PPO Maximizer

Use this form to help you determine the PPO paid benefit.
Bridges: If an anterior or bicuspid tooth is part of a bridge, use the anterior or bicuspid paid benefit. Otherwise, use the molar paid benefit. Paid benefit identifies the paid bridge restoration type. Refer to D6000 codes on fee schedule for fees, if listed.

KEY:
APC = All Porcelain Crown (CDT 2740) PFNM = Porcelain Fused to Noble Metal Crown (CDT 2752) FNMC = Full Noble Metal Crown (CDT 2792)
PFG = Porcelain Fused to High Noble Metal (CDT 2750) FGC = Full Gold Crown (CDT 2790) PO = Porcelain Onlay (CDT 2642, 2643, 2644)
PFM = Porcelain Fused to Metal Crown (CDT 2751) FMC = Full Metal Crown (CDT 2791) MO = Metallic Onlay (CDT 2542, 2543, 2544)

"Y" or "N" refers to "Porcelain on Post Teeth" on the Eligibility form "Y" or "N" refers to "Posterior Composites"
Carrier All Porcelain All Porcelain Porcelain Fused to Porcelain Fused to Gold Porcelain Fused to Porcelain Fused to Metal Onlays Inlays Composites
Molar Crown Bicuspid & Anterior Gold Bicuspid & Anterior Crown Metal Molar Crown Bicuspid & Anterior Crown
Crown Molar Crown
Y N Y or N Y N Y or N Y N Y or N Y N Y N N

AETNA APC FNMC APC PFNM FMC PFNM PFM FMC PFM PO PO Composite Amalgam Amalgam
AMERITAS FNMC FNMC APC FNMC PFNM PFG PFM PFM PFM PO PO Composite Amalgam Amalgam
ASSURANT BENEFIT FMC FMC APC PFM FMC PFM PFM PFM PFM PO MO Composite Amalgam Amalgam
BANNER DENTAL APC FMC APC PFG FMC PFG PFM FMC PFM PO MO Composite Amalgam Amalgam
BLUE CROSS/BLUE SHIELD APC APC APC PFG PFG PFG PFM PFM PFM MO MO Composite Amalgam Amalgam
BLUE SHIELD OF CA APC FMC APC PFG FMC PFG PFM FMC PFM PO MO Composite Amalgam Amalgam
CCPOA APC FMC APC PFG FMC PFG PFM FMC PFM PO MO Composite Amalgam Amalgam
CIGNA APC FMC APC PFNM FMC PFNM FGC FMC PFM MO MO Composite Amalgam Amalgam
DELTA DENTAL OF AR APC FMC APC PFG FMC PFG PFM FMC PFM PO MO Composite Amalgam Amalgam
DELTA DENTAL OF AZ APC PFG PFG PFG FNMC PFG PFM FMC PFM PO PO Composite Amalgam Amalgam
DELTA DENTAL OF CA FGC FGC APC FGC FGC PFG FMC FMC PFM MO MO Composite Amalgam Amalgam
DELTA DENTAL OF CO APC PFG PFG PFG FMC PFG PFM FMC PFM PO PO Composite Amalgam Amalgam
DELTA DENTAL OF GA & FL APC FMC APC PFG FMC PFG PFM FMC PFM PO PO Composite Amalgam Amalgam
DELTA DENTAL OF IL APC FMC APC PFG FMC PFG PFM FMC PFM PO MO Composite Amalgam Amalgam
DELTA DENTAL OF MA APC FMC APC PFG FMC PFG PFM FMC PFM PO MO Composite Amalgam Amalgam
DELTA DENTAL OF MI APC FMC APC PFG FMC PFG PFM FMC PFM PO MO Composite Amalgam Amalgam
DELTA DENTAL OF MN APC FMC APC PFG FMC PFG PFM FMC PFM PO PO Composite Amalgam Amalgam
DELTA DENTAL OF MO APC FMC APC PFG FMC PFG PFM FMC PFM PO MO Composite Amalgam Amalgam
DELTA DENTAL OF NJ APC FMC APC PFG FMC PFG PFM FMC PFM PO MO Composite Amalgam Amalgam
DELTA DENTAL OF NM APC FMC APC PFG FMC PFG PFM FMC PFM PO MO Composite Amalgam Amalgam
DELTA DENTAL OF PA APC FMC APC PFG FMC PFG PFM FMC PFM PO MO Composite Amalgam Amalgam
DELTA DENTAL OF TN PFG PFG PFG PFG PFG PFG PFM PFM PFM MO MO Composite Amalgam Amalgam
DELTA DENTAL OF VA APC FMC APC PFG FMC PFG PFM FMC PFM PO MO Composite Amalgam Amalgam
DELTA DENTAL OF WA APC FMC APC PFG FMC PFG PFM FMC PFM PO MO Composite Amalgam Amalgam
DELTA DENTAL OF WI APC FMC APC PFG FMC PFG PFM FMC PFM PO MO Composite Amalgam Amalgam
DELTA DENTAL TRICARE APC FMC APC PFG FMC PFG PFM FMC PFM PO MO Composite Amalgam Amalgam
GEHA CONNECTION DENTAL FMC FMC APC FMC FMC PFG FMC FMC PFM PO PO Composite Amalgam Amalgam
GUARDIAN APC FMC APC PFG FMC PFG PFM FMC PFM MO MO Composite Amalgam Amalgam
HPN APC FMC APC PFG FMC PFG PFM FMC PFM PO MO Composite Amalgam Amalgam
HUMANA DENTAL APC FNMC APC PFG FNMC PFG PFM PFM PFM FNMC FNMC Composite Amalgam Amalgam
LIBERTY DENTAL APC FMC APC PFG FMC PFG PFM FMC PFM PO MO Composite Amalgam Amalgam
METLIFE FGC FGC APC FGC FGC PFG PFM FMC PFM FGC FGC Composite Amalgam Amalgam
OPERATING ENGINEERS APC APC APC PFG PFG PFG PFM PFM PFM PO PO Composite Amalgam Amalgam
PREMIER ACCESS APC FMC APC PFG FMC PFG PFM FMC PFM PO PO Composite Amalgam Amalgam
PRINCIPAL FINANCIAL GRP FNMC FNMC APC FNMC FNMC PFG FNMC FNMC PFM PO PO Composite Amalgam Amalgam
STANDARD APC FMC APC PFG FMC PFG PFM FMC PFM PO MO Composite Amalgam Amalgam
SUNLIFE DENTAL BENEFITS APC FMC APC PFG FMC PFG PFM FMC PFM PO MO Composite Amalgam Amalgam
UFCW TRUST FUND APC FMC APC PFG FMC PFG PFM FMC PFM PO MO Composite Amalgam Amalgam
UMR APC FMC APC PFG FMC PFG PFM FMC PFM PO MO Composite Amalgam Amalgam
UNITED CONCORDIA APC FMC APC PFG FMC PFG PFM FMC PFM MO MO Composite Amalgam Amalgam
UNITED HEALTH CARE APC FMC APC PFG FMC PFG PFM FMC PFM PO PO Composite Amalgam Amalgam

Pacific Dental Services, Inc. Proprietary and Confidential Updated 02/10/2021

 PPO Financial Arrangements

Specifics:
"Paid Benefits" are not required on a PPO FA.
"Basic Covered Benefits" are required on a PPO estimate involving any upgraded procedure or any CEREC® CAD/CAM restoration.
"Choices/Alternatives" are optional and should be Clinician-Led.

Financial Estimate Examples:

FA/Estimate - CEREC Hybrid Crown

Accepted/Planned CEREC Hyb Crown
Choices/Alternatives (Options) CEREC (optional clinical choice)
Basic Covered Benefit Crown Porc Post or Ant (required)

FA/Estimate - CEREC Crown

Accepted/Planned CEREC
Basic Covered Benefit Crown Porc Post or Ant (required)

FA/Estimate - CEREC Fired Crown

Accepted/Planned CERECfired Crown
Choices/Alternatives (Options) CEREC (optional choice)
Basic Covered Benefit Crown Porc Post or Ant (required)

FA/Estimate - CEREC Zirconia Crown

Accepted/Planned CEREC Zirc Crown
Choices/Alternatives (Options) CEREC (optional choice)
Basic Covered Benefit Crown Porc Post or Ant (required)

FA/Estimate - CEREC Onlay

Accepted/Planned CEREC Onlay
Basic Covered Benefit Onlay Porcelain (required)
Choices/Alternatives (Options) Metallic Onlay (optional clinical choice)

FA/Estimate - CEREC Inlay

Accepted/Planned CEREC Inlay
Basic Covered Benefit Inlay Porcelain (required)
Choices/Alternatives (Options) Composite (optional clinical choice)

FA/Estimate - any non-upgraded crown (e.g., PFG)

Accepted/Planned PFG
Choices/Alternatives (Options) Choices are optional (e.g., PFM)

Pacific Dental Services, Inc. Proprietary and Confidential Updated 04/05/2021