mhn CA Medi‑Cal Children Dental Coverage | OpenPayer
CurrentmhnPolicy N/A
CA Medi‑Cal Children Dental Benefits — Diagnostics, Preventive, Restorative (Exhibit A)
Defines covered dental diagnostic, preventive, and restorative services and benefit limits for California Medi‑Cal children, and the documentation/prior authorization and reimbursement rules applicable to providers participating with DentaQuest/California Dental Network.
Policy Summary
Payermhn
PolicyCA Medi‑Cal Children Dental Benefits — Diagnostics, Preventive, Restorative (Exhibit A)
Policy CodePolicy N/A
Change TypeNo material change
Effective Date
Next Review Date
Key ActionSubmit prior authorization only for orthodontic codes; for other listed codes ensure required documentation (narrative, radiographs, photos, treatment plan) is included for pre-payment review.
No material clinical or coverage changes in this revision.
0-21Age coverage range
Ortho onlyPrior authorization rule
60 monthsCommon crown limit
36 monthsExam/radiograph freq
RequiredRadiograph quality
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Coverage criteria and limits
Coverage criteria and billing rules
General coverage principles and reimbursement rules.
Radiographs must be diagnostic quality, properly mounted, dated and identified with the member's name; non-diagnostic films will not be reimbursed or may be recouped.
Prior authorization is required only for orthodontic codes; other listed codes may be subject to pre-payment review but do not require approval before services are rendered.
Billing and reimbursement for cast crowns, post & cores, and other fixed prosthetics shall be based on the cementation date; billing for initial or retreatment root canals is based on the fill date.
Payment for restorative services is based on the number of surfaces restored; similar restorations are not covered for at least 36 months unless there is recurrent decay or material failure.
Providers must submit required documentation as specified per code (examples include narrative of medical necessity, pre-operative radiographs, operative report, pathology report, photos, and treatment plan); absence of required radiographs may result in recovery of prior payments.
Payments already made for inadequate services may be recouped after DentaQuest review.
Coverage criteria and billing rules — Restorative, prosthetic, and endodontic services for CA Medi‑Cal children
Coverage and billing rules for restorative, prosthetic, and endodontic services for CA Medi‑Cal children.
Most restorative and preventive codes are age‑limited to members 0–21 years unless otherwise specified.
Frequency limits vary by code and tooth permanence (examples: many restorative posterior codes one per 12 months for primary per surface and one per 36 months for permanent per surface; many crown/pontic codes limited to one per 60 months per tooth).
Specific restorative and crown codes require authorization and pre‑operative radiographs as noted per code (e.g., D2710 and listed crown codes require pre‑op radiographs).
Restorative fees include associated adjunctive items (liners, bases, bonding agents, curing, polishing, anesthesia) as part of the restoration fee.
Endodontic therapy standards require canals be completely filled apically and laterally; nonconforming work may be required to be redone at no additional cost and endodontic frequency limits are generally one per lifetime per tooth where specified.
Coverage criteria by code group
Coverage entries with limits, authorization, documentation, and age/teeth scopes for listed CDT codes.
D2954: Authorization required; one per lifetime per patient per tooth; pre‑operative radiographs required.
D2980: Age 0–21; not a benefit within 12 months of initial crown placement or previous repair for the same provider.
D3220 / D3310 / D3320 / D3330 / D3346 etc.: Endodontic codes age 0–21; typically one per lifetime per patient per tooth; authorization and documentation flags vary by specific code.
D3410–D3426 (apicoectomy series): Authorization required; narrative of medical necessity and pre‑operative radiographs required; benefit limits commonly reported per 24 months per provider per tooth.
D4210–D4261 (periodontics): Age limitations (e.g., 13–20 for many codes); authorization required for many entries; photographs or pre‑op radiographs required; frequency limits per quadrant apply.
Coverage criteria for prosthodontics and maxillofacial prosthetics
Coverage and limits for listed prosthodontics and maxillofacial prosthetic codes with age, authorization, and documentation requirements.
D5214, D5863, D5865: Authorization required; benefit limit one per 60 months per patient; pre‑operative radiographs required for overdentures.
Selected removable prosthodontics (D5410–D5761, D5850–D5851): Age limited to 0–21; many codes have per‑day and per‑12‑month provider limits as specified in the grid; documentation as noted per code.
Maxillofacial prosthetic codes (D5911–D5937, D5951–D5953): Authorization required; documentation typically narrative of medical necessity; most are age‑limited to 0–21 with some pediatric/adult specifics for feeding/speech aids.
Implant services coverage criteria
Implant-related codes are covered only under documented exceptional medical conditions and require specific documentation.
Benefit condition: Implant services are a benefit only when exceptional medical conditions are documented and services will be reviewed for medical necessity (refer to Implant Services General policies).
Authorization: Most implant codes require authorization; services must be submitted as prior authorization under EPSDT when applicable.
Documentation: Photos, radiographs (pre‑ and as specified), and a treatment plan are required for implant services; narrative of medical necessity is commonly required for related prosthetic codes.
Re‑cementation note: D6092/D6093 re‑cement/re‑bond do not require authorization; the original provider is responsible for re‑cementations within the first 12 months following initial placement.
Pre‑payment review clarification: Pre‑payment review does not require approval before services are rendered; only orthodontic codes require prior authorization prior to rendering treatment.
Coverage criteria by code group — Implant, prosthodontic and oral surgery codes for CA Medi‑Cal children
Coverage and limitations for implant, prosthodontic and oral surgery codes for CA Medi‑Cal children.
D6113–D6117: Age 0–21; teeth 1–32; authorization required; implant services are a benefit only when exceptional medical conditions are documented; documentation required: photos, x‑rays, treatment plan.
D6190: Age 0–21; authorization not required for this specific implant diagnostic/index code (documentation not specified).
D6211/D6241/D6245/D6251 (pontics): Authorization required; age limitations (e.g., 13–20 for some entries); limit one per 60 months per patient per tooth; documentation required: narrative of medical necessity and pre‑op x‑rays.
D6721/D6740/D6751/D6781/D6783/D6791 (crowns): Authorization required; benefit limit one per 60 months per patient per tooth; documentation required: narrative of medical necessity and pre‑op x‑rays.
Surgical extractions and alveoloplasty
Coverage criteria for listed oral/maxillofacial procedures
Coverage applies to listed oral and maxillofacial CDT codes for members aged 0–21 when required authorization and documentation are provided and benefit limits are respected.
Age limit: All listed oral/maxillofacial services in this section are limited to members ages 0 through 21 unless otherwise specified.
Authorization: A substantial subset of oral and maxillofacial surgery codes list 'Authorization Required = Yes' (examples include D7320, D7340, D7350, D7410, many others); submit required documentation with authorization requests.
Documentation: Documentation required varies by code and includes narrative of medical necessity, pre‑operative radiographs, operative report, pathology report, and photos as specified per code.
Selected benefit limits: examples include D7320 one per lifetime per quadrant; D7340 one per 60 months per arch; D7350 one per lifetime per arch; selected incision/drainage codes limited to per‑day allowances as specified.
Coverage with criteria
Coverage for listed oral and maxillofacial D‑codes for CA Medi‑Cal children is provided subject to age limits, authorization, documentation, and occasional benefit quantity limits.
All listed D‑codes are generally limited to members age 0–21 unless otherwise specified; many codes list 'Authorization Required = Yes'.
Documentation required across many D‑codes includes pre‑operative radiographs, operative report, narrative of medical necessity, pathology report, and photos as specified by code.
Benefit limits examples
Per‑code lifetime or time‑based limits apply (examples: one per lifetime per quadrant for D7320; one per 60 months per arch for D7340; D7510 one per day per patient per quadrant).
Some oral/maxillofacial codes impose per‑day or per‑arch quantity restrictions (e.g., D7961/D7962/D7963/D7970/D7972/D7997 one per day per patient per arch/quadrant as specified).
Orthodontic and adjunctive coverage criteria
Orthodontic coverage conditions and required documentation.
For comprehensive orthodontic authorization (D8080) submit together: D8080, associated D8670 and D8680 entries, diagnostic casts (D0470), completed HLD index form DC016, photos, x‑rays and treatment plan; no treatment will be authorized without complete submission.
Benefit limits: many orthodontic codes are one per lifetime per patient (examples: D8080, D8210/D8220 one per lifetime) with additional periodic visit and retention limits (e.g., D8670 one per calendar quarter; D8660 one per 3 months up to six lifetime).
Age limits: orthodontic codes are generally limited to ages 0–21 with specific narrower age ranges for some codes (e.g., D8210/D8220: 6–12).
Documentation required: photos, x‑rays, treatment plan, HLD index form DC016, diagnostic casts (D0470), and narrative of medical necessity where specified.
Coverage criteria by code
Coverage is code‑specific with age limits, authorization flags, benefit frequency limits, and documentation requirements.
D9440: Office visit after regularly scheduled hours — age 0–21; authorization required; one per day per patient; documentation: narrative of medical necessity.
D9610: Therapeutic drug injection — age 0–21; authorization required; limit four per day; documentation: narrative of medical necessity.
D9995: Teledentistry synchronous — age 0–21; authorization required; one per day per provider; up to 90 minutes; documentation: narrative of medical necessity.
Diagnostic and restorative (adults vs children)
D0120/D0150 and radiographs: Adults age 21+ have specific frequency limits (e.g., D0120 one per 12 months; D0150 one per 36 months); radiographs must be diagnostic quality.
Covered restorative and endodontic services with limits
The following codes are covered for members age 21 and older with specified tooth coverage, authorization and documentation rules, and frequency limits.
D2150 (amalgam two‑surface) — Age >=21; teeth covered as listed; authorization not required; frequency limits mirror other restorative codes (per surface per time period: primary 12 months, permanent 36 months).
D2710 (resin‑based composite crown) — Age >=21; teeth 1–32; authorization required; documentation: pre‑operative radiographs; frequency limit: one of listed crown codes per 60 months per patient per tooth.
D3310 / D3330 (endodontic therapy anterior/molar) — Age >=21; authorization flags vary (some require authorization); documentation: pre‑operative radiographs where specified; benefit limit commonly one per lifetime per tooth.
Restorative frequency and payment rules: Payment based on surfaces restored; similar restorations limited to frequency intervals as specified per code.
Coverage criteria for codes in this section
Coverage and requirements for listed codes in this section (removable prosthodontics, maxillofacial prosthetics, extractions, and authorizations).
Removable prosthodontics (selected codes): Age limit commonly 21+ for adult exhibit entries; authorization generally not required for common repair/adjustment codes but overdentures and many maxillofacial prosthetics require authorization.
D5863/D5865 (overdentures): Authorization required; pre‑operative radiographs required; benefit limit one per 60 months per patient.
Extraction rules: Prophylactic extraction of asymptomatic impacted or erupted teeth is not covered; symptomatic conditions (pain, infection, malocclusion causing shifting) may be covered; incidental removal of cyst/lesion at extraction is included in the extraction fee.
Authorization rule (summary): Prior authorization is required only for orthodontic codes prior to rendering treatment; the Prior Authorization column indicates codes subject to pre‑payment review for payment but pre‑payment review does not require pre‑service approval.
Implant and prosthodontic coverage criteria
Implant services coverage condition for adults (21+) and general implant policy statements.
Implant services (adult exhibit): Implant services are a benefit only when exceptional medical conditions are documented and will be reviewed for medical necessity; refer to Implant Services General policies for specifics.
Most implant procedures list 'Authorization Required = Yes' and require documentation such as photos, x‑rays and a treatment plan; benefit limits and tooth coverage are listed per code.
Exceptions and notes
Some implant‑related codes may list 'No' for authorization (specific codes vary); re‑cement/re‑bond implant codes (D6092/D6093) do not require authorization and the original provider is responsible for re‑cementations within first 12 months.
Frequency/benefit limits: Some prosthodontic codes remain limited to one per 60 months per tooth; D5960 and similar maxillofacial prosthetic codes may have two per 12 months limits as specified.
Coverage and requirements for prosthodontics and oral/maxillofacial surgery codes
Per-code coverage entries state age limits (21+), teeth/arch applicability, whether authorization is required, benefit limitations, and documentation required.
Pontic/fixed prosthodontics (D6211, D6241, D6245, D6251): Age limitation (adult entries 21+ or pediatric noted as 13–20 where indicated); authorization required; benefit limit one per 60 months per patient per tooth; documentation: narrative of medical necessity and pre‑op x‑rays.
Crown codes (D6721, D6740, D6751, D6781, D6783, D6791): Age limitation 21+ (or 13–20 as specified in pediatric entries); authorization required; one per 60 months per patient per tooth; documentation: narrative of medical necessity and pre‑op x‑rays.
D6930 (re‑cement / re‑bond fixed partial denture): Covered; authorization not required; original provider responsible for re‑cementations within first 12 months following initial placement.
Extractions and surgical removal
D7111/D7140: Simple extractions covered without authorization; documentation as noted.
Listed procedure codes and coding rules
Select diagnostic and preventive codes with limitsCPTCovered
D0120
Periodic oral evaluation - established patient; age limitation 3-20; one of (D0120, D0150) per 6 months per provider
D0140
Limited oral evaluation - problem focused; age 0-21; one per lifetime per provider
D0150
Comprehensive oral evaluation; age 0-21; one of (D0120, D0150) per 36 months per provider
D1120
Prophylaxis - child; age 0-21; one per 6 months per patient
Radiographic imaging codesCPTCovered
D0210
Intraoral - complete series; age 11-20; one of (D0210, D0330) per 36 months per provider
D0330
Panoramic radiographic image; age 0-21; one of (D0210, D0330) per 36 months per provider
D0272/D0274
Bitewings - two/four images; age limits and one per 6 months per provider
Amalgam restorative codesCPTCovered
D2140
Amalgam - one surface, primary or permanent
D2150
Amalgam - two surfaces, primary or permanent
D2160
Amalgam - three surfaces, primary or permanent
D2161
Amalgam - four or more surfaces, primary or permanent
Resin-based composite restorative codesCPTCovered
D2330
Resin-based composite - one surface, anterior
D2331
Resin-based composite - two surfaces, anterior
D2332
Resin-based composite - three surfaces, anterior
D2335
Resin-based composite - four or more surfaces (anterior)
D2391
Resin-based composite - one surface, posterior
D2392
Resin-based composite - two surfaces, posterior
D2393
Resin-based composite - three surfaces, posterior
D2394
Resin-based composite - four or more surfaces, posterior
Repair resin partial denture base, mandibular — benefit limits: one per 1 day per patient per arch; two per 12 months per provider
D5612
Repair resin partial denture, maxillary — age 21+, per arch; benefit limits similar to D5611
D5621
Repair cast partial framework, mandibular — age 21+, per arch
D5622
Repair cast partial framework, maxillary — age 21+, per arch
D5630
Repair or replace broken retentive/clasping materials per tooth — age 21+; benefit limits: three per day per provider; six per 12 months per provider per arch
D5640
Replace missing or broken teeth - partial denture - per tooth — age 21+; limits four per day per provider per arch; eight per 12 months per provider per arch
D5650
Add tooth to existing partial denture - per tooth — age 21+; limits include one per lifetime per patient per tooth
D5660
Add clasp to existing partial denture — age 21+; one per lifetime per patient per tooth
Various implant placement, abutment and crown codes; authorization required; benefit only when exceptional medical conditions documented; documentation: photos, x-rays, treatment plan
Fixed prosthodontics (pontics/crowns)CPTCovered
D6211, D6241, D6245, D6251
Prosthodontics fixed pontic/crown codes; one per 60 months per patient per tooth; authorization required; documentation: narrative of medical necessity and pre-op x-ray(s)
Listed dental procedure codes and descriptionsCPTCovered
D6211
Pontic - cast base metal
D6241
Pontic - porcelain fused to base metal
D6245
Pontic - porcelain/ceramic
D6721
Crown - resin with base metal
D6740
Retainer crown, porcelain/ceramic
D6751
Crown - porcelain fused to base metal
D6781
Crown 3/4 cast predominantly base metal
D6783
Crown 3/4 porcelain/ceramic
D6791
Crown - full cast base metal
D6930
Re-cement or re-bond fixed partial denture
1–10 of 42
1/5
Caries risk-based frequency — D0601/D0602/D0603 (age 0-6)
D0601One per 6 months for age 0-6 (caries risk-based interval)
D0602One per 4 months for age 0-6 (caries risk-based interval)
Authorization, documentation, and billing actions for providers
Prior Authorization
Prior Authorization / Pre-payment Review — Orthodontics only
PLEASE NOTE: PRIOR AUTHORIZATION IS ONLY REQUIRED FOR ORTHODONTICS. The Prior Authorization column in the benefit tables indicates which codes will be reviewed before payment is made (pre-payment review). Pre-payment review does NOT require approval before services are rendered. ONLY ORTHODONTIC CODES REQUIRE PRIOR AUTHORIZATION PRIOR TO RENDERING TREATMENT. Providers must submit all required documentation (see code-specific documentation requirements below) to avoid delays or recoupment of payments.
Pre-payment review = codes shown in Prior Authorization column will be reviewed before payment but do not need approval prior to service.
Prior authorization (PA) = required only for orthodontic codes (e.g., D8080, D8210, D8220).
Failure to provide required documentation or providing inadequate services may result in recoupment after DentaQuest review.
When services are submitted under EPSDT (children), indicate this on the prior authorization submission where applicable.
Definitions and billing rules
Pre-payment review — definition and PA distinction
Pre-payment review definitionA review process where certain codes are reviewed before payment is made; it does not require approval before services are rendered (except orthodontics)
Distinction from prior authorizationPrior authorization is required only for orthodontic codes and must be obtained prior to rendering orthodontic treatment
Provider actionProvide required documentation as indicated in the benefit table to support pre-payment review or prior authorization
Prior Authorization — orthodontics vs pre-payment review
Orthodontic PA requirementPrior authorization is explicitly required only for orthodontic services (e.g., D8080, D8670, D8680)
Pre-payment review for other codes
Policy Summary
Payermhn
PolicyCA Medi‑Cal Children Dental Benefits — Diagnostics, Preventive, Restorative (Exhibit A)
Policy CodePolicy N/A
Change TypeNo material change
Effective Date
Next Review Date
Key ActionSubmit prior authorization only for orthodontic codes; for other listed codes ensure required documentation (narrative, radiographs, photos, treatment plan) is included for pre-payment review.
D5110–D5214 (removable prosthodontics): Age 0–21; many codes authorization required; major removable prosthesis generally limited to one per 60 months per patient; pre‑operative radiographs often required.
D7111–D7250: Extractions and surgical removal codes age 0–21; surgical/impacted removals often require authorization and documentation (pre‑op radiographs) as specified.
D7310/D7320 (alveoloplasty): Authorization required for D7320; documentation required: pre‑operative radiographs, photos, treatment plan; benefit limits include one per lifetime per quadrant for D7320.
D7280–D7291 (biopsy and related procedures): Many require authorization; limits vary (per day/lifetime); documentation such as narrative of medical necessity, pre‑op x‑rays, and pathology reports may be required.
Providers must include specified documentation when requesting authorization; failure to provide required documentation may result in denial or recovery of payment.
Restorative codes (D2140–D2161, D2330–D2394): For adults age 21+ frequency limits per tooth/surface apply (12 months for primary, 36 months for permanent) and payment is surface‑based.
Authorization and documentation requirements, frequency limits and age applicability are specified per code; consult the exhibit entries for code‑level rules.
Maxillofacial prosthetics (D5911–D5987 examples): Authorization required; documentation usually narrative of medical necessity; some codes have specific frequency limits (e.g., D5933 two per 12 months).
D7210–D7251: Surgical/impacted tooth procedures generally require authorization and pre‑operative radiographs or narrative of medical necessity depending on code.
For all per‑code entries, providers must follow the documentation and authorization flags shown in the exhibit; benefit limits (per day, per 12 months, per lifetime) apply as specified per code.
D0603One per 3 months for age 0-6 (caries risk-based interval)
Target populationApplies to children age 0-6 as specified in exhibit
Restoration repeat rule
Standard repeat ruleA similar restoration will not be covered for at least 36 months unless there is recurrent decay or material failure
Payment basisPayment for restorations based on number of surfaces restored, not number of restorations
Included itemsTooth preparation, adhesives, liners, bases, pulp caps, curing, polishing included in restoration fee
Frequency limits by tooth permanence
Primary teeth restorative limitOne of listed restorative codes per 12 months per patient per tooth/surface for primary teeth
Permanent teeth restorative limitOne of listed restorative codes per 36 months per patient per tooth/surface for permanent teeth
Crown limit (example)Certain crown codes limited to one per 60 months per patient per tooth
Frequency limits examples
One per lifetime examplesSelected codes (e.g., some endodontic, surgical codes) limited to one per lifetime per patient per tooth
24-month exampleSome apicoectomy codes limited to one per 24 months per provider per tooth (D3410, D3421, D3425)
36-month quadrant exampleCertain periodontal codes limited to one per 36 months per quadrant (e.g., D4210/D4211)
60-month exampleMany prosthodontic and crown/pontic codes limited to one per 60 months per patient per tooth
Major removable prosthesis frequency limit
Major removable prosthesisOne of listed major removable prosthesis codes (e.g., D5214, D5863, D5865) per 60 months per patient
DocumentationPre‑operative radiographs required for many removable prosthodontic codes (e.g., D5110, D5214, D5863/D5865)
AuthorizationAuthorization required for specified removable overdentures (e.g., D5863, D5865)
Relines and repairs frequency limits
Relines/repairs annual limitMany reline and repair codes are limited to one per 12 months per patient (e.g., D5730-D5761 group)
Per-day caps for repairsSeveral repair procedures limited to one per day per patient or per provider as specified (examples in prosthodontics grid)
Provider 12-month capsSome repair codes have per‑12‑month per‑provider limits (e.g., two per 12 months for select adjustments/repairs)
Per-day and per-provider caps
D5630 per-day/annual capsD5630: Three per day per provider; Six per 12 months per provider per arch
D5640 per-day/annual capsD5640: Four per day per provider per arch; Eight per 12 months per provider per arch
D5520 per-day/annual capsD5520: Four per day per provider per arch; Eight per 12 months per provider per arch
Benefit limit - modifications (D5959)
D5959 modificationsTwo of D5959 (palatal lift prosthesis modification) per 12 months per patient
DocumentationNarrative of medical necessity required for D5959
AuthorizationAuthorization required for D5959
Benefit limit - D5933
D5933 limitTwo of D5933 (obturator prosthesis modification) per 12 months per patient
DocumentationNarrative of medical necessity required for D5933
AuthorizationAuthorization required for D5933
Frequency limits
60‑month prosthodontic/crown limitMany pontic and crown codes limited to one per 60 months per patient per tooth (e.g., D6211, D6241, D6721, D6740)
Oral surgery lifetime limitsSome oral/maxillofacial surgery codes limited to one per lifetime or per quadrant as specified (e.g., D7320 one per lifetime per quadrant)
DocumentationPre‑op radiographs and narrative of medical necessity commonly required for these codes
Per-day and per-provider caps (per‑day / per‑arch / per‑quadrant limits)
Per-day/per-arch limit examplesCodes such as D7961/D7962/D7963/D7970/D7972/D7997 limited to one per day per patient per arch/quadrant as specified
DocumentationNarrative of medical necessity and photos often required for these procedures
AuthorizationAuthorization required for many of these oral/maxillofacial surgery codes
Frequency limits examples
D8660 frequencyOne of D8660 per 3 months; maximum six lifetime
D9223 frequencyD9223: Five per day per provider or location
D9230 frequencyD9230: Three per 12 months per provider or location
Example frequency limits
D9610 limitD9610: Therapeutic drug injection — limit 4 per day
D9950 limitD9950: One per 12 months
D1354 limitD1354: Up to 10 per day and per‑tooth lifetime limits as specified for caries arresting medicaments
Example frequency limits (selected codes)
D9610 per-dayD9610: 4 per day per provider (adjunctive general services) — see exhibit for details
D9950 per-12monthsD9950: One per 12 months per patient
D1354 per-day/toothD1354: Ten per day per patient; one per 6 months per patient per tooth; four per lifetime per tooth
Crown frequency limit
Crown codes 60-month limitOne of specified crown codes (e.g., D2710, D2740, D2751, D2781, D2783, D2791, D6721, D6740) per 60 months per patient per tooth
Documentation requiredPre-operative radiographs required for many crown codes
AuthorizationAuthorization required for listed crown codes as indicated
Restorative frequency limits
Primary restorative limitOne of listed restorative codes per 12 months per patient per tooth/surface for primary teeth
Permanent restorative limitOne of listed restorative codes per 36 months per patient per tooth/surface for permanent teeth
Payment basisRestoration payment based on number of surfaces restored
Endodontic frequency limit
Endodontic lifetime limitOne of listed endodontic codes per lifetime per patient per tooth (e.g., D3310, D3330, D3346-D3348)
Acceptability standardCanals must be completely filled apically and laterally; nonconforming work may be required to be redone at no additional cost
Billing basisBilling for initial or retreatment root canals is based on the fill date
Prosthodontics frequency limit
Pontic/crown 60-month limitOne of specified pontic/crown codes (e.g., D6211, D6241, D6245, D6251) per tooth every 60 months per patient
DocumentationNarrative of medical necessity and pre-op x-ray(s) required
AuthorizationAuthorization required for these fixed prosthodontic codes
D5960 frequency limit
D5960 limitTwo of D5960 (speech aid prosthesis modification) per 12 months per patient
AuthorizationAuthorization required for D5960
DocumentationNarrative of medical necessity required for D5960
D7285 frequency
D7285 per-dayOne of D7285 (incisional biopsy - hard tissue) per day per patient per arch
AuthorizationAuthorization required for D7285
DocumentationNarrative of medical necessity and pathology report often required
D7286 frequency
D7286 per-day limitThree of D7286 (incisional biopsy - soft tissue) per day per patient
DocumentationNarrative of medical necessity and pathology report required
AuthorizationAuthorization required for D7286
D7310 frequency
D7310 lifetime limitOne of D7310 (alveoloplasty in conjunction with extractions) per lifetime per patient
Payment noteD7310 will pay with simple extractions (D7140); set not to pay with surgical extractions to avoid redundancy
DocumentationPre-operative radiographs required
D7320 frequency
D7320 lifetime/quadrantOne of D7320 (alveoloplasty not in conjunction with extractions) per lifetime per patient per quadrant
AuthorizationAuthorization required for D7320
DocumentationPhotos, x-rays, treatment plan required
D7340 frequency
D7340 per-arch 60 monthsOne of D7340 (vestibuloplasty - secondary epithelialization) per 60 months per patient per arch
AuthorizationAuthorization required for D7340
DocumentationPhotos, x-rays, treatment plan required
Documentation Required
Authorization and Documentation Requirements
Some diagnostic, restorative, endodontic, periodontal, prosthodontic, implant, oral/maxillofacial surgery and adjunctive codes require prior authorization or pre-payment review and supporting documentation. Required documentation may include a narrative of medical necessity, pre-operative radiographs, intra-oral/external photos, pathology reports, diagnostic casts, treatment plan, HLD Index form (DC016) for orthodontics, and operative reports where noted.
Restorative/Crowns: many crown codes (e.g., D2710, D2712, D2721, D2740, D2751, D2781, D2783) require Authorization = Yes and pre-operative radiographs.
Endodontics/Surgical Endodontics: codes such as D3410, D3421, D3425, D3426, D3471-D3473, D3921, D3999 require authorization and narr. of medical necessity and pre-op x-rays; some require photos/treatment plan.
Periodontics: scaling, osseous surgery and gingivectomy codes (e.g., D4210, D4211, D4260, D4261, D4341, D4342, D4920, D4999) require authorization and documentation (photograph, pre-op radiographs, narrative).
Prosthodontics (removable/fixed) and overdentures (e.g., D5211-D5214, D5863, D5865, D5899, D6211, D6241, D6245) often require Authorization = Yes and pre-op radiographs/photos/treatment plan.
Implants: implant placement and implant-supported prosthetic codes (e.g., D6010, D6013, D6040, D6050, D6113-D6116) require Authorization = Yes and photos/xrays/treatment plan; implant services are reviewed for exceptional medical conditions.
Oral/Maxillofacial Surgery: select codes (e.g., D7320, D7461, D7465, D7471, D7630, D7640, D7650, D7770, D7771, D7780, D7961-D7963, D7970, D7990-D7997, D7993-D7995, D7997) require Authorization = Yes and documentation such as pre-op radiographs, operative reports, narratives, pathology reports, and photos.
Prior Authorization
Authorization and prior authorization rules
Authorization Required = Yes for many listed procedure codes outside orthodontics (especially implant, oral/maxillofacial surgery, prosthodontics fixed/removable, select crowns, endodontic surgery and some periodontics). The Prior Authorization column in the benefit tables marks codes subject to pre-payment review; codes with Authorization Required = Yes must have the indicated documentation submitted.
If Authorization Required = Yes, submit required documentation (narrative, photos, xrays, casts, treatment plan) with the authorization request.
Pre-payment review items will be audited at claim/payment; documentation requested should be retained and provided upon request to avoid recoupment.
Implant services: benefits only when exceptional medical conditions are documented; see Implant Services General policies.
Billing Rule
Provider administrative actions for orthodontic cases
Provider administrative actions for orthodontic cases: submit a completed ADA claim form with date of service (banding/banding date) and required documentation via the provider portal, fax or mail. For prior authorization of comprehensive adolescent orthodontics (D8080) submit: D8080, associated periodic visits (D8670), retention (D8680), diagnostic casts (D0470), and completed HLD Index California Modification Score Sheet Form DC016. Notify DentaQuest if the member discontinues treatment. For continuation of care submit the Continuation of Care form, prior approval documentation, ADA claim form, and prior diagnostic models or OrthoCad equivalents when applicable.
Orthodontic start/banding date = date when bands, brackets, or appliances are placed; member must be eligible on that date.
If member becomes ineligible during treatment, member is responsible for any remaining balance.
DentaQuest will reimburse providers for orthodontic records when denial determinations are made — claims must follow timely filing and HIPAA-compliant ADA claim form requirements.
Billing Rule
Benefit quantity limits and per-day/per-arch restrictions
Benefit quantity limits and per-day/per-arch restrictions are specified on many codes and must be followed. Examples include per‑tooth, per‑quadrant, per‑arch, per‑provider, per‑patient, per‑day, per‑calendar quarter and lifetime limits noted in the benefit tables. Some codes have strict numeric limits (e.g., D0320, D0322, D0330, D0601-D0603, D2710/D2712 series, D4341/D4342, D4910, D9210, D9222/D9223, D9230, D9430, D9610, D9910, D5863/D5865 overdentures, D5960 speech aid modifications).
Follow the per‑timeframe frequency limits shown in tables (e.g., one of X per 12 months, per 36 months, per lifetime).
Some limits apply per tooth, per surface, per quadrant, per arch, per provider, or per location — verify the benefit line before billing.
Documentation Required
Authorization and documentation for select Oral and Maxillofacial Surgery codes
Authorization and documentation requirements for select Oral and Maxillofacial Surgery codes: many OMFS procedures require Authorization = Yes and specific supporting documentation such as narrative of medical necessity, photos, pre-operative radiographs, treatment plans, pathology reports, and operative reports. Examples include alveoloplasty (D7320), destruction of lesion(s) (D7465), removal of exostosis (D7471), open/closed reductions and facial bone reductions (D7630-D7780 series), frenectomy/frenuloplasty (D7962-D7963), and craniofacial/zygomatic implant placements (D7993-D7994).
Pre-operative radiographs and operative reports are required for open/closed reductions and many trauma reductions (e.g., D7630, D7640, D7650, D7660, D7770, D7771, D7780).
Narrative of medical necessity and photos are often required for prosthetic, grafting, and atypical reconstructive procedures (e.g., D7465, D7471, D7993-D7995).
Submit EPSDT prior authorization for pediatric maxillofacial prosthetics when applicable.
Note
Pre-payment review clarification
Pre-payment review clarification: codes listed in the Prior Authorization column are subject to review before payment but do not require approval before providing services. Providers should still submit and retain all required documentation; pre-payment review may request records after claim submission.
Pre-payment review = audit of claims/documentation before payment; does not delay care.
Only orthodontic codes require prior authorization prior to rendering treatment.
Other listed codes are subject to pre-payment review but do not require approval before rendering services
Documentation submissionOrthodontic PA requires HLD index form DC016, diagnostic casts, photos, x‑rays, treatment plan per exhibit
Billing and reimbursement timing rule
Crowns / fixed prosthetics billing basisBilling and reimbursement for cast crowns, post & cores and other fixed prosthetics are based on the cementation date
Root canal billing basisBilling and reimbursement for initial or retreatment root canals shall be based on the fill date
Radiograph requirementPost-cementation radiographs must be in chart or payments may be recovered
Root canal standard
Root canal fill standardCanal(s) must be completely filled apically and laterally; nonconforming work may be required to be redone at no additional cost
Complete root canal therapy includesDiagnosis, treatment plan, all appointments, temporary fillings, filling & obturation, intra‑operative and fill radiographs, follow‑up care
Billing basis reiteratedBilling for root canals based on fill date per exhibit language
Complete root canal therapy — definition
Complete root canal therapy definitionIncludes diagnosis, treatment plan, appointments to complete treatment, temporary fillings, filling & obturation of canals, intra‑operative and fill radiographs, and follow‑up care
Acceptability standardCanals must be completely filled apically and laterally; substandard work may require redo at no cost
Billing noteBilling/reimbursement for initial or retreatment root canals is based on the fill date
Billing date rules
Cementation vs fill datesCementation date governs billing for crowns/fixed prosthetics/post & cores; fill date governs billing for root canals
Post-cementation radiographsPost‑cementation radiographs must be in the patient chart and available for review
Example codesApplicable to D2710/D2740 crowns and D2954 post/core entries as listed
Surgical extraction (definition)
Surgical extraction definitionSurgical extractions require elevation of a mucoperiosteal flap and removal of bone and/or sectioning of the tooth and closure
Exclusion noteElevation/sectioning for provider convenience is not considered surgical extraction
Incidental proceduresIncidental removal of cyst/lesion at extraction is included in extraction fee and should not be billed separately
Extraction of asymptomatic impacted teeth
Impacted asymptomatic extractionExtraction of asymptomatic impacted teeth is not a covered benefit unless symptomatic (pain, infection, malocclusion)
Symptomatic criteriaSymptoms include pain, infection, or demonstrated malocclusion causing shifting of dentition
Related billing noteSmoothing/contouring of ridges with surgical removal is inclusive unless additional necessity rationale submitted
EPSDT prior authorization
EPSDT submissionsServices that fall under EPSDT must be submitted as a prior authorization under EPSDT
Pre-payment review vs PAThe Prior Authorization column indicates codes reviewed pre-payment; only orthodontic codes require PA prior to rendering treatment
DocumentationEnsure all required documentation per benefit table is provided for review
Implant services benefit condition
Implant benefit conditionImplant services are a benefit only when exceptional medical conditions are documented and will be reviewed for medical necessity
Documentation requiredPhotos, x‑rays, and treatment plan required for implant services per exhibit
AuthorizationMost implant codes require authorization; refer to Implant Services General policies for specifics
Surgical extractions and related oral surgery rules
Alveoloplasty/D7320D7320 authorization required; one per lifetime per patient per quadrant; documentation: photos, x‑rays, treatment plan
Vestibuloplasty limitsD7340 one per 60 months per arch; D7350 one per lifetime per arch; documentation required
Authorization requirementMany oral/maxillofacial codes list 'Authorization Required = Yes' and require operative reports/pre‑op radiographs
Prophylactic extraction
Prophylactic extraction not coveredProphylactic extraction of asymptomatic impacted or erupted teeth is not covered
Symptomatic exceptionsCoverage may apply when symptomatic (pain, infection, malocclusion) — document medical necessity
Surgical extraction definitionSurgical extractions require flap elevation, bone removal and/or sectioning with closure
Per Quadrant / Per Arch — definition
Anatomical unit definitionPer Quadrant / Per Arch denotes the anatomical unit for benefit limits and teeth coverage (examples: quadrants 10/20/30/40; arches 01/02)
Use in limitsBenefit limits frequently expressed per quadrant or per arch in the exhibit (e.g., D7310 per quadrant)
ReferenceSee per‑code entries showing 'Teeth Covered = Per Quadrant' or 'Per Arch'
Documentation Required — required materials
Required documentation typesNarrative of medical necessity, pre‑operative radiographs, operative report, pathology report, photos, and treatment plan as specified per code
When requiredDocumentation required for authorization or pre‑payment review varies by code — follow benefit table entries
Submission methodsSubmit required documentation via provider portal, fax or mail as instructed for authorizations
Authorization Required — how shown and implication
Authorization required columnThe Prior Authorization column indicates codes that will be reviewed before payment (pre‑payment review); only orthodontic codes require PA before rendering treatment
PA for orthodonticsOrthodontic services require prior authorization and submission of complete documentation before treatment start/banding date
Pre-payment review notePre‑payment review does not require approval before services are rendered for non‑orthodontic codes