Welcome to the Delta Dental of Rhode Island network
Delta Dental of Rhode Island is pleased to welcome the following recently credentialed dentists to our network:
Vrunda Adeshara, DMD
Comprehensive Community Action Program
Kelsey Akin, DMD
South County Smiles
Juyong An, DMD
Pediatric Dentistry Limited
Oluwabukola Awoleye, DDS
Providence Community Health Centers
Lujane Barakat, DMD
Providence Community Health Centers
Valentina Betancur, DDS
Comprehensive Community Action Program
Alexandra Brennan, DMD
Children’s Dentistry of RI II
Laura Carrasco, DDS
Comfort Dental
Hee Yong Chung, DMD
Comprehensive Community Action Program
Sophia Cochran, DMD
North Providence Dental Associates
Ashley Cuevas, DMD
Thundermist Health Center
Laila Dantas, DMD
Cumberland Dental Specialists
Andrew Deek, DDS
University Oral & Maxillofacial Surgery Associates
Hannah Demers, DMD
Atwill Conroy Dental Associates Smithfield
Kaitlin Dickerson, DDS
Maple Avenue Family Dentistry
Donald Ferraro, DDS
Eric George DMD & Associates
Robert Gargano, DDS
Cranston Dental Associates
Zahra Hanif, DMD
Tourister Dental Associates
Stephanie Harding, DDS
Jet Dental Rhode Island
Sanah Hasan, DMD
Capalbo Dental Group of Wakefield
Did you know?
Penn Dental Medicine, with support from Delta Dental, offers a free continuing education program to help improve access to dental care for individuals with disabilities. Nearly 57 million Americans live with disabilities, including an estimated
Kelsey Hebert, DMD
Paolucci Dental Associates
Mimi Higgins, DDS
Atwill Conroy Dental Associates
Ji Yeon Hwang, DMD
East Bay Dental Associates
Yixin Jiang, DMD
Sunny Smile Group
Christian Johnson, DDS
Happy Smile Rhode Island
Caroline Johnson, DMD
Paolucci Dental Associates
Morad Kanan, DMD
Friends and Family Dental
Soung Kim, DMD
Premier Care Family Dental
East Greenwich
Soo Yeon Kim, DMD
Benefit Dental Care
Zachary Kofos, DMD
Pawtucket Orthodontics Health Centers
Yujin Lee, DMD
Warren Dental Associates
Yu Liu, DDS
Riverside Family Dental
Warwick Family Dental Group
Destiny Moser, DMD
Westerly Dental Group
Isabel Chung Leng Munoz, DMD
DeQuattro Orthodontics
Daniel Nho, DMD
Johnston Dental Group
North Providence Dental Associates
Emma Paolella, DMD
Blackstone Valley Community Health Care
Joseph Pierse, DMD
Steven H. Young, DDS
Klara Salib Rasla, DMD
Periodontics Inc.
Bradley Renner, DDS
Arrowhead Dental Associates
25% of Rhode Islanders. Open to all U.S.licensed dentists and their support staff, the program features live webinars and ondemand courses at no cost. Participants who complete 18 or more courses within a threeyear period will earn a Disabilities Dentistry
Nindu Saini, DMD
Ocean State Endodontics
Dr. Matrullo & Associates
Eshani Shah, DDS
Sunny Smile Group
Aaron Shin, DDS
Happy Smile Rhode Island
Janik Shingala, DMD
Paolucci Family Dentists
Jenisha Shrestha, DMD
Cranston Family and Cosmetic Dentistry
Courtney Silva, DMD
Diamond Hill Dental and Associates
Amanjot Singh, DDS
Artistry Dental
Iqra Tahir, DMD
Tourister Dental Associates
Manuela Teixeira, DMD
Pedro Teixeira, DDS
Eric Vu, DMD
RI Oral Surgery & Implant Center
Weihao Wang, DMD
Paolucci Dental Associates
Paolucci Lincoln Dental Associates
Karolina Wasilewski, DMD
Wave Dental
Michelle Yau, DMD
Dental Associates of Rhode Island
Clinician Expert certificate from Penn Dental Medicine, an ADA CERP-recognized provider.
Register and begin earning credit at www.dental.upenn.edu/disabilitiescare
2025 dental recognition
Congratulations to the following dentists for their recent induction to the American College of Dentists (ACD):
• Lagina D. Bickham, DMD
• Gayathri Shenoy, DMD
• Gregory P. Stepka, DMD
• David J. Ward, DMD
Brush up on commonly reviewed procedures
To expedite your pre-treatment estimates and payments, it’s important to submit all required documentation with your initial submission. To assist you with this process, we’ve prepared a Guide for Commonly Reviewed Procedures that includes the required documents needed for the most commonly reviewed procedures, as well as optional information that can help us process your claim more efficiently. We encourage you to print it out and keep it accessible in your office for quick reference.
To access the guide, visit the Dentists section at www.deltadentari.com or scan the QR code.
Delta Dental Premier® annual notice
The national Delta Dental Plans Association (DDPA) requires us to notify participating Delta Dental of Rhode Island dentists annually that they are automatically part of the national Delta Dental Premier® program. As a participant in this national program, you must accept the payment and claims processing policies set forth by the DDPA. Rhode Island participating Delta Dental Premier and Delta Dental PPO dentists are not allowed to balance bill beyond their approved maximum fee allowance (based on each product), except for noncovered services, services over the maximum or for alternate benefits. Participating dentists must accept their approved maximum fee allowance for members when the fee is not payable because of a deductible or for benefits with frequency limitations or waiting periods.
Note: Federal law makes the Rhode Island non-covered services statute inapplicable to claims covered by Delta Dental of California under the FED VIP contract. Balance billing for alternate benefits is not allowed.
Note: The national PPO program is an optional program for participating dentists and a separate contract is required.
Complete claim standard
To meet requirements for prompt and accurate claims processing, it’s important that providers submit certain information for a claim to be considered complete. Delta Dental of Rhode Island cannot process your claim until it meets our Complete Claim Standard. Our Complete Claim Standard outlines the requirements and timelines that all claims documentation must meet. To learn more, visit the Dentists section at www.deltadentalri.com and click on the Utilization Review Guidelines link.
2026 credentialing meeting schedule
Please ensure that your completed application is submitted at least 7 days before the scheduled meeting date. Only fully completed applications will be reviewed at the meeting. If your application is incomplete, it will be reviewed at the next available meeting date once all required documents have been received. Check the graphic below for specific meeting and application due dates.
MEETING DATE
January 14
February 11
March 11
April 15
May 13
June 17
July 15
August 12
September 16
October 14
November 18
December 16
January 13, 2027
January 7
February 4
March 4
April 8
May 6
June 10
July 8
August 5
September 9
October 7
November 11
December 9
January 6, 2027
2026 holiday schedule
Please make note of the following Delta Dental of Rhode Island corporate office closures.
January 1 (Thursday) New Year’s Day
January 19 (Monday) Dr. Martin Luther King Jr. Day*
May 25 (Monday) Memorial Day
June 19 (Friday) Juneteenth*
July 3 (Friday) Independence Day (observed)
August 10 (Monday) Victory Day*
September 7 (Monday) Labor Day
October 12 (Monday) Columbus Day/ Indigenous Peoples’ Day*
November 11 (Wednesday) Veterans Day (observed)*
November 26 (Thursday) Thanksgiving Day
November 27 (Friday) Day after Thanksgiving
December 25 (Friday) Christmas Day
*Delta Dental of RI customer service office is open
Next hygiene workforce program disbursement
coming January 2026
Delta Dental of Rhode Island will issue the next Hygiene Workforce Program disbursement in January 2026 for qualifying hygiene services (D1110, D1120, D4910) rendered between July 1 and December 31, 2025.
Launched in 2024, the Hygiene Workforce Program is designed to support network dentists in recruiting and retaining hygienists amid nationwide staffing challenges in the industry. Many practices have used program funds to attract new talent and offer higher compensation to their existing staff.
We’re proud to continue this initiative and thank participating practices for their commitment to strengthening Rhode Island’s oral health care workforce.
For questions about eligibility or program details, please contact Nancy Thibodeau at 401-752-6227 or nthibodeau@deltadentalri.com
Rhode Island Mission of Mercy nears $4 million in donated dental services with 2025 clinic
The 2025 Rhode Island Mission of Mercy (RIMOM) two-day free dental clinic provided more than $300,000 in free dental services to 611 Rhode Islanders in need. Held on October 4–5 at Providence Community Health Centers, this year’s clinic delivered nearly 2,500 dental procedures ranging from cleanings and fillings to root canals, extractions and partial dentures. Thanks to over 500 volunteers, including Rhode Island dentists, hygienists and assistants, services were provided free of charge on a first-come, first-served basis.
“We’re proud to have helped so many Rhode Islanders access the care they need through this year’s Mission of Mercy,” said Dr. John Kiang, president of the Rhode Island Oral Health Foundation. “Events like this remind us how essential oral health is to an individual’s overall well-being and what can be accomplished when our community comes together to make care accessible to all. We’re deeply grateful to our volunteers, sponsors, organizers, and partners who make this annual event possible.”
Since its founding, RIMOM, presented by the Rhode Island Oral Health Foundation, has delivered nearly $4 million in donated dental services to thousands of Rhode Islanders. Delta Dental of Rhode Island has been the premier sponsor since the initiative’s inception.
For more information, visit www.rimom.org
New CDT codes take effect January 1, 2026
CDT 2026, an annual reference manual published by the American Dental Association (ADA), contains the following changes:
• 31 new codes
• 14 revisions
• 6 deletions
This version is effective for services provided on or after January 1, 2026. To learn more about CDT 2026 or to order new materials for your office, visit www.adacatalog.org. Remember, these codes are used by all insurers to achieve uniformity, consistency and specificity in accurately reporting dental treatment.
12/25 - QTY [BUG]
Reminders
Help keep our records accurate
Accurate information helps us process your claims quickly and efficiently. When changes happen in your office, contact Debra Fernandes in our professional relations department at 401-752-6206, or email dfernandes@deltadentalri.com
Electronic attachments
Delta Dental accepts electronic attachments like X-rays, periodontal charting, narratives, and COB information using National Electronic Attachment, Inc. (NEA) services, Dental Xchange and Change Healthcare.
ADA dental claim form
To ensure your claim is processed without delay, please use the current ADA dental claim form.
Re-credentialing policy
When re-credentialing, please return the following documents:
• Your completed re-credentialing profile.
• A copy of the first page of your current professional liability insurance.
• An updated W-9 form if changes have been made.
Appeals and complaints
To learn more about our appeals and complaints processes, please visit the FAQs page https://deltadentalri.com/ Provider/PublicFAQ
Value-based care reimbursement
Value-based care payments are being reviewed and are scheduled to be distributed toward the end of the year.
Contact
Professional Relations
professionalrelations@deltadentalri.com
10 Charles Street, Providence, RI 02904-2208
Telephone: 401-752-6206
Fax: 401-752-6060
Website: www.deltadentalri.com
Visit deltadentalri.com to view the complete list of policies and procedures included in the Utilization Review Guidelines.
Policy/procedure changes effective January 1, 2026
The following policy changes are required by the Delta Dental Plans Association to ensure consistent claims processing standards and will be effective January 1, 2026. In accordance with R.I. Law, the policy changes are presented in an edited (or “red line”) version. New language is underlined and deleted language is shown as a strikethrough. Please log in to your online account in the Dentists section of our website for the new version of our Utilization Review Guidelines incorporating these changes.
DIAGNOSTIC
Procedure code D0180 comprehensive periodontal evaluation – new or established patient
a. Time limitations are determined by group/individual contract and count towards contractual evaluation limitations.
b. If a D0180 is submitted with a D4910 on the same date of service by the same dentist/dental office it is benefited as a D0120 and the difference in the approved amount between the D0120 and the D0180 is not billable to the patient by a participating dentist.
c. Fees for D4355 D0180 are not billable to the patient by a participating dentist when done on the same date of service as D0180 D4355 by the same dentist/dental office.
Procedure code D0502 Other oral pathology procedures, by report
a. Other oral pathology procedures must be accompanied by a pathology report. The fee for D0502 submitted without the report are not billable to the patient by a participating dentist.
b. Benefits for D0502 are DENIED.
ENDODONTICS
Procedure codes D3346 Retreatment of previous root canal therapy - anterior, D3347 Retreatment of previous root canal therapy - premolar, D3348 Retreatment of previous root canal therapy – molar
Retreatment of root canal therapy by the same dentist/dental office within 24 months is considered part of the original procedure. No payment is made for the retreatment by the same office and the fees are not billable to the patient by a participating dentist. Benefits by a different dentist/dental office are DENIED.
ADJUNCTIVE GENERAL SERVICES
Procedure code D9219 Evaluation for moderate sedation, deep sedation or general anesthesia
No payment is made for evaluation for moderate sedation, deep sedation or general anesthesia and the fees are not billable to the patient by a participating dentist with moderate, deep sedation or general anesthesia. Benefits for D9219 are limited to once per 12 months.
New procedure codes and policies effective
DIAGNOSTIC
D0426 Collection, preparation, and analysis of saliva sample – point-of-care
Benefits for preparation, collection, and analysis of a saliva sample (point of care) are DENIED unless covered by group/individual contract.
D0461 Testing for cracked tooth
Includes multiple teeth and contra lateral comparison(s), as indicated. Diagnostic aids may include but are not limited to pressure sensitivity testing, transillumination, staining, etc.
Testing for cracked tooth is included as part of the definitive procedure and the fees are not billable to the patient by a participating dentist.
PREVENTIVE
D1720 Influenza vaccine administration
Benefits are DENIED unless covered by group/individual contract.
PROSTHODONTICS (removable)
D5877 Duplication of complete denture – maxillary
Does not involve all steps used in initial fabrication.
Benefits are DENIED unless covered by group/individual contract.
D5878 Duplication of complete denture – mandibular
Does not involve all steps used in initial fabrication.
Benefits are DENIED unless covered by group/individual contract.
MAXILLOFACIAL PROSTHETICS
D5909 Maxillary guidance prosthesis with guide flange
Synonymous terminology: guidance device, guidance appliance. A prosthesis which guides the remaining portion of the mandible, left after a partial resection, into a more normal relationship with the maxilla. This allows for some tooth-to-tooth or an improved tooth contact, it may also artificially replace missing teeth and thereby increase masticatory efficiency.
D5930 Maxillary guidance prosthesis without guide flange
A prosthesis which helps guide the partially resected mandible to a more normal relation with the maxilla allowing for increased tooth contact. It does not have a flange or ramp, however, it does assist in directional closure. It may replace missing teeth and thereby increase masticatory efficiency.
D5938 Resection prosthesis, maxillary complete removable
A maxillary complete removable resection prosthesis for the maxillary arch in which a portion of the maxilla is resected and reconstructed with hard or soft tissue.
D5939 Resection prosthesis, mandibular complete removable
A mandibular complete removable resection prosthesis for the mandibular arch in which a portion of the mandibular is resected and reconstructed with hard or soft tissue. Mandibular continuity is maintained or restored.
D5940 Resection prosthesis, maxillary partial removable
A maxillary partial removable resection prosthesis for the maxillary arch in which a portion of the maxilla is resected and reconstructed with hard or soft tissue.
D5941 Resection prosthesis, mandibular partial removable
A mandibular partial removable resection prosthesis for the mandibular arch in which a portion of the mandibular is resected and reconstructed with hard or soft tissue. Mandibular continuity is maintained or restored.
D5942 Resection prosthesis, maxillary implant/abutment supported removable prosthesis for edentulous arch
A maxillary implant/abutment supported removable resection prosthesis for the edentulous maxillary arch in which a portion of the maxilla is resected and reconstructed.
D5943 Resection prosthesis, mandibular implant/abutment supported removable prosthesis for edentulous arch
A mandibular implant/abutment supported removable resection prosthesis for the edentulous mandibular arch in which a portion of the mandible is resected and reconstructed in which mandibular continuity is maintained or restored.
D5944 Resection prosthesis, maxillary implant/abutment supported removable prosthesis for the partial edentulous arch
A maxillary implant/abutment supported removable resection prosthesis for the partial edentulous maxillary arch in which a portion of the maxilla is resected and reconstructed with hard tissue.
D5945 Resection prosthesis, mandibular implant/abutment supported removable prosthesis for the partial edentulous arch
A mandibular implant/abutment supported removable resection prosthesis for the partial edentulous mandibular arch in which a portion of the mandible is resected and reconstructed.
D5946 Resection prosthesis, maxillary implant/abutment supported fixed prosthesis for edentulous arch
A maxillary implant/abutment supported fixed resection prosthesis for the edentulous maxillary arch in which a portion of the maxilla is resected and reconstructed.
D5947 Resection prosthesis, mandibular implant/abutment supported fixed prosthesis for edentulous arch
A mandibular implant/abutment supported fixed resection prosthesis for the edentulous mandibular arch in which a portion of the mandible is resected and reconstructed in which mandibular continuity is maintained or restored.
D5948 Resection prosthesis, maxillary implant/abutment supported fixed prosthesis for the partial edentulous arch
A maxillary implant/abutment supported fixed resection prosthesis for the partial edentulous maxillary arch in which a portion of the maxilla is resected and reconstructed.
D5949 Resection prosthesis, mandibular implant/abutment supported fixed prosthesis for the partial edentulous arch
A mandibular implant/abutment supported fixed resection prosthesis for the partial edentulous mandibular arch in which a portion of the mandible is resected and reconstructed.
IMPLANT SERVICES
D6049 Scaling and debridement of a single implant in the presence of peri-implantitis inflammation, bleeding upon probing and increased pocket depths, including cleaning of the implant surfaces, without flap entry and closure
This procedure is not performed in conjunction with D1110, D4910, or D4346.
Benefits for D6049 are DENIED unless implants are covered by the group/individual contract. When covered:
a. Fees for D6049 are not billable to the patient by a participating dentist when performed in the same quadrant by the same dentist/dental office as D4341/D4342 or D4240/D4241, D4260/D4261, or D6101/D6102.
b. When covered, allow once per tooth per 24 months.
c. Fees for retreatment by the same dentist/dental office within 24 months of initial therapy are not billable to the patient by a participating dentist. If different dentist/dental office then benefits are DENIED.
d. Fees for D6049 are not billable to the patient by a participating dentist when performed within 12 months of restorations D6058-D6077, D6082-D6088, D6094, D6118, D6119.
e. No payment is made for D6049 and the fees are not billable to the patient by a participating dentist when performed in conjunction with D1110, D4910, or D4346.
D6196 Removal of an indirect restoration on an implant retained abutment
Not to be used for a temporary, provisional, or screw retained restoration. The removal of an indirect restoration is included in the definitive treatment and the fees are not billable to the patient by a participating dentist.
D6280 Implant maintenance procedures when a full arch removable implant/abutment supported denture is removed and reinserted, including cleansing of prosthesis and abutments – per arch
This procedure includes active debriding of the implant(s) and examination of all aspects of the implant
system, including the occlusion and stability of the prosthesis. The patient is also instructed in thorough daily cleansing of the implant(s).
Benefits for D6280 are DENIED unless covered by group/individual contract. If implant services D6110 and D6111 are covered,
a. Benefits are limited to once every 36 months. Benefits for D6280 are DENIED if done more frequently.
b. Fees for D6280 are not billable to the patient by a participating dentist if done within 12 months of D6110 and D6111.
ADJUNCTIVE GENERAL SERVICES
D9128 Photobiomodulation therapy - first 15-minute increment, or any portion thereof
The use of low-level laser therapy to alleviate pain or inflammation, modulate the immune response, and promote tissue healing or regeneration.
a. Fees for low level laser therapy are not billable to the patient by a participating dentist when performed as part of another procedure.
b. When billed as a standalone procedure, low level laser therapy is DENIED.
D9129 Photobiomodulation therapy - each subsequent 15-minute increment, or any portion thereof
a. Fees for low level laser therapy are not billable to the patient by a participating dentist when performed as part of another procedure.
b. When billed as a standalone procedure, low level laser therapy is DENIED.
D9224 Administration of general anesthesia with advanced airway – first 15-minute increment, or any portion thereof
With or without co-administration of nitrous oxide. Anesthesia time begins when the doctor administering the anesthetic agent initiates the appropriate anesthesia and non-invasive monitoring protocol and remains in continuous attendance of the patient. Anesthesia services are considered completed when the patient may be safely left under the observation of trained personnel and the doctor may safely leave the room. This procedure is determined by the provider’s documentation of the presence of an advanced airway such as a supraglottic or subglottic airway device, which includes laryngeal tube, esophageal-tracheal tube (Combitube), laryngeal mask airway, or endotracheal tube.
a. Benefit in conjunction with oral surgical procedures (D7000-D7999) when covered, or when necessary due to concurrent medical conditions. Otherwise, the benefit for deep sedation/general anesthesia is DENIED unless specifically covered by group/individual contract.
b. Benefits for more than one hour of deep sedation are not billable to the patient by a participating dentist unless clinical documentation supports more than an hour was necessary. For example, special health care needs patients may require additional units of anesthesia and more than one hour of anesthesia may be a benefit according to group/individual contract.
c. Benefits for deep sedation/general anesthesia are DENIED when billed by anyone other than an appropriately licensed and qualified provider.
D9225 Administration of general anesthesia with advanced airway – each subsequent 15-minute increment, or any portion thereof
a. Benefit in conjunction with oral surgical procedures (D7000-D7999) when covered, or when necessary, due to concurrent medical conditions. Otherwise, the benefit for deep sedation/general anesthesia is DENIED unless specifically covered by group/individual contract.
b. Benefits for more than one hour of deep sedation are not billable to the patient by a participating dentist unless clinical documentation supports more than an hour was necessary. For example, special health care needs patients may require additional units of anesthesia and more than one hour of anesthesia may be a benefit according to group/individual contract.
D9244 In-office administration of minimal sedation – single drug – enteral
In-office administration of a drug, as a single or divided dose, to achieve the desired clinical effect, not to exceed the FDA maximum recommended dose (MRD) for unmonitored home use. The single drug may be administered with or without co-administration of nitrous oxide.
a. Benefits for D9244 are DENIED, unless the group/individual contract specifies that services are a covered benefit.
b. Fees for D9244 are not billable to the patient by a participating dentist in conjunction with IV sedation (D9239 and D9243) and general anesthesia (D9222, D9223, D9224 and D9225).
D9245 Administration of moderate sedation – enteral
When moderate sedation is achieved by administration of drug(s) by enteral route only. With or without coadministration of nitrous oxide. The level of anesthesia is determined by the provider’s documentation of the anesthetic effects upon the central nervous system.
a. Benefits for D9245 are DENIED, unless the group/individual contract specifies that services are a covered benefit.
b. Fees for D9245 are not billable to the patient by a participating dentist in conjunction with IV sedation (D9239 and D9243) and general anesthesia (D9222, D9223, D9224 and D9225).
D9246 Administration of moderate sedation – non-intravenous parenteral – first 15-minute increment, or any portion thereof
When moderate sedation is achieved by administration of drug(s) by parenteral route, not including intravenous. With or without co-administration of nitrous oxide. Anesthesia time begins when the doctor administering the anesthetic agent initiates the appropriate anesthesia and non-invasive monitoring protocol and remains in continuous attendance of the patient. Anesthesia services are considered completed when the patient may be safely left under the observation of trained personnel and the doctor may safely leave the room. The level of anesthesia is determined by the provider’s documentation of the anesthetic effects upon the central nervous system.
a. Benefits D9246 are DENIED, unless the group/individual contract specifies that services are a covered benefit.
b. Fees D9246 are not billable to the patient by a participating dentist in conjunction with IV sedation
(D9239 and D9243) and general anesthesia (D9222, D9223, D9224, and D9225).
D9247 Administration of moderate sedation – non-intravenous parenteral – each subsequent 15-minute increment, or any portion thereof
a. Benefits D9247 are DENIED, unless the group/individual contract specifies that services are a covered benefit.
b. Fees D9247 are not billable to the patient by a participating dentist in conjunction with IV sedation (D9239 and D9243) and general anesthesia (D9222, D9223, D9224, and D9225).
D9936 Cleaning and inspection of occlusal guard – per appliance
This procedure does not include any adjustments.
Benefits for cleaning and inspection of an occlusal guard are DENIED unless covered by group/individual contract.
If covered,
a. Fees for cleaning and inspection of an occlusal guard are not billable to the patient by a participating dentist when done with in conjunction with D9942.
b. Benefit once every 12 months.
Deleted procedure codes effective January 1, 2026
D1352 Preventive resin restoration in a moderate to high caries risk patient – permanent tooth Conservative restoration of an active cavitated lesion in a pit or fissure that does not extend into dentin; includes placement of a sealant in any radiating non-carious fissures or pits.
The American Dental Association recommends using D2391, resin-based composite – one surface, posterior, instead of D1352.
a. Fees for preventive resin restoration completed on the same date of service and on the same surface as a restoration by the same dentist/dental office are considered a component of the restoration and are not billable to the patient by a participating dentist.
b. Benefits for preventive resin restorations are DENIED when submitted documentation or the patient’s claim history indicates a restoration on the occlusal surface of the same tooth.
c. Age limitations for preventive resin restorations are determined by group/individual contract.
d. Preventive resins restorations are payable once per tooth on the occlusal surface of permanent molars. The teeth must be free from overt dentinal caries
e. Benefits for preventive resin restorations or sealants include repair or replacement within 24 months by the same dentist/dental office. Fees for repair or replacement of a preventive resin restoration are not billable to the patient by a participating dentist if performed within 24 or 36 months (based on group/individual contract) of initial placement by the same dentist/dental office.
f. Benefits for preventive resin restorations requested after 24 or 36 months (based on group/individual contract) are DENIED or covered based on group/individual contract.
D1705 AstraZeneca Covid-19 vaccine administration – first dose
SARSCOV2 COVID-19 VAC rS-ChAdOx1 5x1010 VP/.5mL IM DOSE 1
Benefits are DENIED unless covered by group/individual contract.
D1706 AstraZeneca Covid-19 vaccine administration – second dose
SARSCOV2 COVID-19 VAC rS-ChAdOx1 5x1010 VP/.5mL IM DOSE 2
Benefits are DENIED unless covered by group/individual contract.
D1707 Janssen Covid-19 vaccine administration
SARSCOV2 COVID-19 VAC Ad26 5x1010 VP/.5mL IM SINGLE DOSE
Benefits are DENIED unless covered by group/individual contract.
D1712 Janssen Covid-19 vaccine administration – booster dose
SARSCOV2 COVID-19 VAC Ad26 5x1010 VP/.5mL IM DOSE BOOSTER
Benefits are DENIED unless covered by group/individual contract.
D9248 Non-intravenous conscious sedation
This includes non-IV minimal and moderate sedation. A medically controlled state of depressed consciousness while maintaining the patient’s airway, protective reflexes and the ability to respond to stimulation or verbal commands. It includes non-intravenous administration of sedative and/or analgesic agent(s) and appropriate monitoring. The level of anesthesia is determined by the anesthesia provider’s documentation of the anesthetic’s effects upon the central nervous system and not dependent upon the route of administration.
a. DENIED unless covered by group/individual contract.
b. Fees for D9248 are not billable to the patient by a participating dentist in conjunction with IV sedation (D9239 and D9243) and general anesthesia (D9222 and D9223).
