
max
that
app
lies t
o co
vere
d pr
even
tive
and
com
preh
ensi
ve b
enef
its. T
his p
lan
is of
fere
d to
Uni
tedH
ealth
care
Dua
l Com
plet
e m
embe
rs in
Fl
orid
a. T
here
is n
o m
embe
r cop
ay, c
oins
uran
ce o
r ded
uctib
le fo
r In-
Net
wor
k Pr
ovid
ers.
Dent
al P
rovi
ders
with
com
plai
nts a
re to
con
tact
Uni
tedH
ealth
care
Den
tal’s
Pro
vide
r Ser
vice
dep
artm
ent a
t (84
4) 2
75-8
750.
Net
wor
k Pr
ovid
er c
ontr
actu
al d
ispu
tes,
Out
-of-N
etw
ork
prov
ider
dis
pute
s,
and
repr
oces
sing
requ
ests
will
be
logg
ed in
to th
e ap
peal
s dat
abas
e. P
leas
e m
ail t
o th
e Ap
peal
s & G
rieva
nces
PO
Box
list
ed a
bove
. Res
earc
h an
d re
solu
tion
will
be
com
plet
ed w
ithin
30
cale
ndar
day
s.
Mem
ber a
ppea
ls a
re re
view
ed b
y th
e he
alth
pla
n, a
nd a
re n
ot d
eleg
ated
to U
HC D
enta
l. Al
l Mem
ber a
ppea
ls (i
nclu
des P
re-S
ervi
ce a
ppea
ls, I
n N
etw
ork
Prov
ider
app
eals
, and
Out
of N
etw
ork
prov
ider
FL D
NSP
R74
44-0
12 a
nd R
7444
-013
87
8888
1 ev
ery
year
1 ev
ery
36 m
onth
s fro
m la
st d
ate
of s
ervi
ce
2 ev
ery
year
89
2 ev
ery
day
“Prio
r Aut
horiz
atio
n re
quire
d” m
eans
the
prac
titio
ner m
ust s
ubm
it th
ose
proc
edur
es fo
r app
rova
l with
clin
ical
doc
umen
tatio
n su
ppor
ting
nece
ssity
bef
ore
perf
orm
ing
thos
e pr
oced
ures
. To
do th
is c
ompl
ete
a st
anda
rd
ADA
clai
m fo
rm a
nd c
heck
the
box
mar
ked
“Pre
-Tre
atm
ent E
STIM
ATE.
” Pr
ior a
utho
rizat
ion
requ
est c
an b
e su
bmitt
ed v
ia th
e pr
ovid
er w
eb p
orta
l (at
ww
w.m
yuhc
prov
ider
s.co
m),
subm
itted
ele
ctro
nica
lly v
ia y
our
Dent
al P
rovi
ders
with
com
plai
nts a
re to
con
tact
Uni
tedH
ealth
care
Den
tal’s
Pro
vide
r Ser
vice
dep
artm
ent a
t
9090
91
9292
“Prio
r Aut
horiz
atio
n re
quire
d” m
eans
the
prac
titio
ner m
ust s
ubm
it th
ose
proc
edur
es fo
r app
rova
l with
clin
ical
doc
umen
tatio
n su
ppor
ting
nece
ssity
bef
ore
perf
orm
ing
thos
e pr
oced
ures
. To
do th
is c
ompl
ete
a st
anda
rd A
DA
clai
m fo
rm a
nd c
heck
the
box
mar
ked
“Pre
-Tre
atm
ent E
STIM
ATE.
” Pr
ior a
utho
rizat
ion
requ
est c
an b
e su
bmitt
ed v
ia th
e pr
ovid
er w
eb p
orta
l (at
ww
w.m
yuhc
prov
ider
s.co
m),
subm
itted
ele
ctro
nica
lly v
ia y
our c
lear
ingh
ouse
, or
Dent
al P
rovi
ders
with
com
plai
nts a
re to
con
tact
Uni
tedH
ealth
care
Den
tal’s
Pro
vide
r Ser
vice
dep
artm
ent a
t
93
Iden
tific
atio
n Ca
rds
Sam
ple
Mem
ber I
D C
ard*
Fron
t of c
ard
Back
of c
ard
Impo
rtan
t Tel
epho
ne N
umbe
rs &
Web
site
s
Impo
rtan
t Add
ress
es
Impo
rtan
t Ele
ctro
nic
Clai
ms &
Prio
r Aut
horiz
atio
n Su
bmis
sion
Info
rmat
ion
Clai
ms
Prio
r Aut
horiz
atio
n
Appe
als &
Grie
vanc
es
UHC
Med
icar
e Cl
aim
s, P
O B
ox 2
176,
Milw
auke
e, W
I 53
201
UHC
Med
icar
e Au
thor
izatio
ns, P
O B
ox 2
053,
Milw
auke
e, W
I 53
201
UHC
Med
icar
e Co
mpl
aint
s, G
rieva
nces
& A
ppea
ls, P
O B
ox 3
61, M
ilwau
kee,
WI
5320
1
Prov
ider
Rea
son
for M
ailin
g
Call
to In
quire
Abo
utTe
leph
one
Num
ber
Hou
rs o
f Ope
ratio
n
Emai
l to
Inqu
ire A
bout
Web
site
Hou
rs o
f Ope
ratio
n
Med
icar
ew
ww
.med
icar
e.go
v24
hou
rs a
day
To d
iscu
ss y
our p
artic
ipat
ion,
con
trac
tual
issu
es, d
entis
t cha
nges
or o
ffice
upd
ates
(800
) 822
-535
3Li
ve A
gent
: Mon
day
- Frid
ay, 8
:00A
M -
11:0
0PM
, EST
Elig
ibili
ty,
Bene
fits,
Cla
im(s
) and
Aut
horiz
atio
nsw
ww
.uhc
prov
ider
s.co
m
Prov
ider
Qui
ck R
efer
ence
Gui
de -
Effe
ctiv
e 1/
1/20
17U
nite
dHea
lthca
re C
are
Impr
ovem
ent P
lus M
edic
are
Adva
ntag
e
Geo
rgia
24 h
ours
a d
ayCe
nter
s for
Med
icai
d an
d M
edic
are
Serv
ices
ww
w.c
ms.
hhs.
gov
24 h
ours
a d
ay
*Ple
ase
note
that
the
Med
ical
ID C
ard
is u
nive
rsal
and
incl
udes
all
lines
of c
over
age .
The
Med
ical
pla
n ca
n be
HM
O o
r PPO
and
this
doe
s not
refle
ct th
e De
ntal
Pla
n Be
nefit
s. P
leas
e fli
p th
e ID
Car
d ov
er to
see
the
Dent
al
Prov
ider
info
rmat
ion
on th
e ba
ck (i
.e. c
arrie
r web
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and
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free
num
ber)
. Thi
s inf
orm
atio
n ca
n be
use
d to
con
firm
pro
vide
r par
ticip
atio
n, m
embe
r elig
ibili
ty a
nd b
enef
its. T
his i
s a S
AMPL
E ID
Car
d an
d m
ay d
iffer
from
th
e m
embe
r's ID
Car
d.
Elig
ibili
ty,
Bene
fits,
Cla
im(s
) and
Aut
horiz
atio
ns(8
44) 2
75-8
750
Live
Age
nt: M
onda
y - F
riday
, 8:0
0AM
- 6:
00PM
, EST
IVR:
24
hour
s a d
ay
$500
Ann
ual M
axim
um
EDI P
ayer
Num
ber f
or C
laim
s Sub
mitt
edG
P133
9494
unlim
ited
unlim
ited
Freq
uenc
y/Li
mita
tions
1 ev
ery
6 m
onth
s1
ever
y 6
mon
ths
1 ev
ery
6 m
onth
s
1 ev
ery
2 ye
ars
1 ev
ery
2 ye
ars
1 ev
ery
2 ye
ars
unlim
ited
unlim
ited
unlim
ited
unlim
ited
unlim
ited
unlim
ited
1 ev
ery
3 ye
ars
1 ev
ery
3 ye
ars
1 ev
ery
3 ye
ars
unlim
ited
unlim
ited
unlim
ited
unlim
ited
unlim
ited
unlim
ited
unlim
ited
unlim
ited
unlim
ited
unlim
ited
unlim
ited
1 ev
ery
3 ye
ars
1 ev
ery
3 ye
ars
1 ev
ery
3 ye
ars
1 ev
ery
3 ye
ars
No
No
Yes
No
No
No
No
No
No
Yes
Yes
Yes
No
Yes
No
No
No
Yes
Yes
Yes
Yes
No
No
No
No
No
No
No
No
No
No
Yes
Yes
Yes
No
Resi
n-Ba
sed
Com
posi
te -
Thre
e Su
rfac
es, A
nter
ior
No
No
No
No
No
No
No
No
No
Perio
dic
Ora
l Eva
luat
ion
- Est
ablis
hed
Patie
ntLi
mite
d O
ral E
valu
atio
n - P
robl
em F
ocus
edCo
mpr
ehen
sive
Ora
l Eva
luat
ion
- New
Or E
stab
lishe
d Pa
tient
Intr
aora
l - C
ompl
ete
Serie
s of R
adio
grap
hic
Imag
esIn
trao
ral -
Per
iapi
cal F
irst R
adio
grap
hic
Imag
eIn
trao
ral -
Per
iapi
cal E
ach
Addi
tiona
l Im
age
Intr
aora
l - O
cclu
sal R
adio
grap
hic
Imag
eBi
tew
ing
- Sin
gle
Radi
ogra
phic
Imag
eBi
tew
ings
- Tw
o Ra
diog
raph
ic Im
ages
No
No
No
No
Bite
win
gs- T
hree
Rad
iogr
aphi
c Im
ages
Pref
abric
ated
Sta
inle
ss S
teel
Cro
wn
- Per
man
ent T
ooth
Prot
ectiv
e Re
stor
atio
nCo
re B
uild
up, I
nclu
ding
Any
Pin
s Whe
n Re
quire
dPr
efab
ricat
ed P
ost A
nd C
ore
In A
dditi
on T
o Cr
own
Perio
dont
al S
calin
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d Ro
ot P
lann
ing
- Fou
r Or M
ore
Teet
h Pe
r Qua
dran
t
Crow
n - P
orce
lain
Fus
ed T
o N
oble
Met
alCr
own
- Ful
l Cas
t Pre
dom
inan
tly B
ase
Met
alCr
own
- Ful
l Cas
t Nob
le M
etal
Re-C
emen
t or R
e-Bo
nd C
row
nPr
efab
ricat
ed S
tain
less
Ste
el C
row
n - P
rimar
y To
oth
Surg
ical
Rem
oval
Of E
rupt
ed T
ooth
Surg
ical
Rem
oval
Of R
esid
ual T
ooth
(Cut
ting
Proc
edur
e)Al
veol
opla
sty
In C
onju
nctio
n W
ith E
xtra
ctio
ns -
Four
Or M
ore
Teet
hAl
veol
opla
sty
In C
onju
nctio
n W
ith E
xtra
ctio
ns -
One
To
Thre
e Te
eth
Palli
ativ
e (E
mer
genc
y) T
reat
men
t Of D
enta
l Pai
n - M
inor
Pro
cedu
re
Perio
dont
al S
calin
g An
d Ro
ot P
lann
ing
- One
To
Thre
e Te
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Per Q
uadr
ant
Full
Mou
th D
ebrid
emen
tPe
riodo
ntal
Mai
nten
ance
Extr
actio
n, C
oron
al R
emna
nts -
Dec
iduo
us T
ooth
Extr
actio
n, E
rupt
ed T
ooth
Or E
xpos
ed R
oot
Crow
n - P
orce
lain
/Cer
amic
Sub
stra
teCr
own
- Por
cela
in F
used
To
High
Nob
le M
etal
Crow
n - P
orce
lain
Fus
ed T
o Pr
edom
inan
tly B
ase
Met
al
Resi
n-Ba
sed
Com
posi
te -
Four
Or M
ore
Surf
aces
Or I
nvol
ving
Inci
sal A
ngle
Resi
n-Ba
sed
Com
posi
te C
row
n, A
nter
ior
Resi
n-Ba
sed
Com
posi
te -
One
Sur
face
, Pos
terio
rRe
sin-
Base
d Co
mpo
site
- Tw
o Su
rfac
es, P
oste
rior
Resi
n-Ba
sed
Com
posi
te -
Thre
e Su
rfac
es, P
oste
rior
D239
1D2
392
D239
3Re
sin-
Base
d Co
mpo
site
- Fo
ur O
r Mor
e Su
rfac
es, P
oste
rior
Crow
n - R
esin
-Bas
ed C
ompo
site
(Ind
irect
)
D721
0D7
250
D731
0D7
311
D275
2D2
791
D279
2D2
920
D293
0
D233
2
D027
4D0
330
D111
0D2
140
D215
0
D911
0
D434
2D4
355
D491
0D7
111
D714
0
D293
1D2
940
D295
0D2
954
D434
1
D239
4D2
710
D274
0D2
750
D275
1
D233
5D2
390
Cove
red
Den
tal S
ervi
ces:
Proc
edur
e Co
dePr
oced
ure
Des
crip
tion
Prio
r Aut
horiz
atio
n Re
quire
d?
D023
0D0
240
D027
0D0
272
D027
3
D012
0D0
140
D015
0D0
210
D022
0
D216
0D2
161
D233
0D2
331
unlim
ited
unlim
ited
1 ev
ery
6 m
onth
s1
ever
y 6
mon
ths
1 ev
ery
6 m
onth
s1
ever
y 6
mon
ths
1 ev
ery
6 m
onth
s1
ever
y 6
mon
ths
1 ev
ery
6 m
onth
s1
ever
y 6
mon
ths
1 ev
ery
3 ye
ars
1 ev
ery
6 m
onth
sun
limite
dun
limite
dun
limite
dun
limite
dun
limite
dun
limite
d
No
No
Resi
n-Ba
sed
Com
posi
te -
Two
Surf
aces
, Ant
erio
r
Bite
win
gs- F
our R
adio
grap
hic
Imag
esPa
nora
mic
Rad
iogr
aphi
c Im
age
Prop
hyla
xis -
Adu
ltAm
alga
m -
One
Sur
face
, Prim
ary
Or P
erm
anen
tAm
alga
m -
Two
Surf
aces
, Prim
ary
Or P
erm
anen
tAm
alga
m -
Thre
e Su
rfac
es, P
rimar
y O
r Per
man
ent
Amal
gam
- Fo
ur O
r Mor
e Su
rfac
es, P
rimar
y O
r Per
man
ent
Resi
n-Ba
sed
Com
posi
te -
One
Sur
face
, Ant
erio
r
95
Prov
ider
Cla
im D
ispu
tes
Mem
ber A
ppea
ls &
Grie
vanc
es
Prio
r Aut
horiz
atio
n Re
ques
ts
CIP_
SCIO
N 4
02_P
kg D
T457
_DT4
55-P
0500
B-FF
S28
09/2
016
Mai
l mem
ber a
ppea
ls to
: Uni
tedH
ealth
care
, Att
n: A
ppea
ls a
nd G
rieva
nce
Depa
rtm
ent,
PO B
ox 6
106,
MS
CA12
4-01
57, C
ypre
ss, C
A 90
630
“Prio
r Aut
horiz
atio
n re
quire
d” m
eans
the
prac
titio
ner m
ust s
ubm
it th
ose
proc
edur
es fo
r app
rova
l with
clin
ical
doc
umen
tatio
n su
ppor
ting
nece
ssity
bef
ore
perf
orm
ing
thos
e pr
oced
ures
. To
do th
is c
ompl
ete
a st
anda
rd
ADA
clai
m fo
rm a
nd c
heck
the
box
mar
ked
“Pre
-Tre
atm
ent E
STIM
ATE.
” Pr
ior a
utho
rizat
ion
requ
est c
an b
e su
bmitt
ed v
ia th
e pr
ovid
er w
eb p
orta
l (at
ww
w.m
yuhc
prov
ider
s.co
m),
subm
itted
ele
ctro
nica
lly v
ia y
our
clea
ringh
ouse
, or s
impl
y m
ail t
he fo
rm, t
o th
e be
low
add
ress
, alo
ng w
ith a
ny re
quire
d su
pple
men
tal i
nfor
mat
ion
(film
s, n
arra
tive,
per
io-c
hart
ing,
etc
.). Y
our o
ffice
will
then
rece
ive
an E
xpla
natio
n of
Ben
efits
(EO
B)
outli
ning
the
deni
al o
r app
rova
l of r
eque
sted
trea
tmen
t and
pla
n pa
ymen
t am
ount
s whe
n ap
plic
able
.
The
Uni
tedH
ealth
care
Pla
n fo
r Car
e Im
prov
emen
t Plu
s Med
icar
e Ad
vant
age
mem
bers
cov
ers t
he d
enta
l cod
es li
sted
abo
ve. P
rovi
der p
aym
ent i
s mad
e on
a F
ee-fo
r-Se
rvic
e ba
sis.
Mem
bers
hav
e bo
th In
-Net
wor
k an
d O
ut-
of-N
etw
ork
cove
rage
. Som
e se
rvic
es m
ay re
quire
prio
r aut
horiz
atio
n. T
he d
enta
l pla
n ha
s a $
500
annu
al m
axim
um th
at a
pplie
s to
cove
red
prev
entiv
e an
d co
mpr
ehen
sive
ben
efits
. The
re is
no
mem
ber c
opay
, co
insu
ranc
e or
ded
uctib
le. M
embe
r can
be
bille
d fo
r ser
vice
s ove
r the
$50
0 an
nual
max
imum
ben
efit.
Thi
s pla
n is
offe
red
to C
are
Impr
ovem
ent P
lus M
edic
are
Adva
ntag
e m
embe
rs in
Geo
rgia
.
Dent
al P
rovi
ders
with
com
plai
nts a
re to
con
tact
Uni
tedH
ealth
care
Den
tal’s
Pro
vide
r Ser
vice
dep
artm
ent a
t (84
4) 2
75-8
750.
Net
wor
k Pr
ovid
er c
ontr
actu
al d
ispu
tes,
Out
-of-N
etw
ork
prov
ider
dis
pute
s, a
nd re
proc
essi
ng
requ
ests
will
be
logg
ed in
to th
e ap
peal
s dat
abas
e. P
leas
e m
ail t
o th
e Ap
peal
s & G
rieva
nces
PO
Box
list
ed a
bove
. Res
earc
h an
d re
solu
tion
will
be
com
plet
ed w
ithin
30
cale
ndar
day
s.
Mem
ber a
ppea
ls a
re re
view
ed b
y th
e he
alth
pla
n, a
nd a
re n
ot d
eleg
ated
to U
HC D
enta
l. Al
l Mem
ber a
ppea
ls (i
nclu
des P
re-S
ervi
ce a
ppea
ls, I
n N
etw
ork
Prov
ider
app
eals
, and
Out
of N
etw
ork
prov
ider
app
eals
) rec
eive
d by
U
HC D
enta
l will
be
forw
arde
d to
the
heal
th p
lan
via
over
nigh
t mai
l, w
ithin
7 d
ays o
f rec
eipt
of t
he a
ppea
l.
9696
Iden
tific
atio
n Ca
rds
Sam
ple
Mem
ber I
D C
ard*
Fron
t of c
ard
Back
of c
ard
Impo
rtan
t Tel
epho
ne N
umbe
rs &
Web
site
s
Impo
rtan
t Add
ress
es
Impo
rtan
t Ele
ctro
nic
Clai
ms &
Prio
r Aut
horiz
atio
n Su
bmis
sion
Info
rmat
ion
EDI P
ayer
Num
ber f
or C
laim
s Sub
mitt
edG
P133
Prov
ider
Qui
ck R
efer
ence
Gui
de -
Effe
ctiv
e 1/
1/20
17U
nite
dHea
lthca
re C
are
Impr
ovem
ent P
lus S
ilver
Rx
Geo
rgia
and
Sou
th C
arol
ina
24 h
ours
a d
ayCe
nter
s for
Med
icai
d an
d M
edic
are
Serv
ices
ww
w.c
ms.
hhs.
gov
24 h
ours
a d
ay
*Ple
ase
note
that
the
Med
ical
ID C
ard
is u
nive
rsal
and
incl
udes
all
lines
of c
over
age .
The
Med
ical
pla
n ca
n be
HM
O o
r PPO
and
this
doe
s not
refle
ct th
e De
ntal
Pla
n Be
nefit
s. P
leas
e fli
p th
e ID
Car
d ov
er to
see
the
Dent
al
Prov
ider
info
rmat
ion
on th
e ba
ck (i
.e. c
arrie
r web
site
and
toll-
free
num
ber)
. Thi
s inf
orm
atio
n ca
n be
use
d to
con
firm
pro
vide
r par
ticip
atio
n, m
embe
r elig
ibili
ty a
nd b
enef
its. T
his i
s a S
AMPL
E ID
Car
d an
d m
ay d
iffer
from
th
e m
embe
r's ID
Car
d.
Elig
ibili
ty,
Bene
fits,
Cla
im(s
) and
Aut
horiz
atio
ns(8
44) 2
75-8
750
Live
Age
nt: M
onda
y - F
riday
, 8:0
0AM
- 6:
00PM
, EST
IVR:
24
hour
s a d
ay
$100
0 An
nual
Max
imum
Prov
ider
Rea
son
for M
ailin
g
Call
to In
quire
Abo
utTe
leph
one
Num
ber
Hou
rs o
f Ope
ratio
n
Emai
l to
Inqu
ire A
bout
Web
site
Hou
rs o
f Ope
ratio
n
Med
icar
ew
ww
.med
icar
e.go
v24
hou
rs a
day
To d
iscu
ss y
our p
artic
ipat
ion,
con
trac
tual
issu
es, d
entis
t cha
nges
or o
ffice
upd
ates
(800
) 822
-535
3Li
ve A
gent
: Mon
day
- Frid
ay, 8
:00A
M -
11:0
0PM
, EST
Elig
ibili
ty,
Bene
fits,
Cla
im(s
) and
Aut
horiz
atio
nsw
ww
.uhc
prov
ider
s.co
m
Clai
ms
Prio
r Aut
horiz
atio
n
Appe
als &
Grie
vanc
es
UHC
Med
icar
e Cl
aim
s, P
O B
ox 2
176,
Milw
auke
e, W
I 53
201
UHC
Med
icar
e Au
thor
izatio
ns, P
O B
ox 2
053,
Milw
auke
e, W
I 53
201
UHC
Med
icar
e Co
mpl
aint
s, G
rieva
nces
& A
ppea
ls, P
O B
ox 3
61, M
ilwau
kee,
WI
5320
1
97
1 ev
ery
6 m
onth
sun
limite
dun
limite
dun
limite
dun
limite
dun
limite
dun
limite
d
Intr
aora
l - C
ompl
ete
Serie
s of R
adio
grap
hic
Imag
esIn
trao
ral -
Per
iapi
cal F
irst R
adio
grap
hic
Imag
eIn
trao
ral -
Per
iapi
cal E
ach
Addi
tiona
l Im
age
No
No
No
No
unlim
ited
unlim
ited
1 ev
ery
6 m
onth
s1
ever
y 6
mon
ths
1 ev
ery
6 m
onth
s1
ever
y 6
mon
ths
1 ev
ery
6 m
onth
s1
ever
y 6
mon
ths
1 ev
ery
6 m
onth
s1
ever
y 6
mon
ths
1 ev
ery
3 ye
ars
Cove
red
Den
tal S
ervi
ces:
Proc
edur
e Co
dePr
oced
ure
Des
crip
tion
Prio
r Aut
horiz
atio
n Re
quire
d?
D023
0D0
240
D027
0D0
272
D027
3
D012
0D0
140
D015
0D0
210
D022
0
D216
0D2
161
D233
0D2
331
D233
2
D027
4D0
330
D111
0D2
140
D215
0
No
No
No
No
No
No
No
No
No
Perio
dic
Ora
l Eva
luat
ion
- Est
ablis
hed
Patie
ntLi
mite
d O
ral E
valu
atio
n - P
robl
em F
ocus
edCo
mpr
ehen
sive
Ora
l Eva
luat
ion
- New
Or E
stab
lishe
d Pa
tient
D233
5D2
390
D239
1D2
392
D239
3
D911
0
D434
2D4
355
D491
0D7
111
D714
0
D293
1D2
940
D295
0D2
954
D434
1
D721
0D7
250
D731
0D7
311
Resi
n-Ba
sed
Com
posi
te -
Four
Or M
ore
Surf
aces
, Pos
terio
rCr
own
- Res
in-B
ased
Com
posi
te (I
ndire
ct)
Crow
n - P
orce
lain
/Cer
amic
Sub
stra
teCr
own
- Por
cela
in F
used
To
High
Nob
le M
etal
Crow
n - P
orce
lain
Fus
ed T
o Pr
edom
inan
tly B
ase
Met
al
D239
4D2
710
D274
0D2
750
D275
1
Pref
abric
ated
Sta
inle
ss S
teel
Cro
wn
- Per
man
ent T
ooth
Prot
ectiv
e Re
stor
atio
nCo
re B
uild
up, I
nclu
ding
Any
Pin
s Whe
n Re
quire
dPr
efab
ricat
ed P
ost A
nd C
ore
In A
dditi
on T
o Cr
own
D275
2D2
791
D279
2D2
920
D293
0
Alve
olop
last
y In
Con
junc
tion
With
Ext
ract
ions
- O
ne T
o Th
ree
Teet
hPa
lliat
ive
(Em
erge
ncy)
Tre
atm
ent O
f Den
tal P
ain
- Min
or P
roce
dure
Perio
dont
al S
calin
g An
d Ro
ot P
lann
ing
- One
To
Thre
e Te
eth
Per Q
uadr
ant
Full
Mou
th D
ebrid
emen
tPe
riodo
ntal
Mai
nten
ance
Extr
actio
n, C
oron
al R
emna
nts -
Dec
iduo
us T
ooth
Extr
actio
n, E
rupt
ed T
ooth
Or E
xpos
ed R
oot
Intr
aora
l - O
cclu
sal R
adio
grap
hic
Imag
eBi
tew
ing
- Sin
gle
Radi
ogra
phic
Imag
eBi
tew
ings
- Tw
o Ra
diog
raph
ic Im
ages
Perio
dont
al S
calin
g An
d Ro
ot P
lann
ing
- Fou
r Or M
ore
Teet
h Pe
r Qua
dran
t
Crow
n - P
orce
lain
Fus
ed T
o N
oble
Met
alCr
own
- Ful
l Cas
t Pre
dom
inan
tly B
ase
Met
alCr
own
- Ful
l Cas
t Nob
le M
etal
Re-C
emen
t or R
e-Bo
nd C
row
nPr
efab
ricat
ed S
tain
less
Ste
el C
row
n - P
rimar
y To
oth
Surg
ical
Rem
oval
Of E
rupt
ed T
ooth
Surg
ical
Rem
oval
Of R
esid
ual T
ooth
(Cut
ting
Proc
edur
e)Al
veol
opla
sty
In C
onju
nctio
n W
ith E
xtra
ctio
ns -
Four
Or M
ore
Teet
h
Resi
n-Ba
sed
Com
posi
te -
Four
Or M
ore
Surf
aces
Or I
nvol
ving
Inci
se A
ngle
Resi
n-Ba
sed
Com
posi
te C
row
n, A
nter
ior
Resi
n-Ba
sed
Com
posi
te -
One
Sur
face
, Pos
terio
rRe
sin-
Base
d Co
mpo
site
- Tw
o Su
rfac
es, P
oste
rior
Resi
n-Ba
sed
Com
posi
te -
Thre
e Su
rfac
es, P
oste
rior
No
No
Yes
Yes
Yes
Yes
No
Bite
win
gs- T
hree
Rad
iogr
aphi
c Im
ages
Bite
win
gs- F
our R
adio
grap
hic
Imag
esPa
nora
mic
Rad
iogr
aphi
c Im
age
Prop
hyla
xis -
Adu
ltAm
alga
m -
One
Sur
face
, Prim
ary
Or P
erm
anen
tAm
alga
m -
Two
Surf
aces
, Prim
ary
Or P
erm
anen
tAm
alga
m -
Thre
e Su
rfac
es, P
rimar
y O
r Per
man
ent
Amal
gam
- Fo
ur O
r Mor
e Su
rfac
es, P
rimar
y O
r Per
man
ent
Resi
n-Ba
sed
Com
posi
te -
One
Sur
face
, Ant
erio
rRe
sin-
Base
d Co
mpo
site
- Tw
o Su
rfac
es, A
nter
ior
Resi
n-Ba
sed
Com
posi
te -
Thre
e Su
rfac
es, A
nter
ior
No
No
No
No
No
No
No
No
No
No
No
No
No
Yes
No
No
No
No
No
No
Yes
Yes
Yes
No
Yes
No
Yes
Yes
Yes
No
unlim
ited
unlim
ited
unlim
ited
unlim
ited
unlim
ited
1 ev
ery
3 ye
ars
1 ev
ery
3 ye
ars
1 ev
ery
3 ye
ars
1 ev
ery
3 ye
ars
unlim
ited
unlim
ited
Freq
uenc
y/Li
mita
tions
1 ev
ery
6 m
onth
s1
ever
y 6
mon
ths
1 ev
ery
6 m
onth
s
1 ev
ery
2 ye
ars
1 ev
ery
2 ye
ars
1 ev
ery
2 ye
ars
unlim
ited
unlim
ited
unlim
ited
unlim
ited
unlim
ited
unlim
ited
1 ev
ery
3 ye
ars
1 ev
ery
3 ye
ars
1 ev
ery
3 ye
ars
unlim
ited
unlim
ited
unlim
ited
unlim
ited
unlim
ited
unlim
ited
9898
Prov
ider
Cla
im D
ispu
tes
Mem
ber A
ppea
ls &
Grie
vanc
es
Prio
r Aut
horiz
atio
n Re
ques
ts
CIP_
SCIO
N 3
67_P
kg D
T455
_DT4
55-P
1000
a_FF
S28
09/2
016
Mai
l mem
ber a
ppea
ls to
: Uni
tedH
ealth
care
, Att
n: A
ppea
ls a
nd G
rieva
nce
Depa
rtm
ent,
PO B
ox 6
106,
MS
CA12
4-01
57, C
ypre
ss, C
A 90
630
“Prio
r Aut
horiz
atio
n re
quire
d” m
eans
the
prac
titio
ner m
ust s
ubm
it th
ose
proc
edur
es fo
r app
rova
l with
clin
ical
doc
umen
tatio
n su
ppor
ting
nece
ssity
bef
ore
perf
orm
ing
thos
e pr
oced
ures
. To
do th
is c
ompl
ete
a st
anda
rd
ADA
clai
m fo
rm a
nd c
heck
the
box
mar
ked
“Pre
-Tre
atm
ent E
STIM
ATE.
” Pr
ior a
utho
rizat
ion
requ
est c
an b
e su
bmitt
ed v
ia th
e pr
ovid
er w
eb p
orta
l (at
ww
w.m
yuhc
prov
ider
s.co
m),
subm
itted
ele
ctro
nica
lly v
ia y
our
clea
ringh
ouse
, or s
impl
y m
ail t
he fo
rm, t
o th
e be
low
add
ress
, alo
ng w
ith a
ny re
quire
d su
pple
men
tal i
nfor
mat
ion
(film
s, n
arra
tive,
per
io-c
hart
ing,
etc
.). Y
our o
ffice
will
then
rece
ive
an E
xpla
natio
n of
Ben
efits
(EO
B)
outli
ning
the
deni
al o
r app
rova
l of r
eque
sted
trea
tmen
t and
pla
n pa
ymen
t am
ount
s whe
n ap
plic
able
.
The
Uni
tedH
ealth
care
Pla
n fo
r Car
e Im
prov
emen
t Plu
s Silv
er R
x m
embe
rs c
over
s the
den
tal c
odes
list
ed a
bove
. Pro
vide
r pay
men
t is
mad
e on
a F
ee-fo
r-Se
rvic
e ba
sis.
Mem
bers
hav
e bo
th In
-Net
wor
k an
d O
ut-o
f-Net
wor
k co
vera
ge. S
ome
serv
ices
may
requ
ire p
rior a
utho
rizat
ion.
The
den
tal p
lan
has a
$10
00 a
nnua
l max
imum
that
app
lies t
o co
vere
d pr
even
tive
and
com
preh
ensi
ve b
enef
its. T
here
is n
o m
embe
r cop
ay, c
oins
uran
ce o
r de
duct
ible
. Mem
ber c
an b
e bi
lled
for s
ervi
ces o
ver t
he $
1000
ann
ual m
axim
um b
enef
it. T
his p
lan
is o
ffere
d to
Car
e Im
prov
emen
t Plu
s Silv
er R
x m
embe
rs in
Geo
rgia
and
Sou
th C
arol
ina.
Dent
al P
rovi
ders
with
com
plai
nts a
re to
con
tact
Uni
tedH
ealth
care
Den
tal’s
Pro
vide
r Ser
vice
dep
artm
ent a
t (84
4) 2
75-8
750.
Net
wor
k Pr
ovid
er c
ontr
actu
al d
ispu
tes,
Out
-of-N
etw
ork
prov
ider
dis
pute
s, a
nd re
proc
essi
ng
requ
ests
will
be
logg
ed in
to th
e ap
peal
s dat
abas
e. P
leas
e m
ail t
o th
e Ap
peal
s & G
rieva
nces
PO
Box
list
ed a
bove
. Res
earc
h an
d re
solu
tion
will
be
com
plet
ed w
ithin
30
cale
ndar
day
s.
Mem
ber a
ppea
ls a
re re
view
ed b
y th
e he
alth
pla
n, a
nd a
re n
ot d
eleg
ated
to U
HC D
enta
l. Al
l Mem
ber a
ppea
ls (i
nclu
des P
re-S
ervi
ce a
ppea
ls, I
n N
etw
ork
Prov
ider
app
eals
, and
Out
of N
etw
ork
prov
ider
app
eals
) rec
eive
d by
U
HC D
enta
l will
be
forw
arde
d to
the
heal
th p
lan
via
over
nigh
t mai
l, w
ithin
7 d
ays o
f rec
eipt
of t
he a
ppea
l.
99
100100
101
“Prio
r Aut
horiz
atio
n re
quire
d” m
eans
the
prac
titio
ner m
ust s
ubm
it th
ose
proc
edur
es fo
r app
rova
l with
clin
ical
doc
umen
tatio
n su
ppor
ting
nece
ssity
bef
ore
perf
orm
ing
thos
e pr
oced
ures
. To
do th
is
com
plet
e a
stan
dard
ADA
cla
im fo
rm a
nd c
heck
the
box
mar
ked
“Pre
-Tre
atm
ent E
STIM
ATE.
” Pr
ior a
utho
rizat
ion
requ
est c
an b
e su
bmitt
ed v
ia th
e pr
ovid
er w
eb p
orta
l (at
ww
w.m
yuhc
prov
ider
s.co
m),
Dent
al P
rovi
ders
with
com
plai
nts a
re to
con
tact
Uni
tedH
ealth
care
Den
tal’s
Pro
vide
r Ser
vice
dep
artm
ent a
t
102102
103
104104
“Prio
r Aut
horiz
atio
n re
quire
d” m
eans
the
prac
titio
ner m
ust s
ubm
it th
ose
proc
edur
es fo
r app
rova
l with
clin
ical
doc
umen
tatio
n su
ppor
ting
nece
ssity
bef
ore
perf
orm
ing
thos
e pr
oced
ures
. To
do th
is
com
plet
e a
stan
dard
ADA
cla
im fo
rm a
nd c
heck
the
box
mar
ked
“Pre
-Tre
atm
ent E
STIM
ATE.
” Pr
ior a
utho
rizat
ion
requ
est c
an b
e su
bmitt
ed v
ia th
e pr
ovid
er w
eb p
orta
l (at
ww
w.m
yuhc
prov
ider
s.co
m),
Dent
al P
rovi
ders
with
com
plai
nts a
re to
con
tact
Uni
tedH
ealth
care
Den
tal’s
Pro
vide
r Ser
vice
dep
artm
ent a
t
105
106106
107
108108
“Prio
r Aut
horiz
atio
n re
quire
d” m
eans
the
prac
titio
ner m
ust s
ubm
it th
ose
proc
edur
es fo
r app
rova
l with
clin
ical
doc
umen
tatio
n su
ppor
ting
nece
ssity
bef
ore
perf
orm
ing
thos
e pr
oced
ures
. To
do th
is
com
plet
e a
stan
dard
ADA
cla
im fo
rm a
nd c
heck
the
box
mar
ked
“Pre
-Tre
atm
ent E
STIM
ATE.
” Pr
ior a
utho
rizat
ion
requ
est c
an b
e su
bmitt
ed v
ia th
e pr
ovid
er w
eb p
orta
l (at
Dent
al P
rovi
ders
with
com
plai
nts a
re to
con
tact
Uni
tedH
ealth
care
Den
tal’s
Pro
vide
r Ser
vice
dep
artm
ent a
t
109
110110
111
112112
“Prio
r Aut
horiz
atio
n re
quire
d” m
eans
the
prac
titio
ner m
ust s
ubm
it th
ose
proc
edur
es fo
r app
rova
l with
clin
ical
doc
umen
tatio
n su
ppor
ting
nece
ssity
bef
ore
perf
orm
ing
thos
e pr
oced
ures
. To
do th
is
com
plet
e a
stan
dard
ADA
cla
im fo
rm a
nd c
heck
the
box
mar
ked
“Pre
-Tre
atm
ent E
STIM
ATE.
” Pr
ior a
utho
rizat
ion
requ
est c
an b
e su
bmitt
ed v
ia th
e pr
ovid
er w
eb p
orta
l (at
ww
w.m
yuhc
prov
ider
s.co
m),
Dent
al P
rovi
ders
with
com
plai
nts a
re to
con
tact
Uni
tedH
ealth
care
Den
tal’s
Pro
vide
r Ser
vice
dep
artm
ent a
t
113
114114
115
“Prio
r Aut
horiz
atio
n re
quire
d” m
eans
the
prac
titio
ner m
ust s
ubm
it th
ose
proc
edur
es fo
r app
rova
l with
clin
ical
doc
umen
tatio
n su
ppor
ting
nece
ssity
bef
ore
perf
orm
ing
thos
e pr
oced
ures
. To
do th
is c
ompl
ete
a st
anda
rd A
DA c
laim
form
and
che
ck th
e bo
x m
arke
d “P
re-T
reat
men
t EST
IMAT
E.”
Prio
r aut
horiz
atio
n re
ques
t can
be
subm
itted
via
the
prov
ider
web
por
tal (
at w
ww
.myu
hcpr
ovid
ers.
com
), su
bmitt
ed
Dent
al P
rovi
ders
with
com
plai
nts a
re to
con
tact
Uni
tedH
ealth
care
Den
tal’s
Pro
vide
r Ser
vice
dep
artm
ent a
t
116116
117
118118
“Prio
r Aut
horiz
atio
n re
quire
d” m
eans
the
prac
titio
ner m
ust s
ubm
it th
ose
proc
edur
es fo
r app
rova
l with
clin
ical
doc
umen
tatio
n su
ppor
ting
nece
ssity
bef
ore
perf
orm
ing
thos
e pr
oced
ures
. To
do th
is c
ompl
ete
a st
anda
rd A
DA c
laim
fo
rm a
nd c
heck
the
box
mar
ked
“Pre
-Tre
atm
ent E
STIM
ATE.
” Pr
ior a
utho
rizat
ion
requ
est c
an b
e su
bmitt
ed v
ia th
e pr
ovid
er w
eb p
orta
l (at
ww
w.m
yuhc
prov
ider
s.co
m),
subm
itted
ele
ctro
nica
lly v
ia y
our c
lear
ingh
ouse
, or s
impl
y
Dent
al P
rovi
ders
with
com
plai
nts a
re to
con
tact
Uni
tedH
ealth
care
Den
tal’s
Pro
vide
r Ser
vice
dep
artm
ent a
t
119
120120
121
122122
“Prio
r Aut
horiz
atio
n re
quire
d” m
eans
the
prac
titio
ner m
ust s
ubm
it th
ose
proc
edur
es fo
r app
rova
l with
clin
ical
doc
umen
tatio
n su
ppor
ting
nece
ssity
bef
ore
perf
orm
ing
thos
e pr
oced
ures
. To
do th
is c
ompl
ete
a st
anda
rd
ADA
clai
m fo
rm a
nd c
heck
the
box
mar
ked
“Pre
-Tre
atm
ent E
STIM
ATE.
” Pr
ior a
utho
rizat
ion
requ
est c
an b
e su
bmitt
ed v
ia th
e pr
ovid
er w
eb p
orta
l (at
ww
w.m
yuhc
prov
ider
s.co
m),
subm
itted
ele
ctro
nica
lly v
ia y
our
Dent
al P
rovi
ders
with
com
plai
nts a
re to
con
tact
Uni
tedH
ealth
care
Den
tal’s
Pro
vide
r Ser
vice
dep
artm
ent a
t
123
124124
125
126126
“Prio
r Aut
horiz
atio
n re
quire
d” m
eans
the
prac
titio
ner m
ust s
ubm
it th
ose
proc
edur
es fo
r app
rova
l with
clin
ical
doc
umen
tatio
n su
ppor
ting
nece
ssity
bef
ore
perf
orm
ing
thos
e pr
oced
ures
. To
do th
is
com
plet
e a
stan
dard
ADA
cla
im fo
rm a
nd c
heck
the
box
mar
ked
“Pre
-Tre
atm
ent E
STIM
ATE.
” Pr
ior a
utho
rizat
ion
requ
est c
an b
e su
bmitt
ed v
ia th
e pr
ovid
er w
eb p
orta
l (at
Dent
al P
rovi
ders
with
com
plai
nts a
re to
con
tact
Uni
tedH
ealth
care
Den
tal’s
Pro
vide
r Ser
vice
dep
artm
ent a
t
127
128128
129
“Prio
r Aut
horiz
atio
n re
quire
d” m
eans
the
prac
titio
ner m
ust s
ubm
it th
ose
proc
edur
es fo
r app
rova
l with
clin
ical
doc
umen
tatio
n su
ppor
ting
nece
ssity
bef
ore
perf
orm
ing
thos
e pr
oced
ures
. To
do th
is
com
plet
e a
stan
dard
ADA
cla
im fo
rm a
nd c
heck
the
box
mar
ked
“Pre
-Tre
atm
ent E
STIM
ATE.
” Pr
ior a
utho
rizat
ion
requ
est c
an b
e su
bmitt
ed v
ia th
e pr
ovid
er w
eb p
orta
l (at
ww
w.m
yuhc
prov
ider
s.co
m),
Dent
al P
rovi
ders
with
com
plai
nts a
re to
con
tact
Uni
tedH
ealth
care
Den
tal’s
Pro
vide
r Ser
vice
dep
artm
ent a
t
130130
131
132132
“Prio
r Aut
horiz
atio
n re
quire
d” m
eans
the
prac
titio
ner m
ust s
ubm
it th
ose
proc
edur
es fo
r app
rova
l with
clin
ical
doc
umen
tatio
n su
ppor
ting
nece
ssity
bef
ore
perf
orm
ing
thos
e pr
oced
ures
. To
do th
is c
ompl
ete
a st
anda
rd A
DA c
laim
form
and
che
ck th
e bo
x m
arke
d “P
re-T
reat
men
t EST
IMAT
E.”
Prio
r aut
horiz
atio
n re
ques
t can
be
subm
itted
via
the
prov
ider
web
por
tal (
at w
ww
.myu
hcpr
ovid
ers.
com
), su
bmitt
ed
Dent
al P
rovi
ders
with
com
plai
nts a
re to
con
tact
Uni
tedH
ealth
care
Den
tal’s
Pro
vide
r Ser
vice
dep
artm
ent a
t
133
134134
135
136136
“Prio
r Aut
horiz
atio
n re
quire
d” m
eans
the
prac
titio
ner m
ust s
ubm
it th
ose
proc
edur
es fo
r app
rova
l with
clin
ical
doc
umen
tatio
n su
ppor
ting
nece
ssity
bef
ore
perf
orm
ing
thos
e pr
oced
ures
. To
do th
is c
ompl
ete
a st
anda
rd A
DA c
laim
form
and
che
ck th
e bo
x m
arke
d “P
re-T
reat
men
t EST
IMAT
E.”
Prio
r aut
horiz
atio
n re
ques
t can
be
subm
itted
via
the
prov
ider
web
por
tal (
at w
ww
.myu
hcpr
ovid
ers.
com
), su
bmitt
ed
Dent
al P
rovi
ders
with
com
plai
nts a
re to
con
tact
Uni
tedH
ealth
care
Den
tal’s
Pro
vide
r Ser
vice
dep
artm
ent a
t
137
138138
Iden
tific
atio
n Ca
rds
Sam
ple
Mem
ber I
D C
ard*
Fron
t of c
ard
Back
of c
ard
Impo
rtan
t Tel
epho
ne N
umbe
rs &
Web
site
s
Impo
rtan
t Add
ress
es
Impo
rtan
t Ele
ctro
nic
Clai
ms &
Prio
r Aut
horiz
atio
n Su
bmis
sion
Info
rmat
ion
Prov
ider
Rea
son
for M
ailin
g
EDI P
ayer
Num
ber f
or C
laim
s Sub
mitt
ed
No
Annu
al M
axim
um
Call
to In
quire
Abo
utTe
leph
one
Num
ber
Hou
rs o
f Ope
ratio
n
Emai
l to
Inqu
ire A
bout
Web
site
Hou
rs o
f Ope
ratio
n
Med
icar
ew
ww
.med
icar
e.go
v24
hou
rs a
day
To d
iscu
ss y
our p
artic
ipat
ion,
con
trac
tual
issu
es, d
entis
t cha
nges
or o
ffice
upd
ates
800-
822-
5353
Live
Age
nt: M
onda
y - F
riday
, 8:0
0AM
- 11
:00P
M, E
ST
Elig
ibili
ty,
Bene
fits,
Cla
im(s
) and
Aut
horiz
atio
nsw
ww
.uhc
prov
ider
s.co
mCe
nter
s for
Med
icai
d an
d M
edic
are
Serv
ices
ww
w.c
ms.
hhs.
gov
Cove
red
Den
tal S
ervi
ces:
Prov
ider
Qui
ck R
efer
ence
Gui
de -
Effe
ctiv
e 1/
1/20
17U
nite
dHea
lthca
re A
ARP
Com
plet
e Pl
ans (
form
ally
Oxf
ord
DH
MO
)
CT, N
J, an
d N
Y
24 h
ours
a d
ay24
hou
rs a
day
*Ple
ase
note
that
the
Med
ical
ID C
ard
is un
iver
sal a
nd in
clud
es a
ll lin
es o
f cov
erag
e. T
he M
edic
al p
lan
can
be H
MO
or P
PO a
nd th
is d
oes n
ot re
flect
the
Dent
al P
lan
Bene
fits.
Ple
ase
flip
the
ID C
ard
over
to se
e th
e De
ntal
Pr
ovid
er in
form
atio
n on
the
back
(i.e
. car
rier w
ebsi
te a
nd to
ll-fr
ee n
umbe
r). T
his i
nfor
mat
ion
can
be u
sed
to c
onfir
m p
rovi
der p
artic
ipat
ion,
mem
ber e
ligib
ility
and
ben
efits
. Thi
s is a
SAM
PLE
ID C
ard
and
may
diff
er fr
om
the
mem
ber's
ID C
ard.
Elig
ibili
ty,
Bene
fits,
Cla
im(s
) and
Aut
horiz
atio
ns84
4-27
5-87
50Li
ve A
gent
: Mon
day
- Frid
ay, 8
:00A
M -
6:00
PM, E
STIV
R: 2
4 ho
urs a
day
Clai
ms
GP1
33
Prio
r Aut
horiz
atio
nAp
peal
s & G
rieva
nces
Uni
tedH
ealth
care
Den
tal,
PO B
ox 2
176,
Milw
auke
e, W
I 532
01U
nite
dHea
lthca
re D
enta
l, PO
Box
205
3, M
ilwau
kee,
WI 5
3201
Uni
tedH
ealth
care
Den
tal,
Appe
als D
isput
es, P
O B
ox 3
61, M
ilwau
kee,
WI 5
3201
139
In a
n ef
fort
to c
ompl
y w
ith th
e Ce
nter
s for
Med
icar
e an
d M
edic
aid
(CM
S) st
ate
man
date
d re
quire
men
ts, p
leas
e be
adv
ised
that
DHM
O E
ncou
nter
Dat
a Su
bmis
sion
s are
now
requ
ired.
CM
S no
w re
quire
s tha
t we
repo
rt
100%
of u
tiliza
tion
data
for o
ur A
ARP
Med
icar
e Co
mpl
ete
DHM
O m
embe
rs.
To e
nsur
e th
at w
e m
eet C
MS
requ
irem
ent o
f rep
ortin
g 10
0% u
tiliza
tion,
we
are
happ
y to
re-in
trod
uce
our D
enta
l Inc
entiv
e Pr
ogra
m e
ffect
ive
imm
edia
tely
. De
ntal
Ben
efit
Prov
ider
s will
reim
burs
e ou
r pro
vide
rs $
2.00
for e
ach
enco
unte
r cla
im su
bmitt
ed fo
r AAR
P M
edic
are
Com
plet
e D
HM
O m
embe
rs o
nly
for a
ll pr
oced
ures
(cov
ered
und
er th
e m
embe
r's p
lan)
pe
rfor
med
on
thos
e m
embe
rs, f
or e
ach
date
of s
ervi
ce.
All p
roce
dure
s per
form
ed M
UST
be
repo
rted
incl
udin
g pr
oced
ures
whe
ther
or n
ot th
e m
embe
r has
a c
opay
men
t. T
his i
s a re
quire
men
t for
all
cont
ract
ed
prov
ider
s to
subm
it ut
iliza
tion
for e
ach
patie
nt tr
eate
d.
No
D023
0D0
250
D027
0
intr
aora
l - p
eria
pica
l - fi
rst f
ilm
1 ev
ery
6 M
onth
(s)
1 ev
ery
6 M
onth
(s)
No
No
No
No
No
No
No
intr
aora
l - p
eria
pica
l - e
ach
addi
tiona
l film
extr
aora
l firs
t rad
iogr
aphi
c im
age
bite
win
g - s
ingl
e fil
m
Prio
r Aut
horiz
atio
n Re
quire
d?Pr
oced
ure
Code
Freq
uenc
y/Li
mita
tions
Proc
edur
e D
escr
iptio
n
D132
0to
bacc
o co
unse
ling
for t
he c
ontr
ol a
nd p
reve
ntio
n of
ora
l dis
ease
No
D099
9un
spec
ified
dia
gnos
tic p
roce
dure
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bite
win
g - f
our f
ilms
pano
ram
ic fi
lmN
oD0
470
diag
nost
ic c
asts
No
D112
0D1
206
D120
8
prop
hyla
xis -
chi
ldto
pica
l app
licat
ion
of fl
uorid
e va
rnis
hto
pica
l app
licat
ion
of fl
uorid
e
No
No
No
D133
0or
al h
ygie
ne in
stru
ctio
nsN
o
Her
e ar
e a
few
way
s the
Enc
ount
er In
form
atio
n ca
n be
subm
itted
:
1)
Electronically
- As
you
wou
ld a
PPO
or I
ndem
nity
Cla
im
2) W
eb S
ite -
Clai
ms c
an b
e su
bmitt
ed in
divi
dual
ly o
n ou
r web
site
at w
ww
.uhc
prov
ider
s.co
m
3)
By
Mai
l - A
s you
wou
ld a
PPO
or I
ndem
nity
Cla
im
4) U
tiliz
atio
n Re
port
s - M
ust c
onta
in A
LL re
quire
d in
form
atio
n:
•
Subs
crib
er ID
• Su
bscr
iber
Dat
e of
Birt
h •
Gro
up N
ame
or N
umbe
r•
Patie
nt’s
Ful
l Nam
e•
Patie
nt’s
Dat
e of
Birt
h•
Rela
tions
hip
to S
ubsc
riber
• Ph
ysic
al A
ddre
ss•
ADA
Code
Per
form
ed•
Toot
h# /
Qua
dran
t•
Surf
ace
• Tr
eatin
g De
ntis
t Nam
e•
Dent
ist T
ax I.
D. fo
r Bill
ing
Enco
unte
r/U
tiliza
tion
Repo
rtin
g - W
hen
subm
ittin
g En
coun
ter/
Util
izat
ion
clai
ms,
you
mus
t inc
lude
Cod
e D0
999
alon
g w
ith a
ll co
vere
d se
rvic
e pr
oced
ure
code
s you
per
form
on
each
AAR
P M
edic
are
Com
plet
e DH
MO
m
embe
r.
Plea
se n
ote
the
follo
win
g:
1) If
you
subm
it D0
999
alon
e no
add
ition
al $
2.00
reim
burs
emen
t will
not
be
paid
. Ad
ditio
nally
, cla
im su
bmiss
ion
wou
ld b
e co
nsid
ered
non
-com
plia
nt.
2)
If y
ou su
bmit
all s
ervi
ce p
roce
dure
serv
ice
code
s but
don
't in
clud
e D0
999
as w
ell a
s you
won
't be
reim
burs
ed th
e ad
ditio
nal $
2.00
. In
add
ition
, the
cla
im w
ill b
e co
nsid
ered
non
-com
plia
nt.
D022
0
D012
0D0
140
D015
0D0
210
perio
dic
oral
eva
luat
ion
limite
d or
al e
valu
atio
n - p
robl
em fo
cuse
dco
mpr
ehen
sive
ora
l eva
luat
ion
- new
or e
stab
lishe
d pa
tient
intr
aora
l - c
ompl
ete
serie
s (in
clud
ing
bite
win
gs)
D027
2D0
273
bite
win
g - t
wo
film
sN
o
D111
0pr
ophy
laxi
s - a
dult
No
D131
0nu
triti
onal
cou
nsel
ing
for c
ontr
ol o
f den
tal d
isea
seN
o
D027
4D0
330
bite
win
g - t
hree
film
s
No
No
1 ev
ery
6 M
onth
(s)
1 ev
ery
6 M
onth
(s)
1 ev
ery
6 M
onth
(s)
1 ev
ery
6 M
onth
(s)
1 ev
ery
6 M
onth
(s)
1 ev
ery
6 M
onth
(s)
1 ev
ery
6 M
onth
(s)
1 ev
ery
6 M
onth
(s)
1 ev
ery
3 Ye
ar(s
)1
ever
y Ye
ar1
ever
y Ye
ar1
ever
y Ye
ar1
ever
y Ye
ar1
ever
y Ye
ar1
ever
y Ye
ar1
ever
y Ye
ar1
ever
y 3
Year
(s)
1 ev
ery
Year
1 ev
ery
6 M
onth
(s)
140140
Prov
ider
Cla
im D
ispu
tes
Mem
ber A
ppea
ls &
Grie
vanc
es
Prio
r Aut
horiz
atio
n Re
ques
ts
CT, N
J, N
Y_SC
ION
143
_Pkg
DT0
36_D
T036
-H00
00a-
Oxf
rd
09/2
016
“Prio
r Aut
horiz
atio
n re
quire
d” m
eans
the
prac
titio
ner m
ust s
ubm
it th
ose
proc
edur
es fo
r app
rova
l with
clin
ical
doc
umen
tatio
n su
ppor
ting
nece
ssity
bef
ore
perf
orm
ing
thos
e pr
oced
ures
. To
do th
is c
ompl
ete
a st
anda
rd
ADA
clai
m fo
rm a
nd c
heck
the
box
mar
ked
“Pre
-Tre
atm
ent E
STIM
ATE.
” Pr
ior a
utho
rizat
ion
requ
est c
an b
e su
bmitt
ed v
ia th
e pr
ovid
er w
eb p
orta
l (at
ww
w.m
yuhc
prov
ider
s.co
m),
subm
itted
ele
ctro
nica
lly v
ia y
our
clea
ringh
ouse
, or s
impl
y m
ail t
he fo
rm, t
o th
e be
low
add
ress
, alo
ng w
ith a
ny re
quire
d su
pple
men
tal i
nfor
mat
ion
(film
s, n
arra
tive,
per
io-c
hart
ing,
etc
.). Y
our o
ffice
will
then
rece
ive
an E
xpla
natio
n of
Ben
efits
(EO
B)
outli
ning
the
deni
al o
r app
rova
l of r
eque
sted
trea
tmen
t and
pla
n pa
ymen
t am
ount
s whe
n ap
plic
able
.
Dent
al P
rovi
ders
with
com
plai
nts a
re to
con
tact
Uni
tedH
ealth
care
Den
tal’s
Pro
vide
r Ser
vice
dep
artm
ent a
t (84
4) 2
75-8
750.
Net
wor
k Pr
ovid
er c
ontr
actu
al d
ispu
tes,
Out
-of-N
etw
ork
prov
ider
dis
pute
s, a
nd re
proc
essi
ng
requ
ests
will
be
logg
ed in
to th
e ap
peal
s dat
abas
e. P
leas
e m
ail t
o th
e Ap
peal
s & G
rieva
nces
PO
Box
list
ed a
bove
. Res
earc
h an
d re
solu
tion
will
be
com
plet
ed w
ithin
30
cale
ndar
day
s.
Mem
ber a
ppea
ls a
re re
view
ed b
y th
e he
alth
pla
n, a
nd a
re n
ot d
eleg
ated
to U
HC D
enta
l. Al
l Mem
ber a
ppea
ls (i
nclu
des P
re-S
ervi
ce a
ppea
ls, I
n N
etw
ork
Prov
ider
app
eals
, and
Out
of N
etw
ork
prov
ider
app
eals
) rec
eive
d by
U
HC D
enta
l will
be
forw
arde
d to
the
heal
th p
lan
via
over
nigh
t mai
l, w
ithin
7 d
ays o
f rec
eipt
of t
he a
ppea
l.
Mai
l mem
ber a
ppea
ls to
: Uni
tedH
ealth
care
, Att
n: A
ppea
l Dep
artm
ent,
MS
CA12
4-01
57, P
O B
ox 6
106,
Cyp
ress
, CA
9063
0
141
142142
143
144144
“Prio
r Aut
horiz
atio
n re
quire
d” m
eans
the
prac
titio
ner m
ust s
ubm
it th
ose
proc
edur
es fo
r app
rova
l with
clin
ical
doc
umen
tatio
n su
ppor
ting
nece
ssity
bef
ore
perf
orm
ing
thos
e pr
oced
ures
. To
do th
is c
ompl
ete
a st
anda
rd A
DA
clai
m fo
rm a
nd c
heck
the
box
mar
ked
“Pre
-Tre
atm
ent E
STIM
ATE.
” Pr
ior a
utho
rizat
ion
requ
est c
an b
e su
bmitt
ed v
ia th
e pr
ovid
er w
eb p
orta
l (at
ww
w.m
yuhc
prov
ider
s.co
m),
subm
itted
ele
ctro
nica
lly v
ia y
our c
lear
ingh
ouse
,
Dent
al P
rovi
ders
with
com
plai
nts a
re to
con
tact
Uni
tedH
ealth
care
Den
tal’s
Pro
vide
r Ser
vice
dep
artm
ent a
t
145
146146
147
148148
Dent
al P
rovi
ders
with
com
plai
nts a
re to
con
tact
Uni
tedH
ealth
care
Den
tal’s
Pro
vide
r Ser
vice
dep
artm
ent a
t (84
4) 2
75-8
750.
Net
wor
k Pr
ovid
er c
ontr
actu
al d
ispu
tes,
and
repr
oces
sing
requ
ests
will
be
logg
ed in
to
149
“Prio
r Aut
horiz
atio
n re
quire
d” m
eans
the
prac
titio
ner m
ust s
ubm
it th
ose
proc
edur
es fo
r app
rova
l with
clin
ical
doc
umen
tatio
n su
ppor
ting
nece
ssity
bef
ore
perf
orm
ing
thos
e pr
oced
ures
. To
do th
is c
ompl
ete
a st
anda
rd A
DA c
laim
form
and
che
ck th
e bo
x m
arke
d “P
re-T
reat
men
t EST
IMAT
E.”
Prio
r aut
horiz
atio
n re
ques
t can
be
subm
itted
via
the
prov
ider
web
por
tal (
at w
ww
.myu
hcpr
ovid
ers.
com
), su
bmitt
ed e
lect
roni
cally
150150
Iden
tific
atio
n Ca
rds
Sam
ple
Mem
ber I
D C
ard*
Fron
t of c
ard
Back
of c
ard
Impo
rtan
t Tel
epho
ne N
umbe
rs &
Web
site
s
Impo
rtan
t Add
ress
es
Impo
rtan
t Ele
ctro
nic
Clai
ms &
Prio
r Aut
horiz
atio
n Su
bmis
sion
Info
rmat
ion
Prov
ider
Rea
son
for M
ailin
g
EDI P
ayer
Num
ber f
or C
laim
s Sub
mitt
ed
No
Annu
al M
axim
um
Call
to In
quire
Abo
utTe
leph
one
Num
ber
Hou
rs o
f Ope
ratio
n
Emai
l to
Inqu
ire A
bout
Web
site
Hou
rs o
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ratio
n
Med
icar
ew
ww
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icar
e.go
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hou
rs a
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To d
iscu
ss y
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artic
ipat
ion,
con
trac
tual
issu
es, d
entis
t cha
nges
or o
ffice
upd
ates
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nt: M
onda
y - F
riday
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0AM
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:00P
M, E
ST
Elig
ibili
ty,
Bene
fits,
Cla
im(s
) and
Aut
horiz
atio
nsw
ww
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prov
ider
s.co
mCe
nter
s for
Med
icai
d an
d M
edic
are
Serv
ices
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ms.
hhs.
gov
Cove
red
Den
tal S
ervi
ces:
Prov
ider
Qui
ck R
efer
ence
Gui
de -
Effe
ctiv
e 1/
1/20
17U
nite
dHea
lthca
re A
ARP
Com
plet
e Pl
ans (
form
ally
Oxf
ord
DH
MO
)
CT, N
J, an
d N
Y
24 h
ours
a d
ay24
hou
rs a
day
*Ple
ase
note
that
the
Med
ical
ID C
ard
is un
iver
sal a
nd in
clud
es a
ll lin
es o
f cov
erag
e. T
he M
edic
al p
lan
can
be H
MO
or P
PO a
nd th
is d
oes n
ot re
flect
the
Dent
al P
lan
Bene
fits.
Ple
ase
flip
the
ID C
ard
over
to se
e th
e De
ntal
Pr
ovid
er in
form
atio
n on
the
back
(i.e
. car
rier w
ebsi
te a
nd to
ll-fr
ee n
umbe
r). T
his i
nfor
mat
ion
can
be u
sed
to c
onfir
m p
rovi
der p
artic
ipat
ion,
mem
ber e
ligib
ility
and
ben
efits
. Thi
s is a
SAM
PLE
ID C
ard
and
may
diff
er fr
om
the
mem
ber's
ID C
ard.
Elig
ibili
ty,
Bene
fits,
Cla
im(s
) and
Aut
horiz
atio
ns84
4-27
5-87
50Li
ve A
gent
: Mon
day
- Frid
ay, 8
:00A
M -
6:00
PM, E
STIV
R: 2
4 ho
urs a
day
Clai
ms
GP1
33
Prio
r Aut
horiz
atio
nAp
peal
s & G
rieva
nces
Uni
tedH
ealth
care
Den
tal,
PO B
ox 2
176,
Milw
auke
e, W
I 532
01U
nite
dHea
lthca
re D
enta
l, PO
Box
205
3, M
ilwau
kee,
WI 5
3201
Uni
tedH
ealth
care
Den
tal,
Appe
als D
isput
es, P
O B
ox 3
61, M
ilwau
kee,
WI 5
3201
151
In a
n ef
fort
to c
ompl
y w
ith th
e Ce
nter
s for
Med
icar
e an
d M
edic
aid
(CM
S) st
ate
man
date
d re
quire
men
ts, p
leas
e be
adv
ised
that
DHM
O E
ncou
nter
Dat
a Su
bmis
sion
s are
now
requ
ired.
CM
S no
w re
quire
s tha
t we
repo
rt
100%
of u
tiliza
tion
data
for o
ur A
ARP
Med
icar
e Co
mpl
ete
DHM
O m
embe
rs.
To e
nsur
e th
at w
e m
eet C
MS
requ
irem
ent o
f rep
ortin
g 10
0% u
tiliza
tion,
we
are
happ
y to
re-in
trod
uce
our D
enta
l Inc
entiv
e Pr
ogra
m e
ffect
ive
imm
edia
tely
. De
ntal
Ben
efit
Prov
ider
s will
reim
burs
e ou
r pro
vide
rs $
2.00
for e
ach
enco
unte
r cla
im su
bmitt
ed fo
r AAR
P M
edic
are
Com
plet
e D
HM
O m
embe
rs o
nly
for a
ll pr
oced
ures
(cov
ered
und
er th
e m
embe
r's p
lan)
pe
rfor
med
on
thos
e m
embe
rs, f
or e
ach
date
of s
ervi
ce.
All p
roce
dure
s per
form
ed M
UST
be
repo
rted
incl
udin
g pr
oced
ures
whe
ther
or n
ot th
e m
embe
r has
a c
opay
men
t. T
his i
s a re
quire
men
t for
all
cont
ract
ed
prov
ider
s to
subm
it ut
iliza
tion
for e
ach
patie
nt tr
eate
d.
No
D023
0D0
250
D027
0
intr
aora
l - p
eria
pica
l - fi
rst f
ilm
1 ev
ery
6 M
onth
(s)
1 ev
ery
6 M
onth
(s)
No
No
No
No
No
No
No
intr
aora
l - p
eria
pica
l - e
ach
addi
tiona
l film
extr
aora
l firs
t rad
iogr
aphi
c im
age
bite
win
g - s
ingl
e fil
m
Prio
r Aut
horiz
atio
n Re
quire
d?Pr
oced
ure
Code
Freq
uenc
y/Li
mita
tions
Proc
edur
e D
escr
iptio
n
D132
0to
bacc
o co
unse
ling
for t
he c
ontr
ol a
nd p
reve
ntio
n of
ora
l dis
ease
No
D099
9un
spec
ified
dia
gnos
tic p
roce
dure
No
bite
win
g - f
our f
ilms
pano
ram
ic fi
lmN
oD0
470
diag
nost
ic c
asts
No
D112
0D1
206
D120
8
prop
hyla
xis -
chi
ldto
pica
l app
licat
ion
of fl
uorid
e va
rnis
hto
pica
l app
licat
ion
of fl
uorid
e
No
No
No
D133
0or
al h
ygie
ne in
stru
ctio
nsN
o
Her
e ar
e a
few
way
s the
Enc
ount
er In
form
atio
n ca
n be
subm
itted
:
1)
Electronically
- As
you
wou
ld a
PPO
or I
ndem
nity
Cla
im
2) W
eb S
ite -
Clai
ms c
an b
e su
bmitt
ed in
divi
dual
ly o
n ou
r web
site
at w
ww
.uhc
prov
ider
s.co
m
3)
By
Mai
l - A
s you
wou
ld a
PPO
or I
ndem
nity
Cla
im
4) U
tiliz
atio
n Re
port
s - M
ust c
onta
in A
LL re
quire
d in
form
atio
n:
•
Subs
crib
er ID
• Su
bscr
iber
Dat
e of
Birt
h •
Gro
up N
ame
or N
umbe
r•
Patie
nt’s
Ful
l Nam
e•
Patie
nt’s
Dat
e of
Birt
h•
Rela
tions
hip
to S
ubsc
riber
• Ph
ysic
al A
ddre
ss•
ADA
Code
Per
form
ed•
Toot
h# /
Qua
dran
t•
Surf
ace
• Tr
eatin
g De
ntis
t Nam
e•
Dent
ist T
ax I.
D. fo
r Bill
ing
Enco
unte
r/U
tiliza
tion
Repo
rtin
g - W
hen
subm
ittin
g En
coun
ter/
Util
izat
ion
clai
ms,
you
mus
t inc
lude
Cod
e D0
999
alon
g w
ith a
ll co
vere
d se
rvic
e pr
oced
ure
code
s you
per
form
on
each
AAR
P M
edic
are
Com
plet
e DH
MO
m
embe
r.
Plea
se n
ote
the
follo
win
g:
1) If
you
subm
it D0
999
alon
e no
add
ition
al $
2.00
reim
burs
emen
t will
not
be
paid
. Ad
ditio
nally
, cla
im su
bmiss
ion
wou
ld b
e co
nsid
ered
non
-com
plia
nt.
2)
If y
ou su
bmit
all s
ervi
ce p
roce
dure
serv
ice
code
s but
don
't in
clud
e D0
999
as w
ell a
s you
won
't be
reim
burs
ed th
e ad
ditio
nal $
2.00
. In
add
ition
, the
cla
im w
ill b
e co
nsid
ered
non
-com
plia
nt.
D022
0
D012
0D0
140
D015
0D0
210
perio
dic
oral
eva
luat
ion
limite
d or
al e
valu
atio
n - p
robl
em fo
cuse
dco
mpr
ehen
sive
ora
l eva
luat
ion
- new
or e
stab
lishe
d pa
tient
intr
aora
l - c
ompl
ete
serie
s (in
clud
ing
bite
win
gs)
D027
2D0
273
bite
win
g - t
wo
film
sN
o
D111
0pr
ophy
laxi
s - a
dult
No
D131
0nu
triti
onal
cou
nsel
ing
for c
ontr
ol o
f den
tal d
isea
seN
o
D027
4D0
330
bite
win
g - t
hree
film
s
No
No
1 ev
ery
6 M
onth
(s)
1 ev
ery
6 M
onth
(s)
1 ev
ery
6 M
onth
(s)
1 ev
ery
6 M
onth
(s)
1 ev
ery
6 M
onth
(s)
1 ev
ery
6 M
onth
(s)
1 ev
ery
6 M
onth
(s)
1 ev
ery
6 M
onth
(s)
1 ev
ery
3 Ye
ar(s
)1
ever
y Ye
ar1
ever
y Ye
ar1
ever
y Ye
ar1
ever
y Ye
ar1
ever
y Ye
ar1
ever
y Ye
ar1
ever
y Ye
ar1
ever
y 3
Year
(s)
1 ev
ery
Year
1 ev
ery
6 M
onth
(s)
152152
Prov
ider
Cla
im D
ispu
tes
Mem
ber A
ppea
ls &
Grie
vanc
es
Prio
r Aut
horiz
atio
n Re
ques
ts
CT, N
J, N
Y_SC
ION
143
_Pkg
DT0
36_D
T036
-H00
00a-
Oxf
rd
09/2
016
“Prio
r Aut
horiz
atio
n re
quire
d” m
eans
the
prac
titio
ner m
ust s
ubm
it th
ose
proc
edur
es fo
r app
rova
l with
clin
ical
doc
umen
tatio
n su
ppor
ting
nece
ssity
bef
ore
perf
orm
ing
thos
e pr
oced
ures
. To
do th
is c
ompl
ete
a st
anda
rd
ADA
clai
m fo
rm a
nd c
heck
the
box
mar
ked
“Pre
-Tre
atm
ent E
STIM
ATE.
” Pr
ior a
utho
rizat
ion
requ
est c
an b
e su
bmitt
ed v
ia th
e pr
ovid
er w
eb p
orta
l (at
ww
w.m
yuhc
prov
ider
s.co
m),
subm
itted
ele
ctro
nica
lly v
ia y
our
clea
ringh
ouse
, or s
impl
y m
ail t
he fo
rm, t
o th
e be
low
add
ress
, alo
ng w
ith a
ny re
quire
d su
pple
men
tal i
nfor
mat
ion
(film
s, n
arra
tive,
per
io-c
hart
ing,
etc
.). Y
our o
ffice
will
then
rece
ive
an E
xpla
natio
n of
Ben
efits
(EO
B)
outli
ning
the
deni
al o
r app
rova
l of r
eque
sted
trea
tmen
t and
pla
n pa
ymen
t am
ount
s whe
n ap
plic
able
.
Dent
al P
rovi
ders
with
com
plai
nts a
re to
con
tact
Uni
tedH
ealth
care
Den
tal’s
Pro
vide
r Ser
vice
dep
artm
ent a
t (84
4) 2
75-8
750.
Net
wor
k Pr
ovid
er c
ontr
actu
al d
ispu
tes,
Out
-of-N
etw
ork
prov
ider
dis
pute
s, a
nd re
proc
essi
ng
requ
ests
will
be
logg
ed in
to th
e ap
peal
s dat
abas
e. P
leas
e m
ail t
o th
e Ap
peal
s & G
rieva
nces
PO
Box
list
ed a
bove
. Res
earc
h an
d re
solu
tion
will
be
com
plet
ed w
ithin
30
cale
ndar
day
s.
Mem
ber a
ppea
ls a
re re
view
ed b
y th
e he
alth
pla
n, a
nd a
re n
ot d
eleg
ated
to U
HC D
enta
l. Al
l Mem
ber a
ppea
ls (i
nclu
des P
re-S
ervi
ce a
ppea
ls, I
n N
etw
ork
Prov
ider
app
eals
, and
Out
of N
etw
ork
prov
ider
app
eals
) rec
eive
d by
U
HC D
enta
l will
be
forw
arde
d to
the
heal
th p
lan
via
over
nigh
t mai
l, w
ithin
7 d
ays o
f rec
eipt
of t
he a
ppea
l.
Mai
l mem
ber a
ppea
ls to
: Uni
tedH
ealth
care
, Att
n: A
ppea
l Dep
artm
ent,
MS
CA12
4-01
57, P
O B
ox 6
106,
Cyp
ress
, CA
9063
0
153
154154
155
Dent
al P
rovi
ders
with
com
plai
nts a
re to
con
tact
Uni
tedH
ealth
care
Den
tal’s
Pro
vide
r Ser
vice
dep
artm
ent a
t
156156
“Prio
r Aut
horiz
atio
n re
quire
d” m
eans
the
prac
titio
ner m
ust s
ubm
it th
ose
proc
edur
es fo
r app
rova
l with
clin
ical
doc
umen
tatio
n su
ppor
ting
nece
ssity
bef
ore
perf
orm
ing
thos
e pr
oced
ures
. To
do th
is
com
plet
e a
stan
dard
ADA
cla
im fo
rm a
nd c
heck
the
box
mar
ked
“Pre
-Tre
atm
ent E
STIM
ATE.
” Pr
ior a
utho
rizat
ion
requ
est c
an b
e su
bmitt
ed v
ia th
e pr
ovid
er w
eb p
orta
l (at
ww
w.m
yuhc
prov
ider
s.co
m),
157
158158
159
“Prio
r Aut
horiz
atio
n re
quire
d” m
eans
the
prac
titio
ner m
ust s
ubm
it th
ose
proc
edur
es fo
r app
rova
l with
clin
ical
doc
umen
tatio
n su
ppor
ting
nece
ssity
bef
ore
perf
orm
ing
thos
e pr
oced
ures
. To
do th
is c
ompl
ete
a st
anda
rd A
DA c
laim
form
and
che
ck th
e bo
x m
arke
d “P
re-T
reat
men
t EST
IMAT
E.”
Prio
r aut
horiz
atio
n re
ques
t can
be
subm
itted
via
the
prov
ider
web
por
tal (
at w
ww
.myu
hcpr
ovid
ers.
com
), su
bmitt
ed
Dent
al P
rovi
ders
with
com
plai
nts a
re to
con
tact
Uni
tedH
ealth
care
Den
tal’s
Pro
vide
r Ser
vice
dep
artm
ent a
t
160160
161
“Prio
r Aut
horiz
atio
n re
quire
d” m
eans
the
prac
titio
ner m
ust s
ubm
it th
ose
proc
edur
es fo
r app
rova
l with
clin
ical
doc
umen
tatio
n su
ppor
ting
nece
ssity
bef
ore
perf
orm
ing
thos
e pr
oced
ures
. To
do th
is c
ompl
ete
a st
anda
rd A
DA c
laim
form
and
che
ck th
e bo
x m
arke
d “P
re-T
reat
men
t EST
IMAT
E.”
Prio
r aut
horiz
atio
n re
ques
t can
be
subm
itted
via
the
prov
ider
web
por
tal (
at w
ww
.myu
hcpr
ovid
ers.
com
), su
bmitt
ed
Dent
al P
rovi
ders
with
com
plai
nts a
re to
con
tact
Uni
tedH
ealth
care
Den
tal’s
Pro
vide
r Ser
vice
dep
artm
ent a
t
162162
163
164164
165
Dent
al P
rovi
ders
with
com
plai
nts a
re to
con
tact
Uni
tedH
ealth
care
Den
tal’s
Pro
vide
r Ser
vice
dep
artm
ent a
t
166166
“Prio
r Aut
horiz
atio
n re
quire
d” m
eans
the
prac
titio
ner m
ust s
ubm
it th
ose
proc
edur
es fo
r app
rova
l with
clin
ical
doc
umen
tatio
n su
ppor
ting
nece
ssity
bef
ore
perf
orm
ing
thos
e pr
oced
ures
. To
do th
is c
ompl
ete
a st
anda
rd
ADA
clai
m fo
rm a
nd c
heck
the
box
mar
ked
“Pre
-Tre
atm
ent E
STIM
ATE.
” Pr
ior a
utho
rizat
ion
requ
est c
an b
e su
bmitt
ed v
ia th
e pr
ovid
er w
eb p
orta
l (at
ww
w.m
yuhc
prov
ider
s.co
m),
subm
itted
ele
ctro
nica
lly v
ia y
our
167
168168
Iden
tific
atio
n Ca
rds
Sam
ple
Mem
ber I
D C
ard*
Fron
t of c
ard
Back
of c
ard
Impo
rtan
t Tel
epho
ne N
umbe
rs &
Web
site
s
Impo
rtan
t Add
ress
es
Impo
rtan
t Ele
ctro
nic
Clai
ms &
Prio
r Aut
horiz
atio
n Su
bmis
sion
Info
rmat
ion
Live
Age
nt: M
onda
y - F
riday
, 8:0
0AM
- 6:
00PM
, EST
IVR:
24
hour
s a d
ay
24 h
ours
a d
ay
To d
iscu
ss y
our p
artic
ipat
ion,
con
trac
tual
issu
es, d
entis
t cha
nges
or o
ffice
up
date
s80
0-82
2-53
53Li
ve A
gent
: Mon
day
- Frid
ay, 8
:00A
M -
11:0
0PM
, EST
Elig
ibili
ty,
Bene
fits,
Cla
im(s
) and
Aut
horiz
atio
nsw
ww
.uhc
prov
ider
s.co
m
Clai
ms
Prio
r Aut
horiz
atio
nAp
peal
s & G
rieva
nces
UHC
Med
icar
e Cl
aim
s, P
O B
ox 2
176,
Milw
auke
e, W
I 532
01U
HC M
edic
are
Auth
oriza
tions
, PO
Box
205
3, M
ilwau
kee,
WI 5
3201
UHC
Med
icar
e Co
mpl
aint
s, G
rieva
nces
& A
ppea
ls, P
O B
ox 3
61, M
ilwau
kee,
WI 5
3201
Prov
ider
Qui
ck R
efer
ence
Gui
de -
Effe
ctiv
e 1/
1/20
17U
nite
dHea
lthca
re C
omm
unity
Pla
nO
hio
Dua
l Com
plet
e - $
2,00
0 m
ax
EDI P
ayer
Num
ber f
or C
laim
s Sub
mitt
ed
Prov
ider
Rea
son
for M
ailin
g
Call
to In
quire
Abo
utTe
leph
one
Num
ber
Hou
rs o
f Ope
ratio
n
Emai
l to
Inqu
ire A
bout
Web
site
Hou
rs o
f Ope
ratio
n
Med
icar
ew
ww
.med
icar
e.go
v24
hou
rs a
day
Cent
ers f
or M
edic
aid
and
Med
icar
e Se
rvic
esw
ww
.cm
s.hh
s.go
v24
hou
rs a
day
*Ple
ase
note
that
the
Med
ical
ID C
ard
is un
iver
sal a
nd in
clud
es a
ll lin
es o
f cov
erag
e. T
he M
edic
al p
lan
can
be H
MO
or P
PO a
nd th
is d
oes n
ot re
flect
the
Dent
al P
lan
Bene
fits.
Ple
ase
flip
the
ID C
ard
over
to
see
the
Dent
al P
rovi
der i
nfor
mat
ion
on th
e ba
ck (i
.e. c
arrie
r web
site
and
toll-
free
num
ber)
. Thi
s inf
orm
atio
n ca
n be
use
d to
con
firm
pro
vide
r par
ticip
atio
n, m
embe
r elig
ibili
ty a
nd b
enef
its. T
his i
s a
SAM
PLE
ID C
ard
and
may
diff
er fr
om th
e m
embe
r's ID
Car
d.
Elig
ibili
ty,
Bene
fits,
Cla
im(s
) and
Aut
horiz
atio
ns84
4-27
5-87
50
169
No
No
No
No
No
No
intr
aora
l - p
eria
pica
l - e
ach
addi
tiona
l film
intr
aora
l - o
cclu
sal f
ilmbi
tew
ing
- sin
gle
film
1 ev
ery
3 Ye
ar(s
)
D022
0
pano
ram
ic fi
lm
D216
0am
alga
m -
thre
e su
rfac
es, p
rimar
y or
per
man
ent
No
D233
5
Unl
imite
d
No
No
No
Cove
red
Den
tal S
ervi
ces:
Prio
r Aut
horiz
atio
n Re
quire
d?Pr
oced
ure
Code
D023
0D0
240
D027
0
intr
aora
l - p
eria
pica
l - fi
rst f
ilm
No
No
D214
0am
alga
m -
one
surf
ace,
prim
ary
or p
erm
anen
tN
o
D027
4D0
330
bite
win
g - t
hree
film
sbi
tew
ing
- fou
r film
s
prop
hyla
xis -
adu
ltN
o
D216
1am
alga
m -
four
or m
ore
surf
aces
, prim
ary
or p
erm
anen
tN
o
Freq
uenc
y/Li
mita
tions
Proc
edur
e D
escr
iptio
npe
riodi
c or
al e
valu
atio
nlim
ited
oral
eva
luat
ion
- pro
blem
focu
sed
com
preh
ensi
ve o
ral e
valu
atio
n - n
ew o
r est
ablis
hed
patie
ntin
trao
ral -
com
plet
e se
ries (
incl
udin
g bi
tew
ings
)
D233
2re
sin-
base
d co
mpo
site
- th
ree
surf
aces
, ant
erio
rN
o
D012
0D0
140
D015
0D0
210
D027
2D0
273
bite
win
g - t
wo
film
sN
o
D111
0
D233
0re
sin-
base
d co
mpo
site
- on
e su
rfac
e, a
nter
ior
No
D215
0am
alga
m -
two
surf
aces
, prim
ary
or p
erm
anen
tN
o
D233
1re
sin-
base
d co
mpo
site
- tw
o su
rfac
es, a
nter
ior
No
D239
2re
sin-
base
d co
mpo
site
- tw
o su
rfac
es, p
oste
rior
No
resin
-bas
ed c
ompo
site
- fo
ur o
r mor
e su
rfac
es o
r inv
olvi
ng in
cisa
l ang
le (a
nter
ior)
No
D239
0re
sin-
base
d co
mpo
site
cro
wn,
ant
erio
rN
o
D271
0cr
own
- res
in-b
ased
com
posi
te (i
ndire
ct)
Yes
D239
1re
sin-
base
d co
mpo
site
- on
e su
rfac
e, p
oste
rior
No
D274
0cr
own
- por
cela
in/c
eram
ic su
bstr
ate
Yes
D239
3re
sin-
base
d co
mpo
site
- th
ree
surf
aces
, pos
terio
rN
oD2
394
resi
n-ba
sed
com
posi
te -
four
or m
ore
surf
aces
, pos
terio
rN
o
D275
2cr
own
- por
cela
in fu
sed
to n
oble
met
alYe
sD2
791
crow
n - f
ull c
ast p
redo
min
antly
bas
e m
etal
Yes
D275
0cr
own
- por
cela
in fu
sed
to h
igh
nobl
e m
etal
Yes
D275
1cr
own
- por
cela
in fu
sed
to p
redo
min
antly
bas
e m
etal
Yes
D294
0pr
otec
tive
rest
orat
ion
No
D295
0co
re b
uild
up, i
nclu
ding
any
pin
sYe
s
D279
2cr
own
- ful
l cas
t nob
le m
etal
Yes
D292
0re
cem
ent c
row
nN
o
1 ev
ery
6 M
onth
(s)
Unl
imite
d
D721
0su
rgic
al re
mov
al o
f eru
pted
toot
h re
q re
mov
al o
f bon
e, se
ctio
ning
of t
ooth
and
incl
udin
g el
evat
ion
of m
ucop
erio
stea
l fla
pN
oD7
250
D731
0
D731
1D9
110
D711
1ex
trac
tion,
cor
onal
rem
nant
s - d
ecid
uous
toot
hN
oD7
140
extr
actio
n, e
rupt
ed to
oth
or e
xpos
ed ro
ot (e
leva
tion
and/
or fo
rcep
sN
o
D435
5fu
ll m
outh
deb
ridem
ent t
o en
able
com
preh
ensi
ve e
valu
atio
n an
d di
agno
sis
Yes
D491
0pe
riodo
ntal
mai
nten
ance
No
D434
2pe
riodo
ntal
scal
ing
and
root
pla
nnin
g - o
ne to
thre
e te
eth
per q
uadr
ant
Yes
Unl
imite
dU
nlim
ited
Unl
imite
d
Unl
imite
d
Unl
imite
d
1 ev
ery
6 M
onth
(s)
1 ev
ery
6 M
onth
(s)
1 ev
ery
6 M
onth
(s)
1 ev
ery
6 M
onth
(s)
1 ev
ery
6 M
onth
(s)
1 ev
ery
6 M
onth
(s)
1 ev
ery
6 M
onth
(s)
1 ev
ery
6 M
onth
(s)
1 ev
ery
6 M
onth
(s)
1 ev
ery
6 M
onth
(s)
1 ev
ery
6 M
onth
(s)
Unl
imite
d
Unl
imite
dU
nlim
ited
Unl
imite
dU
nlim
ited
1 ev
ery
36 M
onth
(s)
1 ev
ery
36 M
onth
(s)
Unl
imite
d
pref
abric
ated
pos
t and
cor
e in
add
ition
to c
row
nYe
s
No
No
No
No
surg
ical
rem
oval
of r
esid
ual t
ooth
root
s (cu
ttin
g pr
oced
ure)
alve
olop
last
y in
con
junc
tion
with
ext
ract
ions
- fo
ur o
r mor
e te
eth
or to
oth
spac
es, p
er
quad
rant
alve
olop
last
y in
con
junc
tion
with
ext
ract
ions
- on
e to
thre
e te
eth
or to
oth
spac
es, p
er
quad
rant
palli
ativ
e (e
mer
genc
y) tr
eatm
ent o
f den
tal p
ain
- min
or p
roce
dure
Unl
imite
d
Unl
imite
d
Unl
imite
d
D293
0D2
931
pref
abric
ated
stai
nles
s ste
el c
row
n - p
rimar
y to
oth
pref
abric
ated
stai
nles
s ste
el c
row
n - p
erm
anen
t too
thU
nlim
ited
Unl
imite
dN
oN
o
Yes
1 ev
ery
24 M
onth
(s)
perio
dont
al sc
alin
g an
d ro
ot p
lann
ing
- fou
r or m
ore
per q
uadr
ant
D434
1D2
954
GP1
33
Unl
imite
d
Unl
imite
dU
nlim
ited
Unl
imite
dU
nlim
ited
Unl
imite
d
1 ev
ery
24 M
onth
(s)
1 ev
ery
24 M
onth
(s)
1 ev
ery
36 M
onth
(s)
1 ev
ery
36 M
onth
(s)
1 ev
ery
36 M
onth
(s)
1 ev
ery
36 M
onth
(s)
1 ev
ery
36 M
onth
(s)
Unl
imite
dU
nlim
ited
Unl
imite
d
170170
Cove
red
in th
e fo
llow
ing
Ohi
o Co
untie
s: B
utle
r, Cl
ark,
Cuy
ahog
a, F
rank
lin, G
reen
e, H
amilt
on, M
adis
on, M
ahon
ing,
Mon
tgom
ery,
Sta
rk, S
umm
itt, T
rum
bull
and
War
ren
Prov
ider
Cla
im D
ispu
tes
Mem
ber A
ppea
ls &
Grie
vanc
es
Prio
r Aut
horiz
atio
n Re
ques
ts
OH_
SCIO
N 3
69_P
kg D
T057
_DT0
15-H
2000
b-FF
S28
09/2
016
“Prio
r Aut
horiz
atio
n re
quire
d” m
eans
the
prac
titio
ner m
ust s
ubm
it th
ose
proc
edur
es fo
r app
rova
l with
clin
ical
doc
umen
tatio
n su
ppor
ting
nece
ssity
bef
ore
perf
orm
ing
thos
e pr
oced
ures
. To
do th
is
com
plet
e a
stan
dard
ADA
cla
im fo
rm a
nd c
heck
the
box
mar
ked
“Pre
-Tre
atm
ent E
STIM
ATE.
” Pr
ior a
utho
rizat
ion
requ
est c
an b
e su
bmitt
ed v
ia th
e pr
ovid
er w
eb p
orta
l (at
ww
w.m
yuhc
prov
ider
s.co
m),
subm
itted
ele
ctro
nica
lly v
ia y
our c
lear
ingh
ouse
, or s
impl
y m
ail t
he fo
rm, t
o th
e be
low
add
ress
, alo
ng w
ith a
ny re
quire
d su
pple
men
tal i
nfor
mat
ion
(film
s, n
arra
tive,
per
io-c
hart
ing,
etc
.). Y
our o
ffice
will
th
en re
ceiv
e an
Exp
lana
tion
of B
enef
its (E
OB)
out
linin
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nial
or a
ppro
val o
f req
uest
ed tr
eatm
ent a
nd p
lan
paym
ent a
mou
nts w
hen
appl
icab
le.
The
Uni
tedH
ealth
care
(UHC
) Com
mun
ity P
lan
for D
ual C
ompl
ete
mem
bers
cov
ers t
he d
enta
l cod
es li
sted
abo
ve. P
rovi
der p
aym
ent i
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a F
ee-fo
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rvic
e ba
sis.
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rvic
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izatio
n. T
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enta
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n ha
s a $
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0 an
nual
max
that
app
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o co
vere
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even
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and
com
preh
ensi
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enef
its. T
his p
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is o
ffere
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Uni
tedH
ealth
care
Dua
l Com
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embe
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Ohi
o.
Ther
e is
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mem
ber c
opay
, coi
nsur
ance
or d
educ
tible
. Mem
ber c
an b
e bi
lled
for s
ervi
ces o
ver t
he $
2,00
0 an
nual
max
imum
ben
efit.
Dent
al P
rovi
ders
with
com
plai
nts a
re to
con
tact
Uni
tedH
ealth
care
Den
tal’s
Pro
vide
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dep
artm
ent a
t (84
4) 2
75-8
750.
Net
wor
k Pr
ovid
er c
ontr
actu
al d
ispu
tes,
Out
-of-N
etw
ork
prov
ider
dis
pute
s,
and
repr
oces
sing
requ
ests
will
be
logg
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to th
e ap
peal
s dat
abas
e. P
leas
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ail t
o th
e Ap
peal
s & G
rieva
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PO
Box
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bove
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earc
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ithin
30
cale
ndar
day
s.
Mem
ber a
ppea
ls a
re re
view
ed b
y th
e he
alth
pla
n, a
nd a
re n
ot d
eleg
ated
to U
HC D
enta
l. Al
l Mem
ber a
ppea
ls (i
nclu
des P
re-S
ervi
ce a
ppea
ls, I
n N
etw
ork
Prov
ider
app
eals
, and
Out
of N
etw
ork
prov
ider
ap
peal
s) re
ceiv
ed b
y U
HC D
enta
l will
be
forw
arde
d to
the
heal
th p
lan
via
over
nigh
t mai
l, w
ithin
7 d
ays o
f rec
eipt
of t
he a
ppea
l.
Mai
l mem
ber a
ppea
ls to
: Uni
tedH
ealth
care
, Att
n: A
ppea
l Dep
artm
ent,
MS
CA12
4-01
57, P
O B
ox 6
106,
Cyp
ress
, CA
9063
0
171
172172
173
“Prio
r Aut
horiz
atio
n re
quire
d” m
eans
the
prac
titio
ner m
ust s
ubm
it th
ose
proc
edur
es fo
r app
rova
l with
clin
ical
doc
umen
tatio
n su
ppor
ting
nece
ssity
bef
ore
perf
orm
ing
thos
e pr
oced
ures
. To
do th
is c
ompl
ete
a st
anda
rd A
DA c
laim
form
and
che
ck th
e bo
x m
arke
d “P
re-T
reat
men
t EST
IMAT
E.”
Prio
r aut
horiz
atio
n re
ques
t can
be
subm
itted
via
the
prov
ider
web
por
tal (
at w
ww
.myu
hcpr
ovid
ers.
com
), su
bmitt
ed
Dent
al P
rovi
ders
with
com
plai
nts a
re to
con
tact
Uni
tedH
ealth
care
Den
tal’s
Pro
vide
r Ser
vice
dep
artm
ent a
t
174174
175
“Prio
r Aut
horiz
atio
n re
quire
d” m
eans
the
prac
titio
ner m
ust s
ubm
it th
ose
proc
edur
es fo
r app
rova
l with
clin
ical
doc
umen
tatio
n su
ppor
ting
nece
ssity
bef
ore
perf
orm
ing
thos
e pr
oced
ures
. To
do th
is c
ompl
ete
a st
anda
rd
ADA
clai
m fo
rm a
nd c
heck
the
box
mar
ked
“Pre
-Tre
atm
ent E
STIM
ATE.
” Pr
ior a
utho
rizat
ion
requ
est c
an b
e su
bmitt
ed v
ia th
e pr
ovid
er w
eb p
orta
l (at
ww
w.m
yuhc
prov
ider
s.co
m),
subm
itted
ele
ctro
nica
lly v
ia y
our
Dent
al P
rovi
ders
with
com
plai
nts a
re to
con
tact
Uni
tedH
ealth
care
Den
tal’s
Pro
vide
r Ser
vice
dep
artm
ent a
t
176176
177
178178
Dent
al P
rovi
ders
with
com
plai
nts a
re to
con
tact
Uni
tedH
ealth
care
Den
tal’s
Pro
vide
r Ser
vice
dep
artm
ent a
t
“Prio
r Aut
horiz
atio
n re
quire
d” m
eans
the
prac
titio
ner m
ust s
ubm
it th
ose
proc
edur
es fo
r app
rova
l with
clin
ical
doc
umen
tatio
n su
ppor
ting
nece
ssity
bef
ore
perf
orm
ing
thos
e pr
oced
ures
. To
do th
is c
ompl
ete
a st
anda
rd A
DA c
laim
form
and
che
ck th
e bo
x m
arke
d “P
re-T
reat
men
t EST
IMAT
E.”
Prio
r aut
horiz
atio
n re
ques
t can
be
subm
itted
via
the
prov
ider
web
por
tal (
at w
ww
.myu
hcpr
ovid
ers.
com
), su
bmitt
ed e
lect
roni
cally
179
180180
181
182182
“Prio
r Aut
horiz
atio
n re
quire
d” m
eans
the
prac
titio
ner m
ust s
ubm
it th
ose
proc
edur
es fo
r app
rova
l with
clin
ical
doc
umen
tatio
n su
ppor
ting
nece
ssity
bef
ore
perf
orm
ing
thos
e pr
oced
ures
. To
do th
is c
ompl
ete
a st
anda
rd
ADA
clai
m fo
rm a
nd c
heck
the
box
mar
ked
“Pre
-Tre
atm
ent E
STIM
ATE.
” Pr
ior a
utho
rizat
ion
requ
est c
an b
e su
bmitt
ed v
ia th
e pr
ovid
er w
eb p
orta
l (at
ww
w.m
yuhc
prov
ider
s.co
m),
subm
itted
ele
ctro
nica
lly v
ia y
our
Dent
al P
rovi
ders
with
com
plai
nts a
re to
con
tact
Uni
tedH
ealth
care
Den
tal’s
Pro
vide
r Ser
vice
dep
artm
ent a
t
183
184184
Iden
tific
atio
n Ca
rds
Sam
ple
Mem
ber I
D C
ard*
Fron
t of c
ard
Back
of c
ard
Impo
rtan
t Tel
epho
ne N
umbe
rs &
Web
site
s
Impo
rtan
t Add
ress
es
Impo
rtan
t Ele
ctro
nic
Clai
ms &
Prio
r Aut
horiz
atio
n Su
bmis
sion
Info
rmat
ion
EDI P
ayer
Num
ber f
or C
laim
s Sub
mitt
edG
P133
Prov
ider
Qui
ck R
efer
ence
Gui
de -
Effe
ctiv
e 1/
1/20
17U
nite
dHea
lthca
re C
are
Impr
ovem
ent P
lus S
ilver
Rx
Geo
rgia
and
Sou
th C
arol
ina
24 h
ours
a d
ayCe
nter
s for
Med
icai
d an
d M
edic
are
Serv
ices
ww
w.c
ms.
hhs.
gov
24 h
ours
a d
ay
*Ple
ase
note
that
the
Med
ical
ID C
ard
is u
nive
rsal
and
incl
udes
all
lines
of c
over
age .
The
Med
ical
pla
n ca
n be
HM
O o
r PPO
and
this
doe
s not
refle
ct th
e De
ntal
Pla
n Be
nefit
s. P
leas
e fli
p th
e ID
Car
d ov
er to
see
the
Dent
al
Prov
ider
info
rmat
ion
on th
e ba
ck (i
.e. c
arrie
r web
site
and
toll-
free
num
ber)
. Thi
s inf
orm
atio
n ca
n be
use
d to
con
firm
pro
vide
r par
ticip
atio
n, m
embe
r elig
ibili
ty a
nd b
enef
its. T
his i
s a S
AMPL
E ID
Car
d an
d m
ay d
iffer
from
th
e m
embe
r's ID
Car
d.
Elig
ibili
ty,
Bene
fits,
Cla
im(s
) and
Aut
horiz
atio
ns(8
44) 2
75-8
750
Live
Age
nt: M
onda
y - F
riday
, 8:0
0AM
- 6:
00PM
, EST
IVR:
24
hour
s a d
ay
$100
0 An
nual
Max
imum
Prov
ider
Rea
son
for M
ailin
g
Call
to In
quire
Abo
utTe
leph
one
Num
ber
Hou
rs o
f Ope
ratio
n
Emai
l to
Inqu
ire A
bout
Web
site
Hou
rs o
f Ope
ratio
n
Med
icar
ew
ww
.med
icar
e.go
v24
hou
rs a
day
To d
iscu
ss y
our p
artic
ipat
ion,
con
trac
tual
issu
es, d
entis
t cha
nges
or o
ffice
upd
ates
(800
) 822
-535
3Li
ve A
gent
: Mon
day
- Frid
ay, 8
:00A
M -
11:0
0PM
, EST
Elig
ibili
ty,
Bene
fits,
Cla
im(s
) and
Aut
horiz
atio
nsw
ww
.uhc
prov
ider
s.co
m
Clai
ms
Prio
r Aut
horiz
atio
n
Appe
als &
Grie
vanc
es
UHC
Med
icar
e Cl
aim
s, P
O B
ox 2
176,
Milw
auke
e, W
I 53
201
UHC
Med
icar
e Au
thor
izatio
ns, P
O B
ox 2
053,
Milw
auke
e, W
I 53
201
UHC
Med
icar
e Co
mpl
aint
s, G
rieva
nces
& A
ppea
ls, P
O B
ox 3
61, M
ilwau
kee,
WI
5320
1
185
1 ev
ery
6 m
onth
sun
limite
dun
limite
dun
limite
dun
limite
dun
limite
dun
limite
d
Intr
aora
l - C
ompl
ete
Serie
s of R
adio
grap
hic
Imag
esIn
trao
ral -
Per
iapi
cal F
irst R
adio
grap
hic
Imag
eIn
trao
ral -
Per
iapi
cal E
ach
Addi
tiona
l Im
age
No
No
No
No
unlim
ited
unlim
ited
1 ev
ery
6 m
onth
s1
ever
y 6
mon
ths
1 ev
ery
6 m
onth
s1
ever
y 6
mon
ths
1 ev
ery
6 m
onth
s1
ever
y 6
mon
ths
1 ev
ery
6 m
onth
s1
ever
y 6
mon
ths
1 ev
ery
3 ye
ars
Cove
red
Den
tal S
ervi
ces:
Proc
edur
e Co
dePr
oced
ure
Des
crip
tion
Prio
r Aut
horiz
atio
n Re
quire
d?
D023
0D0
240
D027
0D0
272
D027
3
D012
0D0
140
D015
0D0
210
D022
0
D216
0D2
161
D233
0D2
331
D233
2
D027
4D0
330
D111
0D2
140
D215
0
No
No
No
No
No
No
No
No
No
Perio
dic
Ora
l Eva
luat
ion
- Est
ablis
hed
Patie
ntLi
mite
d O
ral E
valu
atio
n - P
robl
em F
ocus
edCo
mpr
ehen
sive
Ora
l Eva
luat
ion
- New
Or E
stab
lishe
d Pa
tient
D233
5D2
390
D239
1D2
392
D239
3
D911
0
D434
2D4
355
D491
0D7
111
D714
0
D293
1D2
940
D295
0D2
954
D434
1
D721
0D7
250
D731
0D7
311
Resi
n-Ba
sed
Com
posi
te -
Four
Or M
ore
Surf
aces
, Pos
terio
rCr
own
- Res
in-B
ased
Com
posi
te (I
ndire
ct)
Crow
n - P
orce
lain
/Cer
amic
Sub
stra
teCr
own
- Por
cela
in F
used
To
High
Nob
le M
etal
Crow
n - P
orce
lain
Fus
ed T
o Pr
edom
inan
tly B
ase
Met
al
D239
4D2
710
D274
0D2
750
D275
1
Pref
abric
ated
Sta
inle
ss S
teel
Cro
wn
- Per
man
ent T
ooth
Prot
ectiv
e Re
stor
atio
nCo
re B
uild
up, I
nclu
ding
Any
Pin
s Whe
n Re
quire
dPr
efab
ricat
ed P
ost A
nd C
ore
In A
dditi
on T
o Cr
own
D275
2D2
791
D279
2D2
920
D293
0
Alve
olop
last
y In
Con
junc
tion
With
Ext
ract
ions
- O
ne T
o Th
ree
Teet
hPa
lliat
ive
(Em
erge
ncy)
Tre
atm
ent O
f Den
tal P
ain
- Min
or P
roce
dure
Perio
dont
al S
calin
g An
d Ro
ot P
lann
ing
- One
To
Thre
e Te
eth
Per Q
uadr
ant
Full
Mou
th D
ebrid
emen
tPe
riodo
ntal
Mai
nten
ance
Extr
actio
n, C
oron
al R
emna
nts -
Dec
iduo
us T
ooth
Extr
actio
n, E
rupt
ed T
ooth
Or E
xpos
ed R
oot
Intr
aora
l - O
cclu
sal R
adio
grap
hic
Imag
eBi
tew
ing
- Sin
gle
Radi
ogra
phic
Imag
eBi
tew
ings
- Tw
o Ra
diog
raph
ic Im
ages
Perio
dont
al S
calin
g An
d Ro
ot P
lann
ing
- Fou
r Or M
ore
Teet
h Pe
r Qua
dran
t
Crow
n - P
orce
lain
Fus
ed T
o N
oble
Met
alCr
own
- Ful
l Cas
t Pre
dom
inan
tly B
ase
Met
alCr
own
- Ful
l Cas
t Nob
le M
etal
Re-C
emen
t or R
e-Bo
nd C
row
nPr
efab
ricat
ed S
tain
less
Ste
el C
row
n - P
rimar
y To
oth
Surg
ical
Rem
oval
Of E
rupt
ed T
ooth
Surg
ical
Rem
oval
Of R
esid
ual T
ooth
(Cut
ting
Proc
edur
e)Al
veol
opla
sty
In C
onju
nctio
n W
ith E
xtra
ctio
ns -
Four
Or M
ore
Teet
h
Resi
n-Ba
sed
Com
posi
te -
Four
Or M
ore
Surf
aces
Or I
nvol
ving
Inci
se A
ngle
Resi
n-Ba
sed
Com
posi
te C
row
n, A
nter
ior
Resi
n-Ba
sed
Com
posi
te -
One
Sur
face
, Pos
terio
rRe
sin-
Base
d Co
mpo
site
- Tw
o Su
rfac
es, P
oste
rior
Resi
n-Ba
sed
Com
posi
te -
Thre
e Su
rfac
es, P
oste
rior
No
No
Yes
Yes
Yes
Yes
No
Bite
win
gs- T
hree
Rad
iogr
aphi
c Im
ages
Bite
win
gs- F
our R
adio
grap
hic
Imag
esPa
nora
mic
Rad
iogr
aphi
c Im
age
Prop
hyla
xis -
Adu
ltAm
alga
m -
One
Sur
face
, Prim
ary
Or P
erm
anen
tAm
alga
m -
Two
Surf
aces
, Prim
ary
Or P
erm
anen
tAm
alga
m -
Thre
e Su
rfac
es, P
rimar
y O
r Per
man
ent
Amal
gam
- Fo
ur O
r Mor
e Su
rfac
es, P
rimar
y O
r Per
man
ent
Resi
n-Ba
sed
Com
posi
te -
One
Sur
face
, Ant
erio
rRe
sin-
Base
d Co
mpo
site
- Tw
o Su
rfac
es, A
nter
ior
Resi
n-Ba
sed
Com
posi
te -
Thre
e Su
rfac
es, A
nter
ior
No
No
No
No
No
No
No
No
No
No
No
No
No
Yes
No
No
No
No
No
No
Yes
Yes
Yes
No
Yes
No
Yes
Yes
Yes
No
unlim
ited
unlim
ited
unlim
ited
unlim
ited
unlim
ited
1 ev
ery
3 ye
ars
1 ev
ery
3 ye
ars
1 ev
ery
3 ye
ars
1 ev
ery
3 ye
ars
unlim
ited
unlim
ited
Freq
uenc
y/Li
mita
tions
1 ev
ery
6 m
onth
s1
ever
y 6
mon
ths
1 ev
ery
6 m
onth
s
1 ev
ery
2 ye
ars
1 ev
ery
2 ye
ars
1 ev
ery
2 ye
ars
unlim
ited
unlim
ited
unlim
ited
unlim
ited
unlim
ited
unlim
ited
1 ev
ery
3 ye
ars
1 ev
ery
3 ye
ars
1 ev
ery
3 ye
ars
unlim
ited
unlim
ited
unlim
ited
unlim
ited
unlim
ited
unlim
ited
186186
Prov
ider
Cla
im D
ispu
tes
Mem
ber A
ppea
ls &
Grie
vanc
es
Prio
r Aut
horiz
atio
n Re
ques
ts
CIP_
SCIO
N 3
67_P
kg D
T455
_DT4
55-P
1000
a_FF
S28
09/2
016
Mai
l mem
ber a
ppea
ls to
: Uni
tedH
ealth
care
, Att
n: A
ppea
ls a
nd G
rieva
nce
Depa
rtm
ent,
PO B
ox 6
106,
MS
CA12
4-01
57, C
ypre
ss, C
A 90
630
“Prio
r Aut
horiz
atio
n re
quire
d” m
eans
the
prac
titio
ner m
ust s
ubm
it th
ose
proc
edur
es fo
r app
rova
l with
clin
ical
doc
umen
tatio
n su
ppor
ting
nece
ssity
bef
ore
perf
orm
ing
thos
e pr
oced
ures
. To
do th
is c
ompl
ete
a st
anda
rd
ADA
clai
m fo
rm a
nd c
heck
the
box
mar
ked
“Pre
-Tre
atm
ent E
STIM
ATE.
” Pr
ior a
utho
rizat
ion
requ
est c
an b
e su
bmitt
ed v
ia th
e pr
ovid
er w
eb p
orta
l (at
ww
w.m
yuhc
prov
ider
s.co
m),
subm
itted
ele
ctro
nica
lly v
ia y
our
clea
ringh
ouse
, or s
impl
y m
ail t
he fo
rm, t
o th
e be
low
add
ress
, alo
ng w
ith a
ny re
quire
d su
pple
men
tal i
nfor
mat
ion
(film
s, n
arra
tive,
per
io-c
hart
ing,
etc
.). Y
our o
ffice
will
then
rece
ive
an E
xpla
natio
n of
Ben
efits
(EO
B)
outli
ning
the
deni
al o
r app
rova
l of r
eque
sted
trea
tmen
t and
pla
n pa
ymen
t am
ount
s whe
n ap
plic
able
.
The
Uni
tedH
ealth
care
Pla
n fo
r Car
e Im
prov
emen
t Plu
s Silv
er R
x m
embe
rs c
over
s the
den
tal c
odes
list
ed a
bove
. Pro
vide
r pay
men
t is
mad
e on
a F
ee-fo
r-Se
rvic
e ba
sis.
Mem
bers
hav
e bo
th In
-Net
wor
k an
d O
ut-o
f-Net
wor
k co
vera
ge. S
ome
serv
ices
may
requ
ire p
rior a
utho
rizat
ion.
The
den
tal p
lan
has a
$10
00 a
nnua
l max
imum
that
app
lies t
o co
vere
d pr
even
tive
and
com
preh
ensi
ve b
enef
its. T
here
is n
o m
embe
r cop
ay, c
oins
uran
ce o
r de
duct
ible
. Mem
ber c
an b
e bi
lled
for s
ervi
ces o
ver t
he $
1000
ann
ual m
axim
um b
enef
it. T
his p
lan
is o
ffere
d to
Car
e Im
prov
emen
t Plu
s Silv
er R
x m
embe
rs in
Geo
rgia
and
Sou
th C
arol
ina.
Dent
al P
rovi
ders
with
com
plai
nts a
re to
con
tact
Uni
tedH
ealth
care
Den
tal’s
Pro
vide
r Ser
vice
dep
artm
ent a
t (84
4) 2
75-8
750.
Net
wor
k Pr
ovid
er c
ontr
actu
al d
ispu
tes,
Out
-of-N
etw
ork
prov
ider
dis
pute
s, a
nd re
proc
essi
ng
requ
ests
will
be
logg
ed in
to th
e ap
peal
s dat
abas
e. P
leas
e m
ail t
o th
e Ap
peal
s & G
rieva
nces
PO
Box
list
ed a
bove
. Res
earc
h an
d re
solu
tion
will
be
com
plet
ed w
ithin
30
cale
ndar
day
s.
Mem
ber a
ppea
ls a
re re
view
ed b
y th
e he
alth
pla
n, a
nd a
re n
ot d
eleg
ated
to U
HC D
enta
l. Al
l Mem
ber a
ppea
ls (i
nclu
des P
re-S
ervi
ce a
ppea
ls, I
n N
etw
ork
Prov
ider
app
eals
, and
Out
of N
etw
ork
prov
ider
app
eals
) rec
eive
d by
U
HC D
enta
l will
be
forw
arde
d to
the
heal
th p
lan
via
over
nigh
t mai
l, w
ithin
7 d
ays o
f rec
eipt
of t
he a
ppea
l.
187
188188
189
190190
“Prio
r Aut
horiz
atio
n re
quire
d” m
eans
the
prac
titio
ner m
ust s
ubm
it th
ose
proc
edur
es fo
r app
rova
l with
clin
ical
doc
umen
tatio
n su
ppor
ting
nece
ssity
bef
ore
perf
orm
ing
thos
e pr
oced
ures
. To
do th
is
com
plet
e a
stan
dard
ADA
cla
im fo
rm a
nd c
heck
the
box
mar
ked
“Pre
-Tre
atm
ent E
STIM
ATE.
” Pr
ior a
utho
rizat
ion
requ
est c
an b
e su
bmitt
ed v
ia th
e pr
ovid
er w
eb p
orta
l (at
ww
w.m
yuhc
prov
ider
s.co
m),
Dent
al P
rovi
ders
with
com
plai
nts a
re to
con
tact
Uni
tedH
ealth
care
Den
tal’s
Pro
vide
r Ser
vice
dep
artm
ent a
t
191
192192
193
194194
“Prio
r Aut
horiz
atio
n re
quire
d” m
eans
the
prac
titio
ner m
ust s
ubm
it th
ose
proc
edur
es fo
r app
rova
l with
clin
ical
doc
umen
tatio
n su
ppor
ting
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197
198198
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rm a
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200200
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x m
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ww
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202202
203
204204
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is
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dard
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rm a
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206206
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is
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im fo
rm a
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208208
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210210
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rm a
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ked
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211
212212
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rm a
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mar
ked
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214214
215
216216
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is
com
plet
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ADA
cla
im fo
rm a
nd c
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box
mar
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“Pre
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217
218218
219
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dard
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rm a
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220220
221
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. To
do th
is c
ompl
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anda
rd A
DA c
laim
form
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che
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e bo
x m
arke
d “P
re-T
reat
men
t EST
IMAT
E.”
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r aut
horiz
atio
n re
ques
t can
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subm
itted
via
the
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ider
web
por
tal (
at w
ww
.myu
hcpr
ovid
ers.
com
), su
bmitt
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cally
via
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al P
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ders
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tal’s
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vide
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vice
dep
artm
ent a
t
222222
223
224224
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is
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dard
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im fo
rm a
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mar
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an b
e su
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ww
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tal’s
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artm
ent a
t
225
226226
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is c
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anda
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clai
m fo
rm a
nd c
heck
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box
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ked
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-Tre
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228228
229
230230
“Prio
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is
com
plet
e a
stan
dard
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im fo
rm a
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mar
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231
232232
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is c
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m fo
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233
234234
Nat
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235
236236
237
Dent
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238238
“Prio
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“Prio
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Prio
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tedH
ealth
care
Den
tal,
PO B
ox 3
0567
, Sal
t Lak
e Ci
ty, U
T 84
130-
0567
Uni
tedH
ealth
care
Den
tal,
PO B
ox 3
0552
, Sal
t Lak
e Ci
ty, U
T 8
4130
-055
2U
nite
dHea
lthca
re D
enta
l, Ap
peal
s Disp
utes
, PO
Box
305
69, S
alt L
ake
City
, UT
8413
0-05
69
Prov
ider
Qui
ck R
efer
ence
Gui
de -
Effe
ctiv
e 1/
1/20
17AA
RP M
edic
areC
ompl
ete
Plan
sAr
kans
as, A
rizon
a, K
entu
cky
and
Ohi
o - $
1000
Ann
ual M
axim
um
24 h
ours
a d
ay24
hou
rs a
day
*Ple
ase
note
that
the
Med
ical
ID C
ard
is un
iver
sal a
nd in
clud
es a
ll lin
es o
f cov
erag
e. T
he M
edic
al p
lan
can
be H
MO
or P
PO a
nd th
is d
oes n
ot re
flect
the
Dent
al P
lan
Bene
fits.
Ple
ase
flip
the
ID C
ard
over
to se
e th
e De
ntal
Pro
vide
r in
form
atio
n on
the
back
(i.e
. car
rier w
ebsi
te a
nd to
ll-fr
ee n
umbe
r). T
his i
nfor
mat
ion
can
be u
sed
to c
onfir
m p
rovi
der p
artic
ipat
ion,
mem
ber e
ligib
ility
and
ben
efits
. Thi
s is a
SAM
PLE
ID C
ard
and
may
diff
er fr
om th
e m
embe
r's ID
Ca
rd.
Elig
ibili
ty,
Bene
fits,
Cla
im(s
) and
Aut
horiz
atio
ns87
7-81
6-35
96Li
ve A
gent
: Mon
day
- Frid
ay, 8
:00A
M -
6:00
PM, E
STIV
R: 2
4 ho
urs a
day
Clai
ms
243
Unl
imite
dU
nlim
ited
Unl
imite
dU
nlim
ited
1 ev
ery
24 M
onth
(s)
1 ev
ery
24 M
onth
(s)
1 ev
ery
24 M
onth
(s)
D731
1al
veol
opla
sty
in c
onju
nctio
n w
ith e
xtra
ctio
ns -
one
to th
ree
teet
h or
toot
h sp
aces
, per
qua
dran
tN
o
D714
0ex
trac
tion,
eru
pted
toot
h or
exp
osed
root
(ele
vatio
n an
d/or
forc
eps
No
D721
0su
rgic
al re
mov
al o
f eru
pted
toot
h re
q re
mov
al o
f bon
e, se
ctio
ning
of t
ooth
and
incl
udin
g el
evat
ion
of
muc
oper
iost
eal f
lap
No
D491
0pe
riodo
ntal
mai
nten
ance
No
D711
1ex
trac
tion,
cor
onal
rem
nant
s - d
ecid
uous
toot
hN
o
D434
2pe
riodo
ntal
scal
ing
and
root
pla
nnin
g - o
ne to
thre
e te
eth
per q
uadr
ant
D911
0pa
lliat
ive
(em
erge
ncy)
trea
tmen
t of d
enta
l pai
n - m
inor
pro
cedu
reN
o
D725
0su
rgic
al re
mov
al o
f res
idua
l too
th ro
ots (
cutt
ing
proc
edur
e)N
o
D731
0al
veol
opla
sty
in c
onju
nctio
n w
ith e
xtra
ctio
ns -
four
or m
ore
teet
h or
toot
h sp
aces
, per
qua
dran
tN
o
Yes
D435
5fu
ll m
outh
deb
ridem
ent t
o en
able
com
preh
ensi
ve e
valu
atio
n an
d di
agno
sis
Yes
D295
4pr
efab
ricat
ed p
ost a
nd c
ore
in a
dditi
on to
cro
wn
Yes
D434
1pe
riodo
ntal
scal
ing
and
root
pla
nnin
g - f
our o
r mor
e pe
r qua
dran
tYe
s
D294
0pr
otec
tive
rest
orat
ion
No
D295
0co
re b
uild
up, i
nclu
ding
any
pin
sYe
s
D293
0pr
efab
ricat
ed st
ainl
ess s
teel
cro
wn
- prim
ary
toot
hN
oD2
931
pref
abric
ated
stai
nles
s ste
el c
row
n - p
erm
anen
t too
thN
o
D279
2cr
own
- ful
l cas
t nob
le m
etal
Yes
D292
0re
cem
ent c
row
nN
o
D275
2cr
own
- por
cela
in fu
sed
to n
oble
met
alYe
sD2
791
crow
n - f
ull c
ast p
redo
min
antly
bas
e m
etal
Yes
D275
0cr
own
- por
cela
in fu
sed
to h
igh
nobl
e m
etal
Yes
D275
1cr
own
- por
cela
in fu
sed
to p
redo
min
antly
bas
e m
etal
Yes
D271
0cr
own
- res
in-b
ased
com
posi
te (i
ndire
ct)
Yes
D274
0cr
own
- por
cela
in/c
eram
ic su
bstr
ate
Yes
D239
3re
sin-
base
d co
mpo
site
- th
ree
surf
aces
, pos
terio
rN
oD2
394
resi
n-ba
sed
com
posi
te -
four
or m
ore
surf
aces
, pos
terio
rN
o
D239
1re
sin-
base
d co
mpo
site
- on
e su
rfac
e, p
oste
rior
No
D239
2re
sin-
base
d co
mpo
site
- tw
o su
rfac
es, p
oste
rior
No
D233
5re
sin-
base
d co
mpo
site
- fo
ur o
r mor
e su
rfac
es o
r inv
olvi
ng in
cisa
l ang
le (a
nter
ior)
No
D239
0re
sin-
base
d co
mpo
site
cro
wn,
ant
erio
rN
o
D233
1re
sin-
base
d co
mpo
site
- tw
o su
rfac
es, a
nter
ior
No
D233
2re
sin-
base
d co
mpo
site
- th
ree
surf
aces
, ant
erio
rN
o
D216
1am
alga
m -
four
or m
ore
surf
aces
, prim
ary
or p
erm
anen
tN
oD2
330
resi
n-ba
sed
com
posi
te -
one
surf
ace,
ant
erio
rN
o
D215
0am
alga
m -
two
surf
aces
, prim
ary
or p
erm
anen
tN
oD2
160
amal
gam
- th
ree
surf
aces
, prim
ary
or p
erm
anen
tN
o
No
No
No
No
intr
aora
l - p
eria
pica
l - e
ach
addi
tiona
l film
intr
aora
l - o
cclu
sal f
ilmbi
tew
ing
- sin
gle
film
No
No
No
No
Cove
red
Den
tal S
ervi
ces:
Prio
r Aut
horiz
atio
n Re
quire
d?Pr
oced
ure
Code
Freq
uenc
y/Li
mita
tions
Proc
edur
e D
escr
iptio
n
Unl
imite
dU
nlim
ited
Unl
imite
d
Unl
imite
dU
nlim
ited
Unl
imite
d
1 ev
ery
3 Ye
ar(s
)
D022
0
D012
0D0
140
D015
0D0
210
perio
dic
oral
eva
luat
ion
limite
d or
al e
valu
atio
n - p
robl
em fo
cuse
dco
mpr
ehen
sive
ora
l eva
luat
ion
- new
or e
stab
lishe
d pa
tient
intr
aora
l - c
ompl
ete
serie
s (in
clud
ing
bite
win
gs)
D023
0D0
240
D027
0
intr
aora
l - p
eria
pica
l - fi
rst f
ilm
1 ev
ery
6 M
onth
(s)
Unl
imite
d
No
No
D027
2D0
273
bite
win
g - t
wo
film
sN
o
D111
0pr
ophy
laxi
s - a
dult
No
D214
0am
alga
m -
one
surf
ace,
prim
ary
or p
erm
anen
tN
o
D027
4D0
330
bite
win
g - t
hree
film
sbi
tew
ing
- fou
r film
spa
nora
mic
film
No
Unl
imite
dU
nlim
ited
Unl
imite
d
Unl
imite
d
1 ev
ery
6 M
onth
(s)
1 ev
ery
6 M
onth
(s)
1 ev
ery
6 M
onth
(s)
1 ev
ery
6 M
onth
(s)
1 ev
ery
6 M
onth
(s)
1 ev
ery
6 M
onth
(s)
1 ev
ery
6 M
onth
(s)
1 ev
ery
6 M
onth
(s)
1 ev
ery
6 M
onth
(s)
1 ev
ery
6 M
onth
(s)
1 ev
ery
6 M
onth
(s)
Unl
imite
d
Unl
imite
d
Unl
imite
dU
nlim
ited
Unl
imite
dU
nlim
ited
1 ev
ery
36 M
onth
(s)
1 ev
ery
36 M
onth
(s)
Unl
imite
d
Unl
imite
dU
nlim
ited
Unl
imite
dU
nlim
ited
Unl
imite
d
1 ev
ery
36 M
onth
(s)
1 ev
ery
36 M
onth
(s)
1 ev
ery
36 M
onth
(s)
1 ev
ery
36 M
onth
(s)
1 ev
ery
36 M
onth
(s)
244244
Prov
ider
Cla
im D
ispu
tes
Mem
ber A
ppea
ls &
Grie
vanc
es
Prio
r Aut
horiz
atio
n Re
ques
ts
AR, A
Z, K
Y, O
H_FA
CETS
D00
1589
4_Pk
g DT
069_
DT01
5-H1
000c
-FFS
28
10/2
016
Mai
l mem
ber a
ppea
ls to
: Uni
tedH
ealth
care
, Att
n: A
ppea
l Dep
artm
ent,
MS
CA12
4-01
57, P
O B
ox 6
106,
Cyp
ress
, CA
9063
0
“Prio
r Aut
horiz
atio
n re
quire
d” m
eans
the
prac
titio
ner m
ust s
ubm
it th
ose
proc
edur
es fo
r app
rova
l with
clin
ical
doc
umen
tatio
n su
ppor
ting
nece
ssity
bef
ore
perf
orm
ing
thos
e pr
oced
ures
. To
do th
is c
ompl
ete
a st
anda
rd A
DA
clai
m fo
rm a
nd c
heck
the
box
mar
ked
“Pre
-Tre
atm
ent E
STIM
ATE.
” Pr
ior a
utho
rizat
ion
requ
est c
an b
e su
bmitt
ed v
ia th
e pr
ovid
er w
eb p
orta
l (at
ww
w.m
yuhc
prov
ider
s.co
m),
subm
itted
ele
ctro
nica
lly v
ia y
our c
lear
ingh
ouse
, or
simpl
y m
ail t
he fo
rm, t
o th
e be
low
add
ress
, alo
ng w
ith a
ny re
quire
d su
pple
men
tal i
nfor
mat
ion
(film
s, n
arra
tive,
per
io-c
hart
ing,
etc
.). Y
our o
ffice
will
then
rece
ive
an E
xpla
natio
n of
Ben
efits
(EO
B) o
utlin
ing
the
deni
al o
r app
rova
l of
requ
este
d tr
eatm
ent a
nd p
lan
paym
ent a
mou
nts w
hen
appl
icab
le.
The
Uni
tedH
ealth
care
Med
icar
eCom
plet
e Pl
ans c
over
the
dent
al c
odes
list
ed a
bove
. Pro
vide
r pay
men
t is m
ade
on a
Fee
-for-
Serv
ice
basi
s. M
embe
rs h
ave
In-N
etw
ork
Onl
y Be
nefit
s. S
ome
serv
ices
requ
ire p
rior a
utho
rizat
ion.
Th
e de
ntal
pla
n ha
s a $
1000
ann
ual m
axim
um th
at a
pplie
s to
cove
red
prev
entiv
e an
d co
mpr
ehen
sive
ben
efits
. The
re is
no
mem
ber c
opay
, coi
nsur
ance
or d
educ
tible
. Mem
ber c
an b
e bi
lled
for s
ervi
ces o
ver t
he $
1000
ann
ual
max
imum
ben
efit.
Dent
al P
rovi
ders
with
com
plai
nts a
re to
con
tact
Uni
tedH
ealth
care
Den
tal’s
Pro
vide
r Ser
vice
dep
artm
ent a
t (87
7) 8
16-3
596.
Net
wor
k Pr
ovid
er c
ontr
actu
al d
ispu
tes,
Out
-of-N
etw
ork
prov
ider
dis
pute
s, a
nd re
proc
essi
ng re
ques
ts
will
be
logg
ed in
to th
e ap
peal
s dat
abas
e. P
leas
e m
ail t
o th
e Ap
peal
s & G
rieva
nces
PO
Box
list
ed a
bove
. Res
earc
h an
d re
solu
tion
will
be
com
plet
ed w
ithin
30
cale
ndar
day
s.
Mem
ber a
ppea
ls a
re re
view
ed b
y th
e he
alth
pla
n, a
nd a
re n
ot d
eleg
ated
to U
HC D
enta
l. Al
l Mem
ber a
ppea
ls (i
nclu
des P
re-S
ervi
ce a
ppea
ls, I
n N
etw
ork
Prov
ider
app
eals
, and
Out
of N
etw
ork
prov
ider
app
eals
) rec
eive
d by
UHC
De
ntal
will
be
forw
arde
d to
the
heal
th p
lan
via
over
nigh
t mai
l, w
ithin
7 d
ays o
f rec
eipt
of t
he a
ppea
l.
245
246246
247
“Prio
r Aut
horiz
atio
n re
quire
d” m
eans
the
prac
titio
ner m
ust s
ubm
it th
ose
proc
edur
es fo
r app
rova
l with
clin
ical
doc
umen
tatio
n su
ppor
ting
nece
ssity
bef
ore
perf
orm
ing
thos
e pr
oced
ures
. To
do th
is
com
plet
e a
stan
dard
ADA
cla
im fo
rm a
nd c
heck
the
box
mar
ked
“Pre
-Tre
atm
ent E
STIM
ATE.
” Pr
ior a
utho
rizat
ion
requ
est c
an b
e su
bmitt
ed v
ia th
e pr
ovid
er w
eb p
orta
l (at
ww
w.m
yuhc
prov
ider
s.co
m),
Dent
al P
rovi
ders
with
com
plai
nts a
re to
con
tact
Uni
tedH
ealth
care
Den
tal’s
Pro
vide
r Ser
vice
dep
artm
ent a
t
248248
249
“Prio
r Aut
horiz
atio
n re
quire
d” m
eans
the
prac
titio
ner m
ust s
ubm
it th
ose
proc
edur
es fo
r app
rova
l with
clin
ical
doc
umen
tatio
n su
ppor
ting
nece
ssity
bef
ore
perf
orm
ing
thos
e pr
oced
ures
. To
do th
is c
ompl
ete
a st
anda
rd
ADA
clai
m fo
rm a
nd c
heck
the
box
mar
ked
“Pre
-Tre
atm
ent E
STIM
ATE.
” Pr
ior a
utho
rizat
ion
requ
est c
an b
e su
bmitt
ed v
ia th
e pr
ovid
er w
eb p
orta
l (at
ww
w.m
yuhc
prov
ider
s.co
m),
subm
itted
ele
ctro
nica
lly v
ia y
our
Dent
al P
rovi
ders
with
com
plai
nts a
re to
con
tact
Uni
tedH
ealth
care
Den
tal’s
Pro
vide
r Ser
vice
dep
artm
ent a
t
250250
251
“Prio
r Aut
horiz
atio
n re
quire
d” m
eans
the
prac
titio
ner m
ust s
ubm
it th
ose
proc
edur
es fo
r app
rova
l with
clin
ical
doc
umen
tatio
n su
ppor
ting
nece
ssity
bef
ore
perf
orm
ing
thos
e pr
oced
ures
. To
do th
is c
ompl
ete
a st
anda
rd
ADA
clai
m fo
rm a
nd c
heck
the
box
mar
ked
“Pre
-Tre
atm
ent E
STIM
ATE.
” Pr
ior a
utho
rizat
ion
requ
est c
an b
e su
bmitt
ed v
ia th
e pr
ovid
er w
eb p
orta
l (at
ww
w.m
yuhc
prov
ider
s.co
m),
subm
itted
ele
ctro
nica
lly v
ia y
our
Dent
al P
rovi
ders
with
com
plai
nts a
re to
con
tact
Uni
tedH
ealth
care
Den
tal’s
Pro
vide
r Ser
vice
dep
artm
ent a
t
252252
Iden
tific
atio
n Ca
rds
Sam
ple
Mem
ber I
D C
ard*
Fron
t of c
ard
Back
of c
ard
Impo
rtan
t Tel
epho
ne N
umbe
rs &
Web
site
s
Impo
rtan
t Add
ress
es
Impo
rtan
t Ele
ctro
nic
Clai
ms &
Prio
r Aut
horiz
atio
n Su
bmis
sion
Info
rmat
ion
$500
Ann
ual M
axim
um
Prov
ider
Rea
son
for M
ailin
g
Med
icar
ew
ww
.med
icar
e.go
v24
hou
rs a
day
Hou
rs o
f Ope
ratio
nTo
dis
cuss
you
r par
ticip
atio
n, c
ontr
actu
al is
sues
, den
tist c
hang
es o
r offi
ce u
pdat
es(8
00) 8
22-5
353
Live
Age
nt: M
onda
y - F
riday
, 8:0
0AM
- 11
:00P
M, E
ST
Elig
ibili
ty,
Bene
fits,
Cla
im(s
) and
Aut
horiz
atio
ns
Prov
ider
Qui
ck R
efer
ence
Gui
de -
Effe
ctiv
e 1/
1/20
17U
nite
dHea
lthca
re C
are
Impr
ovem
ent P
lus (
Silv
er R
x, D
ual A
dvan
tage
)
Arka
nsas
and
Mis
sour
i
24 h
ours
a d
ayCe
nter
s for
Med
icai
d an
d M
edic
are
Serv
ices
ww
w.c
ms.
hhs.
gov
24 h
ours
a d
ay
*Ple
ase
note
that
the
Med
ical
ID C
ard
is u
nive
rsal
and
incl
udes
all
lines
of c
over
age.
The
Med
ical
pla
n ca
n be
HM
O o
r PPO
and
this
doe
s not
refle
ct th
e De
ntal
Pla
n Be
nefit
s. P
leas
e fli
p th
e ID
Car
d ov
er to
see
the
Dent
al
Prov
ider
info
rmat
ion
on th
e ba
ck (i
.e. c
arrie
r web
site
and
toll-
free
num
ber)
. Thi
s inf
orm
atio
n ca
n be
use
d to
con
firm
pro
vide
r par
ticip
atio
n, m
embe
r elig
ibili
ty a
nd b
enef
its. T
his i
s a S
AMPL
E ID
Car
d an
d m
ay d
iffer
from
th
e m
embe
r's ID
Car
d.
Elig
ibili
ty,
Bene
fits,
Cla
im(s
) and
Aut
horiz
atio
ns(8
44) 2
75-8
750
Live
Age
nt: M
onda
y - F
riday
, 8:0
0AM
- 6:
00PM
, EST
IVR:
24
hour
s a d
ay
Call
to In
quire
Abo
utTe
leph
one
Num
ber
Hou
rs o
f Ope
ratio
n
Emai
l to
Inqu
ire A
bout
Web
site
ww
w.u
hcpr
ovid
ers.
com
Clai
ms
Prio
r Aut
horiz
atio
n
Appe
als &
Grie
vanc
es
UHC
Med
icar
e Cl
aim
s, P
O B
ox 2
176,
Milw
auke
e, W
I 53
201
UHC
Med
icar
e Au
thor
izatio
ns, P
O B
ox 2
053,
Milw
auke
e, W
I 53
201
UHC
Med
icar
e Co
mpl
aint
s, G
rieva
nces
& A
ppea
ls, P
O B
ox 3
61, M
ilwau
kee,
WI
5320
1
EDI P
ayer
Num
ber f
or C
laim
s Sub
mitt
edG
P133
253
unlim
ited
unlim
ited
unlim
ited
unlim
ited
unlim
ited
1 ev
ery
6 m
onth
s1
ever
y 6
mon
ths
1 ev
ery
6 m
onth
s1
ever
y 6
mon
ths
1 ev
ery
6 m
onth
s1
ever
y 6
mon
ths
1 ev
ery
3 ye
ars f
rom
last
dat
e of
serv
ice
1 ev
ery
6 m
onth
sun
limite
d
Cove
red
Den
tal S
ervi
ces:
Proc
edur
e Co
dePr
oced
ure
Des
crip
tion
Prio
r Aut
horiz
atio
n Re
quire
d?
D023
0D0
240
D027
0D0
272
D027
3
D012
0D0
140
D015
0D0
210
No
No
No
Perio
dic
Ora
l Eva
luat
ion
- Est
ablis
hed
Patie
nt
1 ev
ery
6 m
onth
s
Lim
ited
Ora
l Eva
luat
ion
- Pro
blem
Foc
used
Com
preh
ensi
ve O
ral E
valu
atio
n - N
ew O
r Est
ablis
hed
Patie
nt
D721
0D7
250
D731
0D7
311
Resi
n-Ba
sed
Com
posi
te -
Four
Or M
ore
Surf
aces
, Pos
terio
rCr
own
- Res
in-B
ased
Com
posi
te (I
ndire
ct)
Crow
n - P
orce
lain
/Cer
amic
Sub
stra
te
D233
2
D027
4D0
330
D111
0D2
140
D215
0
No
No
No
No
D239
4D2
710
D274
0D2
750
D275
1
Pref
abric
ated
Sta
inle
ss S
teel
Cro
wn
- Per
man
ent T
ooth
Prot
ectiv
e Re
stor
atio
n
1 ev
ery
6 m
onth
s
D233
5D2
390
D239
1D2
392
D239
3
D293
1D2
940
No
No
D022
0
D216
0D2
161
D233
0D2
331
unlim
ited
unlim
ited
D275
2D2
791
D279
2D2
920
D293
0
Alve
olop
last
y In
Con
junc
tion
With
Ext
ract
ions
- O
ne T
o Th
ree
Teet
hPa
lliat
ive
(Em
erge
ncy)
Tre
atm
ent O
f Den
tal P
ain
- Min
or P
roce
dure
Perio
dont
al S
calin
g An
d Ro
ot P
lann
ing
- One
To
Thre
e Te
eth
Per Q
uadr
ant
Full
Mou
th D
ebrid
emen
tPe
riodo
ntal
Mai
nten
ance
Extr
actio
n, C
oron
al R
emna
nts -
Dec
iduo
us T
ooth
Extr
actio
n, E
rupt
ed T
ooth
Or E
xpos
ed R
oot
Surg
ical
Rem
oval
Of E
rupt
ed T
ooth
Surg
ical
Rem
oval
Of R
esid
ual T
ooth
(Cut
ting
Proc
edur
e)Al
veol
opla
sty
In C
onju
nctio
n W
ith E
xtra
ctio
ns -
Four
Or M
ore
Teet
h
D911
0
D434
2D4
355
D491
0D7
111
D714
0
D295
0D2
954
D434
1Pe
riodo
ntal
Sca
ling
And
Root
Pla
nnin
g - F
our O
r Mor
e Te
eth
Per Q
uadr
ant
Crow
n - P
orce
lain
Fus
ed T
o N
oble
Met
alCr
own
- Ful
l Cas
t Pre
dom
inan
tly B
ase
Met
alCr
own
- Ful
l Cas
t Nob
le M
etal
Re-C
emen
t or R
e-Bo
nd C
row
nPr
efab
ricat
ed S
tain
less
Ste
el C
row
n - P
rimar
y To
oth
Resi
n-Ba
sed
Com
posi
te -
Four
Or M
ore
Surf
aces
Or I
nvol
ving
Inci
sal A
ngle
Resi
n-Ba
sed
Com
posi
te C
row
n, A
nter
ior
Resi
n-Ba
sed
Com
posi
te -
One
Sur
face
, Pos
terio
rRe
sin-
Base
d Co
mpo
site
- Tw
o Su
rfac
es, P
oste
rior
Resi
n-Ba
sed
Com
posi
te -
Thre
e Su
rfac
es, P
oste
rior
Core
Bui
ldup
, Inc
ludi
ng A
ny P
ins W
hen
Requ
ired
Pref
abric
ated
Pos
t And
Cor
e In
Add
ition
To
Crow
n
Crow
n - P
orce
lain
Fus
ed T
o Hi
gh N
oble
Met
alCr
own
- Por
cela
in F
used
To
Pred
omin
antly
Bas
e M
etal
Intr
aora
l - C
ompl
ete
Serie
s of R
adio
grap
hic
Imag
esIn
trao
ral -
Per
iapi
cal F
irst R
adio
grap
hic
Imag
eIn
trao
ral -
Per
iapi
cal E
ach
Addi
tiona
l Im
age
No
No
No
No
Intr
aora
l - O
cclu
sal R
adio
grap
hic
Imag
eBi
tew
ing
- Sin
gle
Radi
ogra
phic
Imag
eBi
tew
ings
- Tw
o Ra
diog
raph
ic Im
ages
No
No
Yes
Yes
Yes
Yes
No
Bite
win
gs- T
hree
Rad
iogr
aphi
c Im
ages
Bite
win
gs- F
our R
adio
grap
hic
Imag
esPa
nora
mic
Rad
iogr
aphi
c Im
age
Prop
hyla
xis -
Adu
ltAm
alga
m -
One
Sur
face
, Prim
ary
Or P
erm
anen
tAm
alga
m -
Two
Surf
aces
, Prim
ary
Or P
erm
anen
tAm
alga
m -
Thre
e Su
rfac
es, P
rimar
y O
r Per
man
ent
Amal
gam
- Fo
ur O
r Mor
e Su
rfac
es, P
rimar
y O
r Per
man
ent
Resi
n-Ba
sed
Com
posi
te -
One
Sur
face
, Ant
erio
rRe
sin-
Base
d Co
mpo
site
- Tw
o Su
rfac
es, A
nter
ior
Resi
n-Ba
sed
Com
posi
te -
Thre
e Su
rfac
es, A
nter
ior
No
No
No
No
No
No
No
No
No
No
No
No
No
Yes
No
No
No
No
No
No
Yes
Yes
Yes
No
Yes
No
Yes
Yes
Yes
No
unlim
ited
unlim
ited
unlim
ited
unlim
ited
unlim
ited
unlim
ited
unlim
ited
1 ev
ery
3 ye
ars f
rom
last
dat
e of
serv
ice
1 ev
ery
3 ye
ars f
rom
last
dat
e of
serv
ice
1 ev
ery
3 ye
ars f
rom
last
dat
e of
serv
ice
1 ev
ery
3 ye
ars f
rom
last
dat
e of
serv
ice
unlim
ited
unlim
ited
Freq
uenc
y/Li
mita
tions
1 ev
ery
6 m
onth
s1
ever
y 6
mon
ths
1 ev
ery
6 m
onth
s
1 ev
ery
2 ye
ars f
rom
last
dat
e of
serv
ice
1 ev
ery
2 ye
ars f
rom
last
dat
e of
serv
ice
1 ev
ery
2 ye
ars f
rom
last
dat
e of
serv
ice
unlim
ited
unlim
ited
unlim
ited
unlim
ited
unlim
ited
unlim
ited
1 ev
ery
3 ye
ars f
rom
last
dat
e of
serv
ice
1 ev
ery
3 ye
ars f
rom
last
dat
e of
serv
ice
1 ev
ery
3 ye
ars f
rom
last
dat
e of
serv
ice
unlim
ited
unlim
ited
unlim
ited
unlim
ited
254254
Prov
ider
Cla
im D
ispu
tes
Mem
ber A
ppea
ls &
Grie
vanc
es
Prio
r Aut
horiz
atio
n Re
ques
ts
CIP_
SCIO
N 3
66_P
kg D
T456
_DT4
55-P
0500
a-FF
S28
09/2
016
Mai
l mem
ber a
ppea
ls to
: Uni
tedH
ealth
care
, Att
n: A
ppea
ls a
nd G
rieva
nce
Depa
rtm
ent,
PO B
ox 6
106,
MS
CA12
4-01
57, C
ypre
ss, C
A 90
630
“Prio
r Aut
horiz
atio
n re
quire
d” m
eans
the
prac
titio
ner m
ust s
ubm
it th
ose
proc
edur
es fo
r app
rova
l with
clin
ical
doc
umen
tatio
n su
ppor
ting
nece
ssity
bef
ore
perf
orm
ing
thos
e pr
oced
ures
. To
do th
is c
ompl
ete
a st
anda
rd
ADA
clai
m fo
rm a
nd c
heck
the
box
mar
ked
“Pre
-Tre
atm
ent E
STIM
ATE.
” Pr
ior a
utho
rizat
ion
requ
est c
an b
e su
bmitt
ed v
ia th
e pr
ovid
er w
eb p
orta
l (at
ww
w.m
yuhc
prov
ider
s.co
m),
subm
itted
ele
ctro
nica
lly v
ia y
our
clea
ringh
ouse
, or s
impl
y m
ail t
he fo
rm, t
o th
e be
low
add
ress
, alo
ng w
ith a
ny re
quire
d su
pple
men
tal i
nfor
mat
ion
(film
s, n
arra
tive,
per
io-c
hart
ing,
etc
.). Y
our o
ffice
will
then
rece
ive
an E
xpla
natio
n of
Ben
efits
(EO
B)
outli
ning
the
deni
al o
r app
rova
l of r
eque
sted
trea
tmen
t and
pla
n pa
ymen
t am
ount
s whe
n ap
plic
able
.
The
Uni
tedH
ealth
care
Pla
n fo
r Car
e Im
prov
emen
t (Pl
us S
ilver
Rx,
Dua
l Adv
anta
ge) m
embe
rs c
over
s the
den
tal c
odes
list
ed a
bove
. Pro
vide
r pay
men
t is m
ade
on a
Fee
-for-
Serv
ice
basi
s. M
embe
rs h
ave
both
In-N
etw
ork
and
Out
-of-N
etw
ork
cove
rage
. Som
e se
rvic
es m
ay re
quire
prio
r aut
horiz
atio
n. T
he d
enta
l pla
n ha
s a $
500
annu
al m
axim
um th
at a
pplie
s to
cove
red
prev
entiv
e an
d co
mpr
ehen
sive
ben
efits
. The
re is
no
mem
ber c
opay
, co
insu
ranc
e or
ded
uctib
le. M
embe
r can
be
bille
d fo
r ser
vice
s ove
r the
$50
0 an
nual
max
imum
ben
efit.
Thi
s pla
n is
offe
red
to C
are
Impr
ovem
ent (
Plus
Silv
er R
x, D
ual A
dvan
tage
) mem
bers
in A
rkan
sas a
nd M
isso
uri.
Dent
al P
rovi
ders
with
com
plai
nts a
re to
con
tact
Uni
tedH
ealth
care
Den
tal’s
Pro
vide
r Ser
vice
dep
artm
ent a
t (84
4) 2
75-8
750.
Net
wor
k Pr
ovid
er c
ontr
actu
al d
ispu
tes,
Out
-of-N
etw
ork
prov
ider
dis
pute
s, a
nd re
proc
essi
ng
requ
ests
will
be
logg
ed in
to th
e ap
peal
s dat
abas
e. P
leas
e m
ail t
o th
e Ap
peal
s & G
rieva
nces
PO
Box
list
ed a
bove
. Res
earc
h an
d re
solu
tion
will
be
com
plet
ed w
ithin
30
cale
ndar
day
s.
Mem
ber a
ppea
ls a
re re
view
ed b
y th
e he
alth
pla
n, a
nd a
re n
ot d
eleg
ated
to U
HC D
enta
l. Al
l Mem
ber a
ppea
ls (i
nclu
des P
re-S
ervi
ce a
ppea
ls, I
n N
etw
ork
Prov
ider
app
eals
, and
Out
of N
etw
ork
prov
ider
app
eals
) rec
eive
d by
U
HC D
enta
l will
be
forw
arde
d to
the
heal
th p
lan
via
over
nigh
t mai
l, w
ithin
7 d
ays o
f rec
eipt
of t
he a
ppea
l.
255
256256
Iden
tific
atio
n Ca
rds
Sam
ple
Mem
ber I
D C
ard*
Fron
t of c
ard
Back
of c
ard
Fron
t of c
ard
Back
of c
ard
Fron
t of c
ard
Back
of c
ard
Prov
ider
Qui
ck R
efer
ence
Gui
de -
Effe
ctiv
e 1/
1/20
17U
nite
dHea
lthca
re D
enta
l Pla
tinum
Rid
er$1
000
Annu
al M
axim
um
257
Impo
rtan
t Tel
epho
ne N
umbe
rs &
Web
site
s
Impo
rtan
t Add
ress
es
Impo
rtan
t Ele
ctro
nic
Clai
ms &
Prio
r Aut
horiz
atio
n Su
bmis
sion
Info
rmat
ion
1 ev
ery
36 m
onth
s fro
m la
st d
ate
of se
rvic
e1
ever
y 36
mon
ths f
rom
last
dat
e of
serv
ice
1 ev
ery
36 m
onth
s fro
m la
st d
ate
of se
rvic
eun
limite
dD0
416
vira
l cul
ture
No
D035
13D
pho
togr
aphi
c im
age
No
D041
5co
llect
ion
of m
icro
orga
nism
s for
cul
ture
and
sens
itivi
tyN
o
D033
0pa
nora
mic
radi
ogra
phic
imag
eN
oD0
350
2D O
ral/f
acia
l pho
togr
aphi
c im
ages
obt
aine
d in
trao
rally
or e
xtra
oral
lyN
o
No
Call
to In
quire
Abo
utTe
leph
one
Num
ber
Hou
rs o
f Ope
ratio
n
Emai
l to
Inqu
ire A
bout
Web
site
Hou
rs o
f Ope
ratio
n
Med
icar
ew
ww
.med
icar
e.go
v24
hou
rs a
day
To d
iscu
ss y
our p
artic
ipat
ion,
con
trac
tual
issu
es, d
entis
t cha
nges
or o
ffice
upd
ates
800-
822-
5353
Live
Age
nt: M
onda
y - F
riday
, 8:0
0AM
- 11
:00P
M, E
ST
Elig
ibili
ty,
Bene
fits,
Cla
im(s
) and
Aut
horiz
atio
nsw
ww
.dbp
.com
Cent
ers f
or M
edic
aid
and
Med
icar
e Se
rvic
esw
ww
.cm
s.hh
s.go
v
No
No
No
No
re-e
valu
atio
n, li
mite
d, p
robl
em fo
cuse
dco
mpr
ehen
sive
per
iodo
ntal
eva
luat
ion
- new
or e
stab
lishe
d pa
tient
intr
aora
l - c
ompl
ete
serie
s of r
adio
grap
hic
imag
es
Prov
ider
Rea
son
for M
ailin
g
EDI P
ayer
Num
ber f
or C
laim
s Sub
mitt
ed52
133
Prio
r Aut
horiz
atio
nAp
peal
s & G
rieva
nces
Uni
tedH
ealth
care
Den
tal,
PO B
ox 3
0567
, Sal
t Lak
e Ci
ty, U
T 84
130-
0567
Uni
tedH
ealth
care
Den
tal,
PO B
ox 3
0552
, Sal
t Lak
e Ci
ty, U
T 8
4130
-055
2U
nite
dHea
lthca
re D
enta
l, Ap
peal
s Disp
utes
, PO
Box
305
69, S
alt L
ake
City
, UT
8413
0-05
69
No
No
No
No
D014
0D0
145
D015
0
perio
dic
oral
eva
luat
ion
limite
d or
al e
valu
atio
n - p
robl
em fo
cuse
dor
al e
valu
atio
n fo
r a p
atie
nt u
nder
thre
e ye
ars o
f age
and
cou
nsel
ing
with
prim
ary
care
give
rco
mpr
ehen
sive
ora
l eva
luat
ion
- new
or e
stab
lishe
d pa
tient
D017
0D0
180
D021
0
deta
iled
and
exte
nsiv
e or
al e
valu
atio
n - p
robl
em-fo
cuse
d, b
y re
port
Cove
red
Den
tal S
ervi
ces:
Prio
r Aut
horiz
atio
n Re
quire
d?Pr
oced
ure
Code
Freq
uenc
y/Li
mita
tions
24 h
ours
a d
ay
Proc
edur
e D
escr
iptio
n
24 h
ours
a d
ay
*Ple
ase
note
that
the
Med
ical
ID C
ard
is un
iver
sal a
nd in
clud
es a
ll lin
es o
f cov
erag
e. T
he M
edic
al p
lan
can
be H
MO
or P
PO a
nd th
is d
oes n
ot re
flect
the
Dent
al P
lan
Bene
fits.
Ple
ase
flip
the
ID C
ard
over
to se
e th
e De
ntal
Pro
vide
r in
form
atio
n on
the
back
(i.e
. car
rier w
ebsi
te a
nd to
ll-fr
ee n
umbe
r). T
his i
nfor
mat
ion
can
be u
sed
to c
onfir
m p
rovi
der p
artic
ipat
ion,
mem
ber e
ligib
ility
and
ben
efits
. Thi
s is a
SAM
PLE
ID C
ard
and
may
diff
er fr
om th
e m
embe
r's ID
Car
d.
Elig
ibili
ty,
Bene
fits,
Cla
im(s
) and
Aut
horiz
atio
ns87
7-81
6-35
96Li
ve A
gent
: Mon
day
- Frid
ay, 8
:00A
M -
6:00
PM, E
STIV
R: 2
4 ho
urs a
day
Clai
ms
1 ev
ery
year
D016
0
D012
0
1 ev
ery
year
4 ev
ery
year
No
No
D022
0D0
230
intr
aora
l - p
eria
pica
l firs
t rad
iogr
aphi
c im
age
No
D025
1ex
tra-
oral
pos
terio
r den
tal r
adio
grap
hic
imag
eN
oD0
270
bite
win
g - s
ingl
e ra
diog
raph
ic im
age
No
D024
0
D025
0
intr
aora
l - p
eria
pica
l eac
h ad
ditio
nal r
adio
grap
hic
imag
ein
trao
ral -
occ
lusa
l rad
iogr
aphi
c im
age
extr
aora
l - 2
D pr
ojec
tion
radi
ogra
phic
imag
e cr
eate
d us
ing
a st
atio
nary
radi
atio
n so
urce
and
det
ecto
rN
o
D027
4bi
tew
ings
- fo
ur ra
diog
raph
ic im
ages
No
D027
7ve
rtic
al b
itew
ings
- 7
to 8
radi
ogra
phic
imag
esN
o
D027
2bi
tew
ings
- tw
o ra
diog
raph
ic im
ages
No
D027
3bi
tew
ings
- th
ree
radi
ogra
phic
imag
es1
ever
y ye
ar1
ever
y ye
ar1
ever
y ye
ar
2 ev
ery
year
2 ev
ery
year
2 ev
ery
year
2 ev
ery
year
2 ev
ery
year
1 ev
ery
12 m
onth
s fro
m la
st d
ate
of se
rvic
e2
ever
y ye
ar1
ever
y 36
mon
ths f
rom
last
dat
e of
serv
ice
unlim
ited
unlim
ited
unlim
ited
unlim
ited
1 ev
ery
36 m
onth
s fro
m la
st d
ate
of se
rvic
e
258258
1 ev
ery
60 m
onth
s fro
m la
st d
ate
of se
rvic
e1
ever
y 60
mon
ths f
rom
last
dat
e of
serv
ice
1 ev
ery
60 m
onth
s fro
m la
st d
ate
of se
rvic
e1
ever
y 60
mon
ths f
rom
last
dat
e of
serv
ice
1 ev
ery
60 m
onth
s fro
m la
st d
ate
of se
rvic
e1
ever
y 60
mon
ths f
rom
last
dat
e of
serv
ice
unlim
ited
unlim
ited
unlim
ited
unlim
ited
1 ev
ery
60 m
onth
s fro
m la
st d
ate
of se
rvic
eun
limite
dun
limite
dun
limite
dun
limite
dun
limite
dun
limite
dun
limite
d1
ever
y 60
mon
ths f
rom
last
dat
e of
serv
ice
1 ev
ery
60 m
onth
s fro
m la
st d
ate
of se
rvic
e1
ever
y 60
mon
ths f
rom
last
dat
e of
serv
ice
1 ev
ery
60 m
onth
s fro
m la
st d
ate
of se
rvic
e1
ever
y 60
mon
ths f
rom
last
dat
e of
serv
ice
1 ev
ery
60 m
onth
s fro
m la
st d
ate
of se
rvic
e1
ever
y 60
mon
ths f
rom
last
dat
e of
serv
ice
1 ev
ery
60 m
onth
s fro
m la
st d
ate
of se
rvic
e1
ever
y 60
mon
ths f
rom
last
dat
e of
serv
ice
Yes
Yes
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
Yes
Yes
Yes
No
No
No
Yes
onla
y - p
orce
lain
/cer
amic
- fo
ur o
r mor
e su
rfac
esin
lay
- com
posi
te/r
esin
- on
e su
rfac
ein
lay
- com
posi
te/r
esin
- tw
o su
rfac
esin
lay
- com
posit
e/re
sin
- thr
ee o
r mor
e su
rfac
es
resi
n-ba
sed
com
posi
te -
one
surf
ace,
pos
terio
rre
sin-
base
d co
mpo
site
- tw
o su
rfac
es, p
oste
rior
resi
n-ba
sed
com
posi
te -
thre
e su
rfac
es, p
oste
rior
resi
n-ba
sed
com
posi
te -
four
or m
ore
surf
aces
, pos
terio
rgo
ld fo
il - o
ne su
rfac
ego
ld fo
il - t
wo
surf
aces
gold
foil
- thr
ee su
rfac
esin
lay
- met
allic
- on
e su
rfac
ein
lay
- met
allic
- tw
o su
rfac
esin
lay
- met
allic
- th
ree
or m
ore
surf
aces
onla
y m
etal
lic, t
wo
surf
aces
onla
y-m
etal
lic-t
hree
surf
aces
spac
e m
aint
aine
r - re
mov
able
- un
ilate
ral
D216
0am
alga
m -
thre
e su
rfac
es, p
rimar
y or
per
man
ent
D265
0D2
651
D265
2
onla
y-m
etal
lic-fo
ur o
r mor
e su
rfac
esin
lay
- por
cela
in/c
eram
ic -
one
surf
ace
inla
y - p
orce
lain
/cer
amic
- tw
o su
rfac
esin
lay
- por
cela
in/c
eram
ic -
thre
e or
mor
e su
rfac
eson
lay
- por
cela
in/c
eram
ic -
two
surf
aces
onla
y - p
orce
lain
/cer
amic
- th
ree
surf
aces
resi
n-ba
sed
com
posi
te -
one
surf
ace,
ant
erio
rre
sin-
base
d co
mpo
site
- tw
o su
rfac
es, a
nter
ior
resi
n-ba
sed
com
posi
te -
thre
e su
rfac
es, a
nter
ior
resi
n-ba
sed
com
posi
te -
four
or m
ore
surf
aces
or i
nvol
ving
inci
sal a
ngle
(ant
erio
r)re
sin-
base
d co
mpo
site
cro
wn,
ant
erio
r
D242
0D2
430
D251
0
D254
2D2
543
D254
4D2
610
D262
0D2
630
D264
2D2
643
D264
4
1 ev
ery
60 m
onth
s fro
m la
st d
ate
of se
rvic
e1
ever
y 60
mon
ths f
rom
last
dat
e of
serv
ice
1 ev
ery
60 m
onth
s fro
m la
st d
ate
of se
rvic
e
D214
0am
alga
m -
one
surf
ace,
prim
ary
or p
erm
anen
tN
o
D215
0am
alga
m -
two
surf
aces
, prim
ary
or p
erm
anen
tN
o
D155
0re
cem
ent o
r re-
bond
of s
pace
mai
ntai
ner
No
D155
5re
mov
al o
f fix
ed sp
ace
mai
ntai
ner
No
D152
0
D252
0D2
530
No
D152
5sp
ace
mai
ntai
ner -
rem
ovab
le -
bila
tera
lN
o
D151
0sp
ace
mai
ntai
ner -
fixe
d - u
nila
tera
lN
oD1
515
spac
e m
aint
aine
r - fi
xed
- bila
tera
lN
o
D135
3se
alan
t rep
air -
per
toot
hN
oD1
354
inte
rim c
arie
s arr
estin
g m
edic
amen
t app
licat
ion
No
No
D216
1am
alga
m -
four
or m
ore
surf
aces
, prim
ary
or p
erm
anen
tN
oD2
330
D233
1D2
332
D233
5D2
390
D239
1D2
392
D239
3D2
394
D241
0
D135
1se
alan
t - p
er to
oth
No
D135
2pr
even
tive
resi
n re
stor
atio
n - p
erm
anen
t too
thN
o
D120
6to
pica
l app
licat
ion
of fl
uorid
e va
rnis
hN
oD1
208
Topi
cal a
pplic
atio
n of
fluo
ride
- exc
ludi
ng v
arni
shN
o
D111
0pr
ophy
laxi
s - a
dult
No
D112
0pr
ophy
laxi
s - c
hild
No
D046
0pu
lp v
italit
y te
sts
No
D047
0di
agno
stic
cas
tsN
o
D042
3ge
netic
test
for s
usce
ptib
ility
to d
isea
ses-
spec
imen
ana
lysi
sN
o
D043
1ad
junc
tive
pre-
diag
nost
ic te
st th
at a
ids i
n de
tect
ion
of m
ucos
al a
bnor
mal
ities
incl
udin
g pr
emal
igna
nt
and
mal
igna
nt le
isN
o
D041
8an
alys
is o
f sal
iva
sam
ple
No
D042
2co
llect
ion
and
prep
arat
ion
of g
enet
ic sa
mpl
e m
ater
ial f
or la
bora
tory
ana
lysi
s and
repo
rtN
o
D041
7co
llect
ion
and
prep
arat
ion
of sa
liva
sam
ple
for l
abor
ator
y di
agno
stic
test
ing
No
1 ev
ery
6 m
onth
s fro
m la
st d
ate
of se
rvic
eun
limite
dun
limite
d
unlim
ited
unlim
ited
2 ev
ery
year
2 ev
ery
year
unlim
ited
1 ev
ery
36 m
onth
s fro
m la
st d
ate
of se
rvic
e
unlim
ited
unlim
ited
unlim
ited
unlim
ited
1 ev
ery
12 m
onth
s fro
m la
st d
ate
of se
rvic
e
2 ev
ery
year
1 ev
ery
36 m
onth
s fro
m la
st d
ate
of se
rvic
e
1 ev
ery
36 m
onth
s fro
m la
st d
ate
of se
rvic
eun
limite
d1
ever
y 60
mon
ths f
rom
last
dat
e of
serv
ice
1 pe
r too
th1
ever
y 24
mon
ths f
rom
last
dat
e of
serv
ice
2 ev
ery
year
259
1 pe
r life
time
1 pe
r life
time
1 pe
r life
time
1 pe
r life
time
1 pe
r life
time
1 ev
ery
6 m
onth
s fro
m la
st d
ate
of se
rvic
e1
ever
y 6
mon
ths f
rom
last
dat
e of
serv
ice
1 ev
ery
6 m
onth
s fro
m la
st d
ate
of se
rvic
eun
limite
dun
limite
d1
per l
ifetim
e1
per l
ifetim
e
1 pe
r life
time
1 pe
r life
time
unlim
ited
unlim
ited
unlim
ited
2 pe
r too
thun
limite
dun
limite
dun
limite
dun
limite
d1
ever
y 60
mon
ths f
rom
last
dat
e of
serv
ice
unlim
ited
unlim
ited
unlim
ited
1 ev
ery
6 m
onth
s fro
m la
st d
ate
of se
rvic
e1
ever
y 60
mon
ths f
rom
last
dat
e of
serv
ice
1 ev
ery
60 m
onth
s fro
m la
st d
ate
of se
rvic
e1
ever
y 60
mon
ths f
rom
last
dat
e of
serv
ice
1 ev
ery
60 m
onth
s fro
m la
st d
ate
of se
rvic
e1
ever
y 60
mon
ths f
rom
last
dat
e of
serv
ice
1 ev
ery
60 m
onth
s fro
m la
st d
ate
of se
rvic
e1
ever
y 60
mon
ths f
rom
last
dat
e of
serv
ice
1 ev
ery
60 m
onth
s fro
m la
st d
ate
of se
rvic
e1
ever
y 60
mon
ths f
rom
last
dat
e of
serv
ice
1 ev
ery
60 m
onth
s fro
m la
st d
ate
of se
rvic
e1
ever
y 60
mon
ths f
rom
last
dat
e of
serv
ice
1 ev
ery
60 m
onth
s fro
m la
st d
ate
of se
rvic
e1
ever
y 60
mon
ths f
rom
last
dat
e of
serv
ice
1 ev
ery
60 m
onth
s fro
m la
st d
ate
of se
rvic
e
1 ev
ery
60 m
onth
s fro
m la
st d
ate
of se
rvic
e1
ever
y 60
mon
ths f
rom
last
dat
e of
serv
ice
1 ev
ery
60 m
onth
s fro
m la
st d
ate
of se
rvic
e1
ever
y 60
mon
ths f
rom
last
dat
e of
serv
ice
1 ev
ery
60 m
onth
s fro
m la
st d
ate
of se
rvic
e1
ever
y 60
mon
ths f
rom
last
dat
e of
serv
ice
1 ev
ery
60 m
onth
s fro
m la
st d
ate
of se
rvic
e1
ever
y 60
mon
ths f
rom
last
dat
e of
serv
ice
1 ev
ery
60 m
onth
s fro
m la
st d
ate
of se
rvic
e
1 ev
ery
60 m
onth
s fro
m la
st d
ate
of se
rvic
e1
ever
y 60
mon
ths f
rom
last
dat
e of
serv
ice
1 ev
ery
60 m
onth
s fro
m la
st d
ate
of se
rvic
e
No
No
No
No
No
No
No
No
No
No
No
No
No
No
Yes
No
Yes
Yes
Yes
Yes
Yes
No
No
No
No
No
No
No
No
No
No
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
No
Yes
No
No
No
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
endo
dont
ic th
erap
y, b
icus
pid
toot
h (e
xclu
ding
fina
l res
tora
tion)
endo
dont
ic th
erap
y, m
olar
(exc
ludi
ng fi
nal r
esto
ratio
n)tr
eatm
ent o
f roo
t can
al o
bstr
uctio
n, n
on-s
urgi
cal a
cces
s
ther
apeu
tic p
ulpo
tom
y (e
xclu
ding
fina
l res
tora
tion)
pulp
al d
ebrid
emen
t, pr
imar
y an
d pe
rman
ent t
eeth
part
ial p
ulpo
tom
y fo
r ape
xoge
nesi
s - p
erm
anen
t too
th w
ith in
com
plet
e ro
ot d
evel
opm
ent
pulp
al th
erap
y (r
esto
rabl
e fil
ling)
- an
terio
r, pr
imar
y to
oth
(exc
ludi
ng fi
nal r
esto
ratio
n)
pulp
al th
erap
y (r
esto
rabl
e fil
ling)
- po
ster
ior,
prim
ary
toot
h (e
xclu
ding
fina
l res
tora
tion)
endo
dont
ic th
erap
y, a
nter
ior t
ooth
(exc
ludi
ng fi
nal r
esto
ratio
n)
Core
bui
ldup
, inc
ludi
ng a
ny p
ins w
hen
requ
ired
pin
rete
ntio
n - p
er to
oth,
in a
dditi
on to
rest
orat
ion
cast
pos
t and
cor
e in
add
ition
to c
row
nea
ch a
dditi
onal
indi
rect
ly fa
bric
ated
pos
t, sa
me
toot
hpr
efab
ricat
ed p
ost a
nd c
ore
in a
dditi
on to
cro
wn
each
add
ition
al p
refa
bric
ated
pos
t, sa
me
toot
hco
ping
crow
n re
pair
nece
ssita
ted
by re
stor
ativ
e m
ater
ial f
ailu
rein
lay
repa
ir ne
cess
itate
d by
rest
orat
ive
mat
eria
l fai
lure
pref
abric
ated
resi
n cr
own
pref
abric
ated
stai
nles
s ste
el c
row
n w
ith re
sin
win
dow
pref
abric
ated
est
hetic
coa
ted
stai
nles
s ste
el c
row
n - p
rimar
y to
oth
prot
ectiv
e re
stor
atio
nin
terim
ther
apeu
tic re
stor
atio
n-pr
imar
y de
ntiti
on
crow
n, 3
/4 c
ast n
oble
met
alcr
own,
3/4
por
cela
in/c
eram
iccr
own
- ful
l cas
t hig
h no
ble
met
alcr
own
- ful
l cas
t pre
dom
inan
tly b
ase
met
alcr
own
- ful
l cas
t nob
le m
etal
crow
n - t
itani
um
prov
isio
nal c
row
n - f
urth
er tr
eatm
ent o
r com
plet
ion
of d
iagn
osis
nec
essa
ry p
rior t
o fin
al im
pres
sion
rece
men
t or r
e-bo
nd in
lay,
onl
ay, v
enee
r or p
artia
l cov
erag
e re
stor
atio
nre
cem
ent o
r re-
bond
cas
t ind
irect
ly fa
bric
ated
or p
refa
bric
ated
pos
t and
cor
e
onla
y re
pair
nece
ssita
ted
by re
stor
ativ
e m
ater
ial f
ailu
repu
lp c
ap -
dire
ct (e
xclu
ding
fina
l res
tora
tion)
pulp
cap
- in
dire
ct (e
xclu
ding
fina
l res
tora
tion)
crow
n - p
orce
lain
fuse
d to
pre
dom
inan
tly b
ase
met
alcr
own
- por
cela
in fu
sed
to n
oble
met
alcr
own,
3/4
cas
t hig
h no
ble
met
alcr
own,
3/4
cas
t pre
dom
inat
ely
base
met
al
onla
y - c
ompo
site
/res
in -
two
surf
aces
onla
y - c
ompo
site
/res
in -
thre
e su
rfac
eson
lay
- com
posi
te/r
esin
- fo
ur o
r mor
e su
rfac
escr
own,
resi
n-ba
sed
com
posi
te (i
ndire
ct)
crow
n - 3
/4 re
sin-
base
d co
mpo
site
(ind
irect
)
rece
men
t or r
e-bo
nd c
row
nre
atta
chm
ent o
f too
th fr
agm
ent,
inci
sal e
dge
or c
usp
pref
abric
ated
stai
nles
s ste
el c
row
n - p
rimar
y to
oth
pref
abric
ated
stai
nles
s ste
el c
row
n - p
erm
anen
t too
th
crow
n - r
esin
with
hig
h no
ble
met
alcr
own
- res
in w
ith p
redo
min
antly
bas
e m
etal
crow
n - r
esin
with
nob
le m
etal
crow
n - p
orce
lain
/cer
amic
subs
trat
ecr
own
- por
cela
in fu
sed
to h
igh
nobl
e m
etal
D333
0D3
331
D311
0D3
120
D322
0D3
221
D322
2D3
230
D324
0D3
310
D332
0
D295
1D2
952
D295
3D2
954
D295
7D2
975
D298
0D2
981
D298
2
D292
1D2
930
D293
1D2
932
D293
3D2
934
D294
0D2
941
D295
0
D278
3D2
790
D279
1D2
792
D279
4
D279
9D2
910
D291
5D2
920
D272
1D2
722
D274
0D2
750
D275
1D2
752
D278
0D2
781
D278
2
D266
2D2
663
D266
4D2
710
D271
2D2
720
260260
1 ev
ery
36 m
onth
s fro
m la
st d
ate
of se
rvic
e
1 ev
ery
36 m
onth
s fro
m la
st d
ate
of se
rvic
e
1 ev
ery
36 m
onth
s fro
m la
st d
ate
of se
rvic
e
1 ev
ery
36 m
onth
s fro
m la
st d
ate
of se
rvic
e1
ever
y 36
mon
ths f
rom
last
dat
e of
serv
ice
1 ev
ery
36 m
onth
s fro
m la
st d
ate
of se
rvic
e
1 ev
ery
36 m
onth
s fro
m la
st d
ate
of se
rvic
e1
ever
y 36
mon
ths f
rom
last
dat
e of
serv
ice
1 ev
ery
36 m
onth
s fro
m la
st d
ate
of se
rvic
e
1 ev
ery
36 m
onth
s fro
m la
st d
ate
of se
rvic
e
1 ev
ery
36 m
onth
s fro
m la
st d
ate
of se
rvic
e
1 ev
ery
36 m
onth
s fro
m la
st d
ate
of se
rvic
e
1 ev
ery
36 m
onth
s fro
m la
st d
ate
of se
rvic
e1
ever
y 36
mon
ths f
rom
last
dat
e of
serv
ice
1 ev
ery
36 m
onth
s fro
m la
st d
ate
of se
rvic
e
1 ev
ery
36 m
onth
s fro
m la
st d
ate
of se
rvic
e1
ever
y 36
mon
ths f
rom
last
dat
e of
serv
ice
1 ev
ery
36 m
onth
s fro
m la
st d
ate
of se
rvic
e
1 ev
ery
36 m
onth
s fro
m la
st d
ate
of se
rvic
e
1 ev
ery
36 m
onth
s fro
m la
st d
ate
of se
rvic
e1
ever
y 36
mon
ths f
rom
last
dat
e of
serv
ice
1 pe
r life
time
2 pe
r life
time
2 pe
r life
time
1 pe
r life
time
1 pe
r life
time
1 pe
r life
time
per t
ooth
1 pe
r life
time
1 ev
ery
36 m
onth
s fro
m la
st d
ate
of se
rvic
e
1 ev
ery
36 m
onth
s fro
m la
st d
ate
of se
rvic
e
1 pe
r life
time
1 pe
r life
time
1 pe
r life
time
1 pe
r life
time
1 pe
r life
time
1 pe
r life
time
1 pe
r life
time
1 pe
r life
time
1 pe
r life
time
1 pe
r life
time
1 pe
r life
time
1 pe
r life
time
1 pe
r life
time
Yes
Yes
Yes
No
No
No
No
Yes
No
Yes
Yes
Yes
No
No
No
Yes
Yes
Yes
Yes
No
No
No
No
No
No
No
No
No
Yes
No
No
No
No
No
No
No
No
No
No
No
Yes
Yes
Yes
auto
geno
us c
onne
ctiv
e tis
sue
graf
t pro
cedu
re -
each
add
ition
al c
ontig
uous
toot
h, im
plan
t or
eden
tulo
us to
oth
guid
ed ti
ssue
rege
nera
tion
- res
tora
ble
barr
ier,
per s
ite
guid
ed ti
ssue
rege
nera
tion
- non
rest
orab
le b
arrie
r, pe
r site
(Inc
lude
s mem
bran
e re
mov
al)
surg
ical
revi
sion
pro
cedu
re, p
er to
oth
pedi
cle
soft
tissu
e gr
aft p
roce
dure
auto
geno
us c
onne
ctiv
e tis
sue
graf
t pro
cedu
re, p
er fi
rst t
ooth
, im
plan
t or e
dent
ulou
s too
th p
ositi
on in
gr
aft
dist
al o
r pro
xim
al w
edge
pro
cedu
re (w
hen
not p
erfo
rmed
in c
onju
nctio
n w
ith su
rgic
al p
roce
dure
s in
the
sam
e an
atom
ical
are
a)no
n-au
toge
nous
con
nect
ive
tissu
e gr
aft (
incl
udin
g re
cipi
ent s
ite a
nd d
onor
mat
eria
l) fir
st to
oth
impl
ant
com
bine
d co
nnec
tive
tissu
e an
d do
uble
ped
icle
gra
ft, p
er to
oth
free
soft
tiss
ue g
raft
pro
cedu
re e
ach
addi
tiona
l con
tiguo
us to
oth,
impl
ant o
r ede
ntul
ous t
ooth
ging
ival
flap
pro
cedu
re -
incl
udin
g ro
ot p
lann
ing
-one
to th
ree
cont
iguo
us te
eth
or to
oth
boun
ded
spac
es p
er q
uadr
ant
apic
ally
pos
ition
ed fl
apcl
inic
al c
row
n le
ngth
enin
g - h
ard
tissu
eos
seou
s sur
gery
(inc
ludi
ng fl
ap e
ntry
and
clo
sure
) - fo
ur o
r mor
e co
ntig
uous
teet
h or
toot
h bo
unde
d sp
aces
per
qua
dran
tos
seou
s sur
gery
(inc
ludi
ng fl
ap e
ntry
and
clo
sure
) - o
ne to
thre
e co
ntig
uous
teet
h or
toot
h bo
unde
d sp
aces
per
qua
dran
tBo
ne re
plac
emen
t gra
ft -
first
site
in q
uadr
ant
Bone
repl
acem
ent g
raft
- ea
ch a
dditi
onal
site
in q
uadr
ant
biol
ogic
mat
eria
ls to
aid
in so
ft an
d os
seou
s tis
sue
rege
nera
tion
perir
adic
ular
surg
ery
with
out a
pico
ecto
my
retr
ogra
de fi
lling
- pe
r roo
tro
ot a
mpu
tatio
n - p
er ro
otin
tent
iona
l rei
mpl
anta
tion
(incl
udin
g ne
cess
ary
splin
ting)
hem
isec
tion
(incl
udin
g an
y ro
ot re
mov
al),
not i
nclu
ding
root
can
al th
erap
y
ging
ivec
tom
y or
gin
givo
plas
ty -
four
or m
ore
cont
iguo
us te
eth
or to
oth
boun
ded
spac
es p
er q
uadr
ant
ging
ivec
tom
y or
gin
givo
plas
ty -
one
to th
ree
cont
iguo
us te
eth
or to
oth
boun
ded
spac
es p
er q
uadr
ant
anat
omic
al c
row
n ex
posu
re -
four
or m
ore
cont
iguo
us te
eth
per q
uadr
ant
anat
omic
al c
row
n ex
posu
re -
one
to th
ree
teet
h pe
r qua
dran
t
Pupa
l reg
ener
atio
n-in
itial
vis
itPu
lpal
rege
nera
tion-
inte
rim m
edic
amen
t rep
lace
men
tPu
lpal
rege
nera
tion-
com
plet
ion
of tr
eatm
ent
Apic
oect
omy
- ant
erio
rAp
icoe
ctom
y - b
icus
pid
(firs
t roo
t)Ap
icoe
ctom
y - m
olar
(firs
t roo
t)Ap
icoe
ctom
y (e
ach
addi
tiona
l roo
t)
inco
mpl
ete
endo
dont
ic th
erap
y; in
oper
able
, unr
esto
rabl
e or
frac
ture
d to
oth
inte
rnal
toot
h re
pair
of p
erfo
ratio
n de
fect
sre
trea
tmen
t of p
revi
ous r
oot c
anal
ther
apy
- ant
erio
rre
trea
tmen
t of p
revi
ous r
oot c
anal
ther
apy
- bic
uspi
dre
trea
tmen
t of p
revi
ous r
oot c
anal
ther
apy
- mol
arAp
exifi
catio
n/re
calc
ifica
tion-
initi
al v
isit (
apic
al c
losu
re/c
alci
fic re
pair
of p
erfo
ratio
ns, r
oot r
esor
ptio
n,
etc.
ging
ival
flap
pro
cedu
re, i
nclu
ding
root
pla
nnin
g - f
our o
r mor
e co
ntig
uous
teet
h or
toot
h bo
unde
d sp
aces
per
qua
dran
t
Apex
ifica
tion/
reca
lcifi
catio
n/pu
lpal
rege
nera
tion
- int
erim
med
icat
ion
repl
acem
ent
apex
ifica
tion/
reca
lcifi
catio
n - f
inal
visi
t (in
clud
es c
ompl
eted
root
D426
7D4
268
D427
0
D427
3
D427
4
D427
5D4
276
D427
7
D428
3
D424
1D4
245
D424
9
D426
0
D426
1D4
263
D426
4D4
265
D426
6
D343
0D3
450
D347
0D3
920
D421
0
D421
1D4
230
D423
1
D424
0
D335
3D3
355
D335
6D3
357
D341
0D3
421
D342
5D3
426
D342
7
D333
2D3
333
D334
6D3
347
D334
8
D335
1
D335
2
261
1 ev
ery
12 m
onth
s fro
m la
st d
ate
of se
rvic
e1
ever
y 12
mon
ths f
rom
last
dat
e of
serv
ice
1 ev
ery
12 m
onth
s fro
m la
st d
ate
of se
rvic
e1
ever
y 12
mon
ths f
rom
last
dat
e of
serv
ice
1 ev
ery
12 m
onth
s fro
m la
st d
ate
of se
rvic
e
1 ev
ery
6 m
onth
s fro
m la
st d
ate
of se
rvic
e1
ever
y 6
mon
ths f
rom
last
dat
e of
serv
ice
1 ev
ery
6 m
onth
s fro
m la
st d
ate
of se
rvic
e1
ever
y 6
mon
ths f
rom
last
dat
e of
serv
ice
1 ev
ery
6 m
onth
s fro
m la
st d
ate
of se
rvic
e1
ever
y 12
mon
ths f
rom
last
dat
e of
serv
ice
1 ev
ery
12 m
onth
s fro
m la
st d
ate
of se
rvic
e1
ever
y 12
mon
ths f
rom
last
dat
e of
serv
ice
1 ev
ery
12 m
onth
s fro
m la
st d
ate
of se
rvic
e
1 ev
ery
6 m
onth
s fro
m la
st d
ate
of se
rvic
e1
ever
y 6
mon
ths f
rom
last
dat
e of
serv
ice
1 ev
ery
6 m
onth
s fro
m la
st d
ate
of se
rvic
e1
ever
y 6
mon
ths f
rom
last
dat
e of
serv
ice
1 ev
ery
6 m
onth
s fro
m la
st d
ate
of se
rvic
e1
ever
y 6
mon
ths f
rom
last
dat
e of
serv
ice
1 ev
ery
6 m
onth
s fro
m la
st d
ate
of se
rvic
e1
ever
y 6
mon
ths f
rom
last
dat
e of
serv
ice
1 ev
ery
6 m
onth
s fro
m la
st d
ate
of se
rvic
e
1 ev
ery
60 m
onth
s fro
m la
st d
ate
of se
rvic
e
1 ev
ery
60 m
onth
s fro
m la
st d
ate
of se
rvic
e1
ever
y 60
mon
ths f
rom
last
dat
e of
serv
ice
1 ev
ery
60 m
onth
s fro
m la
st d
ate
of se
rvic
e
1 ev
ery
60 m
onth
s fro
m la
st d
ate
of se
rvic
e
1 ev
ery
60 m
onth
s fro
m la
st d
ate
of se
rvic
e1
ever
y 60
mon
ths f
rom
last
dat
e of
serv
ice
1 ev
ery
60 m
onth
s fro
m la
st d
ate
of se
rvic
e
1 ev
ery
60 m
onth
s fro
m la
st d
ate
of se
rvic
e
12 p
er li
fetim
e2
ever
y 12
mon
ths f
rom
last
dat
e of
serv
ice
unlim
ited
1 ev
ery
60 m
onth
s fro
m la
st d
ate
of se
rvic
e1
ever
y 60
mon
ths f
rom
last
dat
e of
serv
ice
1 ev
ery
60 m
onth
s fro
m la
st d
ate
of se
rvic
e1
ever
y 60
mon
ths f
rom
last
dat
e of
serv
ice
1 ev
ery
60 m
onth
s fro
m la
st d
ate
of se
rvic
e
1 ev
ery
60 m
onth
s fro
m la
st d
ate
of se
rvic
e
1 ev
ery
36 m
onth
s fro
m la
st d
ate
of se
rvic
e1
ever
y 36
mon
ths f
rom
last
dat
e of
serv
ice
1 ev
ery
36 m
onth
s fro
m la
st d
ate
of se
rvic
e1
ever
y 24
mon
ths f
rom
last
dat
e of
serv
ice
1 ev
ery
24 m
onth
s fro
m la
st d
ate
of se
rvic
e1
ever
y 36
mon
ths f
rom
last
dat
e of
serv
ice
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
Yes
No
No
No
No
No
Yes
relin
e m
axill
ary
part
ial d
entu
re (c
hairs
ide)
relin
e m
andi
bula
r par
tial d
entu
re (c
hairs
ide)
relin
e co
mpl
ete
max
illar
y de
ntur
e (la
bora
tory
)
add
clas
p to
exi
stin
g pa
rtia
l den
ture
- pe
r too
thre
plac
e al
l tee
th a
nd a
cryl
ic o
n ca
st m
etal
fram
ewor
k (m
axill
ary)
repl
ace
all t
eeth
and
acr
ylic
on
cast
met
al fr
amew
ork
(man
dibu
lar)
reba
se c
ompl
ete
max
illar
y de
ntur
ere
base
com
plet
e m
andi
bula
r den
ture
reba
se m
axill
ary
part
ial d
entu
rere
base
man
dibu
lar p
artia
l den
ture
relin
e co
mpl
ete
max
illar
y de
ntur
e (c
hairs
ide)
relin
e co
mpl
ete
man
dibu
lar d
entu
re (c
hairs
ide)
adju
st p
artia
l den
ture
- m
axill
ary
adju
st p
artia
l den
ture
- m
andi
bula
rre
pair
brok
en c
ompl
ete
dent
ure
base
repl
ace
mis
sing
or b
roke
n te
eth
- com
plet
e de
ntur
e (e
ach
toot
h)re
pair
resi
n de
ntur
e ba
sere
pair
cast
fram
ewor
kre
pair
or re
plac
e br
oken
cla
sp -
per t
ooth
repl
ace
brok
en te
eth
- per
toot
had
d to
oth
to e
xist
ing
part
ial d
entu
re
imm
edia
te m
axill
ary
part
ial d
entu
re -
resin
bas
eim
med
iate
man
dibu
lar p
artia
l den
ture
- re
sin
base
imm
edia
te m
axill
ary
part
ial d
entu
re -
cast
met
al fr
amew
ork
with
resin
den
ture
bas
es
imm
edia
te m
andi
bula
r par
tial d
entu
re-c
ast m
etal
fram
ewor
k w
ith re
sin
dent
ure
base
sm
axill
ary
part
ial d
entu
re -
flexi
ble
base
(inc
ludi
ng a
ny c
lasp
s, re
sts a
nd te
eth)
man
dibu
lar p
artia
l den
ture
- fle
xibl
e ba
se (i
nclu
ding
any
cla
sps,
rest
s and
teet
h)
rem
ovab
le u
nila
tera
l par
tial d
entu
re -
one
piec
e ca
st m
etal
(inc
ludi
ng c
lasp
s and
teet
h)ad
just
com
plet
e de
ntur
e - m
axill
ary
adju
st c
ompl
ete
dent
ure
- man
dibu
lar
unsc
hedu
led
dres
sing
cha
nge
(by
som
eone
oth
er th
an tr
eatin
g de
ntis
t or t
heir
staf
f)co
mpl
ete
dent
ure
- max
illar
yco
mpl
ete
dent
ure
- man
dibu
lar
imm
edia
te d
entu
re -
max
illar
yim
med
iate
den
ture
- m
andi
bula
r
max
illar
y pa
rtia
l den
ture
- re
sin b
ase
(incl
udin
g an
y co
nven
tiona
l cla
sps,
rest
s and
teet
h)
man
dibu
lar p
artia
l den
ture
- re
sin
base
(inc
ludi
ng a
ny c
onve
ntio
nal c
lasp
s, re
sts a
nd te
eth)
max
illar
y pa
rtia
l den
ture
- ca
st m
etal
fram
ewor
k w
ith re
sin d
entu
re b
ases
(inc
ludi
ng a
ny c
onve
ntio
nal
clas
ps, r
ests
and
man
dibu
lar p
artia
l den
ture
- ca
st m
etal
fram
ewor
k w
ith re
sin
dent
ure
base
s (in
clud
ing
any
conv
entio
nal c
lasp
s, re
sts a
nd
non-
auto
geno
us c
onne
ctiv
e tis
sue
graf
t pro
cedu
re -
each
add
ition
al c
ontig
uous
toot
h, im
plan
t or
eden
tulo
us to
oth
prov
isio
nal s
plin
ting
- int
raco
rona
lpr
ovis
iona
l spl
intin
g - e
xtra
coro
nal
perio
dont
al sc
alin
g an
d ro
ot p
lann
ing
- fou
r or m
ore
teet
h pe
r qua
dran
tpe
riodo
ntal
scal
ing
and
root
pla
nnin
g - o
ne -
thre
e te
eth,
per
qua
dran
tfu
ll m
outh
deb
ridem
ent t
o en
able
com
preh
ensi
ve e
valu
atio
n an
d di
agno
sis
loca
lized
del
iver
y of
ant
imic
robi
al a
gent
s via
a c
ontr
olle
d re
leas
e ve
hicl
e in
to d
isea
sed
crev
icul
ar
tissu
e, p
er to
oth
perio
dont
al m
aint
enan
ce
D574
1D5
750
D567
0D5
671
D571
0D5
711
D572
0D5
721
D573
0D5
731
D574
0
D542
2D5
510
D552
0D5
610
D562
0D5
630
D564
0D5
650
D566
0
D522
2
D522
3
D522
4D5
225
D522
6
D528
1D5
410
D541
1D5
421
D511
0D5
120
D513
0D5
140
D521
1
D521
2
D521
3
D521
4D5
221
D428
5D4
320
D432
1D4
341
D434
2D4
355
D438
1D4
910
D492
0
262262
1 ev
ery
60 m
onth
s fro
m la
st d
ate
of se
rvic
e1
ever
y 60
mon
ths f
rom
last
dat
e of
serv
ice
1 ev
ery
60 m
onth
s fro
m la
st d
ate
of se
rvic
e1
ever
y 60
mon
ths f
rom
last
dat
e of
serv
ice
1 ev
ery
60 m
onth
s fro
m la
st d
ate
of se
rvic
e1
ever
y 60
mon
ths f
rom
last
dat
e of
serv
ice
1 ev
ery
60 m
onth
s fro
m la
st d
ate
of se
rvic
e1
ever
y 60
mon
ths f
rom
last
dat
e of
serv
ice
1 ev
ery
60 m
onth
s fro
m la
st d
ate
of se
rvic
e1
ever
y 60
mon
ths f
rom
last
dat
e of
serv
ice
1 ev
ery
60 m
onth
s fro
m la
st d
ate
of se
rvic
e1
ever
y 60
mon
ths f
rom
last
dat
e of
serv
ice
1 ev
ery
60 m
onth
s fro
m la
st d
ate
of se
rvic
e
1 ev
ery
60 m
onth
s fro
m la
st d
ate
of se
rvic
e1
ever
y 60
mon
ths f
rom
last
dat
e of
serv
ice
1 ev
ery
60 m
onth
s fro
m la
st d
ate
of se
rvic
e1
ever
y 60
mon
ths f
rom
last
dat
e of
serv
ice
1 ev
ery
60 m
onth
s fro
m la
st d
ate
of se
rvic
e1
ever
y 60
mon
ths f
rom
last
dat
e of
serv
ice
1 ev
ery
60 m
onth
s fro
m la
st d
ate
of se
rvic
e1
ever
y 60
mon
ths f
rom
last
dat
e of
serv
ice
1 ev
ery
60 m
onth
s fro
m la
st d
ate
of se
rvic
e1
ever
y 60
mon
ths f
rom
last
dat
e of
serv
ice
1 ev
ery
60 m
onth
s fro
m la
st d
ate
of se
rvic
e
1 ev
ery
60 m
onth
s fro
m la
st d
ate
of se
rvic
e1
ever
y 60
mon
ths f
rom
last
dat
e of
serv
ice
1 ev
ery
60 m
onth
s fro
m la
st d
ate
of se
rvic
e
1 ev
ery
60 m
onth
s fro
m la
st d
ate
of se
rvic
e1
ever
y 60
mon
ths f
rom
last
dat
e of
serv
ice
1 ev
ery
60 m
onth
s fro
m la
st d
ate
of se
rvic
e1
ever
y 60
mon
ths f
rom
last
dat
e of
serv
ice
1 ev
ery
60 m
onth
s fro
m la
st d
ate
of se
rvic
e1
ever
y 60
mon
ths f
rom
last
dat
e of
serv
ice
1 ev
ery
60 m
onth
s fro
m la
st d
ate
of se
rvic
e1
ever
y 60
mon
ths f
rom
last
dat
e of
serv
ice
1 ev
ery
60 m
onth
s fro
m la
st d
ate
of se
rvic
e1
ever
y 60
mon
ths f
rom
last
dat
e of
serv
ice
1 ev
ery
60 m
onth
s fro
m la
st d
ate
of se
rvic
e1
ever
y 60
mon
ths f
rom
last
dat
e of
serv
ice
1 ev
ery
60 m
onth
s fro
m la
st d
ate
of se
rvic
e1
ever
y 60
mon
ths f
rom
last
dat
e of
serv
ice
1 ev
ery
60 m
onth
s fro
m la
st d
ate
of se
rvic
e
1 ev
ery
60 m
onth
s fro
m la
st d
ate
of se
rvic
e1
ever
y 60
mon
ths f
rom
last
dat
e of
serv
ice
1 ev
ery
60 m
onth
s fro
m la
st d
ate
of se
rvic
e1
ever
y 12
mon
ths f
rom
last
dat
e of
serv
ice
1 ev
ery
12 m
onth
s fro
m la
st d
ate
of se
rvic
e1
ever
y 60
mon
ths f
rom
last
dat
e of
serv
ice
1 ev
ery
60 m
onth
s fro
m la
st d
ate
of se
rvic
e1
ever
y 60
mon
ths f
rom
last
dat
e of
serv
ice
1 ev
ery
60 m
onth
s fro
m la
st d
ate
of se
rvic
e
1 ev
ery
12 m
onth
s fro
m la
st d
ate
of se
rvic
e1
ever
y 12
mon
ths f
rom
last
dat
e of
serv
ice
1 ev
ery
12 m
onth
s fro
m la
st d
ate
of se
rvic
e1
ever
y 60
mon
ths f
rom
last
dat
e of
serv
ice
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
No
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
No
No
No
No
No
No
No
No
Yes
No
No
No
No
No
reta
iner
cro
wn-
porc
elai
n/ce
ram
icre
tain
er c
row
n - p
orce
lain
fuse
d to
hig
h no
ble
met
alre
tain
er c
row
n - p
orce
lain
fuse
d to
pre
dom
inan
tly b
ase
met
alre
tain
er c
row
n - p
orce
lain
fuse
d to
nob
le m
etal
reta
iner
onl
ay -
cast
pre
dom
inan
tly b
ase
met
al, t
hree
or m
ore
surf
aces
reta
iner
onl
ay -
cast
nob
le m
etal
, tw
o su
rfac
esre
tain
er o
nlay
- ca
st n
oble
met
al, t
hree
or m
ore
surf
aces
reta
iner
inla
y - t
itani
umre
tain
er o
nlay
- tit
aniu
m
reta
iner
cro
wn
- ind
irect
resi
n ba
sed
com
posi
te (n
ot to
be
used
as a
tem
pora
ry o
r pro
visi
onal
cro
wn)
reta
iner
cro
wn
- res
in w
ith h
igh
nobl
e m
etal
reta
iner
cro
wn
- res
in w
ith p
redo
min
antly
bas
e m
etal
reta
iner
cro
wn
- res
in w
ith n
oble
met
al
reta
iner
inla
y - c
ast p
redo
min
antly
bas
e m
etal
, tw
o su
rfac
esre
tain
er in
lay
- cas
t pre
dom
inan
tly b
ase
met
al, t
hree
or m
ore
surf
aces
reta
iner
inla
y - c
ast n
oble
met
al, t
wo
surf
aces
reta
iner
inla
y - c
ast n
oble
met
al, t
hree
or m
ore
surf
aces
reta
iner
onl
ay -
porc
elai
n/ce
ram
ic, t
wo
surf
aces
reta
iner
onl
ay -
porc
elai
n/ce
ram
ic, t
hree
or m
ore
surf
aces
reta
iner
onl
ay -
cast
hig
h no
ble
met
al, t
wo
surf
aces
reta
iner
onl
ay -
cast
hig
h no
ble
met
al, t
hree
or m
ore
surf
aces
reta
iner
onl
ay -
cast
pre
dom
inan
tly b
ase
met
al, t
wo
surf
aces
pont
ic -
resi
n w
ith n
oble
met
al
prov
isio
nal p
ontic
- fu
rthe
r tre
atm
ent o
r com
plet
ion
of d
iagn
osis
nec
essa
ry p
rior t
o fin
al im
pres
sion
reta
iner
- ca
st m
etal
for r
esin
bon
ded
fixed
pro
sthe
sis
reta
iner
-por
cela
in/c
eram
ic fo
r res
in b
onde
d fix
ed p
rost
hesi
sre
sin
reta
iner
- fo
r res
in b
onde
d fix
ed p
rost
hesi
sre
tain
er in
lay-
porc
elai
n/ce
ram
ic, t
wo
surf
aces
reta
iner
inla
y - p
orce
lain
/cer
amic
, thr
ee o
r mor
e su
rfac
esre
tain
er in
lay
- cas
t hig
h no
ble
met
al, t
wo
surf
aces
reta
iner
inla
y - c
ast h
igh
nobl
e m
etal
, thr
ee o
r mor
e su
rfac
es
pont
ic -
cast
pre
dom
inan
tly b
ase
met
alpo
ntic
- ca
st n
oble
met
alpo
ntic
- tit
aniu
mpo
ntic
- po
rcel
ain
fuse
d to
hig
h no
ble
met
alpo
ntic
- po
rcel
ain
fuse
d to
pre
dom
inan
tly b
ase
met
alpo
ntic
- po
rcel
ain
fuse
d to
nob
le m
etal
pont
ic-p
orce
lain
/cer
amic
pont
ic -
resi
n w
ith h
igh
nobl
e m
etal
pont
ic -
resi
n w
ith p
redo
min
antly
bas
e m
etal
inte
rim p
artia
l den
ture
(man
dibu
lar)
tissu
e co
nditi
onin
g, m
axill
ary
tissu
e co
nditi
onin
g, m
andi
bula
rO
verd
entu
re-c
ompl
ete
max
illar
yO
verd
entu
re-p
artia
l max
illar
yO
verd
entu
re -
com
plet
e m
andi
bula
rO
verd
entu
re-p
artia
l man
dibu
lar
pont
ic -
indi
rect
resi
n ba
sed
com
posi
tepo
ntic
- ca
st h
igh
nobl
e m
etal
relin
e co
mpl
ete
man
dibu
lar d
entu
re (l
abor
ator
y)re
line
max
illar
y pa
rtia
l den
ture
(lab
orat
ory)
relin
e m
andi
bula
r par
tial d
entu
re (l
abor
ator
y)in
terim
com
plet
e de
ntur
e (m
axill
ary)
inte
rim c
ompl
ete
dent
ure
(man
dibu
lar)
inte
rim p
artia
l den
ture
(max
illar
y)
D675
0D6
751
D675
2
D661
4D6
615
D662
4D6
634
D671
0D6
720
D672
1D6
722
D674
0
D660
5D6
606
D660
7D6
608
D660
9D6
610
D661
1D6
612
D661
3
D625
3D6
545
D654
8D6
549
D660
0D6
601
D660
2D6
603
D660
4
D621
2D6
214
D624
0D6
241
D624
2D6
245
D625
0D6
251
D625
2
D585
0D5
851
D586
3D5
864
D586
5D5
866
D620
5D6
210
D621
1
D575
1D5
760
D576
1D5
810
D581
1D5
820
D582
1
263
1 pe
r too
th1
per t
ooth
1 pe
r too
th1
per t
ooth
1 pe
r too
th1
per t
ooth
1 pe
r too
th1
per t
ooth
1 pe
r life
time
per t
ooth
unlim
ited
unlim
ited
unlim
ited
unlim
ited
1 ev
ery
60 m
onth
s fro
m la
st d
ate
of se
rvic
e1
ever
y 60
mon
ths f
rom
last
dat
e of
serv
ice
1 pe
r too
th1
per t
ooth
1 pe
r life
time
per t
ooth
1 pe
r life
time
per t
ooth
1 pe
r life
time
per t
ooth
1 pe
r life
time
per t
ooth
1 pe
r life
time
per t
ooth
1 pe
r too
th1
per t
ooth
1 pe
r too
th1
per t
ooth
1 pe
r life
time
per t
ooth
1 pe
r life
time
per t
ooth
1 pe
r life
time
per t
ooth
1 pe
r life
time
per t
ooth
1 pe
r life
time
per t
ooth
1 pe
r life
time
per t
ooth
1 pe
r life
time
per t
ooth
1 pe
r too
th1
per l
ifetim
e pe
r too
th
1 ev
ery
60 m
onth
s fro
m la
st d
ate
of se
rvic
e1
ever
y 60
mon
ths f
rom
last
dat
e of
serv
ice
1 ev
ery
60 m
onth
s fro
m la
st d
ate
of se
rvic
e1
ever
y 60
mon
ths f
rom
last
dat
e of
serv
ice
1 ev
ery
60 m
onth
s fro
m la
st d
ate
of se
rvic
e1
ever
y 60
mon
ths f
rom
last
dat
e of
serv
ice
unlim
ited
1 ev
ery
6 m
onth
s fro
m la
st d
ate
of se
rvic
e1
per l
ifetim
e pe
r too
th
1 ev
ery
60 m
onth
s fro
m la
st d
ate
of se
rvic
e1
ever
y 60
mon
ths f
rom
last
dat
e of
serv
ice
1 ev
ery
60 m
onth
s fro
m la
st d
ate
of se
rvic
e
No
No
No
No
No
No
No
No
No
No
No
No
No
No
Yes
Yes
No
No
Yes
No
No
No
No
No
No
No
No
No
No
No
No
No
Yes
No
Yes
Yes
Yes
Yes
Yes
No
No
No
No
Yes
Yes
Yes
Yes
rem
oval
of b
enig
n od
onto
geni
c cy
st o
r tum
or -
lesi
on d
iam
eter
gre
ater
than
1.2
5 cm
rem
oval
of b
enig
n no
nodo
ntog
enic
cys
t or t
umor
- le
sion
dia
met
er u
p to
1.2
5 cm
rem
oval
of b
enig
n no
nodo
ntog
enic
cys
t or t
umor
- le
sion
dia
met
er g
reat
er th
an 1
.25
cmre
mov
al o
f tor
us p
alat
inus
rem
oval
of t
orus
man
dibu
laris
inci
sion
and
dra
inag
e of
abs
cess
- in
trao
ral s
oft t
issu
e
alve
opla
sty
in c
onju
nctio
n w
ith e
xtra
ctio
n - o
ne to
thre
e te
eth
or to
oth
spac
es, p
er q
uadr
ant
alve
olop
last
y no
t in
conj
unct
ion
with
ext
ract
ions
- fo
ur o
r mor
e te
eth
or to
oth
spac
es, p
er q
uadr
ant
alve
opla
sty
not i
n co
njun
ctio
n w
ith e
xtra
ctio
n - o
ne to
thre
e te
eth
or to
oth
spac
es, p
er q
uadr
ant
vest
ibul
opla
sty
- rid
ge e
xten
sion
(sec
onda
ry e
pith
elia
lizat
ion)
vest
ibul
opla
sty
- rid
ge e
xten
sion
(inc
ludi
ng so
ft ti
ssue
gra
fts,
mus
cle
reat
tach
men
t, re
visi
on o
f sof
t ex
cisi
on o
f ben
ign
lesi
on u
p to
1.2
5 cm
exci
sion
of b
enig
n le
sion
gre
ater
than
1.2
5 cm
exci
sion
of b
enig
n le
sion
, com
plic
ated
rem
oval
of b
enig
n od
onto
geni
c cy
st o
r tum
or -
lesi
on d
iam
eter
up
to 1
.25
cm
surg
ical
acc
ess o
f an
uner
upte
d to
oth
mob
iliza
tion
of e
rupt
ed o
r mal
posi
tione
d to
oth
to a
id e
rupt
ion
plac
emen
t of d
evic
e to
faci
litat
e er
uptio
n of
impa
cted
toot
hin
cisi
onal
bio
psy
of o
ral t
issu
e - h
ard
(bon
e, to
oth)
inci
sion
al b
iops
y of
ora
l tis
sue
- sof
t (al
l oth
ers)
exfo
lliat
ive
cyto
logi
cal s
ampl
e co
llect
ion
brus
h bi
opsy
- tr
ans e
pith
elia
l sam
ple
colle
ctio
ntr
ans s
epta
l fib
erot
omy/
supr
a cr
usta
l fib
erot
omy,
by
repo
rt
alve
olop
last
y in
con
junc
tion
with
ext
ract
ions
- fo
ur o
r mor
e te
eth
or to
oth
spac
es, p
er q
uadr
ant
rem
oval
of i
mpa
cted
toot
h - s
oft t
issue
rem
oval
of i
mpa
cted
toot
h - p
artia
lly b
ony
rem
oval
of i
mpa
cted
toot
h - c
ompl
etel
y bo
nyre
mov
al o
f im
pact
ed to
oth
- com
plet
ely
bony
, with
unu
sual
surg
ical
surg
ical
rem
oval
of r
esid
ual t
ooth
root
s (cu
ttin
g pr
oced
ure)
oroa
ntra
l fis
tula
clo
sure
prim
ary
clos
ure
of a
sinu
s per
fora
tion
toot
h re
impl
anta
tion
and/
or st
abili
zatio
n of
acc
iden
tally
avu
lsed
or d
ispl
aced
toot
h
toot
h tr
ansp
lant
atio
n (in
clud
es re
impl
anta
tion
from
one
site
to a
noth
er a
nd sp
lintin
g an
d/or
st
abili
zatio
n)
reta
iner
cro
wn
- ful
l cas
t pre
dom
inan
tly b
ase
met
alre
tain
er c
row
n - f
ull c
ast n
oble
met
alpr
ovis
iona
l ret
aine
r cro
wn-
furt
her t
reat
men
t or c
ompl
etio
n of
dia
gnos
is n
eces
sary
prio
r to
final
im
pres
sion
reta
iner
cro
wn
- tita
nium
rece
men
t or r
e-bo
nd fi
xed
part
ial d
entu
refix
ed p
artia
l den
ture
repa
ir, n
eces
sita
ted
by re
stor
ativ
e m
ater
ial f
ailu
reex
trac
tion,
cor
onal
rem
nant
s - d
ecid
uous
toot
hex
trac
tion,
eru
pted
toot
h or
exp
osed
root
(ele
vatio
n an
d/or
forc
eps r
emov
al)
surg
ical
rem
oval
of e
rupt
ed to
oth
req
rem
oval
of b
one,
sect
ioni
ng o
f too
th a
nd in
clud
ing
elev
atio
n of
m
ucop
erio
stea
l fla
p
reta
iner
cro
wn
- 3/4
cas
t hig
h no
ble
met
alre
tain
er c
row
n-3/
4 ca
st p
redo
min
atel
y ba
sed
met
alre
tain
er c
row
n-3/
4 ca
st n
oble
met
alre
tain
er c
row
n-3/
4 po
rcel
ain/
cera
mic
reta
iner
cro
wn
- ful
l cas
t hig
h no
ble
met
al
D746
0
D746
1D7
472
D747
3D7
510
D732
0
D732
1D7
340
D735
0D7
410
D741
1D7
412
D745
0D7
451
D728
2D7
283
D728
5D7
286
D728
7D7
288
D729
1
D731
0
D731
1
D723
0D7
240
D724
1D7
250
D726
0D7
261
D727
0
D727
2D7
280
D679
2
D679
3D6
794
D693
0D6
980
D711
1D7
140
D721
0D7
220
D678
0D6
781
D678
2D6
783
D679
0D6
791
264264
Prov
ider
Cla
im D
ispu
tes
unlim
ited
unlim
ited
1 ev
ery
36 m
onth
s fro
m la
st d
ate
of se
rvic
e1
ever
y 12
mon
ths f
rom
last
dat
e of
serv
ice
1 ev
ery
6 m
onth
s fro
m la
st d
ate
of se
rvic
e1
ever
y 60
mon
ths f
rom
last
dat
e of
serv
ice
unlim
ited
unlim
ited
unlim
ited
unlim
ited
unlim
ited
unlim
ited
unlim
ited
unlim
ited
1 pe
r too
th1
per t
ooth
unlim
ited
unlim
ited
1 ev
ery
36 m
onth
s fro
m la
st d
ate
of se
rvic
e1
ever
y 36
mon
ths f
rom
last
dat
e of
serv
ice
unlim
ited
1 pe
r life
time
per t
ooth
unlim
ited
1 ev
ery
60 m
onth
s fro
m la
st d
ate
of se
rvic
eun
limite
dun
limite
d
1 pe
r too
th
1 pe
r too
th1
per t
ooth
1 pe
r too
th1
per t
ooth
1 pe
r too
th1
ever
y 6
mon
ths f
rom
last
dat
e of
serv
ice
1 pe
r life
time
per t
ooth
unlim
ited
1 pe
r too
th
No
No
No
No
No
No
No
Yes
Yes
Yes
Yes
No
No
No
No
No
No
No
Yes
No
No
No
No
No
No
No
No
No
No
No
No
No
Yes
Yes
No
No
occl
usal
gua
rd, b
y re
port
repa
ir an
d/or
relin
e of
occ
lusa
l gua
rds
occl
usal
adj
ustm
ent
occl
usio
n an
alys
is -
mou
nted
cas
eoc
clus
al a
djus
tmen
t - li
mite
doc
clus
al a
djus
tmen
t - c
ompl
ete
inha
latio
n of
nitr
ous o
xide
/anx
ioly
sis a
nalg
esia
intr
aven
ous m
oder
ate
(con
scio
us) s
edat
ion/
anal
gesi
a-ea
ch 1
5 m
inut
e in
crem
ent
non-
intr
aven
ous c
onsc
ious
seda
tion.
Thi
s inc
lude
s non
-iv m
inim
al a
nd m
oder
ate
seda
tion.
cons
ulta
tion
(dia
gnos
tic se
rvic
e pr
ovid
ed b
y de
ntis
t or p
hysi
cian
oth
er th
an p
ract
ition
er p
rovi
ding
tr
eatm
ent)
ther
apeu
tic p
aren
tera
l dru
g, si
ngle
adm
inis
trat
ion
ther
apeu
tic p
aren
tera
l dru
gs, t
wo
or m
ore
adm
inis
trat
ions
, diff
eren
t med
icat
ions
othe
r dru
gs a
nd/o
r med
icam
ents
, by
repo
rtap
plic
atio
n of
des
ensi
tizin
g m
edic
amen
tap
plic
atio
n of
des
ensi
tizin
g re
sin
for c
ervi
cal a
nd/o
r roo
t sur
face
, per
toot
h
exci
sion
of p
eric
oron
al g
ingi
vasu
rgic
al re
duct
ion
of fi
brou
s tub
eros
ity
appl
ianc
e re
mov
al (n
ot b
y de
ntis
t who
pla
ced
appl
ianc
e), i
nclu
des r
emov
al o
f arc
hbar
palli
ativ
e (e
mer
genc
y) tr
eatm
ent o
f den
tal p
ain
- min
or p
roce
dure
fixed
par
tial d
entu
re se
ctio
ning
loca
l ane
sthe
sia
not i
n co
njun
ctio
n w
ith o
pera
tive
or su
rgic
al p
roce
dure
slo
cal a
nest
hesi
a in
con
junc
tion
with
ope
rativ
e or
surg
ical
pro
cedu
res
eval
uatio
n fo
r dee
p se
datio
n or
gen
eral
ane
sthe
sia
deep
seda
tion/
gene
ral a
nest
hesi
a-ea
ch 1
5 m
inut
e in
crem
ent
rem
oval
of f
orei
gn b
ody
from
muc
osa,
skin
, or s
ubcu
tane
ous a
lveo
lar t
issu
ere
mov
al o
f rea
ctio
n-pr
oduc
ing
fore
ign
bodi
es -
mus
culo
skel
etal
syst
empa
rtia
l ost
ecto
my/
sequ
estr
ecto
my
for r
emov
al o
f non
-vita
l bon
em
axill
ary
sinus
otom
y fo
r rem
oval
of t
ooth
frag
men
t or f
orei
gn b
ody
occl
usal
ort
hotic
dev
ice
adju
stm
ent
Bone
repl
acem
ent g
raft
for r
idge
pre
serv
atio
n - p
er si
te
fren
ulec
tom
y (fr
enec
tom
y or
fren
otom
y) -
sepa
rate
pro
cedu
re n
ot in
cide
ntal
to a
noth
er p
roce
dure
fren
ulop
last
yex
cisi
on o
f hyp
erpl
astic
tiss
ue -
per a
rch
inci
sion
and
dra
inag
e of
abs
cess
- in
trao
ral s
oft t
issu
e - c
ompl
icat
ed (i
nclu
des d
rain
age
of m
ultip
le
fasc
ial s
pace
s)in
cisi
on a
nd d
rain
age
of a
bsce
ss -
extr
aora
l sof
t tis
sue
inci
sion
and
dra
inag
e of
abs
cess
- ex
trao
ral s
oft t
issu
e - c
ompl
icat
ed (i
nclu
des d
rain
age
of m
ultip
le
fasc
ial s
pace
s)
D994
2D9
943
D995
0D9
951
D995
2
D924
3
D924
8
D931
0D9
610
D961
2D9
630
D991
0D9
911
D994
0
D797
2
D799
7D9
110
D912
0D9
210
D921
5D9
219
D922
3D9
230
D788
1D7
953
D796
0D7
963
D797
0D7
971
D751
1D7
520
D752
1D7
530
D754
0D7
550
D756
0
The
Plat
inum
Rid
er D
enta
l sup
plem
enta
l ben
efit
cove
rs th
e de
ntal
cod
es li
sted
abo
ve. T
his s
uppl
emen
tal b
enef
it is
offe
red
to m
embe
rs th
at a
re e
nrol
led
in C
are
Impr
ovem
ent P
lus,
AAR
P M
edic
areC
ompl
ete,
Uni
tedH
ealth
care
M
edic
areC
ompl
ete
and
Uni
tedH
ealth
care
Ass
iste
d Li
ving
Pla
ns. P
rovi
der p
aym
ent i
s mad
e on
a F
ee-fo
r-Se
rvic
e ba
sis.
Mem
bers
hav
e In
-net
wor
k an
d O
ut-o
f-net
wor
k be
nefit
s. S
ome
serv
ices
requ
ire p
rior a
utho
rizat
ion.
The
$10
00
annu
al m
axim
um a
pplie
s to
cove
red
prev
entiv
e an
d co
mpr
ehen
sive
ben
efits
. Mem
ber c
an b
e bi
lled
for s
ervi
ces o
ver t
he $
1000
ann
ual m
axim
um b
enef
it. T
here
is n
o m
embe
r cop
ay. T
here
is n
o co
insu
ranc
e or
ded
uctib
le fo
r pr
even
tive
and
diag
nost
ic se
rvic
es. T
here
is a
$10
0 in
divi
dual
ded
uctib
le th
at a
pplie
s to
com
preh
ensiv
e be
nefit
s. T
here
is a
20%
coi
nsur
ance
for m
inor
rest
orat
ive/
adju
nctiv
e se
rvic
es a
nd 5
0% c
oins
uran
ce fo
r maj
or d
enta
l ser
vice
s (E
ndod
ontic
s, P
erio
dont
ics a
nd O
ral S
urge
ry).
Dent
al P
rovi
ders
with
com
plai
nts a
re to
con
tact
Uni
tedH
ealth
care
Den
tal’s
Pro
vide
r Ser
vice
dep
artm
ent a
t (87
7) 8
16-3
596.
Net
wor
k Pr
ovid
er c
ontr
actu
al d
ispu
tes,
Out
-of-N
etw
ork
prov
ider
dis
pute
s, a
nd re
proc
essi
ng re
ques
ts w
ill b
e lo
gged
into
the
appe
als d
atab
ase.
Ple
ase
mai
l to
the
Appe
als &
Grie
vanc
es P
O B
ox li
sted
abo
ve. R
esea
rch
and
reso
lutio
n w
ill b
e co
mpl
eted
with
in 3
0 ca
lend
ar d
ays.
265
Mem
ber A
ppea
ls &
Grie
vanc
es
Prio
r Aut
horiz
atio
n Re
ques
ts
Nat
iona
l_FA
CETS
D00
1337
, D00
1506
7_Pk
g DN
055,
56,
57,
62_
Plat
inum
Den
tal-F
FS28
09/2
016
Mai
l mem
ber a
ppea
ls to
: Uni
tedH
ealth
care
, Att
n: A
ppea
l Dep
artm
ent,
MS
CA12
4-01
57, P
O B
ox 6
106,
Cyp
ress
, CA
9063
0
“Prio
r Aut
horiz
atio
n re
quire
d” m
eans
the
prac
titio
ner m
ust s
ubm
it th
ose
proc
edur
es fo
r app
rova
l with
clin
ical
doc
umen
tatio
n su
ppor
ting
nece
ssity
bef
ore
perf
orm
ing
thos
e pr
oced
ures
. To
do th
is c
ompl
ete
a st
anda
rd A
DA c
laim
fo
rm a
nd c
heck
the
box
mar
ked
“Pre
-Tre
atm
ent E
STIM
ATE.
” Pr
ior a
utho
rizat
ion
requ
est c
an b
e su
bmitt
ed v
ia th
e pr
ovid
er w
eb p
orta
l (at
ww
w.m
yuhc
prov
ider
s.co
m),
subm
itted
ele
ctro
nica
lly v
ia y
our c
lear
ingh
ouse
, or s
impl
y m
ail t
he
form
, to
the
belo
w a
ddre
ss, a
long
with
any
requ
ired
supp
lem
enta
l inf
orm
atio
n (fi
lms,
nar
rativ
e, p
erio
-cha
rtin
g, e
tc.).
You
r offi
ce w
ill th
en re
ceiv
e an
Exp
lana
tion
of B
enef
its (E
OB)
out
linin
g th
e de
nial
or a
ppro
val o
f req
uest
ed
trea
tmen
t and
pla
n pa
ymen
t am
ount
s whe
n ap
plic
able
.
Mem
ber a
ppea
ls a
re re
view
ed b
y th
e he
alth
pla
n, a
nd a
re n
ot d
eleg
ated
to U
HC D
enta
l. Al
l Mem
ber a
ppea
ls (i
nclu
des P
re-S
ervi
ce a
ppea
ls, I
n N
etw
ork
Prov
ider
app
eals
, and
Out
of N
etw
ork
prov
ider
app
eals
) rec
eive
d by
UHC
Den
tal
will
be
forw
arde
d to
the
heal
th p
lan
via
over
nigh
t mai
l, w
ithin
7 d
ays o
f rec
eipt
of t
he a
ppea
l.
266266
267
“Prio
r Aut
horiz
atio
n re
quire
d” m
eans
the
prac
titio
ner m
ust s
ubm
it th
ose
proc
edur
es fo
r app
rova
l with
clin
ical
doc
umen
tatio
n su
ppor
ting
nece
ssity
bef
ore
perf
orm
ing
thos
e pr
oced
ures
. To
do th
is c
ompl
ete
a st
anda
rd
ADA
clai
m fo
rm a
nd c
heck
the
box
mar
ked
“Pre
-Tre
atm
ent E
STIM
ATE.
” Pr
ior a
utho
rizat
ion
requ
est c
an b
e su
bmitt
ed v
ia th
e pr
ovid
er w
eb p
orta
l (at
ww
w.m
yuhc
prov
ider
s.co
m),
subm
itted
ele
ctro
nica
lly v
ia y
our
Dent
al P
rovi
ders
with
com
plai
nts a
re to
con
tact
Uni
tedH
ealth
care
Den
tal’s
Pro
vide
r Ser
vice
dep
artm
ent a
t
268268
269
270270
“Prio
r Aut
horiz
atio
n re
quire
d” m
eans
the
prac
titio
ner m
ust s
ubm
it th
ose
proc
edur
es fo
r app
rova
l with
clin
ical
doc
umen
tatio
n su
ppor
ting
nece
ssity
bef
ore
perf
orm
ing
thos
e pr
oced
ures
. To
do th
is c
ompl
ete
a st
anda
rd
ADA
clai
m fo
rm a
nd c
heck
the
box
mar
ked
“Pre
-Tre
atm
ent E
STIM
ATE.
” Pr
ior a
utho
rizat
ion
requ
est c
an b
e su
bmitt
ed v
ia th
e pr
ovid
er w
eb p
orta
l (at
ww
w.m
yuhc
prov
ider
s.co
m),
subm
itted
ele
ctro
nica
lly v
ia y
our
Dent
al P
rovi
ders
with
com
plai
nts a
re to
con
tact
Uni
tedH
ealth
care
Den
tal’s
Pro
vide
r Ser
vice
dep
artm
ent a
t
271
272272
273
274274
“Prio
r Aut
horiz
atio
n re
quire
d” m
eans
the
prac
titio
ner m
ust s
ubm
it th
ose
proc
edur
es fo
r app
rova
l with
clin
ical
doc
umen
tatio
n su
ppor
ting
nece
ssity
bef
ore
perf
orm
ing
thos
e pr
oced
ures
. To
do th
is c
ompl
ete
a st
anda
rd
ADA
clai
m fo
rm a
nd c
heck
the
box
mar
ked
“Pre
-Tre
atm
ent E
STIM
ATE.
” Pr
ior a
utho
rizat
ion
requ
est c
an b
e su
bmitt
ed v
ia th
e pr
ovid
er w
eb p
orta
l (at
ww
w.m
yuhc
prov
ider
s.co
m),
subm
itted
ele
ctro
nica
lly v
ia y
our
Dent
al P
rovi
ders
with
com
plai
nts a
re to
con
tact
Uni
tedH
ealth
care
Den
tal’s
Pro
vide
r Ser
vice
dep
artm
ent a
t
275
276276
$180
0 An
nual
Max
imum
Iden
tific
atio
n Ca
rds
Sam
ple
Mem
ber I
D C
ard*
Fron
t of c
ard
Back
of c
ard
Impo
rtan
t Tel
epho
ne N
umbe
rs &
Web
site
s
Impo
rtan
t Add
ress
es
Impo
rtan
t Ele
ctro
nic
Clai
ms &
Prio
r Aut
horiz
atio
n Su
bmis
sion
Info
rmat
ion
5213
3
Clai
ms
Prio
r Aut
horiz
atio
n
Appe
als &
Grie
vanc
es
UHC
Med
icar
e Cl
aim
s, P
O B
ox 3
0567
, Sal
t Lak
e Ci
ty, U
T 8
4130
-056
7U
HC M
edic
are
Auth
oriza
tions
, PO
Box
305
52, S
alt L
ake
City
, UT
841
30-0
552
UHC
Med
icar
e Co
mpl
aint
s, G
rieva
nces
& A
ppea
ls, P
O B
ox 3
0569
Salt
Lake
City
, UT
8413
0-05
69
Prov
ider
Rea
son
for M
ailin
g
EDI P
ayer
Num
ber f
or C
laim
s Sub
mitt
ed
Prov
ider
Qui
ck R
efer
ence
Gui
de -
Effe
ctiv
e 1/
1/20
17U
nite
dHea
lthca
re N
ursi
ng H
ome
Plan
, Ass
iste
d Li
ving
Pla
n
Ariz
ona,
Col
orad
o an
d Fl
orid
a
24 h
ours
a d
ayCe
nter
s for
Med
icai
d an
d M
edic
are
Serv
ices
ww
w.c
ms.
hhs.
gov
24 h
ours
a d
ay
*Ple
ase
note
that
the
Med
ical
ID C
ard
is un
iver
sal a
nd in
clud
es a
ll lin
es o
f cov
erag
e. T
he M
edic
al p
lan
can
be H
MO
or P
PO a
nd th
is d
oes n
ot re
flect
the
Dent
al P
lan
Bene
fits.
Ple
ase
flip
the
ID C
ard
over
to se
e th
e De
ntal
Pr
ovid
er in
form
atio
n on
the
back
(i.e
. car
rier w
ebsi
te a
nd to
ll-fr
ee n
umbe
r). T
his i
nfor
mat
ion
can
be u
sed
to c
onfir
m p
rovi
der p
artic
ipat
ion,
mem
ber e
ligib
ility
and
ben
efits
. Thi
s is a
SAM
PLE
ID C
ard
and
may
diff
er fr
om
the
mem
ber's
ID C
ard.
Elig
ibili
ty,
Bene
fits,
Cla
im(s
) and
Aut
horiz
atio
ns87
7-81
6-35
96Li
ve A
gent
: Mon
day
- Frid
ay, 8
:00A
M -
6:00
PM, E
STIV
R: 2
4 ho
urs a
day
Call
to In
quire
Abo
utTe
leph
one
Num
ber
Hou
rs o
f Ope
ratio
n
Emai
l to
Inqu
ire A
bout
Web
site
Hou
rs o
f Ope
ratio
n
Med
icar
ew
ww
.med
icar
e.go
v24
hou
rs a
day
To d
iscu
ss y
our p
artic
ipat
ion,
con
trac
tual
issu
es, d
entis
t cha
nges
or o
ffice
upd
ates
800-
822-
5353
Live
Age
nt: M
onda
y - F
riday
, 8:0
0AM
- 11
:00P
M, E
ST
Elig
ibili
ty,
Bene
fits,
Cla
im(s
) and
Aut
horiz
atio
nsw
ww
.dbp
.com
277
Proc
edur
e Co
dePr
oced
ure
Des
crip
tion
Prio
r Aut
horiz
atio
n Re
quire
d?
D027
3D0
274
D033
0D1
110
D214
0
D012
0D0
140
D015
0D0
270
D027
2
D233
2D2
335
D911
0
D239
2
D215
0D2
160
D216
1D2
330
D233
1
D239
0D2
391
resi
n-ba
sed
com
posi
te -
thre
e su
rfac
es, a
nter
ior
resi
n-ba
sed
com
posi
te -
four
or m
ore
surf
aces
or i
nvol
ving
inci
sal a
ngle
(ant
erio
r)re
sin-
base
d co
mpo
site
cro
wn,
ant
erio
rre
sin-
base
d co
mpo
site
- on
e su
rfac
e, p
oste
rior
resi
n-ba
sed
com
posi
te -
two
surf
aces
, pos
terio
r
bite
win
gs -
four
radi
ogra
phic
imag
espa
nora
mic
radi
ogra
phic
imag
epr
ophy
laxi
s - a
dult
D731
1
D434
1D4
342
D435
5D4
910
D711
1
D275
1D2
752
D279
1D2
792
D292
0D2
930
D293
1D2
940
D295
0D2
954
D714
0
D721
0D7
250
D731
0
D239
3D2
394
D271
0D2
740
D275
0
No
No
No
palli
ativ
e (e
mer
genc
y) tr
eatm
ent o
f den
tal p
ain
- min
or p
roce
dure
extr
actio
n, e
rupt
ed to
oth
or e
xpos
ed ro
ot (e
leva
tion
and/
or fo
rcep
s rem
oval
)su
rgic
al re
mov
al o
f eru
pted
toot
h re
q re
mov
al o
f bon
e, se
ctio
ning
of t
ooth
and
incl
udin
g el
evat
ion
of
muc
oper
iost
eal f
lap
surg
ical
rem
oval
of r
esid
ual t
ooth
root
s (cu
ttin
g pr
oced
ure)
alve
olop
last
y in
con
junc
tion
with
ext
ract
ions
- fo
ur o
r mor
e te
eth
or to
oth
spac
es, p
er q
uadr
ant
alve
opla
sty
in c
onju
nctio
n w
ith e
xtra
ctio
n - o
ne to
thre
e te
eth
or to
oth
spac
es, p
er q
uadr
ant
perio
dont
al sc
alin
g an
d ro
ot p
lann
ing
- fou
r or m
ore
teet
h pe
r qua
dran
tpe
riodo
ntal
scal
ing
and
root
pla
nnin
g - o
ne -
thre
e te
eth,
per
qua
dran
tfu
ll m
outh
deb
ridem
ent t
o en
able
com
preh
ensi
ve e
valu
atio
n an
d di
agno
sis
perio
dont
al m
aint
enan
ceex
trac
tion,
cor
onal
rem
nant
s - d
ecid
uous
toot
h
pref
abric
ated
stai
nles
s ste
el c
row
n - p
rimar
y to
oth
pref
abric
ated
stai
nles
s ste
el c
row
n - p
erm
anen
t too
thpr
otec
tive
rest
orat
ion
Core
bui
ldup
, inc
ludi
ng a
ny p
ins w
hen
requ
ired
pref
abric
ated
pos
t and
cor
e in
add
ition
to c
row
n
crow
n - p
orce
lain
fuse
d to
pre
dom
inan
tly b
ase
met
alcr
own
- por
cela
in fu
sed
to n
oble
met
alcr
own
- ful
l cas
t pre
dom
inan
tly b
ase
met
alcr
own
- ful
l cas
t nob
le m
etal
rece
men
t or r
e-bo
nd c
row
n
No
No
No
amal
gam
- on
e su
rfac
e, p
rimar
y or
per
man
ent
crow
n - p
orce
lain
fuse
d to
hig
h no
ble
met
al
No
No
No
No
No
No
resi
n-ba
sed
com
posi
te -
four
or m
ore
surf
aces
, pos
terio
rcr
own,
resi
n-ba
sed
com
posi
te (i
ndire
ct)
crow
n - p
orce
lain
/cer
amic
subs
trat
e
No
No
No
No
perio
dic
oral
eva
luat
ion
limite
d or
al e
valu
atio
n - p
robl
em fo
cuse
dco
mpr
ehen
sive
ora
l eva
luat
ion
- new
or e
stab
lishe
d pa
tient
bite
win
g - s
ingl
e ra
diog
raph
ic im
age
bite
win
gs -
two
radi
ogra
phic
imag
esbi
tew
ings
- th
ree
radi
ogra
phic
imag
es
No
No
No
No
No
No
No
No
No
No
No
No
No
No
unlim
ited
unlim
ited
No
No
unlim
ited
unlim
ited
unlim
ited
unlim
ited
unlim
ited
unlim
ited
unlim
ited
unlim
ited
unlim
ited
unlim
ited
No
No
No
No
No
No
No
No
No
No
2 ev
ery
year
unlim
ited
2 ev
ery
year
unlim
ited
unlim
ited
unlim
ited
unlim
ited
unlim
ited
unlim
ited
unlim
ited
unlim
ited
unlim
ited
unlim
ited
unlim
ited
unlim
ited
unlim
ited
2 ev
ery
year
2 ev
ery
year
2 ev
ery
year
2 ev
ery
year
1 ev
ery
36 m
onth
s fro
m la
st d
ate
of se
rvic
e2
ever
y ye
ar
Cove
red
Den
tal S
ervi
ces:
Mos
t den
tal s
ervi
ces i
nclu
ding
Pre
vent
ive,
Dia
gnos
tic, R
esto
rativ
e, E
ndod
ontic
s, P
erio
dont
ics,
Ext
ract
ions
, Ora
l Sur
gery
, and
Pro
stho
dont
ics a
re c
over
ed. O
rtho
dont
ics a
nd c
osm
etic
se
rvic
es a
re n
ot c
over
ed. T
he b
elow
is a
list
of s
ome
of th
e co
vere
d co
des.
amal
gam
- tw
o su
rfac
es, p
rimar
y or
per
man
ent
amal
gam
- th
ree
surf
aces
, prim
ary
or p
erm
anen
tam
alga
m -
four
or m
ore
surf
aces
, prim
ary
or p
erm
anen
t
unlim
ited
unlim
ited
unlim
ited
unlim
ited
unlim
ited
unlim
ited
unlim
ited
unlim
ited
unlim
ited
unlim
ited
unlim
ited
unlim
ited
resi
n-ba
sed
com
posi
te -
one
surf
ace,
ant
erio
rre
sin-
base
d co
mpo
site
- tw
o su
rfac
es, a
nter
ior
No
No
No
No
resi
n-ba
sed
com
posi
te -
thre
e su
rfac
es, p
oste
rior
Freq
uenc
y/Li
mita
tions
278278
Prov
ider
Cla
im D
ispu
tes
Mem
ber A
ppea
ls &
Grie
vanc
es
Prio
r Aut
horiz
atio
n Re
ques
ts
AZ, C
O, F
L_FA
CETS
D00
1477
7_Pk
g DT
052_
DT00
1-P1
800a
-FFS
28
09/2
016
Mai
l mem
ber a
ppea
ls to
: Uni
tedH
ealth
care
, Att
n: A
ppea
ls a
nd G
rieva
nce
Depa
rtm
ent,
PO B
ox 6
106,
MS
CA12
4-01
57, C
ypre
ss, C
A 90
630
“Prio
r Aut
horiz
atio
n re
quire
d” m
eans
the
prac
titio
ner m
ust s
ubm
it th
ose
proc
edur
es fo
r app
rova
l with
clin
ical
doc
umen
tatio
n su
ppor
ting
nece
ssity
bef
ore
perf
orm
ing
thos
e pr
oced
ures
. To
do th
is c
ompl
ete
a st
anda
rd
ADA
clai
m fo
rm a
nd c
heck
the
box
mar
ked
“Pre
-Tre
atm
ent E
STIM
ATE.
” Pr
ior a
utho
rizat
ion
requ
est c
an b
e su
bmitt
ed v
ia th
e pr
ovid
er w
eb p
orta
l (at
ww
w.m
yuhc
prov
ider
s.co
m),
subm
itted
ele
ctro
nica
lly v
ia y
our
clea
ringh
ouse
, or s
impl
y m
ail t
he fo
rm, t
o th
e be
low
add
ress
, alo
ng w
ith a
ny re
quire
d su
pple
men
tal i
nfor
mat
ion
(film
s, n
arra
tive,
per
io-c
hart
ing,
etc
.). Y
our o
ffice
will
then
rece
ive
an E
xpla
natio
n of
Ben
efits
(EO
B)
outli
ning
the
deni
al o
r app
rova
l of r
eque
sted
trea
tmen
t and
pla
n pa
ymen
t am
ount
s whe
n ap
plic
able
.
The
Uni
tedH
ealth
care
Nur
sing
Hom
e Pl
an a
nd A
ssis
ted
Livi
ng P
lan
cove
rs th
e de
ntal
cod
es li
sted
abo
ve. P
rovi
der p
aym
ent i
s mad
e on
a F
ee-fo
r-Se
rvic
e ba
sis.
Mem
bers
hav
e bo
th In
-Net
wor
k an
d O
ut-o
f-Net
wor
k co
vera
ge. S
ervi
ces d
o no
t req
uire
prio
r aut
horiz
atio
n. T
he d
enta
l pla
n ha
s a $
1800
ann
ual m
axim
um th
at a
pplie
s to
cove
red
prev
entiv
e an
d co
mpr
ehen
sive
ben
efits
. The
re is
no
mem
ber c
opay
, coi
nsur
ance
or
dedu
ctib
le. M
embe
r can
be
bille
d fo
r ser
vice
s ove
r the
$18
00 a
nnua
l max
imum
ben
efit.
Dent
al P
rovi
ders
with
com
plai
nts a
re to
con
tact
Uni
tedH
ealth
care
Den
tal’s
Pro
vide
r Ser
vice
dep
artm
ent a
t 877
-816
-359
6. N
etw
ork
Prov
ider
con
trac
tual
dis
pute
s, O
ut-o
f-Net
wor
k pr
ovid
er d
ispu
tes,
and
repr
oces
sing
re
ques
ts w
ill b
e lo
gged
into
the
appe
als d
atab
ase.
Ple
ase
mai
l to
the
Appe
als &
Grie
vanc
es P
O B
ox li
sted
abo
ve. R
esea
rch
and
reso
lutio
n w
ill b
e co
mpl
eted
with
in 3
0 ca
lend
ar d
ays.
Mem
ber a
ppea
ls a
re re
view
ed b
y th
e he
alth
pla
n, a
nd a
re n
ot d
eleg
ated
to U
HC D
enta
l. Al
l Mem
ber a
ppea
ls (i
nclu
des P
re-S
ervi
ce a
ppea
ls, I
n N
etw
ork
Prov
ider
app
eals
, and
Out
of N
etw
ork
prov
ider
app
eals
) rec
eive
d by
U
HC D
enta
l will
be
forw
arde
d to
the
heal
th p
lan
via
over
nigh
t mai
l, w
ithin
7 d
ays o
f rec
eipt
of t
he a
ppea
l.
279
280280
281
282282
“Prio
r Aut
horiz
atio
n re
quire
d” m
eans
the
prac
titio
ner m
ust s
ubm
it th
ose
proc
edur
es fo
r app
rova
l with
clin
ical
doc
umen
tatio
n su
ppor
ting
nece
ssity
bef
ore
perf
orm
ing
thos
e pr
oced
ures
. To
do th
is c
ompl
ete
a st
anda
rd
ADA
clai
m fo
rm a
nd c
heck
the
box
mar
ked
“Pre
-Tre
atm
ent E
STIM
ATE.
” Pr
ior a
utho
rizat
ion
requ
est c
an b
e su
bmitt
ed v
ia th
e pr
ovid
er w
eb p
orta
l (at
ww
w.m
yuhc
prov
ider
s.co
m),
subm
itted
ele
ctro
nica
lly v
ia y
our
Dent
al P
rovi
ders
with
com
plai
nts a
re to
con
tact
Uni
tedH
ealth
care
Den
tal’s
Pro
vide
r Ser
vice
dep
artm
ent a
t
283
284284
2017 Provider Quick Reference Guide for Medicare Advantage Plans
UnitedHealthcareAttn: Provider Quick Reference Guidec/o PCA15 W. Aylesbury Road, Suite 200Timonium, MD 21093
SAMPLE