CurrentBlue Cross Blue Shield - MainePolicy 09-900

Teledentistry

Governs delivery, documentation, licensure, and reimbursement guidance for dental services provided via teledentistry to members of Blue Cross Blue Shield - Maine; applies to dentists and allied dental personnel delivering remote dental care.

Policy Summary

PayerBlue Cross Blue Shield - Maine

PolicyTeledentistry

Policy CodePolicy 09-900

Change TypeNo material change

Effective DateJan 1, 2026

Next Review DateJan 1, 2026

Key ActionVerify member contract benefits and prior authorization requirements because reimbursement is for the performed procedure codes rather than teledentistry-specific codes.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

CDT 2026Current dental terminology referenced

01/01/2026Current effective date

10/17/2025Last review date

09-900Guideline number

Coverage Criteria for Teledentistry

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Licensure and authorization: Dentist and allied dental personnel must be licensed or credentialed in accordance with the laws of the state where the patient receives services and services must be lawful within the scope of the licensee; delivery must comply with state scope of practice laws, regulations, or rules.

Supported by the ADA Comprehensive Policy Statement on Teledentistry and state practice requirements.

Clinical appropriateness: Procedures delivered via teledentistry must be dentally necessary and appropriate as determined by standards of generally accepted dental practice.

Teledentistry benefits are available to the same extent as in-person care when procedures are dentally necessary and appropriate.

Coverage under contract: Procedures must be otherwise covered under the member's certificate of coverage or evidence of coverage to be reimbursed.

Reimbursement is for procedures performed rather than for teledentistry-specific codes themselves.

Privacy and documentation: Services must conform to applicable state privacy and security laws; documentation must meet state recordkeeping and informed clinical and financial consent requirements.

Documentation must conform to state requirements for recordkeeping and consent.

Quality and supervision protocols: Providers must establish protocols for contacting allied dental personnel and patients, for referrals and monitoring, and for supervision, credentialing, initial and ongoing evaluation components, and case selection limitations (including specific protocols for orthodontic teledentistry where applicable).

Protocols should address monitoring, supervision, credentialing, evaluation components, and referral handling.

No separate coverage is established for teledentistry-specific codes. Reimbursement is available for the underlying dental procedures actually performed (procedure codes) rather than for teledentistry codes themselves; providers must verify the member's certificate of coverage or evidence of coverage to determine whether a procedure is payable and whether prior authorization is required.

Coding — CDT Codes and Groups

Clinical Oral Evaluations (CDT)CDT

D0120	periodic oral evaluation
D0140	limited oral evaluation
D0145	oral evaluation for a patient under three years of age
D0150	comprehensive oral evaluation
D0170	re-evaluation - limited
D0171	re-evaluation post-operative
D0180	comprehensive periodontal evaluation
D0190	screening of a patient
D0191	assessment of a patient
D0601	caries risk assessment - low

1–10 of 12

1/2

Diagnostic Imaging (CDT)CDT

D0210	intraoral - comprehensive series
D0220	intraoral - periapical first image
D0230	intraoral - periapical each additional image
D0240	intraoral - occlusal image
D0270	bitewing - single image
D0272	bitewings - two images
D0273	bitewings - three images
D0274	bitewings - four images
D0277	vertical bitewings - 7 to 8 images
D0330	panoramic image

Preventive (CDT)CDT

D1110	prophylaxis - adult
D1120	prophylaxis - child
D1206	topical application fluoride varnish
D1208	topical application of fluoride excluding varnish
D1301	nutritional counseling
D1320	tobacco counseling
D1330	oral hygiene instruction
D1351	sealant
D1352	sealant repair
D1354	interim caries arresting medication application

Provider Actions, Billing, and Documentation

Prior Authorization

Prior Authorization and Reimbursement Note

Reimbursement is available for covered dental procedures performed via teledentistry rather than for teledentistry-specific codes. Verify member contract and benefits at time of service; prior authorization requirements, if any, follow the usual rules for the underlying procedure.

Verify member's contract and evidence of coverage for procedure-level benefits
Follow standard prior authorization processes for the procedure billed (not for a teledentistry modality)

Note

Provider Operational Requirements

Providers remain responsible for complying with provider-impact requirements in this policy: maintain appropriate licensure and credentials, follow supervision and credentialing protocols, and adhere to case-selection and monitoring protocols when providing services remotely.

Ensure credentialing, licensing, and specialty documentation are current and available
Follow written protocols for initial and ongoing evaluation, monitoring, and referrals

Documentation Required

Recordkeeping and Consent

Documentation of teledentistry encounters must meet all applicable state recordkeeping requirements and include clinical details sufficient to support the billed service. Obtain and document informed consent (clinical and financial) per state law and the member's plan requirements.

Record date/time, modality (synchronous/asynchronous), participants (provider and allied personnel), clinical findings, assessment, treatment plan, and any images or digital records used to render care
Document informed consent specifics (discussion of limitations/risks, alternatives, financial responsibility) and retain consent per state retention laws
Retain records in the same manner and for the same duration as in-person care and make available for audit or continuity of care

Billing Rule

Licensure and Scope Compliance

Services delivered via teledentistry must be within the provider's scope of practice and in compliance with the laws and regulations of the state where the patient receives services. Providers must be licensed or otherwise authorized by the state board to deliver the services provided remotely.

Confirm provider is licensed in the state where the patient is located or otherwise authorized by that state's dental board
Only perform procedures that are lawfully within the provider's licensed scope and permitted via teledentistry under state law
Establish protocols for referrals and coordination with in-person providers when required

Background

Teledentistry is the delivery of diagnostic, consultative, and limited educational dental services when the dentist and patient are in different locations using information and audio‑visual communication technology. Services may be provided synchronously or asynchronously and must follow evidence‑based practice guidelines and established protocols for referrals, monitoring, supervision, credentialing, and evaluation components where applicable.

Teledentistry enables diagnostic and consultative functions (for example, clinical oral evaluations, caries risk assessment, and diagnostic imaging) and supports limited preventive and educational interventions when those services can be lawfully performed within the scope of the provider's license and are clinically appropriate.

Documentation, privacy, and informed consent requirements that apply to in‑person dental care also apply to teledentistry; providers must maintain state‑specific recordkeeping and consent documentation and ensure services are within the scope of practice and licensure for the state where the patient receives care.

Definitions

Teledentistry — Definition

DefinitionThe delivery of dental services including diagnostic, consultative, and educational limited dental procedures by a dentist to a patient located at a different location through the use of information and audio-visual communication technology.

Included service typesDiagnostic, consultative, and educational limited dental procedures delivered remotely.

TechnologyInformation and audio-visual communication technology enabling synchronous or asynchronous interactions.

Provider roleServices are delivered by a dentist (may involve allied dental personnel under appropriate supervision and licensing).

Location requirementPatient and dentist are located at different physical locations during service delivery.