Date: 18/10/2021
Reference: CG 08/2021
External Circular
Subject: Billing Guidelines for the 2018 Dental Code
(CDT) published on eClaimlink and Policy of Insurance
Coverage of Emergency Cases
To All health service providers (Dubai and Northern
Subject: Update (4) on Bed Occupancy data in Sheryan
Emirates) registered
and COVID on19
thePatients
insurance claims system
in HASANA
(Eclaim), and all HIPs (Insurers and TPAs).
The Dubai Health Authority extends its sincere thanks
and appreciation to all its strategic partners in the field of
health care and the health insurance system for their
contribution and efforts in providing better health care to
members of society.
With reference to the above subject and in continuation of
the efforts of the Dubai Health Authority, to improve the
quality of health care provided, ensure the upgrading of
various levels of services, and provide its strategic
partners with all developments related to the health
insurance system, and accordingly the authority is pleased
to attach the following:
1. Approved billing guidelines for the Current Dental
Terminology (CDT) 2018 code set; Advertised via the
insurance claims system (eClaimLink - Dubai Health
Authority.)
2. Policy of Insurance Coverage of Emergency Cases
‫تعميم خارجي‬
‫ إرشادات الفوترة لمجموعة رموز مصطلحات‬:‫الموضوع‬
‫( المعلنة عبر نظام المطالبات‬CDT) 2018 ‫األسنان الحالية‬
‫ وسياسة التغطية التأمينية للحاالت الطارئة‬، ‫التأمينية‬
‫ جميع مقدمي الخدمة الصحية (إمارة دبي واإلمارات‬: ‫إلى‬
Subject: Automated External Defibrillator Device
‫ وجميع‬،‫المطالبات التأمينية‬ ‫الشمالية) المسجلين في نظام‬
Guidelines
.‫شركات التأمين وشركات إدارة المطالبات‬
Subject: Update (4) on Bed Occupancy data in
Sheryan
‫لجميع‬ ‫والتقدير‬and COVID
‫الشكر‬ ‫خالص‬ ‫الصحة في دبي‬
19‫ب‬Patients in HASANA
‫تتقدم هيئة‬
‫شركائها االستراتيجيين في مجال الرعاية الصحية ومنظومة‬
‫الضمان الصحي لمساهتهم وجهودهم المبذولة في توفير رعاية‬
.‫صحية أفضل الفراد المجتمع‬
‫وباإلشا ا ا ااارة إلاا ا ااى الموضا ا ا ااوس أعا ا ا ااد واسا ا ا ااتمرارا لجها ا ا ااود هيئا ا ا ااة‬
‫الصا ا ا ا ا ااحة ف ا ا ا ا ااي دب ا ا ا ا ااي "الهيئا ا ا ا ا ااة" بتحسا ا ا ا ا ااين جا ا ا ا ا ااودة الرعايا ا ا ا ا ااة‬
‫الصا ا ا ا ا ا ا ا ااحية المقدما ا ا ا ا ا ا ا ااة وضا ا ا ا ا ا ا ا اامان االرتقا ا ا ا ا ا ا ا ااا بمسا ا ا ا ا ا ا ا ااتويات‬
‫ وتزوياا ا ا ا ا ااد ش ا ا ا ا ا ااركائها االساا ا ا ا ا ااتراتيجيين‬،‫مختلف ا ا ا ا ا ااة الخ ا ا ا ا ا اادمات‬
‫بكافا ا ا ا ا ا ا ااة المسا ا ا ا ا ا ا ااتجدات المت لقا ا ا ا ا ا ا ااة بمنظوما ا ا ا ا ا ا ااة الضا ا ا ا ا ا ا اامان‬
:‫ وعليه يسر الهيئة إرفاق اآلتي‬،‫الصحي‬
‫ اإلرشادات الم تمدة بشأن الفوترة لمجموعة رموز‬.1
‫( ؛ (الم لنة عبر‬CDT) 2018 ‫مصطلحات األسنان الحالية‬
(eClaimLink - Dubai Health ‫نظام المطالبات التأمينية‬
Authority
:‫سياسة التغطية التأمينية للحاالت الطارئة‬ .2
‫‪Accordingly, everyone must refer to the guideline attached‬‬ ‫ع ا ا ا ا ا ا ااى الجميا ا ا ا ا ا ااع االطا ا ا ا ا ا اادس ع ا ا ا ا ا ا ااى‬ ‫وعليا ا ا ا ا ا ااه يتوج ا ا ا ا ا ا ا‬
‫‪to this circular, and strictly adhere to all of its provisions.‬‬ ‫المرفق ا ا ا ا ااات الملحق ا ا ا ا ااة به ا ا ا ا ااذا الت م ا ا ا ا اايم والتقي ا ا ا ا ااد الت ا ا ا ا ااام‬
‫بكافة ما ورد فيها من أحكام‪.‬‬

‫‪This circular shall be enforced as of the date of‬‬ ‫يا ا ا ا ا ا ااتم ال ما ا ا ا ا ا اال بها ا ا ا ا ا ااذا الت ما ا ا ا ا ا اايم اعتبا ا ا ا ا ا ااارا ما ا ا ا ا ا اان ت ا ا ا ا ا ا ااا ي‬
‫‪20/10/2021 and everyone must adhere to what was stated‬‬
‫‪ 2021/10/20‬وع ا ا ا ا ا ااى الجمي ا ا ا ا ا ااع االلتاا ا ا ا ا اازام بم ا ا ا ا ا ااا ورد فياا ا ا ا ا ااه‬
‫‪in it to avoid any violations or legal accountability.‬‬
‫تفاديا ألي مخالفات أو مسا لة قانونية‪.‬‬

‫‪This circular is for regulatory actions and is not intended as‬‬ ‫هذا الت ميم لإلجرا ات التنظيمية وغير مخصص كمحتوى‬
‫‪content for media publishing.‬‬ ‫للنشر اإلعدمي‪..‬‬

‫‪For any further enquiries, please direct your emails to‬‬ ‫لمزيد من الم لومات‪ ،‬يرجى التواصل من خدل‬
‫‪ISAHD@dha.gov.ae‬‬ ‫البريد اإللكتروني‪ISAHD@dha.gov.ae :‬‬

‫‪With Regards- DHA‬‬ ‫مع التحيات – هيئة الصحة في دبي‬

 Guideline
Technical objectives:
1. Set the market of the standard and reiterate the
mandatory of basic coverage of Dental Emergency.
2. Standardize adjudication rules and billing guidelines
for the Current Dental Terminology (CDT) 2018
code set (published on eClaimlink)
 General Circular Approved billing guidelines for the
Current Dental Terminology (CDT) 2018 code set:
Dental Emergency Coverage:
1. Emergency Definition
Defining the emergency as stipulated in Law No. (11) of
2013 regarding health insurance in the Emirate of Dubai.
A situation that requires immediate medical intervention
from the health service provider to save a person's life or
eliminate the danger threatening him
The definition of emergency is as advised in Policy
Directive of Insurance Coverage of Emergency Cases “An
Emergency is defined as the sudden onset of an illness,
injury or medical condition manifesting itself by acute
symptoms of sufficient severity (including severe pain)
requiring immediate and unscheduled medical care, and if
left untreated could result in placing the person’s life
and/or health in serious jeopardy; serious impairment to
bodily functions; serious dysfunction of a bodily organ or
‫الدليل اإلرشادي‬
:‫األهداف الفنية‬
‫ ض ا ا ا ا اابا وتحدي ا ا ا ا ااد م ا ا ا ا ااايير م ا ا ا ا ااامدت الت ا ا ا ا ااأمين‬.1
‫الصا ا ا ا ااحي والتأكيا ا ا ا ااد ع ا ا ا ا ااى التغطيا ا ا ا ااة األساسا ا ا ا ااية‬
.‫للحاالت الطارئة ل دج األسنان‬
‫ توحي ا ا ا ا ااد إرش ا ا ا ا ااادات الف ا ا ا ا ااوترة لمجموع ا ا ا ا ااة رم ا ا ا ا ااوز‬.2
(CDT) 2018 ‫مصا ا ا ااطلحات األسا ا ا اانان الحاليا ا ا ااة‬
‫؛ (الم لن ا ا ا ا ا ا ا ا ا ا ااة عب ا ا ا ا ا ا ا ا ا ا اار نظ ا ا ا ا ا ا ا ا ا ا ااام المطالب ا ا ا ا ا ا ا ا ا ا ااات‬
(eClaimLink - Dubai Health ‫التأميني ااة‬
Authority
‫اإلرشادات المعتمدة بشأن الفوترة لمجموعة رموز‬ 
(CDT) 2018 ‫مصطلحات األسنان الحالية‬
‫تغطية الحاالت الطارئة لعالج األسنان‬
‫ ت ريف الحالة الطارئة‬.1
)11( ‫ت ريف الحالة الطارئة كما هو منصوص عليه في القانون رقم‬
‫ الحالة التي‬.‫ بشأن الضمان الصحي في إمارة دبي‬2013 ‫لسنة‬
‫تستدعي تدخد طبيا فو يا من مقدم الخدمة الصحية إلنقاذ حياة‬
.‫شخص أو زوال الخطر المهدد له‬
‫وكما تم ت ريفه في سياسة التغطية التأمينية للحاالت الطارئة‬
‫"يتم ت ريف الحالة الطارئة ع ى أنها البداية المفاجئة لمرض أو‬
‫إصابة أو حالة طبية تظهر من خدل أعراض حادة شديدة (بما في‬
،‫رعاية طبية عاجلة وغير مجدولة‬ ‫ذلك األلم الشديد) التي تتطل‬
‫وإذا تركت دون عدج فقد يؤدي ذلك إلى ت ريض حياة الشخص و‬
‫ أو‬. ‫ أو صحته لخطر شديد؛ مضاعفات خطيرة في وظائف األعضا‬/
،‫عضو أو جز من ال ضو؛ تشو خطير أو في حالة المرأة الحامل‬
." ‫يشكل خطرا جسيما ع ى صحة الجنين‬
part; serious disfigurement; or in the case of a pregnant
woman, serious jeopardy to the health of the foetus”.
It is the emergency medical condition of the patient, not
the diagnosis, which drives the necessity for immediate
treatment. Symptoms must be sufficiently severe to
cause the patient to seek immediate medical aid.
2. Dental emergency:
1) Dental Emergencies conditions that must be
covered include, but are not limited to:
 Trauma including facial/oral laceration and/or
dentoalveolar injuries (e.g. avulsion of a permanent
tooth).
 Oro-facial swelling that is significant and
worsening.
 Dental conditions that have resulted in acute
systemic illness or raised temperature because of
dental infection.
2) In emergency cases, Healthcare Services
Providers shall first provide medical treatment
to the Insured and then seek reimbursement of
incurred costs from the insurers.
3) Emergency dental encounters must adhere to
standard basic emergency encounter protocols
and processes.
4) Emergency dental encounters do not require
prior approval. From insurance companies or
TPA.
5) Dental Emergency consultations and medication
for Essential Benefit Plan (EBP) members must
only be billed at General Dental Practitioner
rates.
،‫ وليس التشخيص بحد ذاته‬،‫فإن الحالة الطبية الطارئة للمريض‬
‫أن تكون‬ ‫ بحيث يتوج‬.‫هي التي تدعو إلى ضرورة ال دج الفوري‬
‫المساعدة‬ ‫األعراض شديدة بما يكفي لحمل المريض ع ى طل‬
.‫الطبية الفو ية‬
:‫ الحاالت الطارئة ل دج األسنان‬.2
‫) تشمل الحاالت الطارئة ل دج األسنان التي يج‬1
. :‫ ع ى سبيل المثال ال الحصر‬،‫تغطيتها‬
‫ أو‬/ ‫ الفم و‬/ ‫إصابة بما في ذلك تمزق الوجه‬ 
‫اإلصابات السنية (مثل اإلصابة التي تؤدي إلى‬
.)‫فقدان سن دائم‬
.‫انتفاخ الفم والوجه بشكل كبير ومتفاقم‬ 
‫حاالت األسنان التي أدت إلى أمراض جهازية حادة أو‬ 
.‫ارتفاس في درجة الحرارة نتيجة اللتهاب األسنان‬
‫ع ى مقدمي الخدمات الصحية‬ ‫ يج‬،‫) في الحاالت الطارئة‬2
‫بداية توفير ال دج الطبي للمؤمن عليهم ومن ثم طل‬
.‫ت ويض التكاليف المتكبدة من شركات التأمين‬
‫أن تلتزم ال دجات السنية في الحدت الطارئة‬ ‫) يج‬3
‫ببروتوكوالت وعمليات الحاالت الطارئة األساسية‬
.‫الم تمدة‬
‫موافقة مسبقة‬ ‫) الحاالت الطارئة ل دج األسنان ال تتطل‬4
‫من شركة التأمين أو شركات إدارة المطالبات التأمينية‬
‫) عند إصدار الفواتير الخاصة باالستشارات الطبية‬5
‫ وفي حال‬،‫المت لقة بالحاالت الطارئة ل دج األسنان‬
‫أن تنحصر باألدوية الموصوفة‬ ‫ يتوج‬،‫تضمينها أدوية‬
‫ وذلك وفقا‬،‫) فقا‬EBP( ‫ألعضا خطة المزايا األساسية‬
.‫األسنان ال ام‬ ‫ألس ار ممارس ط‬
‫تقديم المطالبات التأمينية للحاالت الطارئة ضمن‬ ‫) يج‬6
.‫ غرفة الحاالت الطارئة‬+ ‫ = بدون سرير‬2 ‫ نوس الحالة‬-
 6) Emergency encounters must be submitted under
- Encounter Type 2 = No Bed + Emergency
room.
7) Emergency encounters that require admission
and fall under Day case or Inpatient are to be
covered up to the annual aggregate limit.
8) Coverage of dental emergencies is subject to
‫التدخل الطبي‬ ‫تغطية الحاالت الطارئة التي تتطل‬ ‫) يج‬7
‫وتندرج تحت جراحة اليوم الواحد أو المرضى الداخليين‬
.‫تحت الحد اإلجمالي السنوي‬
‫) تخضع تغطية الحاالت الطارئة ل دج األسنان لتوافر‬8
.‫الحد اإلجمالي السنوي‬
‫) ال يقتصر عدج الحاالت الطارئة لألسنان ع ى شبكة‬9
‫مقدمي الخدمات الصحية المحددين في وثيقة الضمان‬

availability of annual aggregate limit. .‫الصحي‬

9) Treatment of a dental emergency is not

restricted to the Healthcare Payers (Payers) or
Third Party Administrators (TPAs) network.

 General adjudication Rules And Billing Guidelines ‫ضوابط التحقق من المطالبات التأمينية وإرشاداتها‬ 
.‫ال يمكن المطالبة باستشارتين لألسنان في نفس الفاتورة‬ 1
1. Two dental examinations cannot be claimed in the
‫اإلجرا ات مت ددة المراحل إصدار فواتير بشأنها عند‬ ‫تتطل‬ 2
same invoice.
.‫االنتها من ا كتمال كل الخطوات المطلوبة‬
2. Multistage procedures are to be billed upon
‫هو تا ي ا كتمال عدج‬ ‫تا ي االنتها من حشوة جذر ال ص‬ 3
completion of all stages required.
. ‫ال ص‬
3. The completion of endodontic procedure is on
‫ع ى مقدمي الخدمات الصحية توفير صور األش ة‬ ‫يج‬ 4
obturation date.
.‫الموافقة‬ ‫السينية والمخططات الداعمة أثنا عملية طل‬
4. Healthcare Providers (Providers) must provide
‫أن يتأكد مقدمو الخدمات الصحية من أن الخدمات‬ ‫يج‬ 5
supporting X-Rays and charts during the
‫تقريرا مؤكدا لمرجع علم األمراض موثقة وفقا‬ ‫التي تتطل‬
authorization process.
‫لذلك وأن التقا ير المستندة ع ى مرجع علم األمراض متاحة‬
5. Healthcare Providers (Providers) must ensure that
.‫في وقت المراج ة‬
services that require a confirmatory pathology
report, are documented accordingly and that
pathology reports are available at the time of Audit.
:‫الترميمات‬
Restoration:
1 When multiple restorations for the same tooth are ‫أو إجرا عمليات ترميم مت ددة لنفس‬ ‫ عند طل‬1

requested or performed, multi-surface codes should ‫ ال‬."‫استخدام رموز "ت دد األسطح‬ ‫ يج‬،‫السن‬

be used. It’s not acceptable to bill each surface .‫إصدار فاتورة لكل سطح ع ى حدة‬ ‫يج‬
separately.
 Example: If a composite, filling is done on buccal and
occlusal surfaces, the appropriate procedure code:
D2391 resin-based composite - two surfaces,
posterior.
2 All restorations (direct or indirect), should include
but limited to: Tooth preparation, adhesives, etching,
liners, bases, pulp capping, temporary restorations,
buildups, cement, impressions, laboratory fees, filling
material, polishing, occlusal adjustment, re-cement
and local anesthesia.
3 Restoration provided for cosmetic purposes are non-
payable.
4 The QUANTITY of fillings is limited to four (4)
fillings per claim/per day (not applied for general
anesthesia cases).
5 The number of dental procedures done in one
visit\invoice is limited to Four (4) procedures per
claim per day excluding consultation and diagnostic
services. Not applicable for general anesthesia
cases).
Crowns:
‫ع ى األسطح الشدقية‬ ‫ إذا تم الحشو المرك‬:‫مثال‬
: ‫ فإن كود اإلجرا المناس‬،‫واإلطباق‬
D2391 resin-based composite - two surfaces,
posterior.
،)‫جميع الحشوات الترميمية (المباشرة أو غير المباشرة‬ 2
،‫ المواد الدصقة‬،‫ تحضير األسنان‬:‫أن تشمل‬ ‫يج‬
‫ الترميم‬، ‫ تغطية الل‬،‫ القواعد‬،‫ البطانات‬،‫النقش‬
،‫ رسوم المختبر‬،‫ الطب ات السنية‬،‫ الترا كمات‬،‫المؤقت‬
‫ إعادة األسمنت‬،‫ ت ديل اإلطباق‬،‫ التلميع‬،‫مواد الحشو‬
.‫والتخدير الموض ي‬
.‫الترميم المقدم ألغراض تجميلية غير مستحق للدفع‬ 3
‫) حشوات لكل‬4( ‫تقتصر عدد الحشوات ع ى أ بع‬ 4
.)‫ في اليوم (ال تنطبق ع ى حاالت التخدير ال ام‬/ ‫مطالبة‬
‫األسنان التي يتم إجراؤها في‬ ‫يقتصر عدد إجرا ات ط‬ 5
‫) إجرا ات لكل‬4( ‫ فاتورة واحدة ع ى أ ب ة‬/ ‫زيارة‬
‫مطالبة في اليوم باستثنا خدمات االستشارة‬
.)‫ (ال ينطبق ع ى حاالت التخدير ال ام‬.‫والتشخيص‬
:‫التيجان‬

1 Crowns are OPTIONAL benefits as per policy terms ‫التيجان هي مزايا اختيا ية وفقا لشروط وأحكام وثيقة‬ 1

& conditions .‫التأمين‬

2 Crowns are only eligible for a permanent tooth that ‫التيجان مؤهلة فقا لألسنان الدائمة التي انتهت من عدج‬ 2

has finished a root canal treatment ( refer to policy )‫قناة الجذر (راجع شروط وأحكام السياسة‬

Terms & conditions) ‫يلزم تقديم أش ة للموافقة ع ى أي جز اصطناعي ثابت‬ 3

3 It is mandatory to submit x ray’s for approval of any .‫للحصول ع ى الموافقة‬

fixed prosthesis for authorization. ‫أن يتم إصدار فاتورة باإلجرا ات مت ددة المراحل فقا‬ ‫يج‬ 4

4 Multistage procedures must only be billed upon . ‫عند االنتها‬

completion. .‫تا ي التثبيت‬ ‫يتم االنتها من التيجان حس‬ 5

5 The completion of crowns is as per the cementation ‫ ع ى سبيل المثال ال‬،‫رسوم خدمة األجزا االصطناعية الثابتة‬ 6

date. ‫ الجراحة‬،‫ الشمع التشخيصي‬،‫ تحضير األسنان‬:‫الحصر‬

6 The fee for a fixed prosthesis service such as, but
not limited to: tooth preparation, diagnostic wax-up,
electro surgery, temporary restorations, cement
bases, impressions, laboratory fees, occlusal
adjustment within 6 months after the restoration,
post-operative visits, local anaesthesia, crown
lengthening and gingivectomy on the same date of
service. These procedures are disallowed when
submitted as a separate charge.
Pulp Capping and Endodontic Procedure
1 Local anaesthesia is considered part of Endodontic
procedures
‫ الطب ات‬،‫ قواعد األسمنت‬،‫ الترميم المؤقت‬،‫الكهربائية‬
‫ أشهر‬6 ‫ ت ديل اإلطباق في غضون‬،‫ رسوم المختبر‬،‫السنية‬
،‫ التخدير الموض ي‬،‫ زيارات ما ب د الجراحة‬،‫ب د الترميم‬
‫ حيث أن‬،‫إطالة التاج واستئصال اللثة في نفس تا ي الخدمة‬
.‫هذ اإلجرا ات غير مسموح بها عند تقديمها كرسم منفصل‬
‫وإجرا ات عدج الل‬ ‫تغطية الل‬
‫ي تبر التخدير الموض ي جز ا من إجرا ات عدج جذور‬ 1
.‫األسنان‬

Detailed listing of 2018 CDT dental billing and CDT 2018 ‫يتم سرد القائمة التفصيلية لقواعد فوترة األسنان‬
adjudication rules are listed in APPENDIX A
"‫وضوابط التحقق من المطالبات في الملحق" أ‬

Current Policies and Updates: :‫السياسات والتحديثات الحالية‬

According to the table of benefits for Essential Benefits
Plan (EBP), dental care services are considered a special
case to exclude medical emergencies where the
diagnostic and treatment services for dental and gum
treatments are covered and are subject to the
beneficiary's participation.
‫ تُ د‬،‫وفقا لجدول المزايا للباقة األساسية للتأمين الصحي‬
‫خدمات رعاية األسنان بمثابة حالة خاصة الستثنا الحاالت‬
‫الطارئة الطبية حيث يتم تغطية خدمات التشخيص وال دج‬
‫الخاصة ب دجات األسنان واللثة وتخضع لمشاركة المستفيد‬

REFERENCES

 Health regulation department (2012), Dubai health authority, Outpatient Care Facilities Regulation2012.
[Available at:
https://www.dha.gov.ae/Documents/Regulations/Outpatient%20Care%20Facilities%20Regulation.pdf
 Hawai medical assurance association(2010) Dental Procedure Guidelines.[Available at:
https://www.hmaa.com/wp-content/uploads/2012/11/dental_procedure_guidelines.pdf
 Delta Dental of California(2013),Federal Government Programs Division, Dentist Handbook[available at:
http://www.deltadentalfeds.org/downloads/dentist-handbook.pdf
 Delta Dental of North Carolina(2014),PARTICIPATING DENTIST UNIFORM REQUIREMEN TS.[ available at
http://www.deltadentalnc.com/MediaLibraries/Global/documents/DDNC_DDS_UNIFORM_REQUIREMEN
TS.pdf
 American association of endodontist(2018) Endodontists’ Guide to CDT© 2018. Available at:
 https://www.aae.org/specialty/practice-management/dental-claims-coding-submission/
 American dental association(2017),CDT-2017 CODE ON DENTAL PROCEDURES AND NOMENCLATURE
Effective January 1, 2017
 Appendix A

2018 Billing
Category Code 2018 CDT Definition Guideline Requirement
The codes in this section recognize the cognitive skills necessary
for patient evaluation. The collection and recording of some data
and components of the dental examination may be delegated; • Any Dental consultation/oral evaluation is covered by
however, the evaluation, which includes diagnosis and treatment the same dentist within period of 3 month. Dental visits
D0120- D0160 planning, is the responsibility of the dentist. As with all ADA after initial consultation/evaluation consider as follow
procedure codes, there is no distinction made between the up visits and shouldn’t claimed or bared by patient PA x-rays
CLINICAL ORAL evaluations provided by general practitioners and specialists. •No consultation or evaluation to be billed if the dentist
EVALUATIONS Report additional diagnostic and/or definitive procedures does any dental procedure in same visit/day. Therefore,
separately. If provider had initiated any Dental treatment within
re-evaluation - limited, problem focused (established patient; not the initial visit as treatment, service fee should include
D0170
post-operative visit) consultation charges
Periodontal chart or
comprehensive periodontal evaluation - new or established patient
D0180 bitewing x-ray or OPG
• A patient encounter with a practitioner whose opinion
or advice regarding evaluation and/or management of a
consultation - diagnostic service provided by dentist or physician specific problem; may be requested by another Periodontal chart or
D9310
other than requesting dentist or physician practitioner or appropriate source. The consulted bitewing x-ray or OPG
practitioner may initiate diagnostic and/or therapeutic
services
D0210 intraoral - complete series (including bitewings)
• Initial X-ray for any dental treatment can be billed
D0220 intraoral - periapical first film separately; other x-ray taken during treatment is part of
D0230 intraoral - periapical each additional film the procedure cost.
D0240 intraoral - occlusal film • Any combination of intraoral radiographs (periapical,
occlusal, bitewing and/or panoramic films) taken by the
D0270 bitewing - single film same dentist/dental office on the same day with fees
RADIOGRAPHS/DIAGNOSTIC D0272 bitewings - two films that equal or exceed fees for complete series will be
IMAGING (INCLUDING D0273 bitewings - three films processed as D0210.
INTERPRETATION) • D0210 is limited to once per year
D0274 bitewings - four films
• Panoramic x-ray is covered once a year
panoramic film • Panoramic X-Ray (D0330) is utilized for member 7
D0330 years and older unless there is a dental necessity
Coverage for this procedure is limited to members who
D0340 cephalometric film
have Orthodontic Plan Benefits.
These are procedures generally performed in a pathology
ORAL PATHOLOGY
laboratory and do not include the removal of the tissue sample Pathology report
LABORATORY D0472 - D0485 from the patient.
 D0502 other oral pathology procedures, by report Any code that had the paraphrase (by report) requires Pathology report
unspecified diagnostic procedure, by report submission of report for payment Pathology report
D0999

• Prophylaxis performed on the same date by the same

dentist/dental office as a Periodontal Maintenance
(D4910) or • Scaling and Root Planing (D4341/D4342) is
D1110 prophylaxis - adult considered to be part of those procedures and the fee is
disallowed
• Prophylaxis is covered twice a year. Both Codes D1110
or D1120 can’t be used together

prophylaxis - child Child codes to be utilized for age of 14yrs old and
D1120 below.
topical fluoride varnish; therapeutic application for moderate to Topical application of fluoride used for members up to
D1206
high caries risk patients 18 years old. It includes fluoride gel, fluoride gel Carrier
D1208 topical application of fluoride – excluding varnish or fluoride varnish application.
• Sealant- per tooth (D1351) are payable ONCE per
tooth on the occlusal surface of permanent first and
second molars only.
sealant - per tooth
• Sealant is limited to patients up to 18 years of age.
Sealant is an OPTIONAL benefits as per policy terms &
DENTAL PROPHYLAXIS AND D1351 conditions
PREVENTIVE SERVICES D1510 space maintainer - fixed - unilateral • Service includes impression, space maintainer devise,
D1515 space maintainer - fixed - bilateral lab charges & cementation.
• Space maintainers are considered as preventive
D1520 space maintainer - removable - unilateral services and will be only considered if requested from
orthodontist or pedodontist specialty when proven
D1525 space maintainer - removable - bilateral medically indicated as per policy terms & conditions
This code cannot used by the same dentist who cement
re-cementation of space maintainer the space maintainer unless 6 months period passed
D1550 from initial cementation
• Benefits for removal of fixed space maintainer by the
same dentist/dental office who placed the appliance
D1555 removal of fixed space maintainer are disallowed.
• D1555 is disallowed when submitted with re-
cementation.
• Service includes impression, space maintainer devise,
lab charges & cementation.
• Space maintainers are considered as preventive
D1575 Distal shoe space maintainer - fixed - unilateral
services and will be only considered if requested from
orthodontist or pedodontist specialty when proven
medically indicated as per policy terms & conditions
 D1999 Unspecified preventive procedure, by report Any code that had the paraphrase (by report) requires
submission of report for payment.
D2140 amalgam - one surface, primary or permanent • Amalgam fillinga are limited to one per 10 years per
tooth.
D2150 amalgam - two surfaces, primary or permanent • Tooth preparation, all adhesives (including amalgam
amalgam - three surfaces, primary or permanent bonding agents), liners and bases are included as part of
D2160
the restoration.
amalgam - four or more surfaces, primary or permanent • If pins are used, they should be reported separately
D2161 (see D2951).
D2330 resin-based composite - one surface, anterior
• Composite filling is limited every two years per tooth
D2331 resin-based composite - two surfaces, anterior surface
• Resin-based composite refers to a broad category of
RESTORATION D2332 resin-based composite - three surfaces, anterior materials including but not limited to composites. may
resin-based composite - four or more surfaces or involving incisal include bonded composite, light-cured composite, etc.
D2335
angle (anterior) • Tooth preparation, acid etching, adhesives (including
D2390 resin-based composite crown, anterior resin bonding agents), liners and bases and curing are
included as part of the restoration.
D2391 resin-based composite - one surface, posterior • Glass ionomers, when used as restorations, should be
D2392 resin-based composite - two surfaces, posterior reported with these codes. If pins are used, they should
be reported separately (see D2951). •
D2393 resin-based composite - three surfaces, posterior Local anesthesia is usually considered to be part of
restorative procedures
D2394 resin-based composite - four or more surfaces, posterior
D2710 crown - resin-based composite(indirect)
D2712 crown - ¾ resin-based composite (indirect)
D2721 crown - resin with predominantly base metal
D2722 crown - resin with noble metal
D2740 crown - porcelain fused to predominantly base metal
D2751 crown - porcelain fused to predominantly base metal • Provider should submit clear periapical obturation x-
CROWNS ray for the approval of the crown. PA xray
D2752 crown - porcelain fused to noble metal • This codes does not include facial veneers.
D2781 crown - 3/4 cast predominantly base metal
D2782 crown - 3/4 cast noble metal
D2783 crown - 3/4 porcelain/ceramic
D2791 crown - full cast predominantly base metal
D2792 crown - full cast noble metal
 • Provisional crown (D2799) and temporary crown
provisional crown- (D2970), which is fitted crown over a damaged tooth as
further treatment or completion of diagnosis necessary prior to an immediate protective device of at least six months
final impression, Crown utilized as an interim restoration of at least duration.
six months duration during restorative treatment to allow • This is not to be used as temporization during routine
D2799 adequate time for healing or completion of other procedures. This crown fabrication. when followed by permanent crowns
includes, but is not limited to changing vertical dimension, provisional crowns are included with the permanent
completing periodontal therapy or cracked-tooth syndrome. This crown cost.
is not to be used as a temporary crown for a routine prosthetic • Permanent crown authorization cannot be obtained
restoration. prior to 6months period from provisional crown
(D2799) authorization obtained
Re-cement or re-bond indirectly fabricated or prefabricated post • Recement crown (D2920) is billed only if is it done
D2915 from different provider or in different facility than the
and core
clinic which the crown was delivered. Recemantation of
crown is not covered for the provider in the same day of
D2920 Re-cement or re-bond crown delivery. Its only accepted if it is needed after delivering
the crown 6 month. D2920 and D2915 are not benefits
on the same tooth on the same service date by the
D2921 Reattachment of tooth fragment, incisal edge or cusp
same dentist office. If submitted, D2915 will be
disallowed.
D2930 prefabricated stainless steel crown - primary tooth • Stain steel crown is crown that covers deciduous
teeth.
Other type of crown is not covered for deciduous
D2931 prefabricated stainless steel crown - permanent tooth teeth.
• Prefabricated stainless steel crown (D2930) is
considered as restorative service for deciduous tooth &
OTHER RESTORATIVE coverage will be subjected to medical necessity and as
D2932 prefabricated resin crown per policy terms & conditions. However any other
SERVICES fillings/restorative services will be disallowed with
stains steel crown service.
• Protective restoration is a benefit for emergency relief
of pain.
• A separate fee for protective restoration Is NOT
covered when performed in combination with
D2940 protective restoration
restoration or endodontic access closure or as a
temporary filling It is not allowed to utilize another
dental procedure on the same tooth for 30 days unless
service authorization is canceled.

D2950 core buildup, including any pins when required • Core build up (D2950) cannot be billed with
composite filling when a crown is to be placed on the
PA xray
tooth. Either composite filling or core build up codes is
D2951 pin retention - per tooth, in addition to restoration covered with the crown.
 • Core is built around a prefabricated post. This
D2952 post and core in addition to crown, indirectly fabricated procedure includes the core material

D2953 each additional indirectly fabricated post - same tooth

D2954 prefabricated post and core in addition to crown

Post removal code can utilize with submitting x-ray and

only when it is complex, deep and, time-consuming For
D2955 post removal removal of posts (e.g., fractured posts) not to be used in PA xray
conjunction with endodontic treatment or endodontic
retreatment (D3346, D3347, D3348).
each additional prefabricated post - same tooth (To be used with
D2957
D2954)

D2980 crown repair, necessitated by restorative material failure PA xray

Any code that had the paraphrase (by report) requires

D2999 Unspecific restorative procedure by report
submission of report for payment

• This procedure protects the pulp from additional

D3110 pulp cap - direct (excluding final restoration) injury and to promote healing and repair via formation
of secondary dentin. This code is not to be used for
bases and liners when all caries has been removed
• Pulp cap - cannot be utilized with protective
restoration, and it is not allowed to utilize filling
D3120 pulp cap - indirect (excluding final restoration) procedure on the same tooth for a minimum period of 4
weeks.
• Pulpotomy includes removal of pulp, application of
therapeutic pulpotomy (excluding final restoration) - removal of
PULP CAPING AND medicament and temporary filling.
D3220 pulp coronal to the dentinocemental junction and application of
•This is not to be construed as the first stage of root
ENDODONTIC PROCEDURES medicament
canal therapy
Pulpal debridement, primary and permanent teeth code
D3221 pulpal debridement, primary and permanent teeth (D3221) can only be utilized if the member didn’t show
up to complete endodontic treatment.
partial pulpotomy for apexogenesis - permanent tooth with
D3222
incomplete root development
pulpal therapy (resorbable filling) - anterior, primary tooth
D3230 • Endodontic therapy for primary tooth includes
(excluding final restoration)
removal of pulp, application of medicament and
pulpal therapy (resorbable filling) - posterior, primary tooth temporary filling.
D3240
(excluding final restoration)
 • This is not to be construed as the first stage of root
canal therapy
• If patient did not complete root canal treatment or
D3310 endodontic therapy, anterior tooth (excluding final restoration)
patient didn’t show up to complete the treatment.
Provider should submit code D3221(pulpal
D3320 endodontic therapy, bicuspid tooth (excluding final restoration) debridement, primary and permanent teeth).
• If patient decided to complete the treatment and
D3330 endodontic therapy, molar (excluding final restoration) provider already submitted D3221, the TPA.Payer may
adjust the price of endodontic treatment PA xray
D3331 treatment of root canal obstruction; non-surgical access • Endodontic treatment includes local anesthesia, canal
preparation, intracanal medication, temporary
incomplete endodontic therapy; inoperable, unrestorable or restorations, buildups, pulpal debridement, canal
D3332
fractured tooth obturation, incision and drainage of
abscess(D7510).limit of two periapical x-rays to be
D3333 internal root repair of perforation defects
billed with this code.
D3346 retreatment of previous root canal therapy - anterior • Retreatment codes (D3346, D3347, D3348) include
removing of the post, removing all restoration, incision
D3347 retreatment of previous root canal therapy - bicuspid and drainage of abscess if required and obturation of Pre-operative X-ray
canals
retreatment of previous root canal therapy - molar
D3348 • Retreatment is payable once per tooth
Any code that had the paraphrase (by report) requires
Unspecific Endodontic procedure by report
D3999 submission of report for payment
D3355 pulpal regeneration – initial visit
D3356 pulpal regeneration -interim medication replacement

pulpal regeneration –
D3357
completion of treatment

APEXIFICATION, D3410 apicoectomy - anterior

APICOECTOMY AND OTHER D3421 apicoectomy/periradicular surgery - bicuspid (first root) Pre-procedural x-ray Pre-procedural x-ray
ENDODONTIC PROCEDURES D3425 apicoectomy - molar (first root)
D3426 apicoectomy (each additional root)

Periradicular surgery without apicoectomy

D3427
retrograde filling - per root

D3430 retrograde filling - per root

• Gingivectomy or gingivoplasty can't be utilized if

gingivectomy or gingivoplasty - four or more contiguous teeth or Periodontal chart or
SURGICAL SERVICES D4210
tooth bounded spaces per quadrant
related to member esthetic condition such as Gummy
bitewing xray or OPG
smile, or as treatment of side effects of non-covered
 treatment. also shouldn’t use in purpose of crown
gingivectomy or gingivoplasty - one to three contiguous teeth or lengthening. Procedure is a benefit if the pocket depth
D4211
tooth bounded spaces per quadrant is greater than or equal to 5 mm
• It’s limited to once per four year in one oral site for
members above 12 years of age.
Gingivectomy or gingivoplasty to allow access for restorative • A separate benefit for gingivectomy or gingivoplasty-
D4212
procedure, per tooth per tooth is disallowed when performed in conjunction
with the preparation of a crown or other restoration by
anatomical crown exposure - four or more contiguous teeth per the same dentist/dental office
D4230
quadrant
D4231 anatomical crown exposure - one to three teeth per quadrant
gingival flap procedure, including root planing - four or more • Provider can utilize gingival flap services (D4240,
D4240 4241 and 4245) if member has Loss attachment and
contiguous teeth or tooth bounded spaces per quadrant
periodontitis condition.
gingival flap procedure, including root planing - one to three • Procedure is a benefit if the pocket is greater than or
D4241
contiguous teeth or tooth bounded spaces per quadrant equal to 5 mm. OPG x-ray or bitewing x-
• Procedure D4240 includes root planing (D4341/4342) ray
and the benefit for root planing will be disallowed when
D4245 apically positioned flap performed in conjunction with D4240/4241.
• Frequency limit is 5 year per tooth and as per policy
terms & conditions
• Crown lengthening is applied only when bone is
removed and sufficient time is allowed for healing.
• Benefits for crown lengthening are disallowed when
performed on the same day as crown preparations or
restorations.
D4249 clinical crown lengthening - hard tissue • A separate fee for crown lengthening is disallowed
when performed in conjunction with osseous surgery
on the same teeth. If more than one tooth, indicate
teeth numbers in the narrative.
• The fee for multiple crown lengthening sites within a
single quadrant will not exceed the benefit for D4260.
• The fee for osseous surgery includes: ▪ Osseous
contouring ▪ Distal or proximal wedge surgery • Scaling
and root planing (D4341, D4342) ▪ Gingivectomy
osseous surgery (including flap entry and closure) - four or more OPG or/and Periodontal
D4260 (D4210, D4211) ▪ Flap procedures (D4240, D4241)
contiguous teeth or tooth bounded spaces per quadrant chart
• This procedure is a benefit if the pocket depth is
greater than or equal to 5 mm.
• Usually only two full quadrants of osseous surgery
 are allowed on the same date of service. Benefits in
excess of two osseous surgeries on the same date of
Osseous surgery (including elevation of a full thickness flap and service are denied unless a narrative is supplied to
D4261 closure) - one to three contiguous teeth or tooth bounded spaces explain exceptional circumstances. - If periodontal
per quadrant surgery is performed less than four weeks after scaling
and root planing, the benefit for the scaling and root
planing will be deducted from the surgery. - For one to
three teeth, when subsequent treatment of the same
procedure is required within the same quadrant, the
total benefit is limited to the allowance of the quadrant
Bone replacement graft - retained natural tooth - first site in fee. - For D4261, if more than one tooth, indicate teeth
D4263
quadrant numbers in narrative.
• Osseous surgery is a benefit on the same tooth once
every 3 years.
• The following procedures may be a benefit separately
on the same day:
Osseous grafts (D4263, D4264)
Bone replacement graft - retained natural tooth - each additional Exotosis removal (D7471)
D4264 Hemisection (D3920) Extraction (D7140) Apicoectomy
site in quadrant
(D3410) Root Amputations (D3450)
Guided Tissue Regeneration (D4266) Soft tissue grafts
(D4271)
• This procedure is a benefit if the pocket depth is
greater than or equal to 5 mm. Benefits for bone
grafting are available only when billed for natural teeth
D4265 Biologic materials to aid in soft and osseous tissue regeneration and performed for periodontal purposes.
• The benefit for bone grafting is denied as a
specialized or elective technique when billed in
conjunction with implants, ridge augmentation,
extraction sites, periradicular surgery, etc. – refer to
D7950, D7951 and D7953. - This procedure must be
submitted with a gingival flap (D4240/D4241) or
osseous surgery (D4260/D4261) entry procedure. -
D4266 Guided tissue regeneration - resorbable barrier, per site • Maximum benefit for bone replacement grafts is two
sites per quadrant. Bone graft for the second site in the
same quadrant will be processed as D4264
• Narrative should specify donor site and if one of the
following conditions applies: Active recession
• No attached gingival No keratinized gingival
Mucogingiva defect Progressive perio disease
Guided tissue regeneration - nonresorbable barrier, per site • Not a benefit when performed for cosmetic purposes.
D4267
(includes membrane removal) • Benefits for guided tissue regeneration
(D4266,D4267) are denied in conjunction with soft
tissue grafts in the same surgical area.
• Benefits for Frenulectomy (D7960) or Frenuloplasty
 (D7963) are disallowed in conjunction with soft tissue
grafts (D4271, D4275).
• Extraoral grafts are not covered benefits.

D4268 Surgical revision procedure, per tooth

D4270 Pedicle soft tissue graft procedure
• Maximum benefit for free soft tissue graft is two sites
Autogenous connective tissue graft procedure (including donor per quadrant. • Free soft tissue graft for more than two
D4273 and recipient surgical sites) first tooth, implant or edentulous tooth sites within a quadrant will be denied to the eligible fee.
position in graft • Provider can utilize Graft services once in a lifetime
Mesial/distal wedge procedure, single tooth (when not performed for same oral site; in which no other consideration can
D4274 in conjunction with surgical procedures in the same anatomical be given if member graft had failed for any reason
area)
D4276 combined connective tissue and double pedicle graft, per tooth
D4320 provisional splinting - intracoronal • NOT covered for members less than 12 years of age.
• For those over 12 years of age It is covered once per
D4321 provisional splinting - extracoronal quadrant/ year
periodontal scaling and root planing - four or more teeth per Whenever scaling and root planning is needed (D4341
D4341 and D4342) more than 2 quadrants within a single visit,
quadrant Full-mouth periodontal
the following should be documented/ submitted upon
charting, OPG or bitewing
periodontal scaling and root planing - one to three teeth per requested: full-mouth periodontal charting, OPG or
D4342 X-
quadrant bitewing X-ray, and the treatment plan. Once in 6
months.
Full mouth debridement code (D4355) billing is
full mouth debridement to enable comprehensive evaluation and disallowed
D4355
NON-SURGICAL diagnosis Prophylaxis (D1110) is disallowed if performed on the
PERIODONTAL SERVICE same day as D4341 or D4342.
localized delivery of antimicrobial agents via a controlled release
D4381 Any code that had the paraphrase (by report) requires
vehicle into diseased crevicular tissue, per tooth, by report
submission of report for payment
• Periodontal maintenance (D4910) code used for
patient with chronic periodontal disease. it can be
utilized 3 months after scaling and root planning and
requires submission of a periodontal chart or bitewing Periodontal chart or
D4910 periodontal maintenance
x-ray or OPG reflecting the disses of member. bitewing x-ray or OPG
• Periodontal maintenance and Scaling polishing
services should have a 6 months duration span between
each other.

D4999 unspecified periodontal procedure, by report Any code that had the paraphrase (by report) requires
submission of report for payment
ORAL SURGERY D7111 extraction, coronal remnants - deciduous tooth
 extraction, erupted tooth or exposed root (elevation and/or
D7140
forceps removal)
Extraction, erupted tooth requiring removal of bone and/or
D7210 sectioning of tooth, and including elevation of mucoperiosteal flap
• Any extraction includes local anesthesia, removal of
if indicated
tooth structure, incision, bone removal, tooth
D7220 removal of impacted tooth - soft tissue dissection, suturing, removal of suture, routine post-
D7230 removal of impacted tooth - partially bony operative care. Pre-procedural X-ray
• Billing for unsuccessful attempts at extractions is not
D7240 removal of impacted tooth - completely bony permitted
removal of impacted tooth - completely bony, with unusual
D7241
surgical complications
D7250 surgical removal of residual tooth roots (cutting procedure)
D7251 coronectomy – intentional partial tooth removal
D7260 oroantral fistula closure
D7261 primary closure of a sinus perforation Pre-procedural X-ray
tooth reimplantation and/or stabilization of accidentally evulsed or
D7270
displaced tooth
D7280 Exposure of an unerupted tooth
D7285 biopsy of oral tissue - hard (bone, tooth)
D7286 biopsy of oral tissue – soft
D7287 exfoliative cytological sample collection
• This service is disallowed when performed in
D7288 brush biopsy - transepithelial sample collection conjunction with an apicoectomy (D3410, D3421,
D3425 or D3426), or surgical extraction (D7210), by the
D7410 excision of benign lesion up to 1.25 cm
same dentist/dental office in the same surgical area and
D7411 excision of benign lesion greater than 1.25 cm on the same date of service.
• Biopsy of oral tissue – soft (D7286) and removal of
D7412 excision of benign lesion, complicated benign odontogenic cyst or tumor up to 1.25 cm Pathology report and
D7440 excision of malignant tumor - lesion diameter up 1.25 cm (D7450) may be disallowed in conjunction with Periodontal chart
extraction procedures
removal of benign odontogenic cyst or tumor - lesion diameter up
D7450
to 1.25 cm
removal of benign odontogenic cyst or tumor - lesion diameter
D7451
greater than 1.25 cm
• The fee of Incision and drainage of abscess-intraoral
D7510 incision and drainage of abscess - intraoral soft tissue soft tissue (D7510) is not covered when done on the
same date with endodontics (D3110-D3999), oral
incision and drainage of abscess - intraoral soft tissue - surgery (D7111-D7999), and surgical periodontal
D7511
complicated (includes drainage of multiple fascial spaces) procedures (D4210-D4276). Furthermore, It’s covered

D7520 incision and drainage of abscess - extraoral soft tissue
incision and drainage of abscess - extraoral soft tissue -
D7521
complicated (includes drainage of multiple fascial spaces)
once per tooth.
• Once Incision and drainage authorization is taken it is
not allowed to utilize another dental procedure on the
same tooth for a period of 30 days unless I&D is
canceled.

D7910 suture of recent small wounds up to 5 cm • Suturing is part for any surgical treatment.
• Separate suture fees are not covered.
local anesthesia not in conjunction with operative or surgical
D9210
procedures
D9211 regional block anesthesia • Local anesthesia is part of any dental treatment.
• Separate fees for local anesthesia are not covered
D9212 trigeminal division block anesthesia
local anesthesia in conjunction with operative or surgical
D9215
procedures
D9220 deep sedation/general anesthesia - first 30 minutes
D9221 deep sedation/general anesthesia - each additional 15 minutes
• Sedation codes (D9220, D9221, D9230, D9241,
D9230 inhalation of nitrous oxide / anxiolysis, analgesia
D9242, D9248) can only be utilized for a members who
D9241 intravenous conscious sedation/analgesia - first 30 minutes are 10 years of age and below. Unless medical
intravenous conscious sedation/analgesia - each additional 15 indication exist then it will be subjected to TPA review
D9242
minutes
D9248 non-intravenous conscious sedation

D8010 limited orthodontic treatment of the primary dentition

D8020 limited orthodontic treatment of the transitional dentition

D8030 limited orthodontic treatment of the adolescent dentition
D8040 limited orthodontic treatment of the adult dentition
D8050 interceptive orthodontic treatment of the primary dentition
D8060 interceptive orthodontic treatment of the transitional dentition Coverage for this codes is limited to members who have
ORTHODONTIC PROCEDURE D8070 comprehensive orthodontic treatment of the transitional dentition
Orthodontic Plan Benefits and subject to pokicy term
and condition
D8080 comprehensive orthodontic treatment of the adolescent dentition
D8090 comprehensive orthodontic treatment of the adult dentition
D8210 removable appliance therapy
D8220 fixed appliance therapy
pre-orthodontic treatment examination to monitor growth and
D8660
development
D8670 periodic orthodontic treatment visit
orthodontic retention (removal of appliances, construction and
D8680
placement of retainer(s))
D8690 orthodontic treatment (alternative billing to a contract fee)
D8691 repair of orthodontic appliance
D8692 replacement of lost or broken retainer
D8693 Re-cement or re-bond fixed retainer
D8694 Repair of fixed retainers, includes reattachment
D8999 unspecified orthodontic procedure, by report