Fidelis Care supplemental dental Coverage

Key Definitions & Plan Scope

Offer de prestations du plan — plan benefit offer

DefinitionOffer de prestations du plan — the specific plan benefit package referenced on the member's certificate (attestation d'assurance). See the member's 2025 certificate for the exact plan offer and plan ID.

Applies toRules in this document apply to the 2025 dental benefit offers listed on the member certificate for NY plans (examples: H5599001000, H5599003000, H4868004000, H4868014000, H2775112000).

Location on certificateThe plan benefit offer is shown on the member's attestation d'assurance in the lower right corner of the certificate.

Autorisation pralable (Prior authorization)

DefinitionAutorisation prealable — prior authorization required for certain imaging codes (examples: D0364, D0365, D0366, D0368).

ScopeCertain CBCT capture/interpretation codes require prior authorization; some imaging is covered only for implants or specific clinical indications.

EffectPrior authorization verifies eligibility and available benefits at time of request but is not a guarantee of payment (see Prior authorization explanation).

Third molars

DefinitionThird molars — third molars (wisdom teeth) are excluded from many crown/core and replacement periodicities unless there is documented medical necessity.

ExamplesCodes such as D2928, D2950 and many crown codes explicitly state: exclude third molars except in case of medical necessity.

ApplicationWhen third molars are treated, medical necessity must be documented to override the exclusion.

50% bone support

Definition50% bone support — many pulpal/endodontic procedures require at least 50% remaining alveolar bone support to be eligible for coverage.

ExamplesCodes with this requirement include D3110, D3120, D3220, D3310, D3320, D3330 and retreatment codes; periodicity often listed as once per lifetime per tooth with the 50% support requirement.

Clinical implicationProviders must document remaining alveolar bone support in the dental record to support coverage for these procedures.

Periodicit (Periodicity)

Common periodsExamples in this schedule: prophylaxis D1110 once per 6 months; D4341/D4342 once every 24 months; many crowns/bridges once every 60 months; dentures once every 96 months; some services lifetime-limited.

Code-specific rulesEach CDT code entry specifies the periodicity; refer to the code line item for the precise interval and any exceptions.

Numeric limits per arch/dent

DefinitionNumeric limits per arch/dent — explicit numeric caps in the policy for implant-related items (for example, limit to 4 implants upper arch and 2 implants lower arch unless medical necessity is documented).

Exception handlingProviders should document medical necessity if requesting coverage beyond numeric arch limits; prior authorization may be required for some implant procedures.

Periodicity / frequency limits

DefinitionFrequency limits (periodicity) for coverage of a code — many prosthodontic and crown codes are limited per patient/same tooth (e.g., once every 60 months, once every 84 months for D6548).

ExamplesD6720-D6794 crown/prosthodontic group: once every 60 months per patient/same tooth; D6548: one per tooth every 84 months; dentures D5110/D5120: once every 96 months.

Clinical exceptionReplacement earlier than the stated periodicity may be allowed if additional tooth loss requires construction of a new appliance and at least 50% bone support remains (exceptions exclude third molars unless medically necessary).

Coverage limit per patient / per same tooth

RuleCoverage limit is applied per patient and per the same tooth; replacements are generally limited to the stated periodicity unless additional tooth loss necessitates a new appliance.

ExceptionThird molars are excluded from routine replacement periodicities unless medical necessity is documented.

Date of end of treatment

DefinitionDate of end of treatment — the date when treatment is complete and billable (examples: delivery dates for prostheses, final cementation for crowns/bridges, final root canal filling).

PurposeUsed to determine when a service is considered complete for applying periodicity and replacement intervals.

DocumentationProviders should use the treatment completion date on the claim to determine eligibility under periodicity rules.

Prior authorization: explanation and effect

ExplanationPrior authorization is required for certain codes; it verifies eligibility and available benefits at the time of request but is not a guarantee of payment — payment approval depends on member eligibility on date of service, dental record documentation, policy limitations, and remaining benefits.

ExamplesCertain codes explicitly require prior authorization (e.g., D7952 for sinus augmentation vertical approach; CBCT codes D0364-D0366,D0368 require prior authorization).

Action for providersSubmit prior authorization requests with clinical documentation; approval does not replace final eligibility or documentation review at time of service.

Coverage Criteria, Limits, and Exclusions

Coverage criteria and limits (by code/group)

Coverage of dental services is defined per CDT code with specified frequency limits, exclusions (e.g., third molars except for medical necessity), and special rules (prior authorization, provider restrictions).

Coverage and periodicity are determined at the CDT-code level; limits are expressed as per patient, per tooth, per quadrant, per arch, or lifetime as specified for each code.

ALL of the following

Periodic limits apply as stated for each code (examples: D0120 once every 6 months; D0330 once every 36 months).see code-specific entries
Radiograph reimbursement on a single date of service is limited to fees for one complete series (D0210).
Certain imaging (CBCT) codes (D0364–D0366, D0365, D0368) require prior authorization or are only covered for implant-related care.

ALL of the following

Crowns and related core/post procedures are commonly limited to once every 60 months per patient/same tooth; third molars are excluded except for medical necessity.
Replacement before periodicity may be allowed when additional tooth loss necessitates construction of a new appliance or when at least 50% alveolar bone support remains, per code guidance.

ALL of the following

Prostheses (complete/partial dentures) are generally limited to once every 96 months per patient unless code-specific exception applies.
Prosthesis adjustments (D5410–D5422) are limited (up to four per 12 months) and are not covered within 6 months of insertion.

Restorative and endodontic criteria (partial)

Frequency and coverage criteria for restorative and endodontic procedures:

Prefabricated and indirect crown/core procedures (e.g., D2928, D2931–D2933, D2950–D2954) are generally limited to once every 60 months per patient and per same tooth; third molars excluded except for documented medical necessity; some items (eg, D2951) have separate shorter periodicity (two per 12 months).

ALL of the following

Direct/indirect pulp capping and pulpal therapies (D3110, D3120, D3220, D3230, D3240) are generally limited to once per lifetime per tooth and require at least 50% alveolar bone support remaining.
Endodontic therapy codes (D3310, D3320, D3330) are limited to once per lifetime per patient per tooth and require at least 50% bone support remaining.

ALL of the following

Post and core (D2952, D2954) and related core build-up codes are limited to once every 60 months per tooth; specific rules govern multiple post units per tooth and same-day limits between D2952 and D2954.

Periodontal surgery and graft criteria (partial)

Periodontal surgical and regenerative procedures:

Periodontal flap and surgical procedures (D4240, D4241) are limited per quadrant every 36 months.

Apically positioned flap (D4245) requires prior authorization before it is covered.

ALL of the following

Gingivectomy/gingivoplasty for access (D4212) is limited to one per tooth per lifetime.
Periodontal bone surgery and guided tissue regeneration codes (D4260–D4267) have specified periodicity (commonly 36 months or lifetime limits for grafting/regeneration); certain regenerative codes (D4266/D4267) are limited to once per lifetime per site.

ALL of the following

Prosthodontics and denture maintenance (partial)

Prosthodontic (dentures/partials) frequency and adjustment restrictions:

Complete and partial removable prostheses (D5110, D5120, D5211, D5212, D5213, D5214, D5225, D5226, D5284, D5286) are generally limited to once every 96 months per patient; quadrant/arcade rules apply where specified.

Immediate dentures have the same 96-month periodicity per arcade as replacement prostheses (D5130, D5140).

ALL of the following

Denture adjustments (D5410–D5422) are limited to up to four adjustments per 12 months per patient and are not covered within 6 months following insertion of the prosthesis.
Prosthesis repairs (D5511, D5512, D5520 series) have their own periodicity (e.g., D5511 twice per 12 months).

Tissue conditioning (D5850, D5851) is limited to once every 60 months but is covered within 6 months prior to placement of a new prosthesis as specified.

Coverage criteria by code and rule

Coverage decisions follow code-specific periodicity and limits. Key rules extracted from the chunks:

Standard periodicity: Many codes specify a recurring interval (examples: 12 months for many maxillofacial/prosthetic facial codes; 60 months for many pontic/bridge/crown codes; 96 months for many implant-supported crowns/abutments).

Not covered within 6 months: Certain prosthesis-related codes (e.g., D5761, D5765) and adjustment codes are not covered within 6 months following insertion.

Per-arch and per-dent numeric limits: Implant placement and implant-supported prosthesis codes commonly include numeric arch limits (limit of 4 upper, 2 lower) unless medical necessity is documented; applicable to D6010/D6013, D6056–D6057, D6065–D6067, D6110–D6113 and related codes.

Service-specific exceptions: Bridge/pontic and crown replacements may be allowed sooner than stated periodicity if additional tooth loss or fracture necessitates construction of a new appliance and at least 50% bone support remains; third molars are excluded except for medical necessity.

Crown and prosthodontic periodicity with clinical exception

Coverage subject to code-specific periodicity and clinical exceptions

ALL of the following

The listed crown and fixed-prosthodontic codes (e.g., D6720–D6794 group) are limited to once every 60 months per patient for the same tooth.
D6548 (porcelain/ceramic appliance for fixed prosthesis) is limited to one per tooth every 84 months.
Clinical exception: replacement before the stated periodicity may be allowed when additional tooth loss requires a new appliance (for example, loss or fracture of additional teeth) provided at least 50% alveolar bone support remains; third molars are excluded except for documented medical necessity.

Short-interval services

Diagnostic and minor restorative services periodicity rules

Selected diagnostic and minor restorative/repair codes such as D6930 (repair/recementation of fixed partial), D7287/D7288 (exfoliative cytology/brush biopsy) are limited to once every 24 months per patient/site/quadrant as specified.

Lifetime-limited surgical procedures

Extractions and many surgical services are limited to one per lifetime per patient per tooth/quadrant as noted

Many extraction and related surgical codes (including D7111, D7140, D7210, D7220, D7230, D7240, D7241, D7250) are limited to one per lifetime per patient for the same tooth.

Multiple additional oral surgery codes (D7251, D7260, D7261, D7270, D7272, D7280, etc.) carry lifetime or site-specific lifetime limits as listed; follow the code-specific periodicity.

Limits and Exclusions

High-level limits and exclusions

Optional/alternate treatment: If a member selects a more expensive service than the usual service, an alternative allowance may be paid and the member is responsible for the cost difference.

When posterior teeth are missing in both quadrants of the same arch, benefits for fixed bridges in that arch are limited to a conventional tissue-supported partial denture.

Payment for porcelain/ceramic or metal-fused crowns on implants is based on the allowable for an equivalent conventional crown (payment parity rule).

Exclusions: congenital/developmental correction, cosmetic services, hospital/test/histopathology charges, services lacking dental necessity, experimental services, services not meeting accepted dental practice, services covered by hospital/medical/drug programs (including Medicare Advantage), TMJ devices, procedures to increase vertical dimension, and services not listed are excluded.

Date of end of treatment: the date when treatment is complete and billable (e.g., prosthesis delivery, final cementation for crowns/bridges, final root canal filling).

CDT Codes, Frequencies, and Coding Rules

Representative CDT codes and frequenciesmixedCovered

D0120	Periodic oral evaluation — established patient; frequency: once per 6 months; not covered same date as D9310 or D9430
D0150	Comprehensive oral evaluation — new or established patient; frequency: once in lifetime per provider or center; not covered same date as D9310 or D9430
D0330	Panoramic radiographic image; frequency: once every 36 months per patient
D1110	Adult prophylaxis; frequency: once per 6 months per patient
D1206	Topical fluoride varnish; frequency: up to four per 12 months per patient
D2140	Amalgam one surface; frequency: every 24 months per patient, same tooth/surface
D2710	Composite crown (indirect); frequency: once every 60 months per tooth
D2720	Resin with high noble metal crown; frequency: once every 60 months per tooth

Selected crown/core codesCPTCovered

D2928	Porcelain/ceramic prefabricated crown; frequency: once every 60 months per tooth; exclude third molars unless medically necessary; must include 4 surfaces.
D2950	Core build-up, including any pins; frequency: every 60 months; exclude third molars unless medically necessary; must include 4 surfaces.
D2951	Pin retention (per tooth) in addition to restoration; frequency: two per 12 months per patient per same tooth.
D2952	Post and core, cast; frequency: once every 60 months per patient per same tooth.

Selected endodontic codesCPTCovered

D3310	Endodontic therapy, anterior tooth; frequency: once per lifetime per patient per tooth; requires at least 50% alveolar bone support remaining.
D3330	Endodontic therapy, molar; frequency: once per lifetime per patient per tooth; requires at least 50% alveolar bone support remaining.
D3346	Retreatment of root canal, anterior; frequency: once per lifetime per patient per tooth; requires at least 50% alveolar bone support remaining.

Prosthesis replacement codesCPTCovered

D5110	Complete maxillary denture; frequency: once every 96 months per patient.
D5120	Complete mandibular denture; frequency: once every 96 months per patient.
D5211	Maxillary partial denture, resin base; frequency: once every 96 months per patient.

Misc prosthesis and tissue conditioningCPTCovered

D5761	Periodicite: Non couvert(e) dans les 6 mois suivant la mise en place
D5765	Doublure souple pour protheses completes ou partielles (indirectes) — non couverte dans les 6 mois suivant la mise en place
D5850	Conditionnement des tissus, maxillaire — Un par 60 mois; covered within 6 months before new prosthesis
D5851	Conditionnement des tissus, mandibulaire — Un par 60 mois; covered within 6 months before new prosthesis

Implant placement and abutmentsCPTCovered

D6010	Placement of endosteal implant body — lifetime per patient per same tooth; limits 4 upper, 2 lower except medical necessity
D6013	Placement of mini-implant — lifetime per patient per same tooth; limits 4 upper, 2 lower except medical necessity
D6056	Prefabricated abutment — once every 96 months per patient; limit 4 upper, 2 lower
D6057	Custom abutment — once every 96 months per patient; limit 4 upper, 2 lower

Pontic/bridge components (60-month periodicity)CPTCovered

D6210	Pontic metal very noble cast — once every 60 months per patient; same-tooth rules and exceptions described
D6240	Pontic porcelain fused to high noble — once every 60 months per patient; same-tooth rules and exceptions described
D6250	Pontic resin with high noble metal — once every 60 months per patient; same-tooth rules and exceptions described

Crown/prosthodontic codes with 60-month periodicityCPTCovered

D6548	Porcelain/ceramic appliance for fixed prosthesis; periodicity: one per tooth every 84 months
D6720	Resin crown with high noble metal; periodicity: once every 60 months per patient/same tooth
D6721	Resin crown with base metal; periodicity: once every 60 months per patient/same tooth
D6722	Resin crown with noble metal; periodicity: once every 60 months per patient/same tooth
D6740	Porcelain/ceramic crown; periodicity: once every 60 months per patient/same tooth
D6750	Porcelain fused to high noble metal crown; periodicity: once every 60 months per patient/same tooth
D6751	Porcelain fused to base metal crown; periodicity: once every 60 months per patient/same tooth
D6752	Porcelain fused to noble metal crown; periodicity: once every 60 months per patient/same tooth
D6753	Porcelain fused to titanium crown; periodicity: once every 60 months per patient/same tooth
D6780	Three-quarter cast high noble metal crown; periodicity: once every 60 months per patient/same tooth

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Other restorative/diagnostic periodicity codesCPTCovered

D6930	Amalgam or rebonding of fixed partial denture; periodicity: once every 24 months per patient, same quadrant
D6980	Repair of fixed partial denture; periodicity: once every 60 months per patient, same quadrant
D7287	Exfoliative cytology; periodicity: once every 24 months per site
D7288	Brush biopsy; periodicity: once every 24 months per site

Extraction and related surgical codes with lifetime limitsCPTCovered

D7111	Extraction, residual crown primary tooth; periodicity: one per lifetime per patient, same tooth
D7140	Extraction, erupted tooth or exposed root; periodicity: one per lifetime per patient, same tooth
D7210	Surgical extraction of erupted tooth including mucoperiosteal flap; periodicity: one per lifetime per patient, same tooth
D7220	Removal of soft tissue impaction; periodicity: one per lifetime per patient, same tooth
D7230	Removal of partially bony tooth; periodicity: one per lifetime per patient, same tooth
D7240	Removal of completely bony tooth; periodicity: one per lifetime per patient, same tooth
D7241	Removal of completely bony tooth with unusual complications; periodicity: one per lifetime per patient, same tooth
D7250	Surgical removal of residual tooth roots; periodicity: one per lifetime per patient, same tooth

Selected CDT codes and notesCPT

D7660	Malaire et/ou arcade zygomatique — reduction fermee.
D7710	Maxillaire reduction ouverte.
D7720	Maxillaire reduction fermee.
D7870	Arthrocentese — periodicity: one per 6 months.
D7880	Occlusal orthotic device — one per 12 months.
D7951	Sinus augmentation — one lifetime per patient, same quadrant; covered only for implants.
D7952	Sinus augmentation via vertical approach — prior authorization required.
D9222	Sedation/anesthesia general 15 first minutes — two per week.
D9230	Inhalation nitrous oxide analgesia — not allowed same day as certain sedation codes.
D9944	Occlusal appliance hard; complete arch — one per 12 months.

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Radiograph per-date-of-service reimbursement cap

RuleRadiograph per-date-of-service reimbursement cap — reimbursement for radiographs on a single date of service is limited to the fees for one complete series (D0210).

ExamplesMultiple extraoral or intraoral capture-only codes referenced on the same date of service are subject to this per-date cap; see D0330/D0210 and related entries.

Claiming noteProviders should expect radiograph fees billed on a single date to be adjudicated with the cap applied; submit only necessary imaging codes with supporting documentation.

Crown frequency limit

RuleCrown frequency limit — crowns are generally limited to once every 60 months per patient/same tooth; third molars are excluded except for medical necessity.

Affected codesApplies to crown groups including D2710, D2720, D2721, D2722, D2740, D2750, D2780, D6740, D6750 and related codes as listed in the schedule.

ExceptionReplacement earlier than 60 months may be allowed if additional tooth loss necessitates a new appliance and at least 50% bone support remains; documentation required.

D4381 frequency and timing

Clinical documentationProviders must document pocket depths and prior scaling/root planing (D4341/D4342) and the 28-day interval to support billing D4381.

ScopeLimit is per patient and counts toward the 24-month limit across providers; follow documentation requirements for coverage.

Prosthesis adjustment limits

RuleProsthesis adjustment limits — D5410-D5422: up to 4 adjustments per 12 months per patient; adjustments are not covered within 6 months following initial insertion of the prosthesis.

ExamplesD5410 (maxillary complete denture adjust) and D5411 (mandibular) are limited to four per 12 months and not covered in the first 6 months post-insertion.

ImplicationClaims for adjustment within 6 months of insertion should be supported by documentation showing medical necessity if billed.

Implant per-arch numeric limits

RuleImplant per-arch numeric limits — limit to 4 implants in the upper arch and 2 implants in the lower arch per patient unless medical necessity is documented.

Affected codesLimits apply to implant placement and implant-supported prosthesis codes including D6010, D6013, D6056, D6057, D6110-D6113, and related implant component codes.

Exception processProviders should document medical necessity and may require prior authorization for cases exceeding numeric arch limits.

Bridge/crown replacement interval

RuleBridge/crown replacement interval — most pontic/bridge/crown codes are limited to once every 60 months per patient/same tooth; some crown/bridge groups may have longer intervals (84 or 96 months) as specified per code.

ExamplesPontic codes D6210-D6252 show a 60-month periodicity; D6548 has an 84-month per-tooth periodicity; denture replacements (D5110/D5120) are 96 months.

Clinical exceptionEarlier replacement may be allowed if additional tooth loss requires a new appliance and sufficient bone support remains; document condition and tooth loss.

Minimum remaining bone support rule

RuleMinimum remaining bone support rule — replacement or new construction may be allowed when additional tooth loss requires a new appliance only if at least 50% alveolar bone support remains.

ApplicationThis rule is referenced for many crown, bridge and fixed prosthesis codes as the clinical exception to normal periodicity limits.

DocumentationClinical records must document percent bone support and the additional tooth loss situation to justify exception to periodicity limits.

D6548 per-tooth limit

RuleD6548 per-tooth limit — D6548 is limited to one per tooth every 84 months (per-tooth periodicity).

Related codesD6548 is a porcelain/ceramic appliance for fixed prosthesis; verify code-specific line item for billing.

Examples of frequency thresholds

ExamplesExamples of frequency thresholds in the schedule include: per lifetime limits (many surgical/extraction codes), per 6 months (e.g., D7870 arthrocentesis), per 12 months (e.g., occlusal appliance D7880), per week (sedation codes limits), and per date of service (e.g., D9610 therapeutic injection).

PurposeThe schedule lists code-specific periodicity next to each CDT code; providers should consult the code entry for exact thresholds.

Claiming noteUse the date of end of treatment and code-specific periodicity to determine whether a service meets frequency limits before billing.

OpenPayer

Supplemental dental benefits schedule and coverage rules

Key Definitions & Plan Scope

Coverage Criteria, Limits, and Exclusions

CDT Codes, Frequencies, and Coding Rules

Prior Authorization, Documentation & Billing Requirements